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NC50553 | Concerns regarding five children aged between 4- and 12-years in February 2016. Mr W, father of the two youngest children, had watched Category A, B and C child abuse images and uploaded them for others to watch. In September 2014 he admitted the offences, was arrested and released on bail conditions not to have unsupervised contact with any child. In February 2016 evidence was found that Mr W had sexually abused one of the children living in the family home; he pleaded guilty to 43 child sex offences and was jailed for 18 years. There had been historic concerns from schools and the police regarding neglect and potential emotional abuse starting in 2007, concerns of domestic violence between mother and Mr W and physical abuse towards the children by them both. Prioritises six findings: the huge increase in the number of men viewing online child sexual abuse images has not been matched by professional knowledge; the absence of a clear framework for interviewing children outside the established process; insufficient appropriate professional challenge and the use of escalation processes; a tendency for professionals to uncritically accept what parents tell them about their children; professionals are deskilled in their response and inconsistent in how they name child and adolescent neglect; and evidence of lack of rigour and focus in child protection processes. The review was undertaken using the Learning Together systems model developed by the Social Care Institute for Excellence. There are no recommendations presented as such, but under each finding are questions for the Board. Concludes by raising concerns regarding the collective and cumulative impact that resource pressures can have on delivery of services.
| Title: Report of the serious case review regarding 5 siblings (Family M). LSCB: Wiltshire Safeguarding Children Board Author: Jane Wiffin Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 40 Report of the Serious Case Review regarding 5 Siblings (Family M) Author: Jane Wiffin SCIE Lead Reviewer Page 2 of 40 Contents Page 1. Introduction Page 3 2. Why this case is being reviewed Page 3 3. Summary of the case Page 3 4. Summary of the Review Methodology Page 5 5. Family Involvement Page 6 6. The Lead Reviewer Page 6 7. Appraisal of Professional Practice in this case Page 7 8. Appraisal of Practice Page 7 9. The Findings Page 20 10. Finding 1 Page 21 11. Finding 2 Page 25 12. Finding 3 Page 28 13. Finding 4 Page 31 14. Finding 5 Page 34 15. Finding 6 Page 36 16. Final Thoughts or Conclusion Page 39 17. References Page 40 Page 3 of 40 1 Introduction Why this case is being reviewed 1.1 This serious case review was commissioned by Wiltshire LSCB (WSCB) because of concerns regarding five children and a young unrelated adult who was living in the family home. In September 2014 evidence became available that the Father of the two younger children (Mr W) was found to have watched Category A, Category B and Category C1 child abuse images online and uploaded them onto shared sites so others could watch them. At this time, the identity of the children in the images was not known, but it was known they were of pre-pubescent boys aged between 10 and 12 years old and some girls who appeared to be around the age of 10. In February 2016, it was found that one of the children, living in the family home, had been sexually abused by Mr W who then pleaded guilty to 43 child sex offences and received a custodial sentence of 18 years. 1.2 Serious Case Reviews play an important part in the broader efforts of the LSCB to achieve a safer child protection system and ensure all children and young people are effectively safeguarded. Consequently, it is important to consider what happened and try and discover why in a particular case; but then to go further and reflect on what this might reveal about underlying gaps and strengths in the child welfare system that may reappear in other cases. In this case the purpose is to reflect on the service response to the children and their parents. Summary of the case 1.3 This review focuses on five children Sibling 1 aged 4, Sibling 2 aged 6, Sibling 3 aged 8, Sibling 4 aged 10 and Sibling 5 aged 12 (all ages at the start of the review period). They were all living with their Mother and Mr W. There are also two older siblings (14 and 15) who lived away from home with their Father and had no contact with professionals during the period under review. All the children have the same Mother; the two youngest children’s Father is Mr W. Sibling 3, 4 and 5 all have different Father’s. A young person called YP1 (aged 17) also lived in the family home. The family are white/British. 1 Images that involve penetrative sexual activity with a child are classed as category A images. Images that involve non-penetrative sexual activity are classed as category B images. Other child sexual abuse images not falling within categories A or B fall into category C. DA distinction is also drawn regarding possession, distribution and production and this influences the assessment of the severity of the criminal activity and likely sentencing. Sentencing Council (2013) Sexual Offences Definitive Guidelines; page 76 https:// www.sentencingcouncil.org.uk/wp-content/uploads/Final_Sexual_Offences_ Definitive_Guideline_content_web1.pdf Page 4 of 40 1.4 There had been historic concerns from schools and the police regarding the neglect and potential emotional abuse of the children starting from 2007, when Sibling 3 was 9 months old, Sibling 4 aged 2 and a half and Sibling 5 aged nearly 5. In addition, there were some concerns regarding Mr W being domestically abusive to Mother and both Mr W and Mother being physically abusive to the children. Over time assessments were completed by Children’s Social Care and these culminated either in a conclusion that the concerns had not been substantiated or, in the later years, that further assessment was needed, but which did not happen. In 2013 Early Help Common Assessment Framework (CAF2) plans were opened on the children, but Mother and Mr W did not attend meetings and these were discontinued. 1.5 In September 2014 Mr W was found to have downloaded video images of children being sexually abused and shared these images with others in chat rooms. Mr W admitted the downloading offences, was arrested and released on bail conditions not to have unsupervised contact with any child. He moved to live with a relative. Mother was made aware of the seriousness of the concerns and asked by Children’s Social Care to sign an agreement not to allow Mr W to have any unsupervised contact with the children, which she agreed to do. 1.6 Joint Police and Children’s Social Care (CSC) Child Protection inquiries3 were planned and Criminal inquires started. The criminal investigations were delayed because of the volume of ongoing serious police investigations regarding adults involved in sexual abuse. There was a further assessment by CSC and an Initial Child Protection Conference (ICPC)4 was planned but cancelled after an assessment had been completed, and the children were made subject to Child in Need (CIN) Plans5. The CIN process continued for 14months. There were initially a number of changes of social worker but for 10 months there was a consistent group of professionals. During this time, there were concerns held by schools regarding neglect and the children’s emotional wellbeing, which were unaddressed. 2 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 3 Children’s Services have a legal duty to look into a child's situation if they have information that a child may be at risk of significant harm. This is called a child protection enquiry or investigation. Sometimes it is called a “Section 47 investigation” after the section of the Children Act 1989 which sets out this duty. The purpose of the enquires is to gather information about the child and their family so that social workers can decide what action, if any, they need to take to keep a child safe and promote their welfare. 4 An Initial Child Protection Case Conference is a multi-agency meeting often attended by family members which takes place within 15 days of the strategy discussion/meeting if as a result of the child protection enquiries a child or young person is considered to be at risk of significant harm . Those at the meeting (conference) discuss the risk to the child and decide what needs to happen to make sure they are kept safe. 5 A child in need plan should be clear about what the assessment (Initial or Core) has identified as needing addressing, which agencies will provide services and what is expected of the parents/caregivers and the child or young person. http://www.legislation.gov.uk/ukpga/1989/41/section/17 Page 5 of 40 1.7 Mother separated from Mr W in 2015, started a new relationship and was pregnant in August 2015. There were some concerns that emerged regarding this new partner, which were considered, but not fully assessed. 1.8 The CIN plans were ceased in October/November 2015 but there were growing concerns regarding Sibling 5 and her Mother’s negative and emotionally abusive behaviour towards her in the period November 2015 to January 2016. 1.9 Mr W’s bail conditions remained in place until February 2016. There were anonymous allegations that he was seen at the family home, but there were unannounced social work visits and surveillance by the community policing team and these allegations were never substantiated. In February 2016 it was established, through forensic examination, that the sexual abuse images provided evidence that one of the children had been subject to sexual abuse by Mr W and he was convicted of a number of child sex offences. 1.10 The children were made subject to child protection plans. Sibling 4 had already moved to live with his Father (in September 2014) and Sibling 5 moved to stay with her Father. Care proceedings were sought regarding those children remaining at home. YP1 moved to independent accommodation. Summary of the Review Methodology 1.11 The expectations of a Serious Case Review as contained in Working Together 2015i is that they are conducted using a systems approach, but no specific methodology is prescribed. This review has been undertaken using the Learning Together systems model developed by the Social Care Institute for Excellence and more details about this can be found at http://www.scie.org.uk/publications/guides/guide24/index.asp. SCIE provided quality assurance supervision at key points in the data analysis process and at the end when the final report was in draft form. 1.12 Information is provided in Appendix 4.1 about the methodology, the author and the process of this review. 1.13 The review was also assisted by a case group of frontline professionals across all the relevant agencies, who either had direct involvement with the children, Mother, Mr W and the extended family or were managing and supervising the professionals. They provided data and sensitive critical reflections to help to understand the professional response at the time. This has not been an easy thing to do and the Independent Reviewer is genuinely grateful to them for their honesty and openness. Page 6 of 40 1.14 Interviews were held with all professionals and a substantial quantity of case records from across the agencies was accessed and reviewed. This data was analysed by the Review Team and formed the basis of this report. The Case Group were involved in subsequent discussions about emerging findings. Family Involvement 1.15 Family members and YP1 were offered the opportunity to meet with the reviewer and share their views, but these offers were declined. The Lead Reviewer 1.16 The Lead Reviewer, Jane Wiffin is accredited in systems learning and the SCIE “Learning Together” model and is an experienced independent investigator and safeguarding lead who has undertaken many Serious Case Reviews nationally over the last 15 years. Jane has a professional background in social work, training and policy development. She has never worked for any agency in Wiltshire and is completely independent. It was originally intended that the Review would be undertaken with a trainee reviewer from a local safeguarding agency. This joint process was started but the second reviewer had to withdraw from the process three months into the review. Page 7 of 40 2 Appraisal of Professional Practice in this case 2.1 This section provides a summary chronology and appraisal of practice. This sets out the view of the Review Team and Case Group about how effective the professional response was to this family, in the time under review. Where possible, it provides explanations for the practice seen and indicates where these issues will be discussed more fully in the detailed findings. Section 3 then discusses in detail the priority findings that have emerged from this Serious Case Review. Appraisal of Practice 2.2 The professional response to the children and family in this case was influenced by a number of issues. First, the very serious and growing issue of adult men who view and share child abuse images. This is a rapidly growing area of concern for all child protection agencies, and it is an area where knowledge of best professional practice lags behind the growth in harmful activity. There is national debate about judging both the seriousness of these offences, and the likelihood of viewing child abuse images- often referred to as “non-contact sexual abuse” - turning into the contact sexual abuse of children. These are complex matters and matters that faced professionals throughout this review. This review starts with the belief that viewing child abuse images is not a passive activity and that behind every child sex abuse image abuse has occurred. Children are the victims of sexual abuse when the images are produced, and they remain victims every time the images are viewed; the knowledge for some that these images can be repeatedly seen by many people causes on going trauma. Watching others sexually abuse children is child abuse. 2.3 The second major issue here is that of long term neglect and how this serious challenge to children’s wellbeing is recognised, communicated, analysed and addressed by the multi-agency group. 2.4 The third issue is the complexity of working with blended families where there are different parent figures and where children live with different members of the family. In this case there were 8 children in the family with 4 different fathers. There was also a young person aged 17 who was not related to the family, but he had moved to stay in the family home. Two of the children were non-resident, living with their Father, but little was known about them other than that they had some contact with their siblings. Making sense of the family circumstances was made more complex both by the number of people involved and uncertainty about who should and could be invited to meetings, who did and did not have parental responsibility, or who should and should not be involved with assessments. 2.5 The final compounding issue was the workload and staffing difficulties experienced by some agencies during the period of time under review. The social work team in one of the locality Page 8 of 40 areas in Wiltshire had simultaneously experienced an increase in referrals, high turnover of staff and the use of agency staff to fill vacant posts. This had an impact on their response to this case. There were six different social workers responsible for the children and the family from the contact in September 2014 to December 2014; as Children’s Services were the Lead Agency this impacted significantly in taking forward the child in need processes and the need for further risk assessments. These issues have subsequently been addressed. 2.6 The school nursing service also experienced high staff turnover and this meant that there were a number of different school nurses involved in the CIN process and the health aspects of the CIN plan were either delayed or not completed. This too has been addressed. 2.7 The Police Child Internet Exploitation Team were undertaking a large number of sexual abuse investigations (94 in total) of a serious and complex nature at this time. The unexpected increase in the volume of work resulted in a waiting list for the forensic examination of the electronic devices seized at the time of the arrest of Mr W, with a consequent 17 months delay in being able to know if any of the images downloaded by Mr W were of the children in the household and therefore whether there was evidence of contact sexual abuse. The waiting list has been reduced considerably. September 2014: Information received regarding child sexual abuse images being downloaded and shared 2.8 At the beginning of September 2014 Wiltshire Police and Wiltshire Children’s Social Care (CSC) received full information regarding the uploading of sexually abusive images of children traced to the home address of Mother and Mr W. A comprehensive Strategy Meeting6 was convened. Information was shared about historic concerns, current worries held by the schools about neglect of the children and the nature of the online images. It was known that the images viewed were of pre-pubescent boys aged between 10 and 12 years old and some of girls who appear to be around the age of 10; there were 14 category A videos7; 2 category B videos8; and 27 category C images9. The conclusion was that there was a significant risk of sexual abuse and possible neglect of the children. It was agreed that a joint police and Children’s Social Care (CSC) child protection inquiry would be undertaken and an Initial Child Protection Conference was planned. This was a clear and appropriate focus and plan of action, which later became diluted over time. 6 A Strategy Meeting (sometimes referred to as a Strategy Discussion) is normally held when there is an indication that a child has suffered or is likely to suffer Significant Harm. The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Child Protection Enquiry 7 video images of sexual acts with children included penetration 8 video images involving children in non –penetrative sexual activity 9 video images involving children in non –penetrative sexual activity Page 9 of 40 Initial Joint Investigation undertaken by the Police and CSC 2.9 The next morning a Police Officer (PO1) and a Social Worker (SW1) visited the family home. Mr W admitted to downloading the images but denied having a sexual interest in children. He was arrested, released on conditional police bail whereby he would have no unsupervised contact with any child under the age of 16. He agreed to go to his Father’s home (PGF1). 2.10 As part of this initial visit Mother was made aware of the seriousness of the offences and the nature of the images found. She was asked to sign a written agreement by SW1 to confirm that Mr W would have no unsupervised contact with the children and supervised contact was organised and managed for the next nine months by CSC. Mother did not take the written agreement seriously10, and there were occasions immediately after Mr W was arrested when she sought clarification of its meaning, and challenged why Mr W could not be in the family home. These issues were raised as a concern by PO1 but the ability of Mother to protect the children was not assessed and an understanding of the importance of this, in the context of an understanding of sexual offending and the risks to children, is discussed further in Finding 1. The dependence (in part) on the written agreement as a way of ensuring safety for the children, in the absence of a clear assessment of Mother’s ability to protect the children, was overly optimistic. Children Interviewed 2.11 All the children were interviewed by SW1 and PO1. It was a joint agency decision not to undertake the interview under the auspices of the Achieving Best Evidence Framework (ABE11) because this could be traumatising for the children – with the plan that this ABE Framework would be used if evidence of abuse emerged; this is a routine approach to potential disclosures of abuse. 2.12 The four oldest children were interviewed at school and Sibling 1 at home. The written record of these interviews is very limited, and it is therefore unclear what the children were asked and to what extent concerns, regarding sexual abuse, were explicitly explored. The records suggest there was a more general focus on family life and family relationships. It was not acknowledged that the two younger children did not have the necessary language skills to share any harmful experiences verbally, and there should have been communication 10 Written Agreements are no longer used in Wiltshire and therefore there are no Findings regarding them in this report 11 Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures is Government guidance which describes good practice in relation to the interviewing of and giving of evidence by vulnerable witnesses (children and vulnerable adult witnesses). https://www.cps.gov.uk/publications/docs/best_evidence_in_criminal_proceedings.pdf Page 10 of 40 with the school staff, who knew their communication style well, about how best to undertake the interviews. The issue of appropriate and sensitive interviews with children in the context of possible abuse is addressed in Finding 2. The schools also felt that the arrival of the police and social worker was scary for the children and that this may have unintentionally had an impact on them and their ability to share any concerns. However, this issue was never discussed or addressed and the ability, and confidence, of the multi-agency group to challenge the analysis and decision making of the lead agencies is discussed in Finding 3. 2.13 Once the initial child protection inquiries had been undertaken the Police and CSC investigations became separate processes and there was a lack of meaningful coordination or discussion between these pivotal agencies from this point onwards. This meant that the expertise of the Police Child Internet Exploitation Team was not utilised and did not inform either the CSC assessment or the subsequent CIN processes. This is discussed further in Finding 1. 2.14 The police ensured that data held in America was preserved and Mr W’s electronic equipment was submitted for forensic examination; because of the volume of child abuse investigations the request was placed on a waiting list at number 77. The police carried out a risk assessment which concluded that because Mr W was bailed to live away from home; to not have contact with any children; a written agreement was in place; and that there was to be a multi-agency child protection conference and plan, that protective measures were in place. This risk assessment was not revisited when the decision was made to hold the case at CIN level and at this point there should have been liaison between the Police Child Internet Exploitation Team and CSC to consider what further protective action should be taken. The delay in the examination of electronic devices did have an impact on professionals being able to know whether or not the children had been sexually abused and to understand more clearly the risks that Mr W posed. There was very little contact between the Police and CSC from this point onwards. Each agency continued on with their own core task; the police the investigation of the crime and CSC with the plan to address the needs of the children through a multi-agency CIN process; joint sharing of knowledge and expertise could have in part mitigated the delay in the forensic information. This is discussed further in Finding 1. 2.15 SW2 undertook an assessment of the children and their circumstances. The assessment was concluded quickly and its quality was hampered by the high turnover of social workers and capacity issues within the team. It was over optimistic in its conclusions, was not based on the concerns shared by the schools and focused too much on the needs of the adults whose views were reported verbatim without analysis; this is discussed further in Finding 4. SW2 did not liaise with the police and therefore the concerns about both the risk posed by MR W and Mother’s lack of acknowledgement of those risks were not included. SW2 also Page 11 of 40 interpreted the delay in the forensic examination as meaning no assessment of Mr W could take place because of concerns regarding the influence on any potential criminal proceedings. This was incorrect. It was the expectation that this assessment would use all the available information and expertise to make sense of the risks posed by Mr W and the ability of Mother to effectively protect the children, which could be revised when more information became available. No analysis took place of either risk and this is addressed in Finding 1.12 2.16 The assessment was also supposed to have analysed the considerable historic and current multi agency concerns regarding neglect, but it did not and this is addressed in Finding 5. 2.17 SW2 proposed that there was no need for an Initial Child Protection Conference (ICPC) because the evidence collected through the assessment process suggested that a child in need13 (CIN) plan would address the identified needs of the children. This decision was made on the expectation that there would be a clear, formal CIN process, with a robust plan, clear goals, a focus on outcomes and a clear review process given the level of uncertainty about the current risks mechanism. This did not happen and this is discussed in Finding 6. The assessment was not shared with any of the agencies involved which meant that inaccuracies could not be challenged and the basis on which the CIN plan was to be formulated was not known by all agencies that were to provide services. This was caused by confusion about whether assessments could be shared and this is discussed in Finding 6 in the context of CIN plans. 2.18 The plan not to convene the ICPC was agreed by the Child Protection Chair who informed all other agencies. The decision was taken without discussion with the professionals who knew the children and their circumstances well (the schools), who would have disagreed, and without discussion with the Police, whose risk assessment was predicated on the notion that there would be a child protection plan in place regarding the children and were joint partners in the child protection inquiry. This was not an appropriate decision and it is the view of the Review Team that the ICPC was necessary to ensure the safeguarding of the siblings; that their circumstances met the criteria for the likely risk of significant harm because of the uncertainty regarding the risk posed by Mr W and the concerns regarding Mother’s capacity to recognise the potential risks and keep the children safe. 12 http://www.saferchildrenyork.org.uk/protecting-children-online.htm 13 Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures is Government guidance which describes good practice in relation to the interviewing of and giving of evidence by vulnerable witnesses (children and vulnerable adult witnesses). https://www.cps.gov.uk/publications/docs/best_evidence_in_criminal_proceedings.pdf Page 12 of 40 2.19 This Review has been reassured by the Review Team’s local knowledge that deciding to work at CIN level rather than at the Child Protection level where risks to children remain uncertain, and a multi-agency response is required, is not currently routine practice in Wiltshire. In this case it appears to have been influenced by the over optimism of the assessing social worker and poor management oversight. It is clear that the ICPC was required, given the level of uncertainty about the risks posed to the children, but it would also have been expected that a clear and robust CIN process would have been put into place. This did not happen and this is addressed in Finding 6. 2.20 The decision to cancel the ICPC was challenged by the police and Sibling 5’s school. The Police reiterated their concerns about the risk Mr W posed, and concerns about Mother’s ability to protect. Although it was appropriate that both agencies challenged this decision, they should both have pursued the matter further. The issue of appropriate professional challenge and use of the Escalation Policy is addressed in Finding 3. The First Child in Need Meeting 2.21 At the end of September, the first CIN meeting was convened. This was an important opportunity to consider the needs and circumstances of all five children. This was chaired by SW2 and attended by representatives of the children’s schools, the School Nurse, Mother, Mr W and Sibling 4’s Father. The concern that Mr W had downloaded indecent images of children was discussed, but the detail was not. This appears to have been influenced by Mr W’s presence at the meeting. There was no discussion about the appropriateness of Mr W attending the meeting, given the continued lack of knowledge of his actual offending behaviour or the exact risk he might pose in the context of grooming, and how he might use attendance at any meeting as an influencing factor with the children. This is discussed in Finding 1. 2.22 Mother was asked to give an outline of the circumstances of each child and her overly optimistic view was in sharp contrast to the information provided by the agencies present. This discrepancy was not addressed or discussed and the issue of an uncritical and unanalytical acceptance of parental views is addressed in Finding 4. The impact of this on professional’s ability to analyse and name neglect is addressed in Finding 5. 2.23 A CIN plan was formulated and focused on a number of practical issues: • head lice and school attendance for Sibling 2 • a school place for Sibling 1 (Mother had failed to complete the application in a timely way and no place was available at the school attended by the siblings) • “keep safe work” for all the children (this was never implemented) • a referral to the Young Carers Project for Sibling 5 Page 13 of 40 • a referral to a Family Group Conference (FGC) regarding supervising contact between Mr W and the children in the future. These actions were formulated in the absence of a clear outline or analysis of the central concerns for these children; which was evidence of neglect and possible sexual abuse. 2.24 The CIN process and plan was further undermined by the fact that soon after it was developed SW2 left. As there was no allocated social worker for the children the CIN plan was overseen by different social workers from the Duty Social Work Team. There was also a turnover of school nurses at the same time and so actions agreed for these two agencies did not take place. Continuity was provided by the children’s schools, but they had not been tasked with any actions within the plan. 2.25 In October 2014 the nursery was worried about Sibling 1 (aged 4 and a half) soiling himself, being distressed and Mother’s dismissive attitude towards him. There were similar concerns from school regarding Sibling 2 and head lice. Contact was made with the Duty Social Work Team and information shared although there was no action agreed. This was due in part to the fact that School 1 and the nursery were not as clear as they could have been with regard to concerns about long term neglect (See Finding 5), and because there was no allocated social worker. 2.26 In mid-October 2014 the police and housing services became aware that there were allegations that Mother might be allowing Mr W to have contact at home with the children; this breached both the bail conditions and written agreement. This was followed up by a Duty Social Worker (SW3). Mother said the children had no unsupervised contact with Mr W but she said she had been meeting Mr W in the evenings and had been told by the previous social worker that she was allowed to do so. This was continued evidence that Mother either did not understand the bail conditions/working agreement, or was choosing to disregard them. Either way this required analysis and action. During this visit the Duty Social Worker (SW3) noted that the house was unkempt; dirty and dishevelled; two young people (aged 19 and 17) were asleep on the sofa and there was evidence of empty bottles of alcopops on the floor. YP1 was also at the house. Although these concerns were discussed with Mother, the considerable ongoing concerns regarding the neglect of these children was not addressed. A second strategy meeting 2.27 At the beginning of November 2014 a new social worker was allocated to work with the family (SW4). Sibling 1’s nursery reported to her that Sibling 1 had said “daddy was arrested with handcuffs…because he touched us and he was not allowed”. It has now become clear that these were not the words used by Sibling 1, but things he indicated had happened using nonverbal language. This was another example of inaccurate and potentially Page 14 of 40 misleading recording of children’s views in the context of concerns around abuse which is discussed in Finding 2. 2.28 A further strategy meeting was convened and it was agreed that there would be a joint police and CSC child protection inquiry. The strategy meeting did not consider the verbal abilities of Sibling 1, which were delayed, and given his age, it would have been expected that there would have been discussion and planning about how best he could be supported in interview and to perhaps include a member of nursery staff. Sibling 1 was seen alone; his speech delay was noted and it was concluded that he did not have sufficient verbal skills to talk about what he had reportedly talked about at nursery. No action was agreed to address this. The other children were also interviewed, but there is no detail about what the focus of this interview was or what they actually said beyond that they expressed no worries or concerns. This continued lack of a clear or robust approach to interviewing children about abuse is discussed in Finding 2. 2.29 Mother again denied that Mr W had any unsupervised contact with any of the children, but that he had been at the house helping to decorate when the children were not there. She said she had been told this was acceptable by the previous social worker. This was a similar discussion to the conversation with SW3 10 days earlier and should have raised alarm bells, both about Mother’s understanding of the risk posed by Mr W and her ability to ensure the safety of the children, and the degree to which she may have been attempting to deflect professional attention. Contact was made with the schools, who again shared their continued concerns. However, the child protection investigation only focused on the one incident, rather than taking a holistic view of the current circumstances, and continued to lack a focus on the real issues, which were risk of sexual abuse and concerns about neglect. The conclusion of social work was that the CIN process should continue. This was not communicated to any other agency; rather the schools had to contact SW5, where they expressed concern that the child in need plan was not being fully implemented. Child in Need Plan continued 2.30 In mid-November 2014 SW5 assessed PGF’s suitability to supervise contact between Mr W and the children. SW5 was concerned that PGF seemed to be unaware of the detail of the offences and significantly minimized what had happened. Although SW5 appropriately recommended that PGF should not supervise contact, she did not ask about whether other children visited the family home when Mr W was present and the safety of the children in the wider extended family was not assured (see Finding 1). 2.31 The second CIN meeting was held in December 2014. Much of the discussion was about Sibling 4, who had moved to live with his Father. Professionals agreed that Sibling 4 seemed more settled, happier and healthier since the move. There was no discussion about the Page 15 of 40 implications of this for the care he had previously received and the link to neglect not discussed. This was despite there being continued concerns regarding head lice for Sibling 2, speech delay for Sibling 1, and Sibling 4 and 5 taking on what were described as caring responsibilities. The issue of distinguishing between appropriate early caring responsibilities and neglect is addressed in Finding 5. 2.32 School 1 and school 2 also expressed the professional view that the children were being coached by adults about what to say to professionals. It is of concern that there was no deliberation about this within the CIN meeting, or action to address it. The implications of this on the ability of children to make disclosures and seek help from professionals are considered in Finding 2. 2.33 There was also no discussion regarding the continued risk of sexual abuse including: • lack of progress of the police inquiries; • Mother’s continued testing of the terms of the written agreement; • worries that MR W might be visiting the home; • The family/PGF’s lack of explicit knowledge or acknowledgement of the concerns about sexual abuse. 2.34 Overall the CIN process had made little progress and the plans lacked a focus on an analysis of the children’s circumstances, the potential challenges to their outcomes, and contained little acknowledgement of the major issues. This lack of robustness in the CIN process is discussed in Finding 6. There was no further discussion of YP1. 2.35 In January 2015 SW6 became the new allocated social worker and the family were discussed in her supervision with ATM 1, where the issues of drift in the CIN plan was acknowledged. It was agreed that the CIN plan would be reviewed and should become more child focused. It was agreed that there would be an assessment of Mother’s ability to recognise the potential risks posed by Mr W and keep the children safe, alongside an overdue assessment of Mr W and the likely risk of sexual abuse he might pose. More work regarding the circumstances of YP1 was also agreed. These were all appropriate actions, but none actually happened despite being discussed in subsequent supervision sessions. This lack of progress was caused by the ongoing high caseloads and pressures on the team. 2.36 During January a number of agencies shared information with SW6 including: • the poor condition of the home and garden from housing; • Sibling 2’s chronic and painful head lice and concerns regarding Mother’s attitude and lack of action; • Sibling 5 being upset at school and Mother warning her not to talk to the Pastoral Support Team. Page 16 of 40 School 2 asked that this be dealt with sensitively because Sibling 5 was very worried about SW6 telling Mother that she had been talking about family life and would be angry with her. This concern from a young person about sharing her worries with professionals, because of a likely negative response from a parent, required more reflection and discussion. It is essential that young people are enabled to seek help when they need it and to build trust with professionals which will support disclosures about more sensitive issues, such as sexual abuse. This is discussed in Finding 2. 2.37 SW6 focus at this time was on forming a relationship with Mother and getting to know the children. She spent time doing child focused activities but these lacked a clear purpose and the information gathered reflected a different version of family life and circumstances than that known and seen by the schools. This should have been discussed in the context of the CIN meetings and in an ongoing analysis of the children’s needs and circumstances. This did not happen and the lack of analysis within the child in need process is discussed in Finding 6. 2.38 The third CIN review meeting took place at the beginning of March. This was an opportunity to review progress after a time of drift and a number of worrying incidents. It should also have been a time to review what was known about Mr W’s offending and the risk he posed. None of this happened. A worrying picture of the children’s current circumstances emerged and information that Mother had a new partner was shared. Once again there was no analysis of the children’s circumstances. 2.39 A referral was made to the Family Group Conference service in mid-March and the Family Group Conference (FGC)14 took place in April 2015. Rather than discussing the ongoing concerns about how Mother was coping and the various needs of the children, the FGC focused narrowly on supervising contact. Mother and Mr W did not provide details about the wider family network. Consequently, there was no representation at the meeting of Sibling 5 or 6’s Fathers or any other member of the paternal family who had children, for whom the implications of supervision by family members was relevant. Limited professional information was provided to the conference and the negative assessment of PGF was not shared. The FGC plan focused entirely on practical issues, and the plan produced did not answer the central question about how to make these supervisory arrangements safe. PGF was asked to supervise contact. This plan should not have been agreed by SW6 as it was not safe and this again raises questions about professional understanding of offending behaviour discussed in Finding 1. There was also no discussion about whether it was safe or appropriate for Mr W to attend. 14 A family group conference is a process led by family members to plan and make decisions for a child who is at risk. Children and young people are normally involved in their own family group conference, although often with support from an advocate. https://www.frg.org.uk/involving-families/family-group-conference Page 17 of 40 2.40 During May 2015 School 3 became increasingly concerned again regarding Sibling 1’s soiling; his distress, the unhelpful attitude of Mother and the fact that he often returned to school with the same pants on that he had soiled and which were still dirty. The school’s Designated Safeguarding Lead (DSL)15 and the Teaching Assistant contacted SW6 and expressed their concerns that this behaviour was indicative of sexual abuse. SW6 came to the school and met with Sibling 1; she formed the conclusion that this was a toileting issue and ATM1 agreed with this analysis. School 3 worked hard to suggest that a different analysis was required. This issue of the importance of the appropriate management of professional disagreements is discussed in Finding 4. 2.41 The fourth CIN meeting took place at the beginning of May 2015. The same concerns regarding the children were discussed and although it was clear that there were continued differences of professional opinion regarding the children and their wellbeing, these were still not explicitly discussed or analysed. It was reported that Mother had a new partner. Despite the lack of progress or change, SW6 suggested that the children did not need ongoing social work support and that the children would no longer be subject to child in need plans. The schools and nursery expressed unhappiness about this and expected that this would influence the outcomes. It did not, and the same concerns remained which were not addressed over the next three months. The lack of robustness of the CIN process continued and is discussed in Finding 6 alongside the continued difficulties that professionals had in resolving disagreements about the wellbeing of children; discussed in Finding 3. 2.42 In August 2015 the single assessment16, planned in January, was completed. This assessment was supposed to address the risks posed by Mr W and establish the extent to which Mother could keep the children safe. Because the assessment took 8 months, the ongoing concerns held by the school and nursery, were not sufficiently addressed and there was no mention of neglect. The assessment was not shared with the professionals working with the children, and therefore they were not able to challenge its contents. In supervision, SW6 and her manager agreed that the CIN plan would end after the next CIN meeting. The rationale was that there were a number of agencies who were addressing the children’s needs and the police inquiries would not be completed for some time. There was pressure on the teams at this time to ensure all work with families was focused and necessary because of the volume of work. For these children, there was an incorrect analysis of the 15 The role of the Designated Safeguarding Person was specified in the Children Act 2004 and ensured the every organisation had a “named person” for safeguarding children and young people. Prior to that, the role had frequently been known as the Child Protection Officer. 16 A Single Assessment is an in-depth assessment which addresses the central or most important aspects of the needs of a child and the capacity of his or her parents or carers to respond appropriately to these needs within the wider family and community context. While the Single Assessment is led by Children’s Services, it will involve other agencies or independent professionals, who will provide information they hold about the child or parents, contribute specialist knowledge and/or give advice / undertake specialist assessments. Page 18 of 40 risks and needs held by CSC, compounded by poor assessments, poor plans and a lack of recognition of the expertise of the multi-agency network, who held knowledge about neglect of the children (schools and nursery) and sexual offending (police). 2.43 In August 2015 professionals became aware that Mother was pregnant by her new partner. There was some multi-agency discussion regarding this, and as there were no concerns regarding the pregnancy or the new partner it was agreed that the midwifery team would be in contact if further concerns emerged. 2.44 The next CIN meeting was amalgamated with the review Family Group Conference, which meant that the CIN plan was not discussed as the focus was on the completely separate FGC plan. The Coordinator of the FGC was completely unaware that the review FGC was also being used as a CIN Meeting and would not have agreed to this. This appears to have been a one off incident and therefore, although it was inappropriate and unhelpful to the children, no specific action is proposed as a result of it. 2.45 The next CIN meeting was held in October 2015. It was chaired by SW6, attended by Mother, Mr W and two new professionals from School 1 and the School Nurse Team. The discussion focused on current behavioural difficulties of the children and strategies were suggested. The previous plans, and the lack of progress of some elements, were not part of the discussion. The professionals present were asked whether they agreed with the case closure and step down to support from a CAF. Neither professional knew the family well enough to comment and the professionals who did know the children and were not present at this meeting, were not asked beforehand. Nevertheless, the CIN plan ceased and no CAF was formulated, with the result that the children no longer had any formal status within the multi-agency system. School 2 and School 1 expressed concern when informed about this but were told they could not influence the decision. 2.46 In early November 2015 there were escalating concerns regarding Sibling 5 from school 2, including Sibling 5 running away from home overnight and a disclosure that Mother had been physically abusive to her. This was reported to the Duty Team because SW6 had left by this time and there was no longer an allocated social worker. The Duty Social Work Team asked the school to discuss this further with Sibling 5 and a referral to youth support was proposed. No further action was taken and the school continued to support Sibling 5. 2.47 In January 2016 Sibling 5 returned to school and made further allegations that Mother had been physically abusive to her and she was encouraged to provide a written statement, which was good practice and supportive of Sibling 5 having her concerns recognised. A referral was made to CSC who advised that a single assessment would commence. Sibling 5 exhibited huge anxiety about her Mother being told about the allegations she had made and Page 19 of 40 shared that Mother had told her that she would also assault the Pastoral Support Manager if she discussed this with her. 2.48 The Pastoral Support Manager appropriately discussed this with the Duty Social Worker (SW7) and asked that a social worker come and talk to Sibling 5 (aged 14) before seeing Mother, to provide information and reassurance regarding her disclosure. The social work Assistant Team Manager (ATM1) said that a social worker could not meet with Sibling 5 without Mother’s consent. The school were unhappy with this proposal but felt helpless to do anything about it; this is discussed in Finding 3. Consent was sought, but not agreed by Mother, who said Sibling 5 was making malicious allegations. Mother was visited at home by the Duty Social Worker (SW7) and denied the allegations of physical abuse. It is of concern that Sibling 5’s concerns about the impact of making a disclosure were dismissed without further discussion and this is addressed in Finding 2. 2.49 A week later the police forensic investigation was completed and Mr W arrested and imprisoned. The children were made subject to child protection plans and Care Orders sought. The proceedings have concluded that the children will not return to their mother’s care. Page 20 of 40 3 The Findings Introduction 3.1 This section contains 6 priority Findings that have emerged from this SCR. The findings explain why professional practice was not more effective in protecting the siblings in this case. Each Finding also lays out the evidence, identified by the Review Team and Case Group, that indicates that these are not one-off issues, but are matters that if not addressed could cause risks to other children and families in future cases, because they undermine the reliability with which professionals can do their jobs. Summary of findings 3.2 The Review Team have prioritised 6 findings for the WSCB to consider. These are: Finding Category 1. The exponential increase in the number of men who view online child sexual abuse images is not matched by the development of knowledge of best professional practice, leaving professionals uncertain how to respond and children at continued risk of harm. Professional norms and culture around communication 2. The absence of a clear framework for when interviews with children take place outside of the established ABE process, alongside the pressures to balance the requirements of evidence gathering with the need for child sensitive approaches, can lead to inconsistency and unclear interview approaches. Management systems 3. Appropriate routine professional challenge and the use of escalation processes is insufficiently embedded in the multi-agency network in Wiltshire; leaving differences in professional opinion unaddressed and causing feelings of “learned helplessness” which in turn makes resolution less likely. This undermines the safety and wellbeing of children and does not support action to address concerns. Professional norms and culture around communication – longer term work 4. There is a tendency for professionals to uncritically accept what parents tell them about their children in the mistaken belief that this is “working in Patterns of interaction with families Page 21 of 40 partnership”, resulting in an inaccurate description of children’s needs and circumstances which are left unaddressed as a result. 5. The lack of an effective practice framework for working with neglect in Wiltshire has left professionals deskilled in their response and inconsistent in how they explicitly name child and adolescent “neglect”. Tools 6. Although there have been changes to the way in which Child in Need processes are delivered in Wiltshire, there appears to be continued evidence that they lack a multi-agency approach and the rigour and focus seen in child protection processes is missing, with the result that there is insufficient analysis of children’s needs. Professional norms and culture around communication – longer term work Finding 1: The exponential increase in the number of men who view online child sexual abuse images is not matched by the development of knowledge of best professional practice leaving professionals uncertain how to respond and children at continued risk of harm. Introduction “Possession of indecent images of children is alarmingly commonplace” (CEOP 201217) 3.3 This Finding focuses on the extent to which all professionals feel equipped to recognise, assess and address the risks posed by adults (usually males) who download child abuse images. There has been an exponential increase in the number of men who possess indecent images of children, including images of rape and sexual assault. This is both locally in Wiltshire and nationally. It is clear that the act of downloading and possessing images of children being abused is not a passive activity. Watching children being abused by others is child abuse and should be appropriately challenged. Children are the victims of sexual abuse when the images are produced, and they remain victims every time the images are viewed; the knowledge for some that these images can be repeatedly seen by many people causes ongoing trauma. 17 https://ceop.police.uk/Documents/ceopdocs/CEOP%20IIOCTA%20Executive%20Summary.pdf Page 22 of 40 How did the issue manifest itself in this case? 3.4 The early strategy meeting in September made clear that there were significant concerns that Mr W posed a risk of sexual abuse to children. It is of concern that although it was known for certain that he had chosen to watch young children being sexually abused this was never described as sexual abuse; the only action taken against him was the Police Investigation and he was not held responsible for the abuse of these unknown children or the disruption and distress he caused to his own children/stepchildren. Professionals did not discuss this issue, and perceived Mr W’s actions as evidence of passiveness, rather than active abuse. The language professionals then used to describe what was happening in records then either reinforced this passivity, minimized it or normalized it; thus watching children being sexually abused was often referred to as watching “child pornography” a phrase that is widely used nationally, but which undermines a true picture of the harm. 3.5 There was never an assessment of the risk posed by Mr W. Initially this was because the social worker at the time incorrectly believed no assessment could take place whilst the police investigation was ongoing. The urgent need for an assessment of Mr W was then lessened because he was bailed to live away from home, but there was considerable evidence over time that he spent time at the house; there was no evidence that he had contact with the children, but Mother made it clear that he continued to play some part in family life. An assessment of the risk he might pose was necessary. Over time this need was discussed, but no assessment ever took place. No assessment of Mother’s Ability to Protect 3.6 The initial assessment process did not assess Mother’s ability to protect the children at the time of the initial child protection investigation or at any point during the next 17 months, despite immediate concerns regarding her ambivalence and dependency on Mr W. In the first assessment Mother and Mr W were interviewed as a couple together, and there was no discussion about how Mother might cope financially or practically with Mr W absent. 3.7 Mother consistently questioned the terms of the bail conditions and there were concerns that Mr W was visiting the home and then proof was obtained that he was. Reassurance was provided by Mother that this was only when the children were not there and for the purposes of decorating or talking about the children. Researchii is clear that a Mothers’ ability to protect children from likely offenders is linked to the ability to separate emotionally and practically from the perpetrator. Mother never did this, and the implications for the care of the children were not assessed in an ongoing way. When Mother started a new relationship there was some reassurance, but Mr W continued to attend meetings. Although there was evidence that this new partner had associates who were sexual offenders, this too was never assessed. Page 23 of 40 3.8 Over and above the early interviews with the children, there is no evidence that issues of sexual abuse and keeping themselves safe was ever discussed. At the first CIN meeting it was agreed that the children would be referred to a “Keep Safe18” programme – but this was never actioned. It was only Sibling 4’s Father who put some boundaries in place and stopped all contact for Sibling 4 with Mr W supported by the courts. Early on it was clear that PGF did not take the concerns seriously and did not recognise the risks that his son could pose. This was not addressed in regards to how seriously the whole family took these risks. 3.9 This lack of understanding and/or knowledge of the seriousness of the issue meant that it was not possible for the wider family to ensure that Mr W did not engage in a grooming or coercive manner to the siblings or other children in the family. Indeed, when a Family Group Conference was organised only some members of the family were invited, and no details of the offences were shared. In this context, the family were tasked with creating a safe plan for supervising contact between Mr W and the siblings although they did not have enough information on which to base such a plan. Other children in the family were not included and therefore not safeguarded. 3.10 Finally, there was no discussion, in the context of grooming processes and the use of adult authority, whether it was appropriate for Mr W to attend meetings about his biological children (Siblings 1 and 2) or other children within the household (Siblings 3,4 and 5). The fathers of the other siblings were not asked about this, and Mr W attended many meetings, including the Family Group Conference, where sibling 5 was present. If Mr W was grooming her or coercing her, this put him in an unhelpful position of authority. This risk should have been discussed as part of a much wider safety plan for the children. The absence of a clear approach to sexual offending meant that this did not happen, compounded by the poor decision at the time to cancel the child protection conference and place the children on Child in Need plans. How do we know the issue is underlying? 3.11 Because this Finding concerns the professional knowledge-base in relation to sexual offending and sexual abuse it is one that is highly likely to occur across other casework that has a similar profile. At best, in the absence of any framework or practice guidance, it makes good practice reliant on the knowledge and experience of individual professionals, particularly the social workers that lead the multi-agency work at statutory level. How widespread is the issue? 3.12 There is an absence of advice, guidance, tools or framework for the multi-agency child protection network nationally, so it is likely that this issue will be replicated more widely 18 Specialist group work programme Page 24 of 40 than Wiltshire. It is not specifically addressed in Working Together 2015iii and only Essex and London19 LSCBs have produced practice guidance in England. This appears to have left child protection professionals aware that those who download sexual abuse images pose significant risks to children, but often unclear about how to assess the risk these adults pose; how to assess whether another adult/parent is able to protect children and how best to ensure children are not groomed. 3.13 There are specialist assessment frameworks that have been developed, but these have not been integrated into mainstream safeguarding practice. Any assessment needs to take into account the work of Finkelhor (2008iv). Finkelhor’s theory suggests that there are four factors that need to be met for someone to sexual abuse children. These are: • the motivation to abuse a child – and that is often described as a sexual interest in children; • the overcoming of internal inhibitions against acting on that motivation; the downloading images of child abuse is considered to be a way of reinforcing cognitive distortions about the sexual abuse of children. (Some other theorists think that viewing these images might reduce the likelihood of offending because they are a way for adults to control these urges). • Overcoming external barriers and finding a way to come into contact with children in circumstances where they are not appropriately supervised, where children are vulnerable because of their circumstances and where other adults are unable or unwilling to intervene to protect a child. Recent research has suggested that there is a strong link between child neglect and sexual abuse for this reason. This is why assessing the ongoing capacity of any adult responsible for keeping children safe is imperative. • Overcoming the resistance of the child. Sexual offenders target vulnerable children and are practiced at being able to abuse a child through grooming processes which may employ adult authority, coercion and control. That is why limiting access to children is important and why professionals must be aware of not supporting behaviours which reinforce adult authority, such as attendance at key meetings about children or being given tasks in plans which enable the likely perpetrator to display adult authority. 3.14 Finkelhorv suggests that all four pre-conditions need to be met before a perpetrator will abuse children and that understanding and assessment of all four areas is important in understanding risk and harm. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.15 Assessments deal with the potential for harm/safety posed by individuals, not just what can be evidenced as fact. Doing them well involves gathering what information is available from 19 http://dera.ioe.ac.uk/2028/1/final_cads_guidelines.pdf Page 25 of 40 different sources, both within the multi-agency professional network and from family members, then assessing what picture that information is painting of the individual concerned. Judgements are made, not so much on the basis of harmful behaviours that are known, but the probability that harmful behaviours will occur. Current debates within the child protection arena have focused on whether downloading abusive images will lead to offenders sexually abusing children. The research is not clear, but work by CEOP suggests that there is a clear correlation between downloading sexual abuse images and sexual offending against children; although a clear causal pathway cannot be established. The research suggests that it is important to assess the risk that each individual poses, with the presumption that each is a potential sexual abuser, but professionals are not well enough supported at the moment to be able to do that with confidence. Finding 2: The absence of a clear framework for when interviews with children take place outside of the established Achieving Best Evidence (ABE)vi process, alongside the pressures to balance the requirements of evidence gathering with the need for child sensitive approaches, can lead to inconsistency and unclear interview approaches. Introduction 3.16 The central purpose of any child protection inquiry is to discover whether children have been harmed, in what way and by whom. This is achieved through comprehensive assessments and analysis of a child’s circumstances which includes talking to children, parents, wider family members and other professionals. Interviewing children is an essential part of this process. Finding 1: The exponential increase in the number of men who view online child sexual abuse images is not matched by the development of knowledge of best professional practice leaving professionals uncertain how to respond and children at continued risk of harm. The downloading of images of children being sexually abused is a serious and growing problem. The absence of appropriate guidance, assessment tools and a professional workforce who lack knowledge of the best way to work with this threat leaves children at risk of harm. Questions for the Board • Do the Board recognise that this is an issue that needs addressing? How big an issue might it be for Wiltshire? • What immediate action needs taking to address the gap in knowledge across most of the multi-professional network? • What expertise can the Board access to address this Finding? • How will the Board know it has been successful? Page 26 of 40 3.17 Local and national guidance makes it clear that children must be offered an opportunity to be interviewed sensitively and enabled to “tell their story” as well as disclose concerns and harm. This process is not easy for children and research by the Office of the Children’s Commissionervii suggests that as few as one in eight victims of child sexual abuse come to the attention of professionals and many victims wait until adulthood before being able to tell someone about their experiences. Research by the NSPCCviii suggests that this is not because the children do not seek help, but because they are often not heard, not believed, or adults do not notice the behavioural signs that indicate something is going on for them. 3.18 Where there is a strong suspicion that a crime has been committed these interviews will be visually recorded and undertaken by specially trained police officers and social workers under the Achieving Best Evidence in Criminal Proceedings Guidance20. This guidance provides a structured approach to interviewing. Serious thought is given to the appropriateness of using this very formal process, as it may be difficult for children. However, good practice suggests that regardless of the process of the interview, they must be planned carefully, the individual needs of the children taken into account, and the support they need provided. The Achieving Best Evidence Interview Framework is a useful guide to any type of disclosure interview, providing a framework which is mirrored in most good practice guidance about conducting direct work with children. 3.19 It is also essential that interviews are sensitively recorded, and that records provide information about the focus of the interviews, barriers to success, what was asked and what children actually said, using their own words. Accurate recording is necessary as the information might be used in criminal proceedings or as part of legal proceedings regarding where a child will live and with whom, and is part of a process. Children may be interviewed on more than one occasion, and it is important that professionals are aware of what was said in previous interviews in order to build trust and rapport with a child. 3.20 During interviews with children professionals need to balance the rules and requirements of evidence gathering, which requires thought about questions to be asked and who might be involved, with the need to ensure that the interviews are child centred and enabling of children’s disclosures. This is tricky to achieve, which is why a clearly planned and structured approach making best use of those people who know the developmental needs of the children is necessary. 20 This Guidance describes good practice in interviewing vulnerable and intimidated witnesses, both adults and children, in order to enable them to give their best evidence in criminal proceedings. http://lx.iriss.org.uk/sites/default/files/resources/066.%20Achieving%20Best%20Evidence%20-%20Guidance%20Vol%201.pdf Page 27 of 40 How did the issue manifest itself in this case? 3.21 The five siblings were subject to child protection inquiries on two occasions. At the start of the first inquiry there were significant concerns that the siblings may have been sexually abused or been involved in watching inappropriate and indecent images of other children being abused. Appropriately, interviews were agreed. It was decided initially that it would not be appropriate to subject the children to the formal ABE process, and that this would happen if they made any disclosures of harm. 3.22 For the four oldest children, these interviews took place at school. The schools knew the children well and had long term concerns about their vulnerability and wellbeing. The expertise of the schools should have been used to plan the interviews. It is hard to know how the interviews were planned, how the developmental needs of the children were to be addressed, what was asked of them and what they said, as the recording of the whole Section 47 child protection inquiry was superficial and this information was not included. It is clear that the school were concerned that the interview process was unsettling and upsetting for the children; it would have been expected that there would have been a conversation with key school staff before the interview to plan appropriately, and after the interview so that the school staff could support the children. 3.23 The interviews were not undertaken in an optimal or planned way, and it is of concern that this led to the view that because the children had made no disclosures, that no abuse had occurred. This view was confirmed in the closing summary by SW2. This put too much responsibility on the children, given that there were other concerns about Mr W’s and Mother’s attitude and denial, and also over time there were behavioural indicators that suggested that all was not well. There was little reflection or analysis of the possibility that during a brief, unstructured interview with a stranger, that these young and vulnerable children may not be able to say if any harm was occurring to them, either because of their developmental needs or through a process of grooming and coercion. How do we know it is underlying? 3.24 Any interviewing of children that is not done under the formal ABE structure is subject to differ in style and rigour according to team practices at any given time – or in other words, becomes ‘the way we do it here’. There is always the possibility that practice in these circumstances will be good but it was not at the time of this review, which has found no persuasive evidence that practice now would be particularly different to practice then. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.25 Children need professionals to provide the best opportunity for them to be able to talk about any abuse they have experienced, in order that those professionals can form a view that is drawn from a child’s ‘lived experience’ as to the degree to which it is harmful for Page 28 of 40 them to remain at home, with support or at all. There is a human tendency for all professionals to be swayed by information provided by adult parents (see Finding 4). There are many reasons for this, including the more extreme scenarios whereby the parent is particularly adept at manoeuvring around professionals and/or because the professional over-empathizes with the position the adult parent is in. Only a child will know how they feel; for assessments to be able to work effectively with them in their family context, that child needs to be supported to communicate safely in whatever way comes most naturally to them. Finding 2: The absence of a clear framework for when interviews with children take place outside of the established ABE process, alongside the pressures to balance the requirements of evidence gathering with the need for child sensitive approaches, can lead to inconsistency and unclear interview approaches. It is essential that all professionals feel able to talk to children about safeguarding issues and that this happens in a clear and child focused manner. Currently training is provided to Professionals conducting ABE interviews, which provides them with a clear framework and support before they are able to interview children in this setting. Those trained in ABE techniques are usually only a proportion of the numbers of practitioners who may need to talk to children about their living situation at any given time. The ABE rigour does not apply in these situations, making non-ABE interviewing vulnerable to individual style and shortcuts. Questions for the Board • How confident are Board members that practitioners tasked with communicating with children have the necessary skills to do so? • What kind of support might be most effective and who needs it most? • How might those who have received ABE training support those in their organisation (and beyond) who have not; is there scope to capacity build locally? Finding 3: Appropriate routine professional challenge and the use of escalation processes is insufficiently embedded in the multi-agency network in Wiltshire, leaving differences in professional opinion unaddressed and causing feelings of “learned helplessness” which in turn makes resolution less likely. This undermines the safety and wellbeing of children and does not support action to address concerns. Introduction 3.26 This Finding is about the way in which professionals who work across the safeguarding continuum are able to manage and resolve professional differences and disagreements. These disagreements and differences are inevitable given the complexity of the territory to Page 29 of 40 be navigated, the propensity for human bias and fixed thinking alongside the influence of working with a small minority of adults who may have reasons to manipulate and distort the truth. Establishing a culture of openness to change, to constructive challenge and self-criticism is fundamental to addressing these issues. Reder and Duncan (1999)ix, as a result of their review of Serious Case Reviews nearly twenty years ago, argue that front-line staff need to develop ‘a dialectic mind set’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. 3.27 If these inevitable disagreements cannot be resolved professionals can become helpless and de-skilled. Learned helplessnessx is a psychological concept which describes a process or state of mind whereby an individual’s previous experience of unexpected failure, or failure which makes no sense, has a negative effect on future decision making and beliefs about success which can cause paralysis and uncertainty. Essentially, individuals can feel like they can exert little or no control over their own environment or the decisions or actions of others despite knowing that something different needs to be done. When this is unaddressed it can lead to feelings of helplessness and failure, and reduces people’s confidence and belief in their ability in their role and task. How did the issue manifest itself in this case? 3.28 In September 2014 at the very start of this review a number of different agencies were involved in the original strategy meeting regarding the threat of sexual abuse that Mr W might pose. This meeting agreed that the children were at risk of significant harm and that it was appropriate for there to be a multi-agency Initial Child Protection Conference to consider those risks and plan for them. However, as a result of the assessment carried out by CSC a decision was made by CSC alone that the conference would be cancelled and the children would receive a Child in Need service. This happened without any discussion with any other agency and without taking account of their concerns regarding the children. The police and schools appropriately challenged this decision but this challenge was limited and not pursued. 3.29 Over the next 13 months there were numerous occasions when there were disagreements about the nature of the risks facing the children across the multi-agency network. There was little routine discussion of them and they remain unresolved. The school attended by Sibling 2 did not consider that the issue of Siblings 2’s nit infestation and Mothers lack of action was ever taken seriously enough; this was raised with social workers, but never resolved. School 2 were concerned about Sibling 5 and Mother’s physical and emotional abuse to her as they saw it, but this was never adequately addressed. 3.30 In all these situations, the agencies were frustrated and concerned on behalf of the children and although they voiced those concerns over time, nothing changed. Contact was made with the Assistant Team Manager to attempt to resolve the difficulties over time, but this Page 30 of 40 also made no difference. No agency used the Wiltshire Safeguarding Children Board Escalation Policy21 and all agencies felt a sense of helplessness regarding what they could do and felt their own understanding of the children’s circumstances was undermined. Each of the schools were unhappy with regard to the children’s safety and wellbeing but could find no way of getting their individual voices heard. 3.31 The Wiltshire Safeguarding Children Board has a framework for resolving disagreements and this emphasises that the interests of children must take precedence over a professional stalemate. This did not happen in this case; partly because all agencies were not aware of the processes in place to resolve disagreements, but also because over time their confidence in their own analysis of the children’s needs and circumstances was eroded when they tried to advocate on the children’s behalf. Routine attempts through discussion and debate were tried and failed, and no one professional was able to step back and point out that when considering the needs of the children where there are such variances in the understanding of children, as there was in this case, it is likely that no one agency individually or collectively understood the needs of the child/ren or the risks they faced. This required a complex case meeting or process. How do we know it is an underlying issue and not something unique to this case? 3.32 Locally, the Case Group recognised that there were many occasions where disagreements regarding children existed, but where it was not possible to resolve them. There was a lack of awareness of the WSCB escalation processes. How prevalent and widespread is this issue? 3.33 This is an issue which has been recognised nationally as of concern, from the collective review of Serious Case Reviews by Reder and Duncan in 1999xi, to the most recent Triennial Review of SCRs (Brandon et al, 2016xii). It was an issue in the Victoria Climbie Inquiry and also the Munro Review of Child Protectionxiii. It is particularly likely to surface when, and if, practitioners feel under more pressure than usual or when there are weaknesses in the quality of case oversight. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.34 Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in rapidly evolving, often hostile and highly stressful contexts. The single most important factor in minimising errors is to admit that you might be wrong (Munro 1999xiv) and be willing, encouraged and supported to challenge, and where necessary revise views throughout the period of any intervention. The ease with which different people feel that they can 21 http://wiltshirescb.org.uk/wp-content/uploads/2016/10/WSCB_Escalation_Policy.pdf Page 31 of 40 challenge and/or be challenged reflects the culture of the organisation and the degree to which the interests of children are at the forefront of multi-agency work. 3.35 Where there are professional disputes regarding a child’s circumstances there are dangers that professionals can become polarized and alliances form between some of those professionals and the parents against the multi-agency group. This can look and feel like support to vulnerable and disadvantaged people, but can mask collusion and active processes to divide professionals. Finding 3: Appropriate routine professional challenge and the use of escalation processes is insufficiently embedded in the multi-agency network in Wiltshire, leaving differences in professional opinion unaddressed and causing feelings of “learned helplessness” which in turn makes resolution less likely. This undermines the safety and wellbeing of children and does not support action to address concerns. There were differences of views about the family and Mother’s approach that were expressed at the time but never escalated beyond an initial challenge. The absence of reflection or analysis as a practice norm at the time meant that there was no place to explore and therefore understand these different views in the context of the children’s needs or whether Mother’s approach was really an active strategy to divide people. Questions for the Board • How confident is the Board that practitioners and managers across the county are aware of and understand the WSCB Escalation Policy? • What more, if anything, could be done to improve the reach of the WSCB? • How might the WSCB and its member agencies develop the kind of organisational culture across Wiltshire that welcomes and facilitates professional debate and difference? • How might the WSCB monitor the effectiveness of culture change? Finding 4: There is a tendency for professionals to uncritically accept what adults tell them about their children in the mistaken belief that this is “working in partnership”, resulting in an inaccurate description of children’s needs and circumstances which are left unaddressed as a result. Introduction 3.36 It is essential that all professionals working with children and their families do so in a respectful and open way. This is the cornerstone of partnership practice as embedded in the Children Act 1989xv and subsequent guidance and legislation. Partnership means Page 32 of 40 developing effective relationshipsxvi with families, communicating effectively and clearly and ensuring fairness. Professionals take these responsibilities seriously and there is good evidence that working in this way improves outcomes for children. It is important not to just take what parents or carers say at face value when they are asked about the possible abuse of children. 3.37 The Munro Reviewxvii commented that adults in this situation have a number of motives for not always providing a full picture of their or their children’s circumstances. The task of professionals where there are concerns about children is to remain in a position of “respectful uncertainty” and display “healthy scepticism”. This means routinely checking the validity of information provided by parents/adults by cross referencing and triangulating with other sources and testing out the level of parental care and concern for children and the extent to which parents feel a sense of responsibility for their children and their well-being. This did not always happen for the five siblings under review. How did the issue manifest itself in this case? 3.38 There were many occasions throughout the period under review when both Mother and Mr W made assertions about the children and what they had done as a consequence which were recorded as fact without checking. The issue of Sibling 2’s nit infestation was discussed with Mother by the school on many occasions and Mother was given considerable support to take action. Mother reported that she had taken Sibling 2 to the GP who had told her that Sibling 2 was allergic to the nit treatment and she cited this as the reason why the problem was so acute and why she could do nothing about it. This was reported to the social worker during the assessment in September 2014 and discussed during the CIN meetings. Mother’s account was never cross-checked with the GP; none of the children actually saw the GP during this time. This meant that Mother’s lack of action to address this serious issue was never addressed. 3.39 Mother also provided information about the YP1 who was living in the family home. She said, during the assessment process, that the police had checked his circumstances. This was not true. Mother explained why YP1 was living at the family home and this was accepted without comment. It remains unclear what YP1’s circumstances were because Mother’s explanation was accepted without comment or critique. This meant that vulnerabilities were not known, he was never spoken to and his wellbeing was not assured. 3.40 During the first CIN meeting in September 2014 Mother was asked to outline the circumstances of each child. Her report of the children contrasted with that of the professional’s present but this was not commented upon at the time and there was no analysis of what the gap between Mother’s self-report and professional knowledge might mean for the outcomes for each child. For example, during this meeting the issue of the possible young caring responsibilities of Sibling 5 were discussed and Mother reported that Sibling 5 was happy to take these on and that there were benefits for her regarding this. Page 33 of 40 This was not the view of all of the professionals and the lack of discussion meant that no view was formed within the CIN process about this or action agreed. How do we know it is an underlying issue and not something unique to this case? 3.41 Through conversations with the professionals and Case Group it became clear that a norm has developed of recording what parents say without professional critique or analysis. The parents view then becomes the accepted view without challenge. How prevalent and widespread is it? 3.42 Because this has been verified by practitioners involved in the case as a practice norm it is likely to be occurring regularly and to be a feature of any group meetings where parents are present and the nature of abusive behaviour is not clear. Other factors will make it more or less likely, such as the quality of case supervision, the organisational culture (see Finding 3), the knowledge and experience of practitioners and the degree to which they feel under pressure to move the process forward. 3.43 The tendency for professionals to give too much credence to what parents say, because this feels like working in partnership, is an issue that has been noted nationally in the SCR biennial/triennial reviews (Brandon et al 2016xviii) and was something raised in the Munro Review of Child Protection 2011xix. Munro’s latest work, Improving Child Safetyxx highlights the central importance of professional deliberation in order to determine the nature of the issue and the kind of intervention that stands the best chance of addressing it effectively. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.44 It is much safer for children, young people and their families if challenge of what is reported by parents is built into processes such as supervision and decision making, but also into cultural expectations which recognise that asking questions and seeking explanation from parents is something to be valued. A high reliance by professionals on self-report by parents brings with it significant risks of proceeding on false information. 3.45 Arrangements put in place to recognise when there is insufficient challenge, and to increase the value given to challenge, are in the interests of families and professionals. Such arrangements can include ensuring time for in depth supervision, ensuring an independent uninvolved voice at key decision-making meetings, managers modelling that challenge is acceptable, and showing how it can be done in a constructive way so that workers have more confidence in challenging parents. Page 34 of 40 Finding 4: There is a tendency for professionals to uncritically accept what adults tell them about their children in the mistaken belief that this is “working in partnership”, resulting in an inaccurate description of children’s needs and circumstances which are left unaddressed as a result This finding highlights what happens when the requirement to ‘work’ with families loses its meaning. This is not to underestimate how difficult it is for a professional to build a relationship with a parent or anyone in a caring role that is supportive and appropriately challenging, particularly when that parent or carer is resistant to professional intervention in the first place. Questions for the Board • Is there a collective view at the Board about the prevalence of this issue and the scale of change needed around challenge with families? • Is enough known about the perspectives of the workforce on this issue? Is there a view that to challenge parents is to be judgemental? • How could the Board promote a culture where professionals are supported to be challenging when necessary? • Is there clarity about when assessments can and should be shared with multi-agency colleagues? Finding 5: The lack of an effective practice framework for working with neglect in Wiltshire has left professionals deskilled in their response, and inconsistent in how they explicitly name child and adolescent “neglect”. Introduction 3.46 It is essential that professionals are equipped to recognise, assess and intervene effectively regarding child neglect. This requires a focus on the quality of care provided across the developmental domains of physical care, health, education, supervision and safety as well as emotional care, including the development of a moral compass and pro-social behaviour. 3.47 Gaps in the care provided in all these areas should be considered as “global” neglect and requiring serious attention. Understanding which areas of a young person’s life are most affected provides both a pathway to appropriate interventions and protective activities, and may also help to understand current complex and difficult behaviour. 3.48 Alongside a detailed understanding of the quality of care across the developmental domains, it is also essential that professionals assess parental attitude. Neglect is often assumed to be an act of omission with parents /caregivers struggling to provide effective care because of their own impoverished and deprived circumstances. This is very often the Page 35 of 40 case and this knowledge provides a pathway to appropriate support and intervention. However, for some parents or caregivers neglect is an act of commission; they take no responsibility for the quality of care they provide and are often hostile or dismissive to advice or interventions. These parents do not agree with professionals’ concerns and do not engage in services designed to improve their children’s circumstances. These render those services ineffective and require robust challenge. 3.49 Underlying all of this is the importance of trying to establish why parents and caregivers neglect their children and, having established this, attention needs to focus on addressing those primal issues, rather than only dealing with the consequences such as addressing poor physical living standards. If the primary cause is not assessed and addressed, the pattern will continue. Finally, it is important that professionals consider what other abuse runs alongside the neglect of children. There is now a clearly established link between child neglect and the possibility of intra-familial sexual abuse and sexual exploitation. Where children’s needs are not addressed they are vulnerable to these kinds of risks. How did the issue manifest itself in this case? 3.50 There had been long term concerns regarding the neglect of these children spanning many years and from when the younger children were born. The initial strategy meeting noted that there were likely significant concerns about neglect. This was confirmed when the home was visited as part of the initial child protection inquiries. However, an assessment or an analysis of child neglect was not included in either the subsequent child protection inquiries or the full assessment that was completed at this time. Over time the overall concept of child neglect was never explicitly discussed or recorded, despite the myriad of examples that these children were being neglected. 3.51 There appeared to be a reluctance across the professional network to name “neglect” as an issue. It was striking that in the CIN meeting held in December 2014, the wellbeing of Sibling 4 was said to have improved considerably as a result of moving to his Father’s care some 8 weeks earlier. There was no discussion about why this might be the case, and what the implications were for the care of the other four siblings. 3.52 In October 2014 SW3 visited the family home and found it to be in a very poor state of repair and the children were described as looking uncared for. There was evidence of young people using the home for a party and young people asleep on the couch. Concern was expressed, but this was not described as part of a pattern of neglectful care for these children and no action was taken. 3.53 Over time each school attended by the children had concerns about the quality of care they were receiving and the impact that this was having on both their ability to engage fully with school, and their overall wellbeing. The schools were also aware that Mother was often Page 36 of 40 dismissive of the concerns and their impact on the children and took none of the advice given. This was all important information as a picture of neglect, but when these issues were shared with CSC the focus was on the presenting problem in the main, as opposed to a holistic picture and analysis of neglect. 3.54 Finally, both Sibling 4 and 5 were said to have “young caring” responsibilities and there was a proposal that a referral be made to a young carers group. There was never any discussion or analysis of whether these responsibilities were appropriate, and whether they indicated concern about the neglect that Sibling 4 and 5 were experiencing. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.55 There is significant recognition across practice, policy and research networks of the serious negative impact of long term neglect on children’s wellbeing and outcomes across the developmental lifespan into their future as adults. If there are ineffective identification processes, assessment frameworks, tools and interventions to address neglect, it will not be possible to meet the needs of children in the short or medium term and professionals will not be able to break the long cycle of neglect that is often seen from generation to generation. Finding 5: The lack of an effective practice framework for working with neglect in Wiltshire has left professionals deskilled in their response and inconsistent in how they explicitly name child and adolescent “neglect” Neglect is arguably the most difficult kind of abuse to identify, particularly over time if practitioners are not in the habit of working with the kind of historical as well as current data that might enable patterns to be detected. Because professionals tend to over-focus on symptoms of physical care being less than good – symptoms such as dirty clothing, nits etc. – neglect is also susceptible to being explained away as a consequence of poverty. Sometimes this will be the case and sometimes not. In order to identify where it is not, the evidence building as part of any assessment needs to be transparent and systematic; practitioners need to feel confident and supported in naming neglect as neglect where they deem it to be the case. Questions for the Board • How confident are Board members that practitioners tasked with identifying, assessing and addressing neglect have the necessary skills and tools to do so? • What work has the Board done to evaluate the local response to neglect? • What work does the Board need to undertake to help partner agencies improve practice when working with neglect? • How will the Board know they have been successful? Page 37 of 40 Finding 6: Although there have been changes to the way in which Child in Need processes are delivered in Wiltshire, there appears to be continued evidence that they lack a multi-agency approach and the rigour and focus seen in child protection processes is missing, with the result that there is insufficient analysis of children’s needs. Introduction 3.56 The Children Act 198xxi defines Children in Need (CIN) as those children whose vulnerability is such that they are unlikely to reach or maintain their health and development without the provision of services to them and their families. This is a serious issue for all children. Good quality multi-agency assessments that provide a clear analysis of the child’s needs are an essential part of the Child in Need Process; once an assessment has been completed it is expected that a child focused plan will be formulated which addresses those needs and outlines the expected outcomes for the child/ren, services to be provided and the reviewing mechanisms identified. 3.57 These are important formal processes. The aim is to develop plans which improve children’s health and development and which address any challenges to this. CIN plans and meetings were always intended to be multi-agency in approach, amalgamating the analysis of all agencies and developing a plan which addresses the shared concerns. 3.58 Child in Need meetings are intended to be child centred and to be a forum where children are able to contribute and share their perspectives in a supported way. CIN meetings should also fully involve parents or any adult who has a parental role. This involvement needs to be supported; however, boundaries need to be set whereby there are expectations on the behaviour of all present. It is also important to think carefully about whether there are a small number of parents/parent figures who should be asked to contribute to the CIN process in different ways because there are concerns about the way in which they will either disrupt the meetings or use their attendance to impose power and control over adults/children or as a way to groom children. This needs careful thought. 3.59 Clear standards and expectations have been set regarding the process of child protection processes and plans. Although a clear framework exists for best practice in CIN, research suggests that child protection processes can take precedence, particularly at times of high workloads; assessments are single agency and lack analysis; there are unclear goals and outcomes and there are unclear review processes. This was the case here. How did the issue manifest itself in this case? 3.60 It was agreed in September 2014 that the five siblings would have CIN plans and that these would need to be “robust” because of the complexity of their circumstances. From the start the individual needs of each child were not clearly delineated, in part because the first Page 38 of 40 assessment was so adult focused. This could have been addressed at the first CIN meeting when the CIN plan was discussed, but again this did not outline the particular circumstances of each child, nor did it provide an analysis of the key issues that the plan was supposed to address. Concerns about neglect, for example, were never articulated and nor was the risk of sexual abuse. These were acknowledged as central concerns at the beginning of the first CIN meeting and never raised again. 3.61 Plans were agreed at this meeting including sorting out a school place for Sibling 1, addressing the chronic nits for Sibling 2 through health action, a referral to a young carers project and a referral for ‘keep safe’ work. These actions were never taken forward and never reviewed as missing. The pattern that developed in the meetings was that there would be general discussions about the “here and now” which were descriptive, rather than analytical and depended on who was present at the meeting. The actions agreed would often drift or get lost and this was not noted because they were not reviewed. In effect, there was no CIN plan - just meetings that discussed the children in general terms. They were not outcome focused and the children’s own perspective was not apparent. 3.62 The lack of an overall “robust” plan for these children was not noted, and although the issue of drift was raised by multi-agency partners and discussed in January 2015 this led to no action. This lack of focus based on children’s needs meant that the work of the multi-agency network was incident focused and issues were addressed as they arose. The absence of goals or outcomes meant that by June 2015, CSC started discussing the need for the CIN plan to be closed. This was in the absence of any real progress. 3.63 Although CIN plans, based on good assessments, are meant to be multi-agency in approach, for these five siblings it was striking the extent to which those agencies who know the children best, were often unaware of or not invited to attend relevant meetings. 3.64 Mr W was invited to all the CIN meetings and there was no discussion about whether this was appropriate in the context of grooming and the use of adult authority discussed in Finding1. Further thought should have been given to this and whether Mr W’s attendance would prevent there being an overall discussion of the issue of sexual offending. It was clear that given the unknown risks in this case that it should have been managed at a child protection level. However, having agreed a CIN plan, it should have been focused on a good analytical understanding of each child’s needs and circumstances, goals should have been set to address these needs and these should have been reviewed over time with action where these goals were not progressed. This did not happen. How do we know it is an underlying issue and not something unique to this case? 3.65 The Review Team and Case group suggested that it had been helpful to reflect on how CIN processes were operating in Wiltshire. They agreed that although there had been changes Page 39 of 40 locally, the issues of the lack of analysis of children’s circumstances within the meetings and variable review of goals set resonated with their experiences in other cases. Why does it matter? What are the implications for the reliability of the multiagency child protection system? 3.66 CIN processes are a core part of the safeguarding continuum. It is essential that they are delivered in effective ways if children are to be safeguarded, their needs met and outcomes improved. If these processes are not effective there is likely to be repeat referrals. 4 Final Thoughts or Conclusion 4.1 The Review of the circumstances of these five siblings has raised concerns regarding the collective and cumulative impact that resource pressures can have on the delivery of services. These pressures led here to poor assessments, drift and delay in implementing plans, significantly delayed criminal processes and a lack of a consistent approach to the link between the children’s health needs caused by neglect and the child in need (CIN) processes. It is important that the Safeguarding Children Board is confident that they are made aware of these pressures when they occur and the possible implications for the wellbeing of children. Finding 6: Although there have been changes to the way in which Child in Need processes are delivered in Wiltshire there appears to be continued evidence that they lack the rigour and focus seen in child protection processes, with the result that there is insufficient analysis of children’s needs and plans which are incident-led and not focused on addressing the concerns they were tasked with. Child in Need meetings are an important part of the multi-agency protective system, ensuring that children whose development and wellbeing is likely to be impaired receive services which address clearly those needs. If they lack rigour or focus children’s outcomes are likely be compromised. Questions for the Board • Does the Board have sufficient knowledge of how well Child in Need processes are working locally? • Does the Board know the extent to which CIN processes have been embedded in all agencies practice and are truly multi-agency in approach? • Are the Board aware of factors that prevent CIN processes from being multi-agency and what can they do to address this? • Are the Board aware that there is confusion about whether the single assessment, which forms the basis of the CIN plan, are not always shared with agencies? • How will the Board be able to measure any improvements in practice and outcomes for children? Page 40 of 40 i Department for Education (2015) Working Together to Safeguard Children ii Calder, M (2009) Sexual Abuse Assessments: Russel House Publishing iii DfE (2015) Working Together to Safeguard Children: https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 iv Finkelhor, D. Childhood Victimization: Violence, Crime and Abuse in the Lives of Young People. Oxford University Press, 2008. v Ibid vi The Memorandum of Good Practice on Video Recorded Interviews with Child Witnesses for Criminal Proceedings. The Home Office and The Department of Health,1992. Achieving Best Evidence in Criminal Proceedings: Guidance for Vulnerable or Intimidated Witnesses, Including Children. The Crown Prosecution Service, 2001. vii Horvath, M.A.H., Davidson, J.C., Grove-Hills, J., Gekoski, A. and Choak, C. (2014). “It’s a lonely journey” A Rapid Evidence Assessment on intrafamilial child sexual abuse. London: Office of the Children’s Commissioner viii Alnock, D and Miller, P (2013) No one noticed, no one heard: A study of disclosures of childhood abuse: NSPCC. https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/no-one-noticed-no-one-heard ix Reder, P and Duncan, S (1999) Lost Innocents: A Follow-up Study of Fatal Child Abuse: Routledge x Peterson, C., Maier, S.F., & Seligman, M.E. (1995). Learned Helplessness: A Theory for the Age of Personal Control. New York: Oxford University Press. xi Reder, P and Duncan, S (1999) Lost Innocents: A Follow-up Study of Fatal Child Abuse: Routledge xii Sidebotham, P., Brandon, M., Bailey, S., Belderson, P., Dodsworth, J., Garstang, J., Harrison, E., Retzer, A. and Sorensen, P. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: final report. [London]: Department for Education. xiii Munro, E. (2010), The Munro Review of Child Protection – Part One: A Systems Analysis, London: Department for Education. xiv Munro, E. (1999) ‘Common errors of reasoning in child protection work’, Child abuse and neglect, 23, 8, 745–758. xv http://www.legislation.gov.uk/ukpga/1989/41/contents xvi Munro, E. (2010), The Munro Review of Child Protection – Part One: A Systems Analysis, London: Department for Education. xvii Munro, E. (2010), The Munro Review of Child Protection – Part One: A Systems Analysis, London: Department for Education. xviii Munro, E. (2010), The Munro Review of Child Protection – Part One: A Systems Analysis, London: Department for Education. xix Munro, E. (2011), The Munro Review of Child Protection –A Child Centred System, London: Department for Education. xx Munro et al, (2016) Improving Child Safety: deliberation, judgement and empirical research xxi http://www.legislation.gov.uk/ukpga/1989/41/contents |
NC52384 | Significant neglect of two siblings, including neglect of their physical, emotional, social developmental, health and medical needs. Both children had been the subject of child in need plans since October 2016 and child protection plans under the category of neglect since June 2017. Alcohol use and abuse were present in this family but was not identified as a risk factor and addressed. Ethnicity or nationality of family not stated. Learning includes: at times, the focus was on the adults rather than the lived experiences of the children; information sharing within and between agencies was not always consistent; over-optimism about the likelihood of the adult carers improving their care of the children; a lack of challenge to adult family members which led to gaps in information. Identifies good practice, including: direct work carried out by the school nurse, which allowed the child's voice to be heard and shared; recognition by dentist that one of the children's decayed teeth and bleeding gums were indicative of neglect. Recommendations: highlights the improved outcomes that have been identified and should be addressed, including: multi-agency partners can evidence a shared responsibility for the safeguarding and protection of children; multi-agency assessments, risk assessments and effective safety plans are secured and monitored within the child protection conference process, to ensure the best outcomes for children; amending the pathway for capacity assessments of carers with learning difficulties so that they can be undertaken at an earlier stage.
| Title: Serious case review in respect of Family W: executive summary. LSCB: West Sussex Safeguarding Children Partnership Author: Glenys Johnston Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. West Sussex Safeguarding Children Partnership Serious Case Review in respect of Family W Executive Summary FINAL CONFIDENTIAL 20th January 2020 Glenys Johnston OBE Director Octavia Associates Ltd Contents Section Subject Page 1 Background to this Serious Case Review 1 2 The views of the family 1 3 Good Practice 2 4 Conclusions 2 5 Recommendations and learning outcomes 4 Appendix 1 The review process 6 Page | 1 1. Background to this Serious Case Review 1.1 This Serious Case Review concerns two children who experienced life-long difficulties due to the care given to them by their family and the lack of effective intervention by professionals. 1.2 Both children had been the subject of child in need plans since October 2016 and child protection plans under the category of neglect since June 2017, the latter covering the 14- month period prior to the incident that led to this review. 1.3 On 15th April 2019, following a Rapid Review, Lesley Walker, the Independent Chair of the then West Sussex Safeguarding Children Board, from September 2019, the West Sussex Safeguarding Partnership, decided the criteria for a Serious Case Review were met and commissioned a multi-agency review. 2. The views of the family 2.1 West Sussex Safeguarding Partnership is grateful to the family members who accepted an invitation to share their views and experiences with the Independent Reviewer. 2.2 In summary their concerns were; • that they were given insufficient early help to support their parenting of their children; • they found the information, reports and plans that were shared with them at meetings and in writing were not in a language or format they could read and understand; • the frequent changes of social worker were particularly unhelpful in establishing trusting relationships; and • they felt they had been given the impression that the plan was for the children to remain in their care. Information on the Serious Case Review Process is attached at Appendix 1. Page | 2 3. Good Practice 3.1 In seeking to support the needs of the children and improve their care, professionals worked hard to explore the capacity and commitment of the carers and provide agency support and resources, there were examples of good practice: • When the children were subject to child in need planning, timely cognitive assessments of the parents resulted in an agreed PAMs assessment. • The Children’s Social Care practice manager recognised that the allocated worker was not managing the case appropriately and took remedial action by allocating an advanced practitioner to support the existing more inexperienced worker. • The advanced practitioner sought advice from one of the children’s schools about how best to communicate with the child and liaised with Lifelong Services, although at the time, the family did not meet the criteria for a referral to the team, a support worker was allocated to support the child and her family. • The recognition that one of the children’s decayed teeth and bleeding gums were indicative of neglect, the observations that the adults attending the dental surgery were carrying or had consumed alcohol, together with their lack of supervision of the child whilst in the surgery, led to the dentist making a safeguarding referral, this was very good practice. • Referrals were made for one of the parents to have advocacy support and support from the Learning Disability Team which was provided through an adult’s social worker. The advocate was a good source of support, both to aide her understanding and to assist professionals in providing information in a more accessible format. • One of the children was sometimes seen alone, and their wishes and feelings explored with some good direct work, although this was not consistent. The school nurse was clearly able to engage the child and did some very good direct work, as evidenced in her reports to child protection conferences. • The work completed by the Child and Family Intervention service included direct contact with the children and the workers’ case recordings gave a good picture of the children’s experiences. Whenever the worker encountered concerns, the allocated social worker was notified. • The Child and Family Intervention service accessed advice from a psychologist to meet one of the family members to offer advice on how best to work with them and supported intervention, undertaking visits outside of office hours and completing the comprehensive assessment. • A nurse provided easy read documents to the family to ensure they understood how to care for one of the children. • Although outside the scope of this review the support given by one of the children’s schools to support the child’s move to foster care was exceptional and made it much easier for them. 4. Conclusion 4.1 Despite the fact that the family loved the children very much the children in this case they suffered significant physical and emotional neglect for all of their lives, one of the children was often dirty and unkempt, lacked stimulation and proper medical care and did not make the physical and developmental progress that could have been made, they suffered distressing physical condition and discomfort which was not relieved. 4.2 One of the children was able to talk about what life was like, but professionals did not always pick up on the messages and use their professional curiosity to explore them and Page | 3 sometimes his wishes were overlooked. For a long time, the child suffered pain and discomfort in relation to a problem which took too long to address. The child was at times fearful and anxious but despite this was mature, loyal, protective and supportive to their family 4.3 The impact of this neglect has far reaching consequences for both the children. 4.4 These children were not “invisible” to services; they and the adults in their lives were well known to universal services including mental health, some of them to the police and probation and the children went to nursery and then to school; the involvement of early help when the children were very young would have been particularly helpful and may have led to an earlier recognition of the difficulties. 4.5 The issue of alcohol use and abuse runs through this family but was never identified as a risk factor and addressed. 4.6 Cases of neglect are recognised as particularly challenging for professionals, despite the obvious manifestations of neglect in this family there were no clear incidents of physical harm, the adult carers loved the children very much and the children always appeared to professionals to be happy, some professionals described similar situations differently, reaching a shared view as to whether the care given was good enough was difficult. 4.7 Working with neglect can be frustrating for professionals, progress can be slow with no quick solutions and often differences of opinion as to whether the care provided is good enough. Neglectful families can be chaotic and difficult to access, especially if there is resistance to professional scrutiny, as in this case. 4.8 In this case agencies were very mindful of the needs and difficulties of the adult carers and wanted to give them the best opportunity to look after the children, especially as they were very vocal in their love and determination to raise them but reaching a conclusion as to whether the adults had the capacity to care for the children was never properly assessed. 4.9 At times the focus was on the adults rather than the lived experiences of the children which were often omitted from assessments and analysis and did not contribute to safeguarding plans. Assessments, though often delayed, were undertaken but plans were not closely monitored which led to significant drift and delay in improvements. 4.10 Staffing difficulties and a lack of experience in Children’s Social Care contributed to the lack of progress which improved markedly when an experienced worker was appointed, and the social work input was increased. 4.11 The sharing of information within and between agencies, especially those not directly involved in the child protection work was not always consistent and although concerns about the children were regularly shared with social workers, concerns about the lack of progress were not formally escalated. There is a sense that assumptions were made that someone else would be doing what needed to be done, without good supervision and closely monitored plans and a culture of respectful professional challenge, drift and delay set in. 4.12 There was over-optimism about the likelihood of the adult carers improving their care of the children and perhaps a lack of understanding as to what the impact of their intellectual capacity was in practice. The challenges in the relationships between the family and professionals made it difficult to engage them effectively and evaluate progress. 4.13 The cumulative harm they experienced was not sufficiently considered in the planning and there was a lack of urgency in responding to risks. Managers, including the child Page | 4 protection adviser, were aware of the concerns, lack of progress made by the family and the impact on the children, but adequate protective measures were not employed while assessments were undertaken. The level of the risks to the children was underplayed. 4.14 The child protection process was helpful in terms of bringing agencies together to review information and risks but the planning to address the concerns was not adequate and the plans were not progressed in a timely way. The mapping documents were lengthy, were not always updated and therefore contained some outdated information. The mapping document did not capture the discussions held in the core group meetings and thus, important information was not recorded. 4.15 There was a lack of challenge to adult family members which led to gaps in information, some family members were intimidating to professionals and were not always open and honest with them. 4.16 As the report mentions, the Graded Care Profile was not adequately used in this case, whilst not the only tool which is recognised as useful in neglect, agreeing and sharing the profile can provide a shared understanding of what life is like for the children, what needs to be addressed, and whether progress is being made. 4.17 There appears to have been little use of chronologies to reflect on patterns of care and intervention and reach a shared view about the care being good enough or not. 4.18 The review has highlighted more areas for improvement than contained in this overview report, individual agencies have been reflective about their contribution and practice and made recommendations to address improvements in the practice of their individual agencies. 4.19 West Sussex has been the subject of recent external scrutiny and improvements in Children’s Social Care are currently being overseen by a Commissioner, appointed by the Department for Education. This review agrees with the findings of the external scrutineers-Ofsted and the Commissioner; it identifies the same systemic failures that were created by the difficulties described in their published reports. The proposed new arrangements for Children’s Social Care will take time to implement and embed, the West Sussex Safeguarding Partnership has a critical role in contributing to improvements in practice across agencies and monitoring risks to children. 5 Recommendations - learning outcomes 5.1 This report recognises that there are comprehensive improvement plans to: review the Safeguarding Partnership; refresh and relaunch the Neglect Strategy which includes a new multi-agency toolkit and tools to assist social worker’s in assessing neglect and a framework that will measure the impact of the work on children and their families. There are also robust action plans for individual agencies, but these are yet to be fully implemented and their impact assessed. 5.2 This section does not provided recommendations for specific actions as these are already covered by existing plans but it highlights the improved outcomes that have been identified specifically from this review and should be addressed by the WSSCP, which may decide they will be achieved by current improvement plans or that plans need to be enhanced to capture them. In addition, two specific issues for consideration are included. 5.3 West Sussex Safeguarding Partnership should ensure that the following learning from this review is addressed by assuring itself or including actions in improvement plans to ensure that: Page | 5 a) Multi-agency partners can evidence a shared responsibility for the safeguarding and protection of children. b) Multi-agency professionals are skilled and confident in carrying out child centred multi-agency assessments and safety planning to ensure children’s safety and the best outcomes for them. c) Multi-agency assessments, risk assessments and effective safety plans are secured and monitored within the child protection conference process, to ensure the best outcomes for children. d) The use of the West Sussex Safeguarding Partnership Escalation policy and procedure is used effectively to address and resolve professional disagreements and add to the learning of the Partnership. 5.4 In addition, the West Sussex Safeguarding Partnership should consider specifically: e) amending the pathway for capacity assessments of carers with learning difficulties so that they can be undertaken at an earlier stage, currently they are not undertaken unless the situation reaches the threshold for level 4 intervention by Children’s Social Care. Glenys Johnston OBE Director of Octavia Associates Ltd Date:20th January 2020 Page | 6 Appendix 1: The Review Process Recent developments Although Working Together 2018 included new guidance in relation to Serious Case Reviews, this review was commissioned before it was statutory and has been undertaken in accordance with Working Together 2015. However, in accordance with the DfE Transition Guidance for 2015-2018 a Rapid Review was first undertaken to determine whether a Serious Case Review would be recommended to the West Sussex Safeguarding Children Board, Independent Chair. On 21st May 2019, the Child Practice Review Panel supported the Independent Chair’s decision to commission a Serious Case Review under the Working Together 2015 criteria. The Serious Case Review process ‘Working Together 2015’ states: ‘Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt, and services improved to reduce the risk of future harm to children’ When a child dies or is seriously harmed, and abuse or neglect are suspected to be a factor, or there are concerns about how organisations or professionals worked together to safeguard the child the West Sussex Safeguarding Children Board has always conducted a review to: • Establish whether there are lessons to be learned from the case about the way professionals and agencies work together to safeguard and promote the welfare of children. • Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result. • Improve inter-agency working to better safeguard and promote the welfare of children. A Serious Case Review enables all the information known to agencies to be seen in one place. This is beneficial to learning but the Serious Case Review Panel recognises that this information may not have been available to individual practitioners during their work. Reviews should avoid hindsight bias and can only evaluate compliance with extant practice. Independent Reviewer West Sussex Safeguarding Children Partnership commissioned an independent social work consultant Glenys Johnston OBE to lead the review and produce this independent overview report. Mrs Johnston is independent of agencies represented on the West Sussex Safeguarding Children Partnership and has extensive experience of chairing safeguarding boards, child protection inspection, audit and Serious Case Reviews. Scope, methodology and key questions The Serious Case Review Panel agreed the following scope, methodology and key questions to be addressed; Page | 7 Scope: The period covered by the review was April 2015-October 2018 with any relevant information outside the time frame, being included in the chronology. Methodology The methodology used for this Serious Case Review combined narrative reports, Individual Management Reviews and a chronology from each agency with a learning event for practitioners and managers involved in the case. Participating agencies were encouraged to apply a systems approach to the review i.e. explore all contributory factors in order to identify changes needed at an organisational level as well as at individual practice level. The key questions to be addressed: • The lived experience and views of the children • What was known about the children’s voices and lived experiences during this period? What consideration was given to any specific communication needs of the children in hearing their voices? • When and how were their wishes and feelings obtained and considered when making decisions about the provision of services? If not, why was this? • What was known about, and what consideration was given to the impact on the children of other adult family members living in the family home and the grandmothers. • The potential for assumptions to be made about adults in and visiting the two households? Was there significant challenge - both interagency and agency to caregivers - regarding this? • The learning difficulties/disabilities (including their literacy and ability to understand what was said and written by professionals); substance or alcohol use; domestic abuse or criminal record of caregivers and the impact this may have on their caring and protective capability? • Were the communication needs of the family understood and assisted and was this information shared with partner agencies who were also working with the family? If not, why was this? • Why were the child protection plans put in place not taken forward? • How was the Graded Care Profile used to track progress in addressing the neglect of the children? • Did the staff implementing the child protection plan have appropriate levels of knowledge, experience and training? • How effective was management oversight and support via supervision? • Were there frequent changes of staff and were caseloads manageable? • During the period covered by the review how effectively did agencies work with other agencies during this period. Page | 8 Participating Agencies and their roles in the review. Agency Panel Member Report author Chair Head of Safeguarding, West Sussex County Council NA Sussex Police Detective Sergeant – Safeguarding Review Team Crime Review Officer West Sussex County Council Early Help Hub System Leader Team Manager-Process West Sussex County Council Education Department Safeguarding in Education Manager Safeguarding in Education Manager Sussex Community NHS Foundation Trust N/A Named Nurse Safeguarding Children Sussex Partnership NHS Foundation Trust N/A Lead Nurse Safeguarding Children West Sussex County Council Children’s Social Care Deputy Head of Children’s Social Care Interim Auditor – Quality Assurance and Practice Improvement Sussex Clinical Commissioning Groups (CCGs) Designated Nurse for Safeguarding Children - Sussex and East Surrey CCGs NA Western Sussex Hospitals NHS Foundation Trust N/A Named Nurse Safeguarding Children The representation and work of Primary Care were covered by the Panel member from the CCG Paediatric Practice Nurse Page | 9 Appendix 2: Bibliography ‘In the child’s time - professional responses to neglect’. Ofsted survey report - March 2014. Department for Education research report ‘Missed opportunities: indicators of neglect – what is ignored, why, and what can be done’? - November 2014. ‘Growing up neglected a multi-agency response to older children’ Ofsted : Joint Targeted Area Inspection Report - July 2018. ‘The Child's World, Third Edition: The Essential Guide to Assessing Vulnerable Children, Young People and their Families’: Jan Horwath (Editor), Dendy Platt (Editor), Danielle Turney (Contributor). - December 2018. ‘The relationship between poverty, child abuse and neglect: an evidence review’ Paul Bywaters, Lisa Bunting, Gavin Davidson, Jennifer Hanratty, Will Mason, Claire McCartan and Nicole Steils. The Joseph Rowntree Foundation- March 2016 |
NC52437 | Murder of a 1-year-old male child in 2021. At the time of his death, the child was in the care of the local authority and was placed with prospective adopters. The female prospective adopter was found guilty of his murder and child cruelty. Learning includes: medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support; the system would be more robust if these assessments were updated at the point of matching and before an adoption order is made; improvements are required regarding seeking, sharing, and considering any adult vulnerabilities that could be a risk to children; adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household; when it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers. Recommendations are embedded in the learning. Additional national recommendations include: the Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review. Makes a number of local recommendations.
| Title: Child safeguarding practice review: Leiland-James Michael Corkill: review report. LSCB: Cumbria Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. FINAL 1 Child Safeguarding Practice Review Leiland-James Michael Corkill REVIEW REPORT Report Author: Nicki Pettitt Contents 1 Introduction to the case Page 1 2 Process Page 2 3 The case being considered Page 2 4 Analysis and identification of learning Page 3 5 Conclusion and Recommendations Page 17 1 Introduction to the case 1.1 This Child Safeguarding Practice Review (CSPR) was undertaken to identify learning for the Safeguarding Partnership by considering the case of a one-year-old child who died in 2021. 1.2 At the time of his death, Leiland-James was in the care of the local authority and was placed with prospective adopters. He had been living with the couple for five months when he died. The female prospective adopter has since been found guilty of his murder and child cruelty. 1.3 Leiland-James was described by those who knew him as an alert and inquisitive child, who was beginning to explore his environment. He was showing signs of a particularly close relationship with the older birth child of the prospective adopters. His eyes would reportedly ‘light up’ when they came home from school, and they would play happily together. 1.4 Following Leiland-James’s death, actions were taken to safeguard the older birth child. They were spoken to by police officers as a potential witness and disclosed use of physical chastisement by the prospective adopters to both children. Other witnesses in the police investigation state that the children were often shouted at, and family members were aware that the prospective adopters used smacking as a punishment, although this was not shared with professionals at any time prior to Leiland-James’s death. FINAL 2 2 Process 2.1 It was agreed that the review would be undertaken using the SILP (Significant Incident Learning Process) methodology, which engages frontline staff and their managers who were involved with the families in question, avoids hindsight bias or individual blame, identifies opportunities for improvement within systems for safeguarding children and promotes good practice. An independent lead reviewer was commissioned to undertake the review1. Due to Covid-19, engagement with professionals was predominantly via video technology, however a face-to-face event was held in September 2021. 2.2 The review has considered in detail the period from the start of the assessment of the prospective adopters until Leiland-James’s death. Detailed case information that is known and was considered will not be disclosed in this report2 unless it is relevant to the learning established during this review. 2.3 The partnership will be sharing the learning from this review with Leiland-James’s mother. The lead reviewer requested meetings with the prospective adopters to potentially identify additional learning from their point of view. They did not respond to this request. 3 Case information 3.1 Leiland-James was the subject of care proceedings and was placed with foster carers following his birth. This was due to significant concerns about the ability of his birth parent/s to care for him. The agreed care plan for Leiland-James was adoption and he was placed with the prospective adopters when he was seven months old3. 3.2 The prospective adopters in this case had been unable to have a second birth child and applied to adopt to increase their family. They underwent an assessment and were approved as adopters in 2019. The match with Leiland-James was made just less than a year later. 3.3 There had been no known concerns about the prospective adopter’s care of their older child. They had used IVF4 to conceive and said that they did not wish to undergo treatment again, due to the financial, physical, and mental health impact. The adoptive mother had said during her assessment to adopt that she had suffered with low mood and anxiety in the past, initially linked to her infertility and then due to her reported tendency to ‘over-think’ and ‘worry.’ Her GP was involved in the assessment of the adopters and stated at the time that there was “no reason or medical conditions that may affect her ability to care for a child”. 3.4 New Covid-19 restrictions were implemented not long after Leiland-James was placed. 4 Analysis and identification of learning 4.1 The rapid review undertaken shortly after Leiland-James’s death outlined the initial learning from this case. This CSPR built on this and will identify additional learning for the systems in Cumbria. It is unusual to be undertaking a review of this type on a child placed for adoption, 1 Nicki Pettitt is an experienced safeguarding professional and lead reviewer who is entirely independent of CSCP and all agencies 2 Statutory Guidance expects full publication of CSPR reports, unless there are serious reasons why this would not be appropriate 3 Both Leiland-James and the prospective adopters are white British. There was no learning identified regarding culture 4 Fertility treatment - In vitro fertilisation FINAL 3 and the impact on the birth family and the professionals of this tragic case has been taken into consideration throughout. Thematic analysis The adoption processes Support and emerging concerns Impact of Covid 19 The adoption processes 4.2 While it is the responsibility of the local authority to assess prospective adopters and to place children in their care for adoption, multi-agency involvement is required in the process. The assessment and approval of the prospective adopters in this case was described by those involved at the time as ‘unremarkable’. The Adoption Assessment followed the Cumbria County Council ‘Assessment and Approvals of Prospective Adopters’ Policy and Procedure. This is closely based on the Department of Education ‘Statutory Guidance on Adoption’ (July 2013). The assessment of the adopters included references, medical information, and police checks. The prospective adopters attended the required training and group sessions. The adoption panel scrutinised the case and recommended that the couple were suitable adopters. They later recommended the match with Leiland-James. Both decisions were considered and agreed by the Agency Decision Maker (ADM) who had no concerns about either the assessment or supporting information. The chair of the adoption panel and the ADM are both independent of the management of the case and attended the practitioner events and reflected that in their opinion the written adoption assessment report (PAR) and the supporting evidence was of good quality and provided what was required for a decision. The written PAR includes strengths and vulnerabilities and fulfils the purpose of providing evidence of the assessment undertaken and concludes whether the couple are suitable adopters. Following Leiland-James’s death there was a thorough audit of the quality of the PAR in this case and learning was identified, particularly regarding areas where there could have been more challenge and exploration of what the adopters reported. This learning will be used in training and auditing activity. 4.3 The Adoption Social Workers analysis of the prospective adopters was that they presented as a “united couple” with a “strong and solid relationship.” This was confirmed by those friends and family members who provided references. Interviews with personal referees for potential adopters are undertaken in face-to-face meetings by the assessing social worker, and written references are also requested and provided. They are specifically asked about any safeguarding concerns. The references included questions about the parent’s relationship with their birth child and specifically asked if they are aware if the prospective adopters use smacking, physical chastisement, or inappropriate discipline. All were positive about the prospective adopters and shared nothing of concern. It was seen as a benefit that the couple had close family and friends living near-by who categorically stated that they would support a placement. 4.4 The CoramBAAF form AH adult health report is an important part of the adoption process. It is requested by the adoption team and is completed at Part A by the prospective adopters and their GP then undertakes a physical medical and completes Part B. The assessment is then returned to the adoption team and is considered by them and by the adoption panel medical advisor. It is then the role of the advisor to give an opinion based on what has been shared by the prospective adopter/s and the GP. There were gaps in the health information shared with FINAL 4 Children’s Services by the prospective adopters during the assessment and again when Leiland-James was placed. This has been found to be a significant learning point in this case. 4.5 At the time of the assessment some issues had emerged in relation to how much alcohol the couple consumed. The ‘Summary Report from the Medical Advisor’ commented that their drinking was above the healthy recommended limit and that this should be explored further by their social worker. The female adopter had stated on her form that she drank two bottles of wine a week and the male adopter had stated that he drank around 10 cans of cider a week, both wrote ‘on and off’ on the handwritten forms. The assessing social worker undertook a further exploration of the couple’s drinking and evidence of the challenge and additional assessment was then included in the PAR. This was acceptable to the adoption panel who approved the adopters and later the match. The social worker concluded that the couple had a ‘healthy and informed approach to alcohol’. However, information which the prospective adopter had shared with First Step5 at the time shows that she was drinking significantly more than this. This was not known by any other agency at the time. (See 4.11 below) 4.6 The female prospective adopter had disclosed a physical health issue6 and said that this was managed with medication. This was confirmed by her GP during the assessment. As the condition can be painful, this was discussed with the prospective adopter by their assessing social worker as living with pain is a vulnerability that professionals working with Leiland-James and with his prospective adopters needed to be aware of and consider. It is now known that the female prospective adopter had historically suffered with juvenile arthritis, which was not shared on the health form and not identified later as the GP recorded “nil” in the musculoskeletal system section of the AH form, so this was unknown by the assessing social worker or the adoption panel medical advisor. The review has found that in this case the GP did not appear to have thoroughly considered the medical records to ensure that they provided independent verification of what the patient reported about their medical history. This was due to not all the information having been received and recorded and the limited time available for the GP to thoroughly complete the medical assessment, leading to a potential risk in the system that important information will be missed7. The review also found that there is a common feeling among GPs (and most professionals) that prospective adopters are likely to be open and honest about their past and current medical issues, and that when there is an older child in the family and no known concerns, this potentially also gives false reassurance. 4.7 The view of the family GP is significant in the adoption assessment, as they are specifically asked on the CoramBAAF form to comment on health and lifestyle issues which may impact on the applicant’s ability to care for a child. In this case the GP had written on the female prospective adopters AH form that there were ‘no reasons or medical conditions that may affect her ability to care for a child.’ This is a clear statement, but the medical advisor could and should challenge this if they believe it is required. The medical advisor to the Cumbria adoption panel has since devised a questionnaire that is being completed by all potential adopters. It asks much more detailed questions about their medical history and medication. While this is helpful to the assessment process and decision making, it must be acknowledged that this relies on the prospective adopters self-recording, and there is still a need for rigorous professional curiosity 5 First Step was part of Cumbria Partnership Foundation Trust, providing free talking therapies to adults, at the time the service was accessed by the adopter 6 Swollen intercostal muscle in her rib cage 7 While the medical assessment in this case was undertaken prior to the 2020 COVID 19 pandemic, it is noted that there have been more recent concerns highlighted in 2021 about the challenges GPs are facing in completing medicals for prospective foster carer and adopters. The RCGP and BMA issued a joint statement to the DforE supporting GPs regarding the pressure they are experiencing in this area. FINAL 5 about the information shared from the assessing adoption social worker, the GP and the medical advisor. 4.8 There is also a need to consider how the medical assessment is updated if there is a delay in a child being matched with the adopters. There needs to be a system in place to ensure that any new medical issues that emerge can be considered at the point that a match is made and then during the placement prior to an adoption order being made. In this case this was a significant issue, as the female adopter was diagnosed with rheumatoid arthritis in September 2020, weeks after Leiland-James’s placement with them. Those working with Leiland-James or with her in respect of the adoption were not aware that she had been unwell or of the diagnosis. It was not disclosed by the family and the GP did not share any information with CSC. There was no indication at any visit that the female carer was unwell or in pain. The current national system does not have in place an expectation that updated medical reports are provided at the time of matching, during the child’s placement or prior to an adoption order being made. This gap is an issue that requires changes to national guidance, so a recommendation has been made. This new information was particularly significant as a concern had been raised by the consultant in his letter to the GP regarding the prospective adopter’s alcohol consumption, as outlined below at 4.14. 4.9 The GP told the review that they were not formally informed that a child had been placed with the family, and that they only knew because the family registered Leiland-James at the surgery. No ‘flag’ was added to the patient records for either the child or the adults. Strengthening Families dispute this. They told the review that they informed the GP surgery that Leiland-James was a child in care placed for adoption and provided information including the contact details for the allocated social worker. CSC also had a record of this notification to the GP which was placed on to Leiland-James’s electronic case file. Single agency learning for primary care has been identified about the need for significant information to be formally flagged on patient GP records. 4.10 It is now known that the female prospective adopter was struggling with her mental health around the start of the adoption assessment. An Initial Visit Form was completed by the assessing adoption social worker at their first visit to the couple in January 2019. The screening questions include “have you ever needed support, advice or medication for depression, anxiety or stress and other mental health problems.” Nothing was disclosed by the applicants during the first meeting. When the medical form was completed, it emerged that the female prospective adopter had spoken to her GP about anxiety and low mood in 2011 and 2018. It was reportedly linked to her infertility both before and after she had her child. The matter of not disclosing this information was later addressed with the prospective adopter who stated that she felt that the question at the initial visit only related to whether she was experiencing current mental health difficulties, so she had answered in the negative. The adoption social worker and her supervisor told the review that it is not uncommon for applicants to fail to disclose all information at the ‘Initial Visit’ and that if there were no subsequent attempts to “cover up” this information or to avoid talking about it, they were not concerned. This was therefore not viewed as a lack of potential openness and honesty. The prospective adopter presented her mental health issues as historic, and no indication was given that they were as recent as it is now known they were. 4.11 The criminal investigation into Leiland-James’s death identified that the female prospective adopter was receiving ‘talking therapy’ support from First Step at the time of the adoption assessment. This information was not known to the assessing social worker and was not shared by the GP in the adoption medical report other than a sentence that she had ‘reported anxiety FINAL 6 and depression and received counselling in 2011 and 2018’ and which had ‘settled on its own’. First Step informed the GP of their involvement in the early months of 2019 but did not include any details regarding what was discussed with the female adopter. During the review, First Step confirmed that they had worked with the female adopter from December 2018 – April 2019. The couple’s application to be assessed as adopters was made in January 2019, so this on-going work was relevant to the assessment. The adoption team did not request permission to make checks with First Step as they had been under the impression from the adopters and from the GP information that the involvement was historic and related to the female prospective adopter’s feelings about the couple’s infertility. This was not in fact the case. The information held by First Step shows that the prospective adopter had issues with her low mood, anxiety, and anger management. This included her self-report that she was often irritable and short tempered, including shouting too much at her young child. She spoke about feeling judged by other parents and that she avoided company. She also reported drinking six bottles of wine a week which impacted on her motivation and mood, although she denied it had an impact on her parenting. 4.12 The initial assessment by First Step was completed and it was agreed that ‘talking therapy’ was required. The assessment was a telephone appointment, and the treatment appointments were face to face, following their guided self-help model. At the prospective adopter’s request, the focus of the work was on her anxiety and mood. No consideration was given to the impact on a young child of her reported issues and no safeguarding or clinical supervision was sought by the assessing mental health worker and the information shared by the mother was not considered through a safeguarding lens. First Step were not aware that the couple had applied to adopt a child and that an assessment was being completed. They did share with the GP that they were working with her, although no detail of what was discussed with the prospective adopter was included. In April 2019, the work with First Steps stopped at the client’s request and again the GP was informed. This correspondence was not reflected in the GP information shared during the adoption medical assessment and was not shared with or sought by CSC. 4.13 The male prospective adopter was spoken to about his wife’s mental health by the assessing adoption social worker, and it was stated that he presented as a supportive and understanding partner, who was clear that he balanced his wife’s reported tendency to ‘worry’ and ‘over-think’ things. The fact that the female adopter reported that her GP was supportive was seen as a positive support and safety factor, as was her reported good experience of CBT in the past. Once the placement was underway her social worker continued to speak to the female adopter about how she was feeling. There was no indication that any of the symptoms reported to First Step early in 2019 were an issue, but as those involved were not aware they were not specifically discussed. It is not current practice for an adoption assessment to contact an agency that has provided counselling for information. A recommendation has therefore been made. 4.14 As stated above at 4.8, following Leiland-James’s placement the female prospective adopter had further health concerns. She was diagnosed with rheumatoid arthritis and during the process of diagnosis was referred to a consultant gastroenterologist by the GP and seen in September 2020, around a month after Leiland-James was placed, for a separate health condition. During the consultation a concern was raised with her about her alcohol intake by the consultant gastroenterologist, which at that stage was reportedly 27 units a week8 and was thought to be having an impact on her health condition. This information was shared with the GP in a letter but neither the health issue or the alcohol use was shared with any other agency, 8 UK Chief Medical Officer’s advice is to consume no more than 14 units/week. FINAL 7 so it was not considered in respect of the potential impact on Leiland-James or the older child. The prospective adopters did not disclose this new health issue to their own social worker or Leiland-James’s. 4.15 The assessment of prospective adopters also includes a financial assessment. They are asked to complete a finance form and to provide bank statements and other financial documents to corroborate their information. The review has had access to the handwritten form that was completed in this case and was then considered during the assessment. The review was informed that it was found out after Leiland-James’s death that the family had significant loans and credit card debt without having the income to service this debt. It was apparent that the design of the form did not clearly ask for the total money owed, rather it asked for how much money was being spent each month on loans and credit cards. This does not give the full picture and enabled the family to disguise what they owed and that they were only paying the minimum amount each month, leading to the debt increasing. Changes were made to the form in 2019, but after this couple’s assessment. Adoption managers have since undertaken a piece of work to reconsider all the other financial assessments undertaken at the time. There is also a plan to review financial assessments at the time of a match being considered to ensure that information is up to date. 4.16 A Placement Order had been agreed by the court in July 2020, Leiland-James was effectively free to be placed for adoption. Several meetings were held to consider the potential match with these adopters in the month that followed, and the required reports were written. The adoption panel that considered the match was held in August 2020 as an additional panel. This was a pragmatic and timely response to ensure that the proposed plan of introductions could start, and Leiland-James could be with the family prior to his new sibling starting school. The panel’s recommendation for the match was agreed by the ADM and an adoption support plan was drawn up by staff from CSC responsible for Leiland-James and the prospective adopters. 4.17 There had been a gap of nearly a year between the prospective adopters being approved and them being matched with Leiland-James and him moving to their care. This is not unusual. During this time the adopters attended courses and a support group where they met other prospective adopters, some of whom they then had informal contact with outside of the group. They also had contact with their adoption social worker monthly and received a regular adoption newsletter with relevant updates. Along with all prospective adopters in Cumbria they were offered membership to a site for therapeutic support.9 The couple shared with their support worker that the waiting was hard. Those with extensive experience of working in adoption spoke during the review of the need to manage approved adopter’s expectations about the potential for a long wait for a placement if they want a baby, and this family was no exception. The first national lockdown response to Covid-19 was implemented around six months after their approval and much of the support available was moved to virtual platforms. It is noted that all approved adopters have an annual review if they are approved but waiting for a placement. This is an opportunity to consider any changes and to renew checks. The timing of the placement meant that these prospective adopters were not subject to an annual review as the placement was made 11 months after their initial approval. 4.18 After the potential match was identified, the prospective adopters were given information about Leiland-James and his wider family history. This included consideration of the issues they may face in the future. They had a consultation with the community paediatrician who is the medical advisor to the adoption panel when the match was being considered. This is an 9 The membership of the National Association of Therapeutic Parenting was a specific service funded by ASF Covid money to give additional support during Covid. FINAL 8 important meeting for all adopters, as they are provided with medical information about the child and their parents/siblings and is an opportunity to know what may lie ahead. In this case the adopters appeared to understand what health needs Leiland-James may have and they were reportedly not overly concerned. A ‘Chemistry Meeting’ between Leiland-James and the prospective adopters was held in July 2020 at the foster carer’s home, which was reportedly positive. 4.19 The plan made for the introductions included a combination of time spent at the foster care placement, outside of the placement, at the adopter’s home and with the older birth child as appropriate. Sessions were observed by the social worker for the child. All plans had to be Covid-19 aware even though during August 2020 there were fewer restrictions than previously or than were to come, and the plan was subject to a Covid-19 risk assessment. The male prospective adopter had time off from work on adoption leave when Leiland-James moved into his new home. He had recently returned to work after a period of furlough and worked on permanent nights. The prospective adopters later reflected that they wished that the introductions had included more time spent at their home to ease the transition for Leiland-James, although at the time they were incredibly positive and voicing their wish for him to move to their home as soon as possible. 4.20 The adoption service in Cumbria had previously learned from other cases that gradual and focused transitions tend to result in more successful adoptions. This was found when work was undertaken to consider learning from adoption breakdowns around four years ago. In Leiland-James’s case there were valid reasons for the matching decision to be made at an additional panel meeting and for the introductions to be completed slightly more quickly than the adoption service would ideally like. Despite the norm in Cumbria being a longer period of introductions, the eight days of introductions in this case is around the national average. 4.21 A planning meeting is always held as soon as possible after a match has been agreed to plan the introductions. Usually, it includes both the existing foster carers and the prospective adopters, the social workers for both sets of carers and the social worker for the child. This case has shown that there is a case to be made for it also including the health visitor for the new placement, to ensure information sharing and to include the support that could be required from the health visitor - who is likely to be a Strengthening Families (SF) worker as was the case with Leiland-James. The newly allocated SF worker for Leiland-James visited him in his prospective adoptive placement within three weeks of him being placed, having telephoned the week before. They told the review that ideally they would have visited sooner, but that they don’t tend to be told until the day of the placement. Learning has been identified about the requirement for the health visitor / SF worker and the child’s GP being informed of the proposed placement as soon as a match is agreed. (Ten days earlier in this case.) Wishing to improve practice in this area, SF are considering the feasibility of undertaking the adoption equivalent of ante-natal visits to prospective adopter’s pre-placement, to consider what advice and support is required. For example, with the potential issues of Leiland-James having a milk intolerance and possible developmental delay. There have been recent changes in the local authority adoption service to ensure improved information sharing with SF, which includes them being invited to matching meetings10. 4.22 Less than 20% of children in Cumbria who are placed for adoption are placed in a family with a birth child. A larger number of families have already adopted a child previously (over a third) 10 It is acknowledged that it is more complex when a child is placed outside of Cumbria, but as the child remains ‘looked after’ until the adoption order is made, corporate responsibility for the child should ensure that there is good information sharing and an expectation of multi-agency support across areas, as part of the care plan. FINAL 9 so considering the impact on another child is common when planning for introductions and placement. During Leiland-James’s matching process, there had been careful consideration given to the impact on the birth child and awareness that they would be starting school around the time of the placement. This was taken into consideration for the introductions and the plan for when Leiland-James should move in. At the time of the adoption assessment, the adoption social worker had spent time with the birth child as part of this assessment and they had been able to talk about what they liked doing, showing the social worker their bedroom and toys. This was felt to be age appropriate at the time. By the time the match was proposed they were around 18 months older. While there is no expectation in guidance that they would be formally engaged with to explore their view of the family and lived experience at this stage of the process, this would have been good practice. The review believes that there is a benefit of undertaking this as a specific piece of work in all cases after a child has been placed. Where to record this information about a birth child needs consideration. A recommendation has been made. Following Leiland-James’s death, the sibling was able to give a very clear account to police officers and social workers about what was happening at home. Learning If a prospective adopter has had contact with a service providing mental health support or counselling, consideration should always be given to requesting consent to contact the agency during the assessment to request information. Those providing therapeutic interventions to the parents of children should consider the impact on a child of what is reported, and clear information should be shared with the GP about reported alcohol consumption. It is important that the prospective adopter health assessments undertaken by GPs, are allocated sufficient time to consider and record historic and current health information. Any known potential vulnerabilities, including the physical and mental health of prospective adopters, should be formally reconsidered at the point of matching and at the child looked after review following placement, to confirm if there have been any changes. The new health visitor / SF worker who will be involved following a move to adopters and the prospective adopter’s GP should be immediately notified about a planned placement. The new health visitor / SF worker should be invited to the meeting planning introductions and the move. The health visitor / SF worker and the GP should consider what pre-placement support they can provide and share any concerns or issues that they are aware of. It is important that all professionals across agencies understand the importance of their consideration and involvement in the cases of children who are in adoption placements. They remain children looked after until the adoption order is made and require a focus from all professionals at this time of transition. Information must be sought and considered in assessments to ensure a full understanding of a prospective adopter’s financial situation, which includes a clear and achievable plan for how any debt is to be managed. When prospective adopters have another child, that child should be engaged with in an age-appropriate way to understand their day to day lived experience, at each stage of the process. FINAL 10 Support and emerging concerns 4.23 After Leiland-James went to live in his new home, small but potentially significant concerns began to emerge. The older child had a pre-arranged operation which was not disclosed to the local authority. The family also appeared to be calling Leiland-James by his middle name despite them agreeing they would not do so. Then, against clear advice and unbeknown to the social workers, it was shared that Leiland-James was spending significant amounts of time, including overnight stays, alone with his soon to be adoptive grandparents and aunt and uncle. The experienced staff involved acknowledged that Leiland-James’s placement was vulnerable to breakdown, and that there was likely to be an impact on his attachment to his new parents. Local levels of pre-adoption disruptions are low, with just one disruption in the four years prior to Leiland-James’s death. However, those involved with Leiland-James recognised the signs and were concerned that the information emerging was an indication that the placement was at risk of breaking down, and they planned to increase support to the family. 4.24 The head teacher at the older child’s school had been told by the local authority that the family were hoping to adopt and had provided a reference both in writing and verbally as part of the assessment. The school was not updated at the time that the match was made, as this is not usual practice. The family informed their social worker that they had informed the school themselves, as is expected. This was not the case. The school may have been well placed to support the birth child at the time of the placement. They told the review that, with hindsight, they believe the placement possibly had an impact on the adoptive sibling’s behaviour at school, as they presented as ‘emotional and very needy’ at this time. 4.25 The older child’s planned operation in November 2020 involved the family having to isolate at home for a week and the older child missing school for two weeks. Afterwards the older child reportedly needed extra care and attention from the parents and was particularly clingy to their mother, struggling with Leiland-James getting attention. This was at the time that Leiland-James was reportedly to be particularly in need of developing a close relationship with his adopters and this dynamic would have added to the family stress. The prospective adopters had not informed either their own social worker or Leiland-James’s social worker, so there was no opportunity to consider the impact on Leiland-James of this period of isolation and the birth child’s likely reaction to the operation. 4.26 There was a degree of anxiety shared by the adopters at the time of matching about the name given to Leiland-James when he was born, which was distinctive and spelt unusually. The prospective adopters asked if they could just use James instead. This was not agreed, as it is good practice to ensure a child retains their birth name to assist them in the transition as it is the name they are accustomed to, and later when there is a need to understand their identity. It was agreed that it was in Leiland-James’s best interests to change the spelling to make him less identifiable as he grew up. A lot of work was undertaken with the adopters about the need for him to retain his birth name, including being clear that if they didn’t like or accept the name they shouldn’t progress with the match. The social worker for Leiland-James and the adopter’s social worker later found out that he was being referred to by James by the older child and other family members. This was denied by the adopters, but there was a suspicion that it was their intention to call him James going forward, despite advice to the contrary. The school was able to confirm during the review that Leiland-James was known to them as James, including on a pre-school application. This shows a degree of ‘disguised compliance’ by the adopters, where they agreed with what the professionals said in meetings but did not comply with this advice. While this may have been one of the only areas where this was the case, it shows that the adopters did not entirely understand Leiland-James’s (or any adopted child’s) needs and FINAL 11 leads the review to question both the meaning of the child11 to them and their commitment to working with professionals. 4.27 Despite advice to the contrary, it emerged in December 2020 that Leiland-James had been cared for by extended family members, including overnight stays, on around four occasions. The first six months of an adoption placement are crucial to the child attaching to their new parents and there is an expectation that this time is invested in the child by their immediate carers. While wider family members are crucial in supporting the placement, the early months need to focus on the child being part of the nuclear family. When discussing concerns about how the placement was going, the prospective adopters shared that they had been feeling let down by some family members who were not supporting them as much as promised. This perceived lack of support may have been due to Covid 19 and the hard to decipher Government advice about what mixing was allowed. There may also have been a view from the wider family that initially Leiland-James needed to be with his new parents. 4.28 Network Meetings were held during the assessment and when the match was confirmed. They were well attended by extended family and friends, who were reportedly very willing to help support the family with Leiland-James. There is no requirement to have these meetings, but in Cumbria they have become part of the process and are best practice. There is no process of review of these meetings following the placement however to ensure that the support offered is happening, and to enable family members and friends to share any concerns. Family members are expected to contact the allocated worker if they are worried, and the adoption service is now specifically outlining at the network meetings that the network have a responsibility to make this contact. Although the meetings held are called Network Meetings – a term used in the Signs of Safety methodology, they are not used in their pure sense where the network have some accountability to make sure that the plan is working. When used in adoption, they are a meeting where information is shared with the wider family and friend’s network and where the support available is clarified and agreed. 4.29 When Leiland-James was placed in August 2020, there had been some issues with feeding and reflux. He had been on a ‘milk-ladder’12 at the foster carers and this was transferred with him when he was placed for adoption. Leiland-James was slightly overweight and had not progressed with his expected mobility. This was thought to be in large part due to him being carried a lot in the previous foster care placement. (It was acknowledged that there were two carers and several much older children in the placement and that they tended to hold Leiland-James a lot, particularly when they were all at home during the Covid-19 lockdown.) As well as having an impact on his mobility, this meant he was not always easy to settle by the prospective adopters who were unable to hold him as much as he had become used to. 4.30 As the months progressed, while there was communication between professionals and with the prospective adopters, direct social work home visits to Leiland-James were largely limited to statutory visiting frequency13. The social worker for the adopters and the social worker for Leiland-James spoke to each other regularly and there is evidence that the case was discussed in supervision. Leiland-James was only seen once in placement by his allocated social worker, once by another member of the child’s social work team, and on three occasions by the social worker for the prospective adopters. Considering the concerns about the possibility of placement breakdown, learning has been identified about the need to have more direct 11 The meaning of the child in the case of adoption is influenced by the adoptive parent’s expectations of adoption and their motivations to adopt. This is not always determined by the child’s needs but by the expectations of that child. 12 A plan for increasing a child’s exposure to cow’s milk gradually, to build up their tolerance. 13 Statutory regulations state that a child looked after must be visited within one week of the start of any placement, then at intervals of no more than six weeks during the first year of the placement FINAL 12 contact with a child in a vulnerable placement than the minimum expected, and a recommendation has been made. 4.31 At the approval stage there had been some questions regarding the in-depth understanding of adoption from the prospective adopters. There was no doubt at the time of their wish to be committed adopters and to love and care for an adopted child, but they appeared to have a limited understanding of what adoption really means for a child. This limited insight was identified at the adoption panel that they attended when they were approved. While they had clearly been provided with a lot of detailed information, they came across to the panel as “slightly limited in their understanding of adoption”. Following Leiland-James’s placement and a lot of detailed information being shared about him and his needs, this limited knowledge and understanding of adoption may have exacerbated the situation. Those who work in adoption told the review that not all adopters have a lot of understanding of therapeutic parenting and need support. Many adopters are ordinary people who must learn and build skills over time. In this case the adoption assessment led those involved to believe that the couple had both the time and the commitment to develop as positive carers of an adopted child. It is now clear that the professionals were lied to during the assessment and after Leiland-James was placed, and that the processes and practice did not lead to the disclosure of concerning information that was available. 4.32 From the start of the placement until he died, Leiland-James remained a child in the care of the local authority. This means he still had statutory reviews and statutory visits. Two review meetings14 were held on-line during the time he was with the prospective adopters. The focus of a CLA (Child Looked After) review is on the child’s health, emotional and behavioural development, family and social relationships and identity. Consideration will also be given to contact arrangements with birth family, and potentially with the foster carers he initially lived with. In Leiland-James’s case there was no health representation at the CLA reviews held when he was placed with the prospective adopters. This was an area where the attendance of the SF worker would have been helpful to provide reassurance and support with issues such as his feeding, development and crying. There is no evidence that the SF worker was formally invited or asked to attend the review. The IRO service confirmed that they previously invited SF until a child is placed for adoption and will ensure they do so again. 4.33 There is a need to always consider the child’s lived experience and ensure that their voice is heard above that of their carers, both in reviews and when visiting. This is essential even when the carers are prospective adopters. It is acknowledged that prospective adopters also require the support of professionals and there is a need for them to develop an effective and respectful relationship with professionals. In this case, Leiland-James’s voice was heard, particularly regarding whether the placement was the right one for him. He did not seem to be settling as would be hoped and there was evidence that the adopters were struggling to bond with him and love him as they stated that they wished to do. However, there was also evidence of him as a sociable little boy who was babbling, smiling, clapping and laughing. He made good eye contact with both adopters and appeared to have a positive and developing relationship with the older child. This was pointed out to the adopters along with other encouraging signs that had been noted by those involved. At the time the professional focus included the relational aspects of care as the worries were about whether the placement could meet Leiland-James’s emotional needs and whether the carers, with support from the therapeutic worker, could 14 An Initial CLA Review meeting will take place within 28 days of a new placement, then within a further period of 91 days, and most future reviews will take place within a further period of 183 days if an adoption order is not yet made FINAL 13 connect with him enough to give him a safe, positive and loving home for the rest of his childhood. 4.34 A social worker from the children’s team visited the placement on 4 November 2020 as a statutory visit to a child looked after and met with Leiland-James and the female prospective adopter. The social worker, who had not met the family before, said that the prospective adopter had shared that she was struggling and was worried that she did not love Leiland-James as she had expected to. Her mood was described as ‘flat’. The social worker told the review that she had no concerns for Leiland-James’s care on the day but did recognise that support was going to be required. The social worker ensured that the prospective adopter had emotional support from her network over the next few days and suggested she speak to both social workers involved. She was reassured that the carer remained child focused despite her concerns. She came across as open, honest and straightforward. Leiland-James was reported to be showing signs of good attachment at this early stage in the placement and was noted to be appropriately snuggling into his prospective mother’s embrace. The social worker who visited shared information from the visit soon afterwards with the social workers with responsibility for Leiland-James and the adopters. There is no evidence that the male prospective adopter was alerted to the concerns or spoken to by CSC. The agency report also found that this visit was not recorded at the time but after Leiland-James’s death, and action has been taken about this. 4.35 The review considered the impact on the case of this visit, which was undertaken by a social worker who was not the child’s allocated social worker and who did not have an existing relationship with the child or the carers. If a social worker is unable to undertake a statutory visit, another worker from the team may do this on their behalf. This can be positive as it can provide a fresh pair of eyes, but it can also mean that continuity of relationship and the ability to compare with previous contacts is lost. In this case this was the first visit to Leiland-James and the carers by the child’s social work team since the first week after placement. The Local Authority has undertaken further work to establish how common this is in the case of children placed for adoption and has assured the review that it is not regular practice for visits to be undertaken by a social worker who is not allocated to the child. 4.36 The social worker who visited reflected, with hindsight, that ‘post adoption depression’ (PAD) may have been an issue. Post Adoption Depression Syndrome was first written about by June Bond in 1995. It describes the stress, anxiety, and depression that many parents experience following adopting a child. Estimates suggest that up to 65% of adopters experience it at some point after having a child placed with them. It describes a mental health impact which may be from ‘the stress inherent in parenting, attachment/bonding challenges and when the needs of the child are more significant than expected’. It can also be due to unresolved grief and loss due to any infertility issues that resulted in the application to become adopters. All adoptive parents and professionals need to know and understand that low mood following a child being placed is normal and to be expected, and that support is available and will help. In Leiland-James’s case this may have been an issue that would have impacted on his lived experience. The female prospective adopter’s known and admitted history of low mood and anxiety may have made her more susceptible to PAD. The adoption social workers in Cumbria are experienced in guiding adopters through the possible responses to what can be the overwhelming experience of caring for an adopted child. The review has found that there are benefits if this support is multi-agency however and that it is essential to ensure that the second carer in the family is made aware of any concerns. It is acknowledged that the extent of the carer’s mental health issues and her negative feelings about her own child, told to First Steps in 2018, were not known or shared at the time. FINAL 14 4.37 Those involved reflected, that concerns about bonding do emerge as an issue in an adoption placement, and that resources are available to work on this. In this case, when their social worker spoke to them on the telephone after the November visit described above, the female carer was more positive and accepted the work proposed. The social workers formulated a plan to provide support from the therapeutic service which they hoped would address the concerns about an absence of bonding / attachment. An initial appointment was arranged and held on 16 December 2020, around 6 weeks after the duty social workers visit. This meeting was held at the time of the statutory visit15 to Leiland-James undertaken by the adoption social worker, and this was the first time that Leiland-James had been seen in person by CSC since the previous statutory visit early in November by a social worker from the child’s team. A plan was made for more work to be undertaken in the New Year. This perceived delay was due to the expectation that this is a longer-term piece of work rather than an emergency response. It was not due to capacity issues or limited resources within the therapeutic service. The review identifies learning for the service regarding the lack of a timelier response. 4.38 The workers involved were experienced adoption professionals and they planned a conversation with the carers about potential adoption breakdown. Not all adoptions go smoothly and the social workers who work in the adoption teams understand this. They are used to having difficult conversations with prospective adopters, and in this case they did ask, in the meeting held in December, whether the adopters wished for Leiland-James to be removed from their care. The adopters were clear they did not want this. Having an emotional connection with the child is important in an adoption, and it can take time and support for this to develop. When this is absent, as at times it appeared to be with Leiland-James and his prospective adopters, professionals are always concerned that the placement will fail. However, it was noted that the family were looking forward to Christmas and Leiland-James’s first birthday. It was the plan to work intensively with the family to see if the therapeutic service could have a positive impact and improve the outcome of the placement. Those involved reflected that a prospective adopter admitting they are struggling and need help is seen as a positive. The review was told that planned work rather than an immediate response is what is generally required in cases where bonding is an issue. 4.39 There were concerns about how the adopters were managing with caring for Leiland-James, although not to the degree that it was of concern for his short or medium-term wellbeing. Due to teething at the time of the move, Leiland-James was crying a lot and his social worker stated that he had a particularly high-pitched cry. He liked to be held and screamed if the carers left the room. It was reported that he had settled to a degree by mid-November, but the early issues likely had an impact on the placement. It is noted that the male prospective adopter worked night shifts and slept during the day. Over the winter this must have been difficult for the children and for the family to manage. COVID restrictions would have limited the opportunities to leave the house and have a positive social life. 4.40 The SF worker was aware of some tensions in the family. The female prospective adopter stated that she found it hard to be so scrutinised by professionals and described her relationship with Leiland-James as ‘like baby-sitting’ rather than parenting. This was not shared with CSC at the time. The prospective adopters appeared to be open and honest with strengthening families and with CSC about the difficulties they were having and in voicing their concerns regarding the impact on their birth child. This was seen as positive and a sign that they would accept support and therapeutic intervention. However, there was also a degree of child blaming in 15 CSC have undertaken a piece of work to see whether the practice in this case, where the adoption social worker undertook a statutory visit to a child in care, to understand whether this was a wider issue that requires consideration. They have concluded that it is not a wider issue and is not general practice. FINAL 15 their language, with Leiland-James being described as ‘clingy’ and ‘resistant to affection.’ Those involved were concerned about this and recognised the need for intervention from the therapeutic social worker, who was to work on promoting attachment and therapeutic parenting. 4.41 In November 2020, the female prospective adopter spoke to her GP about her arthritis as she was struggling with some basic tasks such as opening jars due to pain in her hands and feet. There is no indication that there was a discussion about how this could impact on her ability to care for the baby, or that the information was shared with other professionals by the adopter or by the GP. Leiland-James was described as a ‘heavy’ baby, and it is known that he wanted to be carried a lot. This may have been painful or at least uncomfortable for the female prospective adopter who did most of the childcare. The GP service has identified the need to place a flag on GP records stating that a person is applying to adopt. This will allow a GP to consider sharing information if anything new emerges, as it did in this case. A recommendation has been made to ensure that this happens across Cumbria. Prospective adopters are told that they need to share with CSC if they have any new health issues. In this case the information was not shared by the prospective adopters or their GP. 4.42 As stated above (4.40) the first meeting between the adopters and the therapeutic service was held on 16 December 2020. The adopter’s social worker was with the carers in the home and the therapeutic worker joined via video link due to the result of a COVID 19 risk assessment required at the time. After the session the social worker and the therapeutic worker had a conversation to reflect on the session. They agreed that the carers appeared to be negative about Leiland-James and found it hard to show any joy about parenting him during the meeting. They were described as tense and ‘flat’. It was concluded that work was required, and that while they should join a therapeutic group starting in February, they would require support from all involved prior to that. The social worker spent time with the family that day and recorded afterwards that while there were issues, there were also positive interactions observed and indicators that Leiland-James appeared more settled. The review was told that following the meeting there was consideration in the adoption social workers supervision that support was needed. There was no plan made for increased visiting in the days and weeks that followed, however. The social worker who was present did not assess that this was required as she had noted that Leiland-James was well cared for physically, that he engaged happily in peek-a-boo, and that he appeared to be meeting his developmental milestones. His warm and positive relationship with the older child was also noted. 4.43 It was of concern at the time that the female prospective adopter stated during the meeting in December 2020 that she wanted a break and required ‘respite’ from Leiland-James. It appears this was in response to challenge when information was shared that Leiland-James had stayed overnight with family members, against advice. It was agreed that Leiland-James’s social worker needed to be made aware of this concern. Emails were sent16 and an agreement made that there needed to be a care planning meeting. No meeting was held prior to his death. 4.44 Leiland-James was only seen once more by a professional on 23 December 2020, when he attended the GP surgery with the male prospective adopter for routine immunisations which were undertaken by the practice nurse. The response to Leiland-James’s injuries and then death the following month was appropriate. There were no identified delays in information 16 These emails were sent on 31st December. The delay following the visit on 16th December appears to have been in part due to due to Christmas bank holidays, leave and part time working. FINAL 16 sharing, correct processes were followed and there was appropriate safeguarding of the birth child. Learning When a child who is in the care of the local authority is placed for adoption, there should be a multiagency plan, to include health and schools17 That the wider family and friends’ network are explicitly made aware of their responsibility to share any concerns with the local authority. Information about how they do this must be shared during the network meetings and in writing afterwards18 That the support of the health professionals involved with the child is requested to ensure that updated health information about the adopters is available for consideration at key stages in the process, such as child looked after reviews When a prospective adopter/s presents in a way that leads to concerns about the emotional care being provided to a child, there needs to be provision of an appropriate, more timely and robust response Impact of COVID-19 4.45 Any review being completed that considers systems and practice from March 2020 needs to consider if there was any impact due to the COVID-19 pandemic. Leiland-James’s case is no exception. There had been a delay in the final hearing in the care proceedings due to a court backlog during the first lockdown. It was not significant however and Leiland-James was 7 months old when he was placed with the prospective adopters. There were other areas where Covid-19 potentially had an impact on the case. They included the limited availability of community activities and parenting support such as mother and baby groups and play activities, and some limits to the support the family could request from family and friends. For example, visiting from mixed households was not allowed in December other than on Christmas Day 2020, unless there was a clearly defined support bubble. The review was told that despite the restrictions in place, some childcare support was provided by the extended family. 4.46 There was a need at the time for questions to be asked of all families receiving support from agencies about the impact of Covid-19 on their family and on them as individuals. It is now known that the male prospective adopter had some time on furlough during the first lockdown. This had a significant financial impact which was not shared with the social workers at the time. The family also struggled with isolation during lockdown. None of these were unusual for any family in their situation, but with the female prospective adopter’s known history of anxiety and low mood and her long-term health issues, this required robust consideration. It is noted that at the time Leiland-James was placed in August 2020, things were less restricted and there was a feeling that life was getting back to normal. The further lockdown in November 2020 and news that a further lockdown may be implemented in early January 2021 would have had more of an impact. The family was still adjusting to having a new baby, it was winter, and the potential need for the older child to be home schooled from January may have had an impact. 4.47 There had been a shorter than usual (in Cumbria) period of introductions for Leiland-James. Although this was largely due to the need for sufficient introductions to happen before the older child started school, it was also due to COVID-19 and the wish to limit the frequency of face-to-face contact between those involved in the move. While the plan was similar to those common 17 When there is an older child (either a birth child or an adopted child) who attends school, including the nursery class prior to statutory schooling, consideration should be given to the best way of including the school in any planning to support an adoption placement. The school’s assistance in capturing the ‘voice of this child’ is an important part of the process. 18 Action has been taken in respect of this. FINAL 17 in the UK as a whole, in Cumbria they had seen the benefit of a longer period of introductions and preferred to do this when possible. All the meetings held as part of the matching, introduction planning and child in care reviews following the placement were held virtually (on-line). Professionals had become used to this by August 2020 and they told the review that it did not have an impact on the quality of the plan/planning. One exception to this was the therapeutic social worker who had her first consultation with the couple around a week before Christmas. She reflected that the start of a therapeutic relationship was impacted by not meeting the prospective adopters face to face for the initial appointment. It is difficult to know if the lack of face-to-face support groups had any impact on how the prospective adopters were managing. 4.48 There is increasing research about the impact on children of the COVID 19 restrictions, and a view that it may affect their development and ability to adapt to different environments and people. This was likely to be an issue for both Leiland-James and the older child in the family. The prospective adopters told the adoption social worker that they missed having regular visitors to the home and going out as a family. They liked to eat out and have day trips, but this was impossible at the time. Leiland-James himself needed to adapt from being in a home with a lot of people, to living with a small family, with a father who slept during the day due to night shifts and limited or no visitors due to the new lockdown restrictions. This and the resulting stressors needed to be factored into the support being offered. Learning The many impacts of Covid-19 on children and families cannot be underestimated and will require robust consideration by professionals during assessments and contacts for some time 5 Conclusion and recommendations 5.1 Leiland-James died while being cared for by a couple who had been successfully assessed and who were being supported by professionals and their own network. Following his move, indicators emerged that it might not progress to be the right placement for Leiland-James, and that his longer-term emotional needs may not be met. There were no known indicators that Leiland-James was at risk of physical harm from his carers, however. What was not known at the time was that the prospective adopters had not been honest about their debt, their mental and physical health, their alcohol consumption and use of physical chastisement during the assessment, at the time of Leiland-James being matched with them or during his time living with the family. Learning has been identified that information in these areas should be robustly sought, shared, and considered. This is significant, as had the information held by First Steps and the gastroenterologist been known, along with the understanding that the prospective adopters were hiding these issues, the assessment could have better reflected the vulnerabilities and potential risks. 5.2 The learning from this review has been clearly set out above, but has identified the following pivotal findings regarding systems and practice which were considered when making the recommendations below: The medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support. The system would be more robust if these assessments were updated at the point of matching and before an adoption order is made FINAL 18 Improvements are required regarding seeking, sharing, and considering any adult vulnerabilities19 that could be a risk to children Adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household When it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers 5.3 Ongoing service improvements in the Cumbria adoption service, unrelated to this case, include a pilot with the University of East Anglia ‘Moving to Adoption’ Model. This outlines three key stages ‘getting to know each other’, ‘making the move’, and ‘supporting relationships’ after the move. Each stage has key principles that need to be achieved and so is not prescriptive about timeframes and details on the planning. The focus is on outcomes for the child and being flexible to their needs’. Those involved in the review believe that these changes will contribute to improvements for children who are to be adopted, and hopefully enable them to thrive and have a successful placement. 5.4 CSC informed the review that they recently commissioned the Local Government Association to undertake an in-depth independent review of practice in the adoption service. This review has provided assurance about adoption practice. Positive improvements reported in the adoption service include additional management oversight, seeking information from providers of mental health support and inviting Strengthening Families workers to key meetings. 5.5 The following additional recommendations are made to ensure that the Partnership can be confident that any areas identified as being of particular concern are addressed. National recommendation: 1. The Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review. Revised guidance should include: the need for all health information for adopters and children in the family to be updated and reconsidered at key points in the case, such as at matching, at Child Looked After Reviews and when an adoption application is made seeking assurance that medical assessments do not rely on the self-report of the prospective adopters the need for flags to be placed on the GP records for prospective adopters/adopters the need for financial information, including the total of any debts, to be robustly assessed during any assessment of prospective adopters. Local recommendations: 1. Due to the likely delay in changes to national guidance, relevant partner agencies in Cumbria to be told to raise awareness of the importance of adoption health assessments, and to ensure that health information is requested, analysed20, and shared at the key adoption process stages to inform decision making, such as when agreeing a match21. 2. The CSCP to ask partner agencies to determine how they will ensure that ‘systems’ identify a person as a prospective adopter, so that professionals are aware of this. Additionally, all 19 To include physical and mental health, alcohol consumption, and financial issues. 20 Including the role of the medical advisor. 21 In this case it is health information that is relevant. It is acknowledged that this could also include the need to consider updating all checks undertaking at the matching stage, including police and local authority checks. FINAL 19 GP records locally should have a flag placed on the record of prospective adopters, with the expectation that GP’s share any information that pertains to changes in health or lifestyle that may have implications for a child in their care. 3. That the CSCP asks all relevant partner agencies to determine how they will ensure that all professionals are aware that children placed for adoption remain in the care of the local authority until an adoption order is made, to ensure an improved awareness of their potential vulnerabilities and the need for professional oversight. 4. That Cumbria CSC, the CCG and the Adoption Panel Medical Advisor are asked to provide assurance regarding the need for all information to be sought, shared, and considered thoroughly in adoption assessments to enable a full understanding of a prospective adopter’s health and mental health. 5. That Cumbria CSC are asked to provide information and assurance in the following areas: - That all necessary information is sought and considered in assessments to enable a full understanding of a prospective adopter’s financial situation - That the voice of other children in the household is sought at regular points in the assessment and placement - That there has been a review of visits to children in adoption placements to ensure that those with allocated responsibility for the child visit the child in placement at least in line with statutory requirements, and more often when there are concerns about the viability of the placement - That there is an appropriately timely and robust response in cases where there are concerns about bonding with a child placed for adoption. |
NC52288 | Review of the services provided for three teenage boys following a serious knife crime in 2018 in which one of the boys was seriously injured. Considers what led to the boys' involvement in serious youth offending and ways in which professional interventions may have safeguarded them more effectively. Recommendations include: ensure that primary schools are able to identify children who show severe behavioural difficulties, respond to their needs and make an appropriate referral for additional early help services; ensure that early help interventions are family-focused and take a full account of the child's history; ensure that secondary school transfer arrangements identify any child who has shown severe behaviour problems in primary school; ensure that policies, procedures and practice reflect the best current thinking about contextual safeguarding risks; and ensure that agencies and partnerships actively engage with black and minority ethnic communities over the prevention and reduction of serious youth violence.
| Title: Serious youth violence: thematic serious case review. LSCB: Buckinghamshire Safeguarding Children Partnership Author: Keith Ibbetson Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Buckinghamshire LSCP Serious Youth Violence: Thematic Serious Case Review Independent Chair Buckinghamshire Safeguarding Children Partnership Sir Francis Habgood QPM Independent Lead Reviewer Keith Ibbetson Serious Youth Violence: Thematic Serious Case Review 1 INTRODUCTION 3 2 FINDINGS AND LEARNING 7 2.1 Introduction 7 2.2 Early help 9 2.3 Secondary transfer and the emergence of difficulties in the early years of secondary school 13 2.4 The ability of the criminal justice system and other agencies to address emerging criminality and possible gang associations 18 2.5 What kind of safeguarding plan is needed to protect children when the risk comes from the community as well as the family, and when the young person also poses a risk to others? 22 2.6 The planning, operational coordination and strategic oversight of services to combat serious youth violence 26 2.7 Providing services to black and minority ethnic families 29 3 RECOMMENDATIONS 31 Appendices 35 I How the review was undertaken 35 II References and links to articles on the ‘public health response’ to serious youth violence 40 3 | P a g e 1. INTRODUCTION The events that triggered the review 1.1. Between December 2018 and October 2019, Buckinghamshire Safeguarding Children Board (the LSCB) carried out a review of the services provided for three teenage boys. The review was triggered by a violent crime in which one of the boys was very seriously injured. 1.2. The review was carried out under the guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.1 This document sets out the review findings. 1.3. Further details of the incident are not provided because of the likelihood that this would lead to the identification of the young people, placing them and their families at risk of serious harm. The safeguarding partnership has done everything possible to prevent that from happening, while at the same time seeking a wide professional audience for the learning in this review. The partnership specifically asks that professionals who may know the identity of those involved do not make it public, either deliberately or inadvertently and that the media do not seek to connect this report to any specific event. 1.4. In order to make the report easier to understand the three boys are referred to where necessary as Child A, Child B and Child C. Reasons for conducting the review 1.5. The incident was brought to the attention of the LSCB by the acute hospital trust that initially treated the victim. The LSCB was also approached by the mother of one of the boys because she believed that he had been treated unfairly by his school and other services which had failed to identity his mental health problems and provide him with education suited to his special needs. 1.6. The LSCB decided that a SCR should be undertaken because children involved had suffered serious harm and that there had been concerns about the way in which agencies had worked together to safeguard them.2 1.7. In reaching its decision the LSCB also took account of the wider context. The incident was one of a growing number of serious knife crimes in the Thames Valley Police area in 2018. In the six months 1 Working Together to Safeguard Children (2015), 4.1 and 4.6 2 Section 4.17 Working Together to Safeguard Children 2015 4 | P a g e during which this offence took place the number of incidents was 19% higher than the equivalent period in 2017. The increase in the local police area where it happened was close to 40%, bringing it in line with the busiest urban areas covered by this police service.3 1.8. This highlighted the need to ask how services in Buckinghamshire should respond to a problem that had previously been considered to be one that affected London and other large cities. The LSCB therefore decided that greater benefit would be derived from a wider thematic review of the response of agencies to the emerging problem of serious youth violence in Buckinghamshire, building on the review of the services provided for the young people whose circumstances were judged to meet the criteria for a SCR. The scope of the review and the information considered 1.9. The Terms of Reference for the SCR are set out in full in Appendix 1 of this report along with details of the review method. 1.10. Given its thematic approach, the SCR has sought to obtain information from a wide variety of sources and informants. Information about the three boys involved in the incident has been provided by all of the local agencies and contracted professionals that are known to have worked with them, all of which are based in Buckinghamshire: • Buckinghamshire County Council (children’s social care, SEN service, early help services, youth services) • Buckinghamshire Youth Offending Service • Buckinghamshire Healthcare Trust (health services including acute hospital services, community paediatrics and health visiting) • Thames Valley Police • Oxford Health NHS Foundation Trust (Child and Adolescent Mental Health Services – CAMHS) • Schools, academies and colleges • District Council housing services • General Practice. 1.11. Agencies provided the review with chronologies and management reports that give factual accounts of agency contacts with the family and other professionals and evaluate the services provided. In addition a small number of staff and managers who worked with the family have spoken to the reviewers directly in order to provide more detailed information about their work, reflect on their experience of work with the young people and their families and suggest ways in which services 3 Thames Valley Police management report provided to the SCR. Figures refer to reported violent or sexual crimes involving the use or threatened use of a knife or bladed weapon. Not all violent knife crime is committed by young people 5 | P a g e might be improved. More senior and specialist staff have been able to advise the reviewers on policies and procedures. 1.12. The report has also drawn on the large number of published reports on serious youth violence, publicising research and advocating solutions. Two reports by other safeguarding children boards which build on a detailed knowledge of individual cases to reach wider thematic findings are particularly relevant.4 In addition the independent reviewers have drawn on their own work in reviewing services aimed at preventing serious youth violence and gang activity in other local authority areas. 1.13. The review does not address directly the question of whether the incident could have been predicted or prevented. To do so would require a detailed understanding of the circumstances and the motivations of those involved and of other young people, which the review cannot obtain. The review has however examined the histories of the young people involved to consider whether different approaches could reduce the risk of this type of incident in future. Family involvement 1.14. The review has sought to involve the families and the young people themselves. 1.15. The independent lead reviewer and a representative of the LSCB met the family member who had made the initial representation to explain how the review would be conducted and that it would not be able to investigate all of her concerns in detail. She accepted this, agreeing that the main focus of the review should be on improving services for the future. 1.16. Representatives of two families participated through direct meetings with the independent reviewer. The father of the third young person drew attention to previous lengthy complaint correspondence with social care, which the review has taken into account, but did not respond to further requests to be directly involved. The views of all three families informed the report at a number of points. 1.17. Information about the review was provided to the young people involved via family members or professionals who had direct contact with them. Two were in youth custody at the time limiting the possibility of direct access to explain the reasons for the review. None was willing to contribute to the review, leaving a disappointing gap. 4 Alex Chard (2015) Troubled Lives Tragic Consequences – a thematic review, Tower Hamlets Safeguarding Children Board; Charlie Spencer, Bridget Griffin & Maureen Floyd (February 2019) Vulnerable Adolescents Thematic Review, Croydon Safeguarding Children Board. The citation of these reports should not be taken as an indication that the author or the board endorses their thinking or findings. 6 | P a g e How can this learning review assist in improving services to reduce violent youth crime? 1.18. Although the review is concerned to focus on all serious youth violence, knife crime is an important part of this. As this review began its work in late 2018, there was a spate of murders and woundings involving young people in England. In early 2019 the surge in the number of serious knife crimes involving young people appeared to stop, although there remain weeks when a series of incidents coincide, underlining the persistence of the problem. 1.19. Overall the recent trend is clear. Violent or sexual offences involving knives or sharp instruments increased from approximately 31,000 per year in 2010-11 to over 44,000 in 2018-19. 5 The spread from cities to smaller urban areas and counties is reflected in national as well as local figures as ‘there were increases in 32 of the 43 forces in England and Wales, including big percentage rises in rural counties’.6 1.20. Much professional and political discussion of these trends highlights common risk factors among the perpetrators and some victims.7 Professionals working with young people (who are often perpetrators of crime but also most likely to be the victim of a violent crime) recognise common factors in their backgrounds. They are also aware that most young people who grow up in deprived circumstances or who have suffered difficult early experiences don’t commit violent crimes and that successful work with young people requires an emphasis on their own responsibility and agency. 1.21. Regardless of the common factors in the individuals’ backgrounds, or how constrained their choices are, it is dangerous to blur the moral distinction between robbing or stabbing someone and being robbed or stabbed, even if the individuals concerned come from similar backgrounds or might a few days or weeks before have been victim rather than perpetrator, or vice versa. The perpetrators of violent crimes have made choices which have brought harm and distress to victims and their families. 1.22. The view of the author is that to blur that distinction in any way will give a confusing message to young people and make it harder for their parents, responsible adults in their communities and professionals to help them behave differently. This does not prevent professionals from recognising that some young people who are committing offences are being exploited, sometimes by adults and sometimes by older or more ruthless adolescents whose criminal behaviour is more entrenched. Nor 5 https://www.thetimes.co.uk/edition/news/jump-in-knife-crime-puts-overall-offending-at-15-year-high-prm5dvqzb accessed on 18 October 2019 6 ibid 7 Croydon LSCB op cit 7 | P a g e does it reduce the responsibility of professionals to understand and to seek to address factors in young people’s background and social context that have made them more vulnerable. 1.23. It is common sense that there should be a collaborative approach to serious youth violence and for some time it has been policy that a ‘public health approach’ to violent crime is needed. Politicians and others contest what this means, how it should be implemented and how long it could take to succeed.8 Appendix III has links to background material about this. Section 2.4 of this report contains some information about the practical measures taken by Thames Valley Police since 2018 to combat knife crime in Buckinghamshire. 1.24. If it is to have any value, a collaborative approach must be developed and put into operation at a local level, informed by young people, families, communities and the professionals who are working with children. Young people can only be helped if professionals are able to understand the effectiveness of the services that have been provided for children and their families: what worked well; gaps and weaknesses in existing services and ideas about what might have been done differently. This review has sought to make some sense of the lives of the young people involved in one incident in a way that can contribute to that discussion. 8 The public health approach has in fact been government policy since 2011, though it is be a matter of dispute as to whether it has been implemented. See for example https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/97861/gang-violence-summary.pdf 8 | P a g e 2. FINDINGS AND LEARNING 2.1. Introduction 2.1.1. This section of the report seeks to shed light on the pathway that for these young people led to involvement in serious youth offending and the points at which professional intervention may have safeguarded the young people more effectively. It evaluates the impact of service provision made over more than a decade. Given the scope of the review, the most important and recurring themes are highlighted and not every episode is considered in detail. 2.1.2. The review identifies points in the development and education of children and young people and themes in the provision of services that are particularly important because signs and symptoms which may be associated with later youth violence are seen and there may be opportunities to intervene. 2.1.3. In Sections 2.2 – 2.6 the review considers the services provided to children under the following headings: Problems and help in early childhood and the primary school years Transfer to secondary school and the emergence of difficulties in school years 7 - 8 The ability of the criminal justice system and other agencies to address emerging criminality and possible gang associations The kind of multi-agency plan needed to protect children when the risk comes from the wider community rather than (or as well as from) the family and when the child’s behaviour is also a risk to others? 2.1.4. The analysis points to the need for a model of service delivery which will draw on the skills and knowledge of different professionals groups to respond quickly to children at these points, sometime because there is an immediate risk, sometimes to offer support that may help a family avoid later difficulties. 2.1.5. Some patterns in service provision are clear. Lack of engagement (for whatever reason) with services such as CAMHS, Speech and Language Therapy (SALT) or educational support services when problems are first recognised has been identified in many children’s histories as prefiguring latter difficulties. 2.1.6. In the past the families of young people involved in serious offending have often experienced intermittent service delivery, including professionals closing cases because there has been a little progress, or the child has not been brought to appointments. Such cases are often re-referred and the pattern repeats. 2.1.7. The extent of some young people’s offending is often not appreciated because so many reported offences are not successfully prosecuted. 9 | P a g e Taken together this suggests the need for coordination of the services so that action is based on the full and rapid sharing of information and that assessment can take account of a full history, including whether or not services have engaged with the family successfully. 2.1.8. The review has found that during the period under review prior to 2018, some aspects of service coordination are currently poor. Examples are given in each of the following sections. Better operational coordination in turn requires strategic oversight and a framework for planning. Without this better coordination and oversight improvements in individual services will have less impact. This is addressed further in Section 2.6 2.1.9. The risk factors associated with serious youth violence may apply to different degrees to any child. The review points to a concentration of risk factors in some minority ethnic families in Buckinghamshire and to barriers (some arising from the professional side and some arising from families) to addressing them. This is addressed in Section 2.7. 2.2. Early help and difficulties in primary school Introduction 2.2.1. This section considers the early infancy and primary school years of the three young people, identifies the difficulties that they experienced, evaluates the services provided and identifies areas of possible improvement. The provision discussed was made over several years before 2018, under different Buckinghamshire early help policies and strategies so the learning focuses on general principles. 2.2.2. Recommendations on early help services are made in Section 3. Recommendations 2 and 3 10 | P a g e Information from the narrative Domestic abuse and safeguarding concerns in early childhood 2.2.3. Police were called to reports of domestic abuse in two of the families. Child C was referred to social care on several occasions but not assessed because the individual reports of domestic abuse were not deemed to have been serious enough to merit this. There was a high level of concern about this child at school. 2.2.4. His younger siblings suffered from chronic illnesses and disability. The family was very happy with the health services that were provided and did not want to receive any voluntary support from the local authority. 2.2.5. There was persistent domestic abuse in Child A’s family, including allegations of serious assaults on the mother by members of the extended family. The circumstances were never fully understood by professionals but this is likely to have caused significant distress and harm. In this family the long-standing, safeguarding concerns bi-passed the early help services. 2.2.6. The boy and his younger brother (who also went on to commit serious criminal offences) were the subject of a child protection plan which focused largely on their living arrangements and practical care but did not seek to understand the origins of the family’s difficulties. Had it done so agencies are likely to have realised that they were profound and persistent, probably meeting the threshold for statutory legal intervention. 2.2.7. The children’s father (who did not live with the children and had been released from prison) believes that there were no proper safeguards in place when the children were living with the extended family. He also believes that professionals failed to give him enough opportunity to be involved in his children’s lives. 2.2.8. When the child protection plan ended (when the children were 11 and 9), a lot of professional effort was made to support the care of the children but there was little parental or wider family cooperation so a meaningful child in need plan could not be drawn up. Behavioural problems at primary school 2.2.9. Two of the boys experienced behavioural difficulties in primary school. Schools made efforts to address these problems and were supported by the primary age Pupil Referral Unit (PRU) which supported the boys and their schools by visiting, observing them and offering advice. 2.2.10. Child C changed school which helped keep him in mainstream schooling because his parents had more faith in the staff at the new school. Child A was offered a special school place on secondary transfer, but said he did not want to attend. His family went along with this, so it was refused. 11 | P a g e 2.2.11. Chronologies suggest that the level of external additional support available to primary schools varied. The interventions appear to have been largely focused on the child’s school problems and were not linked to work with the families which might have more effectively addressed the causes and severity of the children’s behaviour problems. Failure at the time by services to engage the family in an early help offer 2.2.12. Child B had no marked problems in primary school (this would have been before 2017), though investigations were made into some specific cognitive problems. There is no evidence that these seriously impaired his learning and he was not identified as a child with any additional emotional or behavioural difficulties at the point of secondary transfer, an indication that the most potentially risky children will not necessarily always have severe difficulties at primary school. 2.2.13. Over several years there were a number of incidents that might have led to the involvement of early help services. On each occasion there were delays in offering help, sometimes there was a gap of several weeks or months between the referral and the assessment. His mother refused help saying that by the time an early help assessment was offered, things had improved. She told the SCR that she genuinely believed that this was the case. The refusal was accepted and involvement ceased without considering the full range of information that could have been made available (such as the extent of Child B’s educational difficulties) and the repeated pattern of family difficulties. Learning and questions for the partnership 2.2.14. It is useful to draw on the findings of reviews conducted by other safeguarding boards, avoiding simple comparisons with other local authority areas that are very different in their social and cultural makeup. The Buckinghamshire histories have a number of similarities to the findings of the Croydon and Tower Hamlets thematic reviews. In Tower Hamlets ‘several of the children who subsequently perpetrated extreme violence were displaying behavioural difficulties in primary school’.9 In Croydon 19 of 60 adolescents categorised as ‘vulnerable’ had received fixed term exclusions in primary school, all of whom subsequently received criminal convictions.10 2.2.15. The Croydon review found that ‘the primary schools had limited interventions available to them to address such behaviour and referred on to other agencies. It is not clear if they were aware of any potential causal factors that could explain the children’s behaviour to inform the interventions that were put in place. There was a range of parental 9 Tower Hamlets LSCB (op cit) page 3 10 Croydon LSCB (op cit) page 9 12 | P a g e factors, such as absent parents, substance misuse, mental health problems, parental criminality and domestic abuse, but parental interventions and interventions for children were not joined up in a coherent whole family plan. Adult services and children’s services did not work together, and the needs of the children remained unmet.’ 2.2.16. In Buckinghamshire professionals in the family support, early help and youth services described the evolution of their work over recent years from one that had been focused exclusively on the child in school to one where the intervention (if it was accepted by the parents) would consider the needs of the family as a whole, including parents and older children who might be influencing younger siblings. 2.2.17. Very often in the case histories decisions about the level and type of need and therefore the relevance of different services were not made on the basis of all-round information about the child and family, the child’s educational difficulties and the extent to which the family had previously engaged with services. This led to a pattern of repeat referrals and assessments that covered the same ground. 2.2.18. Early help and child in need services should ensure that their assessments take a full account of the child’s history, information from the full range of agencies involved and relevant information about all family members. As with younger children there is a case that more should be done to work with families and young people who do not engage with early help or child in need services. 2.2.19. The Buckinghamshire youth service described how it is now looking in detail at the histories of the young people who cause the most concern and looking back to understand how they presented in primary school in order to target interventions at that age more effectively. There is now greater clarity about the way in which those children who are at risk of behaving violently later on may present at primary school. 2.2.20. The local authority and the safeguarding partnership have recently reviewed the early help strategy and it is important that in its implementation it takes account of the learning from this SCR. The report makes a recommendation in relation to this. 2.3. School transfer and the emergence of difficulties in the early years of secondary school 2.3.1. This section considers the response of schools and other agencies to the emergence of attendance and behaviour problems in the early years of the boys’ secondary education. A recommendation is made in Section 3 of the report (Recommendations 4,5 and 6). Information from the narrative Transfer to secondary school 13 | P a g e 2.3.2. Based on school records and interviews with some staff who knew them, all three boys made the transition to secondary school without immediate problems. During the first two years of secondary schooling all three found it increasingly difficult to participate constructively and their behaviour deteriorated, resulting in a large number of temporary exclusions, despite efforts by the schools to avoid this. The route to unplanned school moves -including permanent exclusion 2.3.3. All three boys left mainstream secondary school when alternative approaches had failed though their routes out of mainstream school were different.11 Many of the exclusions took place because of persistent, severe disruptive behaviour, including violence or threatened violence to staff, pupils or both. 2.3.4. Child A was assessed as being in need of a special school secondary place and offered one. He refused to attend and his family went along with this. In year 7 his attendance was poor and his behaviour problems were managed within the achievement and behaviour policies of the school that he attended. During years 8 and 9 his behaviour became more openly defiant and aggressive, leading to a number of temporary and then permanent exclusion. 2.3.5. At this point he transferred to the PRU where staff found that he fitted in well, though his attendance was never good and he did not engage much with education. His parents were not able (because of mental health problems and absence from the family) to support his education and his extended family carers do not feature in school records. It is strongly suspected that he was involved in criminal activity from about the age of about 13. 2.3.6. Child B had a large number of fixed term exclusions. His school believes that the deterioration in his behaviour and attendance at secondary school was explained by academic difficulties and his desire to be accepted by friends who did not value academic achievement. In contrast his mother’s view is that the school failed to recognise that Child B had special educational needs because of ADHD, which adversely affected his behaviour, and specific educational needs which made it difficult for him to organise himself, produce written work and cope with mainstream secondary school. Differing definitions of the cause of the child’s difficulties led to a deterioration in the relationship between the school and parents. The school did not believe that there was consistent support for its strategy. 11 There is no evidence that any of the boys was removed from mainstream school using ‘illicit’ methods. Nor is there evidence that the removals took place to protect the schools’ league table positions, as has been recently suggested nationally. For example https://www.bbc.co.uk/news/education-48172917 and other media reports (accessed and checked 4 November 2019) 14 | P a g e 2.3.7. The school referred Child B to CAMHS in 2016 because of his anger in school including an assault on another child. There was only a very brief screening and gathering of information from other agencies which established that Child B had been referred to the early help service and there was a proposal for him to see an educational psychologist. There was no CAMHS assessment and the outcome was to rely on early help family support services (which were due to be involved but his mother came to believe she did not need). It was also agreed that Child B should be seen by an educational psychologist, which happened but after a considerable delay. Symptoms of ADHD, recognised in 2018 after Child B had attended three different secondary schools and been permanently excluded, were not identified at this point. 2.3.8. An assessment by staff from the PRU suggested that Child B would manage much better in smaller classes, which the PRU could provide and proposed a planned transfer to pre-empt exclusion. This happened only shortly before his managed move and his mother says that she was not aware of the recommendation. 2.3.9. In a final effort to avoid permanent exclusion the school arranged a managed move to a new school, but Child B was quickly excluded. Teachers from the schools involved told the SCR that such moves represent a genuine attempt to offer a fresh start to a child, but that they often break down because for schools to be able to trust one another to accept a pupil who is known to have problems, they tend to take place between schools that have similar philosophies and approaches to managing behaviour.12 His mother believed that having failed in one school he would inevitably fail in another that was making essentially similar provision and that both schools therefore failed to assess his special needs. Further disagreement between his mother and the education authorities meant that he then had to be educated at home. 2.3.10. Child C was temporarily excluded for a total of 32 days over 12 episodes in the first two years of secondary school, culminating in his permanent exclusion at the age of 13. Child C’s father complained that his son had been bullied and threatened and that his school responded unfairly when this happened, failing to investigate fully or protect him. It is not possible to know whether this account is correct. It is clear that Child C bullied and threatened other pupils. Again the breakdown in trust meant that it was impossible to for the school and family to collaborate in efforts to help his son. 12 The review has been given different information by schools and by the education service about the overall effectiveness of managed moves. Schools report that they offer a limited chance of success whereas the education authority maintains that there is a high success rate, which would of course be influenced by the criteria used to measure success. 15 | P a g e 2.3.11. Managed moves to other schools were attempted and the PRU tried to assist. Between the ages of 13 and 16 Child C was on the roll of two different PRUs, firstly a local authority managed unit and then a setting managed by a national organisation that specialises in PRU provision. At both the problems of poor attendance and disruptive behaviour, including assaults on other pupils, continued. Child C sought to be at the centre of attention by boasting about his criminal and anti-social exploits and being physically dominant in every interaction with staff and other pupils. Learning and recommendations 2.3.12. Although the specific factors leading to exclusion were different there are common patterns. Two features of the service provision stand out. An effective partnership between schools and parents 2.3.13. Permanent exclusions happened in part because – for a variety of reasons – the schools had been unable to achieve parental or wider family support for their strategies to help the child. Child A had no family to support the school. Child B’s mother and the school defined his problems in different ways. Child C’s father had no trust in the school. Almost by definition, without parental engagement, schools were unable to understand the child’s problems in relation to their family background or to involve family members in management and solutions. Multi-agency engagement 2.3.14. Schools often appear to have been acting without substantial support from other agencies when seeking to help these pupils. Sometimes other agencies were not involved, or if they were information was not being shared between agencies, leaving schools unaware of important factors, such as the extent to which children were involved in anti-social or criminal behaviour in the community, or had severe family problems. Conversely in this case it appears important external agencies such as social care and the Youth Offending Service (YOS) may not know in detail about school problems. 2.3.15. Sometimes this meant schools placed reliance on parents to exercise a degree of control or influence that other agencies (who knew the family better) would have known was unrealistic. For one boy social workers appear to have taken the existence of an educational plan or a very limited level of compliance with school regime (for example attendance at the PRU) as a positive when in fact the child was not attending well, engaged or cooperative. Overall, it is likely that more could have been achieved if external agencies (such as family support and social care, behaviour support and CAMHS) had been more involved and had worked together in a collaborative way from the point of secondary transfer. 2.3.16. School governing bodies have the final responsibility for school exclusion, but there is a strong case that a permanent school exclusion or any hasty, 16 | P a g e unplanned move to a different educational setting should only happen after the full range of resources of the multi-agency professional network has been engaged to support the child, family and school. 2.3.17. There is no doubt that schools can play a vital protective role: ‘Both research and wisdom show us that regardless of the adversity they face, if a child can develop and maintain a positive attachment to school, and gain an enthusiasm for learning, they will do so much better in their lives. The role of teachers in the lives of traumatised children cannot be underestimated.’13 2.3.18. The best way to achieve this must be to harness a greater, more collaborative, multi-agency effort to address the early deterioration in the secondary school attendance and behaviour of children (mostly but not exclusively boys) who have a history of violence and other behavioural difficulties (often linked to past adverse experiences) where it has proved difficult to achieve family engagement in the approach proposed by the school. 2.3.19. The questions posed for the multi-agency network about service design and coordination mirror those for primary schools (see the previous section) with the recognition that by the age of 13-14 the need for action has become more urgent and it is more likely that the child has begun to experience unhelpful external influences from other pupils or from the community at large. 2.3.20. Secondary schools and the safeguarding children partnership should consider how best to promote this approach, considering the following: Is sufficient help targeted at this critical phase in children’s development and how can resources best be protected, focused and coordinated? Is there a need for specific additional help to liaise between parents and school in situations where the relationship has broken down? Are professionals sufficiently aware of the range of risk factors that should be used to prioritise children and families that need help? Is this being used to identify pupils who need additional support? Can the current work of the youth service focused on primary school children be extended? Is the multi-agency early help assessment tool being used and is it effective? Does it trigger a comprehensive sharing of information so that other agencies involved with the child (for example the YOS) are made aware of the extent of school difficulties? Similarly does it enable 13 Child Safety Commissioner in the Australian State of Victoria (2007).Calmer Classrooms cited in Tower Hamlets LSCB op cit (page 4) 17 | P a g e schools to be more aware of difficulties in the child’s home life and the community? If referrals are made to external agencies (such as early help, social care, educational support services and CAMHS) do approaches to assessment and the thresholds used to allocate resources reflect knowledge about risk? As it appears that engagement with more specialist services is vital in achieving positive outcomes for children, can the multi-agency network as a whole do more to enable parents to take their children to appointments? If practice that is informed by an understanding of children’s histories is believed to be the most effective, can school staff be trained to work in this way or does this approach require the involvement of the multi-agency group? Does the school structure support this? 18 | P a g e 2.4. The ability of the criminal justice system and other agencies to address emerging criminality and possible gang associations 2.4.1. This section considers the evidence about the response of agencies to the emerging criminal activity of the three boys. Much of this criminality was serious, involving violence that affects the community at large including, other young people and vulnerable individuals. Information from the narrative and staff interviews 2.4.2. In order to understand how their criminal activity developed, it is necessary to distinguish the small number of convictions which the three boys had before the incident that triggered this review from the much larger number of episodes in which there was strong suspicion of their involvement in offences but insufficient evidence to achieve a criminal prosecution. The latter form an important part of their pattern of behaviour and assessments of risk should take account of both. 2.4.3. Child A was involved in criminal activity, which became increasingly violent, from the age of 13. The offences which the police were aware of were consistent with involvement in local drug dealing. It is not clear who organised this, how organised it was or how Child A became involved. Professionals believed that there was no family or community pressure to desist from offending. After the incident that triggered the SCR he continued to offend and received a custodial sentence for possession of drugs with the intent to supply. 2.4.4. Child A was referred to YOS in his early teens on a voluntary basis and later under an order, but he did not cooperate in any meaningful way and the interventions had no effect. 2.4.5. Child B’s initial contacts with the police included incidents in which he was missing from home, assaulted his mother and assaulted a younger vulnerable child. Police believe that Child B was involved in local drug dealing but have no evidence of wider exploitation. His family believe that Child B was being pressurised into criminal behaviour. 2.4.6. In 2017 there were three significant episodes involving threatened violence and the use of knives in the 9 months before the incident that triggered this SCR. The YOS has recognised that the incidents in which knives were found did not receive the intervention that they merited. One incident in which Child B was a target of gang-orchestrated violence pointed to risk to Child B and family and possible gang / revenge motivation. It is acknowledged that it should have been taken more seriously by the agencies that were aware of it. 2.4.7. Child C had a long history of behaving aggressively towards other pupils at school (which was not reported to the police) but relatively little history of violence in the community. If the information about the extent of Child C’s home and school problems had been compiled systematically and the 19 | P a g e very negative influence of some of his peers had been taken into account, together with the lack of apparent adult concern for his welfare, agencies may have recognised a higher level of risk. 2.4.8. Although probably the least serious offender, Child C was caught more often and as a result had more contact with the YOS. These interventions give the appearance of having been designed to comply with a required process, rather than thinking about Child C’s individual needs, and were not effective. In the months before the incident that led to this reviewthere were social care interventions which proceeded separately from the work of the YOS and did not inform or support one another. The YOS has recognised that its interventions did not pay sufficient attention to the children’s family background and circumstances. 2.4.9. At this point a teacher who knew two of the young people well initiated a mapping exercise seeking to understand the contacts and relationships between different boys in his school in order to better understand the influences on them and risks to them. He experienced frustration at the time because other agencies showed little interest in this well-intentioned and potentially useful exercise. When he brought individual pieces of information about networks of young people to the attention of the local authority it did not lead to any action, probably because when considered in isolation the information did not point to the need for intervention. This initiative was not taken on at the time by senior members of staff. Learning and recommendations 2.4.10. It is important to underline the distinction between the small number of convictions which the boys had before the incident that led to this review from the much larger number of episodes in which there was insufficient evidence of their involvement to achieve a criminal prosecution. These included assaults and robberies in which: the victim was unwilling to make a formal complaint the perpetrator could be recognised on CCTV but there was insufficient other evidence, or by a witness who refused to provide a formal identification there was plausible intelligence of a suspect’s involvement but no useable evidence forensic or circumstantial evidence linked the individual to the crime without sufficient corroboration A large number of other crimes go unreported, especially if the victim is vulnerable or known to the perpetrator. Two of the young people had been involved in complex and serious incidents which remained ‘under investigation’ some months later. 2.4.11. These instances are significant because information about them (including information about arrests and release under investigation) was not always 20 | P a g e shared between agencies, or was shared only after a delay. One of the reasons for this is that police officers viewed the young people involved in the alleged incidents as potential perpetrators and did not recognise that they might also be in need or at risk. Thames Valley Police has recognised that there needs to be clarity about the need to share information about such incidents with the Multi-Agency Safeguarding Hub (MASH), which screens possible referrals to the local authority and for the MASH to consider relevant cases, linking this information to that held by other agencies. 2.4.12. If information about strongly-suspected criminality is not shared with other agencies it will not inform their assessment. When there are violent incidents this can be an important gap which may significantly alter the professional understanding of risk and need. 2.4.13. Other factors influence the extent to which information about criminal activity can be acted on by the police or comes to the attention of other agencies. During much of the period under review, political influences discouraged the use of stop and search powers, police training emphasised the need for officers to be extremely cautious in its use, there was less confidence among officers using the power and a fear of negative community reaction. Consequently records show only a small number of instances in which these three young people were found carrying a knife, although police intelligence indicated that two of them did so habitually. 2.4.14. At this time when a young person was found with a knife the outcome may have been a caution or a caution associated with a referral to the YOS, even if it was a repeat occurrence. When Child B refused to engage in activities, the YOS was not keen to return him to court to offer the court the option of a different sentence. 2.4.15. As a result young people are likely to realise that there is little chance of being caught in possession of a knife and that if they are caught the punishment for carrying or threatening to use a knife is not one that acts as a strong disincentive. 14 Taken together this is extremely frustrating for the police and others working in the criminal justice system. 2.4.16. It is often stated that the police acting alone cannot solve the problem of serious youth violence and that other agencies need to address the underlying causes. However if there is no effective response to patterns of serious offending (including carrying knives) the message that this risks giving to young people is that the adults have lost control, rendering 14 A flexible approach is sometimes adopted by other professionals. Research by Ofsted in London has shown that many school heads choose not to report children who bring knives to school to the police though there is no evidence that any of the Buckinghamshire schools adopted this stance. Ofsted, March 2019, Safeguarding children and young people in education from knife crime 21 | P a g e measures to address wider welfare, social and educational concerns less likely to be successful. Positive welfare, health and social measures need to run alongside strong enforcement and firm sentencing.15 This was always clear in the development of the ‘public health’ approach developed in Glasgow, but is not highlighted in some current discussions.16 2.4.17. To be effective the response to organised criminal activity involving young people must be better organised. Based on the incidents involving these three young people this requires six things: consistent reporting and sharing of information about offending (including suspected events that remain under investigation) between all of the agencies involved in the criminal justice system and a proportionate sharing of information with other agencies. mapping of incidents and networks to provide a more fully informed assessment of risk rapid responses to incidents which cannot depend on the outcome of a criminal investigation, including disruption activity directed against illegal activity more attention from the YOS to children’s family circumstances and history tighter supervision from the YOS when young people are referred for voluntary preventative work to ensure that the intervention is meaningful. All of these require that professionals have a greater awareness of the signs and symptoms of gang affiliation and criminal exploitation. 2.4.18. This all in turn requires a closer and more responsive working relationship between agencies (particularly but not exclusively) police, YOS, social care and schools. Additional information and support must come from health agencies (such as Emergency Department, other unscheduled care settings and CAMHS) 2.4.19. Since the period under review there has been a recognition on the part of Thames Valley Police and the Youth Offending Services that some existing approaches were not effective. As a result there was a significant (27%) rise in the use of stop and search in the town where the incident took place. Positive outcomes in this area have been the highest in the Thames 15 See for example Centre for Social Justice (2018) It can be stopped: A proven blueprint to stop violence and tackle gang, Chapter 2. This summarises the approach taken in many cities including Cincinnati, Boston and Glasgow which included more effective detection, gang call-ins making it clear to gang members that there was no community tolerance of their behaviour while at the same time offering positive avenues for gang members. 16 For example the Violence Reduction Unit set up by the Mayor of London which has little focus on heightened police enforcement, https://www.london.gov.uk/what-we-do/mayors-office-policing-and-crime-mopac/violence-reduction-unit-vru/public-health-approach-reducing-violence 22 | P a g e Valley Police area (28%) during this period, suggesting effective use of the power. 2.4.20. There has been a greater focus on the involvement of young people who are involved in criminal drug supply through closer weekly scrutiny of all ‘possession with intent to supply’ crime reports. When youth suspects are identified, their details are shared with the relevant social care team. In January 2018 there was a period of intense activity targeting ‘county lines’ activity. 2.4.21. There is a recognition that some of the crimes in these reviews pose particular challenges for investigators including multiple offenders, multiple victims (some of whom might be involved in criminality or are reluctant to engage through fear of retribution), complex forensic enquiries and digital / media interrogation. 2.4.22. The police service has a programme of improvement for investigative work in place which takes account of the complexities of criminal activity raising safeguarding concerns. This will need to ensure that risks associated with knife crime and substance misuse are fully documented so that they can be considered by the MASH. 2.4.23. The YOS has also provided the SCR with a comprehensive account of the improvements in management and oversight of staff and young people implemented since 2018, based on its audit work. 2.4.24. At the time the assessments of the young people failed to identify the specific needs of the individual child, which resulted in intervention plans that were weak, containing very general objectives and failing to address specific problems for the child and his or her family. Management oversight did not test the effectiveness of interventions for individual children due to only specific levels of risk being signed off by a manager. 2.4.25. The safeguarding partnership will now want to confirm that these improvements are having a significant impact on outcomes for children. A recommendation is made in Section 3 of the report (Recommendation 7) 2.5. What kind of safeguarding plan is needed to protect children when the risk arises from the community as well as the family, and when the young person also poses a risk to others? 2.5.1. This section of the report highlights the need for a wider discussion about the most effective approach to the safeguarding of children when risks arise from their contacts in the community (including from gang affiliation) as well as from the family, and when the behaviour of the young person itself poses a risk to others in the community (referred to as ‘contextual safeguarding’). A recommendation is made in Section 3. Information from the narrative 23 | P a g e 2.5.2. Child A was first made the subject of a protection plan when he and his younger brother were at primary school. The children’s parents were living separately. There were allegations of domestic abuse including assaults by extended family members on the mother. The children had severe behaviour problems in school which therapy services could not improve. The mother had very poor mental health which prevented her from caring for the children who were living intermittently with extended family members. The father later spent a period in prison. 2.5.3. At this time there are a substantial number of professional meetings and social work visits to see the children but it is hard to establish from the records what the objectives for the work were, other than to check that the children had somewhere secure to live and that they were able to keep in contact with their mother. 2.5.4. The local authority has recognised in hindsight that too much attention was focused on these basic issues, rather than on the quality of the children’s day to day lives, the care they were receiving, its impact on their health and development and whether it was a satisfactory way of safeguarding their welfare in the long term. The records seen do not explain why this plan was closed when the child transferred to secondary school, a point at which it would have seemed likely that the family might need more, rather than less, help. The local authority was not involved over the following two years (Oct 2012 – 2014) when the child’s behaviour at school and education deteriorated, nor for a further year. 2.5.5. The boy and his younger brother were made the subject of a further child protection plan again in 2015 (under the category of neglect). This remained in place throughout a period when both boys were involved in increasingly serious and violent offending. 2.5.6. This plan was not effective. This was acknowledged by late 2017 when discussions began about the use of the Public Law Outline (PLO) as a possible pre-cursor to care proceedings. It is now recognised that there may have been grounds to make a court application much earlier. It is also not clear whether the use of the PLO – which challenges the parents to provide better care in order to avoid the need for care proceedings – was relevant to the main concerns about the boys at that time particularly the risks arising from their offending and involvement with other young people. 2.5.7. Across several years, social care interventions took insufficient account of Child A’s problems at school and escalating pattern of offending. Social workers seemed to know about developments in these areas but to treat them as issues to be dealt with by separate interventions, rather than an indication of overall risk that needed to be addressed in a single plan or linked plans. 24 | P a g e 2.5.8. The child protection plan directed measures to address these concerns at his parents when it is doubtful if they were in a position to exert effective control over their children. At some points it appears that reliance was placed on involvement with the YOS but during 2017-18 the YOS interventions were not effective, there was limited coordination between the YOS and social care and the impact of the work of the YOS was never critically evaluated as part of an overall protection plan. There is no evidence that the protection plans ever directed attention to external influences and risks. Learning and recommendations 2.5.9. It is clear from talking to a number of social care professionals who worked with this family that there was a considerable effort to help the children and their parents but that the work done prior to 2018 when the children were younger was not effective. Throughout the period under review professionals involved in the child protection and child in need plans seemed at a loss to know how to intervene. As a result the activity was characterised by repeated re-assessment and discussion. 2.5.10. Work was hampered by frequent changes in social workers and managers sometimes leading to inconsistent supervision and plans that were not informed by interventions that had already been attempted. Consequently assessments did not properly understand the day to day lives of the children or delve sufficiently deeply into the origins of their problems. Plans often lacked focus and responded to the changing circumstances of the child without having clear objectives. Steps to address the safeguarding concerns arising from peers and the community (including possible gang involvement) did not seem to be part of the professional vocabulary. 2.5.11. This must be understood in the context that local authority social care services as a whole in Buckinghamshire were judged by Ofsted to be ‘good’ in 2011 but ‘inadequate’ in 2014 so the shortcomings in these plans were not unusual.17 However there are very similar findings in the Croydon LSCB thematic review suggesting that other local authorities struggle with similar problems. Discussing the effectiveness of child protection plans it notes that ‘throughout their childhood, children continued to come to the notice of Children’s Services; some were placed on new child protection plans, and at age 14 there was a peak of children in the cohort coming into care, suggesting that the children’s situations had deteriorated and interventions to that point had been unsuccessful.’ 2.5.12. The Croydon LSCB review interviewed a smaller sample of the 60 children who it found appeared to be ‘resigned to their situation’ because ‘the 17 Individual inspection reports and monitoring visits can be found at https://reports.ofsted.gov.uk/provider/44/825 25 | P a g e issues of domestic abuse, bereavement and related trauma were never addressed and as indicated in research, the impact of these traumas became entrenched. Family difficulties often remained’. The report identified a link between this and gang involvement because ‘the children subsequently sought a sense of belonging, purpose and safety from their peers’.18 2.5.13. Two issues are highlighted by this. The first is a well-established one. How can plans for children (both child in need plans and child protection plans) be made more effective for younger children who are identified as being at risk so that the repeated pattern of referral, assessment, plan, disengagement and re-referral in deteriorating circumstances is broken? 2.5.14. The local authority in Buckinghamshire is subject to close external monitoring. In January 2019 the quality of child protection plans still required improvement, in part at least because rapid staff turnover.19 It is not necessary for the SCR to make a specific recommendation in relation to the way in which the local authority should seek to improve its practice as there are a number of models of practice that have been proposed nationally to ensure greater effectiveness in this type of work with families. It is important however that the multi-agency safeguarding partnership should continue to monitor and challenge the local authority in its improvement work. 2.5.15. The second issue is one that many local authorities are seeking to address: what is the most effective way of intervening to prevent further harm when young people (who may have entrenched family problems) are at risk from other young people or adults in the community, including through criminal exploitation or gang affiliation, and who may in addition also be placing others at risk? 2.5.16. The risk to these children stemmed from factors both within their family and from their contacts in the wider community – for example poor school engagement and contact with other criminals. This illustrates the difficulty of applying existing thresholds and approaches to a problem that is rooted in the young person’s interaction with the local community. The contextual safeguarding approach advocates a series of community-focused interventions targeting wider patterns of behaviour and attitudes that are seen as condoning or promoting violence by and against young people. This may prove to be more effective than seeking to apply child protection procedures designed for families in which the parents are believed to be the source of the risk. 18 Croydon Safeguarding Children Board (2018) op cit 19 Ofsted Monitoring Visit Letter 8 January 2019, https://files.api.ofsted.gov.uk/v1/file/50048619 26 | P a g e 2.5.17. Buckinghamshire has previously participated in efforts to address the problem of ‘contextual safeguarding’ through projects on ‘peer-on-peer abuse’.20 It now needs to address the needs of young people who are involved in serious youth violence, some of whom may have been exploited by criminals. 2.5.18. The local safeguarding partnership will need to consider how effectively its current provision addresses contextual risks, what sort of interventions are most effective and how they should best be coordinated. These are likely to include youth services, the voluntary sector, substance misuse services and a range of others. 2.5.19. . Recommendations 8, 9 and 10 address these findings. 2.6. The planning, operational coordination and strategic oversight of services to combat serious youth violence 2.6.1. The majority of the professionals who contributed to the review noted that serious youth violence is a growing problem in Buckinghamshire; one that requires different solutions. More than one told this review that ‘this is organised crime and it needs a better organised response’. 2.6.2. Two themes emerge strongly from this overview. Firstly, giving priority to certain services such as the early years prevention, early help in primary schools and behaviour support in years 7 and 8 in secondary schools. Secondly intensive responses to emerging serious youth offending, coordinating the activity of different agencies and partnerships in early help, for those on the cusp of becoming involved in violent crime and those already involved. 2.6.3. Cooperation and coordination will require (among other things) agreement on priorities, the allocation and reallocation of resources as well as agreement of thresholds, information sharing arrangements and joint training, as well as challenges to agency culture and methods of working. This in turn will require strategic oversight. 2.6.4. At present a number of partnerships, boards and reviews have an interest in this work, including: • Youth Offending Service Board • Safer Stronger Partnership Board • Bucks County Council Improvement Board • Early Help Review • Special Educational Need Review 20 C.Firmin et al (2016), Towards a contextual response to peer-on-peer abuser: Research and resources from MsUnderstood local site work 2013 -2016, International Centre Researching Child Sexual Exploitation, Violence and Trafficking , 27 | P a g e 2.6.5. During the course of the SCR it was agreed that responsibility for oversight and coordination of the work on criminal exploitation and serious youth violence would sit with a subgroup of the Safer Stronger Partnership Board. The safeguarding partnership should continue to work closely with this partnership board and this is reflected in Recommendation 1. 28 | P a g e 2.7. Services for black and minority ethnic families 2.7.1. All three of the boys came from black and minority ethnic backgrounds, including Asian and mixed heritage. This section of the report deals with the adequacy and appropriateness of service provision to minority ethnic and religious communities in Buckinghamshire. 2.7.2. Information provided to the review by the Youth Offending Service indicates that there is a slight over-representation of young people of mixed heritage in the youth justice population. In contrast young Asians are understood to be under-represented generally in the population that is known to the youth offending service, but over-represented among those arrested and convicted for possession and supply of drugs. 2.7.3. Professionals report that Child A’s family was very fragmented during most of the period under review, his father living separately and his mother suffering periods of mental illness. The perception of statutory agencies is that members of the mother’s family who were caring for Child A and his brother were very difficult to engage and would do enough to be seen to comply with agency requests without ever accepting the agency’s agenda. 2.7.4. Child B’s mother discussed her concern about the disproportionately high levels of temporary and permanent school exclusion for black and mixed-parentage children with the independent reviewer.21 However she does not claim that his school racially discriminated against him. 2.7.5. Child C’s father presented a mixture of experiences. He described the town where he lived (and Buckinghamshire generally) as open, friendly places where he felt accepted. He described living in a mixed part of the town and being on good terms with neighbours, people drawn from a variety of backgrounds. He was extremely angry with one his son’s schools, which he said had failed to stop him being bullied and with the actions of the local authority education services. However he was very positive about other schools attended by his children and about the health provision made for his children. His descriptions of the extent of his son’s conduct at school played down the level of difficulties. Learning and recommendations 2.7.6. These young peoples’ stories highlight some important themes, including gaps in understanding between some statutory services and some minority communities. 21 https://www.ethnicity-facts-figures.service.gov.uk/education-skills-and-training/absence-and-exclusions/pupil-exclusions/latest#temporary-exclusions-by-ethnicity-and-local-authority Exclusion rates for Asian children are lower. The greatest disparity is the higher rate of permanent exclusion of black pupils. These rates of simple comparisons which do not take account of any additional background social information on the population of pupils. 29 | P a g e 2.7.7. The Asian community in Buckinghamshire is unusual. About 50% of Britain’s black and minority ethnic population lives in areas with relatively high migration and pockets of high social deprivation, with about half living in London, Birmingham and Manchester.22 In contrast the Asian communities in Buckinghamshire live in a county which is predominantly white and largely, relatively affluent, concentrated in a small number of wards in the two towns of High Wycombe and Aylesbury. Numbers of children from black and minority ethnic communities in Buckinghamshire are expected to grow significantly during the next two decades.23 2.7.8. The Asian community in Aylesbury is currently poorly represented on the local authority 24 and (according to staff interviewed) there are relatively few professionals working in statutory agencies who come from this minority community or who have first-hand personal experience of it. Some professionals experience this as an inward-looking community with a low level of integration with the majority population, sometimes seemingly motivated by different values and priorities. Numerous examples given to the review suggest that standards of practice with families from the Asian communities can be poor, with some professionals showing limited knowledge or curiosity about the lives that people lead or the factors that shape the need for services. This lack of knowledge can lead both to negative assumptions being made and to risks not being recognised. 2.7.9. Services, other than community health providers, had not succeeded in making good provision for the families of Child A and Child C. Their parents had been reticent to engage and there are records that show how from a very young age, Child A, his brother and Child C expressed negative attitudes to school, police and sometimes wider mainstream British society. On a number of occasions the women and children in the families have been harmed by violence from partners but also from the wider community. The records all indicate a desire to ‘resolve’ problems within the community rather than approaching or trusting statutory agencies. 2.7.10. These difficulties have been identified before, but not successfully addressed. The panel that led the LSCB case review on child sexual exploitation (CSE) went to very great lengths to consult and involve the communities in its work, because of the marked racial and religious disparity between the known perpetrators and the identified victims of 22 Figures are from Louise Casey Review, Department for Communities and Local Government (2016) 23 Buckinghamshire Early Help Partnership Plan 24 For example only two of the 29 Aylesbury Vale DC councillors appear to be from the Asian community, https://democracy.aylesburyvaledc.gov.uk/mgMemberIndex.aspx 30 | P a g e sexual abuse.25 This evidently needed to be understood and although the CSE review made considerable efforts to do so, it failed. Apart from meeting with individuals and some small groups, attempts to engage the community were abandoned. 2.7.11. At its conclusion the review made a general recommendation on this directed at a subgroup of the LSCB, which is unlikely to have had the power to influence the high level strategy or the culture of agencies. The review has been told that this subgroup spent some time working out a strategy about how to engage with and consult minority ethnic communities but did not then take forward the work. 2.7.12. There is a strong case that a similar wide-ranging effort is needed to understand the specific factors that affect this community in relation to crime and serious youth crime. In what ways are members of the Asian communities victims of crimes and what crimes? What is the experience of Asian youths of crime as victims or perpetrators? What are the specific factors that have driven involvement with gangs and drug dealing? This needs to enable better informed practice across all of the areas of prevention, early help and specialist services discussed in this review. This approach is reflected in Recommendation 11. 25 Buckinghamshire Safeguarding Children Board (2016) http://www.bucks-lscb.org.uk/wp-content/uploads/Serious_Case_Reviews/CSE-Serious-Case-Review.pdf The action plan is also published http://www.bucks-lscb.org.uk/wp-content/uploads/Serious_Case_Reviews/CSE-SCR-Action-Plan.pdf 31 3. RECOMMENDATIONS Strategic oversight of activity to combat serious youth violence Recommendation 1 The multi-agency Serious Violence Strategy should include a strategy to combat serious youth violence (including but not limited to knife crime). The Safer Stronger Buckinghamshire Partnership Board (‘Community Safety Board’) should have oversight of the coordination of activity, the prioritisation of resources and the training of staff required to address the areas of service provision identified in this review. The Serious Youth Violence Strategy should focus on services which can make the most impact during the phases in children’s development highlighted in the review. The recommendations are broad, allowing for action plans to be shaped by local knowledge. As the review had little information about the early years of the children involved, it offers no recommendations in relation to early years. Recommendation 2 The safeguarding partners should work with primary schools to ensure that they are able to identify children who show severe behavioural difficulties, especially physical violence and anti-social behaviour, respond to their needs and if necessary make an appropriate referral for additional early help services. Recommendation 3 The safeguarding partners should ensure that early help interventions for children in primary schools, even when triggered by concerns about school behaviour and attendance, are family-focused and take a full account of the child’s history, family circumstances and any safeguarding concerns. 32 Secondary school transfer The review has highlighted secondary school transfer and the response to emerging behaviour problems in school years 7 – 9 as crucial Recommendation 4 Maintained and academy schools in Buckinghamshire should provide assurance to the safeguarding partners to demonstrate that secondary school transfer arrangements identify any child who has shown severe behaviour problems in primary school and that there is a concerted effort to successfully integrate the child into secondary school involving the full range of school and external services. Recommendation 5 When children in school years 7-9 are experiencing severe behavioural or emotional difficulties, schools and other family support services should make and document persistent attempts to engage the parent in efforts to support the child’s plan. Recommendation 6 Schools and the safeguarding partners should take steps to further reduce unplanned school moves drawing on a multi-agency approach to support the pupil, school and family. This should be informed by improved management information about the reasons for exclusions and other unplanned school moves. The review has shown that there needs to be a better multi-agency response to incidents of serious youth crime in real time and that this should not rely on charges being brought or conviction as in many serious instances this is delayed or does not happen Recommendation 7 The safeguarding partners should ensure that there is a much more rapid, coordinated, multi-agency response to the emerging serious criminality of young people. 33 The review has shown that failure to engage parents in plans for their children is strongly predictive of poor long-term outcomes, including refusal to take the child to a service, repeatedly miss appointments or drop out before anything is achieved. Recommendation 8 The safeguarding partners should ensure that there is a renewed focus on those parents who (for a variety of reasons) do not take up services for their children (including for example CAMHS, Speech and Language Therapy and educational psychology, early help and family support). This should be a feature of the actions taken to implement all of the above recommendations. The poor outcomes for the children were adversely affected by the poor overall quality of local authority safeguarding work. There is an existing improvement plan which the partnership should monitor Recommendation 9 The safeguarding partnership should seek assurance from the local authority that there is continued improvement in the effectiveness of safeguarding work with younger children who are subject to CP or CIN plans so that those plans reflect the daily experience of children and the pattern of referral, assessment, plan, disengagement and re-referral in deteriorating circumstances is broken. The review has highlighted a low level of awareness among some staff in relation to the risk of serious youth violence, gangs, criminal exploitation and contextual safeguarding. The partnership must develop a coherent approach to safeguarding problems originating outside the family. Recommendation 10 The safeguarding partners should ensure that its policies, procedures and practice reflect the best current thinking about contextual safeguarding risks. Black and minority ethnic groups are over-represented in some aspects of serious youth violence in Buckinghamshire, but agencies have not 34 engaged with communities to the extent necessary. This is an important issue as the percentage of ethnic minority children in the local population will increase significantly over coming years. Recommendation 11 The safeguarding partners should ensure that agencies and partnerships actively engage with black and minority ethnic communities over the prevention and reduction of serious youth violence. 35 Appendices Appendix 1 How the review was undertaken and Terms of Reference Appendix 2 Roles of staff interviewed or in attendance at group sessions Appendix 3 References and links to information on the ‘Public Health Approach’ to serious youth crime Appendix I Principles from statutory guidance informing the review method The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith. Reviews should also: Recognise the complex circumstances in which professionals work together to safeguard children. Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. Be transparent about the way data is collected and analysed. Make use of relevant research and case evidence to inform the findings. Working Together to Safeguard Children 2015 (Sections 4.9 and 4.10) 36 Terms of reference for Serious Case Review – Serious Youth Violence REDACTED VERSION Overall objectives 1. To provide a multi-agency narrative of the services provided to (three children involved in serious violent youth crime) and to their families. 2. To evaluate the services provided in order to identify areas in which improvements can be made and to make recommendations 3. In addition to coming to a detailed understanding of the specific case histories, the review will seek • to establish how far the practice in this case is representative of wider approaches and • to understand whether there are underlying weaknesses in safeguarding arrangements and in the services to prevent serious youth violence that the participating agencies and partnerships should understand more fully and address. 4. The review will take account of information about cases that have similarities and draw on relevant inspection findings and research to identify wider or recurring problems. 5. The SCR findings will be reported to the Buckinghamshire Safeguarding Children Board (or its successor body) and will also inform the strategies of the following local partnerships: Youth Offending Service Board Safer Stronger Partnership Board Bucks County Council Improvement Board Early Help Review Special Educational Need Review Specific lines of enquiry and wider questions to be addressed 6. To establish the quality of assessments and plans for the young people • prior to their involvement in the youth justice system • during the period when they were part of the youth justice system (drawing on audits and inspections already undertaken) 37 7. To consider whether individual assessments are taking sufficient account of the relationships that young people form in their neighbourhoods, schools and online (referred to as contextual safeguarding) to inform an understanding of risk to the young person, to his or her family and to the community, and to manage that risk. 8. To assess the effectiveness of multi-agency working arrangements for early help and prevention (in circumstances when the needs of the children did not meet statutory thresholds for social care or criminal justice intervention) 9. To establish whether the services received by the young people were timely and appropriate to the level and type of need identified (noting any wider findings on work with adolescents). 10. To evaluate how adequately professionals understood the impact of the children’s social, ethnic, religious and linguistic background and any disability or special educational needs 11. To understand how professionals obtained and took account of children’s wishes and feelings and involved their parents or carers 12. To understand more about the indicators of risk and vulnerability for children at risk of entering the youth justice system in Buckinghamshire. 13. To consider what more should be done by local partnerships and agencies to increase understanding of ‘contextual safeguarding’ (defined above) to inform and develop interventions to reduce serious youth violence in Buckinghamshire. Areas excluded or limited in scope The focus of the SCR activity and the published report will be on the areas that are considered to be the most important, as the work of the review progresses. The review panel may add additional items may be added to the terms of reference if new information emerges. The SCR will not address directly the question of whether the trigger event could have been predicted and prevented. It will examine the histories of the young people involved to consider whether there were indications that an event such as this should have been anticipated. The objective of the review is to point to potential improvements in services in order to make an event such as this less likely to happen in future. It will therefore not seek to make detailed judgements about all of the services provided to the three young people. The decision to conduct the SCR will not in any way restrict the rights of the children or their parents to seek further detailed enquiry which might be warranted within the complaint procedures of individual agencies. 38 Review method 1. The LSCB asked member agencies to compile chronologies of key events based on the written and electronic agency records. 2. The LSCB established a review panel to oversee the conduct of the review consisting of an independent chair, an independent lead reviewer and author and senior staff from participating agencies. 3. Agency representatives prepared brief management reviews of their involvement with the young people and their families 4. The lead reviewer obtained and considered a range of original documents and records 5. The lead reviewer and independent chair spoke to staff and managers from participating agencies in agency or separate professional groups . 6. The lead reviewer prepared draft reports and findings which were discussed with the review team 7. Further drafts of the report were prepared and circulated to panel members taking into account feedback from the agencies and professionals involved 8. An action planning session was held with senior managers to refine the recommendations arising from the review and begin the development of an action plan 9. The report was discussed by Buckinghamshire Safeguarding Children Partnership 39 Appendix II References Guidance Working Together to Safeguard Children (2015), 4.1 and 4.6 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/97861/gang-violence-summary.pdf Other research and case reviews Buckinghamshire Safeguarding Children Board (2016) http://www.bucks-lscb.org.uk/wp-content/uploads/Serious_Case_Reviews/CSE-Serious-Case-Review.pdf The action plan is also published http://www.bucks-lscb.org.uk/wp-content/uploads/Serious_Case_Reviews/CSE-SCR-Action-Plan.pdf Louise Casey Review, Department for Communities and Local Government (2016) Centre for Social Justice (2018) It can be stopped: A proven blueprint to stop violence and tackle gang, Chapter 2. Alex Chard (2015) Troubled Lives Tragic Consequences – a thematic review, Tower Hamlets Safeguarding Children Board; David Finkelhor, (2008) Childhood Victimization-Violence, Crime and Abuse in the Lives of Young People, Oxford C.Firmin et al (2016), Towards a contextual response to peer-on-peer abuser: Research and resources from MsUnderstood local site work 2013 -2016, International Centre Researching Child Sexual Exploitation, Violence and Trafficking , Charlie Spencer, Bridget Griffin & Maureen Floyd (February 2019) Vulnerable Adolescents Thematic Review, Croydon Safeguarding Children Board. Violence Reduction Unit set up by the Mayor of London which has little focus on heightened police enforcement, https://www.london.gov.uk/what-we-do/mayors-office-policing-and-crime-mopac/violence-reduction-unit-vru/public-health-approach-reducing-violence 40 Links to articles on the ‘public health response’ to serious youth violence Government summary ( 2011) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/97861/gang-violence-summary.pdf Led by the Home Secretary (alongside the Secretary of State for Work and Pensions), the review looked into the scale of the problem of gang and youth violence, analysed its causes, and identified what can be done by government and other agencies to stop the violence and to turn around the lives of those involved. The cross-government report, published on 1 November 2011, set out detailed plans to make this happen through: providing support to local areas to tackle the problem preventing young people becoming involved in violence in the first place, with a new emphasis on early intervention and prevention pathways out of violence and the gang culture for young people wanting to make a break with the past punishment and enforcement to suppress the violence of those refusing to exit violent lifestyles partnership-working to join up the way local areas respond to gang and other youth violence Government report (2012) government report https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216977/Violence-prevention.pdf Information about the ‘Glasgow approach’ https://www.theguardian.com/uk-news/2018/apr/06/treat-london-violence-as-public-health-crisis-say-scottish-experts “It is about stabilising the patient first of all. We’re 12 years into this now, but we started off with policing – police on the ground, stop and search, mass enforcement,” he said. In its early years, the VRU lobbied successfully for increases in maximum sentences for carrying knives. The style of policing was critical to success in London, said McCluskey. “You need to put your best cops into the community and keep them there. People who are genuinely motivated, understand that they’ve got a latitude and discretion to engage and get to know people, because they’re also gathering intelligence at the same time. If you just have loads of cops in cars rushing from call to call, that’s not the same. You have to police by consent.” 41 The VRU adapted initiatives first used in the US city of Cincinnati, targeting known gang members and asking other members of their community, including bereaved mothers, to explain the ripple effects of violence. It offered young men a way out through education, training and mentoring – importantly, delivered by someone with similar experience of street violence. It has gone on to develop ground-breaking prevention programmes for schools and A&E departments, as well as bystander training for bar and nightclub staff. Niven Rennie, the director of the Scottish violence reduction unit, said: “The SVRU started by treating violence as a disease which was infecting our communities. From teachers and social workers to doctors and dentists, police and government, we have all worked together to make Scotland safer. https://www.theguardian.com/uk-news/2018/sep/19/sadiq-khan-london-mayor-launches-anti-violence-plan-based-on-glasgow-unit To do this the VRU has had to think and work creatively looking around the world for inspiration. In tackling gang crime the unit imported a successful anti-gang violence initiative spearheaded in Boston in the 1990s. The Community Initiative to Reduce Violence (CIRV) programme broke up Glasgow's long established gangs by offering members an alternative to the violent lives they were living . The VRU also successfully lobbied for increases in maximum sentences for carrying knives. With studies suggesting police under-recorded violence by as much as 50 to 70% the VRU's researchers have carried out injury surveillance in A&E departments, helping to fully define the scale of the problem facing Scotland. The unit has also supported the training of vets, dentists, hairdressers and firefighters to identify the signs of domestic abuse, giving professionals the skills to safely and effectively intervene. The VRU team is a mixture of researchers, police officers , civilian staff and former offenders who have turned their lives around and are now seeking to help others do the same. http://actiononviolence.org/about-us British Medical Journal (May 2018) https://www.bmj.com/content/361/bmj.k1578 42 London Violence Reduction Unit https://www.bbc.co.uk/news/uk-england-london-45570905 https://www.london.gov.uk/city-hall-blog/mayor-sets-violence-reduction-unit-tackle-violent-crime https://www.london.gov.uk/press-releases/mayoral/new-public-health-approach-to-tackling-violence There is a view that the London VRU has failed to adopt key elements of the approach taken in Glasgow Centre for Social Justice (2018) It can be stopped: A proven blueprint to stop violence and tackle gang, Chapter 2. The evaluation of an initial pilot undertaken in three boroughs in 2015-16 explored the reasons for this in more detail https://www.london.gov.uk/sites/default/files/gvi_london_evaluation270117.pdf |
NC51197 | Non-accidental head injury to a 2-year-old boy, Child A, in February 2016. The injury was discovered during an unannounced visit by a social worker. His mother had no explanation for the injury and had not sought medical help. Child A lived with his mother and older brother (Child A1) who was born in 2007. Both children were subject to Child Protection Plans under the category of risk of emotional harm on two separate occasions. Reports of incidents of domestic abuse as well as the physical abuse of older brother by mother. Evidence of mother's complex mental health issues, drug and alcohol abuse and series of abusive relationships. Child A1 is described as a young carer for his mother and younger brother. Ethnicity or nationality of Child A is not stated. Lessons learned include: the seriousness of the concerns and risks to the children were not effectively communicated, shared or addressed; professionals need to retain open minded curiosity and consider all potential risks to children; and professionals should be supported in considering the impact on them of working with people who present as aggressive or with challenging behaviour. Recommendations include: conduct a multi-agency review of the use of the category of emotional harm in child protection plans; ensure that professionals understand the purpose of the Core Group and Child Protection Conference; and recognise the impact on practice when working with adults with violent and aggressive behaviour or disguised compliance.
| Title: Overview report: serious case review: SCR Case A 2017. LSCB: Leicestershire and Rutland Safeguarding Children Board Author: Sue Gregory Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final March 20191 OVERVIEW REPORT SERIOUS CASE REVIEW SCR Case A 2017 Independent Chair and Author: Sue Gregory Final March 20192 Contents Page Section 1 Introduction 3 Section 2 Methodology 4 Section 3 Key events during scoping period 5 Section 4 Analysis and practice learning 5 Section 5 Conclusions 10 Section 6 Learning Points 11 Section 7 Recommendations 12 Section 8 Actions to date 12 Appendix 1 Terms of Reference 16 Final March 20193 1. Introduction 1.1 Child ‘A’ was born in 2014 and lived with his mother and his brother, Child ‘A1’, who was born in 2007. 1.2 On 21/2/2016, Child ‘A’ was found with an untreated head wound by a Social Worker (SW) during an unannounced visit to the family home. His mother had no explanation for the injury and had not sought any medical attention. A medical examination at Leicester Royal Infirmary found he had a depressed fracture to the frontal parietal bone of his skull which was suspected to be a non-accidental/unexplained injury. A full investigation was undertaken in accordance with S47 of The Children Act 1989. Child ‘A’ and Child ‘A1’ were subsequently placed with their respective fathers where they have remained. Child ‘A’ has recovered from his injuries. 1.3 Both children were subject to Child Protection Plans (CPP) under the category of risk of Emotional Harm at the time of Child ‘A’s injury. This was the second episode of them being subject to a CPP. 1.4 The Leicestershire and Rutland Local Safeguarding Children Board (LSCB) commissioned a Serious Case Review (SCR) in accordance with Working Together to Safeguard Children 2015 and the Local Safeguarding Children Board Regulations 2006. The Terms of Reference (TOR) for this SCR are found in Appendix 1. 1.5 The LSCB appointed Sue Gregory as Independent Chair and Overview Author for this review. Sue is a Health and Care Professions Council (HCPC) registered SW with over 30 years’ experience, predominantly in children’s services and, in particular safeguarding, as front line worker, manager, child protection co-ordinator, head of safeguarding and director. She has worked independently as MatthewThomas Associates since 2009 and has extensive experience of undertaking independent reviews in both children and adult services. 1.6 This report seeks to provide an analysis of what happened, what could be done differently and what has already changed. The specific questions to be considered in this review were identified by the LSCB as: Were all assessments and interventions timely? Were all risks and the source of those risks to the children identified and addressed? Was there sufficient professional challenge of mother and her behaviour? Was Emotional Harm the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks? In addition, the Independent Chair of the L&R LSCB requested: Scrutiny of the step down process from CPPs and to clarify whether this was followed through and was effective in this case Consideration of any required improvements in local pathways to respond to Domestic Abuse (DA). Final March 20194 2. Methodology 2.1 All agencies to whom Child ‘A’, Child ‘A1’ and their mother were known have participated in this review. 2.2 Agencies were asked to complete a detailed chronology of their involvement with the family during the scoping period, 1/1/2014 to 21/4/2016. They were also asked to identify any relevant information prior to this period, in particular, issues relating to DA, Adult Mental Health, Child Protection and Alcohol/Substance misuse. Sue Gregory met with the authors of these reports. 2.3 The Serious Case Review Panel, chaired by Sue Gregory, met on four occasions to plan and deliver the review, and formulate the findings and conclusions. Membership of this panel is found in the TOR in Appendix 1. 2.4 A multi-agency meeting of staff who had worked directly with the family contributed significantly to the accuracy of facts, analysis and learning. This was also an opportunity for operational staff to feel part of the review process as well as provide a sounding board and challenge to the Independent Chair and Overview Author’s findings at that point. Final March 20195 3. Key Events during the Scoping Period 3.1 The scoping period can be divided into 4 phases of activity: January 2014 until first Initial Child Protection Conference (ICPC) on 21/8/2014 ICPC and CPP until removal of CPP on 6/5/2015 End of CPP and beginning of Children in Need Plan (CiN) until second ICPC on 26/2/2016 ICPC and CPP until incident on 21/4/2016. 4. Analysis and Practice Learning 4.1 This section sets out to analyse practice in the context of the specific questions set out in the TOR for this review and will address each in turn. 4.2 Were all assessments and interventions timely? 4.2.1 There had been 11 Social Care led assessments in respect of the family up until the incident that led to this review. While there is no indication that these were not completed within the required timescales, there is concern about the robustness and outcomes of these assessments. A significant example of this is the Core Assessment that was noted as being completed on 25/3/2014 in respect of concerns about Child ‘A1’ as a result of the reports of incidents of DA. The children’s mother was known to be 4 months pregnant at the time of the assessment. The SW’s assessment appropriately identified that the threshold of significant harm was met in relation to DA, mother’s mental health and that Child ‘A1’ was describing supporting his mum after Child ‘A’s father had upset her. In addition the children’s mother was in denial about the concerns. It is of concern that the manager’s decision was not to proceed to ICPC but that a Signs Of Safety (SOS) meeting should be convened and that support should be given to the children’s mother and Child ‘A1’ regarding DA issues and risks to the new baby. Learning Point: An ICPC should be convened whenever the outcome of an assessment is that the threshold of significant harm has been reached and there is no evidence that the risks to the child, including unborn child, have not been minimised or removed. A SOS meeting does not replace the requirement for an ICPC. 4.2.2 The referral to Social Care by the Midwife on 7/4/2014 should have been recorded as a referral and should have at least prompted a review of the decision not to proceed to ICPC less than 2 weeks earlier. 4.2.3 The children’s mother’s attendance at hospital on 14/4/2014, following trauma to her abdomen and fear about her unborn baby, should have been referred to Social Care. Similarly, the Midwife’s concerns, noted on seeing the children’s mother on 30/4/2014 when she had a broken thumb and scratches allegedly as a result of a fight, should have been referred to Social Care. This would have provided another opportunity to review earlier decision making. 4.2.4 The S47 enquiries leading to the first ICPC were conducted in a timely manner and the meeting was arranged within required timescales. Final March 20196 4.2.5 Child ‘A1’s disclosure of being physically abused by his mother just 8 days after the first ICPC and being placed on a CPP were appropriately investigated under S47. However, a visit should have been made to the family home and the child seen on the same day and not completed 3 days later, particularly as the intervening time was a weekend and therefore Child ‘A1’ could not be monitored in school. The Police referral following the DA incident on 11/1/2015 assessed as Medium Risk was not followed up by Social Care. It would be expected that the children would have been seen. Learning Point: The decision not to see the child on the same day following a disclosure of physical abuse was not compliant with the LSCB procedures. While these should have been followed, it was even more pertinent for a child who was already on a CPP. Similarly, the children should have been seen following the referral from Police. 4.2.6 Child Protection Review Conferences were held within required timescales. The decision was made at the second review conference on 6/5/2015 that a CPP was no longer needed and that outstanding work, including completion of Social Care assessments and direct work, would be completed under a CiN plan. This appears to have been made on the basis that: there had been no reported incidents of DA since January; a belief that the children’s mother and Child ‘A’s father were no longer in a relationship; and that the children’s mother was co-operating with professionals. It is of concern that the SW records meeting Child ‘A’s father soon after the review conference “as agreed in the CiN plan”, and gathering information about his background, parenting experience and wishes in connection with Child ‘A’. It would have been expected that this should have been completed to inform the previous CPP. There is no evidence of this information being placed in the context of an assessment. Learning Point: On the basis of information available to this review, this decision was over optimistic and the sustainability of a safer environment had not been thoroughly assessed or tested. 4.2.7 The School promptly and appropriately referred the injuries seen on Child ‘A1’ and his disclosure on 8/2/2016. The information was correctly investigated under S47 and resulted in the second ICPC. It is unclear why legal advice was not recommended or sought given the history, lack of real change and lack of impact planning. Learning Point: Legal advice should be sought where there is a long history of concern with no evidence of real change. 4.2.8 The SW should have visited the home and seen the children after being informed about the injury to Child ‘A’ and the subsequent hospital visit on 3/3/2016. There should have been more professional curiosity about the incident in the context of him already being on a CPP. Learning Point: as 6.2.5 4.2.9 It is of concern that it is only noted at the Core Group meeting on 14/3/2016 that parenting assessments should be completed in respect of all of the parents. Such assessments should have been undertaken much earlier. 4.2.10 All health related assessments in respect of the children’s mother, including her mental health, appear to have been completed appropriately and timely in a context of the children’s mother cancelling and DNA some appointments. Final March 20197 4.2.11 Most appropriate health assessments were completed in respect of both children although the children’s mother missed some significant appointments for example Child ‘A’s 1 year assessment. All appointments were rearranged by Health professionals and assessments were eventually completed. 4.2.12 DASH (Domestic Abuse, Stalking & Harassment and Honour Based Violence Risk Assessment Checklist) risk assessments were completed appropriately in the majority of incidents. 4.3 Were all the sources of risks to the children identified and addressed? 4.3.1 Throughout the scoping period, there appears to have been a held view that the risk to the children was as a result of the incidents of DA when the children’s mother was in a relationship with Child ‘A’s father. The belief that this relationship had ended, and therefore the risk had been removed, informed the removal of the first protection plans in May 2015. It is of concern that the evidence of the children’s mother’s own violent behaviour was not addressed or considered in the assessments or decision making. 4.3.2 Throughout this period there was a wealth of information about the children’s mother’s multiple complex issues which included mental health, diagnosis of Unstable Personality Disorder, Eating Disorder, and alcohol and drug abuse. There is no evidence that the impact of all of this on her ability to provide safe care for her children was robustly assessed. 4.3.3 There were a number of occasions when information was available about both parents of Child ‘A’s drinking, as well as potentially driving while under the influence of alcohol, but no evidence of questioning whether the children were with them at the time or who was caring for them. Learning Point: All professionals need to retain open minded curiosity and consider all potential risks to children. 4.3.4 It is of concern that Child ‘A1’ was identified and labelled as a ‘Young Carer’ and was referred to Barnardo’s for support as such. This potentially masked the real issue which was that the children’s mother inappropriately required him to undertake a caring role for Child ‘A’ (there was evidence of him scalding his hand warming milk and another time when the children’s mother was angry with him for overheating it). Child ‘A1’ also reported that he comforted his mum when she had been arguing with Child ‘A’s father and suggestions that he thought of himself as her protector. Learning Point: Caution should be used when referring to children living with parents with mental health and substance misuse issues. An assessment of whether their needs are being met and whether they are at risk should always be undertaken and inform the appropriate pathway. 4.4 Was there sufficient challenge of mother and her behaviour? 4.4.1 There is little doubt that the children’s mother had complex needs and was a victim of abuse. There was, however, significant evidence of her being a perpetrator of verbal and physical aggression. Her mood and behaviour were inconsistent and were likely to have at times been affected by her use of prescribed medication / alcohol / illegal substances. At times she was described as unstable and unpredictable while, other times, she was clearly able to engage with staff. It is clear that her behaviour impacted on staff and while some Final March 20198 continued to engage with her and provide appropriate challenge, e.g. the Head teacher, others were able to say it was impossible e.g. Home-start. Learning Point: All professionals should be supported in considering the impact on them of working with people who present as aggressive / with challenging behaviour. 4.4.2 There are points when the relationship between the children’s mother and her SW was concerning. For a period of time, a significant amount of communication was conducted via text messages. There is also evidence that, on more than one occasion, the SW was asking the children’s mother’s permission to visit the house, thanking her for allowing the visit and apologising for upsetting her. It is not clear how much this was influenced by the children’s mother’s behaviour or was just poor practice but it is understood the issues have been addressed with the individual worker. Learning Point: The use of texting as a means of communication should be used appropriately to provide factual information and reminders and not to replace a telephone call or face to face conversation. 4.5 Was Emotional Harm the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks? 4.5.1 On the basis of information provided to this review, it is clear that the category of ‘Emotional Harm’ was used in recognition of the evidence that living with DA is emotionally harmful. There is no doubt that the environment that both these children had lived in since birth, whether the children’s mother was in a relationship or not, was emotionally damaging and potentially the cause of long term harm. However, the immediate and short term risk to these children was of Physical Abuse, both as a result of the violence within the children’s mother’s relationships or perpetrated by the children’s mother herself. It is clear that some professionals held a clear view that the children were at risk of physical harm with at least one challenging the decision at conference. They report being told that ‘Emotional Abuse’ would cover all risks which would be addressed in the protection plan. Attendees at the focus group believed that they had a voice in the decision whether or not a child should be made subject to a protection plan but that the decision about the category of harm is the responsibility of the chair. Learning Point: The purpose of naming a risk is to place professionals’ and the family’s attention where it should be and, in this case, should have been physical harm. All forms of abuse are inherently emotionally harmful but Emotional Harm is not intended to be used as a catch all category. 4.5.2 The protection plan did not appropriately address the presenting risks and the sources of those risks to these two children because they had not been properly identified. The plan was not SMART and it was therefore difficult to measure its effectiveness. There is evidence that the frequency of Social Work visits, and the children being seen by SWs, did not meet the requirements of the plan or comply with LSCB procedures. This should have been picked up in meetings of the Core Group and Social Work supervision. It is of concern that the Core Group meetings were noted as reviewing the plan when the purpose is to review the implementation of the plan and address any challenges. It is suggested that it is the purpose of the Review Conference to review the plan and make any significant changes. Learning Point: Plans should be SMART. The distinct purpose of both the Core Group and Review Conference should be clear. Compliance with the plan should be monitored by the Core Group and in professional’s supervision. Final March 20199 4.6. The effectiveness of step down processes from CP to CiN 4.6.1 The step down from CP to CiN was premature in this case and evidence suggests there remained confusion about whether actions were to protect the children or provide support to the children’s mother and the children. While there was a plan on the SW file, there was no evidence of any multi-agency meetings to agree the content and implementation of the plan. In this case it meant that, although there remained a great deal of activity by all agencies with evidence of some communication and sharing of information, there was no agreed and understood sense of purpose or co-ordination of that activity. 4.6.2 It is of concern that Health and Education colleagues on the panel and the focus group reported that the experience in this case was not unusual. Learning Point: CiN plans are a statutory process under S17 of the Children Act and are intended to provide multi-agency plans to provide services to promote a child’s welfare. They should be afforded a clear focus of attention, be formulated by a multi-disciplinary meeting and be SMART. 4.7 Are improvements required in the local pathways to respond to DA where there are children in the family? 4.7.1 All but one of the incidents reported to the Police were appropriately identified as DA. A DASH risk assessment was completed and appropriate referrals were made to Children’s Social Care. An appropriate referral was made to ‘Project 360’ which resulted in a Victim Support Worker visiting the children’s mother. Concerns about the children on that visit were passed to the SW. An appropriate referral was made to Wallaction for ongoing support though the Independent Domestic Violence Advisor (IDVA) service but, despite numerous attempts to contact the children’s mother, she failed to engage. The concerns were referred to a Multi-Agency Risk Assessment Conference (MARAC), but lack of capacity meant that Child ‘A’s father and risk to the children’s mother were not discussed for 2 months. Learning Point: On the basis of interventions in this case, it appears that the local pathways are adequate; however there should be consideration given to the capacity of the MARAC and whether it can meet local need in a timely fashion. 4.8 Other issues 4.8.1 Supervision: there is evidence of key Health staff accessing safeguarding supervision. There is also evidence of the SWs accessing regular supervision with the team manager. However, there is concern that many of the sessions appeared unfocused, did not provide adequate challenge or reflection and did not meet the policy requirements or standards. 4.8.2 There is evidence of good direct work with Child ‘A1’ by the School Nurse (SN) who used a variety of tools to ascertain his wishes and feelings. This elicited a great deal of information about what life was like for him and his relationship with his mother, including that he was scared of her and at the same time sought to support her. 5. Conclusions Child ‘A’ and his brother had lived in a high risk environment since birth where there was evidence of, at times, uncontrolled violence Final March 201910 That the children’s mother had a long history of mental health issues and alcohol abuse and that there was a long history of a series of abusive relationships Although the family were visible and well known to a range of universal and specialist services, the seriousness of the concerns and risks were not effectively communicated, shared or addressed That the children’s mother did, in the main, meet the basic needs of her children (a roof, clothing, food) There is evidence of professionals being committed to engaging the children’s mother and working hard to support her needs, but that sometimes the primacy of the safety and well-being of the children was lost There is evidence of some good practice, particularly by the School staff and SN, to hear Child ‘A1’s voice and represent that to Social Care who had a duty to investigate. Child ‘A1’ was able to tell his story of what life was like for him and Child ‘A’ and the responsibility he felt (and was placed on him by the children’s mother) to support his mum and brother. This responsibility was compounded by professionals who regarded him as a “Young Carer” That the focus of Social Care assessments and interventions was based on a belief that the source of risk was from the violence within relationships and, when these ended, the risk was reduced. It appears that professionals did not maintain open minded curiosity and did not hear / see the complexity of risks that were present despite there being a wealth of information readily accessible. It is suggested that the numerous Social Care led assessments either did not ask the effective questions or use all of the available information. Although it was outside of the scoping period, it is hard to believe that the threshold of significant harm was not previously met in relation to Child ‘A1’ The use of Emotional Harm did not accurately reflect the risk to the children. This is of particular concern at the second conference that had been convened following a physical assault on Child ‘A1’ by the children’s mother. It is suggested that poor assessments and an inappropriate category contributed to the ineffectiveness of the Protection and CiN plans in achieving sustainable change. As a result: Both children remained at risk of physical harm. Final March 201911 6. Learning Points An ICPC should be convened whenever the outcome of an assessment is that the threshold of significant harm has been reached and there is no evidence that the risks to the child, including unborn child, have not been minimised or removed. A SOS meeting does not replace the requirement for an ICPC. The decision not to see the child on the same day following a disclosure of physical abuse was not compliant with the LSCB procedures. While these should have been followed, it was even more pertinent for a child who was already on a CPP. Similarly, the children should have been seen following the referral from Police. On the basis of information available to this review, this decision, at 4.2.6 regarding the CPP being no longer needed, was over optimistic and the sustainability of a safer environment had not been thoroughly assessed or tested. Legal advice should be sought where there is a long history of concern with no evidence of real change. All professionals need to retain open minded curiosity and consider all potential risks to children. Caution should be used when referring to children living with parents with mental health and substance misuse issues. An assessment of whether their needs are being met and whether they are at risk should always be undertaken and inform the appropriate pathway. All professionals should be supported in considering the impact on them of working with people who present as aggressive / with challenging behaviour. The use of texting as a means of communication should be used appropriately to provide factual information and reminders and not to replace a telephone call or face to face conversation. The purpose of naming a risk is to place professionals’ and the family’s attention where it should be and, in this case, should have been physical harm. All forms of abuse are inherently emotionally harmful but Emotional Harm is not intended to be used as a catch all category. Plans should be SMART. The distinct purpose of both the Core Group and Review Conference should be clear. Compliance with the plan should be monitored by the Core Group and in professional’s supervision. CiN plans are a statutory process under S17 of the Children Act and are intended to provide multi-agency plans to provide services to promote a child’s welfare. They should be afforded a clear focus of attention, be formulated by a multi-disciplinary meeting and be SMART. On the basis of interventions in this case, it appears that the local pathways are adequate; however there should be consideration given to the capacity of the MARAC and whether it can meet local need in a timely fashion. Final March 201912 7. Recommendations 9.1 That the LSCB: Commission a multi-agency review of the use of the category of Emotional Harm, that the findings and recommendations are reported to the Board and that the Board seeks assurance that recommendations are implemented The Board seek evidence that professionals in all agencies understand the distinct purpose of the Core Group and Child Protection Conference That consideration be given to how the Board can be assured that CPPs are both SMART and robustly implemented Consideration is given to Board to seek assurance that management supervision in all agencies recognises the potential impact on standards of practice when working with adults with violent and aggressive behaviour or disguised compliance The Board to seek assurance of evidence that staff in all organisations are supported in being aware of the impact of working with violence and aggression, and in mitigating against it, affecting practice and interventions For the LSCB to be assured that robust information sharing pathways are designed to ensure all agencies, including GPs, are informed about serious and medium risk DA incidents. 8. Actions taken to date Commission a multi-agency review of the use of the category of Emotional Harm, that the findings and recommendations are reported to the Board and that the Board seeks assurance that recommendations are implemented The LSCB has formed a multi-agency group, led by the Leicestershire Children’s Social Care Head of Children’s Safeguarding, to manage a case file check of cases which have used the Emotional Abuse category in either the last six months or last 20 cases. This is to establish if Emotional Abuse was the appropriate category to be used in the circumstances of the case. This group will report back to the LSCB in order to provide assurance to the Board. In addition, as part of the SCR process, all Independent Reviewing Officers (IROs) were spoken to by the Individual Management Review (IMR) author. As a result, it is felt that IROs have a better understanding of the issues and are more likely to use the category of Physical Abuse when it is appropriate. Final March 201913 The Board seek evidence that professionals in all agencies understand the distinct purpose of the Core Group and Child Protection Conference The LSCB has instructed safeguarding leads in partner agencies to ensure relevant staff, who may attend Case Conferences and Core Groups, are fully aware of their role and responsibilities at the meetings. The main agencies involved are: Children’s Social Care (CSC) Police Education Leicestershire Partnership NHS Trust (LPT) University Hospitals of Leicester NHS Trust (UHL). The intention is that CPPs can be managed more effectively to reduce risk. This will be monitored through the IROs reviewing CPPs and raising quality assurance alerts on the CPP to ensure it is effectively managed by core groups to reduce risk. The Safeguarding Boards’ publication, ‘Safeguarding Matters’, will also highlight this issue for staff across all local agencies. A new training course for safeguarding professionals that will cover the responsibilities of Core Groups and CP Conferences is the Tier 3 Working Together Course that is in the process of being commissioned. This is expected to be delivered during the first quarter of 2019. That consideration be given to how the Board can be assured that CPPs are both SMART and robustly implemented Work is being undertaken with Case Conference chairs and the Children’s Social Care Safeguarding Unit to ensure that CPPs are both ‘SMART’ and robustly implemented. A learning session has been delivered to all team managers on ‘SMART’ action planning. The practice excellence team have provided a training session to the IROs. As a result, IROs have been made aware of the issues and are more likely to use the category of Physical abuse rather than Emotional abuse when it is appropriate. Consideration is given to Board to seek assurance that management supervision in all agencies recognises the potential impact on standards of practice when working with adults with violent and aggressive behaviour or disguised compliance And The Board to seek assurance of evidence that staff in all organisations are supported in being aware of the impact of working with violence and aggression, and in mitigating against it, affecting practice and interventions Safeguarding leads in partner agencies have agreed to ensure managers and supervisors are aware of these issues. The main agencies involved are: Final March 201914 CSC Police Education LPT UHL. The LSCB undertakes a regular programme of multi-agency case file audits; as a routine part of these audits, case supervision notes are viewed and commented on. As part of the ‘Growing Quality’ framework, management oversight and supervision are an integral part of all quality assurance. Further work is planned by Local Authority Learning and Development to focus on disguised compliance, managing aggressive behaviour and the impact on professional curiosity. The messages previously published in the Safeguarding Matters publication under ‘25 things to consider’, which currently includes disguised compliance, will be republished adding a reference to the fear of violence/ intimidation. When the above actions are complete, a review of progress and outcomes is to be reported to the LSCB to provide assurance. For the LSCB to be assured that robust information sharing pathways are designed to ensure all agencies, including GPs, are informed about serious and medium risk DA incidents. All agencies will review their current position on Domestic Abuse information sharing pathways to allow for progress and outcomes to be reported to the LSCB to provide assurance. The agencies involved are: Police LPT UHL GPs Local Authorities (Social Care & Education) Progress on this recommendation includes: Leicestershire Children’s Social Care is currently developing a new integrated multi-agency approach in information sharing pathways. This applies specifically to Domestic Abuse incidents. They have daily meetings with the Police over reported DA incidents. The Leicestershire Education Service, CSC and the Police have Operation ‘Encompass’ in place with schools to enhance communication between the Police and schools where a child is at risk from domestic abuse. Further information can be found at: http://lrsb.org.uk/about-operation-encompass The local Clinical Commissioning Groups are working with the Police and GP practices to further develop Domestic Abuse pathways for reporting incidents which affect children and young people. Final March 201915 Key areas include the development of referral forms and letters that can be accessed via the GP clinical system to support: GPs providing information from patients’ records to MARAC MARAC informing GPs when their patients have been discussed at MARAC. Final March 201916 TERMS OF REFERENCE Appendix 1 1. Composition of SCR Panel: Sue Gregory Independent Chair & Author Chris Nerini Head of Service, Safeguarding Improvement & Quality Assurance, Children & Family Services Leicestershire County Council Janette Harrison Designated Nurse, Children and Adult Safeguarding, Leicester City Clinical Commissioning Group (CCG) Hosted Safeguarding Team Carolyn Corbett Professional & Clinical Lead Safeguarding Children Leicestershire Partnership NHS Trust Siobhan Barber Serious Crime Partnership Manager Leicestershire Police Lisa Morgan Schools Effectiveness Officer Targeted & Intervention Leicestershire County Council Michael Clayton Head of Safeguarding University Hospitals of Leicester NHS Trust Chris Tew Board Officer Leicestershire & Rutland Safeguarding Board Business Office Sue Hughes Administration Leicestershire & Rutland Safeguarding Board Business Office Final March 201917 2. Agencies requested to submit IMR/Chronology Reports : Leicestershire Police Leicester City Clinical Commissioning Group (GPs) Leicestershire Partnership NHS Trust Leicestershire Education (School and College) Leicestershire Children’s Social Care University Hospitals of Leicester NHS Trust (UHL) Leicestershire Adult Social Care Wallaction (Domestic Abuse) Cafcass 3. Scoping period: 1st January 2014 to the 21st April 2016 There is an expectation that any information which is outside the Scoping Period but relevant to the SCR will be included in the Chronology / IMR in particular in relation to any issues relating to: Domestic Abuse Adult Mental Health Child Protection incidents Alcohol or other substance misuse. 4. Agency Chronology: The attached Chronology / IMR template should be completed and used as the basis to consider the specific areas below. Information included in the Chronology should be succinct. The attached record of single agency actions should be completed where issues are identified during the Chronology / IMR process that requires noting by the overview author or further action by the agency. 6. Specific areas to consider in relation to this case: Were all assessments and interventions timely? Were all the risks and the source of those risks to the children identified and addressed? Final March 201918 Was there sufficient professional challenge of mother and her behaviour? Was ‘emotional harm’ the right category of risk for these children and therefore was the protection plan appropriate and relevant to address the risks? In addition, the Independent Chair of the LSCB requested: Further scrutiny is made of the step-down process from CPP to CiN support and in this case, to clarify if this was followed through and how effective it was. Also, the independent author will be asked to consider what improvements may be required in the local pathways to respond to DA where children are in the family. Policies and Procedures: Was the work in this case consistent with: The Agency’s Policies and Procedures for safeguarding and promoting the welfare of children. LSCB’s multi-agency Policy and Procedures. Professional standards. 7. Legal Grounds for Information Sharing: The LSCB Regulations 2006 set out the functions of the LSCB which include undertaking SCRs. The Regulations also confer the power on the Board to engage in any other activity that facilitates or is conducive to the achievement of its objectives. Section 14B Children Act 2004 provides that if the LSCB request a person or agency / organisation to supply information to the Board then that agency / organisation is under a statutory duty to comply with that request provided that: the request is made to assist the Board to perform its functions and; the request is made to a body who the Board consider are likely to have relevant information; and the information requested relates to a person in respect of whom the agency / organisation exercises a function / engages in activity to the agency / organisation to whom the request is made to the functions / activities of the agency / organisation to whom the request is made. |
NC52467 | Death of a 17-year-old girl after an epileptic seizure in 2019. Sarah was considered at risk of being criminally and sexually exploited, and on the day of her death emergency services were called to the home address of a male who was subject of police bail conditions not to have any contact with her. Learning focuses on: mental capacity assessment and cognitive understanding; placements and independent living; understanding contextual safeguarding; understanding and responding to child sexual exploitation; mental health support and counselling; understanding medical conditions; the role of keyworkers. Identifies good practice around: specialist epilepsy support; adult support services; role of foster carers; social care support; and professional curiosity. Recommendations include: ensure that child protection procedures are followed and strategy meetings are convened appropriately, with health, police and children's social care in attendance as a minimum, as well as other agencies who should be included; the use of Missing Intervention or Multi-Agency Child Exploitation (MACE) meeting must not be used in place of child protection procedures; ensure that pharmacies and practices will work collaboratively to support looked after young people with chronic health conditions to encourage regular collection of prescribed medication required to manage their condition; seek assurance that all agencies working with young people understand the requirements of the Mental Capacity Act when considering the ability of young people to make safe decisions.
| Title: Overview report: child safeguarding practice review in respect of: Sarah. LSCB: Worcestershire Safeguarding Children Partnership Author: Jonathan Chapman Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 OVERVIEW REPORT Child Safeguarding Practice Review in respect of Sarah Author Jonathan Chapman Date of submission 21st June 2021 2 TABLE OF CONTENTS Page no 1. Executive Summary 3 2. Foreword 4 3. The family view 6 4. Analysis of involvement 6 5. What are the learning points from this case? 17 6. Recommendations 19 3 1. Executive Summary The subject of this review is Sarah, at the time her death Sarah was 17 years of age. Since an early age, Sarah had suffered from epilepsy, which had been managed by medication. Sarah suffered her first epileptic seizure at the age of 8 months. Between the age of 4 and 5 the seizures ceased but returned in 2009, with 80% of seizures occurring at night. In July 2017, Sarah underwent a brain procedure to limit the number of seizures she was experiencing. In June 2017, Sarah became a Looked after Child (LAC) under a voluntary agreement between the Local Authority and her parents. This meant that both Sarah’s parents maintained parental responsibility. Sarah became looked after following her behaviour becoming more challenging and putting other household members at risk. This challenging behaviour meant Sarah became involved with a number of agencies. Sarah was accommodated with foster carers, but when these placements broke down, more latterly she resided in residential accommodation and then semi independent living arrangements. Over a period of time there were numerous occasions where Sarah was reported as missing from these placements. There were concerns regarding Sarah’s vulnerability and in particular the effect of her medical condition. There were concerns regarding Sarah’s relationships with men who were older than her and the relationship with one male in particular. Sarah was considered at risk of being criminally and sexually exploited. At the time of her death this male was subject of police bail conditions not to have any contact with Sarah. In June 2019, emergency services were called to the home address of this male as Sarah had suffered a seizure and was unconscious. Sarah was conveyed to hospital. Sarah’s medical support was removed and sadly, she passed away. The Worcestershire Safeguarding Children Partnership undertook this review in accordance with guidance1 to identify improvements to be made to safeguard and promote the welfare of children. All agencies identified were involved in this review and the author has had the opportunity to speak with Sarah’s family. The review has identified a number of areas of development to improve how agencies work together to safeguard children and young people. There were two main areas identified which impacted on Sarah. The first was her medical condition and how this was recognised and managed by professionals, in particular when she became a looked after child. The second was how agencies worked together to identify and manage Sarah’s vulnerability to sexual exploitation. 1 Working Together 2018, HMG 4 2. Foreword Worcestershire Safeguarding Children Partnership accepts the findings and recommendations of this report. The Partnership also recognises its responsibility to ensure that the tragic circumstances of Sarah’s death, and the challenges she faced during her short life have led to positive change in the safeguarding of children and young people in Worcestershire. We are grateful to the author of this report that there is clear recognition of the service improvements that have taken place within Worcestershire during the two years since Sarah’s death. In acknowledging these improvements, the recommendations do still serve to remind us that we must never accept our position as being ‘good enough’ and must always strive to improve how we safeguard our children and young people across the county. In support of this the partnership introduced its Get Safe programme in 2019 so coinciding with the commissioning of this review. The Get Safe programme is an innovative and child-focused approach to tackling the many forms of child criminal exploitation and has brought together child safeguarding agencies from across Worcestershire to design and implement enhanced multi-agency processes for the identification, assessment, planning and response to this problem, based on a contextual safeguarding framework. As part of the improvement work we have also firmly embedded our joint working arrangements in our care and child protection process for those children and young people. This has included audit, service user feedback and management of performance measures. As a result we have seen a significant and sustained improvement in the contributions of our partner agencies to those child protection processes, for example since 2018 we have seen attendance and contributions of partners to strategy discussions consistently at 98% or above for Police and Health attendance and in a 2020/2021 survey of 107 children and young people 96% told us that they felt listened to and had their views taken into account. We have strong partnership engagement in our case work and over the past two years 354 partners have undertaken Signs of Safety partnership training so we can talk the same language when we work with families in identifying risk and supporting needs. This partnership working within the context of exploitation has been further embedded through the development of our Multi-Agency Child Exploitation (MACE) framework, a dedicated Worcestershire Children First Get Safe team which works closely with partner agencies, and weekly reviews of missing episodes. These resources use our multi-agency plan of intervention and support which is based on an approach of prepare, prevent, protect and pursue in order to keep safe those most vulnerable to exploitation. This is all underpinned by a programme of multi-agency training for practitioners across the partnership. In addition, the Climb programme and Community Link Workers have strengthened the support available for young people at risk of, or suffering exploitation. This work has been informed by feedback from local young people who have been helped by these services and has had a positive impact on the timeliness and effectiveness of our collective response to children and young people at risk of exploitation within Worcestershire. The recommendations within this report have also highlighted the importance of the effectiveness of review meetings for Looked After Children. Again, in the two years since this review was commissioned there has been a clear focus on improvement in this area, leading 5 to comprehensive change. Quality assurance checks are now undertaken to ensure the review and planning is effective for the child or young person, that the right contributions have been made and that there is no drift and delay in their care planning. This is supported by an audit process which considers partnership attendance, working and communication within the Looked After Child review process. In 2019 Ofsted reported “IROs are active in ensuring that plans progress without delay in most cases. IROs use a well-developed escalation process to resolve practice issues”, evidencing independent validation of the role of the IRO and the well-established dispute resolution process. During the last three years there has also been a significant focus on improving the timeliness and quality of health assessments. A monthly multi-disciplinary meeting is now held that robustly interrogates the completion rates of health assessments whilst looking at solutions for upcoming issues or blocks, to ensure that all children and young people are offered a timely health assessment The last inspection took place July 2019 under the Inspection of Local Authority Children’s Services (ILACS) framework and the report identified the following key findings; • The Local authority has made considerable progress in improving the quality of services to children and families since 2016. • Essential steps have been taken to meet the goals in the service improvement plan. • Senior Leaders and elected members are ambitious for and committed to ensuring the wellbeing, safety and outcomes for children in the county. • Senior Leaders have successfully created a strengthened workforce of stable and permanent workers who know their children well. • As a result, outcomes form many children and their families are better, the changes are embedded on core practice and there is evidence of a sustained trajectory of improvement. The report made eight recommendation for areas of work to focus on. Those recommendations formed part of our business planning 20/21. The WCF business plan can be located at; Meetings and key documents Information - Worcestershire Children First (worcschildrenfirst.org.uk) Clearly, the hard work of all involved in this improvement journey over the last two years and the progress made as a result cannot change the outcome for Sarah. We do hope however that the way in which children and young people across Worcestershire are now benefiting from those improved services, and most importantly who are safer as a result, can bring some comfort to all those who knew Sarah. 6 3. The family view 3.1 Sarah’s family would describe there being two Sarah’s, one was loving and full of fun and her other side was much more challenging and difficult. This was very much dictated by her condition. 3.2 Sarah would suffer serious epileptic seizures of between 4 and 7 minutes, when they exceeded 5 minutes, rescue medication had to be administered. It was a constant source of family concern that no one would be available to administer this medication when Sarah was moved to more independent living. 3.3 The family had a good understanding of Sarah’s condition, having cared for her through some significant epileptic episodes but strongly feel that their voice was not heard when they tried to communicate the level of risk that her condition presented. 3.4 The family feel that Sarah was not capable of caring for herself, if not reminded she would not look after her personal hygiene, she could not manage money, she was easily led and influenced and therefore sometimes, made poor decisions. More concerning for Sarah was that she was not able to adhere to her medicine regime, which presented a real risk. 3.5 The family feel that Sarah functioned emotionally at a level below her years and requested on numerous occasions that this was properly assessed and understood. This was very important for the family as they feel as Sarah moved towards independence her own ability to make good decisions and provide a good level of self-care was not understood and this led to Sarah being placed in accommodation that was not appropriate for her and contributed to her placing herself at risk. 3.6 The family feel that it was clear that Sarah was vulnerable and it was clear that over a period of time, this vulnerability was being exploited by known individuals but this was never effectively addressed and therefore she was not protected. 4. Analysis of involvement Whilst the analysis will look at areas under the themes identified in the terms of reference, it should be noted that the various aspects are inextricably linked. For instance, medical condition, being linked to cognitive functioning, being linked to behaviour and vulnerability, being linked to exploitation and risk-taking behaviour. The underlying theme is that all of these aspects need to be holistically assessed, understood and addressed in a coordinated child centred manner. 4.1 How effective was the partnership’s approach to the recognition recording, information sharing, and management of the risk of Sarah being sexually exploited? 4.1.1 The risk of Sarah being sexually exploited was recognised as early as January 2017, when it was raised by Sarah’s foster carer at the time. The early identification and reporting of the concern is noted as good practice on behalf of the foster carer. 7 4.1.2 Sarah went missing from foster carers and placements with regularity, during the scope of this review which spans 2 ½ years (1st January 2017 to 26th June 2019) Sarah was reported missing on 36 occasions (14 occasions in 2017, 11 in 2018 and 11 in 2019). The Worcestershire Child Sexual Exploitation Strategy 2017-2019 identifies that there is a clear link between children going missing and CSE2. 4.1.3 The regularity of the missing episodes left agencies struggling to effectively keep up with the most recent incident. Whilst there was discussion about multi agency meetings there seemed to be a confused response and important information that should have been discussed was not. It was not clear at various stages what the planned response was and how risk was to be mitigated. Each of these missing episodes were also accompanied with activity that presented a risk to Sarah and these were not considered holistically. The cumulative and escalating effect of Sarah’s behaviour was not effectively assessed. 4.1.4 All of these incidents below warranted consideration of a statutory strategy meeting3 on the basis that Sarah had suffered or was likely to suffer significant harm. The strategy meeting would have enabled sharing of information and pulling together of recent events as well as behaviours that were also happening during these periods of time, enabling a holistic view of Sarah’s lived experience. • Between 10th and 19th April 2017, Sarah took an overdose, was using cannabis and spoke about heroin. • Beginning of May 2019, Sarah had assaulted her foster carer, Sarah, 15 years old at the time disclosed she was pregnant by an older male. • End of May 2017, Sarah had been repeatedly missing, during one episode Sarah was in the company of an older male under investigation for sexual activity with her. • Mid-June 2017, when accommodated in supported accommodation Sarah made an allegation of indecent assault against another resident. • February 2018, on a weekend visit to her family it was believed that Sarah was sending sexual images of herself to an 18-year-old male, police were involved and seized the phone. • December 2018, evidence of concerning contact with Peter which was being denied at this stage by Sarah. • January 2019, evidence that Sarah was using cannabis, she had been to parties and stated that she had sex with a number of males, this was followed by her seeking medical attention for vaginal bleeding. • End of May 2019, after the second arrest of Peter, he admitted setting up false social media accounts to contact Sarah and paying her money. 2 Worcestershire Safeguarding Children Board Child Sexual Exploitation Strategy 2017-2019 (accessed 07/11/20) - Child Sexual Exploitation Strategy 2017-2019 3 West Midlands Regional Child Protection Procedures (accessed 07/11/20) - West Midland Child Protection Procedures - strategy-meeting-discussion 8 5.1.5 When a strategy meeting was convened in March 2019, regarding Sarah’s contact with Peter, it was acknowledged that Sarah was very vulnerable and being manipulated by Peter. After Sarah failed to engage with discussions with CSC and police the strategy enquiry was closed on the basis that Sarah had not suffered significant harm and the police would continue to seek an interview. This decision did not consider the ongoing likelihood of significant harm. As identified by the CSC IMR author, a legal planning meeting could have been sought at any time. This would have provided the opportunity for senior management oversight as well as legal options to be considered. 5.1.6 Child protection procedures were not followed, and therefore a strategy meeting was not convened with health police and CSC in attendance as a minimum, as well as other agencies who should have been included. The use of Missing Intervention or MACE meeting must not be used in place of child protection procedures. 5.1.7 Where MACE and missing intervention meetings were convened, they did not have appropriate agency attendance and the actions set were not effectively followed up. The meetings did not seek to fully understand what the risk factors were or to investigate and understand what the factors were causing Sarah’s missing behaviour and vulnerability. These are often referred to as the push and pull factors. There were numerous opportunities where these factors could have been explored and better understood in Sarah’s case, return interviews, missing meetings and MACE meetings to name but a few. Agencies did not routinely receive minutes of the MACE meetings that did take place. This finding would accord with the comments made in response to the Ofsted Monitoring visit of January 2019, which focused on the local authority’s arrangements for the protection of children and young people vulnerable to child sexual exploitation and who go missing from home or care.4 5.1.8 A more holistic assessment may have understood the contextual safeguarding factors that existed and influenced Sarah’s behaviour. The abuse to Sarah was occurring outside of the family and a better understanding of the external influences would have allowed for more detailed assessment and problem solving. 5.1.9 More latterly in the case, the staff at the YMCA feel that they had started to build a relationship with Sarah and she disclosed information to them, which started to indicate a trust. They felt that this was achieved as the staff were present for more extended hours to support her. 5.1.10 The family, on numerous occasions, raised concerns that Sarah was being paid money by Peter on a regular basis. He presented her with gifts in the form of expensive mobile phones and a gift of a sexual nature on her 17th birthday. More latterly it was apparent that Sarah was spending excessive amounts of money on 4 Monitoring visit of Worcestershire local authority children’s services January 2019 - Ofsted monitoring visit 2019 9 scratch cards and if this had formed into a gambling habit it was an additional factor for Sarah to seek money and therefore the company of Peter. 5.1.11 In June 2019, Worcestershire implemented GET SAFE5.This agenda coordinates action under the 4 P’s of Prevent, Prepare, Protect and Pursue. The initiative includes an risk assessment tool and a GET SAFE pathway. As well as information and support for young people, professionals and parents/carers. This initiative has received national recognition and has received positive evaluation in the year since its launch. 5.1.12 West Mercia Police are enhancing their focus on youth vulnerability by implementing The National Strategy for Policing Children and Young People. They will seek to draw on guidance and continue to develop working relationships with other agencies. This will include each police Problem-Solving Hub having a dedicated Missing Intervention Officer and a Care Home Intervention Officer. Both will focus on young missing persons and facilitating instigation of missing intervention multi agency meetings. 5.2 How effective was the approach to managing the risk the alleged perpetrator presented to both Sarah and others 5.2.1 Apart from the generic risk of Sarah being sexually exploited there were two identified perpetrators. The first was the older (21 year old ) male and the second and more enduring was Peter. 5.2.2 In May 2017, Sarah disclosed that she was pregnant by the older male. He had previously been corresponding with Sarah, aged 15 years at the time, claiming to be 14 years when he was in fact 21. He was interviewed by police and released under investigation. Over the next few months, it was apparent that the contact with him continued but the risk was not addressed. At the initiation of the investigation there was no strategy meeting and one did not take place as the risk continued, consequently the known risk was not addressed. 5.2.3 The risk from Peter was first highlighted in records in August 2018, on Sarah’s 17th birthday. The family had raised concerns prior to this on a number of occasions. A strategy meeting was convened, and investigation showed that Peter’s activity with Sarah and a number of other young people was concerning. Around three weeks later Peter was arrested for sexual grooming offences and his computer was seized. The computer was later found to have extreme pornography on it, for which Peter was later cautioned. Although this arrest was timely it did not provide protection for Sarah. 5.2.4 Peter was released on bail with conditions not to contact Sarah or any young person under 16 years. The issue with police bail is, that if breached there is no power of 5 GET SAFE (accessed 07/11/20) - WSP - GET SAFE 10 arrest except of arrest for the original offence under investigation. If the police are not in a position to initiate proceedings, at that stage, by charging the person, the conditions, whilst being deterrent, are in fact ‘toothless’. Peter did go on to breach the bail by maintaining contact with Sarah. 5.2.5 The police did seek a legal view on obtaining a civil order to manage Peter’s behaviour, this legal advice took some two months to achieve. It advised that a civil order would not be appropriate whilst the criminal proceedings were being progressed. 5.2.6 The time it took the advice to be achieved and the view taken did not assist in managing the risk. The bail conditions offered no enforceable option and without an enforceable order, Peter was at liberty to continue with his harmful behaviour. 5.2.7 Early consideration should have been given to a Sexual Risk Order (SRO) or an Interim Sexual Risk Order6. This order does not require an individual to be convicted or cautioned. SROs can be issued when an individual has carried out an act of a sexual nature and there is reasonable cause to believe that such an order is necessary to protect an individual or the wider public from harm. 5.2.8 Another area where there could have been more expediency is Children Social Care seeking legal advice with regard to considering what measures would protect Sarah such as a wardship7 or court order. Although moving to legal advice was discussed it was not progressed. 5.2.9 Too much emphasis and expectation was put on the criminal proceedings and on any view these were likely to be protracted and in the interim did not afford any protection to Sarah. 5.2.10 Examination of the events indicate that efforts were made to seek to mitigate the risk posed by Peter but there remained a frustration that not much could be done. There was a sense of professional helplessness. The police issued Child Abduction Warning Notices (CAWN) to Peter over his contact with two other young persons under the age of 16. This power, often used as an early intervention and disruption tool, in cases of CSE, whilst open to be used for young people in care of the local authority, it does not cover children or young people looked after under section 20 of the Children Act. This represents a big gap in the use of this valuable tool. This was recognised by the Children Society in 2015, when they lobbied for changes in the Policing Bill to include young people who became looked after under section 20. In 2014 of the 4510 young people aged 16 or 17 years who became looked after, only 190 (5%) were under section 31 and therefore covered by the Abduction Act 6 Sexual Risk Order, Sexual Offences Act 2013 (accessed 07/11/20) - Legislation Sexual Risk Order 7 A Wardship is a civil injunction which can be used to prevent an ‘undesirable association’ between a child and an individual(s). A local authority can make a Wardship application to the High Court to make a named child a ward of court and to seek an injunction against a named individual(s) to prevent that person from making any contact with the child. 11 (CAWN) leaving the 95% of children looked after under section 20, not covered. This still remains an area of concern and legislatively has not been addressed. 5.2.11 In October 2018, the section 47 was completed on the basis that Sarah was not having contact with Peter. Within weeks there was evidence that this was not the case. Sarah moved to independent living, supported by outreach (fully discussed later) and there was information that Peter was staying at the address and hotels with Sarah. This offered the opportunity for this decision to be reviewed or consideration of another strategy discussion. 5.2.12 There continued to be information and intelligence that Peter was having a sexual relationship with Sarah. By March 2019, this had progressed to Sarah informing agencies that she did feel that she had been groomed by Peter and disclosed sexual activity. In May 2019, Sarah disclosed more sexual activity with Peter and there was continued evidence of their association. Had it been felt that an SRO or other civil remedy was not viable at an earlier stage, by May there was strong evidence to support a civil order, the threshold for proof of which, is lower than that of a criminal prosecution. The police had at an earlier stage sought advice on obtaining an SRO but were informed that a criminal standard of proof was required. 5.2.13 There was a reliance on criminal prosecution, those involved in this were tenacious but the options for this were limited in these circumstances. There was consideration about the level of Sarah’s cognitive functioning and whether sexual activity with her as a vulnerable person presented any opportunity. A mental capacity assessment for Sarah was discussed on at least three occasions but this was not progressed. (Discussed in more detail later in the report). 5.2.14 On reflection agencies feel that there could have been a more timely and innovative approach to early intervention and disruption of Peter and his activities. The family strongly feel that when considering the CSE threat their voice was not heard and they felt frustrated that it continued in the area where they lived. 5.2.15 Should the same situation occur today the partnership feels that through ‘GET SAFE’ professionals will be better equipped to deal with the situation and young people will be better protected. The GET SAFE response pathway identifies what needs to happen next for that child. It uses a Red, Amber, Green traffic light system which determines the right initial response to that child/ young person’s GET SAFE risks and vulnerability. Children on the red or amber pathway have the opportunity for direct work from a GET SAFE Link Worker who will work with that child intensively and flexibly in their own environments to understand, educate and support that child with the aim of building safety, being a trusted adult and engaging that child with positive activities or community services with the aim of supporting that child, building safety and disrupting the perpetrators. 12 5.3 To what extent did agencies working with Sarah consider the level of her cognitive function, and the impact that may have had on her ability to contribute to keeping herself safe and to manage her own epilepsy? 5.3.1 Sarah’s family are clear that anyone who had cared for Sarah would agree that emotional function was lower than her age would indicate. ‘Left to her own devices’ Sarah would struggle with basic tasks such as personal hygiene, managing her money, managing her medication it is very evident that Sarah was not able to do any of these things’. The family frustration was that despite their requests that Sarah’s functioning was assessed, it did not occur. The result of this effected the level of support afforded to Sarah. 5.3.2 Section 3 of the Mental Capacity Act says that any person from the age of 16 is able to make their own decision if they can do all of the following four things: 1. Understand information given to them. 2. Retain that information long enough to be able to make the decision. 3.Weigh up the information available to make the decision; and 4. Communicate their decision. The Mental Capacity Act starts on the premise that everyone is able to make their own decision, and decisions can only be made on their behalf if it can be proven that they lack capacity to do so. 5.3.3 Sarah’s mental capacity was first discussed in a strategy meeting on 30th August 2018, a recommendation for a section 47 enquiry was also recommended. This assessment was delayed and not completed until October 2018. This assessment stated that a capacity assessment was not undertaken but it was the social workers view that Sarah had capacity. 5.3.4 In February 2019, a section 47 enquiry stated that ‘Sarah will continue to make choices in relation to her ongoing contact with Peter and has capacity to do so despite there being reason to believe that she is being groomed and manipulated by Peter’ It was recognised that Sarah was not making safe decisions and consideration should be given to her cognitive capacity. 5.3.5 On 17th May 2019, a request was made by the social worker for a formal cognitive assessment, this request was forwarded by the Team Manger to the Group Manager. This request was not put in place before Sarah’s death. 5.3.6 The requirement for a capacity assessment was not given the priority that it required. A capacity assessment may have identified the need for a cognitive assessment, which would have assisted professionals understanding of Sarah’s ability. The CSC IMR recognises that it is of concern that LAC reviews did not escalate the drift and delay in this assessment taking place. 5.3.7 Training on managing epilepsy was delivered to foster carers and to staff at at the residential placement from the specialist epilepsy nurse. The local authority state that specialist epilepsy equipment was purchased but this is disputed by the family who feel that the right equipment was not offered. In particular when Sarah went into 13 independent living, where she was most at risk, a mattress alarm was not purchased. The reason given that the flat given to Sarah did not have a phoneline. This calls into question the suitability of this placement. The family felt it was wholly unsuitable and made this known on a number of occasions. 5.3.8 The training on identifying and dealing with epilepsy which was delivered to the staff at the residential placement was not repeated at the YMCA, leaving staff with no knowledge how to deal with Sarah’s seizures. In June 2019, Sarah returned to the YMCA late having consumed alcohol, she collapsed and was not responsive. She was conveyed to hospital, where Sarah said that she had suffered two seizures. After observation Sarah was discharged back to the YMCA by taxi, which did not recognise the risk that further seizures or Sarah not going back the YMCA presented. 5.3.9 In October 2018, the specialist epilepsy nurse and doctor raised a concern regarding the risk of SUDEP and a concern regarding Sarah living independently. A month later Sarah was given the placement where she received daily outreach support. Despite tenacious efforts the outreach worker was only able to have limited contact with Sarah. 5.3.10 The family feel that more effective use of their knowledge and experience of caring for Sarah and her epilepsy could have been made. They feel that despite repeated requests their voice was often not heard. 5.3.11 Another factor which influenced Sarah and the way that she managed her epilepsy was Peter. It is recorded by CSC that Sarah had stated that Peter did not believe that she suffered from epilepsy and she had been mis-diagnosed. It is likely that Peter was able to exert considerable influence on the management of her condition. This would have presented another consideration for legal action on the basis that Peter’s influence was likely to cause Sarah’s significant harm. 5.3.12 Other factors appeared to exacerbate Sarah’s condition, one of these was anxiety and the other, the use of controlled drugs. Sarah stated that she was using cannabis and this, when used, appears to have initiated a seizure. The consideration of the use of controlled drugs does not appear to have been properly considered on the risk to her due to her condition. 5.3.13 There needed to be a holistic management plan with regard to Sarah’s epilepsy management, which included both the specialists, the family and Sarah. This did not occur. 5.3.14 It was believed at various stages that Sarah was not taking her epilepsy medication. This was confirmed post her death when large quantities of medication were located, and it was established that she had not collected her medication since January 2019. There needs to be a link between the failure of a young person, particularly those who are vulnerable and looked after, not collecting their prescription and CSC, who have the responsibility for their care. 14 5.3.15 Apart from the specialist epilepsy support that Sarah received there was a lack of recognition of the impact and risks associated with Sarah’s epilepsy. Research indicates that Children and young people with epilepsy are more likely to have emotional or behavioural difficulties than children and young people who do not have a chronic illness.8 There is also evidence that worsening epileptic seizures are a clear risk factor for premature mortality.9 5.3.16 When considering the SUDEP risk factors (having poorly controlled seizures, having seizures at night or in bed, having seizures when on your own, frequent and abrupt changes to medication, not taking medication as prescribed, drinking lots of alcohol) many of these applied to Sarah, as identified by the family and specialist epilepsy care. Without careful and constant monitoring and support Sarah was unable to care effectively for herself, particularly when exposed to adverse influence 5.3.17 Support for those involved with Sarah to better understand her condition could have been sought from other specialist organisations such as SUDEP Action10.Advice if sought may have assisted professionals in understanding the risk and complex nature of Sarah’s condition. 5.4 How effectively did agencies balance the competing strands of vulnerability, specifically Sarah’s health issues, her risk of being exploited, her missing episodes and the fact that she was a Looked After Child? 5.4.1 The issues of vulnerability, health issues, risk of exploitation, going missing and being a looked after child, and more particularly the root causes, were not viewed holistically and whilst many agencies and individual practitioners worked hard to address the risks and keep Sarah safe, any actions lacked overall coordination. 5.4.2 The family also feel that one area that would have benefitted Sarah was counselling to address any underlying issues. Sarah was receiving CAMHS support in October 2016 but was discharged for what is described as non-compliance and ambivalence to treatment. A number of referrals were made during the course of the case, in May 2017 Sarah was seen in a CAMHS clinic and assessed as having fluctuating mood and emotional dysregulation. In January 2019, the GP recorded that Sarah was seen following an overdose and requested that a referral be made for her. 5.4.3 In August 2018, the consultant wrote a very powerful letter to CSC setting out Sarah’s background and the adverse experiences she had endured, linking these to potential attachment issues. The consultant made the case that CAMHS support had been declined and questioned what counselling support was being provided. The 8 Young Epilepsy, 2019 - Paediatric Epilepsy Research Report (accessed 07/11/20) - Paediatric Epilepsy Research Report 9 Shankar R, Jalihal V, Walker M et al. (accessed 07/11/20) - Epilepsy mortality and risk factors for death in epilepsy: a population-based study 10 SUDEP Action - SUDEP Action is dedicated to raising awareness of epilepsy risks and tackling epilepsy deaths including Sudden Unexpected Death in Epilepsy (accessed 07/11/20) - SUDEP.org 15 epilepsy nurse also gave a view that Sarah was not ready for independent living. These views were not factored in effectively to decision making. 5.4.4 There were opportunities for the various strands to be pulled together and one coherent plan formed. An opportunity for this was the LAC reviews. The LAC reviews tended to focus on Sarah moving towards independence instead of perhaps focusing on whether Sarah was ready to achieve independence and what the risks to her were. 5.4.6 The CSC IMR author makes the point that ‘In the LAC review on 21st November 2018, there is no record of the risk Peter posed being discussed within the review meeting. It is also of concern that in the LAC review on the 26th March 2019, the agencies did not discuss in detail the missing and CSE risks and the fact that Sarah had stopped taking her medication and was not collecting prescriptions. The focus of this review was on her placement and independence. The links to actions from the missing intervention meetings and MACE meetings were not pulled together and reviewed in her LAC review and a single child’s plan formulated.’ 5.4.7 Whilst it is acknowledged that there was good communication between the social worker and the specialist epilepsy nurse, the health professional did not attend any of the LAC review meetings despite being invited. There was also a delay in the completion of Review Health Assessment by the LAC nurse and part of the rationale given for this is a 30% absence rate in the team at the time. 5.4.8 It would have been the role of the chair of the LAC meeting to pull the concerns together and address the apparent drift in areas such as capacity assessment and legal planning. 5.5 What specifically was Sarah telling professionals, and to what extent was this used to inform the services Sarah received? 5.5.1 Whilst agencies recorded Sarah’s views, what is reflected in the agency reports and from the reflective discussion is that Sarah regularly changed her views and wishes for the future and they felt this made it very difficult to make plans. This highlights the real need for a capacity assessment to effectively understand Sarah’s ability to make decisions without undue influence from those who had ulterior motives, such as Peter. If it was the case that Sarah regularly altered her views, the reasons why should also have been better explored and this may have revealed a level of coercion from others. 5.5.2 The influence of Peter on Sarah’s ‘voice’ cannot be underestimated, apart from her cognitive ability to make decisions, her ability to make clear decisions must have been inhibited by the coercion being exerted on her by Peter. Professionals stated they never felt that they really knew the real Sarah. 16 6.5.3 Sarah’s family state that too much credence was given to Sarah’s desire to move to independent living as they felt strongly she would not be able to take care of her basic needs, this again supports the necessity for effective assessment. 5.5.4 When considering what Sarah was telling professionals it is also important to consider what Sarah was not directly saying but what her actions and behaviour may have indicated. One of the strongest areas voiced by Sarah was her dislike of the independent flat placement in November 2018. From the outset Sarah was not happy in the placement and this was echoed by her family. Sarah did not feel safe and there was no night-time support for her. She regularly absented herself from the flat or had Peter staying there on the basis that she did not feel safe. Sarah remained in this placement until March 2019, when she presented herself as homeless. Sarah’s voice at this point could not have been stronger. 5.5.5 During Sarah’s time in this accommodation she undertook a number of risky activities aside of the ongoing relationship with Peter. This included drug use and sexual activity which resulted in Peter attending hospital. Sarah went missing and was found at Peter’s address, she was conveyed by police back to the placement address, which she had already stated she did not feel safe in. 5.5.6 It is acknowledged that the outreach worker made strident attempts to make contact with Sarah on a daily basis, but this was often futile. It remains that the suitability of this placement and Sarah’s ability to live independently were questionable from the outset. 5.5.7 Worcestershire has since this time introduced Supported Board of Lodgings (SBL) which offers care leavers additional residential supported living. Had it been available at the time it is felt that this would have offered Sarah a better alternative. 5.5.8 Although Sarah maintained contact with Peter, through March and May 2019, she did make significant disclosures regarding the influence that he had over her and claimed that she had been blackmailed by him. These disclosures may have been Sarah’s cry for help although her actions did not support them, as she continued to reach out to Peter. Sarah stated that Peter was the only one who understood her, and he described her as his fiancée. In January 2019, Peter was informed by police that there would be no further action into the investigation for the grooming offences and this seemed to give Peter an increased confidence, almost a licence to continue his activities. There needed to be a considered assessment of why Sarah was drawn to Peter and what she was possibly trying to convey to agencies. 17 5. What are the learning points from this case? 5.1 Developmental learning • Strategy meetings – Child protection procedures were not followed, and therefore strategy meetings were not convened with health police and children’s social care in attendance as a minimum, as well as other agencies who should have been included. The use of Missing Intervention or MACE meeting must not be used in place of child protection procedures. • MACE meetings – The MACE meetings need to be effective with clear actions, which are recorded and followed through. The meetings need to have appropriate attendance and minutes of the meetings need to be made available to agencies who require the knowledge. • Missing meetings – There needs to be clarity on the process for the convening of these meetings and in particular where there are multiple missing episodes. The specific push/pull factors need to be considered and mitigated appropriately. • LAC reviews – In addition of permanence and independence the current risks, such as CSE, drugs use, and medical risks need to be addressed and form part of the overall plan. Arrangements for LAC reviews need to be communicated to families in a timely fashion to allow their attendance. The chair of the meeting should ensure that there are not areas of drift on actions. All relevant agencies should attend or submit a report in their absence. It is important there is a clear link and information exchange between these meetings • Mental Capacity assessment and cognitive understanding – Although professionals recorded that Sarah had capacity to make certain decisions a Mental Capacity Assessment would have given clarity and may have led to a cognitive assessment. There were enough professionals concerned that she had an impairment (the impact of her severe epilepsy, serious brain surgery and failure to adhere to her medication regime) that it shouldn’t have stopped them undertaking formal assessments under the MCA whilst awaiting a cognitive assessment. This would have assisted in how to best help and support Sarah. There were repeated requests for this assessment, which did not occur. This would have informed some important decisions, such as living independently. • Placements and independent living – There is a view that Sarah was best supported and happiest whilst at the residential placement, she craved more independent living but greater consideration needs to be given to the suitability of any placement. Those who knew Sarah well agree that she needed boundaries and structure and it is difficult to see how this would be achieved in independent accommodation with outreach support. A better understanding of Sarah’s capacity would have informed decision making as she became more independent. Where placements are changed it is important that families and other agencies engaged with the young person, particularly those providing specialist care, are notified in a timely way. 18 • Understanding Contextual safeguarding – the risks of abuse faced by Sarah where those outside of her family and home setting. Professionals need to understand the concept of contextual safeguarding. Be able to identify the risks, understand how they may be able to disrupt or change them to make the young person safe. • Understanding CSE – It is important in cases of CSE that there a coordinating keyworker or role, who is able to link important strands of concern and build a relationship with the young person. A better understanding of CSE may be achieved by working with young people who have lived experience. • Responding to CSE – Agencies, including those who advise them on legal matters should be aware of what legal remedies are available to intervene at the earliest opportunity, disrupt activity and protect the vulnerable. Civil orders should not be overlooked on the basis that there is a possible criminal case. Priority should be given to putting protective and enforceable measures in place. There is a substantial gap in the ability to use Child Abduction Warning Notices and this should be highlighted. • Mental health support and counselling – although there were periods where CAMHS were involved with Sarah, this was not consistent either due to her moving areas or not engaging. It remained that Sarah presented emotional dysregulation and mood fluctuations, which were not addressed. Nor, is there any evidence of consideration of how this factored on her risk-taking behaviour and impacted on her medical condition. The family feel that the area of counselling for Sarah was one that was consistently overlooked. • Understanding medical conditions – When professionals are dealing with persons with serious or chronic conditions, they need support to fully understand the implications of it. This support was well provided when requested by the epilepsy nurse and doctor. They briefed the social worker and outreach worker on the need for consistent medication regime and the risks of it not being complied with. What was not clear is who would monitor this on a daily basis. Where there is a looked after child with significant health needs there needs to a consistent health link and this role would most ideally be performed by the LAC nurse, which, at times, was missing in this case. This would have assisted to bridge the gap between pharmacy and GP surgery if, as in this case, the young person is not collecting medication. This specialist support was not available in all situations, such as when Sarah moved to the YMCA. • Role of a keyworker – The reflective discussion event clearly identified a view that in cases such as this there needs to be a keyworker assigned to the young person. To understand CSE a young person needs to trust and build a relationship with a professional. This key worker role would exceed the services provided by a looked after child personal advisor, whose role focuses more on personal development, education and career advice. This is a role which will be available to high and medium risk cases within the GET SAFE initiative. 5.2 Drawing on good practice • Specialist Epilepsy support – There is evidence of good support from the specialist services and that they recognised and highlighted risks of Sarah not complying with her medication regime. 19 • Adult support services – Adult support services which were in place for Peter recognised and reported concerns regarding activity with young people. • Role of foster carers – Very early on in the case foster carers raised the concern of Sarah potentially being sexually exploited and continued to raise these concerns. • Social Care support – Of particular note was supporting Sarah at health appointments. The specialist epilepsy team found it invaluable to have a carer present who knew Sarah and her history. • Professional curiosity – In January 2017, when Sarah was being admitted to hospital for a planned procedure she disclosed, she may be pregnant to a student nurse who displayed good professional curiosity in obtaining more information and appropriately passing the required information on. 6. Recommendations 1. The Worcestershire Safeguarding Children Partnership should seek assurance from all agencies involved in the review that any single agency learning identified in the review has been appropriately implemented within their organisations. 2. The Worcestershire Safeguarding Children Partnership should seek assurance from relevant partners that child protection procedures are followed and strategy meetings are convened appropriately, with health, police and children’s social care in attendance as a minimum, as well as other agencies who should be included. The use of Missing Intervention or MACE meeting must not be used in place of child protection procedures. 3. The GET SAFE initiative in Worcester will allow the identification and tackling of Child Sexual Exploitation to be more effective, the learning from this review should be used to enhance the ongoing development of the initiative, with particular focus on: - • Ensuring that MACE meetings are convened in a timely fashion, appropriately attended, properly recorded with clear actions that are followed up to ensure outcome. • That there is a clear link between the missing meetings and MACE and that the reasons for young people going missing is properly considered. • That the ongoing development of GET SAFE considers the views and input from those with lived experience of exploitation. • There is a clear link to the police problem solving hubs. • Development and use of the role of GET SAFE coordinators to work with and build relationships with young people who have experienced CSE. 4. When dealing with perpetrators of CSE West Mercia Police and Worcestershire Children First should give early consideration to the use of available civil orders 20 such as Sexual Risk Order or Wardship11 to provide protection to the young person at the earliest opportunity. Too much reliance should not be placed on criminal proceedings and associated bail conditions, which could be protracted and ineffective to enforce. 5. The Worcestershire Safeguarding Children Partnership should highlight through appropriate channels the restriction in the use of Child Abduction Warning Notices (CAWNS) in cases where young persons are vulnerable, under the age of 18 but looked after under section 20 of the Children Act. 6. The Worcestershire Safeguarding Children Partnership should be assured that LAC review meetings are effective by ensuring that – • There are up to date and complete health assessments • That the meeting is attended by the relevant professionals or appropriate reports are submitted • That the milestones set out in the plan are achieved and not allowed to drift 7. The Worcestershire Safeguarding Children Partnership should be assured that pharmacies and practices will work collaboratively to support Looked After Young People with chronic health conditions to encourage regular collection of prescribed medication required to manage their condition. 8. The Worcestershire Safeguarding Children Partnership should be assured that all agencies working with young people understand the requirements of the Mental Capacity Act when considering the ability of young people to make safe decisions. 9. Worcestershire Children First should ensure that where there is a Looked after Child with a chronic condition or illness that any placement is equipped with the information and knowledge to support and manage the condition and that any placement is appropriate to their needs. 10. Worcestershire Children First should review procedures to ensure that families are appropriately communicated with when a child who is looked after dies and the parents retain parental responsibility. 11 Department of Education, 2017,Annexes to ‘Definition and a guide for practitioners, local leaders and decision makers working to protect children from child sexual exploitation’ (accessed 07/11/20) - CSE Guidance annexes - disruption |
NC043711 | Executive summary of a review into the death of a 4-year-old boy in December 2009, as a result of chronic neglect; Hamzah's body was discovered by police during a search of the family home in September 2011. Six of Hamzah's seven siblings were living in the family home at the time of the discovery of his body; all siblings under the age of 18 became subjects of care proceedings at this time. Mother was convicted of manslaughter and child cruelty in October 2013. Maternal history of: chronic alcohol dependency; depression; social isolation; domestic abuse; and reluctance to engage with services, including registering children with health and education services. Father was made the subject of a non-molestation order in 2008 following an arrest for assault against mother. Issues identified include: invisibility of children to services; failure to recognise the impact on children of living with domestic abuse; absence of enquiry into the cultural and religious complexity of the family; insufficient significance given to disclosure by adolescents; lack of professional curiosity and missed opportunities to conduct assessments; insufficient interagency cooperation and lack of an overall picture of family life. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and raises issues for consideration in regards to identified themes for learning. Themes include: cognitive influence and human biases; viewing incidents in isolation and failing to identify patterns that represent harm to children; and tools for effective sharing and analysis of information. Includes a Learning and Improvement Report and statements from the Independent Chair of Bradford Safeguarding Children Board and the Independent Chair of the review.
| Title: A serious case review: Hamzah Khan: the executive summary LSCB: Bradford Safeguarding Children Board Author: Peter Maddocks Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Bradford Safeguarding Children Board A Serious Case Review Hamzah Khan The Executive Summary November 2013 Page 2 of 18 Page 3 of 18 Index 1.1 Introduction................................................................................................................. 4 1.2 Rationale for conducting the serious case review ....................................................... 5 1.3 Communication and contact with the family subject of the review............................... 6 1.4 The methodology of the serious case review.............................................................. 6 1.5 Details of the timescale and conduct of the serious case review................................. 7 1.6 Summary of the serious case review .........................................................................11 1.7 The summary of the events examined by the review .................................................12 1.8 Key themes from the review ......................................................................................14 1.9 Priorities for learning and change as a result of the review ........................................15 1.10 Critical challenge for future development of safeguarding in Bradford .......................16 Influence of human biases.................................................................................................16 Family and professional contact and interaction................................................................17 Response to incidents and information..............................................................................17 Longer term work with vulnerable children and troubled families.......................................17 Tools to support professional judgment and practice.........................................................18 Management systems .......................................................................................................18 Page 4 of 18 1.1 Introduction 1. Hamzah died on the 15th December 2009 but his body was not discovered until September 2011. He died because he was neglected by his mother, Amanda Hutton. She was convicted of manslaughter and child cruelty in October 2013. 2. The death of any child, whatever the circumstances is a traumatic and shocking experience and Hamzah’s is profoundly disturbing. Hamzah had been starved and neglected and this was not known about until the evidence was laid before a judge and jury in the autumn of 2013 following an extensive criminal investigation. 3. The circumstances under which Hamzah’s dead body had remained hidden have shocked professionals and the wider community. The trial also revealed other significant information about the family and the circumstances of the children that had not been known until then. 4. It was not possible whilst preparing this SCR to establish an exact date for Hamzah’s death. However, it became apparent during the court hearing that he died on 15.12.2009. Information provided through statements and from the post mortem examination indicates that Hamzah’s death may have occurred in late 2009 when Hamzah would have been aged four years old. The circumstances and cause of Hamzah’s death was the subject of separate and parallel inquiries by the police and the coroner. The review does not investigate why or how the death of Hamzah was not disclosed by any member of the family. 5. A theme in this review is the extent to which Hamzah was unknown and invisible to services throughout his short life. The circumstances that caused mother in particular to withdraw increasingly from any contact with services are complex. A contributory factor appears to be the degree of domestic violence she suffered and the social isolation she felt. Associated with this was the reaction from some people in the community to a relationship that involved partners from different cultures and religions. Hamzah was invisible to services largely because neither of his parents participated in the routine processes such as ensuring he saw health professionals on a regular basis or was enrolled for early years to educational provision. 6. Although Amanda Hutton had become a criminally neglectful parent she had not always been such an inadequate mother. She had become pregnant as a teenager with a teenaged boyfriend at a time when there was little specialist support available. It was a relationship that became abusive and violent. 7. Little is known or recorded about the first pregnancies but the limited agency information from health visiting records for example and accounts from some of her family indicate that Amanda Hutton had applied herself to parenting her older children. She had cared for members of her extended family. By the time she had neglected Hamzah to such an extent that Hamzah died having been subjected to cruel treatment, her circumstances had entirely changed as had her ability to function as an adequate parent as a consequence of her chronic dependency upon alcohol that had such appalling consequences. Page 5 of 18 8. Hamzah’s body was discovered by police officers during a search of the house in September 2011. The police were at the house following up concerns about anti-social behaviour and the very poor conditions in the home and were also trying to establish the whereabouts of the younger children who had not been seen for some time. 9. The review coincided with major changes to national guidance and frameworks for safeguarding children. These changes have included how for example the assessment of children should be undertaken. Some of the problems and issues highlighted by Professor Eileen Munro in her national review of safeguarding were factors in this case and are discussed in the overview report. There have also been changes to guidance and law in regard to domestic violence. There have also been changes to the way that serious case reviews are undertaken. 10. The review had to be completed using the previous frameworks for a serious case review but has taken account of the severe limitations that traditional reports have had. It is for this reason that the review has used an adaptation of systems learning for the findings from the unusual and tragic circumstances that occurred in this case and to consider what the implications are for safeguarding practice and service more generally. Account has also been given to the severe limitations that traditional recommendations have in transferring learning from a review into professional practice. It is for that reason that although there are agency recommendations made by individual services, the overview report provides a series of challenges to the BSCB rather than setting out specific recommendations. 11. Those challenges and reflections emphasise that working with troubled families and vulnerable children is complex and has to take account of how there is always an inter play of many different and often contradictory factors that are not helpfully addressed through rigid or SMART recommendations and action plans that tend to rely on additional rules, protocols or procedures. 12. The overview report analyses the implications for how MARAC functions and has provided a focus for improvement to assessment frameworks and practice locally. Changes have been made to how the education service is notified about children born in the district as well as acknowledging that areas such as Bradford have a mobile population. The review also highlights the implications for contracting and compliance arrangements for the delivery of services such as GPs. 13. Helping children to talk about their worries and concerns, giving people working in schools, health, police and social care settings the capacity to talk with and listen to children’s accounts, being mindful of how issues such as domestic abuse and depression erode the capacity of victims to access or engage with help and the implications that has for how professionals plan and act. The findings of the review also address the challenge of dealing with issues such as neglect. Hamzah did not die as a result of a single and devastating act of harm but died as a result of persistent and longer term lack of nutrition. 1.2 Rationale for conducting the serious case review 14. The reason for commissioning the review was that the circumstances under which Hamzah had died and the fact that the death had not been reported was indicative of Page 6 of 18 Hamzah having been neglected. The information about the very significant impairment of physical growth was not known until the trial. 15. The overall purpose of the review is to establish if lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and to better safeguard and promote the welfare of children in Bradford. 1.3 Communication and contact with the family subject of the review 16. Amanda Hutton and the children’s father were made aware of this serious case review at the outset. In view of the separate investigation by the police as well as the coroner’s enquiry, the serious case review panel had to ensure that all contact with the family was the subject of appropriate consultation and advice. The panel used the national guidance agreed between the Association of Chief Police Officers (ACPO), the Crown Prosecution Service (CPS) and the Directors of Children’s Services in England. 17. Both parents had initially confirmed that they wished to provide information for the review and agreed to speak with the independent chair of the panel. The chair of the panel and the BSCB manager each made several efforts to contact both parents by letter, telephone and text. The panel chair had a brief discussion with Amanda Hutton on the telephone and although a meeting was planned Amanda Hutton did not keep the appointment. 18. Following the trial the children’s father did meet with the manager of the BSCB. During that discussion he made clear that he had been unaware that Hamzah had not been registered with a GP and had not had any immunisations. 1.4 The methodology of the serious case review 19. The serious case review was completed using the methodology and requirements set out in the national guidance (Working Together to Safeguard Children 2010) that applied at the time of the review being commissioned and completed. That guidance was extensively revised in March 2013 following the publication of Professor Eileen Munro’s final report in 2011. 20. The analysis in the final chapter of this report uses some of the framework developed by SCIE (Social Care Institute for Excellence) to present key learning within the context of local systems. This was in anticipation of the changes to serious case reviews. This also took account of recent work that had suggested that an approach of developing over prescriptive and SMART recommendations had limited impact and value in complex work such as safeguarding children. 21. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct of the review. The panel was chaired by an independent and experienced person who is also the independent chair of a LSCB in another part of northern England. An experienced and independent person has provided this overview report. Page 7 of 18 22. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review and are listed in the overview report. 23. An overview of the health agencies was provided in a comprehensive health overview report. Health overviews are no longer a requirement for SCRs. 1.5 Details of the timescale and conduct of the serious case review 24. The serious case review was commissioned by Professor Nick Frost, the independent chair of the BSCB, on the 28th November 2011. A serious case review panel was convened and was chaired by Nancy Palmer who is independent of all services involved and is also a chair of a local safeguarding children board in another area. The panel members are listed below. In addition to the senior and experienced local people drawn from relevant local services the panel had the benefit of additional challenge from a senior manager in a neighbouring authority who acted as a ‘critical friend’. 25. There is an expectation that serious case reviews are completed within six months of being commissioned. A short extension to the timescale was agreed by the independent chair of the BSCB. This occurred as a result of several IMR authors and panel representatives being required to give priority to their participation in the statutory inspection of children’s services that took place in Bradford in May 2012. Position Organisation Professional Development Manager Bradford Metropolitan District Council (BMDC) Adult Services Designated Nurse Bradford and Airedale Teaching PCT BSCB Manager BSCB Medical Director Bradford and Airedale Teaching PCT Detective Chief Inspector West Yorkshire Police Manager Youth Offending Team Group Service Manager BMDC Children’s Specialist Services Assistant Director Access & Inclusion BMDC Access and Inclusion Independent ‘critical friend’ (Assistant Director Performance, Planning & Resources, Children's Services Department) Bolton Council Head of Midwifery Bradford Teaching Hospital Foundation Trust 26. The following agencies had contact with the family at various times. They all conducted management reviews of their agency’s actions and decision making which contributed to the overview report’s analysis and findings; Page 8 of 18 a) Health services that include: o Bradford and District Care Trust (BDCT) o Bradford Teaching Hospitals NHS Foundation Trust o Bradford and Airedale Teaching Primary Care Trust (PCT) o Yorkshire Ambulance Service; b) Bradford Children & Young People’s Specialist Services commissioned the IMR on behalf of Children’s Social Care Services (CSC) c) Bradford Early Years Children’s Services (children’s centre) d) Bradford Education and Early Childhood Service commissioned separate IMRs in respect of education support services, school admissions and from schools the children attended during the period under review. e) Bradford MARAC (multi agency risk assessment conferences)1 f) Bradford Youth Offending Team (YOT) g) Staying Put h) West Yorkshire Police i) West Yorkshire Probation Service 27. Bradford Metropolitan District Council had been made subject to a statutory direction to outsource its education services in July 2001; that direction was lifted from July 2011. This means that for the period that is the focus of this review, the provision of services was through an arrangement with Education Bradford, an independent provider. 28. Information was also received from CAFCASS (children and families court advisory support service), the West Yorkshire Ambulance Service (WYAS), the Bradford Registrar and the Home Hunter service. Checks were also made with services in the east and south of England regarding information provided at various times by the family regarding the whereabouts of specific children. These checks confirmed that the children have always lived in the Bradford area. 29. In compliance with national guidance an overview report was provided on behalf of the various health services that contributed to the review. The overview report for the entire serious case review was completed by Peter Maddocks who attended every meeting of the case review panel. He is independent of all the services involved and he presented the overview report to the Bradford Local Safeguarding Children Board in December 2011. This complied with national requirements for the completion of a serious case review in England. 30. All of the report authors, together with the overview author, were required to collate information and provide analysis in response to several key lines of enquiry identified by the panel and agreed by the BSCB. The key lines of enquiry, which are additional to the terms of reference set out in national ‘Working Together’ guidance were; Recognition i. To what extent were any vulnerabilities or needs of Amanda Hutton recognised and taken into account in terms of any potential risks they posed for Hamzah and his siblings including any information about depression, domestic violence, social or 1 The MARAC is not an agency but is a multi agency framework for sharing information and action in response to identified risk; in this case it relates to incidents of domestic abuse. Although the abuse began in 1996 the MARAC was not established in Bradford until 2008. Page 9 of 18 family involvement or the use of alcohol or drugs; to comment in particular on any action taken to ascertain whether there were any issues of learning or other disability or impairment relevant to agency involvement, and comment on the extent to which any barriers may have contributed to Amanda Hutton’s reluctance to accept help or advice. ii. Provide information about any concerns that were reported by any member of the family and comment, where appropriate, on any action taken in response to such information. iii. Identify any opportunity for enquiring into the whereabouts and well being of Hamzah between June 2005 and September 2011. Assessment and Decision Making iv. The extent to which relevant historical information was sought, understood and considered in work with Hamzah and his family; IMR authors should include a summary of any relevant information known to their service about the parents or family that they judge relevant to the serious case review. v. The quality and timeliness of any assessments and the extent to which they took account of relevant family history, the cultural, ethnic and religious identity of the family, the needs of Hamzah and his siblings and the capacity of the parents (acknowledging they were separated) to meet the needs of their children; this should include comment about any extended family or others and their role and impact in promoting the safety, well being and knowledge of Hamzah prior to the discovery of his death. vi. Consider and comment whether there were opportunities to use any arrangements such as the common assessment framework, team around the child or children going missing protocols to co-ordinate information and help at any stage. vii. Comment on the quality of judgments and decision making and the extent to which it reflected a focus on the needs of Hamzah and his siblings and represented appropriate professional standards and a competent understanding of any relevant theoretical and/or legal frameworks; particular attention should be given to how any evidence of neglect or impaired capacity to parent was collated and analysed. Using and Sharing Information viii. Identify whether information in respect of the family was shared among agencies to the best effect so as to inform appropriate help and interventions; in particular to identify when practitioners in contact with the family saw Hamzah and/or his siblings and recognised any evidence of neglect or other concerns and comment on what action was taken to protect him or a sibling. ix. To comment on the quality of reports and information provided for interagency enquiries and analysis including information provided in meetings of MARAC or the conduct of statutory assessments or for the purpose of identifying and tracing children who have gone missing. Page 10 of 18 Engagement and acceptance of help and advice x. To what extent did either parent accept contact, advice or help from professionals in contact with the family between June 2005 and September 2011? xi. Was there any other action that could have been taken to achieve a better level of contact and engagement with the family? Planning and Help xii. Comment on the clarity and appropriateness of plans and actions undertaken made as a result of the discussion at MARAC, information about siblings missing from school or as a result of any statutory assessment. xiii. Identify what opportunities were taken to seek the views, wishes and feelings of any of the children and comment upon the extent to which the children may have felt inhibited to seek advice, information or help. Practice Support and Supervision xiv. Consider whether all relevant single agency and multi-agency procedures were followed and comment on the extent to which procedures helped or inhibited appropriate judgments and action at the time. xv. Consider whether the policy, procedural, management and resource infrastructure that surrounded each agency’s involvement with Hamzah and his family promoted appropriate decision making; this should include evaluating the training, knowledge and experience of people working with Hamzah and his family, workloads and organisational stability; comment should also be made about whether any shortfall in resources were an impediment. xvi. Consider whether professionals working with Hamzah’s family had sufficient and appropriate supervision commensurate with their role and responsibilities, and the extent to which the case was subject to appropriate and effective managerial oversight and enabled critical reflection. Learning from SCRs and other review processes xvii. Consider relevant research or evidence from previous serious case reviews conducted by the Bradford Safeguarding Children Board; consideration may also be given to evidence from other LSCBs or evaluations of SCRs. Take into account any common themes and actions arising from that research and those SCRs that are relevant to the circumstances of this case and comment on what impact they had in this case. xviii. Consider previous reviews of single agency practice. Take into account any common themes and actions arising from those reviews that are relevant to the circumstances of this case and comment on what impact they had in this case. Page 11 of 18 Agency specific key lines of enquiry xix. Police and children’s social care; report and comment on what information was shared and the actions taken between 12th September 2011 and the 21st September 2011 and whether there was opportunity to have discovered the body of Hamzah at an earlier stage in those enquiries. xx. Education and early childhood services; report and comment on the extent to which any of the children were missing from education or early years provision and the appropriateness of actions taken to ascertain the children’s whereabouts and attendance at school and other provision. 1.6 Summary of the serious case review 31. Several examples of good practice were identified by the review. These examples included; a) The police took prompt action when one of the children asked for help because of the domestic violence; this included ensuring CSC became involved; b) The Registrar made a home visit to register Sibling 3’s birth when she was made aware of Amanda Hutton’s difficulty in being able to attend the office; c) The police officer who gained the trust of Amanda Hutton tried to secure effective help and support in response to the domestic violence which included referral to housing and specialist advice services; d) The ambulance crew ensured that their concerns about the welfare of children was reported to CSC when they were called to the house; e) The health visitor sought advice from specialist advisors when she was failing to get contact with Amanda Hutton and her babies in 2005; f) The discussion at the Primary Health Care Team about the concerns about the children not being seen by health professionals involved the health visiting and GP service; g) The school nurse tried to make a home visit when she was concerned about lack of contact; h) When Sibling 8 attended with the injury to his thigh the A&E staff provided a place of safety and ensured that other services were contacted and continued to provide care and treatment while consultation and plans were made; i) The midwifery service arranged ante-natal home visits in one of the pregnancies in recognition of Amanda Hutton’s difficulty with attending hospital; j) The early childhood service secured access to the home after being asked to provide advice; this contrasted with the lack of success achieved by other services; k) The PCSO (police community support officer) demonstrated very considerable persistence in gaining access to the house in 2011; she sought advice about the concerns she had and did not let the matter drop. . Page 12 of 18 32. Agencies have identified areas for improvement and these are incorporated in the ‘Learning and Improvement’ document published at the same time and in response to the Serious Case Review. 1.7 The summary of the events examined by the review 33. Hamzah’s mother, Amanda Hutton, is white British and father is Asian British Pakistani. Both parents speak English. Amanda Hutton became pregnant with her first child (Sibling 8) 18 months after she had met father when she was aged 16 in the mid 1980’s. The parents stopped sharing a house in late 2008 after the children’s father was arrested following an assault on Amanda Hutton and he was made the subject of a non-molestation order. It is apparent that Amanda Hutton had tried to leave the relationship on previous occasions and was referring to the children’s father as an ex-partner as early as February 2007. With the exception of the two eldest children who were adults at the time of Hamzah’s death, all of the siblings lived with the Amanda Hutton. 34. From the first pregnancy there was a pattern of avoiding contact with health services; the late notification of pregnancies had an impact on the planning of ante natal care. Amanda Hutton experienced low mood and depression with all of the pregnancies. 35. The first report of domestic violence was made in 1996. Amanda Hutton declined to make a formal complaint to the police; this was to be a repeated pattern and is a common feature for women in abusive relationships. Further episodes of violence occurred and nine reports had been made to police between 1996 and 2008. On at least one of those occasions it was one of the children who reported the violence and further information about domestic violence was provided by one of the children when he asked for help in 2007. It is likely from information provided to the review as well as other evidence from research that indicates that domestic abuse is an under reported crime that not all the incidents of violence were reported to services. Around the same time there were incidents in the community; some of these appear to relate to the parents being from different racial and cultural communities although the children’s father says this was not an issue. 36. With all of the children there were problems for the health visiting service and GP in seeing the children (or parents). This became even more of a problem with the later pregnancies. 37. There was contact between services and consultation with safeguarding advisors in the health visiting service. By 2005 it was noted that there was some evidence of Amanda Hutton using alcohol to cope with her circumstances. 38. In 2006 one of the children went to the police to talk about the situation at home and their distress about the domestic violence. The police used their powers of protection to try to arrange accommodation with CSC who returned the child home. 39. Shortly after this there was a further incident when Amanda Hutton asked for police help although by the time they had arrived father had left the house. In February 2007 Amanda Hutton was at A&E with bruises and chest pains following an assault at home. She said that she had separated from father. There were further attendances at A&E Page 13 of 18 one of which was via an ambulance that had been called to the house by one of the children. 40. In 2007 one of the children was injured having fallen when running away from his father. The child went to A&E and whilst there asked for help to live away from his family. This led to involvement by CSC as well as the police. The child did not make a formal complaint and no further action was taken by either of the services at that time. 41. By the summer of 2007 Amanda Hutton was asking for help to find alternative accommodation away from father. Several services became involved in trying to help; this included YOT, the police as well as specialist services. In spite of Amanda Hutton asking for help, she was unable to take up appointments that were made for her. Further incidents of violence occurred later in the year. 42. There was further contact in 2008 from Amanda Hutton with the police; on one occasion one of the children had gone missing from home. In April 2008 Amanda Hutton asked to meet with a specific police officer who had provided support in 2007. By the time the officer was able to contact Amanda Hutton she did not want to meet. 43. In 2008 there was a discussion at MARAC. In December 2008 there was a further incident at home when father forced an entry to the property and assaulted Amanda Hutton. He was prosecuted and received a community sentence with a requirement to attend sessions of a domestic abuse programme designed to help men to change their behaviour. He was asked to leave the group due to his disruptive behaviour and lack of cooperation. 44. In April 2009 three of the children were not collected from their primary school at the end of the school day. The police made a welfare visit that included checking all of the rooms in the house. One of the children did not have a bed and for another the arrangements were not clear. Amanda Hutton appeared to be under the influence of some unknown substance. The police sent information to CSC to suggest that a follow up visit by a social worker might be required. 45. In October 2009 the children and Amanda Hutton were removed from the register of the GP practice. This followed a protracted period when Amanda Hutton had been asked to bring the children for routine health and developmental checks and immunisations and was after warnings of the intention to remove them from the practice list unless health professionals were able to see the children. 46. During 2010 there was correspondence between health visitors, education and early childhood services and CSC which centred on the difficulties in seeing the children. The health visitor had realised that the younger children had not been in contact with health services and were not registered with a GP. It was in response to the enquiries that Amanda Hutton sought to misdirect further local contact by insisting that the younger children were living with relatives in the south of England. The school were noticing that at least one of the children who was attending the school was looking more neglected. Father told his offender manager at probation that the two eldest children were living with him. 47. There was an anonymous referral in March 2011 about the children. This did not involve any home visit following consultation with education services and the school. In July Page 14 of 18 2011 the school attendance officer began inquiries with the police about four of the children; this included Hamzah who had never been enrolled for education. Amanda Hutton wanted all of the services to believe that the children were living outside Bradford with relatives. Various places in the south of England were mentioned and inquiries were made with another local authority that had no information; the children were never living outside Bradford. 48. In September 2011 there was a further referral. Over a period of several days a police community support officer (PCSO) made persistent attempts to see Amanda Hutton and the children without success. The PCSO made a child protection referral to CSC who requested a uniformed police officer to visit the property when Amanda Hutton had refused access to the PCSO. When the police gained access to the house Hamzah’s body was discovered. 1.8 Key themes from the review 49. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. Chapter 3 of the overview report provides a summary. Important messages for learning from this review include: a) The importance of encouraging children to talk about their concerns, feelings or worries; b) Troubled families and parents who are suspicious or unwelcoming of contact from sources of help and support are also the most at risk of becoming isolated and invisible; c) Using phrases such as ‘safe and well’ to describe children’s circumstances based on short or superficial contact can create optimistic mindsets that can also influence how further information is processed; d) Ensuring that assessment practice is based on a thorough foundation of theoretical understanding and can show rigour in triangulating evidence from direct observation of children and what they say; previous history and chronology; and thorough and reflective enquiry with relevant third parties or professionals; e) Thorough and reflective practice requires people having time and capacity to spend time with children and for talking with each other in enough detail; f) Children need to be the focus of professional contact with vulnerable adults who may be reluctant to accept help or support; what emerged in the court case was that coercion can be applied by adults determined to keep information secret; g) Concepts such as vulnerability and neglect do not reflect one off events or single behaviours; they represent a longer process of multi layered issues and patterns that will not be obvious through limited contact, observation, recording or partial sharing of information; h) Helping professionals to ‘Think Family’ and to see adult behaviour in terms of implications for their children; i) Workload pressure and contractual or commissioning arrangements can influence the capacity and focus of professional’s ability to respond to information or lack of engagement; j) Ensuring that procedures and processes that support the seeking and exchange of information in important areas such as identifying whether children are missing are not seen as substitutes for appropriate and curious professional enquiry; Page 15 of 18 k) The importance of primary health professionals in maintaining contact and oversight of pre-school children that extends further than administration of routine health care; l) The interplay of alcohol dependency, depression and domestic abuse increase the likelihood of child neglect and increase the risk of other abuse but does not predict such abuse; it therefore requires appropriately curious and proactive enquiry and assessment; m) Short cuts to systems and processes that may help ameliorate short term workload pressures may undermine the integrity and quality of critical activity such as assessment and information exchange and recording; n) Professionals are effected by the physical and emotional demands of their work that can be exacerbated by other temporary crises or difficulties that effect their performance such as the bereavement for one of the professionals in this case; o) Children may not feel able to articulate emotional and psychological distress and can face emotional and psychological barriers in providing full disclosure of information out of loyalty to their family or to other significant people in their lives; p) Emergency services such as the ambulance service (and by implication the fire and rescue services who are not involved in this case) may have significant information about families relevant to agency enquiries or MARAC discussions that is not routinely sought; q) Women who suffer domestic violence will face varied difficulties and barriers in being able to ask for and then use help and assistance; professionals need to be aware of relevant research as well as being empathetic; r) Men remain largely invisible to services that work with vulnerable children even when their behaviour as in this case is one of the sources of concern and risk for children; s) Responding to older children when they ask for help can present challenges to professional and agency orthodoxies; a teenager describing their home life as intolerable may not be describing the tensions associated with adolescent development but rather is describing harmful abuse. 50. The recommendations developed in response to the IMRs and health overview report set out a detailed response to support learning and improvement. The final chapter of the overview report provides critical challenges for the BSCB that provide an opportunity for further work on developing the systems in response to the insights that the case provides about general patterns rather than addressing the specific issues highlighted from this case. 1.9 Priorities for learning and change as a result of the review 51. Each agency has identified areas for improvement; these are set out in the ‘Learning and Improvement document’. The review also acknowledges that some of the shortfalls that are highlighted for example in how domestic violence was handled have been the subject of improved training and practice. 52. This is an unusual case and the review panel have focussed on identifying lessons that help to continue with the development of effective systems and practice rather than trying to address the unique features of one particular case. It is for these reasons that the panel have not made traditional interagency recommendations but have instead provided a series of reflections and challenges for local services in regard to the learning from the case; these are placed within a context of systems learning. Page 16 of 18 53. The most important points of learning from the review are; a) Cognitive influence and human biases: developing mindsets that are open to fresh or different information; repeated exposure of professionals to intractable and long term problems contributing to a normalisation in the response; understanding the significance of deviant or risky parental behaviour. b) Family and professional contact and interaction; putting children’s needs, views and wishes at the forefront of interaction and enquiry; achieving balance in how vulnerable parents are helped; recognition of barriers that inhibit engagement and implications for practice. c) Responses to incidents and information; viewing individual incidents or crises in isolation; identification and clarification of patterns or inconsistencies that could represent significant harm to children. d) Longer term work with vulnerable children and troubled families; recognition of long term behaviours and changes to circumstances; multi agency understanding about what constitutes good enough parenting; systems that rely on parents doing the right thing. e) Tools to support professional judgement and practice; availability and use of tools for collating, sharing and analysing information; promoting analytical discussion and revealing underlying and long term patterns such as neglect. f) Management systems; improving the local arrangements to use information about vulnerability to promote the well being of children (especially pre-school); developing models of help and support; moving to more assertive forms of help when required. 1.10 Critical challenge for future development of safeguarding in Bradford 54. Having considered the overview report, the Bradford Safeguarding Children Board and the local agencies have agreed to consider the following issues to improve future practice. This is in addition to the recommendations being implemented by services as a result of their individual management reviews. Influence of human biases 1) Is the support for professionals from different professional backgrounds sufficiently rigorous and challenging to prevent inappropriate erosion of concerns especially in regard to older children? 2) Can professionals distinguish with sufficient clarity between indicators of neglect and other factor such as social disadvantage? 3) What is the capacity in terms of skills, knowledge and organisational capacity for services in being able to work effectively with resistant adults? Page 17 of 18 Family and professional contact and interaction 1) How can professionals maintain an appropriate focus on the needs and risk for children when working with adults who have longstanding difficulties that can include depression, substance misuse or domestic abuse? 2) How can professionals identify evidence of inappropriate resistance? 3) How can professionals satisfy themselves that relevant children’s views, wishes and feelings are considered and influence judgements and decisions? 4) How can the revised arrangements such as Think Family be evaluated for their effectiveness and are there particular issues for children of multiple births? 5) How can professionals ensure that frameworks for responding to domestic violence recognise the barriers to effective help and what are the implications for offence management and social support and intervention? Response to incidents and information 1) How do the arrangements for responding to individual incidents or crises provide sufficient opportunity to place them within a context of previous history and to identify emerging patterns or dissonance/inconsistency? 2) How does the training and support provided to practitioners equip them to understand the importance of and have the capacity to identify underlying patterns such as emotional neglect as a result of issues such as alcohol dependence or domestic violence? 3) How does professional interaction in regard to contact, sharing information and making referrals consistently identify underlying concerns or patterns relevant to the development or vulnerability of a child over and above information about a specific incident? 4) How do practitioners have the guidance, confidence and skills to overcome the resistance of adults who may wish to divert or redirect professional focus or concern (that might include disguised compliance)? Longer term work with vulnerable children and troubled families 1) Is the apparent level of uncertainty amongst different professionals about what constitutes ‘not good enough’ parenting acceptable? 2) Are local systems for ensuring children have access to appropriate health care and education (including pre-school) robust enough to compensate when parents are unable or unwilling to act in the interests of their children? 3) Are the increased rates of babies known to the early year’s service leading to improved access for the most isolated and vulnerable of children? Page 18 of 18 Tools to support professional judgment and practice 1) To what extent is local assessment practice a reflection of a child focussed, professionally controlled activity rather than being driven by local and national bureaucracy? 2) Are the tools for collecting and recording information about children and their families adequate and able to promote sufficient interagency assessment? 3) How does the training and development of professionals undertaking assessments across all services provide sufficient understanding about child development and childhood vulnerability? Management systems 1) Do professionals require written protocols and procedures to understand whether their action is appropriate and sufficient when enquiring into the whereabouts of a child? 2) How do professionals undertaking complex work that is subject to a great deal of primary legislation and regulation secure and maintain an appropriate level of knowledge and understanding? 3) Are there particular issues in a cosmopolitan city such as Bradford regarding how the community is kept informed about arrangements and agreements to look after children outside of their immediate family? 4) Are the current arrangements for permitting a child to be removed from a GP practice list appropriate? 5) Are the current arrangements for identifying any child living in the city not registered for school or for a pre-school service appropriate? 6) Does the BSCB have sufficient confidence in current arrangements for identifying children who are missing from home, education or health care and oversight? 55. A formal response will be published by the BSCB. Progress will be overseen by the Bradford Safeguarding Children Board. The serious case review has been submitted to the Department of Education. The serious case review will not be the subject of a formal evaluation by Ofsted; that arrangement was ended in July 2012. The serious case review and the associated responses will be examined as part of the unannounced inspection of arrangements to protect children that takes place in all English local authority areas with children’s social care responsibilities. |
NC049511 | Serious injury of a 2-year-11-month-old boy in June 2016 from third-degree burns. Joe had been the subject of a child protection plan for over two years, due to presence of family violence in the home, and continued to receive support through a Child in Need Plan from January 2016. Father had previously been in jail and was known to mental health services. Mother continually refused to disclose information regarding new partner and was misusing drugs. Joe lived in temporary housing with his mother. On the day of the incident he was found home alone by the buildings manager. Mother was arrested and sectioned under Mental Health Act and taken to a psychiatric hospital; later diagnosed as suffering from an episode of drug induced psychosis. Lessons identified include: protection of children will be compromised if a child protection plan is not working and there is insufficient insight into safeguarding processes; lack of robust inter- and intra-agency decision making jeopardises childrens safety; family and kinship are critical members of the safeguarding network and should be regarded as such. Methodology based on the Welsh Child Practice Reviews Guidance, taking a multi-agency approach, focussing on systemic strengths and weaknesses. Recommendations include: to ensure a robust, timely multi-agency process that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact; professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments.
| Title: Serious case review: Joe. LSCB: Croydon Safeguarding Children Board Author: Ghislaine Miller Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Joe CSCB SCR Joe - Publication Feb 2018 2 Why This Case Is Being Reviewed On 30.6.16 Joe (2 years old) was found in a room in a temporary housing establishment by the buildings manager. He was alone and appeared to be suffering from severe injuries. Joe was subsequently admitted to a specialist burns hospital where it was found that he was suffering from 3rd degree burns over 25% of his body. His mother was arrested and was later sectioned under the Mental Health Act and taken to a psychiatric hospital. She was later diagnosed as suffering from an episode of drug induced psychosis. The case was referred to Croydon Serious Case Review Sub Group on 12th July 2016 and a decision was made that this case met the criteria for undertaking a Serious Case Review (SCR), as specified in Working Together 2015. Methodology The methodology used for this serious case review is based on the Welsh Child Practice Reviews Guidance.1It is a nationally recognised model that features the following components: Establishment of the Child Practice Review Panel A Practitioners Learning Event A Child Practice Review Report It is a model that takes a multi-agency collaborative approach, with a focus on systemic strengths and weaknesses. The goal is to move beyond the specifics of the case (what happened and why) to identify the deeper, underlying issues that are influencing practice more widely. It is these generic patterns that count as lessons from a case, and changing them should contribute to improving practice more widely. Data came from reviewing a range of multi-agency documents, meetings with a multi-agency review team, with the practitioners involved, and with family members. 1 Protecting Children in Wales: Guidance for Multi-Agency Child Practice Reviews, Crown Copyright, 2012. CSCB SCR Joe - Publication Feb 2018 3 Process In line with this methodology, a Child Practice Review Panel was formed to undertake this SCR. This team of multi-agency senior managers had no direct line management of the case at the time. Their responsibilities were to assist in providing relevant information, read and analyse documentation and contribute to the lessons learnt. The Review Panel met on five occasions2 and included the following membership: - Croydon Health Services (including Croydon University Hospital, Health Visitors and School Nurses and Family Nurse Partnership) - Metropolitan Police, SCR Team - Croydon Children’s Services - Croydon Clinical Commissioning Group, (including GP Practice) - Croydon Housing Needs - Best Start Croydon Early Help (Early Intervention and Support Services) - South London and Maudsley NHS Foundation Trust (SLAM)- Adult Mental Health - Croydon Safeguarding Children Board Methodological Comment There was a wide range of multi-agency services involved with this family and there was good attendance at the Review Panels by most of these agencies. Mental Health Services were only minimally involved in providing services to father, although it was felt important that they contribute to this SCR. However, despite efforts to gain the involvement of the safeguarding lead from this service, attendance was only achieved at two of the meetings towards the latter stages of the process. Croydon Community Rehabilitation Company Services were invited, but did not attend. The absence of these key safeguarding agencies is relevant to Lesson 3. 2 A flow chart detailing the Child Practice Review process is contained in Appendix 2. CSCB SCR Joe - Publication Feb 2018 4 The Lead Reviewer and Chair Two independent people were appointed to lead this review, Ghislaine Miller was appointed as the Lead Reviewer and Bridget Griffin as Chair of the Review Panel. Both are experienced Serious Case Lead Reviewers and are independent from all the agencies. During this SCR, due to unforeseen circumstances, the Lead Reviewer withdrew. Bridget Griffin took on the role of Lead Reviewer and the position of Chair was taken up by the Safeguarding Board Manager. The Learning Events Learning events are a significant element of the review and all practitioners involved with the child or the family attended these with line managers wherever possible. These events provide a unique opportunity to hear the views of professionals who provided services to the child and family during the period under review. They are a key source of information for the Lead Reviewer and supports how lessons are learnt. Three learning events took place, they were led by the Lead Reviewer and the Chair and were well attended by multi-agency practitioners. The first event examined in detail the time under review, enabling a multi-agency perspective to be gained. This exercise brought out the story of multi-agency involvement, helping to identify key periods of time that were significant and allowing the group to see how practice unfolded and how services were delivered from an inter-agency perspective. The Review Panel discussed the contributions made by the practitioners, reviewed and analysed the documentation and several tentative lessons and hypotheses were agreed for further exploration. These were then discussed at the next Learning Event, practitioners were asked to consider whether they agreed with these lessons and whether the lessons were applicable to other cases. The purpose of this exercise is to test out with practitioners the validity of the emerging lessons and, based on their experience in Croydon, to seek their input as to whether the issues are systemic and thus resonate with a wider range of cases. Based on this feedback the lessons were either dismissed, modified or agreed. CSCB SCR Joe - Publication Feb 2018 5 After further analysis of the data, the Review Panel decided there was insufficient evidence to confirm two of the hypotheses (Ref: Appendix 1) and concluded that two alternative lessons should be included (Lessons 1 & 6). The final stage of a learning event is to ask practitioners to identify lessons they have learnt that will inform their own practice and that of their service area. All practitioners engaged in this exercise with commitment and several important learning objectives were identified to be taken forward. Interviews with Practitioners This particular methodology does not normally involve interviews with members of staff. As it was not possible for all practitioners to be part of the learning events, five key practitioners who were unable to attend were interviewed separately. Involvement of Family Members Unfortunately, despite several attempts, it was not possible to meet with Joe’s mother. The Lead Reviewer met with Joe’s maternal grandparents. Joe’s father, paternal aunt and paternal grandmother agreed to have a telephone conference conversation with the Lead Reviewer and the Board Manager. Unfortunately, paternal grandmother was not able to take part in this conversation. Father spoke about his worries about mother’s care of Joe, citing the frequent visitors to the home. He confirmed he saw mother and Joe at the home address on many occasions during the time under review. He said the purpose of these visits was to check that Joe was safe. He was not able to offer a view about the services that were provided. On speaking to Joe’s maternal grandparents and to paternal aunt, it was clear that they had not been aware of the concerns about mother’s care or about the services that had been involved. Both sides of the family said had they known about the extent of concerns, they would have been more involved and would have monitored the care provided to Joe more closely. CSCB SCR Joe - Publication Feb 2018 6 Croydon Safeguarding Children Board are grateful for the time given by family members to this SCR. Terms of Reference The Welsh Child Practice Review methodology presets several practice areas to be analysed as part of any review, these were discussed at the first scoping meeting involving representatives from Croydon Serious Case Review Panel and are contained within Appendix 3. The Welsh Model encourages a time line of about a year, so that the review can focus on recent practice and learning lessons that are relevant to current practice and service provision. Thus, the review covered just over 1 year, from 1st June 2015 - 1st July 2016. However, agencies were keen for the history of multi-agency involvement to be considered and where relevant this history has been referenced in this report. An integrated multi-agency chronology was completed, and agencies produced a short single agency summary covering the time line. This was produced to assist the Serious Case Review Sub-Group in scoping this review and to assist the work of the Child Practice Review Panel. The purpose of the review Working Together (2015) states a Serious Case Review should: provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; be written in plain English and in a way that can be easily understood by professionals and the public alike; and be suitable for publication without needing to be amended or redacted. CSCB SCR Joe - Publication Feb 2018 7 And in response, the Local Safeguarding Children Board should: Oversee the process of agreeing with partners what action they need to take in light of the SCR findings, establish timescales for action to be taken, agree success criteria and assess the impact of the actions3. Key Areas of Analysis – A summary The following is a summary of the key areas requiring analysis in this case (as detailed in Appendix 3): How well was the psycho-social history4 of the child and family considered when providing services and achieving desired outcomes? How well did the multi-agency services assess and manage risk? How well did plans meet the needs of the child and family? Explore the rationale for the duration of the child protection plan and consider how thresholds were applied and decisions made in relation to the various levels of service provision. How well did multi-agency services challenge each other and were there any obstacles that hindered practice decision making and service provision? Identify whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this will include consideration of both organisational issues and other contextual issues). After all documents had been read and reviewed by the panel, several concerns were identified about the effectiveness of the child protection case conference process and the Lead Reviewer was asked to pay particular attention to this safeguarding process. 3 Working Together to Safeguard Children. DfE 2015 4 Psycho-social history is a term applied to the psychological and social history of the parent. CSCB SCR Joe - Publication Feb 2018 8 Family Composition Family Member Age at incident (where relevant) Joe 2 years 11 months Rebecca (sister) 7 years Mother 25 years Father 30 years Significant Events The history of multi-agency service involvement was considered as part of this SCR. A time line of significant events from 1985 – April 2015 is contained in Appendix 4. Period under review: 1st June 2015 – 29th June 2016 Date Significant Events 1.6.15 Announced Social Work (SW) home visit: Joe seen - home observed to be untidy and cluttered, Mother reports no contact with Father. 4.6.15 Landlord reports to Housing. Mother evicted from property due to ‘noise nuisance, men in and out of property possible drug use and damage to property’. 9.6.15 Mother moves to a B&B (offer of new home withdrawn after mother missed appointments with housing). 11.6.15 Core Group Meeting: Mother did not attend. 25.6.15 Announced SW home visit: property presented as clean and tidy. Mother reported no contact with father. 30.6.15 Father attended SW office requesting contact with Joe. July 2015 Father referred to Mood, Anxiety and Personality (MAP) services by his GP citing possible psychosis. 1.7.15 Maternal Grandmother (MGM) contacted Kingston CSC stating mother is requesting return of Rebecca to her care. MGM expresses her view that mother is not able to look after her – advice given. 8.7.15 Paternal Grandmother (PGM) contacted SW requesting contact with Joe, states mother continued to have contact with father whilst he was in prison. 10.7.15 Announced SW visit: contact between Joe and father discussed. 14.7.15 Father released from prison and attends SW office with PGM requesting contact with Joe. 22.7.15 Core Group Meeting: Health visitor and social worker. 29.7.15 Child Protection (CP) Case Progress Review: SW, Child Protection Chair and Unit Manager. 30.7.15 Police called to remove father from PGM’s home due to aggressive behaviour. CSCB SCR Joe - Publication Feb 2018 9 Aug 2015 Father attends a (SLAM) Assessment: noted he has been imprisoned on three occasions with the most recent being breach of an injunction against his ex-partner (mother) “with whom he has a 2-year-old child”. Father started on antipsychotic medication. 26.8.15 Child in Need Risk Screen completed by the care coordinator (SLAM). The risk screen completed stated father did not have any dependent children and had no access to children. 28.8.15 Announced SW visit: SW gained entry after 20 mins Joe and Rebecca at home with mother. 2.9.15 Review Child Protection Case Conference: Joe remained the subject of a child protection plan under categories of emotional and physical abuse. 3.9.15 SW supervision with manager: Plan - to progress to Public Law Outline5. 14.9.15 Police attended Paternal Grandparents (PGP) address: concern that Joe’s father was experiencing a mental health episode -father escorted from the premises. 13.10.15 Core Group Meeting. 16.10.15 Father arrested by police for assault and criminal damage at PGP home. 9.11.15 Early Help worker allocated to provide parenting support. 12.11.15 Home visit Early help: lack of engagement by mother leads to offer of services at children’s centre rather than parenting support. 19.11.15 Re-ablement team (SLAM) meet father with his Community Psychiatric Nurse (CPN): Decision to close his case due to father’s non -engagement. 20.11.15 Father’s CPN refers to ‘Active Minds’ for assessment. 21.12.16 Case Review: CP plan 2+ years (Quality Assurance Manager, Unit Manager & SW). 13.1.16 Review Child Protection Case Conference: Joe’s name removed from a CP plan. Feb ‘16 Mother accommodated in a multi-occupancy temporary housing. The Buildings Manager notices mother appeared ‘spaced out’ and is told by other residents that she is using cannabis and taking cocaine (information gained during the review, not known to professionals at the time). 10.2.16 Core Group Meeting: Mother’s non- engagement with the Children’s Centre noted. 24.2.16 Care coordinator (SLAM) refers Father to SNAP (supported housing). 7.3.16 SW4 allocated. 22.3.16 Father presents as homeless to SLAM office. 29.3.16 Housing confirm with SLAM that Father has had been evicted from two bed and breakfast facilities, re-housing not possible due to father’s behaviour. 31.3.16 Father discharged from the Mood, Anxiety and Personality (MAP) service due to non-engagement. 7.4.16 Child In Need (CIN) meeting: Concerns discussed including mother’s non-engagement and observation of Joe presenting with ‘watchful wariness’, escalation of case back to child protection discussed. 8.4.16 Concerns noted about mother’s continued contact with men who pose a risk. 11.4.16 SW visit: mother continues to refuse to give details of “fiancé”. Case transferred to Best Start Early Intervention Team SW4 allocated. 17.5.16 SW5 allocated (Best Start). 6.6.16 SW5 raises concerns with manager about inability to see mother and Joe after 3 attempts to make contact, lack of sustained changes since 2013 - escalation back to CP discussed. Outcome: to be reviewed after CIN meeting. 22.6.16 Re-referral received from the GP by SLAM: clarity around Father’s diagnosis requested plan made for non-urgent medical assessment. 27.6.16 CIN meeting: SW, Nursery Staff and Mother. 29.6.16 Joe found at home by buildings manager with severe burns. 5 The Public Law Outline (PLO) is a Practice Direction under the Family Procedure Rules which are mandatory court rules, this sets out what should happen before care proceedings are issued. CSCB SCR Joe - Publication Feb 2018 10 Events under the Timeline – an appraisal of practice- a synopsis All those professionals who knew Joe were shocked and saddened to hear of Joe’s injuries. The subsequent criminal investigation and this SCR process have been difficult for all those involved. Despite this, professionals and family members have contributed fully and been open and reflective about the professional response to Joe. Joe was at risk of significant harm for two years and six months and whilst it is the view of the Review Panel that Joe’s horrific injuries could not have been predicted, it was concluded that opportunities were missed to provide Joe with the protection he needed. The Review Panel were struck by the number of services providing support to this family. These services were provided with the intention of making a positive difference to Joe’s life. However, the view of the Review Panel was that there was a lack of proper consideration of the family history, insufficient involvement of the kinship and the full safeguarding network, a lack of evidence based decision making, repeated unresolved concerns about drug use and little understanding of possible impact, poor child protection planning, poor management oversight and a lack of inter-agency and intra- agency challenge leading to drift. During the time covered by this review there were considerable challenges faced by services, particularly Children’s Services. These challenges included an unusually high turnover of front line social workers and managers, high vacancy rates, exceptionally high caseloads of significant complexity and insufficient management support or guidance. This context should be held in mind whilst reading this appraisal. CSCB SCR Joe - Publication Feb 2018 11 1st June 2015 – 1st September 2015 At the start of this period, Joe had been the subject of a child protection plan for over 2 years under the categories of emotional and physical abuse. The health visitor and social worker worked well together, they made regular announced and unannounced visits to the family home and on occasions these visits were made jointly. As a result, there was excellent communication between these two key professionals. The joint visits that took place enabled the sharing of information and demonstrated unity within the professional network. During a home visit made to the family home on the 1st of June 2015, mother was asked whether she had contact with Joe’s father as there were ongoing concerns about the risks he posed to Joe, mother stated she was having no contact and this was accepted. However, when the housing records were released as part of this SCR, the records for the same period showed that a housing officer had recently observed a male leaving the house (believed to be the father of Joe) but as housing services were not included in the safeguarding network, this information was not shared. The absence of housing services involvement in the safeguarding of Joe and the undue weight placed on parental self-report meant that the risks to Joe were under-estimated. In addition, although it was right to continue to evaluate the risks posed by father, mother had a history of neglectful parenting and evidence suggested that there was little improvement in the parenting she provided to Joe since his birth. The undue focus on father meant that the risks posed by mother were not properly considered. A core group meeting was held at the required time on 22nd July 2015 and was attended by the health visitor, social worker and mother. At this meeting, concerns about the length of time Joe had been the subject of a child protection plan were appropriately discussed. Professionals were right to raise these concerns as Joe had been the subject of a child protection plan for 2 years and six months. CSCB SCR Joe - Publication Feb 2018 12 This is of concern both locally and nationally and children who are the subject of a child protection plan for 2 years are expected to be the subject of management review to ensure effective action is taken. During this time, Croydon Children’s Services were changing the existing processes for reviewing these children. There were considerable delays in these management reviews, and as a result Joe’s case had not been reviewed. The absence of a management review left Joe at continued risk of harm, and left front-line practitioners (including the chair) without the management guidance they needed. It is understood that a new inter-agency reviewing process for children subject to a child protection plan for 2 years is currently being implemented, this is discussed later in the report. On 29th July 2015 a ‘child protection progress case review’ took place involving the Child Protection Chair, the Social Worker and the Unit Manager for the Social Work Team. It was agreed that the social worker would refer Joe for a developmental assessment and ascertain whether there were any restraining orders on father. These decisions did not reflect the seriousness of this case. At this point, the only assessment available was a pre-birth assessment which had been completed when mother was living in Kingston, no core assessment had been completed in Croydon. This meant that there was no comprehensive understanding of Joe’s needs or of mother’s parenting capacity and no bench mark on which progress (or the lack of it) could be measured. The absence of a core assessment was not discussed at this meeting, this was an important omission. It was understood that if there is a pre-birth assessment on the child’s file, the current data recording system in Children’s Services does not prompt social workers to complete a core assessment. In addition, it was learnt that the social work report to conference is often regarded as an assessment update. CSCB SCR Joe - Publication Feb 2018 13 This approach does not meet the needs of children, for children to be adequately safeguarded dynamic risk assessments are critical and social work reports to conference should not be regarded as a substitute for an updated assessment. (This is discussed later in this report.) Whilst the decision to pursue a paediatric assessment could have been an attempt to gain evidence to support legal action, this was not explicit in the recording of this meeting as it should have been. Importantly, the lack of time scales set for the assessment and the absence of a clear plan to progress with Public Law Outline (as a prerequisite to court proceedings) contributed to the drift in this case and left the social worker without the management guidance that was needed. There had been repeated recommendations made at case conferences for mother to: disclose the names of all household visitors to enable an assessment of risk refrain from drug and alcohol misuse give permission for maternal grandmother to be contacted engage in parenting work keep all health appointments And for the case to progress under Public Law Outline. None of these recommendations had been progressed and this was not challenged by the CP chair or the manager. This lack of challenge left Joe at continued risk of harm. During June, July and August 2015, the social worker made regular announced and unannounced visits to the family home. Mother was challenged about her non-attendance at various appointments and about her non-engagement with the child protection plan. The social worker was right to challenge this non-engagement and was tenacious in her efforts to gain access to the family home to see Joe. However, in the absence of management guidance to the contrary, much of the social worker’s time was taken up negotiating the feasibility of supervised contact arrangements between Joe and his father and this diverted the social work focus away from the risks posed by mother. CSCB SCR Joe - Publication Feb 2018 14 After receiving a referral from father’s GP, reporting concerns that father was suffering from psychosis, the South London Adult Mental Health service (SLAM) met with father in August 2015 and completed an initial ‘risk screen’. Father reported he had no dependent children and had no contact with any children and this self-report was accepted. At the time, father was making several attempts to have contact with Joe through the social worker. However, information available to other professionals suggested that father was having contact with Joe. As SLAM was not included in the safeguarding network around Joe, they were unaware of Joe. Review Child Protection Case Conference: 2/9/15 This case conference was held within the required time frame and was attended by the health visitor, social worker and mother. Probation and the Police Child Abuse Investigation Team (CAIT) had been invited, but did not attend. CAIT sent a report and this was included in the social work report. No report or update was provided by Probation and Adult Mental Health Services (SLAM) were not invited. It is questionable whether the membership of this conference was quorate, and this should have been discussed. The London Child Protection Procedures state that when there are no other professionals having direct contact with the child, minimum quoracy can be overridden. However, it is important to consider any professional group, services or family members who may have valuable information to share. In this case, adult mental health, housing, paternal and maternal grandparents all had valuable information to share, but they had not been invited to attend and the absence of their contribution was not acknowledged. Had they been invited to contribute, vital information about the risks to Joe6 would have been known and the safeguarding network around Joe would have been strengthened. 6 Including information from housing about concerns from landlords, information about father’s mental health and information from MGM about her observations of mother and father who were visiting her home in another London Borough CSCB SCR Joe - Publication Feb 2018 15 The plan that was included in the social work report was not the plan made at the previous case conference, this plan related to a case conference that took place in December 2014. Although the child protection plan in the social work report for conference was incorrectly included, the plan from the previous conference was correctly reviewed in the conference and professionals had been following this plan. The health visitor report to this conference was good, the template allowed the health visitor to provide full information about her involvement and to provide a good description of Joe’s perspective. The historical background and current risks were clearly outlined and the lack of compliance by mother with the child protection plans was highlighted. Indeed, mother had not engaged with the child protection plan and so the vast majority of the recommendations remained unmet. The social work report appropriately recorded observations of Joe and these observations gave a reasonable (albeit limited) picture of Joe. The social worker concluded that mother ‘could provide basic care to Joe’ and that there was a ‘good attachment’ between Joe and his mother. There was no evidence provided to support these assertions and the use of terminology such as this, without any supporting evidence, can have unintended consequences for how risks to children are understood. There was an over emphasis placed on the social work view that mother was committed to ending her relationship with Joe’s father and the focus of concern in the social work report (and the conference) was on the risks father posed to Joe. Mother’s lack of compliance with the child protection plan and the lack of progress made by services to implement the plan was not discussed. The reasons for this lay partly in the lack management support provided to the professionals and partly in the primary focus of the child protection plan. Joe was the subject of a plan under the categories of emotional and physical abuse. The rationale for these categories was stated as being the risk of Joe living in a household where there was domestic violence and this category is commonly used in these circumstances. CSCB SCR Joe - Publication Feb 2018 16 However, whilst the category of emotional and physical abuse was arguably appropriate at the Initial Child Protection Conference in May 2013 subsequent concerns about mother’s care of Joe, her lack of engagement with the CP plan, father’s departure from the family home (and the view of the professionals that he was not having contact) should have led to a change in this category. The category of neglect that had been used in Kingston when Joe’s sister was the subject of a child protection plan should have been used. The continued use of the emotional and physical abuse category had the effect of diverting skewed the plans and decision making away from neglect and promoted an overriding focus on the risks posed by father. At this conference, information was shared about father and this included information from paternal grandmother that mother had been in contact with father whilst he was in prison. A report from the police suggested that father had been in the family home when Joe was present in May 2015: In May of this year a police report states they were called to the address and believed father had been present in the property, evidence that people had been up late drinking at the address house in poor condition stale air no bed sheets toys all over lager cans lying around. This information appeared to be set aside in favour of mother’s reports that she was having no contact with father and the evidence of neglect was overlooked. In the absence of a focus on mother’s neglect, the assertion that there were now changes in mother’s relationship with father led to a false optimism that Joe no longer required a child protection plan. The chair concluded that the risks had reduced and expressed a view that a Child in Need (CIN) plan could be made. The view of the chair was contrary to the view expressed by the social worker (that the child protection plan should continue for a limited period to allow for monitoring) and to the view of the health visitor (who was clear that the risks remained), but neither the social worker nor the health visitor challenged the position the chair was taking. CSCB SCR Joe - Publication Feb 2018 17 None of the professionals had been provided with the management support they needed and the absence of inter-agency and intra-agency oversight and challenge compromised decision making. Just prior to the conference ending, mother responded inappropriately to a request to disclose details of her new partner. Based on this response, the chair decided that the CP plan should continue and that Joe should be placed under the category of neglect. The decision to change the category was correct, mother had not engaged with many of the recommendations made at all previous conferences and there was evidence that mother was unable to prioritise Joe’s needs above her own. It would have been expected practice for the chair to be explicit about the evidential basis for changing the category and for this to be clearly recorded. However, the reasoning recorded in the minutes was muddled. That said, a more robust plan was made at this conference. This plan identified several outstanding actions from previous case conference and gave some clear timescales for completion of tasks (including the need to seek legal advice). However, although the decision to change the category to neglect was recorded in the conference minutes an administrative error led to Joe’s name remaining on the list of children subject to a CP plan under the category of emotional and physical abuse, and so the focus of concerns remained on father. The reason for this error was said to be due to the reduction of administrative staff and the high volume of conferences in Croydon. This is discussed later in this report. CSCB SCR Joe - Publication Feb 2018 18 3rd September 2015 - 7th January 2016 On the 3rd of September (the day after the conference), a management decision was recorded on Children’s Services case file: to progress the case for Public Law Outline (PLO) 7, tasks to be completed (before progressing to PLO): paediatric assessment of Joe and case to be discussed with senior management. These were clear management decisions and were appropriate to the risks in this case. However, these decisions were not discussed with the social worker as part of a formal supervision session (as they should have been) and no timescales were set for the completion of tasks. Mother had been regularly asked to disclose the details of her partner, on the 16th of September 2015 the social worker asked for these details again, and asked if Joe was ever left in his care. Mother agreed that Joe was left in his care but refused to provide details of her new partner. This was a key point in the case, a manager had noted on the file that the case should progress to PLO and this new information suggested that Joe was being cared for by an unknown male. There was suspicion that mother was pregnant and, given mother’s history, it was reasonable to conclude that both Joe and any unborn child may be at risk from this man. No action was taken in response to this information, it was merely recorded on file. It was not possible to understand why no action was taken although it is understood that at this time there were unacceptably high caseloads held by social workers and a high turnover of staff, both of which would have had an impact on practice standards. 7 Public Law Outline is the initial stage of legal proceedings CSCB SCR Joe - Publication Feb 2018 19 On the 25th of September 2015, a manager made a note on the case file asking to be informed if the case progressed to PLO. This should have formed part of a supervisory meeting with the social worker to ensure they were appropriately guided in their work, this did not happen. A core group meeting was held within the expected time on the 13th of October 2015 and included mother, the health visitor and the social worker. The plan made at the previous case conference was correctly included in these minutes. This showed that whilst some of the tasks appeared to be in progress, the most essential tasks at this point (that of gaining legal advice and gaining the details of mother’s new partner) had not been taken forward and the manager’s decisions (recorded on file) were not discussed. It was not possible to fully conclude why, although given that these decisions had not been discussed with the social worker, it is entirely possible that at the time of the core group the social worker was not aware of these management decisions. During the next few weeks, the social worker made several visits to the household and attempted to engage mother with the work of the Family Engagement Partnership (FEP)8 team. On several occasions, both the social worker and the FEP worker could not access the home and struggled to receive any response from mother, as a result there was little contact with Joe. Over this period, there was no evidence found to suggest that the manager drew the social worker’s attention to their decisions, no evidence found that the social worker was aware of these decisions, and no attempts were made to progress the case to PLO. On the 21st of December 2015, a Quality Assurance Manager (who was manager of the CP chair) met with the social worker and the manager. This was recorded as a meeting to review the case of a child on a child protection plan for more than 2 years, it is unclear why the chair (who held a central position of authority within the case conferences) was not present. This was an opportunity to realise the risks in this case and take forward the outstanding task of progressing the case to PLO, the agreement reached at the meeting was recorded as: 8 FEP: An Early Help service for children under 5 and their families. CSCB SCR Joe - Publication Feb 2018 20 “some tasks have to be completed before the CP plan could end, but others could be managed under a CIN plan or TAF (Team Around the Family)”. This contradicted both the CP plan and the management decisions recorded on Joe’s file. In addition, the decisions were not made with key safeguarding partners and partners were not informed of the decisions. This reflected the single agency approach to decision making on high risk cases such as these9 operating at the time and meant that there had been no effective challenge to Children’s Services about the significant delays. This is discussed later in the report. 13th January 2016 – 16th May 2016 Review Child Protection Case Conference: 13th January 2016 The conference was attended by the newly allocated social worker, health visitor and the family support worker. Relevant issues in relation to quoracy and the involvement of the full safeguarding network have been previously discussed and equally apply to this conference. The social work report to the conference briefly detailed Joe’s wellbeing and these comments were generally positive. However, only 2 visits to the family had taken place since the last child protection conference. Despite this limited social work involvement, the social worker noted a “good attachment” between Joe and his mother and asserted that Joe’s basic needs were met> The quality of this report fell below expected practice standards, relevant issues relating to the quality of social work reports and the use of misleading terminology are explored later in this report. The conference was conducted using a ‘Strengthening Families’ approach; the format and structure of the meeting was of a far better quality than that previously seen. However, there were several problems in the quality of information sharing, assessments, and decision making. 9 Children subject to a CP plan for over 2 years CSCB SCR Joe - Publication Feb 2018 21 Reports presented to the conference, outlining changes in family circumstances since the last conference, were almost entirely based on mother’s self-report and this self -report had not been triangulated with other sources of evidence. Critical information about mother’s new partner and her suspected pregnancy was not shared. The police report stating that Joe’s father had come to the attention of the police on four occasions since the last conference was not discussed. Reports of Joe being withdrawn and observations that he could appear “frozen - wanting to cry but unable to do so” were not regarded with the seriousness these observations warranted. During the conference, a statement was made that maternal grandmother was allowing unsupervised contact to take place between mother and Joe’s sister (Rebecca) and this was regarded as a positive sign. In fact, this contact had been taking place since 2013 as maternal grandmother (MGM) was not aware that Joe was the subject of a child protection plan. Importantly, by allowing Rebecca to stay with her mother, MGM was unknowingly placing Rebecca at risk of significant harm. Had she been contacted, valuable information would have been known about mother’s ongoing relationship with Joe’s father and Joe’s safeguarding network would have been strengthened. This SCR identified that twelve recommendations from the last case conference had not been completed. These related to key areas of the child protection plan that had remained unmet for the duration of child protection planning. These included but were not exclusive to: the need to seek legal advice with the intention of progressing to PLO mother to disclose the details of household visitors mother to disclose the details of her new partner maternal family to be contacted a core assessment to be completed CSCB SCR Joe - Publication Feb 2018 22 During the child protection conference, the lack of progress in these key areas was not acknowledged. In addition, of critical importance was mother’s drug mis-use; but there had been no objective assessment or monitoring of this. Despite external evidence to the contrary, mother’s self- report that she was not using drugs was taken at face value. As a result, there was no consideration about how her drug use might be impacting on Joe, on mother’s own mental health, or on her capacity to change. Mother’s drug use was only minimally referenced within the child protection conferences and at this last conference it was not discussed. The newly allocated social worker reported a good relationship with mother, this relationship seemed to influence their professional opinion as an overly positive report was presented about the parenting Joe was receiving. This report was not supported by the evidence that was available. The conference placed disproportionate weight on the involvement of a family support worker (FSW) and mother’s attendance at the Children’s Centre, this was cited as evidence of her “engagement and motivation” and of her ability to safeguard Joe. In fact, due to mother’s lack of engagement, the Best Start Early Intervention Team had decided they were unable to offer a service and only saw mother on two occasions at the Children’s Centre. In addition, mother had attended the Children’s Centre for only 3 (out of a possible 20) sessions. Conference members decided that the threshold for a child protection plan was no longer met and Joe’s name was removed from a child protection plan. Monthly social work visits were recommended, the health visitor was asked to see Joe “if and when required,” mother was asked to attend the Children’s Centre twice a week, and there was a recommendation that the case was not closed until a CIN meeting took place. The decision to remove Joe’s name from a child protection plan was not based on any evidence suggesting that there had been material changes in Joe’s lived experiences, or the risks he faced. CSCB SCR Joe - Publication Feb 2018 23 Joe remained at risk of significant harm and the plan agreed at the conference did not adequately safeguard Joe from future harm. The lack of a core assessment, and the poor quality social work reports, provide a partial answer for the absence of coherent risk assessment and planning. However, it is important to note that the safeguarding of children can never be achieved by one professional or by one service. There was a need for all agencies to take ownership of the poor safeguarding practice in this case and take appropriate action to ensure Joe was the subject of legal proceedings. At this time there was a high turnover of social workers in Croydon, staff were holding unacceptably high caseloads, there was little management guidance and insufficient support and challenge provided from both within Children’s Services and across the multi-agency services. Providing services to Joe as a Child in Need: 14th January 2016 – 11th April 2016 Typically, when a child protection plans ends, the level of scrutiny and support reduces. This is appropriate and necessary but carries with it the potential for families to be left relatively unsupported or with inadequate monitoring.10 On the 7th April 2016, a child in need (CIN) meeting took place and correctly held in line with the recommendation made at the previous child protection conference that the case should not be closed to Children’s Social Care before a CIN meeting was held. Housing was not invited to this meeting as they should have been, but the meeting was appropriately attended by the Probation Service, the Family Support Worker, the Health Visitor and the newly allocated social worker. The meeting correctly identified several long-standing concerns, including concerns about mother’s recent withdrawal from services. 10 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016). CSCB SCR Joe - Publication Feb 2018 24 During this meeting, Joe was described as exhibiting “watchful wariness” but as a full picture of Joe had not been previously gained it was not possible to know whether this was Joe’s normal presentation or something new that may have been prompted by a change in the care he was receiving. Although there was little description of what this meant, it was a critical observation that should have resulted in far greater attention paid to Joe; including opportunities to undertake a close observation of Joe’s overall emotional and behavioural development and well-being. However, as the term of ‘good attachment’ had thus far been used to describe Joe’s relationship with mother this may have served as an antidote to this concerning observation. The meeting concluded mother stopped engaging with services as soon as Joe’s name was removed from a plan and decided that the case should be escalated back up to statutory child protection services. Despite this decision, three days later, Joe’s case was transferred to the Early Intervention Services. No effective action was taken by any of the services to challenge this decision. It is understood that there is now a pathway in place encouraging and guiding the process of professional challenge from within Early Intervention Services to enable swift escalation of cases to statutory services where needed. As a result, no lesson has been formulated in relation to this issue although the lack of multi-agency challenge that is explored in Lesson 2 is relevant. Involvement of the Early Intervention Team (Best Start) 11th April – 29th June ‘16 On the 11th of April 2016, a social worker from the Best Start Team was allocated. However, this social worker was not involved with the family as they left the service shortly after allocation. Over 4 weeks later, another social worker was allocated (this was the fifth social worker during the period under review). Given the concerns in this case, this delay in allocation was poor practice. It was understood that at this time there were a high volume of cases being transferred to this team, management oversight was in the process of being established, and there were few procedures in place facilitating challenge about the transfer of cases. Changes to this transfer process have now been made, resulting in strengthened management oversight and challenge. CSCB SCR Joe - Publication Feb 2018 25 No specific lessons have been identified in relation to this, although the issues identified in Lesson 2 are relevant. The social worker made several attempts to contact mother, but was unsuccessful. On the 6th of June 2016, the social worker discussed the case with the team manager and expressed significant concerns about Joe and the drift in the case. The social worker’s early grasp of the risks was commendable and for the first time the impact on Joe of mother’s cannabis use was appropriately raised as a significant area of concern. In the absence of a clear agreement between services, specifying how escalation could be achieved, the manager felt it was important to gather as much evidence as possible to achieve successful escalation. The manager advised that a child in need (CIN) meeting should take place before attempts could be made to escalate the case back up to statutory child protection services. Whilst the rationale for this approach is understandable, this led to further delay. Over the next 3 weeks, the social worker gathered evidence to achieve escalation; arrangements were made for a CIN meeting, Joe was observed at nursery and several visits were made to the family home. The social worker appropriately challenged mother’s use of cannabis and expressed her concerns about the routine delays she experienced when attempting to gain entry to the home. She challenged mother about her lack of engagement with services and evidence found on ‘Face Book’ relating to mother’s drug use and her association with unknown males, this was excellent social work practice. At a CIN meeting on the 27th June 2016, the social worker again appropriately raised her concerns. However, two days later (before further action could be taken) Joe was found at home by the Buildings Manager with severe burns to his body. The action taken by the Buildings Manager to safeguard Joe was commendable. Key Lessons A total of nine lessons have been learnt from this case, all of which are pertinent to the multi-agency safeguarding system. CSCB SCR Joe - Publication Feb 2018 26 Many of the lessons are interlinked, meaning that changes in one part of the system may ultimately have a positive impact on other areas of learning and development identified within this report. The appraisal of practice details how the child protection conferences and the child protection plans made at these conferences did not provide Joe with the protection he needed. The first three lessons are focused on the services provided to children who are the subject of child protection case conferences and plans. The first lesson looks at the internal mechanisms within Local Authority Children’s Services that enable child protection case conferences and child protection planning to take place and the management oversight and support required to ensure these mechanisms provide children with the protection they need. Lesson 2 explores the importance of multi-agency challenge and Lesson 3 explores the importance of involving the full multi-agency network in safeguarding children. Lesson 1: When Child Protection Conferences and Child Protection Plans are not working as they should, and there is insufficient oversight of these crucial safeguarding mechanisms, the protection of children will be compromised. The appraisal of practice outlines several issues relevant to this lesson including the quality of social work reports to the conferences, concerns about the plans made for Joe, administrative mistakes in relation to child protection plans and recording , the lack of implementation of child protection plans, the absence of a core assessment, the fragility of the evidence base on which decisions were made, the lack of analysis, the categorisation in use and the absence of effective management oversight. It was understood that multiple factors contributed to this position and that a ‘Strengthening Families’ approach to child protection conferences was introduced in Croydon in November 2013 and has more recently been subject to review. Whilst this approach will improve practice in this area, it will not address some of the systemic shortcomings identified in this case. CSCB SCR Joe - Publication Feb 2018 27 Members of the Review Panel were asked whether these vulnerabilities were relevant to a wider range of cases and the following factors were identified as continuing to impact on service delivery, including, but not exclusive to: the reduction of administrative staff employed to support child protection conferences systems errors within the data recording system that lead to the wrong plan appearing in the case file and to there being no trigger to prompt the completion of an updated assessment the high caseloads of child protection chairs, the lack of robust management oversight (that is overly focused on performance indicators and process at the expense of practice oversight and guidance) the systemic organisational tolerance of poor quality social work reports and assessments (and the lateness of submission) the low status ascribed to child protection recommendations the conflict that can exist between chairs and team managers when recommending legal advice, the lack of escalation of concerns by chairs The inter-agency sharing of information, discussion, challenge and joint planning that is achieved through the mechanism of child protection conferences should not be underestimated. These components underpin the multi-agency system that routinely achieves the protection of children. However, if these processes are eroded and the intrinsic value of this multi-agency risk assessment and decision-making forum is not sufficiently supported and reviewed, the protection of children will be compromised. CSCB SCR Joe - Publication Feb 2018 28 Lesson 1: Issues for the Board - CSCB and Children’s Services to review the quality assurance data 11 currently provided to ensure that the standard of this data is sufficient to enable adequate evaluation of child protection services. - Child protection chairs must be routinely expected to challenge how children are safeguarded. Their effectiveness in providing challenge should be the subject of regular review and evaluation both internally within Children’s Services and by the CSCB. - Children’s Services to conduct an internal review of the issues identified and determine how these issues will be addressed. CSCB to review and evaluate impact of changes. Note: The recent Ofsted inspection (June- July 2017) has identified similar issues, CSCB should consider the issues raised in this lesson and recommendation made above to determine whether current action is sufficient. Lesson 2: The lack of robust inter-agency and intra-agency decision making and challenge, about the services provided to children who are the subject of child protection plans, jeopardises children’s safety. This lesson explores the critical role of inter-agency and intra-agency challenge in safeguarding children and demonstrates how the absence of this challenge has a significant impact on whether the right services are provided to children when protecting them from harm. 11 Ref: Analysis of Data of Children Subject to Child Protection Plan May 2016. Croydon Safeguarding and Quality Assurance Service (presented to CSCB Oct’16) CSCB SCR Joe - Publication Feb 2018 29 The issues identified in this lesson are not particular to Croydon, Serious Case Reviews conducted across the UK frequently refer to the absence of professional challenge in safeguarding work.12 Joe was the subject of a child protection plan for 2 years and six months. As identified in the appraisal of practice, there were several key areas of the child protection plan that were not implemented and were simply rewritten into the plan for almost the entire duration of child protection planning. There was no evidence that members of the professional network effectively challenged this status-quo, instead the same recommendations were simply repeated. A critical part of the plan was to seek legal advice and to progress matters under the Public Law Outline. But despite this recommendation being constantly repeated, it was not progressed. This was not challenged by multi- agency partners, by the various child protection conference chairs, or by managers. The lack of inter-agency and intra-agency challenge has been mentioned in the appraisal of practice and needs no further exploration. However, it is of note that in the Learning Event managers and practitioners spoke of feeling concerned that Joe was not being adequately safeguarded, but were unable to explain why no challenge was made. When Joe’s child protection plan was at danger of exceeding the maximum 2-year period, in line with established custom, practice and procedure, Joe’s case was the subject of management scrutiny. A review of the plan was conducted by the Police Child Abuse Investigation Team (CAIT) in August 2014, to challenge: “the ineffectiveness of the child protection plan”, this was completed without reference to the agencies involved and resulted in no effective change to the status quo. 12 Case reviews: National case review repository (NSPCC) CSCB SCR Joe - Publication Feb 2018 30 Another review was completed by the operational manager responsible for the allocated social worker and the manager responsible for the child protection chair, their responses are detailed in the appraisal of practice. In summary, there were differing views about what should happen in this case but in any event their observations and concerns made little difference to the course of events. Of relevance is the disparate way in which this multi-agency management system worked to consider the question of Joe’s protection there was no consultation across the agencies involved and there was no effective challenge to the status quo. As part of this SCR, relevant local policies were reviewed. There was no policy found that addressed the review of children subject to child protection plans for 2 years. 13 Two policies were found outlining the steps that need to be taken to escalate concerns about a case. One was an internal Children’s Service document addressing the role of the Independent Reviewing Officer (and child protection chair)14 and the other a CSCB escalation policy.15 Whilst it is important that both CSCB and Children’s Services have such a framework in place, it was understood that there is no information available to understand how effective these polices are in facilitating challenge and as there was no expressed challenge/disagreement to the plans in this case these policies did not apply. In addition, in the absence of a framework that sets a cultural tone to working practices (i.e. one that encourages professional curiosity, debate, challenge and respectful uncertainty) the overriding focus on disagreements and escalation can inadvertently lead professionals and services to view challenge in a negative light and the current focus of existing policies on disagreements or disputes (that require a process to be followed to reach resolution) may run the risk of dissuading inter-agency and intra-agency debate and challenge. 13 It was understood that a new policy is currently being written 14 Croydon’s Escalation and Resolution Protocol for Children, Families and Learning Partnership March 2015 15 Croydon Safeguarding Children Board Escalation Policy. Resolution of professional disagreements in work relating to the safety of children. March 2015 CSCB SCR Joe - Publication Feb 2018 31 Lesson 2: Issues for the Board - Members of the multi-agency network to outline what steps will be taken to improve the quality of their contribution to child protection conferences and decision making and how the absence of challenge will be addressed. CSCB to evaluate impact. - CSCB to ensure that there is now a robust timely multi-agency process in place that scrutinises child protection plans for children who are the subject of a child protection plan for 18+ months and evaluate impact. Lesson 3: The restricted view held about which agencies are part of the safeguarding network, and who holds responsibility for safeguarding children, results in valuable information not being shared and leaves the onus of responsibility with the few. The phrase “Safeguarding is everyone’s responsibility” lies at the heart of statutory guidance and practice, dictating how children are safeguarded. Working Together 2015, The Munro Review of Child Protection16, various SCRs, research and associated literature are clear that children can only be safeguarded within a multi-agency partnership characterised by shared responsibility. These collective responsibilities include shared multi-agency ownership of assessments, analysis, plans and outcomes, and includes multi-agency partners across the management hierarchies. There were several examples in this case indicating that this shared responsibility did not translate to multi-agency practice on the front line and this left the onus of responsibility with a handful of practitioners. This lesson explores how the composition of the safeguarding network had a significant impact on the services provided. 16 Munro review of child protection: a child-centered system. Department for Education May 2011 CSCB SCR Joe - Publication Feb 2018 32 At the start of this SCR, the Review Panel concluded that although there was either minimal or no apparent involvement by Housing, Community Rehabilitation Company and Adult Mental Health Services, there was a need to include the full safeguarding network in this SCR and representatives were invited to attend. Housing services were a consistent member of the panel but as identified in the methodological limitations, there was inconsistent representation from Adult Mental Health Services and the London Community Rehabilitation Service did not attend. This was reflected in the case, housing had significant involvement, but this was not shared at the time, at one-time Probation Services were active in the safeguarding network but overall they had limited involvement, and whilst there were evident concerns about father’s mental health, adult mental health services were not included in the safeguarding network. The absence of these safeguarding partners was important for several reasons. In terms of housing services, it was only when gathering information for the purposes of this SCR that the extent of information known about the family became clear, this included important information about the anti-social behaviour of mother and allegations by landlords and neighbours of “noise nuisance, drug dealing and prostitution.” 17 Had this been known by the professional network, it would have provided valuable information to strengthen the protection of Joe. In terms of the Community Rehabilitation Company services, they were involved with father at various times but they were not routinely invited to case conferences.18 It has been argued that when father was in prison he was not receiving services from the Community Rehabilitation Company, so they were not involved. This rigid definition of the safeguarding network should have been challenged. 17 There was no corroborating evidence to suggest mother was involved in prostitution 18 Probation were invited to one CP conference (out of a possible 6 of the 6 conference minutes reviewed) but did not attend CSCB SCR Joe - Publication Feb 2018 33 Whether the Community Rehabilitation Company services were actively involved or not, they could have been asked to provide important guidance and support in seeking information from the prison service that would have assisted in gaining a greater understanding of father to inform the protection of Joe. Likewise, although adult mental health services were not consistently involved in providing services given the ongoing unanswered questions about father’s mental health advice and guidance from this service would have provided valuable information to support decision making. As part of this SCR, the minutes of six child protection case conferences were reviewed and showed that the only professional attendees of the CP conferences were the police, the health visitor, the chair and the social worker. In 4 (out of a possible 6) case conferences no police representative was present19 and in the final conference that removed Joe’s name from the child protection plan only the health visitor, social worker and chair were present. It was the view of the Review Panel that the absence of safeguarding partners at case conferences was not unusual, the suggested reasons for this include a lack of knowledge about which services are involved in family life and the non- attendance of services. It is understood that a relatively recent report to the CSCB has identified this as an area of concern and action is currently being taken to address this, the effectiveness of this action is not known at the time of writing. The importance of including the full safeguarding network in these critical planning forums is undisputed. Responsibility for ensuring the right people are invited commonly sits with Children’s Services in the form of the allocated social worker. This reliance on one individual does not create a safe system, it is the responsibility of all agencies to have systems in place to support the contribution of multi-agency staff, across a range of adults and children’s services. 19 It was understood that police policy is that they will only attend an initial case conference and will attend future case conferences only ‘as and when ‘required. CSCB SCR Joe - Publication Feb 2018 34 Lesson 3: Issues for the Board - Recent SCR’s in Croydon have highlighted concerns about the lack of involvement by housing services in safeguarding children and several measures have been put in place that have strengthened this area of safeguarding practice. CSCB are invited to review improvements that have been made and consider if anything further is now needed. - Are safeguarding partners adequately prioritising and facilitating the attendance/contribution of relevant staff at case conferences? How will this be evidenced and kept under review? - What systems need to be put in place to ensure that the full safeguarding network is correctly identified and that the attendance/involvement of all safeguarding partners is achieved? Lesson 4: There was sufficient information about various concerns that should have allowed clear judgements about risk to be made but the over focus on assessments and self -report caused significant drift. ‘The balance of probabilities’ is the standard of proof used in all care proceedings and should be used as the governing principle in safeguarding work. There was sufficient evidence in this case to suggest that this standard of proof had been met, but instead there appeared to be a perennial seeking of evidence to prove that Joe was the subject of harm beyond all reasonable doubt. (and a converse position of decision making based on a highly questionable evidential base in the form of self – report) CSCB SCR Joe - Publication Feb 2018 35 Throughout the documentation the quest to obtain assessments about father, was strikingly repetitive. “……excessive emphasis on assessment can lead to drift or failure to proactively work with families.” 20 Child protection plans recommended that assessments were needed to assess father’s cognitive functioning, his mental health needs, his anger management, his use of drugs and the risk he posed of sexual abuse. These assessment proposals were variably repeated within the time under review, and in the conferences that preceded this period. These assessments were never achieved so whilst plans rightly identified action needed to ensure Joe’s safety from his father, there was sufficient evidence held across the agencies that should have led to a judgement that - on the balance of probability - Joe’s father posed a significant risk to Joe. Whilst this was tentatively inferred by the actions taken, the perpetual seeking of assessments to confirm this risk resulted in an undue focus on father and came at the expense of making plans that sought to address the risks posed by mother. There was sufficient information to suggest that mother was a long-term cannabis user, that she mis-used alcohol, regularly had loud parties at the home when Joe was present, was not prepared to inform agencies about a variety of household visitors who could pose a risk to Joe, was not engaging with plans and services and was not prepared to place Joe’s needs above her own. Judgments about the care Joe was receiving were too often based on mother’s self-report and on the evidential criteria used in criminal law (i.e. beyond reasonable doubt). Had these judgements been based on the correct legal threshold (i.e. on the balance of probability), the risks to Joe would have been successfully identified. No audits could be found to show that the comparison of these care judgements has been the subject of quality assurance activity in Croydon. 20 Brandon et al – Triennial Analyses of Serious Case Reviews 2011-2014 CSCB SCR Joe - Publication Feb 2018 36 The recent Ofsted inspection has identified the poor quality of risk assessments; including the over reliance on self -report, lack of a sound evidential base and lack of analysis. The action already being taken to address these issues should be considered alongside this finding and the recommendation that has been made. Lesson 4 Lesson 4: Issues for the Board - Professionals to be supported in gathering evidence and triangulating evidence to improve risk assessments, ensuring that judgements about risk are based on a sound evidential base that properly considers the balance of probability/ likelihood of harm. Lesson 5: Some of the terminology used by professionals in safeguarding work requires greater explanation and scrutiny to understand what it means, using this terminology without adequate explanation risks assumptions being made that compromise a child’s safety. There were terms used within assessments, reports, minutes of case conferences and core group meetings that were used to denote aspects of the care Joe received. Examples include: “(Mother) is able to provide basic care”, “(Joe) seems to have a good attachment to mother”. These terms frequently appeared within the narrative but were accompanied with little description of what they meant, or the meaning for Joe. The use of these terms can have a powerful emotive impact on professional thinking and can active as an antidote to a wider context of serious concerns. (as they did in this case.) The repeated assertion that a parent can provide “basic care” is a not an unusual statement to see within assessments, minutes of case conferences, reports and case recordings, but what this means in practice is often unclear, and is prone to subjective interpretation. For some basic needs are as simple as food, water and shelter and if this is the definition that was used to describe the care that Joe received then this may well have been correct. CSCB SCR Joe - Publication Feb 2018 37 However, children’s basic needs are more complex than this and the question of whether Joe’s emotional and psychological needs were being met should have been considered. Joe was living in an unstable environment that featured drug use, frequent household visitors, a visibly chaotic home, a notable lack of stimulation and frequent concerns that mother was not taking him to required appointments, to assert that Joe’s basic needs were being met was arguable. Again, it is not unusual to see the terms ‘good attachment’, ‘strong attachment’ or ‘insecure attachment’ in case documentation across agencies, when describing the relationship between a child and a carer, but this is rarely explored or challenged. If the relationship between a carer and child is described as a “good attachment”, and taken at face value, this can serve to be a powerful emotive description of the relationship between a child and carer. In an article in ‘Community Care’21 with the headline: “Never use the word ‘attachment’ again”, according to an expert on attachment theory (Professor David Shemmings) the terminology of ‘good’ or ‘strong attachment’ should not be used: A child can have a strong attachment to someone they are very insecure with…. When working with babies and very young children it is particularly important to appreciate this stage of development, their vulnerability and resultant dependency on their primary care giver for food shelter warmth and protection and to be aware of how this survival instinct can be wrongly interpreted as attachment. Understanding the relationship from the child’s perspective, should involve in- depth observation and exploration of the interaction between a carer and child: Observations of different aspects of the child’s routine at various times of the day can evidence a parent’s sensitivity, availability and attunement and provide a rich and invaluable source of attachment-based information.22 21 J. Silman, Community Care 9/8/16 22 Professor David Shemmings quoted in Community Care 9/8/16 CSCB SCR Joe - Publication Feb 2018 38 Issues for Lesson 5: Issues for the Board - The Strengthening Families approach is a helpful way of encouraging practitioners to detail their observations. CSCB to review the implementation of this approach to evaluate whether the issues identified in this finding are being satisfactorily addressed. - CSCB to seek assurances that front line staff are being provided with effective supervision that allows for case reflection, and facilitates informed professional judgements. - How can the knowledge and experience of professionals within the multi-agency network be used to support an understanding of child development and parent – infant relationships? Lesson 6: Contemporary cultural acceptance of the use of cannabis has led to a normalisation of its use, this has impacted on professional judgements on the question of risk posed to children who are living in households where its use is commonplace. Throughout documentation seen as part of this SCR, there were frequent references to mother’s cannabis use. At various times, professionals noted the smell of cannabis in the household and there were records held by the police and housing services recording complaints of drug use by mother and a variety of household visitors. However, the potential impact on Joe, on mother’s parenting capacity (and her capacity to change) rarely featured in professional recordings and despite Joe often being observed as ‘drowsy’, it was not properly considered as a risk factor. It was only towards the end of professional involvement that the risks of this substance misuse started to be recorded by social worker 5 and for the first time the impact on Joe was considered: “Joe presented as though passively exposed to cannabis in his demeanour” and concerns were expressed about: “Joe’s continued exposure to poor parenting relating to cannabis use”. Research stresses that exposure to parental substance misuse does not inevitably lead to poor outcomes for children. CSCB SCR Joe - Publication Feb 2018 39 Of crucial importance is that each situation is assessed according to the specific drug(s) in use, duration, frequency, impact, age and development of the child/ren in the household. Importantly, in the use of cannabis, there should be an awareness that if certain vulnerability factors are present there is a risk that the user may develop mental health difficulties. Research published by the NSPCC 23, presents evidence that parental substance misuse can harm children’s development, both directly through exposure to toxins in utero and indirectly through the impact it has on parenting capacity and on the home environment in which children are brought up: The nature and severity of the harm not only differs with the age of the child, but is heavily influenced by the broader context in which substance misuse occurs, including factors such as poverty, social isolation, inadequate parenting skills and parental conflict. Child maltreatment or neglect might exist when limited finances are prioritised for the procurement of drugs/alcohol over basic needs of the child. It may take the form of poor monitoring leading to accidents in the home due to impaired judgement resulting from acute intoxication, being unresponsive to the child’s emotional or material needs and/or failing to provide a stable nurturing environment. In addition, the way in which the drugs are obtained (and the potential of additional risks posed) is noted to be an important consideration. This SCR has found that the generic use of the term ‘cannabis’, is potentially misleading. Under this umbrella term sit a range of variants of the plant (such as ‘skunk’ or ‘sinsemilla’) which have varying chemical properties and variable potency. Recent research24 into the properties of cannabis currently available on the ‘street market’ is showing an increase in the availability of higher potency cannabis, and a growing concern about the risks of heavy cannabis use on the mental health of users: ……..frequent use of the drug can increase the risk of psychosis in vulnerable people.25 23 Estimates of the number of infants (under the age of one year) living with substance misusing parents: Dr Victoria Manning, National Addiction Centre, Institute of Psychiatry: NSPCC 2009 24 Therapeutic Advances in Psychopharmology: Published by Sage 2012 25 Cannabis: Scientists call for action amid mental health concerns The Guardian April 2016 CSCB SCR Joe - Publication Feb 2018 40 The Review Panel were curious about the sparse attention paid to mother’s drug use and attempted to understand why it was the subject of only sporadic subjective observation by professionals, with little analysis of impact. The view of the Review Panel was that the growing normalisation of cannabis use, including the decriminalisation of its use within contemporary society, may well be a key factor in the lack of attention paid to the risks. The legalisation of cannabis continues to be the subject of popular debate, with some politicians and some mainstream political parties taking a libertarian view to its use.26 Research from a UK longitudinal study27 reports ‘accommodating attitudes’ to drug use, especially by non-users, and ‘a degree of cultural accommodation of illegal drug use’. It is not within the scope of this SCR to enter this debate. However, the Review Panel were keen to highlight how these societal influences may have a significant impact on the assessment of risk to children. It was felt important to draw the attention of CSCB to the growing concerns about the potential risks to children and the risks of mental health difficulties (including the onset of an acute psychotic episode) for certain vulnerable users. Issues f Lesson 6: Issues for the Board - This SCR is not suggesting that an alarmist approach is taken to the issue of cannabis use, the changes in the chemical formation of the drug and the implications for the wider population are issues for consideration by public health agencies. It is recommended that a proportionate approach is taken to this issue so that its use is properly considered as possible risk factor. (balanced alongside the individual characteristics of each case) The Board is invited to debate this issue and consider what response is needed. 26 Such as the UK Green Party 27 The Normalization of ‘Sensible’ Recreational Drug Use. Further Evidence from the North West England Longitudinal Study Howard Parker Lisa Williams Judith Aldridge First Published November 2002 CSCB SCR Joe - Publication Feb 2018 41 Lesson 7: Family and kinship are critical members of the safeguarding network but if they are not routinely regarded in this way valuable information that could strengthen the protection of children will be lost. In a system that is working well, a child’s kinship is enabled to make a valuable contribution to the lives of children who are the subject of statutory intervention; supporting children in situations of risk or in times of family difficulties, giving professionals information to inform assessments and plans about a child’s needs, wishes and feelings and providing a safe environment for a child when needed. When children are seen outside of the context of kinship, or when judgments are made about this kinship that are not based on proper assessment, there will be a narrow focus on supporting children and their immediate families through professional intervention alone and significant information that could strengthen how a child is safeguarded will be lost. When the Lead Reviewer met with Joe’s maternal grandmother and her partner, it was learnt that they had only been contacted once28 during the time under review. Paternal and maternal family members had not been informed that Joe was the subject of a child protection plan and so were unaware of the concerns about Joe’s safety. Members of Joe’s maternal family were caring for Joe’s sister (after another London Borough had removed her from mother’s care because of longstanding concerns about neglect). Joe’s sister was known to the professionals involved as she often visited her mother and would stay with her mother and brother at their home. Child protection case conference referred to this kinship and recommended that they should be contacted. When discussing the reasons why this kinship was not contacted by professionals it seemed that although they were aware of this kinship, the importance they could play in safeguarding Joe was overlooked. It was understood that mother would not give consent to contact being made with family members, and professionals believed that her consent was required. 28 Contact was made with MGM by Best Start, during the latter part of the period under review CSCB SCR Joe - Publication Feb 2018 42 It seemed that the lack of consent is commonly cited, and accepted, as justification as to why family members are not involved in safety planning. Safeguarding a child is the paramount principle in law and, when acting to safeguard a child, a lack of consent can be overridden. The child should be at the centre of all decision making, it was in Joe’s interests for this kinship network to be engaged. Valuing the kinship in the life of a child, and the important contribution that this kinship can make in the protection of children has been raised in a recent SCR in Croydon,29 and has been the subject of national research.30 Insufficient weight is given to information from family, friends and neighbours and there is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk. Lesson 7: Issues for the Board - CSCB are encouraged to review the steps that have already been taken in response to the recent SCR to ensure that the involvement of the kinship in safeguarding work has been strengthened and to consider what else may be needed. Lesson 8: The quality of engagement with services by parents is often used as a basis to determine both the degree of risk to a child and the type of services that are provided, but how this is judged is currently unclear. There is a wealth of literature 31 and guidance about engagement or non-engagement by parents with services. The terminology currently used to describe non-engagement by parents or carers include terms such as: disguised compliance, resistant families, false compliance etc. and many serious case reviews have identified this as an area of concern. 29 CSCB SCR Claire 2017 30 Ten pitfalls and how to avoid them. What research tells us? Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln NSPCC September 201O 31 Such as: Yatchmenoff 2005, Shemmings, Shemmings and Cook 2012, Turney 2012. Forrester, Westlake and Glynn 2012, Laird 2013, Ferguson 2011, Fauth et al. 2010. Calder, McKinnon and Sneddon 2012, Platt and Turney 2012. CSCB SCR Joe - Publication Feb 2018 43 These issues of resistance and disguised compliance have been identified in previous biennial reviews, as well as in much of the literature and again were identified in many of the SCRs in this cohort.32 During the time under review, there were several occasions when reports to the case conference described mother as ‘engaged’ and this judgement seemed to form the basis of professional opinions that the child protection plan should end (April 2015, September 2015 and January 2016). However, this judgement was based on the relationship the social worker or other professionals had achieved with mother or on mother’s self -report, not on changes that would have made a difference to Joe. The basis of these judgements was both subjective and situational. Decisions about the quality of engagement can be pivotal in safeguarding children from harm, the degree of engagement shown by parents or carers with services needs careful analysis and judgements should not be predicated on a subjective opinion or a situational context. Central to this judgement are the needs of the child and whether these needs are being met in time for the child. In this case (despite frequent requests), many aspects of the plan were never implemented by mother (e.g. household visitors were never identified, Joe was not taken to required health appointments, mother was dishonest about her drug taking and was often not at home when announced visits had been arranged). During the Learning Events, practitioners said it was not uncommon for judgments about engagement to be predicated on the quality of a relationship that exists between a service user and a professional. It is not an area that has been the subject of performance management nor is it something that can be easily audited. 32 Brandon et al – Triennial Analyses of Serious Case Reviews 2011-2014 CSCB SCR Joe - Publication Feb 2018 44 Lesson 8: Issues for the Board - The recommendations made previously, relating to evidence based assessments and decision making and the improvements needed in the quality and quantity of management supervision and oversight, will have a significant impact on this. As a result, no specific recommendation is made. SCB are invited to consider what more may be needed. Lesson 9: In Croydon, frontline staff working with children and their families provide much needed care and protection to hundreds of children. If the contribution they make is not sufficiently recognised, there is a risk that the morale of the work force will be detrimentally affected. This will have an inevitable impact on the recruitment and retention of staff and ultimately on the services provided to children and their families. Everyday across the country, multi-agency practitioners provide services to children and their families that protect them from harm and enable children to reach their potential. The number and range of services provided are vast and the number of practitioners who strive each day to achieve these outcomes with dedication, commitment and passion are countless. Many of these practitioners give more to the work than they are paid to do and in the most part these practitioners are rarely acknowledged for the difficult and challenging work that they undertake, and for the lives they change for the better. There were several examples of good practice in this case, the panel have chosen two examples to demonstrate this: When the social worker in the Best Start Team started to visit the family, she was very quickly concerned and made several astute observations about the home environment including the time it took mother to open the door when she visited (and the meaning of this in terms of the possible risks to Joe within this home that mother may be attempting to hide). CSCB SCR Joe - Publication Feb 2018 45 She was clear she could smell cannabis in the hallway and, despite mother’s denial, she strongly suspected mother was taking drugs. When she raised these issues with mother, she was very clear about her concerns and the changes that were expected. The social worker had read the file and so understood the history of the case, she knew that despite the repeated concerns about mother’s use of drugs this had not been properly investigated and was aware that she had to remain vigilant. She was clear that mother’s use of drugs was likely to having a significant impact on Joe, both in terms of his experiences at home and on mother’s engagement to achieve desired changes. She also knew that mother’s drug use had financial implications for the family and was concerned about how these drugs were being supplied, and the implications for Joe’s safety. She chose not to be reliant on mother’s self-report when she denied her use of drugs instead she accessed her face book page, this provided valuable information that triangulated evidence of the long-standing concerns. The social worker focused on the lived experience of Joe, displayed professional curiosity, used her intuition to access contemporary social media to triangulate her concerns and was tenacious in clarifying the risks. She appropriately raised all her concerns with mother and was committed to challenging the status-quo that had existed for several years. The availability of systemic social work training provided her with significant post- qualifying professional development, and the availability of reflective supervision within the service provided important support to her in her role. Unfortunately, this effective professional practice came at a late stage of service intervention; drift was endemic in the case and for child protection action to be taken (in the form of a strategy meeting/child protection response) the case had to be referred back to Children’s Social Care. The Buildings Manager of the residential complex where Joe lived had responsibility for the running of the building. She felt a sense of responsibility for the residents so when residents needed support, she did what she could to support them. This went beyond the responsibilities of her specific role in the organisation, but it was this attitude that may have saved Joe’s life. CSCB SCR Joe - Publication Feb 2018 46 When she saw mother without Joe, she felt concerned about mother’s presentation and wondered where Joe was. She went to mother’s flat and, noticing that the door was open, went inside and found Joe on the floor. She was shocked by the extent of Joe’s injuries, but managed to compose herself and maintained a calm manner, she spoke softly to Joe whilst calling the emergency services. During the 20-minute wait for assistance, she soothed Joe and playfully engaged and reassured him until the paramedics arrived. The manager was neither expected to take this kind of action nor was she trained in safeguarding work, her actions embodied the mantra: ‘safeguarding is everyone’s responsibility’ (regardless of position, role or circumstance). Lesson 9: Issues for the Board - CSCB to consider the benefits of routinely completing learning reviews that learn from examples of good practice. - Children’s Services to explore in greater detail the work of the Best Start Social Work Team to examine what supported the good practice that was demonstrated and consider whether any systemic features can be promoted more widely. CSCB SCR Joe - Publication Feb 2018 47 Appendix 1. Additional Learning The impact of staff changes on how children are protected At various points throughout this review, the changes of staff combined with the changes of address of the family were raised. This led to the panel testing out a hypothesis that these changes can lead to ‘risks being unnoticed making effective, timely safeguarding work very difficult to achieve’. It was clear that there were several changes of staff within Children’s Social Care (e.g. 5 social workers) but the same turnover of staff was not apparent in the wider multi-agency group (e.g. the same health visitor worked with the family for the duration of service involvement). It was the view of Joe’s maternal grandmother that the changes of staff had a significant impact on mother and her engagement with services, and there is no doubt that this can have an impact on working relationships. However, this SCR has found that it was not so much the changes of staff that had the greatest impact, it was the vulnerabilities identified in the lessons. It was concluded that if these remain unaddressed, the multi-agency safeguarding work can be overly dependent on the individual relationships between front line staff and the family. This is unsustainable in a working environment where changes of front line staff are a perennial feature. Changes in the system that stand the test of time are required, regardless of organisational change and changes of staff, to mitigate against this risk. Fathers as a source of risk and a source of protection On the information available at the start of this review there was a concern that Joe’s father (both as a source of risk and possible safety) had not been fully considered and this was due to the lack of value placed on fathers in the lives of children. As this SCR progressed it became clear that father was clearly regarded as a risk, assessments were pursued and plans were made that considered this risk. It was equally clear that practitioners were keen to promote the bond between father and Joe, and were involved in some protracted negotiations to enable supervised contact to happen. As a result, this hypothesis was dismissed as having no relevance to this case. CSCB SCR Joe - Publication Feb 2018 48 Appendix 2. Child Practice Review Process First Review Panel Practicalities including Learning Event participants and their preparation Sense making of the situation First pass at issues and questions to explore Set dates and venue for Learning Event Second Review Panel Confirming tasks done Checking on participants Further thoughts and issues Engaging with Family Members Learning Event Learning Identifying effective practice Possible action points Post Learning Event Writing up learning points and circulate to participants to check for accuracy/agreement Draft Report Third Review Panel Discussion of draft report Fourth Review Panel (NB: a 4th meeting might not be necessary. If things are straightforward there is a possibility all of this can be done at the third panel meeting) Finalising report Outline action plan Feedback to Family Presentation to SCB CSCB SCR Joe - Publication Feb 2018 49 Appendix 3. TERMS OF REFERENCE FOR EXTENDED PRACTICE REVIEW Core Tasks Determine whether decisions and actions in the case comply with the policy and procedures of named services and LSCB. Examine interagency working and service provision for the whole family Determine the extent to which decisions and actions were child focused. Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. Hold a learning event for practitioners and identify required resources.
For extended reviews ONLY. In addition to the review process, to have particular regard to the following: Was previous relevant information or history about the child and/or family members known and taken into account in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances? How did that knowledge contribute to the outcome for the child? Did agencies contribute appropriately to the development and delivery of the multi-agency plan? What aspects of the plan worked well, what did not work well and why? To what degree did agencies challenge each other regarding the effectiveness of the plan, including progress against agreed outcomes for the child? Was the protocol for professional disagreement invoked? Were the respective statutory duties of agencies working with the child and family fulfilled? Were there obstacles or difficulties (such as substance and alcohol misuse and DV) in this case that prevented agencies from fulfilling their duties? This should include consideration of both organisational issues and other contextual issues? Were the statutory duties of all agencies fulfilled? CSCB SCR Joe - Publication Feb 2018 50 Appendix 4. History of Significant Events 1985 – April 2015 Date Events 1985 Father of Joe born. 1990 Mother born – the youngest of 3 children. 1996 Mother’s father died, mother is provided with bereavement counselling. July – Sept 2000 Mother is accommodated by Kingston CSC. Oct 2000 Father arrested for robbery/assault. Dec 2003 Father found in the possession of cannabis. May 2004 Father arrested for possession of an offensive weapon. March 2007 Father noted by GP to be unkempt and ‘not acting normally’. May 2008 Mother arrested on suspicion of attempted robbery and theft. June 2008 Mother noted to be verbally abusive to police when challenged for using out of date travel card and was reported as being known for anti-social behaviour. Nov 2008 Pre-birth assessment and conference after Mother came to attention of police when father of unborn child assaulted her. Reports note concern about mother being under the influence of alcohol ‘or other substances’. Decision of conference – CIN services to be provided. March 2009 Rebecca born. April 2009 Case closed to Kingston after advice and support provided. July 2009 Mother stopped in a stolen car - Rebecca present. Sept 2009 Mother with Rebecca seen by police rolling a cannabis cigarette - given a warning. Sept 2009 Mother arrested for assault. Dec 2009 Police called to a domestic incident – Rebecca present. Jan 2010 Mother arrested on suspicion of burglary. Jan 2011 Neighbour refers to Kingston reporting multiple loud parties, use of alcohol and drugs – poor/ chaotic home environment noted. Initial Assessment commenced. Feb 2011 Mother issued with a notice to quit her housing due to anti-social behaviour. Feb 2011 Father of Joe convicted of assault and battery on ex- partner and receives a custodial sentence. April – June 2011 x 5 Neighbours and police report concerns about use of cannabis in the house. August – November 2011 Continuing concerns about mother’s use of cannabis, chaotic lifestyle, loud parties, unkempt family home, lack of access to home, lack of insight, concerning associates, and continuing DV incidents in the family home when Rebecca present results in a CP conference - Rebecca placed in the care of maternal grandmother. CSCB SCR Joe - Publication Feb 2018 51 November 2011 x 2 Mother evicted twice from different residencies. November 2011- Feb 2013 24 recorded incidents across agencies relating to Joe’s father & mother involving cannabis use, alcohol misuse, domestic incidents including assault of mother and loud arguments. Father’s parents contact the GP on 3 occasions concerned about her son’s unusual behaviour and anger management. Feb 2013 Kingston CSC refer to Croydon CSC stating mother pregnant and listing history of previous concerns and current concerns for unborn child due to use of cannabis, domestic abuse, anti- social behaviour and history of neglect of Rebecca. Feb 2013 Midwife refers concerns – pre-birth assessment to take place in Kingston Croydon CSC take NFA as uncertain about mother’s housing situation /confirmed residency in Croydon. March 2013 Croydon accept case responsibility – case unallocated. April 2013 Croydon Housing serve statutory order for noise nuisance father seen at property. 15th April 2013 Father convicted for threatening mother, court adjourned for reports prior to sentencing. 29th April 2013 Police called to mother’s address due to father’s threatening behaviour. May 2013 Court Hearing: Residence Order granted to MGM for Rebecca. 21st May 2013 Father received 6-week custodial sentence 22nd May 2013 Initial CP conference: Joe made the subject of a plan under the categories of physical and emotional abuse. 30th July 2013 Joe born. 6th Aug 2013 Police called to maternity ward when father becomes volatile. 6th Aug 2013 Father seen at SW office is volatile and abusive. 14th Aug 2013 Review Child Protection Conference Joe remains subject to a CP plan under the categories of physical and emotional abuse. Sept 2013 Police called to home x 3 for disturbances when mother and father present. October – Dec2013 Various contact arrangements negotiated with family members. Concerns about mother’s cannabis use. 15th Jan 2014 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse. 22nd Jan 2014 Police attend home address after mother reports father’s presence at the address. CSCB SCR Joe - Publication Feb 2018 52 12th Feb 2014 Father arrested for assault on mother, bail conditions included a requirement not to go near mother’s address. 29th April 2014 Mother alleges to police father assaulted her in her home – appeared under the influence of drugs or alcohol. 1st May 2014 Police visit the address after a call from neighbour’s mother reports assault by father. 18th June 2014 CSC Review of file: 16 serious incidents between April ’12 and May2014 between mother and father – Joe has come to the attention of the police 10 times since birth. 8th July 2014 Father subject to an 18-month suspended sentence for domestic violence offences. July – Aug 2014 SW’s unable to access the home or see Joe. Aug – Dec 2014 Police called to home x 3 for domestic violence incidents 13 Nov 2014 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse. Minor changes in levels of risk – legal planning meeting to take place. 7th Jan 2015 Father convicted for multiple breaches of restraining order and receives custodial sentence. 15th April 2015 Review Child Protection Conference. Joe remains subject to a plan under the categories of physical and emotional abuse. CSCB SCR Joe - Publication Feb 2018 53 References Brandon et al – Triennial Analysis of Serious Case Reviews 2011-2014. Croydon Children’s Services: Croydon’s Escalation and Resolution Protocol for Children, Families and Learning Partnership March 2015. Croydon Children’s Services: Analysis of Data of Children Subject to Child Protection Plan May 2016 (Croydon Safeguarding and Quality Assurance Service). Croydon Safeguarding Children Board Annual Report 2013/14 & 2014/15 Croydon Safeguarding Board Serious Case Review Claire (2017). Croydon Safeguarding Children Board Escalation Policy. Resolution of professional disagreements in work relating to the safety of children. March 2015. Guardian Newspaper: Cannabis: Scientists call for action amid mental health concerns (reported: April 2016). London Child Protection Procedures (LSCB: 2015). Munro review of child protection: a child-centered system (Department for Education May 2011). NSPCC: Case reviews: National Case Review Repository (2017) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 – 2014 (DfE 2016). Ten pitfalls and how to avoid them. What research tells us? Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln NSPCC September 2010. Therapeutic Advances in Psychopharmology: Published by Sage 2012. The Normalization of ‘Sensible’ Recreational Drug Use. Further Evidence from the North West England Longitudinal Study Howard Parker Lisa Williams Judith Aldridge First Published November 2002. Working Together to Safeguard Children. DfE 2015. |
NC51238 | Death of an adolescent boy due to a fatal stabbing. Child Y's murder believed to be linked to a feud between local gangs. Emotional and learning needs highlighted when Child Y began secondary school. He was excluded twice and had several managed school moves, including one to a Pupil Referral Unit. Moved in with aunt after physical punishment by father; Children's Services involved, and Interim Supervision Order made. Victim of a stabbing and admitted to hospital. Allocated support worker from Safer London Gang Exit Service (SLGE). Family is Black Caribbean. Learning includes: early help and prevention is critical; schools should be at the heart of multi-agency intervention; disproportionality, linked to ethnicity, gender and deprivation, requires attention and action; an integrated, whole systems approach is needed across agencies, communities and families. Recommendations include: review evidence-based practice to revise and publish Croydon's model of intervention to effectively respond to vulnerable, risky, and gang-linked young people; review service arrangements and introduce support for mental health patients to support a child's relationship with their parent and provide support to the care giving parent; ensure adequate sustainable resources are in place to support the multi-agency response to address gangs and serious youth violence.
| Title: Serious case review summary: Child Y. LSCB: Croydon Safeguarding Children Board Author: Charlie Spencer Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. P a g e 1 | 23 Serious Case Review Summary Child Y Charlie Spencer May 2019 P a g e 2 | 23 The contribution made by family members to this report has been invaluable. Croydon Safeguarding Children Board are extremely grateful for their courage in coming forward to share their experiences of the services provided so that other children and families may benefit from the lessons learnt by this review. Croydon Safeguarding Children Board offer sincere condolences to Child Y’s family for the tragic loss of their child who was dearly loved by all family members. P a g e 3 | 23 Contents Section Page Chapter 1 Introduction 4 Chapter 2 Background to the review 4 Chapter 3 Methodology 5 Chapter 4 Family perspectives 8 Chapter 5 Practitioner perspectives 9 Chapter 6 Case History, Analysis & Recommendations 10-21 Chapter 7 Conclusion 21 Appendix 1 References 23 P a g e 4 | 23 CHAPTER 1 - Introduction This Serious Case Review (SCR) was commissioned by Croydon Safeguarding Children Board (CSCB) following the tragic death of Child Y, who was the victim of a fatal stabbing. This summary SCR report should be read in conjunction with the Croydon Thematic Vulnerable Adolescent Review Report. Could this happen again? The prevalence of knife crime has been detailed in the Croydon Thematic Vulnerable Adolescent Review. This Serious Case Review Summary illustrates the complexities involved for services and families when attempting to safeguard children who are affected by gangs and serious youth violence. CHAPTER 2 - Background to the review Croydon Safeguarding Children Board Serious Case Review Subgroup reviewed the circumstances of Child Y’s case and agreed that the statutory1 criteria had been met for a Serious Case Review. This guidance specifies the following: a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Serious Case Review should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. Purpose The purpose of the SCR is to: Look at what happened in the case and why and what action will be taken to learn from the review findings Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children. 1 Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2015 P a g e 5 | 23 Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children. 2 CHAPTER 3 -Methodology Two independent consultants were commissioned to undertake this Serious Case Review. Exemplary co-ordination and administrative support was provided by the CSCB Business Manager and team. Bridget Griffin, Independent Consultant, was appointed as Chair of the Serious Case Review Panel. Bridget has extensive experience in statutory safeguarding children work with specialist knowledge of being a chair and author in Serious Case Reviews. Charlie Spencer, Independent Consultant, was appointed as the Lead Reviewer and author of this SCR report, Charlie has extensive experience in Youth Offending, young people services, and has led and participated in numerous multi-disciplinary peer reviews, on behalf of the Home Office, in ending gangs and serious youth violence. A serious case review (SCR) panel was established, chaired by the Independent Chair, and attended by the lead reviewer/ report author and senior professionals from all agencies to manage and oversee the review. A key role of the panel members was to facilitate the completion of independent management reports (IMRs) and chronologies relating to their agency’s involvement. Five SCR panel meetings were convened, where members were able to analyse, explore, and challenge the information gathered to identify learning across all agency involvement with the family. The membership of the panel is set out below: Names/ designation Organisation Role Bridget Griffin Independent Safeguarding Consultant Independent chair Charlie Spencer Independent Consultant Lead reviewer/ overview report author Manager Croydon Safeguarding Children Board Panel member Head of Adolescent Services Croydon Children’s Social Care and Early Help, People Department Panel member/ IMR author Head of Youth Offending Service Croydon Youth Offending and Gangs Service (YOS) Panel member/IMR 2 Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2015 P a g e 6 | 23 Head of School Place Planning Admissions and Learning Access Croydon Education. Panel member/ IMR author Detective Sergeant Police Specialist Crime Review Group (SCRG) Met Police Panel member/ IMR author Head of Safeguarding, Designated Nurse Children Croydon Clinical Commissioning Group (CCG) Panel member Designated Doctor for Child Protection Croydon Clinical Commissioning Group (CCG) Panel member Associate Director Nursing, Adults and Children’s Safeguarding Croydon Health Service (CHS) Panel member SWL Community Involvement Officer London Ambulance Service (LAS) Panel member/ IMR author Team Leader, St Georges Hospital Redthread Panel member Director of Projects Safer London Panel member Young Person Team Manager, Drugs & Alcohol Croydon Recovery Network - Turning Point Panel member Safeguarding Manager and Prevent Lead Camden and Islington NHS Foundation Trust Panel member (from 12.06.18) Child Protection Coordinator Islington Children’s Service Panel member Service Manager Children and Family Court Advisory and Support Service (CAFCASS) Panel member Head of Safeguarding Children & Adults St George’s University Hospitals NHS Foundation Trust Panel member/ IMR author (from 01.08.18) Terms of reference The Terms of Reference (TOR) agreed by the Panel included learning outcomes and the SCR timeline. The review had several key strands including: Individual agency chronologies Individual agency independent management reports (IMR’s) Composite chronology of all agency events Author engagement with the SCR panel Practitioner learning event Family member contact Completion of Overview report P a g e 7 | 23 Learning outcomes: To gain an understanding of the factors that might be present in a child’s life that would make them vulnerable to a life-ending result. To gain an understanding of what services were provided in order to inform what might work for others in the future, to prevent the same outcome. To influence commissioning of timely and appropriate services to address these issues. To ensure the learning from this SCR is disseminated across partner agencies, in order to inform future practice. Practitioner learning event (PLE) Key professionals from a number of agencies (who had direct involvement, case holding responsibilities and knowledge of the case) came together for a one-day event to contribute to the review and case analysis. The event provided a supportive, non-judgemental environment that enabled professionals to clearly express their views about the challenges, responses and actions taken to safeguard Child Y, and to support his family. Professionals were encouraged to think about service improvements that could reduce the likelihood of other families experiencing such a devastating outcome. One to one meetings A number of one to one meetings were held with key practitioners, these interviews were invaluable in setting out the environment in which services were delivered, and for practitioners to be able to share their personal professional thoughts about their work including the key challenges. Family involvement Identifier Role Ethnicity Child Y Subject Black Caribbean Ms S Sister Black Caribbean Ms M Mother Black Caribbean Mr F Father Black Caribbean Mrs A1 Paternal Aunt Black Caribbean Mrs A2 Paternal Aunt Black Caribbean The death of Child Y has been an enormous loss for his mother, father, his sister, his aunts and all of his extended family and kinship. It took great courage for family members to speak to the Lead Reviewer and the Independent Chair. The perspectives of family members has been gained by meeting with Mr F, Ms M and Ms S individually, plus a joint meeting with two of Child Y’s paternal aunts (Mrs A1 & Mrs A2). P a g e 8 | 23 With the support of her treatment team, attempts were made to engage Ms M during the course of this SCR but Ms M was not deemed well enough to participate. However, Croydon Safeguarding Children Board persisted in their attempts to establish contact and during the final stages of this SCR Ms M’s health improved and a meeting between the chair, Ms M and her support worker took place to discuss the report. Croydon Safeguarding Children Board are extremely grateful for the contributions they have made. Where relevant, the family’s views have been included throughout this SCR to provide an insight into how they felt or perceived actions that happened at the time. CHAPTER 4 - Family perspectives All family members are devastated at the loss of Child Y, who was a vital member of the family. Ms S and Child Y were exceptionally close siblings, he was very much loved by all family members. Mr F was open in saying that he was ‘learning on the job’ as the father of a new-born premature child. He said he requested and received some financial support for 6 months to assist with childcare, but no other support was provided. He was hardworking, keen to provide for his children and said he was a strict father. He described Child Y as a fun loving, affectionate and charismatic child who enjoyed spending time with his family. Mr F believes that things were going well until Child Y went to secondary school and his behaviour changed. He said that at this time, Child Y no longer followed his direction which he said was very frustrating. Mr F believes things got worse when Children’s Services were involved and says that Child Y’s exclusion from mainstream education, and his placement at the pupil referral unit (PRU) after he was stabbed, was pivotal. Thereafter, it is Mr F’s view that Child Y’s motivation and aspirations suffered; he was exposed to more risk at PRU and in the community and Mr F says that Child Y’s behaviour deteriorated thereafter. He said that he was trying to instil discipline and respect into his son, who ‘ran away’ from discipline in the home. He said he resented being told he was a bad parent especially by young practitioners who he believed had no idea of what it was like to be a single parent, and he felt patronised by them. Mr F stated he would have preferred to work with a more experienced social worker, who engaged with him more sensitively. At times, Mr F believes that crucial information relating to his son (such as an incident where Child Y had been assaulted) was not shared with him by professionals. From Ms M’s perspective, she knew little about the various agencies involved in Child Y’s life. Although she had contact with Child Y throughout his life, it seemed she was not consulted with about decisions made by multi-agency professionals. Ms M recalls receiving a large amount of papers through the post on one occasion and it seemed these papers related to the care proceedings. She said she was not P a g e 9 | 23 supported to read and understand the content of these documents. Ms M was clear that Child Y’s exclusion from school and placement in a pupil referral unit was devastating for him, she said he missed his friends, missed his school and missed his relationships with teachers and adults from this school. She said that placement in a pupil referral unit should be a last resort. When speaking to Ms M about her relationship with her son, Ms M said she understood he would have found it difficult to understand her ill health and the impact this had on her relationship with him. She said both she and her son would have benefitted from receiving support to make this relationship the best it could be. Mr F, Ms S, Mrs A1 and Mrs A2 were angry and upset with the response and involvement of Children’s Services from different perspectives and were convinced that the ‘system failed’ Child Y. Ms S felt she and her brother were let down by services and that she was excluded from assessments and decision making. Mrs A1 and Mrs A2 stated they became aware of problems in Child Y’s teenage years. They acknowledged that bringing up children as a single parent is challenging for any parent and they described Mr F as working very hard to provide a comfortable home. Mrs A1 and Mrs A2 had a good relationship with Child Y throughout his life. They recognised that Child Y was significantly affected by the loss of his grandmother, to whom he was very close, and enrolled Child Y in a project which supports children with bereavement counselling. Both aunts feel that when Children’s Services were initially involved, the wider family could have been supported in supporting Mr F to care for Child Y. Neither believed they were fully engaged, kept informed or supported by Children’s Services. Mrs A1, Mrs A2, and Ms S were all very clear that they wanted to put in place a solution that provided support to both Child Y and Mr F but in their opinion, this was never explored or encouraged. All family members were very clear that Child Y was not involved in a gang or gang activity. They spoke about Child Y having peers who were friends in the local area that he had known from a young age. Ms S said she had spoken with many of his friends after her brother had died who said that Child Y was not involved in a gang, this perspective was also shared by the professionals who knew Child Y well. The family are all very concerned about the impact of social media and how this can fuel gang rivalry and pose risks to children in the community. They are keen that lessons are learnt from Child Y’s tragic death so that children can be better safeguarded. CHAPTER 5 - Practitioner perspectives This section has been informed by a practitioner learning event attended by 19 practitioners, plus 4 one to one interviews with key case holding practitioners who worked directly with Child Y. This is a summary of their views. P a g e 10 | 23 Practitioners recollected the time they spent with Child Y with affection: when asked to describe Child Y they used words such as: ‘lost, vulnerable, searching, huge potential, misunderstood, hopeful, charming, likeable, and a good friend’. He had a ‘huge infectious smile’, but they felt he was ‘let down from the beginning’. There was a general belief amongst some practitioners that the pressures on Children’s Services led to cases being closed too quickly before risks and vulnerabilities had been fully understood, and support services established. Some practitioners were surprised by Child Y’s case history, there was information shared throughout the practitioner learning event that many did not know. It was accepted that everybody will not know everything, but it seemed that practitioners predominantly worked on the presenting issue and did not reflect on the case history, which led to a collective response that was reactive rather than proactive. During the event, it was clear that some agencies were engaging and learning about each other’s roles, responsibilities, barriers and challenges for the first time. They agreed the best outcomes for children are supported by effective multi agency working, however no one could recall instances when they have been involved in any multi-agency training or workshops that sought to build relationships or a true sense of working collaboratively with each other. The lack of opportunity to forge these relationships created tensions and disagreements relating to an agreed way forward. Resources, workloads and staff capacity were all highlighted as key issues across most agencies in attendance. It was said that resources previously available are no longer available; the reduction in available resources, the influx of new children and families that appear more complex (where risks seem more dynamic, behaviours more concerning and changes in circumstances are more frequent) means caseloads that were manageable are no longer manageable, and work continues in a context of heightened service and inspectorate expectations. Practitioners were not confident that the current systems in place effectively responded to address the needs of Child Y. Practitioners spoke about services being constructed to address safeguarding risks in the home, not the community. Processes and decision making were described as slow and bureaucratic, with the general ethos being minimal incremental intervention, as opposed to using the right tool or response at the right time. Delays are therefore created whilst decisions are made, providing the time for behaviour to escalate and get worse. CHAPTER 6 - Case History Analysis Early Years Croydon Vulnerable Adolescent Thematic Report articulates the importance of proving support to families at the earliest possible opportunity, the lessons learnt about providing support to parents to understand the impact of attachment in early years, and the need for adult and children services to work together to provide a whole family approach. This finding is relevant to Child Y and his family. P a g e 11 | 23 Through no fault of her own, Ms M’s ill health prevented her from caring for Child Y throughout his childhood. As he grew up, it was clear that this relationship was a source of confusion and sadness for him. It was only when he spent some considerable time with a school counsellor in secondary school that he began to understand how his mother’s ill health impacted on her ability to form a relationship with him. This was a significant relationship for Child Y that he and his mother needed support to understand, and for it to be the best it could be. ‘You want your mum even when she’s ill, especially when you’re just a kid.’3 Recommendations Finding 1, in the Croydon Vulnerable Adolescent Thematic Review, is relevant to Child Y: Early help and prevention is critical, as are the corresponding recommendations. Two additional recommendations are made in respect of Child Y’s specific circumstances. SCR Child Y: Recommendation 1. Working arrangements between adult services and children’s services to be reviewed to ascertain how effectively existing protocols are working to support the relationship between children and parents who are unwell. SCR Child Y: Recommendation 2. Adult Mental Health Commissioners to review service arrangements and, where appropriate, to introduce support for mental health patients to support a child’s relationship with their parent and provide support to the care giving parent. Primary years: 5 -11 years ‘The range and coordination of early help provision for children and families are not fully established. Individual partner agencies are unclear about the early help offer and have not been involved in developing a shared approach to delivering services.’ 4 As highlighted in the Croydon Vulnerable Adolescent Thematic Review, opportunities are often present in a child’s primary years to identify that a child may need support in addition to their learning needs. This requires primary schools to recognise a child’s needs and provide services, as they did for Child Y, but also to consider what more a child and family may need. Child Y was living with his father at the time and a referral was made to Children’s Services, but this did not meet the 3 Family Minded Supporting children in families affected by mental illness. J. Evans and R. Fowler Barnardo’s 2006 4 OFSTED London Borough of Croydon: Inspection of services for children in need of help and protection, children looked after and care leavers, The experiences and progress of children who need help and protection P a g e 12 | 23 threshold for service provision. It seems that no other referral was made, and it is unclear what early help services were available at the time. Recommendation Finding 2: Schools should be at the heart of multi-agency intervention from the Croydon Vulnerable Adolescent Thematic Review was also relevant to Child Y. Secondary years: 11 years plus School Life Child Y’s needs were highlighted when he transferred to secondary school and support for his learning and emotional needs was provided at his new school. However, at the end of Year 8 there was a gap in provision when his specialist teachers left, and they were not replaced for some time. He continued to see the school counsellor throughout his time at this school and this provided important emotional support to Child Y. The counsellor represented an adult Child Y could turn to, and trust. Schools need to be suitably equipped and resourced to respond to the additional needs of children so that their learning, emotional and behavioural needs can be responded to over time. The importance of meeting the emotional, social and behavioural needs of children at an early point in their lives is well evidenced in research. Croydon Vulnerable Adolescent Thematic Review identifies this as an important issue and makes relevant recommendations. Preventative Services Early help works best when all agencies take on and deliver on their responsibilities, with agencies and professionals having a clear understanding of what provision is on offer. Where robust early help services are not in place there is a natural knock on effect to Children’s Services who inevitably experience higher caseloads and demand for services. Historically, the availability of universal, targeted and outreach youth services, who could provide constructive activities and informal education to young people on issues that directly impacted their lives, was a key part of the local landscape. Numerous national reports have been published since 2008 detailing the level of cuts to youth services across the country.5 6 As local authority budgets have been cut, this has resulted in non-statutory youth services being cut, reduced or closed, in some areas. Without access to local community-based youth services many young people can be left with nothing to do outside school hours and this can result in young people spending more time on the streets, susceptible to the influences of 5 https://www.independent.co.uk/news/uk/politics/cuts-to-youth-services-will-lead-to-poverty-and-crime-say-unions-9659504.html 6 https://www.cypnow.co.uk/cyp/news/1158579/youth-services-cut-by-gbp387m-in-six-years P a g e 13 | 23 more negative peers. Croydon Vulnerable Adolescent Thematic Review identifies this as an important issue and makes relevant recommendations. Exclusions, managed moves and pupil referral units. ‘Mainstream schools should be bastions of inclusion’7 Child Y received a fixed term exclusion at the start of Y10 and two days later received another fixed term exclusion. The school responded by arranging a managed move of Child Y to another secondary school. Guidance from the Department for Education (DFE) and Association of Chief Police Officers (ACPO) advice to schools suggests that these incidents were not serious enough to warrant this response. Whilst it is the responsibility of schools to determine their own behaviour policy, it was a more robust approach than most Croydon schools. The school counsellor was not involved in this decision, nor were other professionals. During interview with Mr F, he expressed that Child Y was devastated to leave his school and was very keen to do what was required of him so he could return there. Child Y was not able to return, as a decision was taken to terminate his place. He was the subject of a managed move at his next school and was placed in a Pupil Referral Unit. It was understood from family members that the structure, timetable and expectations of the Pupil Referral Unit were at odds with Child Y’s wishes and feelings. He was described as’ desperate to go back to mainstream education’ and felt he was given ‘false hope’ that if he did well enough, he could return after two weeks. In reality, mainstream schools in the area did not want to offer him a place. One of the issues the placement at the PRU was seeking to mitigate was the ‘influence of negative peers’, yet he was placed in a PRU that was populated with other more concerning young people who proved to have a greater capacity to have a negative influence on him. At this critical time in his life, Child Y did not have the structure or support a mainstream school offers, resulting in him having more time in the community exposed to serious risks and violence. Consequently, the placement at PRU did not appear to meet Child Y’s needs, if anything, it seemed to increase his risk and make him more vulnerable as his situation deteriorated significantly thereafter. Evidence suggests that children educated in a PRU achieve far less academically than children in mainstream education. In addition, these children are more likely to get involved in crime, anti-social behaviour and gang related activity. Research also evidences that alternative education for some pupils is highly effective in meeting their needs, but the quality of provision is variable as are the academic achievements of the pupils. 7 House of Commons Education Committee Forgotten children: alternative provision and the scandal of ever-increasing exclusions Fifth Report of Session 2017–19 P a g e 14 | 23 ‘Our vision is to ensure that all AP (Alternative Provision) settings provide high quality education and that the routes into and out of AP settings work in the best interests of children’8 The latest statistics on exclusions show that, following a downward trend, the rates of permanent and fixed-period exclusions have risen since 2013/149. A significant number of children attend alternative education settings due to behaviour and/or special educational needs. In addition, some ethnic groups such as African, Caribbean, white and black Caribbean are over-represented in alternative education. It is understood that government are in the process of reviewing alternative provision, it is suggested that this review should include the experiences of children like Child Y, whose behaviour did not pose a direct risk to other children and who, with the right support, could have remained in mainstream education. Recommendations Croydon Vulnerable Adolescent Thematic Review identifies two relevant findings: Finding 4: Schools should be at the heart of multi-agency intervention and Finding 5 : Disproportionality, linked to ethnicity, gender and deprivation, requires attention and action. These findings are relevant to Child Y, as are the corresponding recommendations. An additional recommendation is made in respect to Child Y’s specific circumstances. SCR Child Y: Recommendation 3 CSCB and Croydon Learning Access to work with head teacher forums and the Fair Access Panel to; define pupils with safeguarding needs, the potential for increased risky behaviour of pupils if excluded or are the subject of a managed move and consider these vulnerabilities in decision making. In addition, an appropriate monitoring system should be in place to promote consistency of how behavioural policies are applied in practice. Engaging and supporting families Child Y was first reported missing when he was 14 years old, and over the following months there were a significant number of professionals involved with Child Y and family life. Mr F was disappointed and frustrated by Child Y’s behaviour and attempted to instil boundaries. This led to tensions at home, which on occasions resulted in physical confrontations. After one such confrontation, Child Y went to live with his aunt and Children’s Services were involved. Whilst Children’s Services regarded this as a positive move, despite requests from family members, no support was provided. 8 Rt. Hon Damian Hinds MP Secretary of State for Education 9 Creating opportunity for all Our vision for alternative provision March 2018 P a g e 15 | 23 Throughout multi-agency involvement Ms S was available to her brother, and she was prepared to provide care to Child Y. The relationship between Child Y and his sister was close, he turned to her when needed and she provided love, guidance and care to him. Her presence in Child Y’s life was not acknowledged by services, the value of her relationship with Child Y was not understood and the possibility of her providing alternative care to Child Y was never explored. Family and kinship are a vital part of a child’s life and if supported and engaged in decision making and planning they can provide the kind of support to children that professional intervention, in isolation, cannot. Recommendations Finding 3, in the Croydon Vulnerable Adolescent Thematic Review, identifies a relevant finding: An integrated, whole systems approach, is needed across agencies, communities and families. An additional recommendation is made in respect to Child Y’s specific circumstances. SCR Child Y: Recommendation 4. Safeguarding children and providing alternatives to their care cannot be achieved through professional intervention alone. Children’s Services to review what may be needed to achieve collaborative partnerships with families and kinship. Responding to critical incidents Child Y was the victim of a stabbing and was admitted to hospital. He was seen by hospital staff, and also a hospital based service which specialises in working with children who are the victims of serious youth violence. A sensitive piece of work was completed with Child Y. The London Child Protection Procedures state that in these circumstances a strategy meeting is needed, convened by the Local Authority. This did not happen and there was no challenge by involved professionals about this important oversight. These are critical points in a child’s life and can provide an opportunity to effectively intervene to divert a child from behaviour that may pose a risk of future harm. There was no alternative planning forum put in place (such as a discharge planning meeting) and this meant there was no coherent multi-agency plan to respond to Child Y’s needs. It is understood that changes to multi-agency practice now results in a different response. Now when a young person is admitted to hospital with a knife injury it is understood that the hospital Safeguarding Team will follow up the referral to children’s social care with a request for the local authority to convene a strategy meeting. It is understood that the hospital trust has agreed a new process of escalation in the event that strategy meetings are not convened. These are welcome developments. P a g e 16 | 23 SCR Chid Y: Recommendation 5. The newly agreed escalation process, established by the hospital trust, needs to be the subject of evaluation and review and CSCB informed of any future difficulties. SCR Child Y: Recommendation 6. CSCB to work with major trauma centres in London and the Association of London Directors of Children’s services (ALDCS) to establish a good practice model of safeguarding children and young people who sustain serious injuries to ensure a consistency of approach and appropriate management oversight. Trusted Adults Child Y was allocated a support worker from the Safer London Gang Exit Service (SLGE) and the relationship formed was very supportive to Child Y. Again, the importance of trusted adults in the lives of vulnerable children was evidenced. This relationship ended when Child Y was transferred to another service (YOS), this was a significant loss for Child Y. There was a need to organise provision based on Child Y’s needs, which was for this relationship to be maintained, the needs of a child should take precedence over decision making based on service boundaries. Overall, Child Y’s experience of engaging with professionals was short lived, and on occasions negative. This resulted in a lack of trust and confidence in the professional network. However, when key people had the time to build an honest, consistent, trusted relationship, he responded well. The school counsellor and the support worker from SLGE were trusted adults in Child Y’s life, they acted as advocates who would make representations on his behalf. After his managed moved to another secondary school and after the transfer of his case to YOS, he lost these trusted adults. There is a growing body of research evidencing that a trusted adult relationship, often outside the familial environment or statutory services, are essential for a child’s well-being. The recent Early Intervention Foundation (EIG) rapid evidence assessment commissioned by the Home Office in 201710 establishes the value of trusted adults in children’s lives. SCR Child Y: Recommendation 7. CSCB to reflect on how to promote the identification and engagement of trusted adults to support vulnerable children. Multi-agency response to risk Metropolitan Police Service (MPS) Gangs Matrix Child Y’s behaviour subsequently deteriorated in the community and he came to the notice of the police more often; for alleged offending behaviour, when reported as 10 Building Trusted Relationships for Vulnerable Children and Young People with Public Services. February 2018 P a g e 17 | 23 missing and when stopped and searched by the police. Police formally added Child Y’s name to the gang’s matrix11 and was risk assessed to be ‘an amber nominal’.12 He grew up in an area where there was gang activity and his friends were thought to be associated with a local gang, but to Child Y these were just friends from childhood. His minor offending history suggested that he was not immersed in criminal activity or high-risk behaviours that are characteristic of gang membership. The label of a gang member is a serious matter for young people to carry and must be validated via detailed assessment of professionals and police before its application. The MPS gang matrix manager worked with the Gangs Team (who were not working with Child Y at the time) to inform this judgement using a range of intelligence sources. However, Child Y’s gang membership was disputed by agencies working with him. Ideally, all agencies should pool their information to arrive at an agreed position in regard to the risk a young person poses, with the suspicion of gang membership being validated over time and regularly re-assessed to avoid stigmatising young people such as Child Y unnecessarily. An assessment had been undertaken by Redthread and SLGE, based on their interaction with Child Y, both concluded that he had associates that were gang members, but he did not conduct or see himself in that way. Other professionals and family members were also clear that Child Y was not a gang member. The office for the Mayor of London has established that young people from BME communities are disproportionately represented on the gangs’ matrix13 and young people from BME communities are over-represented as both victims and perpetrators of serious youth violence. More transparency to improve the community confidence in the application of the gang’s matrix which will assist to reinforce the matrix as a non-racist tool. Adding Child Y to this matrix did not change Child Y’s predicament or change the multi-agency approach to Child Y’s vulnerability or risky behaviours. SCR Child Y: Recommendation 8. Police to reflect on the wider learning articulated in this SCR and explore with multi-agency services how local safeguarding practices, and their understanding and involvement in informing the gangs matrix, can be improved. 11 The MPS gangs’ matrix is an intelligence tool used to identify and risk assess gang members across every London borough based on violent offences and intelligence 12 There is a RAG (red, amber, green) rating which is a grading system devised to manage risk and define level of response, activity or engagement by police 13 Review of the MPS Gangs Matrix. Mayor of London December 2018 P a g e 18 | 23 Multi-agency planning to mitigate risk The view taken by the Local Authority was that the methods used by Mr F to attempt to curb Child Y’s behaviour caused harm, and Child Y was made the subject of a child protection plan. There were differences in how physical chastisement was defined, viewed and responded to by the professional network. Whilst Child Y was the subject of a child protection plan, an Interim Supervision Order (ISO) was made. In the view of the Guardian and the judge, Mr F was using physical chastisement to maintain boundaries at home in an attempt to curb Child Y’s behaviour. Whilst chastisement was not endorsed, it was the view of the court that Child Y’s needs would be best met by continuing to be in the care of his father and for increased support to be provided, this was in line with Child Y’s wishes. English common law allows parents and others who have ‘lawful control or charge of a child’ to use moderate and reasonable chastisement or correction. The legal defence of reasonable punishment is detailed under Sc58 of the Children Act 2004. A review of relevant procedure and local guidance provides little assistance to practitioners in defining reasonable punishment. Therefore, it is perhaps understandable that different meanings and interpretations are applied. If professionals are unclear, it is perhaps unsurprising that parents are equally unclear. This is particularly relevant for parents who have been brought up in families where physical chastisement was commonly accepted as a part of family life, and something that was used in the belief that this would improve a child’s behaviour and outcomes. This is an important issue that requires attention and is undoubtedly an issue that is not unique to Croydon. SCR Child Y: Recommendation 9. Information to be provided to families and practitioners to raise awareness about the definition and response to physical chastisement. Training and guidance to be provided to the children’s workforce to assist in definition, assessment, plans and service provision. Use of established child protection frameworks to mitigate risk By now, the significant numbers of professionals involved was overwhelming for family members and a child protection plan and ISO seemed to make little difference to the risks or plans that were made. As a parent, Mr F felt criticised and undermined by professionals from Children’s Services and understandably, this impacted on his engagement. The focus on home life, and the lack of a coherent plan to address the risks in all domains of Child Y’s life, led to a fragmentation in service provision and P a g e 19 | 23 ‘professional paralysis’14. In the absence of a coherent multi-agency plan agreed by services and family members there was duplication and confusion. Practitioners have knowledge of risk and protective factors that does not always translate into effective assessments or intervention.15 Multi-agency services are increasingly being challenged to effectively intervene with more adolescents who display riskier behaviours that progress rapidly and require a timelier response. The child protection system was established to protect children from abuse in the home and not in the community.16 Recent statutory guidance17 now emphasises the importance of taking a contextual safeguarding approach in order to recognise the risks and vulnerabilities for children across all domains of their life. ‘Contextual Safeguarding is an approach to understanding, and responding to, young people’s experiences of significant harm beyond their families. It recognises that the different relationships that young people form in their neighbourhoods, schools and online can feature violence and abuse. Parents and carers have little influence over these contexts, and young people’s experiences of extra-familial abuse can undermine parent-child relationship where the focus of safeguarding reflects the risks at home and in the community’.18 There was no specific multi-agency model of working with adolescents, there was not a clear early help offer, youth service, or youth crime and gang prevention service. As part of service improvements, Croydon Children’s Services have reorganised to create an Adolescent Service so that the Youth Offending Service, the Gangs’ Team, Children Exploited and Missing Intelligence Team all sit under one Head of Service, along with two newly created Adolescent Support Teams. Croydon have taken this important step in recognising that this specialist integrated service provides a greater opportunity to improve outcomes for vulnerable children. Recommendations Finding 3, in Croydon Vulnerable Adolescent Thematic Review, identified that: An integrated, whole systems approach, is needed across agencies, communities and families. This finding, and the corresponding recommendations, are relevant to Child Y. Additional recommendations are made in respect to Child Y’s specific circumstances. 14 Children Social Care IMR : A term used to describe service input to manage risk 15 Preventing gangs and youth violence. A review of risk and protective factors. Home office/ Early intervention Foundation 2015 16 Teenagers at risk. The safeguarding needs of young people in gangs and violent peer groups. NSPCC March 2009 17 Working Together to Safeguard Children HMG 2018 18 Contextual safeguarding (Firmin November 2017) P a g e 20 | 23 SCR Child Y: Recommendation 10. In light of the recent changes in service provision to young people in Croydon, CSCB are invited to consider the learning from this case and conclude whether these changes adequately address improvements required. SCR Child Y: Recommendation 11. CSCB to review provision of multi-agency training and/or workshops to enable better understanding of roles, responsibilities, remits and working practices. SCR Child Y: Recommendation 12. CSCB to review available evidence-based practice to revise and publish Croydon’s model of intervention to effectively respond to vulnerable, risky, and gang-linked young people. SCR Child Y: Recommendation 13. Croydon Local Strategic Partnership to ensure adequate sustainable resources are in place to support the multi-agency response to address gangs and serious youth violence. Working in partnership – Police Throughout service involvement, police often notified Children’s Services of any potential safeguarding concerns via PAC Merlin notifications. The Police IMR author identified that there were three occasions when a PAC Merlin was not documented and should have been. On four occasions, intelligence checks and/or risk grading’s were inconsistently recorded. The police use an integrated information system informed by six different operating and intelligence systems. The IMR author confirms that whilst all staff have access to use the intelligence system, the results can vary depending on a number of variables; including terms used to search, spellings, misspellings, and, in the case of Child Y, if information has not been recorded or sufficiently detailed. Police intelligence pictures are informed by various data strands, to include notifications from other agencies (e.g. when professionals are aware that an alleged crime has been committed). The Police records therefore did not evidence a full picture of all issues and concerns relating to Child Y. A more detailed exploration to understand how the system worked for Child Y is needed to identify what could be improved in regard to; notification, risk assessment, expected actions and actions taken by Police, MASH and Children’s Services, to ensure each agency discharges its responsibilities in accordance with the system, but more importantly to better safeguard children such as Child Y. Had the nature and frequency of call outs been viewed in their entirety, the pattern of similar reports and potential safeguarding concerns would have been clearer. P a g e 21 | 23 Throughout the summer months, Police, YOS and gangs’ team were made aware of a violent feud between two of Croydon’s rival gangs, resulting in a series of violent incidents in the community. Further threats had been made on social media and via gang related music videos. The individuals concerned were known to the gangs’ team who visited parents to alert them to their concerns of further serious incidents occurring. Mr F and Child Y were not visited to warn them of any potential danger to him as it was believed that Child Y was not an intended target. Towards the end of summer Child Y was the victim of a fatal stabbing in his local area, it was believed his murder was directly linked to the ongoing feud between rival local gangs. Several questions arise: Could more have been done to prevent further escalation via police enforcement or other actions? Could an Osman warning19 have been put in place? Should there have been an increase in high visibility policing in the areas they believed the gangs to be operating? Could action have been taken to stop the music videos being uploaded and promoting violence and revenge? SCR Child Y: Recommendation 14. MPS to consider the questions posed above and inform CSCB of any relevant service developments. SCR Child Y: Recommendation 15. MPS to review safeguarding advice and guidance to front line officers, to include the expectations of Merlin completion. SCR Child Y: Recommendation 16. MASH/ Children’s Services to review actions taken on receipt of PAC Merlin and MIS Merlin to identify any areas of improvement to ensure risks are identified an appropriate action taken as a result. CHAPTER 7 - Conclusion Child Y was described by all without hesitation as a likeable fun-loving child who had an infectious smile and who enjoyed the company of family and friends. He was not a prolific offender nor was he an active gang member with related behaviours, but a boy who grew up around and associated with young people who were known to be in gangs. The prevalence of gangs and serious youth violence is on the increase across London with more and more young people being affected by the issues as perpetrators, victims, or those that are dealing with the trauma having known somebody that has 19 Police issue an "Osman warning" letter when there is intelligence of a threat to someone's life, but not enough evidence to justify the police arresting the possible offender P a g e 22 | 23 been killed or seriously assaulted. The Centre for Criminal Justice recent report ‘It Can Be Stopped’ August 2018 states that gang membership has increased by 20,000 to 70,000 in the past 10 years.20 In this time over 700 young people have been fatally stabbed or shot. In a time of reduced resources, the challenge for local authorities and partners is enormous, making it essential that staff are trained, and available resources are effectively deployed. But in the absence of a national intervention model, to address gangs and serious youth violence across the country, local partnerships will struggle to make a difference. 20 IT CAN BE STOPPED A proven blueprint to stop violence and tackle gang and related offending in London and beyond. Centre for social justice, August 2018 P a g e 23 | 23 Appendix 1: References Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2015 Family Minded: Supporting children in families affected by mental illness. J. Evans and R. Fowler. Barnardo’s 2008 OFSTED London Borough of Croydon: Inspection of services for children in need of help and protection, children looked after and care leavers. The experiences and progress of children who need help and protection https://www.independent.co.uk/news/uk/politics/cuts-to-youth-services-will-lead-to-poverty-and-crime-say-unions-9659504.html https://www.cypnow.co.uk/cyp/news/1158579/youth-services-cut-by-gbp387m-in-six-years House of Commons Education Committee Forgotten children: Alternative provision and the scandal of ever-increasing exclusions. Fifth Report of Session 2017–19 Creating opportunity for all: Our vision for alternative provision. March 2018 Building Trusted Relationships for Vulnerable Children and Young People with Public Services. February 2018 Review of the MPS Gangs Matrix. Mayor of London. December 2018 Preventing gangs and youth violence: A review of risk and protective factors. Home office/Early Intervention Foundation 2015 Teenagers at risk: The safeguarding needs of young people in gangs and violent peer groups. NSPCC March 2009 Contextual Safeguarding. C. Firmin. November 2017 IT CAN BE STOPPED: A proven blueprint to stop violence and tackle gang and related offending in London and beyond. The Centre for Social Justice. August 2018 |
NC52183 | Serious harm suffered by a 11-week-old baby boy in October 2016. Child O was taken to hospital by his parents where he was found to have injuries indicative of abusive head trauma. Child O was seen as vulnerable but no safeguarding concerns were identified. Sibling S had previously been subject to a Child in Need plan. Following hospital discharge, both Child O and Sibling S were placed in foster care. Family are White British (former travellers), and known to multiple agencies. Maternal history of: mental health problems; severe adverse childhood experiences; persistent non-engagement; teenage pregnancies; subject to Child Protection Plan. Learning focuses on the following themes: importance of: timely record keeping and information sharing, including relevant past histories; engagement with fathers, young people and hard to reach individuals, including at or below the Child in Need threshold; high quality, reflective, restorative supervision and management oversight; planning to achieve outcomes; professional scepticism/challenge; adherence to agency and multi-agency policy, procedures and good practice in a timely way, especially when dealing with new born babies; consider the impact of adverse childhood experiences; incorporate family culture and context into assessments; quality assurance of supervision for health providers. Recommendations include: ensure the needs and risks of new born babies are given sufficient attention in their own right; promote restorative practice; seek multi-agency involvement before closing a in Child in Need case.
| Title: Child O serious case review. LSCB: Sutton Local Safeguarding Children Board Author: Briony M Ladbury Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CHILD O SERIOUS CASE REVIEW Author: Briony M Ladbury Independent Safeguarding Consultant RN, RM, HV cert, FP cert, Specialist Practitioner Award (Child Protection) BA, MSc. November 2019 2 GLOSSARY OF TERMS ACE Adverse Childhood Experience CAMHS Children and Adolescent Mental Health Services CIN Child in Need under the definition of the Children Act 1989 CNN Community Nursery Nurse CSE Sexual Exploitation ECP Enhanced Care Package (Maternity) EDT Emergency Duty Team EPP Early Parenting Pathway EPU Early Pregnancy Unit FGC Family Group Conference FNP Family Nurse Partnership GP General Practitioner HCP Healthy Child Programme ICPC Initial Child Protection Conference JAS Joint Adolescent Service MASH Multi-agency Safeguarding Hub NHSE National Health Service England NSPCC National Society for the Prevention of Cruelty to Children PICU Paediatric Intensive Care Unit RAS Referral and Assessment Team STARS Sutton Tuition and Reintegration Service TAC Team Around the Child TIC Trauma Informed Care 3 Contents Introduction ................................................................................................................................. 4 Executive summary ................................................................................................................... 5 The reson for commissioning a Serious Case Review.................................................. 8 Background history, key circumstances, and context of case. .................................... 9 Miss A’s pregnancy with Sibling S ...................................................................................... 10 The period between the birth of Sibling S and the pregnancy of Child O ................ 11 The period covering the antenatal period and subsequent birth of Child O ............ 12 The following months until the incident took place ........................................................ 14 Key questions and critical analysis .................................................................................... 14 Key themes and learning points .......................................................................................... 27 Conclusion.................................................................................................................................. 33 Recommendations ................................................................................................................... 34 Appendix A - Methodology ........................................................................................................ 36 Appendix B Genogram ............................................................................................................ 37 Appendix C Summary of IMR recommendations (table) .................................................... 38 Appendix D LSCP Action plan to implement recommendations (table) .......................... 40 4 1. Introduction 1.1 This is the Serious Case Review (SCR) into the circumstances of Child O, who suffered a serious brain injury at the age of 11 weeks. 1.2 The SCR was commissioned to be undertaken by an independent author under the statutory guidance of ‘Working Together to Safeguard Children’ 20151. The Sutton Local Safeguarding Children Board’s (LSCB) revised arrangements under Working Together 2018 became operational on 4 July 2019 and are now referred to as Sutton Local Safeguarding Partnership (LSCP). The report is therefore structured as recommended in the Safeguarding Practice Review Panel: Practice Guidance2 (2019). 1.3 Child O is the focus for this review. It has also considered the care needs of the mother, Miss A with regards to her own complex history and the impact of past trauma on her mental health, cognitive development and her ability to parent. She was year 17 years old when Child O was injured. 1.4 Learning from this review has been drawn from professional interactions during Miss A’s pregnancies, and the care of Child O’s older half-sibling, Sibling S, who was 16 months at the time of the incident. 1.5 The full methodology is set out in appendix A. It acknowledges the significant contribution made by the family and practitioners in the interviews that inform the learning of this review. The IMR and SCR action plans set out how the recommendations will be implemented. 1.6 Many of the key themes emerged in individual agency reviews of their own practice and many safeguarding system improvements have already been implemented. Their action plans to implement their recommendations are in an appendix at the end of this report. 1.7 The LSCP SCR action plan is also set out in an appendix and the implementation of learning will be reported in the annual review of the effectiveness of the LSCP. The report will be submitted to the Safeguarding Practice Review Panel as required in Working Together 20183. 1 HM Government (2015) Working together to safeguard children: statutory guide on interagency working to safeguard and promote the welfare of children, London: The Stationery Office. 2 HM Government (2019) Child safeguarding practice review panel: practice guidance, London: https://www.gov.uk/government/publications/child-safeguarding-practice-review-panel-practice-guidance 3 HM Government (2018) Working together to safeguard children: statutory guide on interagency working to safeguard and promote the welfare of children, London: The Stationery Office. 5 2. Executive summary 2.1 On 5 October 2018, Child O was taken by his parents to the local hospital where he was found to have suffered a subarachnoid haemorrhage indicative of abusive head trauma. Child O was subsequently transferred to the nearest tertiary hospital for specialist treatment. Child O recovered in hospital but has been left with a debilitating condition and permanent impairment. Following hospital discharge, Child O was accommodated with foster carers under section 20 of the Children Act 1989. 2.2 On 11 October 2018, it was identified that the case met the legal requirement under 16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) that the Local Authority must notify incidents to the Safeguarding Practice Review Panel where a child has been abused or neglect is known or suspected if: a. ‘The child dies or is seriously harmed in the local authorities area’ 2.3 On 21 December 2018, Sutton LSCB submitted the multi-agency Rapid Review response to the Safeguarding Practice Review Panel as required in Working Together 20183. The Safeguarding Practice Review Panel subsequently confirmed that the case met the criteria for a Serious Case Review (SCR) under the previous guidance of Working Together (2015) because: ‘Abuse is suspected, a child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.’ 2.4. The SCR Panel was chaired by the Independent Chair of the Local Safeguarding Children Board in the London Borough of Sutton. The Independent Reviewer was appointed by the Panel and the brief provided was the terms of reference for this SCR. 2.5 The investigation was completed during the period of 13 May 2019 to 13 September 2019. The report and its recommendations were considered and approved by the Board of the Sutton Local Safeguarding Partnership (LSCP) on 26 September 2019. 2.6 The information for this review was extracted from the single agency reports, family interviews and follow up conversations with professionals and additional reading. The analysis was framed around seven key questions to identify learning points for practice improvement. The learning points were then organised into six emerging themes: ‘quality of assessments’, ‘supervision and management oversight’, ‘effective care planning’, ‘consent and securing engagement’, ‘multi-agency partnership working’, and ‘policy and procedures’. 6 2.7 The overall conclusion is that there is no evidence to suggest that Child O, or Sibling S, were at risk of or had suffered neglect or abuse in the lead up to the incident. Medical experts are yet to provide an opinion to the Court as to the cause of Child O’s injury, and the criminal investigation is still to be concluded. 2.8 The review found that the immediate responses to the serious injury followed established safeguarding procedures and care proceedings were initiated for both children as required. As practice followed policies and procedures, there was no learning to be extracted from this aspect of the review. 2.9 The review has considered the attendance and engagement with health and social care services during Miss A’s pregnancies and after the birth of both children. A pattern of missed and cancelled appointments has been a recurring feature throughout the review and was particularly noticeable during the time Sibling S and Miss A were subject to a Child in Need plan. Following closure of that plan, a further three referrals were made to CSC in a seven month period, which did not result in ongoing work or early help interventions. 2.10 During the antenatal and postnatal period for Child O, there was appropriate engagement with the hospital and community midwifery services, including during the first two weeks after discharge. Signs of disengagement presented after the handover to the health visiting service. In total, the health visitor visited the home on three occasions and saw Child O in a baby clinic setting once, when he was accompanied by his grandmother. Child O was immunised by the GP at 8 weeks but did not attend for his eight week development check with the health visitor. 2.11 Health professionals assessed Child O as vulnerable and in need of additional services, but did not identify any safeguarding concerns from the time he was born until the incident that led to this review. Additional services were offered but declined by the mother. 2.12 This review raises important issues about working with hard to engage families. It also looks at quality of professional engagement with young people who have complex needs. This is considered in the context of previous social care engagement with the mother that included interventions under S.47 of the Children Act 1989. The history confirmed that the mother had been exposed to a range of Adverse Childhood Experiences (ACEs) which were likely to have had an impact on her cognitive development, parenting ability and ability to form trusting relationships. 2.13 Subsequent multi-agency practice developments have been undertaken as a result of the learning from this review to ensure that young mothers and fathers, in similar circumstances, will be engaged through different and more purposeful 7 approaches. For example using trauma informed practice and a contextual safeguarding approach designed especially for young people. 2.14 The analysis of findings is comprehensive and the learning is summarised for each line of enquiry into a section entitled ‘Summary of Learning’. Thirty seven relevant findings have been identified and summarised under the eleven learning points. The learning has been further condensed into six themes that underpin the recommendations. The actions from the individual agency‘s own management reviews together with the LSCP action plan will provide the basis for assurance that the recommendations from this SCR will be fully implemented. 8 Serious Case Review Report for Child O 1. The reason for commissioning a Serious Case Review 1.1 This section provides brief details about the birth and the events leading up to the notification about the serious injury of Child O, and the subsequent decision by the Child Safeguarding Practice Review Panel that the criteria for undertaking a SCR had been met. 1.1.1 On 31st July 2018 Child O was born prematurely by caesarean section at 36 weeks gestation. Both parents were present at the birth. The immediate post-operative period for Child O was uneventful, apart from slight respiratory distress. Child O and Miss A were deemed fit for discharge the next day. A routine discharge procedure was undertaken. 1.1.2 On 5th October 2018, at 22.59 pm Miss A and Child O’s father took Child O in the family car to the local hospital Accident and Emergency Department after he was found to be unresponsive and suffering breathing difficulties at home. He was severely collapsed and required resuscitation on admission. The collapse was found to be caused by bleeding on the brain from head injuries that were indicative of inflicted harm. 1.1.3 Following the provisional diagnosis, the statutory agencies followed established child protection procedures and took immediate action to secure the safety, health and wellbeing of Child O and his half-sibling, Child S, aged 13 months, who was living in the family home. 1.1.4 A statutory child protection strategy meeting involving key multi-agency partners took place with a plan to progress to an Initial Child Protection Conference. However the parents of Child O and Sibling S agreed for both children to become Looked After Children, thus becoming the responsibility of the Local Authority. This action rendered the Child Protection Conference as unnecessary. Following CSC assessments Sibling S was placed with his maternal grandmother. 1.1.5 On 11 October 2018, the London Borough of Sutton made the decision that the reported incident of a suspected ‘shaken baby’ met the criteria for a notification to the national Child Safeguarding Practice Review Panel. The decision was made on the grounds that Child O had been seriously harmed. 1.1.6 The LSCP Rapid Review response was submitted on 21 December 2019 and the response by the Child Safeguarding Practice Review Panel was received on 22 January 2019. A first SCR panel was held on 27 February 2019 when the LSCP made the decision to commission a SCR. 9 2 Background history, key circumstances, and context of case. 2.1 Housing Family members of Miss A’s household included her mother, stepfather and brother. Her grandmother lived nearby and is described as a significant influence within the family. Extended family members were regular visitors to the family home. Social work records confirm that Miss A is White British and the CSC notes record a link to the travelling community. Child O’s father is also White British. 2.1.2 The small family home is part of social housing provision and is situated in an area described as a pocket of deprivation in an otherwise affluent part of the London Borough of Sutton. The family appears to have experienced financial difficulties at times. 2.1.3 When the third pregnancy (Child O) was confirmed, Miss A’s mother contacted the MASH to report concerns about the house being overcrowded. She had contacted Sutton Housing Partnership some months before but did not pursue an offer of a housing transfer. A CSC social work home visit followed the MASH contact, but no further action was taken. 2.2 Safeguarding and Mental Health Care Needs of Miss A 2.2.1 By the age of 13 years, Miss A had been exposed to several adverse childhood experiences (ACEs)4 including sexual abuse and sexual exploitation. Miss A’s school referred concerns about self-harming behaviour to CAMHS. Miss A and her parents attended CAMHS appointments which resulted in Miss A transferring to Sutton Tuition and Reintegration Service (STARS), a pupil referral unit for children with complex medical needs. Subsequently, Miss A and her family were offered family therapy to help manage her complex behaviours, but it was not taken up. Professional notes allude to the family minimising Miss A’s mental health problems. 2.2.2 A Child Protection Plan for Miss A was in place for eight months when she was 13 years old and deemed to be at risk of child sexual exploitation. The plan was subsequently stepped down to a Child in Need response under section 17 of the Children Act 1989. The case was closed after a further 10 months, near Miss A’s 15th birthday, when concerns had reduced. 2.2.3 Miss A became pregnant for the first time at 15 years old. In the early weeks of the pregnancy, she was reported to be self-harming and displaying auditory hallucinations. In February 2016 referrals were made to CAMHS by the school and the social worker. An appointment was offered the next day with a 4 ACEs:Adverse Childhood Experiences are stressful events occurring in childhood: they can have a long-lasting impact on an individual’s ability to think, learn and interact with others. 10 consultant but Miss A did not arrive at the clinic. In addition, Miss A’s mother expressed that she had no concerns about her daughter’s mental health, and suggested the CAMHS consultant saw her at school. The CAMHS consultant agreed to this arrangement and an appointment to assess Miss A at school was made. However, Miss A refused to attend the appointment as arranged and it was concluded that mental health problems were no longer a concern. The case remained closed to CAMHS despite information that Miss A was refusing to attend school. 2.2.4 When the first pregnancy was confirmed STARS (Medical Pupil Referral Unit) and a hospital midwife, independently, reported concerns about Miss A’s capacity to care for a child. The reports were duly followed up by children’s social care but no safeguarding concerns were identified. The pregnancy resulted in a miscarriage a few weeks later. 2.2.5 Mental health concerns were identified again when Miss A was pregnant for the second time with Sibling S, aged 16. A school welfare check was undertaken but CAMHS did not reopen the case for further work. 2.2.6 Safeguarding concerns were expressed by STARS during the second pregnancy (Sibling S). The STARS social worker reported that Miss A did not have the cognitive capacity to care for a baby and she would not be sufficiently supported by her family to parent a child. Miss A disengaged from education at the beginning of the pregnancy and did not return. 2.2.7 Reports of low mood were expressed again during Miss A’s third pregnancy and ante-natal period for Child O. This resulted in an antenatal enhanced care pathway (ECP). The service included regular review of her emotional wellbeing by specialist midwives in a vulnerable women’s meeting, held in the maternity unit. 3. Miss A’s pregnancy with Sibling S 3.1 Miss A was referred to Children’s Social Care by the local hospital maternity unit when her second pregnancy was confirmed. A child and family assessment was commenced, following a multi-agency CiN meeting.5 A social worker was allocated to complete the assessment. As part of the care plan, the social worker provided support to re-engage Miss A with education but this was not achieved. 3.2 Miss A was referred to the Family Nurse Partnership service (FNP) as part of the Child in Need Plan. She was offered the service shortly after the pregnancy was confirmed, but it was declined. She did however engage at 26 weeks gestation and completed an enrolment visit in her home. Subsequently, there 5 Child in Need Meetings: A statutory requirement under the Children Act 1989. Enable children, young people, families and professionals to be clear about their responsibilities in the plan, the role of the allocated social worker and the timescales for interventions and expected outcomes. 11 were four programmed visits before Sibling S was born. The last FNP ante-natal visit took place at 36 weeks gestation and Miss A was reported to be preparing well for her new baby. 3.3 STARS referred concerns about Miss A’s capacity to care for Sibling during the first trimester of her pregnancy and requested an Initial Child Protection Conference (ICPC). Whilst it was reasonable for the locality social worker to consider that the threshold for an ICPC conference might not have been met, due to lack of evidence indicative of significant harm6, it would have been appropriate to check out that assumption by means of a strategy discussion, to ascertain the views of other partners. Instead it was decided to explore the concerns through the Child in Need assessment already underway and no strategy discussion or meeting with the partnership took place. The social work assessment concluded that there were no safeguarding concerns at the threshold for a statutory child protection response. 4. The period between the birth of Sibling S and the pregnancy of Child O 4.1 At 38 weeks gestation, Sibling S was delivered by caesarean section. A multi-agency discharge planning meeting was held the next day in the hospital, after which he was discharged home with his mother. 4.2 FNP support continued to be part of Miss A’s CiN plan and was therefore reviewed in the multi-agency CiN review meeting after Sibling S was born. Miss A consistently expressed however that she did not want to participate in the FNP programme which consisted of weekly or fortnightly visits lasting 60 to 90 minutes. Eight invitations, with text message follow up, were sent to Miss A to enable the delivery of the FNP program. However, due to a reluctance to participate Miss A participated in only two FNP sessions and a third was cut short after fifteen minutes. The FNP closed the case when it became clear that Miss A had no intention of engaging with the service. 4.3 A CIN planning review went ahead for Miss A, without partner agencies being present, when Sibling S was almost four months old. No concerns were identified in the meeting. The immediate family was said to be giving good enough support to Miss A and her baby and Sibling S was thriving. The case was subsequently closed by Children’s Social Care, with management approval. 4.4 At the point of case closure, the health visitor had still not met the family, despite several attempts to try and make contact. A further unannounced home visit was also unsuccessful and a follow up invitation to attend a baby clinic for an 6 Children Act 1989: “Harm” is the ill treatment or the impairment of the health or development of a child. Ill-treatment includes sexual abuse and forms of ill-treatment which are not physical, e.g. emotional abuse. It also includes 'impairment suffered from seeing or hearing the ill-treatment of another'. Significant harm is determined by “comparing a child’s health and development with what might be reasonably expected of a similar child”. 12 assessment was declined. Sibling S was almost 20 weeks old by this stage. The health visitor was unaware that CSC had closed the case. 4.5 The health visitor saw Sibling S for the first time at clinic when he was 23 weeks old. No concerns were identified. Miss A agreed to engage with the health visiting service and a Universal Plus7 threshold was applied. 4.6 Within a month of the CIN plan being closed, Miss A and the father of Child O came to the attention of the police having been involved in a violent incident whilst out with friends. The victim, however was unwilling to proceed with charges. It was jointly decided with the police that the case did not need to be reopened by CSC as the criminal investigation had been dropped. There was a two month delay before informing the family of the ‘no further action’ decision, which created unnecessary anxiety for the family. The police did express their concern to the social worker about the type of people Miss A and her partner appeared to be socialising with. 5. The period covering the antenatal period and subsequent birth of Child O 5.1 Miss A was approaching her seventeenth birthday when her third pregnancy with Child O was confirmed. She attended the Early Pregnancy Unit (EPU), within two months of the police incident. The father of the baby was a 16 year old boyfriend who had moved into her family home. 5.2 A home visit was undertaken by the health visitor which was satisfactory, but numerous follow-up telephone calls did not elicit a response from the family. Following safeguarding supervision advice, a formal request was made by the HV to the social worker to escalate the concerns about mother’s vulnerability and persistent non-engagement. The HV was informed by the social worker that the CIN plan had closed during this conversation. Written confirmation was requested, but was not received by the health visitor until five months later. 5.3 A successful antenatal booking consultation at the hospital took place after the first antenatal appointment had been missed. A referral to the teenage clinic for subsequent care was made. The booking midwife also referred the case to the MASH for the attention of Children’s Social Care (CSC). 5.4 MASH recommended support from the ‘Families Matter’ service, which was part of the Government grant funded Troubled Families programme8, as it provided a range of Early Help family support interventions. However, ‘Families Matter’ closed the case immediately, as Miss A chose to decline the service and they could not proceed without consent. A referral for a child and family and pre- 7 Universal plus offers a targeted response from the local health visiting service for families with additional needs. It is a threshold described in the ‘Healthy Child Programme’ 0-19 (Public Health England) 8 The ‘Sutton Families Matter’ service provided a keyworker-led approach to whole-family support, offering coordination and targeted support to families with multiple problems. The service was commissioned in response to the Government ‘Troubled Families’ strategy and programme (2012). 13 birth assessment nearer the due date, was also suggested. Thresholds were not considered to have been met at that 5.5 A further referral was made by Miss A’s mother directly into the MASH to request support. Family relationships were said to be under stress due to overcrowding in the home. This would worsen when the new baby arrived. An unannounced visit to the family took place as the family did not respond to initial telephone contacts by the social worker. The social worker reviewed the family’s concerns and decided they were not a matter for CSC intervention as they only related to housing needs. The assessment concluded that the care of Sibling S was good. Checks were undertaken on Miss A’s new partner, and they confirmed he was not known to CSC. It was noted that he offered good support and care to Sibling S. The case was subsequently closed. 5.6 Routine antenatal care was planned by the teenage pregnancy service after an appointment with the booking midwife. It was documented that Miss O had recently self-referred to the Sutton UPLIFT service9 for support, due to low mood. This led to the decision to discuss Miss A at the monthly ‘Vulnerable Women’s Meeting’ held by the hospital midwifery team. 5.7 The health visitor saw Sibling S and Miss A in a routine baby clinic setting and nothing of concern was observed. The HV suggested that the Early Parenting Pathway (EPP)10 could provide useful additional support. A further home visit took place to arrange a meeting with the Community Nursery Nurse (CNN) who would deliver the EPP service, under the management of the health visitor. Subsequently, Miss A did not respond to three telephone invitations from the CNN. 5.8 Miss A missed Sibling S’s planned health visitor assessment at the baby clinic and did not attend an audiology appointment. Two antenatal clinic appointments at the hospital were also missed. However, in the lead up to the birth, two successful home visits were made by the health visitor. The family were coping well but the HV noted that Miss A had still not consented to the EPP programme as a means of support following delivery. 5.9 Miss A was admitted in early labour and Child O was born prematurely by caesarean section at 36 weeks gestation. Mother and baby were routinely discharged on the following day. Following discharge from hospital, the community midwifery team, did not identify or report any concerns about the parenting ability of either parent. Concerns related only to persistent jaundice of the new-born, which necessitated frequent monitoring at home and at the hospital. 5.10 The health visitor undertook a routine new birth visit when Child O was 10 days old, but the case was not formally discharged by the community midwives into the sole care of the health visitor until Child O was two months of age, due to persistent jaundice. A professional handover did not occur between these two services at the point of transfer. 9 Sutton ‘UPLIFT’ is an integrated primary care mental health service commissioned by Sutton CCG 10 Sutton EPP is a community parenting programme delivered by health visitors and Nursery Nurses which offers co-ordinated and sustained support to young parents. 14 5.11 Four hospital appointments to follow up Child O’s prolonged infant jaundice were reported to have been missed, although Miss A denies ever receiving them. The case remained closed to CSC as no further concerns were referred by other agencies. 6. The following months until the incident took place 6.1 The health visitor observed positive parenting from mother and father involving both of the children at the new birth visit. Miss A continued however to decline support via the EPP, stating she was already an experienced mother, and had good support from her family. 6.2 The health visitor saw Child O and Miss A at home on two occasions and once in clinic when he was accompanied by his grandmother. A further scheduled eight week development check by the health visitor at the baby clinic was missed, although the infant did attend the GP surgery for an eight week assessment and routine immunisations. 6.3 Child O was not seen again prior to the admission to the local hospital at 11 weeks old following his collapse at home. 7. Key questions and critical analysis Child O is the subject of this review, however agency involvement was limited prior to the incident that triggered this review. To maximise the learning, the critique of practice has included a wider time frame than just the pregnancy, birth and care of Child O. It also looks at information pertaining to the pregnancy and care of Sibling S, as there was a considerable amount of agency input during this time that is entirely relevant to the care of Child O. Agencies involved at this time include Children’s Social Care, hospital services, GP, Community health, CAMHS and STAR services. 7.1 What if any, was the impact of the family history, culture and circumstances? 7.1.1 Details in social care files noted that the family had links to the travelling community. Whilst the family were settled and living in a house at the time of this SCR, many of the vulnerabilities associated with this case are reflected in research relating to travelling and ex-travelling communities11. Studies have shown that the physical and mental health and wellbeing of travelling communities, including those who are living in houses, is generally poorer than that of other communities. 11 Gypsy and traveller healthcare: Health equity, action and learning Fairhealth 2019 15 7.1.2 Researchers also found that discriminatory attitudes towards travellers’ in the past, have caused travelling communities to be deeply suspicious of state intervention generally. This may result in poor engagement when services are offered. 7.1.3 Multi-agency awareness and joint working is an essential approach for overcoming any barriers to engagement for families from any minority group who might be suspicious of state intervention. This is to prevent negative outcomes and improve health and wellbeing12. 7.1.4 The possibility of a cultural link did not seem to feature in the assessments of any practitioners participating in this review. This suggests a lack of cultural awareness, or lack of application of cultural awareness in the assessment process. 7.1.5 The review has also found evidence that Miss A was exposed to several adverse childhood experiences (ACEs)13 in her early life, that probably influenced her risk taking behaviour and which contributed to the need for a Child Protection Plan at the age of 13. There is a body of research to support that such exposure is likely to have had a negative impact on her ability to engage, trust and interact with others, including with professionals that will endure into adulthood. 7.1.6 Miss A’s relationship with her parents was described as a source of concern by some of the practitioners supporting the family, although there is contradictory evidence in some agency records that suggest the mother and daughter relationship was supportive. Historical notes from previous education and CAMHS interventions note that Miss A’s parents struggled to moderate their daughter’s complex behaviours and that the actual support Miss A received from her parents was both limited and at times inconsistent. Evidence also confirms that, due to work commitments, Miss A and her partner were left unsupervised for several hours at a time. The assumption therefore, that Miss A was well supported by her family was probably over optimistic. 7.1.7 Miss A’s disengagement with, and refusal to go to school resulted in poor educational attainment, which placed her at an even greater disadvantage with regards to developing her own parenting capacity, style and ability. Summary of learning: The review has concluded that indicators pertaining to family history, culture and circumstances, and especially exposure to ACEs were likely to have had a negative impact on Miss A’s education, emotional well-being and ability to trust. This lack of trust might have extended to accepting professional help, thereby limiting the ability of practitioners to deliver early help successfully. 12 ‘You likes your way, we got our own way’: Gypsies and travellers’ views on infant feeding and health professional support. Louise J Gordon, Debra Salmon (2014). Health expectations:International Journal of Public Participation in Healthcare and Healthcare Policy. 13 ACEs:Adverse Childhood Experiences are stressful events occurring in childhood:they can have a long-lasting impact on an individuals ability to think, learn and interact with others. 16 7.2 What, if any, were the consequences of the pattern of the non-engagement with services? 7.2.1 The FNP accepted the case when Miss A was pregnant with Sibling S as it perfectly fitted their profile for early structured support to young pregnant mothers. From the outset, Miss A expressed on several occasions that she was complying purely because she had to. This was due to a belief that her baby would be removed from her if she did not meet the conditions of the CiN plan. She was clear at meetings and home visits that she did not want to participate in the FNP structured activities, or any other intervention. This consistent reluctance to engage, interrupted and reduced the flow of the FNP programme and only very few of the FNP programmed activities were delivered. 7.2.2 The FNP service was subsequently decommissioned and was not available at the time of Child O’s birth. Even so, Miss A continued to decline to engage with the replacement Early Parenting Programme (EPP) during the pregnancy for Child O, giving the reason that she was already an experienced mother receiving good support from her family. Support from the ‘Families Matter’ service was also declined following a referral to MASH early in her pregnancy with Child O. 7.2.3 The non-engagement with services resulted in missed opportunities to receive professional help to develop Miss A’s parenting skills and capacity. It also reduced the opportunities for professionals to observe the family dynamics and lived experience of the children. Limited access therefore, affected the practitioners’ ability to make well informed professional judgements about the parenting capabilities of Miss A and the health and welfare of Sibling S, which could have further informed the decision making for Child O. 7.2.4 STARS confirmed that Miss A’s cognitive capacity14 was behind others of her age. However, there was no recognition in case records of how her significant gaps in education, coupled with continuing mental health concerns might have impacted on her capacity to make decisions that were in her best interest. This raises questions as to how practitioners communicated information to promote engagement with the services on offer and whether explanations were appropriately tailored to her needs. Without such attention to detail it is possible that she did not fully understand why the interventions might be of benefit, which in turn would have influenced her decisions about participation. 7.2.5 Prior to Child O’s delivery and following the MASH referral from Miss A’s mother reporting tensions at home due to overcrowded housing conditions, an unfamiliar social worker attached to a new team in a new service structure, interviewed family members on three separate occasions. The proposed solution was that S.20 accommodation for Miss A, Sibling S and the new baby, could be arranged if suitable housing could not be found, the social worker also concluded that the housing concern did not warrant further work from children’s social care. 14 Cognitive capacity: The total amount of information the brain is capable of retaining at any particular moment. 17 7.2.6 The S20 accommodation suggestion was completely unacceptable to the family and appears to have resulted in the family disengaging from social care services altogether. The family confirmed, during their SCR interview, that the family had established a good working relationship with their previous social worker from the Joint Adolescent Service (JAS) with whom they had regular and frequent contact as part of the CiN plan until it was closed. The family sought no further advice and made no other contact with social care following the visit from the new social worker. 7.2.7 This raises issues about the change of social worker and the importance of continuity in practice to help complex young parents and families engage and remain engaged with services. A joint visit involving a housing officer, supported by JAS (now replaced by an Integrated Youth Service) might have enabled a more meaningful and trusting relationship, to facilitate and engage the family in a solution focused conversation about their housing options. There is no information that suggests a follow up conversation with either the housing department or the previous social work team took place. 7.2.8 This review has considered whether the risk factor of disguised compliance15 was a feature in this case. Some practitioners believe it was, others do not. Records confirm that Miss A never hid the fact that she did not wish to engage with services and practitioners did not record concerns about disguised compliance when they had direct contact with the family. Similarly, the possibility of risk through disguised compliance does not appear in the safeguarding supervision notes for any practitioner. The definition of disguised compliance, does not easily translate to this case, but there certainly was evidence of deliberate avoidance and deflective strategies being employed by the family. 7.2.9 The SCR concludes that it is the recurring pattern of reluctant and inconsistent engagement, initially recorded in Miss A’s school years and a constant concern until the serious injury of Child O, that posed the most significant risk to Miss A’s children. The history of disengagement should have been considered within a Child in Need assessment framework, instead, the CiN plan was closed and subsequent referrals did not trigger further CSC activity. Summary of learning: The pattern of non-engagement with services is a key theme for this review which resulted in Miss A not benefiting from available early help support. Findings suggest there is a need to use more effective approaches when trying to engage young people with complex needs, who through exposure to ACEs and trauma, might find compliance with care plans difficult or threatening. New approaches include restorative practice and trauma informed care, designed to build trust and resilience, for bringing about effective and sustainable change. 15 'Disguised compliance' involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. 18 7.3 Were the responses of individual agencies and the wider partnership sufficient, in respect of family support, multi-agency information sharing and multi-agency working? 7.3.1 In relation to past professional practice for managing Miss A’s experience of Sexual exploitation (CSE) in 2013, the SCR panel acknowledged that it did not meet the standards expected today, although the decision to protect Miss A under the category of ‘risk of CSE’ in 2013 was entirely appropriate. 7.3.2 Prior to the Independent Inquiry into Organised Sibling Sexual Exploitation in Rotherham16, (2014) that outlined systemic failures in multi-agency practice for managing CSE cases, not all professionals in Sutton were aware of their responsibilities for supporting sexually exploited children. A multi-agency CSE strategy was implemented in 2015 -18 which has led to improved systems and practices. As a result CSE cases are now reviewed through a Multi-Agency Child Exploitation Panel that is set up to review exploitation within a wider context. 7.3.3 Whilst teenage pregnancy per se is not a child protection risk, professionals consistently assessed Miss A to be a vulnerable young person. This was clearly a shared concern for education, health and social care professionals. However, there was insufficient multi-agency engagement to fully discuss Miss A’s complex past and behaviours in the ongoing assessment and planning process. The decision to close the CiN plan was taken by Children’s Social Care alone, rather than in a multi-agency CiN review meeting. The closure was not effectively communicated to partners, and was not uploaded onto the CSC recording system until eighteen months later. Evidence also confirms that social care professionals were not totally aware that the FNP had withdrawn their service due to lack of participation. 7.3.4 A repeating thread in this SCR, is that the past did not sufficiently inform the future in respect of a joined up multi-agency effort to determine the vulnerabilities and needs of Miss A and her baby. The wealth of complex historical information held within the partnership, particularly highlighting a pattern of disengagement, was not given enough weighting in the assessment process. Had a consistent multi-agency approach with frequent multi-agency information sharing had taken place, it is likely that a pre-birth assessment for Child O would have been undertaken. 7.3.5 Miss A was seen in the A and E department of the local hospital for an early pregnancy related problem when she was 17 and expecting Child O. She was seen by adult clinicians because routine transition to adult hospital services occurs at the age 16. Being seen as an adult commonly interrupts the flow of information in safeguarding cases for young people aged 16 and 17 years old and it has been identified as a problematic area for safeguarding practice for many years. Being unaware of relevant past history, together with unfamiliarity or a lack of knowledge and experience, as adult clinicians, in the field of safeguarding children practice compounds the situation. The A and E 16 Independent Inquiry into Child Sexual Exploitation in Rotherham (August 2014) Alexis Jay OBE 19 attendance did not result in information being shared in a safeguarding context although this is by no means unusual. A discharge note summarising the early pregnancy consultation would have been sent to the GP as of routine. 7.3.6 In contrast however, the GP holds information on past history, and has close contact with the community health visitor. GPs are therefore key safeguarding professionals. There is no evidence of any proactive information sharing from the GP in relation to this case. Primary care practice systems must be able to process, code and alert the relevant clinicians and practitioners when vulnerable young people come to their attention. GP’s must also be prepared to share information as well as receive it, when it pertains to young patients with complex needs. 7.3.7 Despite Miss A’s complex history and recent CSC activity, it would be a full two months after the pregnancy was confirmed that the antenatal booking midwife informed social care that she was pregnant again. Evidence confirmed however that Miss A was seen by the EPU on two occasions as soon as she suspected she was pregnant for the third time. The explanation for the EPU staff not sharing information at the time Miss A presented was that they do not normally share information for very early pregnancies due to the high risk of miscarriage. It was also confirmed that CSC will not accept referrals from the EPU for young women before twelve weeks gestation. It is important that organisations and departments encourage information to be shared about vulnerable young people at the earliest opportunity. 7.3.8 There is little evidence of information sharing within and between health agencies. This was particularly relevant after the deliveries of Sibling S and Child O. Apart from the discharge planning meeting which took place one day following Sibling S’s birth, there appears to have been minimal dialogue, if any, between midwives, health visitors and GPs for either child. The transition between health departments or one health service and another is known to be a risky time for children and young people. It is important therefore, that clinical pathways particularly from one service to another incorporate proper handover discussions and information sharing protocols. Summary of learning: This SCR concludes that some partnership responses were insufficient in relation to multi-agency information sharing and multi-agency working. Insufficient attention was paid to past information, previous involvement and significant situational changes. Information from the wider partnership must be sought and considered by CSC, at the point of referral, during an assessment, and again at the point of case closure. There is also important learning with regards to information sharing between health professionals and disciplines particularly at the point of transfer from one health service or department to another. New information held on record should be shared promptly amongst relevant partners and written summaries should not be subject to delay. 7.4. What was the impact of the lack of engagement and inclusion of Child O's father? 20 7.4.1 Sibling S and Child O had different fathers and they were both relatively young. The first partner was aged 18 years during Miss A’s pregnancy and when Sibling S was born. Sibling S’ father remained involved for approximately six months until his relationship with Miss A failed and he left the household. The second partner was aged 16 throughout the pregnancy and when Child O was born. He was living in Miss A’s family home during the pregnancy and remained there until the time that Child O was injured. 7.4.2 Miss A attended for all of her seven antenatal appointments when she was pregnant with Sibling S. Her 18 year old partner attended for five. However, little information is recorded about him in the maternity notes. After his delivery, there was an expressed intention in the CiN plan to gather more information about Sibling S’s father. Despite this direction, he continued to be an unknown entity and remained invisible within the assessments of all the agencies involved. 7.4.3 There is no mention of the relationship breakdown or the arrival of a new partner in any of the agency records at the time that these significant changes occurred. None of the agencies participating in this review have been able to give an accurate account of why. This raises important questions about the role of fathers and the way that professionals incorporate them into assessment and care planning processes. 7.4.4 Miss A started the relationship with 16 year old man, within two months of her previous partner’s departure. The new partner, Child O’s father, had known Miss A for some time. Despite still being at school, he quickly moved into Miss A’s family home. When interviewed, Child O’s father explained that he wanted to help Miss A look after Sibling S. Evidence suggests that he did indeed have considerable contact with the infant, caring and playing with him when Miss A needed or wanted to rest. 7.4.5 Miss A’s parent’s and the young man’s parent’s accepted the young couple’s decision to live together, despite the young man still being in full time education. The young man’s parents’ were concerned about the arrangement, but were unable to influence his decision. It appears that his attainment at school was suffering as a result. It would have been entirely appropriate and expected practice for the school to raise the adverse impact on his schooling with his parents before passing the matter to the safeguarding designated teacher for an onward discussion with CSC. However this did not happen. 7.4.6 Review of the evidence consistently shows that Child O’s father seemed invisible to all of the practitioners involved with the family during the pregnancy and after the birth of Child O. It has not been possible to find any records that pertain to a meaningful conversation with this very young man in relation to pregnancy, childbirth and early parenthood. There was no inter-professional or multi-agency discussion about him to ascertain what his needs might be, despite practitioners knowing that he had a significant role as carer for both children, particularly Sibling S, and was a source of support for Miss A. 7.4.7 During an SCR interview, Child O’s father spoke at length about being overwhelmed by the pregnancy, openly saying that he was not particularly 21 interested in, and rather fearful of small babies. After Child O’s birth he recalled how he made a conscious decision and effort to stay out of the way of professionals, believing they would only be interested in mothers and children. 7.4.8 It is not unusual for fathers of any age to be apprehensive about becoming a parent, however, Child O’s father was immature, by token of being an adolescent of 16 years. Having only just left school, he would have had a limited experience of taking on adult responsibilities, including caring for others. He was living away from his own parents during the antenatal period, and his main source of support was from Child O’s mother. His fearfulness was both understandable and underestimated. 7.4.9 Scientific studies on brain development have confirmed that intellectual development is not complete until an individual has reached their early twenties. The impact of this immaturity creates specific challenges for young people in their teens particularly with regards to complex decision making, impulse control, and being able to consider multiple options and their consequences. A concentrated effort should have been made by all practitioners to prepare Child O’s father for parenthood. 7.4.10 Recent national research has found that the lack of engagement of fathers is a common feature in cases of serious abuse and neglect17 and research into the health visitor role specifically, has established that the non-engagement of fathers is the norm in the UK18. From 2014, NHSE health visiting specification documents have emphasised the engagement of fathers as an important feature of practice, but despite this direction, engagement of fathers and the quality of that engagement remains inadequate. 7.4.11 The reason why health visitors consistently miss the importance of engaging with fathers was the subject of another study that suggested the service defined itself according to a deeply embedded culture and long standing belief that health visiting is primarily a mother and child service19. 7.4.12 This report noted that there is no specific training to prepare modern health visitors for working with fathers (or men in general) and there are few examples of policies and strategies for local health services to assess, meet and measure the needs of fathers. As in other parts of the country, creative solutions need to be found to change the culture of the health visiting service to prepare health visitors to work more productively with fathers and other significant males. Summary of learning: The almost total lack of engagement with either of the fathers in this review, concludes that practice in this area must improve. Improvement is required in health and social care settings, with a particular emphasis on a change of culture in health visiting services, to ensure that the role of fathers in included in everyday health visiting practice. 17 Pathways to Harm Pathways to Protection: Review of SCR’s 2011-14 (2016) Dr P. Sidebotham Et Al University of Warwick & University of East Anglia. 18 Why do UK health visitors not engage with fathers? (2016) Family Included, A project of The family Initiative, London 19 Why Health visiting? DH Policy Research Programme (2014) 22 7.5 Was there sufficient staff supervision and management oversight of case work? 7.5.1 There were significant issues with the way that the allocated social worker interpreted Miss A’s reaction to being exposed to a range of ACEs, including CSE. The social worker recorded that Miss A’s behaviour, which was equally aggressive and dismissive, was due to being ‘embarrassed by her risk taking past’. Furthermore the notes record that when she was distressed, it was a ‘sign of maturity’. Research, however would suggest that the complexities of her behaviour were more likely to be an indication of unresolved trauma. Practice in Sutton has moved on considerably since those records were written. Sutton LSCP has developed and implemented a multi-agency safeguarding operational panel (MACE) for indicators of ACEs which is currently manged within a child exploitation risk assessment and planning framework. 7.5.2 Being more attuned to Miss A’s behaviour and how it was influenced by past and present lived experiences, trauma and disadvantage, might have enabled a better contextual analysis of why she was reluctant or felt unable to accept help. A more compassionate and flexible approach to finding solutions which incorporate the child’s own wishes, feelings and fears is likely to attract more participation, than a list of directions and instructions. 7.5.3 Trauma-informed care models,20 now standard practice in the USA, are starting to be adopted in health and social care services throughout the country. Trauma informed practice enables practitioners to make sense of past history and behaviours enabling holistic care that is safer, more effective and more compassionate. Key to this model of care is listening to the child’s voice, and exploring what it is they are trying to tell us. 7.5.4 Similarly, there were practice anomalies in respect of the CiN planning process. The approach to Miss A’s CiN plan was to carry on regardless with the same actions and interventions, rather than to critically review and reflect on the effectiveness of those interventions in terms of positive outcomes and sustainable change. In particular the planning process never came to grips with issue of disengagement, and did not put forward any options to try to improve the level and quality of Miss A’s participation. 7.5.5 The management oversight of the plan failed to critically review the information and rationale for the plan or challenge the issue of disengagement. Neither did management advice explore any alternative strategies to address Miss A’s compliance issues. Miss A articulated on more than one occasion that she was complying with interventions only because she felt compelled to, stating she was fearful that Sibling S would be removed by CSC if she didn’t comply. This caused her to resent the CiN plan and the professional activity that went with it. 20 Trauma-Informed Care is a strengths-based framework grounded in an understanding of, and responsiveness to, the impact of trauma, that emphasises physical, psychological, and emotional safety for practitioners and service users, and which creates opportunities for service users to rebuild a sense of control and empowerment. (Hopper et al, 2010). 23 Under these circumstances positive change would be unlikely to occur. These issues were not recorded as significant in the management oversight notes. 7.5.6 The family described how the social worker seemed very close to Miss A, often giving her positive feedback and good reports. This begs the question as to whether this close and positive relationship influenced the decision to close the case. Over identification21 with a service user can be the unconscious result of working with highly vulnerable and complex people. It can also be linked to the ‘rule of optimism’22 cited in many serious case reviews over several decades, and which blocks the unbiased scepticism that is necessary for social work practice. 7.5.7 High quality reflective, restorative supervision facilitated by trained supervisors is the place where professional relational issues can be tested. Supporting practitioners to reflect on their relationships with clients and what factors are influencing their actions, is an extremely important element of safeguarding practice. Children’s Social Care has changed the mode of delivery to a restorative practice model, including group reflective supervision. 7.5.8 Safeguarding supervision was provided to health and social care practitioners involved with the family, although the nature and quality of the supervision delivered was difficult to determine. The supervision notes of the participating agencies were generally brief, descriptive and resulted in a list of management directions. The records did not demonstrate a depth of reflection or critical thinking to identify areas of risk, including those connected to the nature of the relationship. Neither was a clear rationale given for any practice changes. It is the quality, rather than the frequency of supervision therefore, that needs to be assured. 7.5.9 There is also learning in respect of the social worker’s decision to close the case without multi-agency consultation, which was agreed in a management oversight meeting. The rationale, put forward by the social worker, was that Miss A had grown in confidence, her mental health was stable and she was parenting the infant well with help from her relatives. A multi-agency view might have provided a very different perspective. 7.5.10 The pre-birth assessment for Sibling S was also discussed in the management oversight meeting. It was described as positive, even though it did not specifically address the baby’s needs and did not follow the required protocol. The conclusion of this SCR is that the management oversight did not apply sufficient scrutiny and challenge to the work undertaken for the pre-birth assessment or the assessment for Miss A and therefore the case was closed prematurely. Summary of learning: Management oversight and supervision for health and social care agencies did not demonstrate best practice and did not facilitate 21 Over-identification: a form of over protective or benign countertransference when the practitioner loses distance in the relationship and becomes overly engaged in the client’s material. M. Shepherd University of Leicester 22 Rule of Optimism: Belief that what a practitioner is seeing is progress and filtering out or minimizing areas of concern; 24 sufficient reflection, challenge and/or advice regarding the plan for Miss A and Sibling S. Cases deemed to be at the threshold for CiN intervention, where early help is refused, require robust supervision, management advice and oversight to prevent ‘case drift’ and to facilitate lasting change through partnership working. The CiN plan was subject to appropriate management oversight at the point of closure, but the reasoning for closing the case, including why it was safe to close the case at that particular time, was not fully explained in the management oversight record. Subsequently, the decision to close the case was not communicated to the partnership effectively and was subject to delay. 7.6 What, if any, learning was there in respect of the quality of assessment, decision making and care planning? 7.6.1 The initial assessment following the referral when Miss A became pregnant for the second time was completed over a period of six weeks. It concluded that Miss A should receive support as a Child in Need (CiN), as defined in section 17 of the Children Act 1989. A pre-birth assessment for the unborn child (Sibling S) was also considered necessary, and was to be completed later in the pregnancy. Both these decisions were entirely appropriate. At this juncture, actual or likely significant harm had not been identified. It appeared that Miss A was prepared to cooperate and consented to CiN support. 7.6.2 Miss A and her mother in an interview for this SCR, clearly held their allocated social worker in high esteem. They recalled frequent visits and phone calls to see how they were getting on. This level of support showed a great deal of commitment to the family, however many of those contacts were not recorded in the social work assessment record. 7.6.3 As part of the CiN plan, the social worker referred Miss A to the FNP for ante and postnatal support. A health visitor was also allocated to Sibling S and the family. This multi-agency effort to deliver early help indicated a ‘Team Around the Child’ (TAC)23 approach and this planning model is confirmed in the CSC notes. A TAC response became popular after the common assessment framework (CAF)24 was introduced in 2005. It offered integrated and coordinated multi-agency support to children with complex needs, preventing agencies with families in common working in isolation from each other. A TAC approach was entirely appropriate for meeting Sibling S and Miss A’s needs. 7.6.4 However, evidence from practitioners in touch with the family, including the FNP practitioners, reported in their interview that they were sometimes unclear about the status of the CiN response and their influence in the CiN planning process. On occasions partners were unsure if the CiN plan was still 23 TAC is a model of multi-agency service provision, bringing together a range of different practitioners from across the children and young people’s workforce to support an individual child or young person and their family. 24 The common assessment framework (CAF) 2005, is a standardised approach for the assessment of children and their families, to facilitate the early identification of additional needs and to promote a coordinated service response. 25 operational. They were not always invited to attend CiN review meetings and minutes from meetings were either not taken, not circulated or delayed. 7.6.5 To be effective, a lead professional is nominated to coordinate TAC actions, to provide clarity and continuity to professionals and service users. The CiN plan for Miss A was uncoordinated, seldom informed by partners and was organised through ad hoc, unminuted meetings. This did not constitute a TAC approach. In this case, the social worker assumed the lead role by default and the FNP and health visitor interventions remained distinct and separate. 7.6.6 There is no available explanation as to why the CIN planning process did not meet TAC expectations, other than a TAC approach can be difficult to implement. It requires considerable time and commitment from partners. This has been recognised and the strategic leadership for Early Help was transferred from the Children’s Trust Board to the LSCP in 2018. There is now a dedicated Early Help subgroup to ensure compliance with statutory Working Together and other related guidance. 7.6.7 Low staff morale and staffing shortages were identified as a contributory factor which mostly relates to social work practice in 2013-2016. Since then, a service transformation programme has been implemented, resulting in a locality based restorative practice approach alongside a significant investment in targeted Early Help services for cases below the statutory intervention threshold. Summary of learning: There is valuable learning for Children’s Social Care about the effectiveness of the Early Help planning within a CiN assessment framework. CSC need to be mindful of practice standards for social work case recording, pre-birth assessments and non-statutory TAC interventions. The CiN plan in this case included FNP intervention, however there is little evidence of shared responsibility, good inter-agency communication or practice coordination. There is evidence that the social worker was able to engage with Miss A when others could not, but it appears that, over a relatively short period of time, the CiN plan became the sole remit of the social worker, planning in isolation, rather than with the partnership as a whole. Plans for complex young people must involve the young person and be tailored to their specific needs. New borough approaches embrace trauma informed care and restorative practice as standard. 7.7. What, if any, learning was there in respect of adherence to individual agency and multi-agency policy, procedures and practice guidance? 7.7.1 Statutory agencies complied with statutory child protection requirements after Child O sustained his injuries. Prior to this, there is evidence that thresholds were applied correctly and according to the local threshold guidance for referral 26 and assessment. Appropriate follow up actions, to address identified needs took place, including allocation to the appropriate social work team. 7.7.2. A comprehensive written summary was provided at the point of case transfer from the Referral and Assessment Service to the local social worker who would be responsible for ongoing casework for Sibling S and Miss A. This followed Children’s Social Care operational procedures and was good practice. 7.7.3 The CiN and pre-birth assessments for Sibling S however, were not consistent with best practice and the pre-birth assessment protocol for CSC was not followed. In addition, a record of the assessment was not uploaded onto the CSC electronic recording system within the timescale expected. It took a further 18 months for this to happen. The reason for the delay has not been fully explained but is likely to relate to organisational issues at this time. 7.7.4 Many studies have emphasised the increased risk to babies of abuse and neglect due to their frailty and total dependence25 26. It is of the utmost importance that robust post-birth assessments are undertaken, particularly where vulnerable mothers have been identified, to enable the risks and needs for a baby to be predicted early. 7.7.5 The CiN plan did not provide clarity about goals or achievable outcomes and how actions were going to be delivered and evidenced as completed. Planning in this way requires a robust and sensitive discussion with the client as well as professionals to ensure clarity about what was being done and why, and clearly explaining the expectations for all of the individuals involved. This type of planning and review is not evidenced in health or social care records. 7.7.6 Reflecting on the case, practitioners agreed that not enough effort was made to talk to Miss A and Child O’s father directly and alone. Some practitioners observed that there were always family members present when the couple were seen and Miss A’s mother was often reported to answer questions directed to the young parents. This would not have facilitated the views of the young people themselves, or given professionals an insight into what was driving their behaviour from their point of view. 7.7.7 Over time, rather than communicating directly with Miss A and Child O’s father, Miss A’s mother became the principle point of contact and was frequently used by practitioners to deliver and pass on messages or report on progress. This was because it was thought that Miss A’s mother would have more success influencing her daughter than the professionals working with the young parents themselves. There was little evidence that this assumption was true, but the practice continued. Previous education records suggested family support was limited and new information suggests the couple were frequently left unsupervised for many hours. 7.7.8 In addition, there is some evidence that practitioners took information, reported to have come from other professionals, at face value from Miss A’s mother, rather than contacting the appropriate colleague to check out what had been 25 A profile of suspected child abuse as a subgroup of major trauma patients: EMJ, Dec v32,12 (2015) 26 All babies count: prevention and protection for vulnerable babies, NSPCC (2011) 27 said. Using relatives to coordinate activity or as a primary source of information is unreliable and ‘professional to professional’ feedback and discussion should be used as standard to ensure accuracy, continuity and co-ordinated care. 7.7.9 Young people must be seen alone and whilst including the family constitutes an important part of an assessment, it is essential that the child’s voice is central to the planning decisions and arrangements made. 7.7.10 The review has found no evidence of any face to face interaction, formal handover or communication between health professionals, e.g. hospital and community midwives, health visitor and GP during the pregnancy and following the birth of Child O. This would have been expected practice considering the recent family history. It has been identified as an area of improvement for the hospital in their single agency report. Summary of learning: The CSC pre-birth assessment process did not follow the CSC pre-birth protocol. Evidence also suggested that insufficient attention was paid to assessing the specific risks and needs of a new born baby, particularly in this case where Miss A was known to be vulnerable. Procedures were not always followed in relation to working with young people on their own rather than through their parents. There is also considerable learning for all professionals about the importance of adhering to safeguarding policy and procedures and standards for record keeping and processing and sharing information. Established protocols and systems for robust inter-professional communication between community midwives, health visitors and GP’s did not work well in this case. 8. Key themes and learning points The learning points considered against the seven questions in the previous section have been organised into six themes as follows: ‘quality of assessments’, ‘effective care planning’, ‘supervision and management oversight’, ‘consent and securing engagement’, multi-agency partnership working and ‘policy and procedures’. These are also addressed in the agencies own reports and action plans, see appendix C and the LSCP action plan, see appendix D. 8.1 THEME 1: QUALITY OF ASSESSMENTS Learning Point 1: Using systematic analysis and recording techniques Health and social care are both assessment based services which determine the interventions that service users receive. It is an ongoing process and assessments should be reviewed and re-evaluated frequently to assess the quality and gauge progress, so that plans can be changed if outcomes are not achieved. 28 The review found that the social care CiN assessment documentation was not consistent with best practice. This also applied to a pre-birth assessment for Sibling S, which failed to follow the Sutton pre-birth protocol. There were particular issues in respect of failing to record all contacts, minimal recording generally and delay in sending assessment summaries and information to partners. The CiN assessment was based on minimal information, often taken from family members rather than the wider professional partnership, plus the assessment did not differentiate or articulate clearly the separate needs and risks of the baby, Sibling S, and those of the young people who were his parents. Recorded health assessments were brief, mainly descriptive in nature, and vague about desirable outcomes and rationale for interventions. Community family health assessments should be holistic in style and be recorded in a systematic way that includes observations and descriptions, an analysis of the interaction, evidence based conclusions, and outcome focussed care plans. A multi-agency pre-birth assessment protocol with health and social care roles and responsibilities clearly set out alongside a process chart and practice guidance should be developed to ensure consistency of practice across the partnership. Learning Point 2: Risk assessment The routine calculation of risk, using established risk assessment models did not inform the care plans for the young people and infants in this case. Incorporating robust risk assessment techniques into all assessment processes for complex cases, used by the partnership, will enable the necessary critical thinking for considering and articulating thresholds in terms of likelihood of significant harm, as well as merely evaluating the case in terms of the absence of significant harm. Pre-birth risk and/or perinatal risk assessments need to be distinct and separate from the wider family assessment process, so that the potential needs and risks to babies can be identified and don’t become lost or secondary to the family assessment documentation. Health professionals must also be able to assess pre-birth risk effectively. Learning Point 3: Incorporating family culture and context into assessments Health and social care assessments did not fully seek out and incorporate information pertaining to the family’s history, culture and context. Whilst not always being immediately apparent, culture, context, especially linked to trauma and adverse childhood experiences (ACE), can have a profound effect on the behaviour and functioning of the individual who is subject of the assessment. Professional knowledge and understanding of this area must also inform the care plan, especially when there is resistance in accepting services. 29 The effects of changes in the family’s circumstances, for example, when a new partner appeared on the scene and when the housing situation became problematic, were not evaluated to assess the impact on Miss A and her children. Significant changes in circumstances must be fully explored as they are important factors when determining risk and need. Very little attention was paid to exploring the needs of Child O’s parents when they came to police attention whilst out socialising. CSC might like to consider adopting a contextual safeguarding approach, specifically designed to assess the developmental needs of young people, as they explore relationships outside of their immediate family. Learning Point 4: Improving the engagement with fathers Each agency should ensure that they have clear procedures in place for including fathers (or partners) in screening, assessment and planning processes. This includes undertaking necessary background checks. 8.2 THEME 2: EFFECTIVE CARE PLANNING Learning Point 5: Planning to achieve outcomes Agency care plans did not clearly explain the outcomes that services were hoping to achieve for Miss A, her partner and the children. Plans for young adults should be tailored and mindful of their developmental and emotional wellbeing, particularly when ACEs have been part of their lived experience. Planned interventions should consider involving services that specialise in engaging and working with young people and/or young parents. It was noted that the immediate family were acting as facilitators for delivering the plan when professionals were unable to engage with mother. This requires further reflection to take into account who the plan was for and why engagement was difficult. Practitioners in all agencies need to ensure that the voice of the child and their own lived experience is fully taken into account in any assessment and planning process. 8.3 THEME 3: MANAGEMENT OVERSIGHT AND SUPERVISION Learning Point 6: Case management and supervision in social care Case supervision in CSC was of insufficient quality. It did not appear to enable sufficient reflection, self-awareness and the critical thinking to ensure that decisions were objective and made in the best interests of the children concerned. Supervision notes were minimal. CSC management oversight did not apply sufficient scrutiny and challenge to test the social workers rationale for decisions, plans and recommendations. This was evident when the CiN plan was closed, within four months of Sibling S’s birth despite anxiety being expressed in the partnership. 30 At the point of closure, the social worker’s rationale and decision to close could not be evaluated against a set of SMART care planning objectives. The decision was a subjective view of progress, which in hindsight was not entirely correct. Management oversight must test the rationale for closure to ensure sufficient change has occurred to meet the needs of the family. Such evaluation can only be drawn from a broad perspective, including the effectiveness of multi-agency interventions. Sign-off for closure should be based on robust multi-agency assurance that service users no longer need support. Adherence to standards of record keeping is an important part of the management oversight process. Learning Point 7: Quality assurance of supervision for health providers The review of the supervision records of health visitors, FNP and social care professionals confirmed that systems were in place and practitioners sought and received safeguarding supervision regularly. However, the quality of the supervision requires improvement. Generally, supervision notes were minimal, managerial and directive in style, rather than reflective and restorative in nature. Supervision records should be thorough and auditable. Learning Point 8: Safeguarding supervision for practitioners with case responsibilities Safeguarding supervision through reflection and analysis promotes a deeper understanding of what is driving decision making. An appropriately trained supervisor facilitates this through sensitive questioning and challenge, in addition to giving direction and practice advice. Concerns about over-optimism, disguised compliance or lack of curiosity can then be probed and tested, enabling safer outcomes for the child and practitioner alike. Good quality reflective, restorative supervision is essential for health and social care practitioners holding case responsibilities. Many practitioners closely involved with Miss A and her family did not receive regular safeguarding supervision, in particular the teenage pregnancy midwives and the GP. This is being addressed in the single agency action plans. Safeguarding supervision is not always routinely scheduled for staff groups who do not hold ongoing case responsibility for children and families, however some that were involved in this case might have benefited from one to one or group supervision to help them manage this complex case, for example, community midwives, housing officers and EPU staff. 8.4 THEME 4 - CONSENT AND SECURING MEANINGFUL ENGAGEMENT Learning point 9: Consent and engagement at or below the Child in Need threshold Early help support requires the agreement of the parent as there are no statutory levers to secure co-operation. Declining service offers and the 31 consequences of withdrawing consent and refusing to participate severely limited the support that agencies could provide to Miss A. Obtaining informed consent is more than a passing formality: it requires a full understanding of what is on offer within a trusting relationship. Explanations should be in language service users understand, so that interventions are not perceived as a threat or an instruction over which they have no control. CSC did not act to allay Miss A’s fear that her child would be removed if she didn’t comply with the CiN plan. Engagement under duress is unlikely to be effective. Implied consent was obtained from Miss A by the FNP to deliver their programme. However, there is no particular reference or record about how consent was obtained. Given that Miss A’s cognitive ability was assessed as poor, she might not have fully understood the nature of FNP interventions and why they might be of benefit. Despite being 16 years old at the time, adapting a standard NHS Gillick Competency assessment approach might have been helpful in this case. 8.5 THEME 5: MULTIAGENCY PARTNERSHIP WORKING Learning Point 10: Information Sharing and Communication There is evidence that the decision to close the case on completion of the CiN plan was not communicated effectively to the partnership. A written summary to partners to confirm the closure was subject to a severe delay of several months. The family were also left waiting to know the outcome of the social workers discussion with the police, when Miss A and her partner came to their attention. Other instances of poor communication are also in evidence. CSC must ensure that prompt information sharing is central to practice. The hospital A and E department had good systems in place for notifying safeguarding concerns and making child protection referrals. Less robust was the system in the maternity department. The Early Pregnancy Unit, for example did not have a robust protocol in place for sharing information or making referrals about vulnerable young people under the age of 18. The maternity ‘vulnerable women’s meeting’, part of the enhanced care package for vulnerable pregnant women, whilst a very good opportunity for sharing concerns, did not record, circulate or discuss the outcomes with partners. In addition, whilst there was a good example of a post-natal discharge meeting in the hospital before Sibling S went home, no such meeting took place to discuss the vulnerabilities of Child O at the point of discharge. Hospital to community midwife communication was generally insufficient, as was the midwifery to health visitor information exchange, with no evidence of ongoing verbal communication or formal hand-over processes. The hospital has identified the need to review and improve a range of information sharing systems and has a robust plan in place to do so. The lack of robust and effective communication systems created the conditions whereby health practitioners worked in isolation from each other. 32 GP involvement was negligible throughout the timeline of this SCR. A GP practice is an important repository of information, receiving documentation from a range of agencies, however there was no proactive effort by the GP to gather or share information. The case was re-opened by CSC following closure under the ‘three month rule’27 after the young parents were notified to the police having been involved in some anti-social behaviour in October 2017. As it was judged that the threshold for further social work intervention had not been met, CSC responded by contacting the family direct rather than undertaking a face to face visit. This relates to the principle of the three month rule where re-referrals are responded to by the social worker previously known to the case. This is seen as positive in respect of preserving relationships, however there is a need to ensure that new information is checked out with partners and that there remains effective management oversight of the decision making. There was some communication between the police, social care and the family regarding this incident but the issue was not sufficiently shared or discussed with multi-agency partner. The management oversight during this period appears to have been limited which explains why the case was not closed for a period of time following this intervention. Assurance will be required that this has been addressed by CSC so that there is multi-agency involvement in the case closure of all cases that have been subject to a Child in Need Assessment. After Child O’s pregnancy was referred by the hospital to CSC there were several failed attempts by the social worker to contact the family by telephone but a face to face meeting did not occur. A social worker did however interview family members after a subsequent concern about overcrowded housing was reported to the MASH, but there was no onward communication with partners or dialogue with the housing department. 8.6 THEME 6: POLICY AND PROCEDURES Learning Point 11: Adhering to safeguarding protocols, policies and procedures Recommended practice to initiate a strategy discussion was not followed after an initial child protection conference was requested by a partner agency, early in Miss A’s second pregnancy. Instead, the social worker discussed the request with the family. Assessing a child protection concern using information from the wider partnership is standard for deciding whether a child protection response might be required. 27 Three month rule: Automatic re-opening of a case, when a child or children come to the notice of Childrens Social Care within three months of case closure. 33 A CSC pre-birth assessment procedure was in place but was not used for assessing the needs of Sibling S prior to case closure and a written summary for partners was not promptly dispatched when the decision to close the case was made. The A and E department in the hospital demonstrated good adherence to the hospital procedure that followed up children who did not attend for hospital appointments. This procedure has been further enhanced recently to adopt the more accurate phrase ‘was not brought’ to emphasise that the responsibility lies entirely with the parent or carer. The GP surgery will need to improve their response when they become aware that a child is not being taken to appointments, and assurance is needed to evidence that there is a plan of action to do this. 9. Conclusion Child O was 11 weeks old when he was injured, Sibling S was approximately 16 months. Miss A and her partner were also under 18 years of age when the incident happened, and are therefore of interest in this report. Information for this review has come from several sources, although acute and community health services played a significant role, as did professionals from Children’s Social Care. Professionals fully recognised that Miss A, as a complex and vulnerable young person and mother, would benefit from early help. She was therefore considered to meet the criteria and threshold for a statutory child in need response. Records show that a considerable amount of multi-agency resource and effort were directed to offering the family support when the Child in Need plan was in place. Central to this review is the fact that Miss A repeatedly refused consent or actively disengaged with services. However, there was no evidence being seen or heard by practitioners involved with the family that constituted actual or significant harm. To all intents and purposes Miss A and her young partner were considered to be looking after both children adequately and the children appeared to be thriving. The overarching learning for this review has focussed on the issue of how to engage young people, who, through previous trauma and adverse childhood experiences, simply do not wish to participate with statutory services. Many, practitioners realised that the lack of compliance was impeding their ability to deliver effective care but the pattern set by Miss A seemed impossible to change. Eventually, Ms A’s parenting was considered by CSC to be ‘good enough’ for the case to be closed. After closure, further issues came to the attention of CSC, but the case was not reopened. Health agencies continued to deliver care to the family following case closure. Several examples of good practice were identified in this review, and others were found to require improvement. Overall, the learning suggests a change of culture is needed in the way that professionals form their relationships with each other and with service users, using more modern approaches like trauma informed care and 34 restorative practice to enable meaningful engagement. The review also concluded that more thought needs to be given during assessment and care-planning processes to the impact on the service user of past lived experience, family culture and context. Robust management oversight and reflective, restorative supervision is also essential when delivering this type of care. There is also learning with regards to the significance of changes in circumstances as well as making sure partners and fathers are included in the assessment and care planning process. The last key feature of this review is to ensure that the needs and risks of new babies are given sufficient attention in their own right, particularly when their parents have hitherto, been the focus of multi-agency work. The recommendations for the independent management reviews (IMR) have been written by the agencies participating in this SCR, to ensure that the weaknesses in their own safeguarding systems can be put right. The IMR recommendations are set out in Appendix C and those for the Sutton Local Safeguarding Children Partnership are set out in the table below. All recommendations will be subject to the robust independent scrutiny and assurance framework set out in the LSCP local arrangements. 10. Recommendations The independent author recommendations are aligned to the key themes and learning points in this report, and included in the LSCP action plan in appendix D. The expectation is that each agency will take responsibility for undertaking service and system improvements where required. RECOMMENDATIONS 1. To promote restorative safeguarding supervision practice for health professionals who are involved in the care planning of complex and vulnerable adolescents. 2. To ensure that restorative safeguarding supervision (RRS) is available for GPs, community health professionals, hospital staff and other health professionals involved in case work. 3. To provide information, advice and guidance for non-case holding professionals on what to do and who to turn to if they are worried about any of their cases. 4. To develop guidance on multi- agency pre-birth assessment to identify risk and clarify safety planning processes, to form part of the existing multi-agency perinatal and infant mental health protocol. 35 5. To review the CCG health assurance report against the learning points in this SCR to ensure compliance with section 11 requirements under the Children Act 2004. 6. To hold a series of learning seminars and develop a training module on the impact of Adverse Childhood Experiences (ACEs) and trauma. To include: a) the complexities of obtaining consent; b) trauma informed approaches for positive engagement with early help and statutory services. c) context, culture and past and present circumstances when planning interventions for children and young people. 7. To seek assurance that health and social care agencies have undertaken practice developments to increase their knowledge and understanding about the importance of including fathers; in the context of early interventions as well as safeguarding. 8. To seek assurance about multi-agency involvement in the case closure of all cases that have been subject to a Child in Need Assessment. 36 Appendix A - Methodology Methodology 1.1 The period under review extends from 28th November 2016 until 5th October 2018, covering professional involvement until Child O was admitted to hospital following his collapse. Relevant information prior to those dates is also included in the report. 1.2 All relevant agencies involved with Child O were invited to be part of the SCR Panel and Individual Management Reviews (IMRs). SCR panel members have advised the author and provided clarification about events that were not immediately clear or which required technical or professional interpretation. Where necessary, further evidence has been provided, including copies of original notes and case files created by front line practitioners. 1.3 The Panel also set out that the independent review must clarify whether anything could have been done differently at either period to safeguard Child O and prevent the incident from occurring. 1.4 An experienced independent author with a senior national, regional and local health and safeguarding professional background was appointed by the Panel to undertake this review. 1.5 The initial case chronologies and single agency IMR reports were written by professionals who typically have specific safeguarding responsibilities within their organisation. The reports were based on a desk-top review of records and notes and the thoughts and recollections of practitioners involved with the family to help explain the rationale behind their actions. 1.6 The independent author and the safeguarding quality assurance manager for the local authority met with both of Child O’s parents, the paternal grandfather and the maternal grandmother. The visits provided an insight into how the family regarded the care they received as service users. Where appropriate, views from the family were included in the analysis. The learning from this review will be shared with the family members who participated prior to the publication of the report. 1.7 The independent author reviewed all of the information submitted, concentrating on how professionals involved with the family worked individually and together to safeguard Sibling S and Child O. This was done in order to identify the strengths and weaknesses in the wider multi-agency safeguarding system, and to explore whether the single agency and inter-professional collaborative practice was effective in this case. 37 Appendix B Genogram (anonymised) Sources 1.Spelling of names are taken from LB Sutton records 2.All information is drawn from LB case recording 38 Appendix C Summary of IMR recommendations INDEPENDENT MANAGEMENT REVIEW (IMR) RECOMMENDATIONS Item Recommendations 1 Epsom St Helier Hospital 1.1 That all key practitioners directly involved in the internal management review are debriefed and informed of the review findings. 1.2 That the Trust reviews its protocol on the management of enhanced care service to emphasise the importance of information sharing with other agencies (health visitor/ GP) and include written/verbal handover and Discharge Planning Meeting to include the Community Midwifery Team. 1.3 Review the Trust record keeping standards to incorporate robust information gathering on fathers. 1.4 Review the current record keeping standards to ensure: a) Community Midwives handover form from maternity ward is effectively completed; and b) Vulnerable Women’s Forum is effectively monitored/meeting is minuted 1.5 The Trust reviews its Safeguarding Supervision policy to incorporate Teenage Pregnancy Midwives and dedicated supervision session is afforded to the team. 2 GP Services 2.1 That all key practitioners directly involved in the internal management review are debriefed and informed of the review findings (15/05/2019). 2.2 Development of was not brought Policy template for all GP practices to access. 2.3 Review practice record keeping standards to incorporate robust information gathering on fathers. 2.4 Review the GP/ health visitor safeguarding children forum to ensure robustness in partnership working. 2.5 Practices and primary care team review GP safeguarding supervision policy to ensure there is adequate support in place. 3 Children’s Social Care 3.1 To improve Pre-birth assessment, planning and intervention. 3.2 To improve the engagement of fathers within assessment planning and intervention. 3.3 Improve consistency of accurate and timely record, including clear recording of the rationale for case closures. 3.4 To improve the practice skill set of front line staff in engaging with difficult to engage with families when they are distrusting of agencies and do not consent for further assessment / intervention. 3.5 Learning from this case to be shared with social care workforce. 4 Sutton Health & Care (formerly Royal Marsden Community Services) 4.1 The community services current annual supervision audit should be reviewed to ensure that all cases on the EPP programme are being brought to supervision and reviewed and that standardized tools are being used at designated contacts. 4.2 The community annual record keeping audit needs to be reviewed to include analysis of language used to record caregiving observations, if CIN minutes and plans are held/recorded on the clinical system and that supervision is recorded in a timely way. 4.3 The community Child protection and safeguarding children policy to be reviewed and incorporate detail about disguised compliance (linked to the NSPCC factsheet and learning from SCR’s) and advice on use of chronologies by staff when disguised compliance is suspected and supervision sought. 39 4.4 The Sutton Health and Care Alliance organisation to consider specific training on trauma informed practice for practitioners working with young people and young parents. 5 South West London and St Georges Mental Health NHS Trust 5.1 Training around CSE (Child Sexual Exploitation) has already been improved, and plans are in place to improve it further. 40 Appendix D – Sutton LSCP Action plan to implement recommendations CHILD O – LSCP ACTION PLAN RECOMMENDATION RATIONALE ACTION LEAD BY WHEN INTENDED IMPACT 1. To promote restorative safeguarding supervision practice for health professionals who are involved in the care planning of complex and vulnerable adolescents. Restorative supervision is being embedded within children’s social care. It is a recognised model of practice for improving and repairing relationships in a wide range of settings. To utilise promotional material on restorative practice developed by the Local Authority and disseminate and promote within health settings Sutton CCG Sutton Health and Social Care Epsom and St Helier University NHS hospital Trust November 2020 A consistent approach to safeguarding supervision across the partnership. 2. To provide information, advice and guidance for non-case holding professionals on what to do and who to turn to if they are worried about any of their cases. Improved partnership support to non-case holding professionals involved in case work, 2.1 To develop Children First Contact Service to extend information and advice at an early stage. 2.2 To improve and promote online information, advice and guidance to professional and families. Sutton LSCP March 2020 Improved professional support to respond to additional support needs early. 3. To develop guidance on multi- agency pre-birth assessment to identify risk and clarify safety planning Improved partnership responses to pre-birth concerns. To add guidance to the multi-agency perinatal and infant mental health protocol. Sutton CCG December 2020 Improved pre-birth early help and safeguarding responses. 41 processes, to form part of the existing multi-agency perinatal and infant mental health protocol. 4. To review the Sutton CCG health assurance report against the learning points in this SCR to ensure compliance with section 11 requirements under the Children Act 2004. To strengthen health assurance reporting to the LSCP. To update the existing Sutton CCG health assurance report as required for scrutiny by the partnership. Sutton CCG April 2020 Strengthened practice by health providers. 5. To hold a series of learning seminars and develop a training module on the impact of Adverse Childhood Experiences (ACEs) and trauma. To include: a) the complexities of obtaining consent; b) trauma informed approaches for positive engagement with early help services. c) context, culture and past and present circumstances when planning interventions for children and young people. To provide professional development support across the children’s health and social care workforce in Sutton. a) To seek assurance on how agencies and schools are supporting trauma informed responses in their work. b) To commission evidence based assessment training for children’s social care. Sutton LSCP July 2020 Improved practice approaches to respond to vulnerable adolescents. 6. To seek assurance that health and social care agencies have undertaken practice developments to To evidence learning from this SCR. 6.1 Each agency to provide assurance through a summary report that demonstrates Sutton LSCP March 2021 Evidence of improved practice. 42 increase their knowledge and understanding about the importance of including fathers; in the context of early intervention as well as safeguarding. improvement in working with fathers. 7. To seek assurance about multi-agency involvement in the case closure of all cases that have been subject to a Child in Need Assessment. To improve case management system to achieve best practice. 7.1 To undertake actions to strengthen social work supervision and management oversight of case closures. 7.2 To provide assurance to the LSCP of improved social work supervision and case management oversight. 7.3 Practice Directive to be issued to reinforce good practice related to case closure. Children’s Social Care March 2020 Improved case management and management oversight. |
NC049525 | Death of a baby boy in December 2014 aged six-weeks. Cause of death was given as sudden death in infancy; the birth of a second child led to reinvestigation of the case. The pathologist felt the two fractures to the baby's knee were more likely to be non-accidental injuries and not linked to vitamin D deficiency. Both parents were known to statutory services during their childhoods in response to concerns about parental care. The mother was a vulnerable adult and was diagnosed with a mild learning disability. Shared Lives carers described her as needing constant prompting with basic daily living tasks. Mother left the scheme before her pregnancy. Parents received enhanced health visiting services and were in regular contact with a children's centre. Children's social care were not involved with the family at the time. Key findings include: the importance of professional curiosity to ensure roles and remits are well understood; when a learning disabled woman becomes pregnant, the impact on her ability to care for her children should be considered; adult services practitioners require a deeper understanding of their safeguarding responsibilities and should work collaboratively with other agencies; importance of professionals communicating with each other to verify information given to them by family members; the need to communicate key information to the couple should have been informed by a formal assessment. Recommendations to the LSCB: to develop a local partnership-wide "think family" strategy; to secure a better shared understanding of roles and responsibilities to enhance effective joint working; to cascade key learning from this SCR to front-line staff by means of bespoke briefings.
| Title: Serious case review: Baby D. LSCB: Hull Safeguarding Children Board Author: Linda Richardson Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hull SCR/ Baby D/LR Final Report/ February 2018 Serious Case Review Baby D February 2018 2 Contents 1. Circumstances which led to a Serious Case Review 2. The approach used (including details of review team and practitioners group) 3. Scope and terms of reference (including review period and rationale) 4. Overview of what was known to agencies 5. Appraisal and analysis of practice The ways in which professionals in adult services understood parent’s vulnerabilities and the impact these could have on parenting abilities The effectiveness of multi-agency working The effectiveness of communication with the family 6. Concluding comments 7. Summary of Learning Points and Recommendations Appendix 1: Serious Case Reviews 3 1. Circumstances which led to this SCR 1.1. Baby D died in December 2014, aged 6 weeks. 1.2. Baby D had not been identified by health practitioners as being unwell prior to his death. There had been four contacts with the GP when Baby D was being treated for constipation and thrush to the throat but otherwise he appeared healthy and there were no recorded safeguarding concerns. The parents were in receipt of enhanced health visiting services and were in regular contact with a children’s centre and a care co-ordinator (CC1) from the Community Team, Learning Disability (CTLD). A community nurse (CN1) from CTLD also visited occasionally. There was no involvement at the time from children’s social care (CSC). 1.3. After his death, and in line with procedures, a paediatrician examined Baby D. Medical records indicate that he was appropriately dressed and seemingly well cared for. There were no indications of concern, no nappy rash, concerning marks or bruising. However, a skeletal X-ray revealed a recent fracture, and an old fracture, around the right knee. 1.4. The post-mortem showed that Baby D had a vitamin D deficiency and professionals accepted this at the time as an explanation for the fractures to the baby’s knee. The coroner determined the cause of Baby D’s death was sudden death in infancy in association to areas of non-compaction of the left ventricle.1 1.5. The Independent Chair of Hull Safeguarding Children Board (HSCB), supported by a sub-committee of the board, made the decision that, as there were no concerns or evidence of abuse or neglect, the criteria for a Serious Case Review (see Appendix 1) were not met. Although practitioners had previously expressed some concerns around dirty home conditions and had queried how MD, specifically, would cope as a parent, there was no evidence to suggest these factors contributed to the death of Baby D. There were, however, other factors present which are known to be associated with sudden death in infancy: the baby’s age, gender, the winter weather conditions and the baby’s sleeping position at the time of death. Following a discussion at the Child Death Overview Panel, it was agreed that a local “Lessons Learned Review” should be held in order to identify any areas of learning, which could be of benefit to future parents. 1.6. MD gave birth to a second child in 2015. Concerns about the care of that child resulted in family court proceedings. During this process, a pathologist revisited the previous report on Baby D’s injuries and cast doubt on the accepted explanation of how these occurred. The pathologist reported that the two fractures were more likely to be as a result of non-accidental injuries and were not related to any vitamin D deficiency, as had previously been stated. Although these injuries were not linked to Child D’s death they did indicate the possibility that Baby D had been physically hurt at some time during his short life, an unusual occurrence in such a young baby. 1 This is a condition which affects the development of the heart muscle whilst in the womb 4 1.7. On Tuesday 20th September 2016 the Independent Chair, following consideration of the available information and in response to a recommendation from the sub-committee, made the decision that the criteria for a serious case review were now met and that the HSCB would proceed with an SCR in line with statutory guidance. 2. The approach used 2.1. The Board appointed an independent lead reviewer experienced in undertaking serious case reviews, and who had no prior connections to any of the agencies involved in this review, to work alongside an officer of the LSCB and the Designated Nurse for Safeguarding Children (NHS Hull CCG) as joint reviewers. This combination of reviewers, with local knowledge and one without, served the review well and enabled a sensitive and efficient engagement with local agencies. 2.2. A review team was established and chaired by the independent lead reviewer. The review team gathered and analysed data, appraised practice and agreed the content of this report. Agencies represented on the review team were: Linda Richardson Independent Lead Reviewer Lorna Morris Reviewer, NHS Hull Clinical Commissioning Group Lee Smawfield Reviewer, HSCB Professional Practice Officer Neil Colthup Manager, HSCB Laura Bell Business Support Coordinator, HSCB Named Nurse for Safeguarding City Health Care Partnership Professional Practice Officer Adults Social Care, Hull City Council Group Manager Children’s Social Care, Hull City Council Community Housing Manager Neighbourhoods and Housing, Hull City Council Assistant City Manager, Early Help & Commissioning, Hull City Council Named Nurse for Safeguarding Humber NHS Foundation Trust Named Nurse for Safeguarding Hull and East Yorkshire Hospitals NHS Trust Named GP for Safeguarding NHS Hull CCG Written contributions were also received from Humberside Police and Yorkshire Ambulance Service. 2.3. A practitioner’s group was established which brought together frontline professionals who worked directly with the family. Individual conversations were held with seven key professionals in order to better understand their role in working with the parents as vulnerable adults. Individual conversations were also held with the Shared Lives scheme manager and Shared Lives carers. The openness and willingness of practitioners to reflect on their work with this family contributed to much of the learning, which has emerged from this review. 5 2.4. The practitioner’s group consisted of: Health visitor Midwife Children’s Centre practitioner Children’s Centre manager Community Team, Learning Disability social worker Community Team, Learning Disability care coordinator Group Manager, Children’s Social Care Community Nurse, Humber NHS Foundation Trust Children’s Social Care social worker based at the local hospital General Practitioner 2.5. The reviewers also met with the parents and maternal grandfather of Baby D and their views and helpful contributions are represented in this report. 2.6. At the start of the review, a time line of agency interventions was collated to illustrate multi-agency activity, who knew what and when. Agency leads were then asked to complete a first draft of an agency learning report, which described and analysed practice within their own agencies. These learning reports were presented to the review team for comment and challenge. Further data was provided through scrutiny of various assessments and agency records. 3. Scope and Terms of Reference 3.1. The review team agreed that the period under review would be from January 2014 when MD met FD just prior to moving out of the ‘Shared Lives Scheme’2, up until the death of Baby D in December 2014. 3.2. The review team chose not to set specific terms of reference from the outset but allowed key issues to emerge as the review unfolded. This approach allowed a wider exploration of events rather than a pre-determined focus on specific issues without understanding what happened, when and why. After the third panel meeting and with the benefit of agency learning reports and individual conversations with key practitioners, initial lines of enquiry were identified and this helped the review team build a framework with which to review practice and safeguarding systems. These were: The ways in which professionals in adult services understood MD’s vulnerabilities and the impact these could have on their parenting abilities The effectiveness of multi-agency working The effectiveness of communication with the family. 2 Shared Lives Scheme provides family-based accommodation or support for vulnerable people. The emphasis is on providing an ordinary family life, so that people can live or stay within the community. 6 4. Overview of what was known to agencies Background Information 4.1. Both MD and FD were known to statutory agencies at various times throughout their childhoods in response to concerns about parental care, and each had times in their lives when they were estranged from their families. 4.2. As a young adult, FD sought and accessed support from a number of professionals over the years, in respect of his depression and need to better manage his emotions. At times, FD was homeless but then acquired a tenancy in his own right a few weeks before his relationship with MD began. 4.3. As MD grew into her teens, there were professional concerns about her vulnerabilities. A Child and Adolescent Mental Health Service (CAMHS) assessment highlighted that she had significant developmental needs, which could possibly be helped through family work. However, both the family and MD declined offers of support and MD continued to live at home with her father, stepmother and siblings. As MD grew older, she frequently ran away from home and was often picked up by police when they found her sleeping rough, seemingly unaware of the dangers to which she could be exposed. There were continued concerns about her vulnerability and the possibility that she was being sexually exploited. Interventions by the Local Authority Safeguarding Adult (LASA) team when MD was 19 led to a referral in March 2012 to the Community Team, Learning Disability (CTLD)3 for support and assessment of a learning disability.4 4.4. MD continued to go missing at various times and relationships with her family broke down. Concerns about MD continued and a safeguarding strategy meeting was held in October 2012. At the meeting, recommendations were made which required the completion of MD’s assessment to determine the extent of her learning disability and also that MD should be allocated a social worker to provide professional support. As social worker 1 (SW1) was already involved with another family member and had met MD previously, she became the allocated social worker and led on the assessment of MD’s needs. 4.5. Later that month, SW1 began to consider options for an emergency placement for MD when her father and stepmother said she could no longer live with the family. MD very briefly moved in with her birth mother but this arrangement did not last and MD moved back to live with her father and stepmother. 4.6. A cognitive assessment of MD was completed by a clinical psychologist and a community nurse (CN1) from the CTLD team between November 2012 and March 2013 and this diagnosed MD with a ‘mild learning disability’ A recommendation for a referral to family therapy to address ‘systemic issues which were thought to be contributing to MD’s behaviours’ was not accepted by the family and consequently no family work was undertaken. 3 The community learning disability team (CTLD) is the first point of contact to both inpatient and community services. Individuals accessing the service have a learning disability diagnosis, are over 18 years of age or in transition from children’s services. 4 In this document a learning disability refers to the difficulties a person may have understanding new or complex information, learning new skills or coping independently. 7 4.7. The LASA team had previously assessed MD, as having ‘substantial’5 support needs making her eligible to receive services from local authority adults services. After needing an emergency placement following another family breakdown, MD was introduced to a Shared Lives placement 6 in March 2013 and moved in with carers in May of that year. By this time, SW1 was on long-term leave of absence and CC1 took over the case and was responsible for overseeing the support and placement package offered to MD. An occupational therapy assessment around daily living skills was completed whilst MD was living in this placement and concluded that, from observations, MD would continue to need support and assistance to live independently in the community. 4.8. MD stayed in the Shared Lives placement from May 2013 until January 2014. During this period a number of reviews took place each attended by MD, Shared Lives carers, the Shared Lives placement worker, and CC1. During these reviews MD indicated that she was happy and settled in the placement. She was noted to have a wide circle of friends with whom she had regular contact and often talked about wanting a ‘normal life’ and having a boyfriend and a baby. Support was offered to MD about sexual health and contraception. There were no concerns raised regarding her safety but Shared Lives carers did describe MD as requiring ‘constant prompting’ with basic daily living tasks such as preparing food and maintaining personal care. Period under review 4.9. In January 2014, MD left the Shared Lives scheme to move in with FD, who she had met several days earlier, effectively bringing to an end her involvement with local authority adults services. At the time very little was known about FD but it was understood that he had a tenancy of his own. The Shared Lives carers visited MD a few days later and were extremely concerned about the conditions of the home in which she and FD were living. There is no formal record of an end of placement review but the practitioners from adult services recorded that, in their view, MD was capable of making her own decisions and they therefore respected her wish to remain living with FD. The Shared Lives placement was kept open for approximately 4 weeks after she left but then her case was formally closed to adults social care. There was no review of this decision. 4.10. In early Spring 2014, MD became pregnant and there followed numerous calls made to the NHS 111 number, A&E and midwifery services by FD, both in connection with MD’s general health and in relation to her pregnancy. The nature of the calls indicated both parents knew very little about the physical aspects of pregnancy. In the early stages of MD’s pregnancy and following a discussion with the hospital social worker, a midwife made a referral to CSC requesting parental support for the couple. After 4 weeks, when there had been no response from CSC, the midwife rang the duty officer in CSC and was advised to refer the couple onto the children’s centre for support and practical help and that the children’s centre would make a referral to CSC should they consider it necessary. 5 This refers to the Fair Access to Care Services (FACS) eligibility criteria banding of substantial need. FACS contained four bands – low, moderate, substantial, and critical. 6 Shared Lives scheme offers an alternative to residential care for vulnerable adults. Care and Support is provided by trained and approved carers in various locations but usually in the carer’s own home. 8 4.11. Records indicate that MD was seen by 32 midwives at 24 antenatal appointments during her pregnancy even though she was noted to have a healthy and uncomplicated pregnancy. It became clear to midwifery services both before and after the birth, that this was a very vulnerable couple, both of whom were thought to have some learning difficulties and who were observed to have significantly high dependency needs. Contact with CC1 by midwives provided some information about MD’s background and as the pregnancy progressed, the concerns of the midwives as to how the parents would cope once the baby was born continued. 4.12. Although the case was formally closed to adults services, CN1 and CC1 from CTLD initiated some informal contact with the couple throughout the pregnancy and after the birth. Both MD and FD described CC1 to other professionals as their social worker, although this was not the case. 4.13. MD and FD were noted to engage well with the children’s centre sometimes making contact up to 5 times a week. The children’s centre practitioner (CCP1) offered practical advice about budgeting, parenting and house cleaning and the couple willingly accepted any support or advice offered. An enhanced health visiting service was introduced by the health visitor who was concerned about the state of the home and the number of animals living in the house. Professional concerns centred on the extent to which the couple fully understood the advice given to them, but the couple were thought to have prepared well for the birth of the baby. 4.14. Baby D was born in November 2014. Midwifery records refer to some concerns about how the couple would manage but there were no further referrals made by midwifery or any other professionals to children’s social care before or after the birth and Baby D and MD were discharged from hospital following confirmation from both parents they had support from family and from CC1. 4.15. CP1 visited the family to work with the parents on understanding first year of baby’s life and to assist them with securing grants. In early December 2014, Baby D, aged 26 days was seen with MD and FD at the children’s centre post-natal clinic by a community midwife. He appeared well and no concerns were identified so the baby was discharged from midwifery care. Records indicate that both midwives and the health visitor gave appropriate safer sleeping advice and both professionals could recall specific conversations they had with the parents about sleeping arrangements. The health visitor and the children’s centre practitioner last saw Baby D during separate planned appointments on 17th December 2014. There were no concerns identified about the care of Baby D and MD disclosed to both practitioners that she thought she might be pregnant again. 4.16. MD and FD took Baby D to 4 GP appointments following his birth where the parents sought advice about wheezing, crying, constipation and thrush. The GP provided medical treatment and gave advice to MD and FD about not smoking near Baby D and to keep the animals away. The last GP appointment was on 22nd December 2014 but no concerns about Baby D were noted. 9 4.17. Baby D died at the end of December 2014 aged 6 weeks. MD had contacted Yorkshire Ambulance Service via a 999 call and CPR instructions were given over the telephone to FD until the ambulance crew arrived. Baby D’s death was attributed to sudden death in infancy in association with non-compaction of the left ventricle. The pathologist identified Baby D’s risk factors for sudden death in infancy as including: male sex, winter months, age and prone sleeping. 5. Analysis of Practice 5.1. It important to recognise how much hindsight can distort judgment about the predictability of an adverse outcome. Once a tragic outcome becomes known, there can be a tendency to look back over the history of the case and pinpoint certain actions or moments which are believed to be critical in leading to that outcome. Hindsight-bias can also lead to a false reassurance that what happened was predictable and therefore could have been prevented. The review team was particularly mindful of the dangers of hindsight- bias especially given what became known about the parent’s more recent history. Every attempt was made to keep an open mind to understand why certain actions and decisions in relation to this family would have made sense to professionals at the time. 5.2. Whilst the view from the second pathologist was that Baby D’s fractures were more likely to have been caused from non–accidental injuries than as a result of any vitamin D deficiency, they were not deemed to be a contributory cause of his death. However, the possibility that Baby D may have been subject to physical harm during his short life required the review team to consider whether any learning could be drawn from the actions and decision-making of professionals involved with the family at the time. 5.3. The review team identified three areas of significant practice (ASPs), which provided a useful framework to review how well agencies worked together before and after the birth of Baby D. ASP 1: The ways in which professionals in adults services understood MD’s vulnerabilities and the impact these could have on their parenting abilities ASP 2: The effectiveness of multi-agency working ASP 3: The effectiveness of communication with the family 5.4. ASP 1: The ways in which professionals in adults services understood MD’s vulnerabilities and the impact these could have on their parenting abilities. Since 2010, statutory guidance7 has placed much greater emphasis on the responsibilities of adults services to ‘think family’. Whilst the importance of supporting vulnerable adults in their parenting roles is acknowledged, the welfare of the child remains paramount and must precede any consideration of parental rights. This in itself can create challenges for those working in adults services. 7 Working Together to Safeguard Children 2010, 2015 10 The review team wanted to understand how professionals working in adults services understood their safeguarding responsibilities as they relate to the children8 of their service users. The extent to which MD’s vulnerabilities were known 5.4.1 MD's vulnerabilities were well known to practitioners in adults services following three specific assessments which were undertaken when she was a young adult, one of which described her needs as ‘substantial’. The two reviews and one ‘outcome focussed’ review which took place whilst she was living in the Shared Lives placement indicated that, although she was settled in her placement and responded well to support, she continued to need daily prompting about basic living tasks and self-care. Practitioners from adults services were aware of MD’s background and although they had not seen the assessment reports, they told the review team that, even without a diagnosis of a ‘mild learning disability’, they believed that, very possibly because of her early childhood experiences, MD would always have needed support to live independently. 5.4.2 When MD decided to leave the Shared Lives placement in January 2014, concerns were expressed by professionals working with her as to how she would manage, even with the support of a new partner. The Mental Capacity Act 2005 (MCA) has formalised existing case law and added new requirements in respect of decision-making by people aged 16 years and over and states that a person must be presumed to be competent to make their own decisions unless it can be demonstrated otherwise. Professionals from adult services told the review team that, whilst there were some concerns both voiced and recorded about her decision to leave the placement, they did carefully consider her mental capacity and were left with no option but to respect her decision to move out of the Shared Lives placement. The Shared Lives carers stated that in their view, MS’s ‘substantial needs’ had not diminished in any way and she remained highly vulnerable. 5.4.3 The agency learning report for adults social care refers to two reviews, which took place after MD announced her decision to leave. One took place in January, where a decision was taken to keep the placement open until the end of the month, and a second review occurred in early February. This review led to the closure of the case by adults social care, although the case did remain open to the CTLD community nurse in the multi-agency CTLD team. None of the practitioners spoken to as part of this review, including the Shared Lives carers, can recall attending any meeting after MD had left the placement. The review team were not provided with any minutes or records of these reviews, and concluded that these were internal reviews rather than multi-agency ‘end of placement‘ meetings. 5.4.4 It is ‘expected’ practice that ‘end of placement’ reviews take place especially when placements end unexpectedly and MD’s placement agreement identified that such a review would happen when the placement ended. Such a meeting with MD and key practitioners would have needed to acknowledge the circumstances under which MD had left her placement and assessed her future support needs given what was known about her ‘substantial’ vulnerabilities. Good practice would also have ensured some consideration about the possibility that, given her new relationship, MD could well become pregnant at some future date. 8 This includes unborn children 11 The placement agreement had stipulated that while in Shared Lives, MD was to be encouraged to practice safer sex and to continue her contraceptive regime. MD had talked openly to the Shared Lives carers and other professionals about wanting a boyfriend and a baby. The Shared Lives carers told the review team that, had their views been sought, they would have expressed significant concerns about how MD would look after a baby without additional support given that she needed so much daily prompting to care for herself. 5.4.5 The review team were informed that at the time it was not common practice for professionals in adult services to ‘think family’ and practitioners reminded the review team that MD was not pregnant when she left the Shared Lives placement nor when the case was closed to adults social care several weeks later. They also queried the ethical aspect of sharing information without consent if they were no longer formally involved with the family. Learning Point 1: At key transition points in the lives of vulnerable adults, their future needs should be considered alongside a review of the existing service provision 5.4.6 The practitioners from CTLD learnt from Midwife 1 that MD was pregnant, about one month after the case had been closed to adults services. MD had told the midwife that CC1 was her social worker and Midwife 1 appropriately made contact to establish what sort of support was being offered. She was advised however that MD’s case was no longer open to them as she had left her placement earlier that year. It is unclear from midwifery records what information was shared at this stage about MD’s vulnerabilities and her experiences when living in the Shared Lives placement. What does become clear at this point is that MD thought of and described CC1 as her social worker. It appears that Midwife 1 understood that the case was no longer open and assumed this was in response to there being no identified concerns. 5.4.7 This was a missed opportunity to share some important information. However, it emerged from the review process that different professional groups may not share the right information because they work to different criteria for information-sharing, use a different language and lack sufficient understanding of each other’s roles. This means they may not understand what information is important for other agencies to have and so do not ask the right questions or pass the information on. Both CC1 and midwifery acknowledged they knew very little about each other’s roles and this seems to have impacted on their understanding about what they needed to know and what they were able to share. 5.4.8 Both CC1 and CN1 had available to them considerable information about MD in terms of her childhood, her past experiences and her background; CN1 in particular, was in receipt of the specialist assessments relating to MD which described in detail her vulnerabilities and the difficulties she encountered in undertaking daily tasks and retaining even simple information. Sharing information at this stage would have assisted the midwife’s understanding of the extent of MD’s vulnerabilities and could well have supplemented the referral to CSC, which she had made the previous day. However neither professional suggested a meeting to discuss concerns, CC1 because she did not see this as her role and was no longer involved with the family and Midwife 1 because she had been informed by CC1 that the case had been closed and there were ‘no issues’. 12 5.4.9 Following the conversation with Midwife 1, both CN1 and CC1 began to visit MD on an informal basis, describing how they would ‘pop in’ to see how she was doing. Both practitioners acknowledged they had no formal remit for these visits but describe being concerned about MD because of her vulnerabilities and all that had happened in her life. Due to the nature of these ‘pop ins’, the visits and contacts were not recorded by either practitioner so the review team was unable to analyse or assess what they were doing and with what frequency. MD and FD continued to view CC1 as their social worker because she ‘visited and helped us out’. CC1 told the review team she was unaware that she was regarded as a social worker not only by the family but also by other professionals with whom she had contact. Learning Point 2: The importance of ‘professional curiosity’ does not only sit in relation to work with families it also applies to conversations between professionals to ensure that roles and remits are well understood. 5.4.10 The review team was concerned to note that a lack of managerial oversight allowed two professionals to visit a family seemingly without any remit or accountability. The review team was not provided with any records of these visits and yet CC1 liaised with other professionals and offered a view as to how well the couple were managing - feedback which other professionals accepted as being from a professional they assumed had been allocated to work with the family. The commitment of these professionals to ensure MD’s well-being is commended but without a clear purpose or plan for the visits and without any multi-agency collaboration, it is difficult to know or measure what they achieved other than a reassurance for the professionals themselves that MD was ‘OK’. 5.4.11 In discussions with professionals and managers in the review team, it became evident that the practitioners in adults services saw their primary function as supporting MD’s independence as a vulnerable adult and believed any responsibility for considering or protecting the needs of an unborn child lay with childcare workers and health professionals and not themselves as practitioners working in adults services. Comments such as ‘we do not do parenting assessments’ and are ‘only there for the adult’ highlight the need for improved levels of understanding about roles and responsibilities in adults services in relation to the safeguarding of children and unborn babies. 5.4.12 The responsibility for safeguarding children does not only lie with children’s services, it is a requirement of safeguarding children policy that adult services know whether their service users have children or become pregnant. Section 11 of the Children Act 2004 clearly places duties on a range of organisations and individuals including those who work in adult services, to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children. Where a vulnerable woman in receipt of services from adults social care is known to be pregnant, adult service’s assessment should include assessing the potential impact of those vulnerabilities on any children in the family or any child about to be born. 5.4.13 The difficulty in this situation is that the two workers from CTLD were visiting MD on an ‘informal’ basis and described their involvement only as ‘keeping an eye on things’. As the case had been formally closed to adult services, there were no means or mechanisms to update any assessment when MD became pregnant. 13 Neither CN1 nor CC1 considered themselves as ‘working’ with MD or saw the need to share what they knew about MD’s vulnerabilities with any of the professionals working with MD and FD during the pregnancy and after the birth. The review team understood that this was because sharing or offering information about MD and her background was not considered part of their professional remit but also the review team was told that information about MD was ‘never asked for’ and had it been needed, it was presumed that social workers would have asked for it. Learning Point 3: Where a learning disabled woman becomes pregnant (or has other children) it is essential that professionals who are in contact with her consider to what extent her disabilities or vulnerabilities could impact on her ability to care for her children and they should liaise with children’s services accordingly. 5.4.14 According to the agency learning report, both CN1 and CC1 did have some concerns about MD’s ability to parent a child and these were discussed with their respective managers. The report refers to these concerns being also discussed with ‘the local child protection team’ who advised ‘there was no role for [CSC] in work with this family’. The review team could find no record of this conversation in any agency records so it remains unclear what information, if any, was shared, when, by whom and with whom. 5.4.15 When SW1 returned to work and learnt that MD was pregnant, she shared her concerns with her senior, with CC1 and with CC1’s senior. She expressed a high level of concern about how MD would be able to care for a baby, based on what she knew about the difficulty MD had in taking care of herself. Her concerns did not however lead to a referral to CSC and SW1 did not pursue the matter. The agency learning report states that the practitioners believed that if a referral had been necessary, their seniors would have acted accordingly. With the benefit of hindsight, SW1 stated that in future, under similar circumstances, she would refer her concerns directly to CSC. 5.4.16 From conversations and information contained in the agency learning report, it was suggested that concerns not being referred to CSC was possibly linked to a lack of understanding by those in adult services about children’s social care systems. The report also suggests that there may exist within CTLD and wider adult services a belief that parents with learning disability are treated unfairly by children’s social care and that their children are less likely to remain in their care than the children of non-disabled parents. This led the review team to explore with practitioners and managers whether a ‘professional bias’ may have influenced their thinking about ‘reporting ’ their concerns’ about MD’s parenting capacity to CSC or indeed expressing these to other professionals. 5.4.17 CN1 had considerable knowledge about MD and the input from this practitioner would have significantly strengthened any referral to CSC. CN1 was however very clear that it was not within his remit to comment on or assess parental capacity and believed professional judgements about parental abilities and risk to children were best left to those professionals who worked directly with children and families. The review team was equally clear that decisions about parenting abilities must be made by those skilled and experienced in parenting assessments but was also of the view that professionals working in adult services are well equipped to contribute to those assessments and advise on how a person’s learning disability or mental health could impact on their ability and capacity to care for, nurture and protect a child. 14 5.4.18 There were references in panel and practitioner discussions to the view, held by some, that there was never any evidence that Baby D was at risk of anything other than ‘poor parenting’. Such views highlight the importance of practitioners in all services understanding what ‘poor or inadequate’ parenting looks like so they are better able to recognise when a lack of ‘good enough’ care is, or could be, impacting on the safety or well-being of a child. Learning Point 4: This review has highlighted that some practitioners in adult services require a deeper understanding about the roles and responsibilities of colleagues in other agencies but also need to better understand their own safeguarding responsibilities to work collaboratively with other agencies to safeguard and protect children and vulnerable adults. The comments of practitioners suggest that some practitioners in adult services may be reluctant to communicate and share information with other professionals because they view the well-being of the adult as being their primary concern. 5.4.19 CN1 and CC1 described that, although they were ‘aware’ of each other’s involvement with MD and FD, they did not collaborate and knew very little about the contact each had with MD and they did not receive ‘supervision’ as such in relation to their contacts with MD. The review team was informed that, during the period under review, there was little management oversight or supervision of practitioners in CTLD due to a vacant post and long- term sickness. The team was co-located with local authority adults social care staff, however at the time there was a fragmented approach in managing cases within the team, with little discussion or information sharing. This was compounded by inconsistent management and supervisory arrangements. Practitioners acknowledged that parenting and safeguarding children was at the time rarely considered in team meetings or supervision sessions unless there was a high profile case involving several agencies. They acknowledged there were gaps in their knowledge about how children’s services functioned but the review team agreed that this was also evident in health agencies and children’s services in terms of their understanding about the roles and responsibilities of colleagues in adult services. 5.4.20 Safeguarding children training and improved supervisory arrangements will go some way to supporting decision-making and practitioners being better equipped to navigate the safeguarding children system. However, the views expressed by professionals in adult services in relation to the assessments of parents with learning disabilities is concerning and especially so if they influence their decisions about whether or not to liaise with colleagues in children’s services. Learning Point 5: There would be benefit in HSCB seeking clarification from partners in adult services whether these views are held by a minority of practitioners and managers or are representative of a service-wide issue, which requires immediate attention. Learning Point 6: It would be helpful if HSCB sought assurance from senior managers that there are effective systems in place which encourage practitioners in adult services to ‘Think Family’ and which also support managers to monitor those cases which involve dependent children. Where both LA adults' and children's social care are providing services to a family, practitioners need to be better supported to share information in a timely way, undertake joint assessments and agree interventions. 15 5.4.21 Situation now: All practitioners within CTLD are now employed and managed by Humber NHS Foundation Trust and have been since 2016. Safeguarding children supervision is available on a 1:1 basis every three months as a minimum for all staff, facilitated by a supervisor who has completed safeguarding children supervision training. All relevant cases are reviewed at this time. Professionals from the same professional group or from different professional groups may also meet to discuss child protection cases. This provides clinicians the opportunity to bring their own cases for discussion and allows safeguarding practitioners to disseminate learning and facilitate case discussions. Any member of staff, irrespective of their role can access safeguarding children supervision should the need arise, by contacting the Safeguarding Team. 5.4.22 During the board’s section 11 audit and challenge process in 2016, adults social care services completed a self-assessment to review their policy, practice, and procedures in relation to safeguarding children. The audit identified an urgent need for staff training and this was accompanied by a commitment from senior managers to ensure and support the attendance of their workforce to training programmes delivered by HSCB. The review team was told that due to staff shortages, competing priorities and other changes taking place across adults social care, managers faced challenges in releasing staff, and, as a result, only a small number had attended. 5.4.23 HSCB should require partners from adults social care to advise the board on what safeguarding children training has been accessed and by whom and what proposals senior managers have in place for meeting future training needs. Learning Point 7: It seems clear that professionals should work together for the benefit of the child and there are policy imperatives to ensure that agencies work together to provide better services. However, doing so raises a number of challenges. One challenge lies in finding effective ways to manage different professional perspectives and cultures and to promote better ‘joined up’ working between adult and children’s services. If practitioners in adult services have access to high quality training, good supervision, which fosters a culture of respect for staff in different disciplines, and access to multi- disciplinary discussions, they are more likely to consider the safety and development needs of children/unborn babies in their work with vulnerable parents. 5.5. ASP 2: The effectiveness of multi-agency working Safeguarding children is everyone’s business and therefore every agency and person who comes into contact with a child or a prospective parent has a responsibility and a role to play to safeguard children in that family. The need for effective multi-agency working and information sharing in order to secure improved safeguarding outcomes for children is clearly stated in a number of reviews, policies, and statutory guidance. As well as focusing on the actions of the individuals who were directly involved with the family, the review team tried to understand and distinguish the influence of a range of organisational factors in the decisions and actions taken. Whilst the focus on organisational systems does not diminish the responsibility of individuals to act professionally and to work effectively, it does help to explain the organisational factors that sometimes make it harder for them to do so. 16 5.5.1 There was no single or multi-agency assessment informing any of the support services offered and yet the support offered to the family went far beyond that of any universal offer with practitioners describing that they were ‘going above and beyond’ their remits to provide the level of support that they felt the family needed. Although there were good examples of communication between professionals, there were a lot of assumptions made, based on misunderstandings of each other’s roles, remits and what information each agency might have access to, with little evidence of professionals actively seeking out information or sharing information which would have contributed to multi-agency assessment and planning for the family. Referral Pathway 5.5.2 Following MD and FD’s first antenatal appointment in April 2014, Midwife 1 consulted with the children’s social care hospital social worker when the couple told her that MD’s social worker was CC1. Midwives told the review team that it was standard practice to consult with the hospital social worker when they were considering making referrals to children’s social care; the hospital social worker had access to the Care First9 system and, in response to queries about referrals, was quickly able to check the system to determine if there was any ongoing social work involvement with a family. 5.5.3 Midwife 1 was advised that MD was known to CTLD but she should submit a referral to the CSC Access and Assessment Team, stating that MD was pregnant and needed ‘parenting support’. Midwifery records indicate the referral was submitted as advised and although it did not clearly state specific concerns, it did identify that MD was pregnant and she and FD would need support during the coming months and after the birth of their baby. The process for midwives making referrals at that time required a hard copy to be posted to the Access and Assessment Team, a copy sent to the safeguarding midwifery team and a copy sent to the hospital social worker ‘for information only’. 5.5.4 There is however no record that this referral was ever received by CSC and consequently information about Baby D was never ‘opened’ on CSC‘s system either as an open case or as an ‘information share’. Midwifery did not immediately follow up their referral when, not unusually, they did not receive an acknowledgement by CSC. Having submitted the referral, the midwifery team assumed it had been received and actioned, they were reassured as they had spoken with the hospital social worker and believed they had in effect ‘reported that the couple clearly needed support’. The review team was told there was an assumption that the hospital social worker liaised regularly with the Access and Assessment Team. 5.5.5 There was, however, no system in place which required the hospital social worker to follow up the referral she had discussed with Midwife 1 and, as consultations with the hospital social worker were not recorded on Care First, the information shared and included in the submitted referral was lost. Whilst the hospital social worker provided reassurance and guidance to midwives, previous SCRs have identified that this role did lead to some confusion and too easily compromised the referral pathways for midwives. 9 Care First is an integrated computerised business system which supports social work practitioners and managers in undertaking the key tasks of assessment, planning, intervention and review 17 Since February 2017, system changes have meant that the hospital social worker expertise has been taken back into children’s social care and the post is no longer based within the hospital. Mandatory training has been completed within midwifery in order to increase the confidence of midwives in identifying and articulating concerns about unborn children and improvements have been made in midwives contacting CSC directly with any concerns. 5.5.6 Four weeks after the submission of the referral, Midwife 1 again contacted CSC to ask about ongoing support for MD. The advice given by the duty officer was that the family no longer had support from CTLD and a referral should be made to the children’s centre for practical support. It is important to note that this information would have been accessed from records pertaining to MD as no record had been opened in relation to unborn Baby D. 5.5.7 Without a clear understanding of how information is recorded and accessed on the ICT system, the information from the duty officer was interpreted by the midwife as ‘the case had been open but was now closed because there were no concerns.’ The midwife queried why there had been no response to the referral made in April and the duty officer agreed to look into this and get back in touch. Midwife 1 later contacted CSC and the hospital social worker to ask for an update but received no reply and the matter was never escalated. Professional assumptions 5.5.8 It appears that having been given this information by the duty officer, there was an assumption in midwifery that CSC had undertaken some sort of assessment and concluded that no further action was necessary. There were no further referrals into CSC by midwifery staff. MD accessed maternity care from an early point in her pregnancy, receiving an early pregnancy scan at 8 weeks. She had 24 antenatal contacts including the nine antenatal appointments scheduled for uncomplicated pregnancies (NICE 2008). Thirty-two different midwives were involved at various times in MD’s care throughout her pregnancy and during the first four weeks of Baby D’s life. The contacts were in considerable excess of what might be deemed ‘usual’ contact with maternity services and clearly indicated a high level of parental anxiety, which warranted further exploration. At the time there was however no system in place to flag up this unusual pattern of contact by a family. 5.5.9 The midwives contributing to this review explained that they had a high level of concern in relation to the ability of the parents to cope with a new baby and were ‘telling anyone and everyone’ about their concerns but ‘no one was listening’. Despite these frustrations there were no further referrals to CSC and no contact was made with the Safeguarding Midwife for support and guidance. Midwives were reassured that support was being provided to the family by CC1, who was repeatedly described by MD & FD as their social worker. This information was not however verified and led to an assumption that information was being passed back to CSC to help with the task of putting the ‘safeguarding jigsaw together’. Learning Point 8: Assumptions can sabotage effective communication and have the potential to lead people down unintended paths. The finding from this review highlights the importance of professionals communicating with each other to verify information given to them by family members rather than making assumptions about the role and remit of other colleagues in contact with the family. 18 5.5.10 During their involvement with MD and FD, it became evident that both parents, but especially MD, had some form of learning difficulty and this led to heightened concerns from midwives about how the couple would cope with their baby and what support services would be available. There was no explanation as to why the advice of the Learning Disability Liaison Nurse was not sought. This is a post which has been established in the trust since 2011, but the review team was told that, at the time, the service was rarely accessed by midwives and there was very little guidance available to them about working with learning disabled parents. In March 2016, the maternity services launched a vulnerability toolkit for midwives, which includes guidance on how best to support pregnant women with learning disabilities. 5.5.11 Midwifery records refer to a ‘slip’ being forwarded to the children’s centre sometime in May 2014 and the community tracker10 was updated to advise that consent should be sought when the couple attended their next antenatal appointment. However, the children’s centre records show it was not until late September 2014 that they received a referral from midwife 11, making a request for support for the family to improve housing conditions ready for the birth of the child, including obtaining cooking and refrigeration equipment, carpeting; and for help with general household cleanliness including issues with the presence of a number of animals within the home. The delay was partially explained by midwives not always having time to read up on records at clinic and the fact that the family moved to a different area. It did mean however that there was no co-ordinated multi- agency community support offered to the parents during the important second trimester. Assessments 5.5.12 There is no foundation for assuming that parents with learning disabilities will inevitably neglect or abuse their children. Most available research suggests that the majority of learning-disabled parents can provide adequate care, and that, with sufficient support, parental learning disability does not affect child outcomes. However, the presence of learning disability is a risk factor, especially when it is associated with difficulties such as a shortage of money, chronic housing problems, and fraught relationships. Some parents, like MD and FD, will have difficult experiences of being parented themselves thus limiting their opportunities to learn how to be a parent. In such circumstances, assessments are the means by which risks can be identified, support needs recognised, and future planning secured. 5.5.13 Despite the involvement of many professionals during MD’s pregnancy and after the birth of Baby D, there were no formal assessments undertaken to determine the nature and extent of the family’s support needs, although the fact they needed support was clearly evident from the number of professionals involved and the frequency of their contact with the couple. 5.5.14 The importance of timely assessments is highlighted in a wealth of literature and emerges as a key feature in many serious case reviews. Key research findings relating to the assessment of parents’ capacity to meet the needs of their children include the importance of assessing the extent to which parents understand the basic requirements of parenting and of considering parents’ ability to learn and change their behaviours. 10 A business system in midwifery, which allows the tracking of information so practitioners can be alerted when actions are required or overdue. 19 There was evidence in this review that professionals over- estimated the abilities of both MD and FD to understand professional concerns and to make and sustain the necessary changes. 5.5.15 There were many different individual practitioners and services having high levels of contact with, and providing higher than normal levels of help and support to the family during MD’s pregnancy and after the birth of Baby D. It was apparent to the review team, and to the practitioners involved, once all of the single agency information had been gathered together and compiled for this review, that a single, or multi-agency, assessment of the family’s support needs, and of their strengths and difficulties, would have been helpful in this case. While all practitioners working with a child, young person and family are responsible for contributing to the multi-agency assessment and plan, when a child/young person needs a package of support, experience shows that they and their families benefit from having one person who can help them through the system, ensure that they get the right service at the right time and that agencies/ organisations communicate effectively with each other. This person is known as the lead practitioner and will normally be the person responsible for undertaking an assessment. Had a lead practitioner been identified, the ensuing assessment would have helped to ensure that information was shared and needs identified and this might have led to a coordinated support plan for the family. 5.5.16 A good multi-agency plan would have clearly set out goals, including assessing the motivation and abilities of MD and FD to make and sustain changes which demonstrated their capacity to consistently meet Baby D’s needs. No such assessment was however undertaken and the review team was keen to explore this issue further. 5.5.17 Where an unborn baby is considered to be at risk of harm or likely to be in need of services from children's social care when born, partners from any agency are required to make an immediate, timely referral to CSC or make contact with that agency to discuss whether such a referral would be appropriate. Midwifery clearly believed they had made this contact but neither they, nor any other professional, considered that the threshold for harm was met. Whilst the decision to undertake a pre-birth assessment lies with CSC, it remains within the scope of any partner agency to request that such an assessment is undertaken but the need for this was not considered as it was ‘understood’ that CSC were aware of the situation and had no concerns. 5.5.18 SW1 did think a pre-birth assessment might have been useful but this was not communicated to anyone outside of the CTLD team. When a parent is unable to adequately care for and meet their own basic needs they are likely to be challenged in their abilities to adequately care for and meet the needs of another, especially one that is very young and highly dependent. There is however no evidence that the need for an assessment of MD and FDs parenting capability was ever considered or discussed by any of the professionals working with the family and this was explained by professionals as, despite concerns about the couple’s need for a high level of support, they engaged with services, continually sought advice and each agency assumed that CSC were ‘somewhere there in the background’ and would have instigated an assessment had one been necessary. 20 5.5.19 Children’s centres lie at the ‘hub’ of a continuum of support where emerging difficulties can often be first spotted and where families turn to for extra help. They are often the most appropriate settings within which the extra help to families can be sourced and delivered. Children’s centre practitioners told the review team that the role of CC practitioners has, by design, changed – the role is expected to do more in-depth supportive work with families who in the past may well have been allocated a social worker. 5.5.20 Both parents willingly engaged with the children’s centre. There was however no well- developed early help framework in place at the time, within which to assess the needs of families referred to them. This meant that the children’s centre practitioner (CCP1) responded to the needs of the family, as identified in the midwife’s referral and as they observed them. Help and support to the family continued on a very practical level. When discussing the application of thresholds of need with regard to this family, CCP1 stated that, with the information they held, and from their observations of the parents, they did not consider at any point, either during the pregnancy or in the post-natal period, that the threshold for referral to children’s social care was met. This judgement was not based upon a formal assessment but on their understanding of thresholds of need and their observations and interactions with the family. The review team agreed with this judgement. 5.5.21 What did emerge however was recognition that the parents were overly anxious about the pending birth and they needed considerable help and support, including with budgeting and household chores. They had to be frequently ‘prompted’ by practitioners about the importance of certain tasks being undertaken on a regular if not a daily basis and they would often contact the children’s centre practitioner, sometimes up to 5 times per week, to seek advice or ask for assistance. 5.5.22 Practitioners acknowledged that the circumstances of the family as they were presented to individual agencies did not trigger any child protection concerns. However, when taken in the context of historical assessments and/or observations of MD and FD’s functioning, professionals agreed that an early help assessment of MD and FD’s parenting capabilities and capacities may have improved multi-agency understanding of what agencies needed to put in place in order to support parents with the care of Baby D when born. It may also have alerted each professional to the nature and extent of the support the family were receiving from individual practitioners, including those from adult services. 5.5.23 Practitioners have described that if they had been in receipt of all known information about the parents it would have made a ‘fundamental difference’ in the way in which they would have approached their work with the family. However at no point did any agency consider the need for an early help assessment. This could have been completed by any of the practitioners involved with MD and FD and would have pulled together the information that was known to agencies about the strengths and difficulties within the family. It certainly would have supported a more co-ordinated and multi-agency approach to work with the family. Despite the concerns of health professionals and children’s centre workers about how MD and FD would cope as parents, there was no one professional who coordinated work with the family, although professionals continued to assume that the CTLD worker was, as MD repeatedly stated, the social worker involved with the family. 21 5.5.24 This unchecked assumption allowed work with the family to remain uncoordinated, which meant that professionals worked alone to support the family rather than as part of a multi-agency plan. The integrated chronology highlights one day where the family received two home visits, one by the health visitor, and one by the children’s centre practitioner. They also attended a midwifery appointment at the local children’s centre and a GP appointment at the local health centre. The following day, CC1 took the family to a drop in appointment to look at housing needs. Each individual agency was unaware that the other had contact with the family within such a short period. Whilst these visits may have been welcomed by the family, more might have been achieved had professionals collaborated and communicated more effectively. 5.5.25 There is general agreement in literature that IQ is not necessarily predictive of parental competency except when perhaps it falls below 55-60.11 Above this level, the evidence suggests that decisions about whether a person is an effective parent ‘will need to rest upon a case by case judgment of abilities relevant to the rearing of children rather than IQ level alone’. Given that information was not shared about MD’s early assessments, professionals with whom MD came into contact during her pregnancy and after the birth of Baby D were therefore basing their concerns purely on their observations and the extent to which both parents were able to act on advice and maintain improvements in the home. 5.5.26 Key research findings relating to the assessment of parents’ capacity to meet the needs of their children include the importance of understanding the basic requirements of parenting and of considering parents’ ability to change. 12 On occasions, professionals have over- estimated the ability of some parents to understand professional concerns and make the necessary changes. In such cases, psychological assessment can be valuable to assess parental capacity, including sometimes their IQ but it has also been suggested that one way of assessing capacity to change is by giving parents ‘managed’ opportunities to change. In these cases, it is important to be clear what needs to change, how change will be assessed or measured, and over what time scale, how parents are to be supported, and the consequences if no or insufficient changes are made. Had a parenting capability assessment been undertaken, it would have helpfully drawn on the knowledge and expertise from adult services in relation to MD’s learning disability and might have elicited information about how practitioners could best communicate with both parents. 11 ‘Local Authority duties to parents with learning disabilities: G, Taylor Barrister November 2016; University of Bristol, Parenting Assessments for Parents with Learning Disabilities (2013), 12 Rachel Jones, (2009) "The therapeutic relationship in psychological therapy for individuals with learning disabilities: a review of existing literature", Advances in Mental Health and Learning Disabilities 22 5.5.27 The review team found that FD’s learning difficulties, which he self-reported during conversations with the reviewers, were not understood or fully explored, despite the fact that he was constantly present for the ante natal and medical appointments and took a caring role for Baby D after his birth. Unlike many other males who feature in SCRs, FD was described as a supportive partner and an interested father. In the absence of a formal assessment of either MD or FD’s parenting capability, it is unclear whether FD had any support needs of his own in coping with the demands of the role that he had adopted. 5.5.28 There is a wealth of research which acknowledges that fathers, or father figures, can play a key role in ensuring children’s development needs are met in families where the mother has a learning disability. Professionals observed and described that FD was ‘a hands on dad’ and the main carer for Baby D when born, feeding, and changing, etc., completing most domestic tasks and taking on a carer role for MD. FD was present during all planned sessions and was actively engaged and welcoming of agency support. Practitioners have reflected that FD had appeared to adopt a carer role within their relationship and that MD responded positively to this. 5.5.29 Situation now: Learning from local inspections and reviews has since led to the development of a pre-birth vulnerability pathway, which was established in March 2016. Since implementation of the pathway, the pre-birth vulnerability-screening tool has supported midwives in the assessment and care of vulnerable women who are pregnant. Practitioners reflected that if MD had presented to maternity services today then she would have been assessed as vulnerable and referred internally into the vulnerability midwife led ‘Haven clinic’. There would also have been liaison with the learning disability nurse within the hospital for advice and support and a referral, based on clearly identified vulnerabilities, would have been made to children’s social care. Learning Point 9: Whilst multi-agency guidelines now provide a clear framework for greater collaboration between agencies in meeting the needs of parents and unborn babies, HSCB should consider to what extent it can be confident that the agreed pathways are effective in identifying and responding to the needs of vulnerable parents. Joint Working 5.5.30 By its very nature, joint working brings together professionals with different roles and responsibilities as well as divergent professional cultures and these differences can act as barriers to effective joint working. Understanding the roles and responsibilities of colleagues from different disciplines and respecting their expertise is critical to the success of joint working. Professionals in both children’s services and adult services said they knew very little about each other’s roles and remits. For example, CC1 was perceived to be the ‘lead practitioner’ by other professionals working with the family who repeatedly described her as their ‘social worker’. 5.5.31 Practitioners also reflected that as CC1 was perceived to be a specialist CTLD social worker, an assumption was made that any impact of MD’s learning disability on her parenting capability would have been assessed and considered. CC1 was however very clear throughout this review that she saw her role as providing ‘support’ to MD notwithstanding the fact that the case was closed to adult services. 23 Whilst the extent, status and purpose of that support was never clarified it did lead to a false sense of confidence in practitioners that one agency had a good understanding of the strengths and support needs of MD and FD and an understanding of how these would in turn impact on their parenting capability. 5.5.32 This way of working leads to what can be described as ‘silo practice’. The triennial review highlights that ‘silo’ working does not necessarily mean that professionals are working in isolation. ‘It can equally arise in the midst of multi-agency working’ where professionals viewed aspects of [an individual] or family’s need and level of risk, solely from the perspective of their own discipline.’ 5.5.33 The importance of an integrated professional group being accountable for safeguarding children rather than confining the responsibility to children’s social care was stressed in Eileen Munro’s13 first two reports on the child protection system (2010, 2011). A collaborative approach is meant to ensure that not only are parents recognised as having needs in their own right, but also the impact of those needs on their children should be part of a multi-agency response with key professionals sharing information and deciding how best the family could be supported. 5.5.34 It was only after contributing to this review that the GP became aware of the involvement of other agencies. The GP had minimal contact with the family prior to or after the birth of Baby D and at no point were any safeguarding concerns noted. Medical records referred to FD’s depression for which he was offered counselling but records do not indicate whether he attended any sessions. The review team learnt that only if there was a presenting issue or specific contact would a GP review a patient file, but it was acknowledged that MD’s learning disability should have been included on the disability register held at the practice and this may have prompted the GP to ensure the couple were receiving support. 5.5.35 The ‘disconnect’ highlighted in this review, between services for children and adults is not only a local issue. The legislative framework for adult social care places its emphasis on supporting parents with disabilities and parenting roles have not been treated as a central issue within the adult social care policy framework. While these frameworks have emphasised the need for inter-agency cooperation, it is only relatively recently that there has been recognition of the need for children's and adults' services to work together’.14 Learning Point 10: Although It is acknowledged that MD’s learning disability was ‘mild’ and the environment in which she grew up impacted on her ability to care for herself, this review has highlighted the need for practitioners in both specialist and non-specialist services to better understand how they can work together to assess the potential impact of learning disability on parenting capability and capacity to change and the concept of “parenting with support”. 13 The Munro Review of Child Protection: Part 1: A Systems Analysis, 2010; Part 2:The Child’s Journey 2011 14 SCIE Knowledge review 11: Supporting disabled parents and parents with additional support needs By Jenny Morris and Michele Wates Published: November 2006 24 Learning Point: 11: The contribution of practitioners working in specialist adult services to multi-agency assessments and plans for children and families is essential to helping with this understanding and more work is required in Hull to support quality and effective collaboration between adult and children’s services. 5.5.36 The learning, nationally and locally, that timely and purposeful multi-agency meetings support good planning and, with regular review, can improve how services are provided in order to improve outcomes for children and families, is not new. In this review, practitioners acknowledged a belief that ‘another’ was taking the lead or making decisions and agreed that without recourse to any multi-agency meetings, work with the family was fragmented with little to evidence any change in the parents’ functioning. There were three specific missed opportunities when multi-agency meetings could have contributed to a more coordinated approach: When MD first left the shared lives placement to live with FD; When MD’s pregnancy was first confirmed When Baby D was due to be discharged home from hospital. 5.5.37 Whilst practitioners acknowledged the value of working more collaboratively with partner agencies, they also described what they saw as some very real barriers in organising and attending multi-agency meetings, including: A lack of confidence that they are the ‘right’ person to pull a meeting together A lack of confidence that other agencies will attend the meeting especially if they are not called by CSC A view that multi-agency working takes up too much time and is not always seen as a priority. 5.5.38 There is a plethora of research, which confirms that coordinated and well-timed early intervention with families leads to better outcomes for children. The importance of agencies working in partnership lies at the heart of recent changes in early intervention services in Hull. However, whilst there has been considerable progress made in relation to inter-agency working, further work is clearly needed by all agencies to support worker confidence and capacity to take on the lead practitioner role and to coordinate and support multi-agency working, particularly where children’s social care are not the lead agency. 5.5.39 The challenges for all public services, in terms of diminishing resources and workforce pressures, are also well documented. The triennial report of SCRs reflects concerns of competing demands in a number of reviews and describes the reality of ‘a steady increase in child protection activity year on year since 2009’. This increase is matched by an equal increase in child in need activity, and extends back now over several years. All this has occurred during a time when many services have remained static or been cut, thus leading to increased workloads for individual practitioners. 25 5.5.40 These demands are not without impact on professionals but, even in such a challenging climate, multi-agency working continues to offer scope for better joined up services to enhance and improve outcomes for children. Working together avoids duplication of processes across agencies, allows a practitioner to have access to peer support which in turn better supports step-up and step-down processes and thus contributes to more effective allocation of resources. The scope of activities that are needed to work effectively with some families means it is almost impossible for any one agency to deliver those services. For partnership working to be effective however, strong leadership and commitment is required to promote multi-agency collaboration and ensure ‘think family’ practice is accepted, promoted and supported across the continuum of need as not only a cross- partnership responsibility but also a more effective and efficient way of working to support families. Management Supervision 5.5.41 The importance of effective supervision is frequently highlighted in serious case reviews. When functioning well it is seen as a positive and empowering system by practitioners and managers alike; it facilitates reflective practice and continuous improvement, along with a more proactive approach to case management. 5.5.42 The children’s centre practitioner described having easy access to both informal support and formal supervision processes from the children’s centre during the period under review but suggested that, compared to other families with whom they were working, they were far less concerned about how the couple were managing and saw no need to discuss the family or the impending birth with their manager. 5.5.43 Midwives are encouraged to have regular safeguarding supervision regarding their caseloads, but they also did not see a need to discuss this family with their manager or with the Safeguarding Midwife. Had concerns about this family been discussed in supervision, it may have provided an opportunity to review the case, which in turn may have led to a new referral to CSC. In 2014, implementation of safeguarding supervision within midwifery service was however in its early stages. It is now well embedded into current practice. 5.5.44 Within health visiting services, Baby D’s case was being managed at a Universal Partnership plus level. CHCP have a staff supervision policy, which described the importance of supervision for all staff working with families who are in need of family support, or with families where there are child welfare concerns. Safeguarding supervision takes place on a minimum of 3 monthly basis (but can be more frequent as required) for those health practitioners working with families who have been assessed at a partnership plus basis. The health visitor in this case said that she was aware that she could access these supervision processes, however she did not feel that there were any child protection or significant safeguarding concerns in relation to Baby D either prior to, or following, the birth. 5.5.45 Professionals described widely different experiences of supervision. CN1 described how he discussed his concerns about MD with a ‘modern matron’, whilst CC1 could not recall the last time she accessed supervision. 26 Other professionals advised the review team that they did not feel the need to escalate their concerns about this family to their respective managers: both parents engaged with services and actively sought the advice and support of professionals; they were considered to be serious in their attempts to prepare for the birth of their baby and, once born, there were no safeguarding concerns identified and the baby appeared loved and well cared for. 5.5.46 Given the complexity of family situations, relationships and emotional dynamics, research15 suggests it is easy for practitioners working under pressure to lose focus or to get stuck in a particular way of thinking. Professionals need a safe and ‘containing’ space to be able to think about what they are doing and how they make sense of the practical and emotional pressures of the work. It is here where good supervision can make a difference, but the review team was told that busy caseloads and competing priorities often meant that only the most pressing cases were taken to supervision and none of the professionals considered this family sat within that category. 5.5.47 The review team concluded that if professionals had discussed the needs of this family with their respective managers, advice may have been given to liaise with other agencies but a decision to refer to CSC would have been unlikely given what was known about the family at the time. 5.6. ASP 3: The effectiveness of communications with the family In the same way that hearing the voice of the child is central to good assessments, good and clear communication with parents is central to effective safeguarding interventions. Effective partnership with parents requires their engagement, cooperation, and full understanding of what is expected of them and what they can expect of professionals. It is also a legal requirement under the Human Rights Act 1998 that parents should be able to participate fully in any process which relates to the safety and wellbeing of children in their family. The review team wanted to explore how well professionals worked and communicated with the parents and how confident they were that both parents were able to understand and act upon their concerns. Supporting parents with learning disabilities 5.6.1 Although there was a growing awareness of MD’s vulnerabilities and her difficulties in understanding and retaining information, some practitioners were unaware that a formal ‘borderline’ diagnosis of a learning disability had been made and said that even if they had known about the assessment, they were not sufficiently aware of what this meant in terms of MD as a vulnerable adult, as a pregnant women and as a future parent. 5.6.2 Whilst parental learning disability is identified as one of several known factors that can have impact on parents’ capacity to safeguard and promote the welfare of children, parents with learning disabilities, like any other group, are diverse with regard to their parenting skills. 15 SCIE Research briefing 43: Effective supervision in social work and social care (2013) 27 There is little to evidence that any of the practitioners working with this family throughout the pregnancy and after the birth of Baby D thought of MD’s ‘learning disability’ in itself as being a sufficient basis upon which to infer poor parenting, but the need for the parents to have access to information about caring for a baby was well recognised. MD’s ‘mild learning disability’ was however a constant feature in discussions with practitioners during the SCR process. 5.6.3 The family described to the reviewers the feeling that services ‘backed off’ following the birth of Baby D, however practitioner recollection and agency records indicates a continued high level of contact with services. Both MD and FD described the importance of the practical and, sometimes daily, support offered by the maternal grandfather and his family who on several occasions cared for Baby D overnight in order to give the couple a rest when they were ‘walking around like zombies’. The extent of the family support given to the parents emerged only after Baby D had died and was perhaps not recognised by professionals at the time as being so extensive. 5.6.4 The parents told the reviewers that they and CC1 were expecting a ‘support package’ to be put in place after Baby D was born but this had never materialised. Neither they nor CC1 were able to offer any more details about what the package entailed but the parents suggested it was to do with helping them in the house. The parents described that the two types of ‘support’ they received were practical support, such as helping them to obtain kitchen equipment and ‘sort out the house’, and the other was the presence of professionals who offered reassurance when they were worried about doing things right. Although they had agreed to attend a special course for new parents, (BUMPS) they told the reviewers that it didn’t happen because there was no local course and when one did become available, it was too near the birth for the couple to attend. Neither parent was able to think of any additional support that would have been of benefit. Learning Point 12: The term ’support’ can be used too readily to describe the work being undertaken or offered to families. Professionals should ensure that there is always a clear purpose to any support being given to families and that they in turn understand what they can expect from the ‘support’ offered. 5.6.5 When talking with practitioners about working with the family, a challenge, which was continually repeated, was the perception that the couple ‘did not seem to retain information’ and often required almost daily prompting about what to do. There was a view that this was linked to not always remembering what they had been told rather than a lack of motivation or willingness to do things better or differently. However, without an assessment of their capacity to change or learn, such views were based purely on professional observations but left midwives, CCP1 and the health visitor concerned about the best way to communicate important safety messages. 5.6.6 Baby D’s death was attributed to sudden death in infancy in association with non-compaction of the left ventricle. There are several factors known to be associated with sudden deaths in young babies and these were evident when Baby D died: MD’s age; winter weather conditions and the fact that Baby D was male. FD was also known to smoke which is considered as another contributory factor for sudden death in infancy. One of the most significant and modifiable risks however is the baby’s sleeping position and advice to all parents is that babies should be placed on their backs to sleep. 28 5.6.7 Records indicate that safer sleeping advice was given by the midwives, the health visitor and by CCP1. However, there was little to evidence following the birth of Baby D that this information was fully understood by MD or FD; a midwife on the maternity ward noted that despite advice, Baby D was found sleeping on MD’s chest whilst in hospital and a side cot was provided for the baby. The family have described to the lead reviewers that they were advised to ‘prop’ Baby D between two towels as he did not like to sleep on his back, but such advice is at odds with what practitioners know about safer sleeping and there is a possibility that parents either did not follow the advice they were given or did not understand why the baby’s sleeping position was so important. 5.6.8 Practitioners felt that they had a good relationship with the family and that there was a good level of communication between themselves and the parents but the review highlighted that professionals were left assuming that safety messages were being taken on board by the parents, despite their observations that the parents found it difficult to retain information. There is verbal and recorded evidence from this review that practitioners delivered consistent messages about safety to MD and FD, in particular the dangers of smoking near the baby, hygiene in relation to caring for the pet iguana and the dangers of cross infection, and safer sleeping. Practitioners describe that they felt that these messages seem to have been taken on board by the family at the time but were often forgotten when professionals visited a few days later. 5.6.9 Both CP1 and HV1 used some creative visual techniques to try to explain abstract concepts to the couple. When it was known that MD and FD would not be accessing the BUMPs programme, CCP1 worked with both parents on a pack specifically designed to help them better understand their parenting roles. This was a bespoke package which CCP1 prepared and reflected the worker’s response in ‘going above and beyond’ what might be expected of a children’s centre worker. Similarly, HV1 made some illustrated laminated cards for the couple to use to remind them of the importance of hand washing when handling pets and their baby. 5.6.10 Cleaver and Nicholson in their 2011 research 16 found that parents with learning disabilities were more likely to respond affirmatively to professionals and this possibly encouraged over-optimistic assumptions about the extent to which the parents actually understood what was being advised. Even without an assessment of the parents’ capacity to do things differently, professionals had already concluded over a period of several months, that both MD and FD struggled to fully comprehend what was being asked of them and why. Learning Point 13: Practitioners understood that there was a need to communicate with the couple in a different way in order to help them understand key information; however this was not informed by a formal assessment of their communication needs or the use of an advocacy service to ensure that parents fully understood what professionals were communicating. 16 Cleaver and Nicholson: Parental Learning Disability and Children’s Needs: family experiences and effective practice 2011 29 5.6.11 Situation now: A review of how parenting support is offered is currently being undertaken by the local authority in order to ensure that the right support is in place across all services and that families have access to sufficient, accessible and timely parenting support provision which is appropriate to their needs. From April 2017 NHS Hull CCG commissioned the local maternity services provider HEYHT to deliver the Birth Preparation and Antenatal Education service. The aim of this service is to improve accessibility to birth preparation and parent education in order to support readiness for birth and parenting and positive pregnancy outcomes. The programme is midwifery led and offers a personalised approach with a mixture of one to one and group work sessions. Parents are given information about the service at their initial midwifery booking appointment and subsequent appointments. 6. Concluding remarks 6.1. This SCR has not identified a significant contravention or action by any professional that was a critical factor in the death of Baby D in December 2014. Indeed there was evidence of some practitioners going ‘above and beyond’ what was expected and offering extensive support to the family almost on a daily basis during the pregnancy and after the birth. This was a wanted child who appeared to be well cared for and was highly visible to professionals. The parents were, each in their own way, known by professionals to be vulnerable, although the extent to which these vulnerabilities impacted on their parenting roles was never assessed. 6.2. The learning from the SCR does however invite and require a better understanding by managers and practitioners in adult services, children’s centres and health services about the interplay between adult vulnerabilities and parenting especially in terms of shared responsibilities and assessments, multi-agency planning and the effective management of concerns. 7. Summary of Learning and Recommendations Learning Point 1: (Page 10) At key transition points in the lives of vulnerable adults, their future needs should be considered alongside a review of the existing service provision. Learning Point 2: (Page 11) The importance of ‘professional curiosity’ does not only sit in relation to work with families it also applies to conversations between professionals to ensure that roles and remits are well understood. Learning Point 3 (Page 12) Where a learning disabled woman becomes pregnant (or has other children) it is essential that professionals who are in contact with her consider to what extent her disabilities or vulnerabilities could impact on her ability to care for her children and they should liaise with children’s services accordingly. 30 Learning Point 4: (Page 13) This review has highlighted that some practitioners in adult services require a deeper understanding about the roles and responsibilities of colleagues in other agencies but also need to better understand their safeguarding responsibilities to work collaboratively with other agencies to safeguard and protect children and vulnerable adults. The comments of practitioners suggest that some practitioners in adult services may be reluctant to communicate and share information with other professionals because they view the wellbeing of the adult as being their primary concern. Learning Point 5: (Page 14) There would be benefit in HSCB seeking clarification from partners in adult services whether these views are held by a minority of practitioners and managers or are representative of a service-wide issue which requires immediate attention. Learning Point 6: (Page 14) It would be helpful if HSCB sought assurance from senior managers that there are effective systems in place which encourage practitioners in adult services to ‘Think Family’ and which also support managers to monitor those cases which involve dependent children. Where both LA adults' and children's social care are providing services to a family, practitioners need to be better supported to share information in a timely way, undertake joint assessments and agree interventions. Learning Point 7: (Page 15) It seems clear that professionals should work together for the benefit of the child and there are policy imperatives to ensure that agencies work together to provide better services. However, doing so raises a number of challenges. One challenge lies in finding effective ways to manage different professional perspectives and cultures and to promote better ‘joined up’ working between adult and children’s services. If practitioners in adult services have access to high quality training, good supervision, which fosters a culture of respect for staff in different disciplines, and access to multi- disciplinary discussions, they are more likely to consider the safety and development needs of children/unborn babies in their work with vulnerable parents. Learning Point 8: (Page 17) Assumptions can sabotage effective communication and have the potential to lead people down unintended paths. The finding from this review highlights the importance of professionals communicating with each other to verify information given to them by family members rather making assumptions about the role and remit of other colleagues in contact with the family. Learning Point 9: (Page 22) Whilst multi-agency guidelines now provide a clear framework for greater collaboration between agencies in meeting the needs of parents and unborn babies, HSCB should consider to what extent it can be confident that the agreed pathways are effective in identifying and responding to the needs of vulnerable parents. Learning Point 10: (Page 23) Although It is acknowledged that MD’s learning disability was ‘mild’ and the environment in which she grew up impacted on her ability to care for herself, this review has highlighted the need for practitioners in both specialist and non-specialist services to better understand how they can work together to assess the potential impact of learning disability on parenting capability and capacity to change and the concept of ‘parenting with support’. Learning Point: 11: (Page 23) The contribution of practitioners working in specialist adult services to multi-agency assessments and plans for children and families is essential to helping with this understanding and more work is required in Hull to support quality and effective collaboration between adult and children’s services. 31 Learning Point 12: (Page 26) The use of the term ’support’ can be used too readily to describe the work being undertaken or offered to families. Professionals should ensure that there is always a clear purpose to any support being given to families and that they in turn understand what they can expect from the ‘support’ offered. Learning Point 13: (Page 28) Practitioners understood that there was a need to communicate with the couple in a different way in order to help them understand key information; however this was not informed by a formal assessment of their communication needs or the use of an advocacy service to ensure that parents fully understood what professionals were communicating. Recommendations Recommendation 1: That HSCB leads on the development of a local partnership-wide “Think Family” strategy which clearly describes agreed expectations about joint working and lines of communication between adult and children services to further improve outcomes for children and families. HSCB will nominate an from its team to lead on taking this work forward. Recommendation 2: That Hull City Council Adults Social Care provides assurance to the Board about the measures it takes and will take to promote and embed a safeguarding children culture and practices. Recommendation 3: That relevant Hull City Council Adults and Children, young people and family service managers meet together to develop a shared approach to “parenting with support” in relation to parents with a learning disability, in a way which secures a better shared understanding of each other’s roles and responsibilities and creates the conditions for more effective joint working. Recommendation 4: That HSCB ensures that the importance of “professional curiosity” as it was identified in this review is addressed in the Board’s safeguarding training (level 1) and within the equivalent ‘in-house’ single agency training in Hull Recommendation 5: That HSCB leads on a process to test and audit the effectiveness of the agreed pre-birth vulnerability pathway. Recommendation 6: That HSCB seeks assurance about the effectiveness of multi-agency ‘early help’ work and in particular, the use of the agreed early help assessment tool and planning process and the cross partnership responsibility for undertaking the lead practitioner role. Recommendation 7: That HSCB prepares learning materials from this SCR to be cascaded to front-line staff across the partnership by means of bespoke briefings. End/ 32 Appendix 1 Serious Case Reviews 1. Working Together 2015 outlines specific criteria under which a Serious Case Review must always be undertaken by applying Regulation 5 of the LSCB Regulations 2006. For this Serious Case Review Regulation 5(2)(a) and 5(2)(b)(i) applied, that being that the child had died and abuse or neglect of the child is known or suspected. 2. A Serious Case Review is one where: ‘a) abuse or neglect of a child is known or suspected: and b) either – (i) the Child Has died; or (ii) the Child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the authority and their Board partners on lessons to be learnt’ 3. Working Together 2015 requires that Serious Case Reviews are conducted in such a way which: 1. recognises the complex circumstances in which professionals work together to safeguard children; 2. seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 3. seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; 4. is transparent about the way that data is collected and analysed; and 5. makes use of relevant research and case evidence to inform the findings. |
NC047810 | Death of a 6-year-old girl, Child G, in summer 2016. It appears that her father killed her and her two dogs before killing himself. Child G had never had any direct contact with children's social care. Some professionals described the father as having a learning disability although this was not formally diagnosed. He had regular periods of depression and had been referred for psychotherapy following three bereavements and the loss of his job; Child G and her mother were also referred for mental health support. The parents separated and mother had twice reported to the police that the father had gone missing because she was concerned about the risk of suicide. He was assessed by a psychological therapist as being at moderate risk of causing himself harm. Issues identified include: professionals working with the father needed to consider how his mental health problems might affect Child G and what her needs might be; risk assessments need to be continually updated as circumstances change; having a child should not in itself be seen as a factor which can reduce a parent's risk level. Recommendations include: the safeguarding adults board and the safeguarding children board should develop a shared strategic approach to "Think Family"; the joint working protocol for safeguarding children and young people whose parents/carers have problems with mental health, substance misuse, learning disability and emotional or psychological distress should be reviewed and made more accessible to practitioners from the multi-agency partnership.
| Title: Serious case review: Child G: date of incident: summer 2016. LSCB: Isle of Wight Safeguarding Children Board Author: Sian Griffiths Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Prepared for publication 06.02.2017 SERIOUS CASE REVIEW CHILD G Date of Incident: Summer 2016 1 CONTENTS 1. Introduction: 1.1. The circumstances leading to this Serious Case Review Page 2 1.2. Family Composition Page 3 1.3. Methodology Page 3 1.4. Contribution of family members Page 7 1.5. Child G Page 7 2. Summary of the case and agencies’ involvement Page 7 3. Appraisal of Practice and Analysis Page 12 4. Concluding Comments Page 23 5. Recommendations for the Boards Page 23 References Page 25 Appendix A: Individual Agency Actions Page 26 2 1. INTRODUCTION 1.1 The circumstances that led to undertaking this Review 1.1.1 In the summer of 2016 the mother of Child G received a text message from 6 year old Child G’s father, which gave her reason to be seriously concerned. Child G’s father had recently moved out of the family home, but had regular contact with Child G and was caring for her while her mother was at work. The mother called 999 and on arrival at the family home, the police discovered Child G who appeared lifeless. Attempts to resuscitate Child G were made by the police, paramedics and medical staff at A&E, however shortly after midday she was confirmed to have died. The father was also found dead in the house when the police arrived, as were the family’s pet dogs. Information provided to this Review was that it appeared that the father had killed Child G and the two dogs before killing himself. 1.1.2 The case of Child G was referred to the Serious Case Review Sub Group of the Isle of Wight Safeguarding Children Board the day following her death. An initial meeting which took place the following month identified that other statutory reviews were likely to be required as the father had been in receipt of NHS services. This was confirmed at a subsequent meeting and it was established that the following reports would be required. Serious Case Review, Serious Incident Requiring Investigation Report (SIRI) regarding NHS Primary Care Services (Level 2) Serious Incident Requiring Investigation Report (SIRI) regarding NHS Mental Health Services (Level 2) 1.1.3 It was agreed by all the services that these Reviews should work closely together to minimise repetition and ensure the best learning for all. This SCR therefore, as far as possible, acted as a joint agency review. However, the threshold was also met under the NHS Serious Incident Framework1 for a separate ‘Level 3’ Independent Investigation which would be completed within 6 months of the completion of the Level 2 SIRI. It was also agreed that although the criteria for a Safeguarding Adult Review had not been met, there was likely to be learning for the Safeguarding Adults Board, who would also contribute to the process. The purpose of this one Review was therefore, as far as possible to: meet the statutory requirements for a Serious Case Review Identify appropriate learning for the Safeguarding Adults Board Incorporate the learning identified within the two NHS Serious Incident Requiring Investigation Reports 1.1.4 The Serious Case Review Sub Group which met on 20th July 2016 recommended that the Reviews be undertaken on this basis. The 1 Serious Incident Framework NHS England March 2013 (p42) 3 Independent Chair of the Isle of Wight Safeguarding Children Board then formally made a decision to undertake the Serious Case Review and informed the Department for Education the following day. Child G’s case had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20132, in that there was information that: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.1.5 An Independent Reviewer was identified at an early stage and attended the meeting at which the process for achieving a joint review was discussed. This allowed for a timely start to the Serious Case Review Process and the Review was completed in 6 months as a result. 1.2 Family Composition The family members referred to in this review are as follows: Subject – Child G Mother Father of Child G Paternal Grandmother 1.3 Methodology 1.3.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66) 1.3.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which: 2 Working Together: HM Govt 2013 4 recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 1.3.3. The methodology used for this Review was underpinned by the principles outlined in Working Together, including the need to use a systems approach. The author of this report is familiar with a systems based methodology. In particular this approach recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is intended to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. A central purpose therefore is to consider not only the individual circumstances but to consider what can be learnt from this family’s experience about safeguarding practice more widely. 1.3.4. The Review was Chaired by the Independent Chair of the Safeguarding Children Board, Maggie Blyth. The Independent Lead Reviewer was Sian Griffiths who is independent of all the agencies involved. Sian Griffiths has significant experience in undertaking Serious Case Reviews. 1.3.5. A Review team was established and made up of Senior Safeguarding representatives from the following agencies: Service Representative Isle of Wight NHS Clinical Commissioning Group (CCG) Director of Quality and Clinical Services and Executive Lead for Safeguarding Isle of Wight NHS Clinical Commissioning Group (CCG) Head of Safeguarding and Designated Nurse Isle of Wight NHS Trust Executive Director for Nursing Isle of Wight Council, Children’s Services Assistant Director, Children and Families Service Manager, Children and Families Hampshire Constabulary Serious Case Review Team Isle of Wight Safeguarding Adults Board Board Manager Isle of Wight Safeguarding Children Board Strategic Partnerships Manager Hampshire and Isle of Wight LSCBs 5 The Isle of Wight Safeguarding Children Strategic Partnerships Manager and Business Coordinator also provided support to the Review. 1.3.6. The review process included the following written information: Production of a comprehensive chronology provided by the following key agencies: Isle of Wight NHS Trust (Adult Mental Health) University Hospital Southampton NHS Foundation Trust Isle of Wight Council Education and Inclusion Service Isle of Wight NHS Clinical Commissioning Group (for GP practices) Hampshire Constabulary Isle of Wight Childrens Services YMCA Initial Scoping Documents from the agencies which provided chronologies Isle of Wight NHS Trust Serious Incident Investigation Report Isle of Wight Clinical Commissioning Group Serious Incident Investigation Report. Other documents as requested by the Lead Reviewer, including the DASH risk assessment form (risk assessment document regarding domestic abuse.) & IAPT assessments 1.3.7. The Independent Lead Reviewer met with the following professionals who had direct involvement with key members of the family: 4 Family GPs and GP Practice Manager (joint meetings with the Clinical Commissioning Group investigator) Police Constable (telephone conversation) Mental Health Practitioner, Registered Mental Health Nurse (joint meeting with the Isle of Wight NHS Trust investigator) Mental Health Practitioner, Therapist at IAPT, Improving Access to Psychological Therapy service (joint meeting with Isle of Wight NHS Trust investigator) Adult Social Care Safeguarding Consultant Practitioner (telephone conversation) Head Teacher and Class Teacher Notes of the following meetings with professionals undertaken with the Isle of Wight NHS Trust investigator by herself were provided to the Lead Reviewer: Mental Health Practitioner (Single Point of Access) Mental Health Practitioner (Clinical Lead for Single Point of Access) The Lead Reviewer also spoke to a number of other relevant professionals. 1.3.8. A practitioners’ event was undertaken involving 8 practitioners who were directly involved with the family, managers from key organisations and 6 members of the Review Team. The purpose of the event was to ensure information included in the report was accurate and to contribute to the analysis and learning. 1.3.9. The timeframe under consideration for this Review was: March 2015 – Summer 2016 The starting point was chosen as it was identified that at this point the father had sought help from his GP for depression and been referred to the primary mental health care service, IAPT. The end point is the date at which Child G and her father were discovered. 1.3.10. Terms of Reference encompassing the three parallel reviews were produced and are included in Appendix A of this Review. The areas of consideration specific to the Serious Case Review were as follows: 1. Was there sufficient awareness, understanding and application by the agencies involved of the 4LSCB Joint Working Protocol for safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress - with particular emphasis on Part 3 of the protocol? 2. Was sufficient priority given to the needs and safety of the child by the agencies involved and were the risks to the child effectively assessed in the context of the father’s mental health issues? Was there a perception by involved agencies that the child could be seen as a protective factor? 3. Were there missed opportunities by the agencies involved for interventions to have been put in place to minimise risks to the child and promote protective factors. 4. Should a referral have been made to CSC by the agencies involved when the father was expressing that he might harm himself? 5. To explore the links between adult safeguarding and child safeguarding procedures and pathways including how the MASH assesses referrals for linked cases on the IOW 6. Was the male identified as an ‘at risk’ adult within the terms of the Care Act 2014 1.4 Contribution of family members 7 1.4.1. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Both the mother of Child G and the paternal grandmother of Child G agreed to meet with the Independent Lead Reviewer. Their contributions to this review are summarised below and included throughout the report. 1.4.2. The willingness of both the mother and grandmother to contribute to this review, given the highly distressing nature of Child G and her father’s deaths, was particularly appreciated and has provided an important perspective that would otherwise have been missing. 1.5 Child G 1.5.1. What has been striking throughout this review is the incredibly vivid picture that has emerged of Child G. She is consistently described as a bubbly, friendly child, although she could also be quite shy and was very much a ‘mummy’s girl’. Child G loved her pet dogs and also had a favourite toy dog, who she always liked to have with her and was her comfort toy. Child G loved dancing and singing and she was in the school choir. She liked to join in to any activities that she could and was described by her teacher as a child who would ‘get excited at the tiniest of things’. She was obviously viewed as a delightful child by her teacher. She was a very kind, caring child who would always think about others. One of her regular games with her mother was for them to list all the things they had to be grateful for. 2 SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY The following is a chronological summary of what is now known about the family and their involvement with agencies. The summary, as far as is possible, will identify what was or was not known to the relevant agencies at the time the events were taking place. 2.1 Background information 2.1.1. Child G lived throughout her life with her parents and was a pupil at her local primary school. Both parents, who were married, were involved in her care and all the information available prior to her death draws a picture of a much loved child. Prior to the time period covered within this review the father had been in full time work and therefore the mother, who also had part time work, was the main carer during the day. Information provided by the mother is that she had a particularly close relationship with Child G and remained the primary carer throughout her life. Child G’s mother chose to undertake two parenting courses at the local Children’s Centre because she was keen to provide the best care for her child and enjoyed attending these courses. 8 She was clear that Child G loved her father and believed he loved her, but his involvement in his daughter’s care was a less active one, a description that was echoed by her school’s experience of both parents. 2.1.2. Both parents had some history of depression linked to their own early life experiences as well as current life stresses. Information from the family was that Child G’s father had regular episodes of depression throughout his life, that he found it difficult to talk to people and was almost exclusively reliant on his wife for emotional support. Child G’s father was described by some professionals as having a Learning Disability, however there is no evidence of any formal diagnosis, or evidence of assessment since he was a young child. Child G’s mother confirmed that he had particular difficulties for example with reading and writing and lacked confidence in this area. 2.1.3. Prior to the timeline under review Child G had limited contact with agencies other than for universal services, specifically education and health. Child G had had some physical health problems for which she received the appropriate care, but which are not directly relevant to this Review. Child G like her parents was born and lived on the Isle of Wight and was white British. 2.2 Events between March 2015 and the summer of 2016 2.2.1. In the spring of 2015 Child G was attending her local school and was in the reception class. Her attendance was something of a concern to the school, it was 82% in March 2015, but all the absences were accounted for and checked by the Attendance Officer. Child G had had mild heart problems as a younger child and had been under the care of a paediatrician. She was discharged from that care in March 2015. Child G had also had two childhood infections that kept her off school earlier in the year. The paediatrician had referred Child G to the YMCA for counselling in 2014 and again in March 2015 as she had been quite badly affected by two deaths in the family and her mother was also worried about how she would react when her much loved elderly dog died. The mother bought a puppy for Child G hoping that it would make this easier when the time came. 2.2.2. Child G’s father had attended at the family GPs in March 2015, he was known to have had a history of depression and had in recent years suffered 3 significant bereavements. He was referred to IAPT (Improving Access to Psychological Therapies), the Primary Care Mental Health service. It appears from his notes that his depression was linked to some degree to having lost his job. At the time he was identified as being a medium risk of harm to himself. It was noted that he had literacy problems but was given reading and asked to produce a diary. After two appointments he did not attend further and there is no note about the reason for his non-attendance. 2.2.3. In September 2015 Child G moved into Year One. The school staff knew Child G as a kind, caring child, a child that her teacher never needed to tell off. At the start she had been quite anxious and always wanted her cuddly toy dog with her, but they encouraged her to leave it at the door and she settled in. Her mother was very supportive and always concerned about her. 9 She was an only child and her mother described her as a ‘miracle child’ as she had also been premature. Mother was very supportive of Child G in school, but would perhaps over worry about her sometimes. Child G consistently described herself as happy and would skip into school. The school knew that Child G loved her two dogs, particularly the puppy which she regarded as her dog. 2.2.4. Child G’s school attendance did continue to cause some concern, but all the absences were authorised due to illness, and so she was not referred to the Education Welfare Service. The attendance officer reviewed her attendance and was satisfied. The school felt that sometimes Child G’s mother could be over concerned about her health, although this was understandable. 2.2.5. In November 2015 Child G’s mother visited her GP with symptoms of anxiety linked to a recent bereavement and the stress of managing two jobs. The GP was aware of a history of anxiety, prescribed her an anti-depressant and referred her to the primary mental health team, although she did not appear to have taken this referral up. The following month Child G told the school she had experienced a physical health symptom which they felt needed to be followed up. They informed Child G’s mother who immediately took Child G to the doctor for a consultation. Child G’s mother talked to the GP about the stresses at home, particularly as a result of the father having lost his job, and felt that it might be that Child G, who was upset about this, was seeking some attention. The GP was confident that there was no other cause for concern and suggested that she get some support from Barnardo’s. The GP believed that Child G’s mother was quite capable of referring herself to Barnardo’s as she had been to their children’s centre before and enjoyed it. At around the same time the school noted that Child G was not her usual ‘bubbly’ self. Child G’s mother talked to the class teacher about the father being depressed and described it as ‘like looking after two children’. Child G’s father would often collect her from school as her mother was now working. He occasionally came to school events, but was quiet and said little to staff. 2.2.6. In March 2016 Child G’s mother again made appointments for herself with her GP and described stress at home. She said that she was thinking of leaving Child G’s father. Soon after this meeting the police received a call from Child G’s mother saying that Child G’s father had been angry about her having text contact with another man and had left home, saying he would not come back. She told the police she was worried as the father suffered from depression and had previously had suicidal thoughts. The attending police officers located the father at his mother’s address, they did not identify concern about his mental wellbeing and saw no evidence he was at risk of harming himself or others. This was therefore identified as a period of ‘absence’ rather than of his being missing. 2.2.7. Child G’s father went to see his GP the next day. The GP he saw was not his designated GP and had no previous knowledge of his home situation. She was not aware that his wife had also sought help from the same practice for anxiety. The GP was ‘moderately concerned’ about the father and arranged to see him for a follow up appointment in a week, rather than her 10 usual practice of a fortnightly follow up. She took into account that he had thoughts of deliberate self-harm, but that these had been longstanding. The GP prescribed an anti-depressant and talked to him about counselling, but he was not keen on this because when he had gone the previous year he struggled with the expectations on him to read and write. The GP spoke to him about his relationship with his wife and child and encouraged him to talk to his daughter more. She assessed that his relationship with Child G was a protective factor. 2.2.8. In early April 2016 the police were called by Child G’s Mother, because Child G’s father had left saying that if he committed suicide it would be her fault. The police officer spent some time with the mother taking a history. The officers then found Child G’s father at his mother’s home. The father was in bed and did not want to speak. The police officer felt confident that his mother would take care of him and she said that she would take him to the GP in the morning. Child G was seen to be safely asleep in bed and her mother, although upset, was not concerned for their safety. 2.2.9. There was nothing about this incident that stood out for the police officers as being very different from many other similar cases that they routinely attended. The officer did not feel she had any reason to invoke Section 136 of the Mental Health Act in order to take the father to a place of safety and thought that it was likely to be better for the father to go to the doctor the next day with someone he trusted. The officer returned to the station and completed a DASH form to assess the risk of domestic violence. She did this as it is routine part of the police force’s practice in any situation that has a domestic component, not because she had any specific reason to be concerned. She also completed a CA12 (Safeguarding Referral form for adults) and a CYP form (Child and Young Person at Risk) used to notify Childrens Social Care when a child could be considered at risk, again as part of standard practice. These forms were forwarded to the Adult Safeguarding teams and the MASH (Children’s Services Multi Agency Safeguarding Hub) respectively in line with established policy. 2.2.10. The next morning, which was a Monday, the Adult Social Care Safeguarding Team received the CA12 form into their ‘reporting abuse’ e-mail inbox, a system for any referrals which might relate to neglect or abuse of an adult who may have care and support needs. The Adult Safeguarding Team had an informal local agreement to triage all these forms (there could be up to 30 after the weekend), including those intended for the mental health team, which did not have a means to receive the forms directly. In line with the team’s normal practice, an experienced social worker reviewed the form. She identified nothing to suggest that the father would be considered an adult at risk within the criteria of the Care Act3. She was clear that the fact of an adult having suicidal thoughts in itself would not meet the criteria. The father had the support of his own mother, who he was staying with and who 3 The adult safeguarding duties under the Care Act 2014 apply to an adult, aged 18 or over, who: has needs for care and is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect 11 was going to take him to the GP that day. Having reviewed the form she uploaded it onto the PARIS computer system for the Mental Health Team’s information. 2.2.11. The referral form from the police was also considered by the MASH. It was concluded that the appropriate action had already been taken and therefore no further action was required by Children’s Social Care. 2.2.12. The Adult Safeguarding referral (CA12) was received and processed by the Single Point of Access (SPA) within the Mental Health team. The SPA is the first point of contact for all referrals for Secondary Mental Health Services in the Community. It was decided to refer it to the father’s GP and the CA12 was forwarded to the GP. The GP contacted the father by phone and arranged for him to come in for an appointment. When the father attended the GP surgery a couple of days later, the GP contacted the IAPT service and an appointment was made for the father with the therapist. 2.2.13. Child G’s father attended the IAPT service in early summer 2016 for his assessment and was seen by the therapist twice more over the following weeks. The therapist established that the father had suffered depression for most of his life, he felt isolated and had few friends. His immediate problem was that he had separated from his wife who he said had been talking to other men online. The main goal he could identify was getting back to work and the therapist was concerned to encourage him in greater activity. The father was living with his own mother, but was still seeing his wife and daughter with no evidence of there being any conflict. 2.2.14. After the therapy sessions at IAPT had already begun, Child G’s father again attended his GP (he had now transferred to a different GP practice as he was living at his mother’s). Child G’s father spoke about the self-harm attempt when the police were involved the previous month and the GP, who was not aware the father was already being seen by IAPT, made a referral to Mental Health. The GP spoke to a Mental Health practitioner at the Single Point of Access. The Mental Health practitioner in turn spoke to the IAPT therapist and agreed with his assessment that there were no high risks identified and it was appropriate for him to continue with therapy and not at this point be moved to secondary mental health services. A second Mental Health practitioner spoke to the father later that day. They arranged to speak after the father had picked up his daughter from school, demonstrating to the worker an appropriate focus on the child. When they spoke he appeared almost ‘jovial’, feeling hopeful about his situation and not presenting any information that suggested a risk. Child G’s father was very happy with his therapist and did not want to see someone new. This Mental Health Practitioner had previously been a Child Protection Social Worker, as such she was practiced and confident about referring to Children’s Services, but saw no reason to in this case. 2.2.15. Because of Child G’s father’s recent attempts at self-harm the IAPT therapist assessed his risk to himself as moderate, noting that there had been a gap and he was not expressing active thoughts of suicide. There was no information that led the therapist to believe he was a risk to his wife or 12 daughter. Child G’s father did describe a nightmare in which he killed his wife and daughter. The therapist explored this further with Child G’s father, and he was reassured that the father did not have any actual intention to act as these were the two people he most cared about. The therapist was familiar with people having all sorts of seemingly strange dreams and judged that this was likely to be a reflection of the Father’s sense of loss, rather than something to be taken literally. The therapist spoke to Child G’s mother who was supportive and wanted the father to get help. The therapist understood from the mother that she had not ruled out reconciliation. The father did not present in an angry or aggressive way and there were some signs of slight improvement over the three weeks he was involved with IAPT. 2.2.16. At 10am on the day that Child G died, the police received a call from Child G’s mother. Child G’s father was caring for their daughter while the mother was at work. She had received a text from him saying he would “only leave her with memories”. When the police arrived at the house, Child G, her father and the two pet dogs were found apparently dead. Child G was taken to hospital where further attempts were made to resuscitate her, but these were unsuccessful. 2.2.17. The inquest into Child G’s death, which took place when this Review was near completion, concluded that she had been unlawfully killed and that her father had committed suicide. 3 APPRAISAL OF PRACTICE AND ANALYSIS 3.1 Introduction 3.1.1. This Section will appraise the most significant aspects of the multi-agency practice with Child G and her family. It will identify what multi-agency learning there may be and respond to the questions outlined as Areas of Consideration within the Terms of Reference. 3.1.2. Where individual agencies have already established appropriate learning and taken action within their own agency, this will not result in further recommendations within this Review. Learning identified within the two NHS SIRI reports will be noted (Appendix B) but not analysed in detail here unless there is an impact on the wider multi-agency safeguarding partnerships. The analysis has been considered under two broad headings: The Links between Adults and Childrens Services and Assessing the risks posed by the Father. Inevitably, however, there will be a degree of crossover between these two. 3.1.3. Child G and her family were known mainly to universal services, particularly education and health. Up until the last few weeks of her life, there was no information to suggest that she was a child at risk of harm, or was anything other than loved or cared for within her family home. She had experienced loss in her life, with two significant bereavements; however, she was well supported by her mother and provided with child focussed bereavement counselling. Child G had never had any direct contact with Children’s Social 13 Care, whose only involvement was in receiving a routine referral from the police two months before her death. This episode will be considered further in due course. 3.1.4. We cannot know for sure what motivated Child G’s father to kill himself and Child G. However during this Review a number of indicators have emerged that suggest the most likely explanation lies in the father’s separation from the mother and a resultant desire by him to cause her significant suffering. Child G’s mother has no doubt that the father killed his daughter in order to punish her, the mother, and to make her suffer. The paternal grandmother also suggested that her son’s motivation was linked to his unwillingness to accept that another man might take his place with the mother and Child G, although this was not actually part of the mother’s thinking at this time. That he killed the two family pets, who the mother also loved dearly, and sent her a text message making it clear he wanted to take away the things she loved most, supports her view of his motivation. The father’s state of mind as it impacts on how agencies could have responded will be considered in section 3.3. 3.1.5. The predominant focus for the majority of this Review is, unusually, on those services which were working with the father, as the risk to Child G lay with him alone. The conclusion of this report, which will be detailed later in this section, was that the nature of the risk the father posed could not have been identified by professionals in the very short period of time that they were involved with him. Overall the evidence is that agencies and individual professionals provided the appropriate services to Child G’s family. There is evidence that professionals who came into contact with the family fulfilled their roles with proper care and there are no points of significant concern in terms of professional practice or access to services. There is, of course, potential for learning where practice could be developed or improved and some occasions where there were chances to understand more about what might be developing within this family at this time. However, there are no evident actions or inactions by professionals which could reasonably be expected to have halted the chain of events that did eventually occur. 3.2 The links between Adults and Childrens Services: Think Family 3.2.1. It was evident from the outset of this Review that a significant area for consideration would be the degree to which there was an effective relationship between children’s and adults’ services4 and a proper understanding of the need to consider any concerns for the wider family when responding to the needs of individuals within it. Both the Safeguarding Adults Board and the Safeguarding Children’s Board had identified this as a possible area of weakness in practice on the Isle of Wight and were concerned that it appeared to be a feature within Child G’s case. 3.2.2. Developing a holistic approach to the needs of children and families is well recognised as good practice and was formalised by government policy in 2008 in the concept of ‘Think Family’. This was defined as: ‘securing better 4 “Adults’ services” is intended to include all relevant statutory services for adults including health and social care. 14 outcomes for children, young people and families with additional needs by co-ordinating the support they receive from children’s, young people’s, adults’ and family service’.5 3.2.3. There have been two key strands highlighted by Child G’s case which are significant from a Think Family perspective. Firstly, at an organisational level, structures and processes, particularly in relation to information sharing, did not always support a strong ‘Think Family approach’. Secondly the review has highlighted that the level of professional focus on the needs of children across adult services also needs strengthening. 3.2.4. Structures and processes: When, in the spring of 2016, the father was experiencing a period of depression and was expressing suicidal thoughts, the key agencies that responded to him directly were the family GPs, the Mental Health services and the Police. Following his second contact with the Police the attending officers completed and sent notification forms to the Adult Social Care Safeguarding team and Children’s Social Care, as well as completing a Domestic Abuse Risk Assessment (DASH). What this meant in practice was that different forms were sent to different agencies by the attending police officers despite the fact that, with hindsight, it is clear that the information may also have been useful to other agencies. As a result Children’s Services did not receive the Domestic Abuse Risk Assessment form; Adult Safeguarding did not know that a CYP notification form had been completed; the primary mental health team, IAPT, did not receive the Police CA12 and so on. That this was the case should not be interpreted as a criticism of individual police officers, who were following established processes. 3.2.5. What has been recognised by services during this Review, and reflects existing concerns, is the risk that key information is not being effectively shared with all the relevant agencies. At a minimum there is a lack of any clear process to ensure that all agencies are made aware of each other’s involvement with the family. Referral processes have historically been designed to deal with one issue of concern, for example domestic violence or adult safeguarding, and sometimes there will be links between processes. But what appears to be missing here is a clear strategic position about the way in which all information about risks and vulnerabilities identified for an adult should and can be shared with Children’s Services and vice versa. 3.2.6. Suggestions have already been made for some simple solutions to some of the gaps identified, for example: an identifier on a CA12 that an adult has caring responsibilities for a child: routine forwarding of a DASH form to Children’s Social Care along with the CYP form. However, the longer term solution is likely to require a more considered approach and a strategic consideration of the way in which adults and children’s services can work more collaboratively. The Review has been informed that discussions are taking place as to the viability of combining the various forms into one form. In the interim this Review recommends that the Boards seek an early agreement regarding a means for sharing Referral information and risk 5 HM Govt (2009:4) 15 assessments regarding vulnerable adults and children across the relevant agencies. (Recommendations 1 & 2) 3.2.7. The system that was in place at this time for processing Adult Safeguarding Referrals (CA12s) does appear to contain some weaknesses although there is no reason to conclude that these would have impacted on the outcome in this case. The CA12 forms are sent directly to the Adult Social Care Safeguarding Team whose role is to assess whether the adult concerned meets the criteria for identification as an Adult at Risk or to forward the information to Mental Health services if concerns about mental health have been identified. The latter is effectively the Adult Safeguarding team acting as a conduit for Mental Health who do not currently have any other way to receive this information within their own systems. The Review has been informed that this system is now under consideration. Plans are being developed for all mental health referrals to go to the Adult Social Care First Response team for triaging. This team’s role is as the first point of contact for all other referrals and to assess individual’s eligibility for social care services. Such a change would therefore allow routine consideration of an individual’s support needs, as well as any risks after these have been considered by the Adult Safeguarding Team. 3.2.8. What has further been highlighted is that at the point an adult referred to the Adult Safeguarding team is assessed as not meeting the ‘at risk’ criteria, there is no linked system to assess whether that adult might nevertheless be able to access services or support through Adult Social Care or other systems. If the father had been referred to the First Response team after his referral was considered in terms of safeguarding, this would have been an opportunity to assess his wider needs. It is not the assumption of this report that the father would have been deemed eligible for support from Social Care or that he would have taken advantage of any support offered. Even if he had been linked into some support services, whether statutory or otherwise, it would be unreasonable to conclude that any such support could have pre-empted the risks presented to his child. Nevertheless there is evidently an opportunity here to assess need and to link adults into appropriate services. 3.2.9. The professional focus on children within adult services: Practitioners working within adult services rightly have as their prime focus the adult who is accessing that service, whether in mental health, adult social care services or other sectors. These professionals are required to manage their work with adults whilst keeping in mind the statutory expectation6 that all professionals have a role to play in safeguarding children. What has been apparent from all the meetings with the professionals who had direct contact with the father is that they were very aware of their responsibility to raise any safeguarding concerns about Child G. All were alert to aspects of the father’s problems that could lead them to make a Safeguarding referral, and this will be considered further in section 3.3. 6 Working Together 2013 16 3.2.10. What was less obviously at the forefront of professional thinking was whether, in the absence of a specific safeguarding concern, there was an equally clear understanding that Child G might also benefit from a wider assessment of her needs, or the offer of Early Help7 given the pressures that existed in the family. Whilst discussions about Child G took place in most consultations, this was generally in the context of the father’s perspective, for example, how he felt about her and how this affected his frame of mind. 3.2.11. There is less evidence that there was a consciousness of what Child G’s needs might be, how she might be experiencing the father’s mental health problems and whether there was any wider responsibility to her arising out of the service that was being provided to the adult. Child G was not always directly mentioned by the father and one of the GPs acknowledged that he did not proactively ask about whether the father had any caring responsibilities, but would now change his practice. More than one of the GPs also reflected that it could be difficult to appear to be raising concerns about an adult patient’s child without a very clear reason. Two different GPs in one practice saw the two parents separately; they were not aware that this was the case and as a result were not in a position to understand the perspectives of the ‘other person in the relationship’. It was the case that the mother was presenting a less positive picture of the potential for a reconciliation, however, it is difficult to imagine any significant impact this could have had on their response. Nevertheless the SIRI report in relation to primary care (GP practices) has recommended a flagging system within the GP records to close this gap in potential information sharing. 3.2.12. A key tool developed locally for professionals working with adults who have caring responsibilities for children is the 2014 Joint Working Protocol on behalf of 4 Local Safeguarding Children Boards, including the Isle of Wight, entitled: “Safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress.” The purpose of this Protocol being to provide information and guidance for relevant organisations working with adults in these categories. The father of Child G was identified as experiencing a level of depression that required primary mental health care intervention and as a result this Protocol would apply to Child G’s family. 3.2.13. Consistently the reviewers were told by the professionals who worked with the father, that they were mostly aware of the Protocol but had not read it. Despite this it would appear that the practice largely met the basic expectations of the Protocol. That they had not read it reflects not on their commitment to their practice but, in the view of this author, reflects the reality of their working lives and the inaccessibility of documents of this nature in that context. The Protocol, which has clearly been completed by well informed and knowledgeable authors, runs to a total of 50 pages, with some quite dense content and some references that would not be familiar to the 7 Early Help is provided to children, young people and families who are struggling and feel in need of some additional support. See https://www.iwight.com/Residents/care-and-Support/Childrens-Services/Support-and-Advice-for-Families/About-Early-Help 17 non-specialist reader. It is intended to be read by a wide range of professionals and volunteers from A&E departments to Fire and Rescue Services. Whilst it is an interesting and informative document, it is unrealistic to think that many of those professionals, whose day to day job is not primarily concerned with children’s safeguarding, would have the time to read this Protocol, amongst all the other policies and guidance from their own agencies and others. And more importantly, to then have the capacity to absorb and translate these key messages into their routine practice. What is apparent is that a different approach needs to be taken when trying to engage those not directly involved in child safeguarding in order that they can be reasonably expected to have understood and embedded key practice messages. 3.2.14. The professionals concerned unanimously recognised that there was useful learning for them which they would welcome. Examples they gave include knowledge about mental health and parenting capacity as well as skills and confidence in bringing the child into the conversation with an adult patient. They also felt there needed to be a more focussed and role specific way for the Board to communicate policy or practice guidance, such as shorter documents identifying Key Practice points or training workshops linking these messages to their particular work setting. This issue has been made subject to a recommendation in the Isle of Wight Trust NHS SIRI report and is also reflected in Recommendation 3 of this Review 3.2.15. The experience of the professionals in this case was very clearly that they took seriously the requirement on them to be responsive to safeguarding issues for children. However, this would inevitably for most represent one of many different concerns they needed to keep at the forefront of their minds in any contact with an adult, and often during very limited periods of contact. Typically for example a GP has 10-12 minutes for each consultation. Developing a culture where the child is always in the mind of the professionals is a crucial contributor to safeguarding, but requires an explicit multi-faceted approach championed by leaders in the organisations concerned. (Recommendation 2) 3.3 Assessing the risks posed by the father 3.3.1. In order to judge the quality of the assessments that were made about any risk posed by the father and the responses to any concerns, two essential factors need to be considered. Firstly what information was available to those making assessments; secondly what is known from research and practice about assessing risk and dangerousness. 3.3.2. As has already been identified, none of the agencies who had regular direct contact with Child G had any specific reason to consider that she was at risk of harm from her father or anyone else within her family. The school knew both parents and had a good understanding of the broad family situation within the legitimate remit of their role. They had no information to identify that the father had any history of violence or that the family breakdown was other than a sad but familiar feature of family life. Similarly no other professionals who had known Child G earlier in her life - including health 18 professionals and counsellors at the YMCA - had identified anything unusual or concerning about Child G’s relationship with her father or his behaviour within the family. When the police officers were called due to concerns about the father’s mental state, what they saw did not present as particularly unusual in their experience. One of the officers described it as follows: “It definitely didn’t stand out…we deal with things like this on a daily basis…. ….his wife was very pro-us, wanted to get him help…(other) people we see where there is drinking, violence, the house is dirty…there was nothing like that here” 3.3.3. The Police Officer concerned completed both a CYP notification form and the Domestic Abuse assessment form (DASH) in line with Hampshire Constabulary policy where the circumstances might include domestic abuse. The Police Officer spoke for some time to Child G’s mother who was upset about the father’s actions and about the breakdown of the marriage, but did not say anything that suggested domestic abuse was in fact a feature of their relationship. Neither did the Police Officer have any evidence that Child G was at risk. The conclusion of the Domestic Abuse form was that it was a medium risk, because certain categories were identified as a positive. However, having considered the form carefully, it is evident that the mother’s fears were related to the father’s risk to himself, not to her or Child G. 3.3.4. There were a small number of other occasions when there were references in the mother’s GP records to what might be indicators of ‘coercive control’, the emotional and psychological aspect that is often present in domestic abuse, even when physical violence is not a feature8. That the mother was able to speak both to school staff and the GP about the stresses of her relationship with the father however suggests a positive relationship with these professionals. Similarly, following the Police’s contact with the family in April 2016 and the resulting DASH assessment, a safety plan was undertaken in line with Police policy. The mother was subsequently visited by a Police Community Support Officer who discussed the plan with her and provided her with a Domestic Abuse information pack. 3.3.5. The mother of Child G was however clear in her contribution to this review that she was never afraid of the father, she did not consider his behaviour as threatening, although it was very difficult to live with, and if anything she felt that her husband was more like a second child, not a threatening dominating figure in her life. She described him as someone who never really demonstrated any strong emotions, positive or negative, including anger. The paternal grandmother did talk to the reviewers about her son having angry outbursts in the context of her relationship with him, but this was not something that the mother had herself experienced. 3.3.6. Despite the fact that the mother is not identifying to this review that she experienced domestic abuse, it is nevertheless important for agencies to be 8 Controlling or coercive behaviour does not relate to a single incident, it is a purposeful pattern of behaviour which takes place over time in order for one individual to exert power, control or coercion over another. Home Office (2015:3) 19 alert to possible signs of domestic abuse in their work with families. The support offered to the mother by professionals, irrespective of whether there was any explicit disclosure of domestic abuse, was therefore appropriate. 3.3.7. The forwarding of the CYP form by the police to Children’s Social Care in April 2016 potentially created another opportunity to assess any risk to Child G. When the CYP form is received by Children’s Social Care, and where no immediate safeguarding concerns have been identified, checks are made to see if the family is known to the service and a decision overseen by the Assistant Team Manager as to whether this should become a ‘Referral’. This results in it being passed up to a social worker, who would make other relevant checks, for example with schools or health services. In the case of Child G, with no immediate safeguarding concerns identified and the family not being previously known to Children’s Services, the decision to take no further action is a justifiable one. 3.3.8. What has been highlighted during this review is that the DASH forms are not routinely made available to the staff in Children’s Services when making these assessments. Theoretically had the DASH form been with the CYP form, this might have led to it being treated as a referral and from there an offer to the family of Early Help being made. However, given the additional information that this could in fact have provided, it is still unlikely that it would have met the thresholds for progressing further. 3.3.9. The points at which there was some greater opportunity to consider the father’s mental state, whether that be in relation to mental health, or other features of his personality, was when he sought help from the GPs for depression and was referred to the primary mental health service, IAPT. The father was seen by a number of different GPs at two practices, he was provided both with anti-depressants and referrals for talking therapies. It is evident that at times GPs had a somewhat raised level of concern about the father’s risk to himself, most particularly when he was referred to the Community Mental Health Single Point of Access and the referring GP marked this as ‘urgent’. 3.3.10. In making their assessments about any risk that the father posed to himself both the GPs and mental health staff practice reflected established assessment processes for assessing suicide risk. Research9 and research based Clinical Guides for assessing the risk of suicide (eg The Centre for Suicide Research10) identify key factors in order to help professionals assess the presenting risk. The various assessments undertaken during GP and other consultations were in line with current understanding of risk and protective factors. None of the GPs undertook an assessment in relation to risks of violence, because none identified any information that would lead them to do so. 3.3.11. One of the protective factors in relation to suicide risk that has been identified in research and was on more than one occasion identified in relation to the father is that of having caring responsibilities for children. 9 Eg National Confidential Inquiry into Suicide and Homicide by People 2016 10 University of Oxford 20 Whilst this was a legitimate feature of the GPs’ risk assessments, it has nevertheless highlighted the complex nature of risk assessment, particularly where a child is identified as a protective factor. It therefore raises two issues of potential concern for the future, although there is no evidence that in this case these issues impacted on the professional response to the father’s potential risk. Firstly, risk assessments need to be continually updated because of the dynamic nature of risk indicators and protective factors. As such all professionals should be clear that risk assessments are only valid at the time they are undertaken, and any change in circumstances could mean a change in the level of risk. Secondly a child should never themselves be understood as a protective factor against risk. Rather it should be clearly understood that it is the adult’s response to their relationship with the child that could be a protective factor. The Review particularly identified the risks for misinterpretation that this second issue could lead to and as a result a specific recommendation has been made in this regard. (Recommendation 4) 3.3.12. Reflection with the GPs concerned also drew attention to the difficulties for non-specialist workers in assessing parenting capacity. For those GPs who talked to the father about his relationship with Child G, there was a broad awareness that they should consider parenting capacity. However, this to some extent sat uncomfortably with them and they were aware of the limitations of their professional knowledge in this area. There was no lack of awareness of links between mental health and potential concerns for children. However, Child G’s situation did not, based on what they knew at the time, trigger a safeguarding concern. “we can’t refer every child living in a house with mental health issues – there are so many” The GPs described having significantly high numbers of adults with mental health problems in their practices. One of the GPs estimated that 20% of the patients she saw had depression or other mental health issues. Another spoke of “deeply entrenched chronic mental illness” for many of their patients. What emerges from the experience of this group of health professionals are the real difficulties of managing the impact of these problems on their patient lists within the constraints of their time and given the nature of their professional role. A number of recommendations intended to support GPs further in this context have been made by the Clinical Commissioning Group SIRI report. 3.3.13. A cause of concern raised by the GP who referred the father to the Single Point of Access for the secondary mental health team is that they had expected a full assessment of the father to be undertaken by the SPA, rather than a telephone assessment. The Standard Operating Practice for the SPA however is to conduct an initial assessment by phone. If the individual is assessed as likely to meet the criteria for secondary health services, a full assessment is then undertaken, although due to demand current waiting times are approximately 6-8 weeks. This was the process that was followed with the father of Child G. This episode has also led to further learning about potential problems arising out of an overlap between referrals to IAPT and to 21 SPA and these have been made subject to a recommendation in the Isle of Wight NHS SIRI. 3.3.14. Whilst there may be different professional perspectives on the needs of an individual patient for urgent treatment, there is no basis for this Review to conclude that the decision taken by the SPA for the father to remain in treatment with IAPT was misjudged. Whilst it is impossible to say whether there would have been any impact on the outcome had a full assessment taken place, it is of course possible that it may have reached a different assessment of his risk. However, based on what is known about the father, including his reluctance to talk about his own problems and what he had previously told professionals, considerable caution needs to be exercised in any assumption that an assessment by the secondary mental health team would have reached fundamentally different conclusions. Nevertheless, identified learning has resulted from these events regarding the need for better understanding between referring GPs and mental health services about their practice and thresholds. This has been recognised by the SPA team in discussion with the author as an area of communication they could develop with GPs. A resulting recommendation has therefore been made for the Isle of Wight NHS Trust working with the CCG. (Recommendation 5) 3.3.15. Child G’s father attended for his first assessment at the IAPT service three weeks before Child G’s death. At each subsequent treatment session, the therapist reviewed his assessment. The therapist’s assessments are properly documented and clearly identify the risk indicators that have been discussed. He was concerned about the risk of suicide, but noted that the father was not currently having active thoughts or planning for suicide. He identified that the relationship between the father and his wife did not appear to be likely to end suddenly, but nevertheless put in place, with the father, a Risk Management plan if that were to happen. Both the therapist’s records and his reflections on his work with the father are coherent and well considered. It appears that he was beginning to establish a working relationship with the father, and was particularly conscious of the difficulties that the father had with reading and writing which had blocked his contact with IAPT the previous year. 3.3.16. The therapist specifically considered risk to others during his assessments, but concluded that at that time this was not a factor. During the course of the assessment the father described experiencing a nightmare in which he killed his wife and daughter. Armed with the knowledge of what did ultimately take place, this may appear to be a significant cause for concern, but such a conclusion would be misconceived. It was evident that the therapist had asked further probing questions about this, as a result of which he assessed that there was nothing to indicate that the father had any intention to act on this. It seemed to him likely that the nightmare was indicative of the father’s feelings of loss in relation to his family. 3.3.17. Research and practice knowledge in relation to intrusive bad thoughts clearly identify that there is no simplistic link between experiencing bad thoughts 22 and any intention to act them out.11 Baer identifies that everyone occasionally experiences bad or distressing thoughts (in this case, dreams), but only in some limited circumstances are these thoughts indicative of dangerousness. In particular Baer identifies these key indicators: If you do not feel upset about the thoughts instead find them pleasurable If you have ever acted on violent or sexual thoughts or urges in the past If you hear voices, think people are against you or see things that others do not see If you feel uncontrollable anger and find it hard to resist urges to act on your aggressive impulses. In the father’s case none of these features applied, and as is well established the greatest predictor of future behaviour is past behaviour. There was, and still is, no evidence of violence in the father’s history. It should also be noted that although this Review has paid considerable attention to the father’s depression and the professional response to this, we do not know to what degree his mental health, rather than underlying personality traits, may have played a part in his subsequent actions. 3.3.18. A limited body of research is available about the phenomenon of parents who intentionally kill their children, and sometimes themselves, in the context of parental separation. What is known is that this is a rare occurrence although one which takes place with a steady frequency from one year to the next. A major study by O’Hagan12 identified 128 cases of filicide over an 18 year period which would translate to 7 or 8 such cases each year. Analysis of the available statistical information by Berry et al13 in 2013 highlighted that in England and Wales there was an average of 4 parental homicides followed by suicide annually. Whilst the persistent nature of these deaths over time is of serious concern, the very small numbers involved mean that it is extremely difficult to develop a means to identify those parents with the potential to kill their children in this manner. Whilst similarities have been identified between those who kill, thousands of others who share the same traits or indicators do not follow the same path. 3.3.19. Based on the information that was available to the professionals involved with the father, it is not surprising, nor unjustified, that the focus was predominantly on his risk to himself rather than on a risk of violence towards others. In reviewing whether or not professionals could have concluded that the father presented a risk of serious harm to Child G, not only the information provided by the agencies about his presentation has been taken into account, but also the views of his family. Child G’s mother clearly remains bewildered that he could have taken the actions he did. She had seen no evidence of behaviour that would lead her to consider he could harm his daughter. She had not prevented him having any contact with 11 Baer, L 2001 12 O’Hagan, K 2014 13 Berry et al, June 2013 23 Child G after he left the home and had no intention of doing so in the future. She recognised that there were limits to his parenting capacity, but agreed that he should have a significant level of time with his daughter, which she would not have done had she had any indicator of concern. The consistent picture of the father is a man who had periods of depression and was isolated and lonely, that the breakdown of his marriage represented a significant loss for him, but that he showed no indicators such as anger or aggression. Even with hindsight, it is difficult to identify that this was a man who posed such a risk. 4 CONCLUDING COMMENTS 4.1. The purpose of a Serious Case Review is to learn from the case in order that improvements to practice can be put in place to help families in the future. The particularly disturbing nature of the events outlined in this review and the profound impact these events have had on those who loved Child G rightly demanded a careful analysis of what took place. 4.2. What has been evident during this examination of practice has been the depth of professional concern and personal distress for all who have been involved with this family. The events, and the subsequent processes for the 3 linked reviews, have identified areas for learning and improvement and it is evident that there has been a clear desire amongst professionals to reflect and learn. 4.3. Although it is tempting to seek to identify points at which the Father’s intentions could have been thwarted, there is little if anything to suggest that this would have been possible during the short time period during which he accessed services. On the basis of the information to them, neither the professionals involved, nor Child G’s mother, had reason to believe the father had the capacity to commit such an appalling action. 5 RECOMMENDATIONS FOR THE BOARDS Recommendation 1: That the systems for sharing information amongst all agencies involved in the assessment of risk to both adults and children are reviewed and effectively aligned. Recommendation 2: That the Isle of Wight Safeguarding Adults Board and the Isle of Wight Safeguarding Children Board develop a shared strategic approach to ‘Think Family’ for the Isle of Wight and agree priority areas for development within their annual planning. Recommendation 3: The Isle of Wight Safeguarding Children Board to work with its partner SCBs to 24 a) review the current 4LSCB Joint Working Protocol for safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress with a view to developing a more accessible document with practitioner friendly information for the wider multi-agency partnership. b) seek assurance from partner agencies that effective means have been put in place for developing staff knowledge and practice as identified within the Joint Working Protocol. Recommendation 4: That action is taken to ensure that professionals know when undertaking risk assessments with adults, that it is the parental response to any caring responsibilities for children, not the children themselves, that may be considered a protective factor. Recommendation 5 (for Health partners): A plan to be put in place between the IOW CCG and the IOW NHS Trust to develop the professional understanding between primary health care and mental health services of their roles and operating procedures. 25 REFERENCES Baer, L: The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts (2001) Berry et al: Parents who commit suicide after killing their children. (Family Law) June (2013) Centre for Suicide Research, University of Oxford; Assessment of suicide risk in people with depression (undated) Home Office: Controlling or Coercive Behaviour in an Intimate or Family Relationship (2015) HM Govt: Working Together to Safeguard Children. (2015) O’Hagan, K: (2014) Filicide-Suicide. The Killing of Children in the context of separation, divorce and custody disputes. 26 Appendix A: Terms of Reference Areas for Consideration (a) IOW Safeguarding Children Board: 7. Was there sufficient awareness, understanding and application by the agencies involved of the 4LSCB Joint Working Protocol for safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress - with particular emphasis on Part 3 of the protocol? 8. Was sufficient priority given to the needs and safety of the child by the agencies involved and were the risks to the child effectively assessed in the context of the father’s mental health issues? Was there a perception by involved agencies that the child could be seen as a protective factor? 9. Were there missed opportunities by the agencies involved for interventions to have been put in place to minimise risks to the child and promote protective factors. 10. Should a referral have been made to CSC by the agencies involved when the father was expressing that he might harm himself? (b) IOW Safeguarding Adult Board: 1. To explore the links between adult safeguarding and child safeguarding procedures and pathways including how the MASH assesses referrals for linked cases on the IOW 2. Was the male identified as an ‘at risk’ adult within the terms of the Care Act 2014. (c) IOW NHS Trust (mental health) 1. To establish if the process for receiving the CA12 was processed in line with policy, procedure and best practice guidance. To explore and comment on the responsibilities of the relevant organisations when receiving a CA12. 2. To examine if the decision taken on receipt of theCA12 was appropriate to the concerns being raised by the police. Was the decision taken by the clinician at the point of assessing the CA12 appropriate? 3. Was the response of the Mental Health service appropriate for a primary care patient referred into community services? 4. Were sufficient risk assessment and treatment plans in place to safeguard the individual and his family? 5. Could there have been any additional safeguarding steps considered or taken for other members of the household. Should a referral have been made for the child of the household to any other agency? 27 (d) IOW Primary Care (for the adult male) Communication and information sharing: 1. To examine the mechanisms and processes within primary care for practice based staff to raise, discuss and share safeguarding concerns with each other. 2. To examine the mechanisms and processes within primary care for practice based staff to share information and intelligence regarding different household members, where vulnerability and risk exist. 3. To examine the communication intervals/standards between mental health and primary care services both at the point of urgent referral and during the receipt of any IAPT provision. Systems and policies: 4. To examine the available mechanisms within primary care, for the flagging of individuals and/or creation of automated alerts regarding known vulnerabilities and risk for individuals, e.g. Domestic Violence, Mental Health, Safeguarding Concerns (CYP & CA12 forms); as well as examine the mechanisms for mapping these alerts and flags to other family/household members. 5. To examine primary care processes for the recommendation and/or referral of parents to Early Help Services for advice and support and the follow up of this. 6. To examine the policies, processes and pathways which enable primary care to access urgent mental health assessment both in and out of hours and what the criteria and response time parameters are for such requests. 7. To examine what the processes are within primary care which support practice staff in access to peer or specialist review of individuals with chronic mental health conditions. 8. To examine the policies and processes across primary care in relation to the transfer of information between GPs when patients deregister from one practice and register at a new one Workforce knowledge and understanding: 9. To examine awareness, understanding and application of the 4LSCB Joint Working Protocol for Safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress. 10. To explore primary care understanding regarding the risks and vulnerabilities for children of parents with: mental health, substance misuse, learning disability and emotional or psychological distress, to include exploration of understanding in relation to the need for explicit documentation of the consideration of parenting capacity at the point of parental mental health diagnosis and thereafter as appropriate. 28 11. To review primary care staff training in relation to adult safeguarding and their understanding of what they need to do in the presence of safeguarding concerns. 12. To examine the support mechanisms for practice staff following significant events like a MHH. (e) IOW Primary Care (for the child) Communication and information sharing: 1. To examine the mechanisms and processes within primary care for practice based staff to raise, discuss and share safeguarding concerns with each other. 2. To examine the mechanisms and processes within primary care for practice based staff to share information and intelligence regarding different household members, where vulnerability and risk exist. Systems and policies: 3. To examine the available mechanisms within primary care, for the flagging of individuals and/or creation of automated alerts regarding known vulnerabilities and risk for individuals, e.g. Domestic Violence, Mental Health, Safeguarding Concerns (CYP & CA12 forms); as well as examine the mechanisms for mapping these alerts and flags to other family/household members. 4. To examine awareness, understanding and application of the 4LSCB Joint Working Protocol for Safeguarding children and young people whose parents/carers have problems with: mental health, substance misuse, learning disability and emotional or psychological distress. 5. To examine the processes across multi-agency partners which assure the awareness and monitoring of the well-being of children where the parent is known to have issues with mental health, substance misuse, learning disability and emotional or psychological distress. 6. To examine primary care processes for the recommendation and/or referral of parents to Early Help Services for advice and support and the follow up of this. 7. To examine if there are any established processes which assure that the voice of the child is heard and their lived experience elicited when living with a parent with issues with mental health, substance misuse, learning disability and emotional or psychological distress. Workforce knowledge and understanding: 8. To explore primary care understanding regarding the risks and vulnerabilities for children of parents with: mental health, substance misuse, learning disability and emotional or psychological distress, to include exploration of understanding in relation to the need for explicit 29 documentation of the consideration of parenting capacity at the point of parental mental health diagnosis and thereafter as appropriate. 9. To review primary care staff training in relation to child safeguarding and their understanding of what they need to do in the presence of child safeguarding concerns. 10. To examine the support mechanisms for practice staff following significant events like a child death 30 APPENDIX B: RECOMMENDATIONS MADE BY NHS SIRI reports Isle of Wight NHS Trust RECOMMENDATIONS 1. There is liaison between the Adult Safeguarding team both within the Council and the Trust, the Police and the SPA team to gain an understanding of CA12 processes within all organisations. 2. Information gathered at the above meeting should be clearly set out for information within the CRHT SOP. 3. The draft CRHT SOP is reviewed and amended to include clear expectations of what referral information will be documented, and where is should be documented. 4. A plan should be put in place with the Clinical Lead SPA, the CRHT Team Leader and the Matron to ensure that protected time to monitor and develop practice within the team is facilitated. 5. A review of what the ‘on hold’ process was achieving should be carried out, so that any positive factors are not lost in removing the system. 6. A written protocol for liaison and referral between IAPT and SPA should be written. 7. Communication should be given to staff regarding the required standards for documenting risk assessments – to include risk formulation. 8. Work is undertaken to ensure that the content of the 4LSCB Joint Working Protocol is embedded within all mental health teams. 9. There should be work undertaken within the Trust in partnership with the Local Authority to ensure timely availability of Safeguarding Children Training Level 3. 10. Planned changes to the PARIS patient record should support the routine assessment of risks to dependents. 11. All teams within the service should have some level of access to other systems used within the Clinical Business Unit. i.e. IAPTUS, BOMIC, PARIS. 31 Isle of Wight Clinical Commissioning Group (Primary Health Care) 1. GP practices to hold monthly meetings to discuss safeguarding cases 2. Family/household members to be mapped to each other on System One along with their flags to promote dialogue between colleagues within a practice 3. A training matrix to be shared across Primary care identifying level, frequency length and mode of safeguarding training for each staff role 4. Capacity for practice based safeguarding training to be developed via the GP leads for safeguarding, to complement the multi-agency training offered by LSCB 5. There is a need to examine with some urgency whether flags ad alerts have migrated from prior EPRs to System One. 6. Designated GP to review all CA12s received for their patients and summarise for an alert on System One, so that any other GP or primary care practitioner seeing the patient can review, be mindful of and undertake any action required 7. Primary care to agree a standard process for managing new and old flags/alerts 8. An awareness raising exercise in relation to the JWP to be undertaken across Primary care 9. The JWP to be condensed into a small number of key pages and the flowchart it currently includes 10. Capacity for practice based safeguarding training to be developed via the GP leads for safeguarding, to complement the multi-agency training offered by LSCB 11. Need to establish the extent of the issues via: Primary care audit into current structure and frequency of safeguarding case discussion Early Help Audit into referrals received by Primary Care and feedback frequency & timescales Adult mental Health Audit into referrer feedback and feedback to Primary Care in general 12. There is a need for standardisation and compliance across Primary care in relation to: Common key policies, procedures and processes Safeguarding policies and procedures Safeguarding training Use of flags and alerts Risk assessment and evidencing parenting capacity assessment 13. Need to provide information and/or guidance to increase clinician understanding in relation to these key issues: 32 Children as protective factors CBT in people with LD Information sharing 14. Monthly newsletter to be circulated and to include lessons learned |
NC50805 | Death of a 6-month-old infant due to a non-accidental head injury in June 2016. Father called an ambulance to Child A's home as he had found Child A floppy. The Child could not be revived and a forensic post-mortem confirmed a severe bleed to Child A's brain. Mother had been known to Adult Mental Health Services since 2010 and previously to Child and Adolescent Mental Health Services; she had been discharged to GP care and her mental health was stable. Father had a history of depression due to breakdown of a previous relationship and not seeing his child. Family is white British. Learning: not all professionals have the same level of expertise in all areas of practice, so use of those with expert knowledge, e.g. mental health, can provide a more in depth understanding of the client; robust communication is key in understanding concerns across all agencies particularly where there is cross border working; NICE guidance indicates that routine enquiry into domestic abuse should be undertaken during pregnancy. Uses a mixed methods approach based on systems methodology. Recommendations include: hearing the voice of the child, particularly for younger children, where parental issues may be the more obvious focal point; understanding of coercive control; to formulate guidance on the importance of engaging with fathers; to reconsider the effectiveness of prescriptive thresholds guidance; robust systems in place to share information relating to safeguarding concerns; to implement a communication model across partner agencies. Please note that this report was written in February 2017 but was published in November 2018.
| Title: Serious case review case 5: Child A: overview report. LSCB: Walsall Safeguarding Children Board Author: Karen Rees Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Walsall Safeguarding Children Board Better Together for Children www.wlscb.org.uk Serious Case Review Case 5 Child A Overview Report Author: Karen Rees Presented to Walsall Safeguarding Children Board (WSCB) February 2017 2 CONTENTS 1 Introduction 3 2 Circumstances leading to the review 3 3 Methodology 3 4 Reviewer 5 5 Process and Scope 5 6 Parallel Processes and Family Engagement 5 7 Background Prior to Scoping 6 8 Key Phases 7 9 Thematic Analysis 19 10 Good Practice 32 11 Conclusion and Learning 33 12 Recommendations 35 Appendix 1: Terms of Reference (Redacted for publication) 38 Appendix 2: Falkov’s Crossing Bridges Model 42 Appendix 3: Pathways to harm, pathways to protection 43 Appendix 4: A Model of Communication 44 3 1. Introduction 1.1. This Serious Case Review is undertaken following a notification of a childcare incident to Ofsted on 12th June 2016 and subsequent discussions with the National Panel which concluded that the criteria for a Serious Case Review was met. 1.2. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. 1.3. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: abuse or neglect of a child is known or suspected; and either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.4. The request for a Serious Case Review was agreed by the Independent Chair of the WSCB on 19th July 2016. 2. Circumstances Leading to the Review 2.1. An ambulance was called to the home of Child A by Father in June 2016. He informed the call handler that he had gone to get Child A’s bottle, came back and found that Child A was floppy. 2.2. Child A was brought into Area B’s (see 5.2 below) Accident and Emergency Unit. Upon arrival, there were no signs of life. Cardiopulmonary respiration was being performed by paramedics and resuscitation continued. Child A could not be revived. 2.3. On examination Child A had a very small bruise on the right side of the face. Child A had no major injuries but there was evidence of a bilateral haemorrhage in that both the eyes were cloudy. No other injuries were found. A forensic post-mortem was carried out; this confirmed that there was a severe bleed to Child A’s brain; Child A was six months old at the time of the incident; the sibling was 19 months old. 3. Methodology 3.1. Working Together to Safeguard Children 20151 does not prescribe a fixed methodology for Serious Case Reviews, but states that reviews should be conducted in a way in which; 1 HM Government (2015) Working Together to Safeguard Children 4 recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 3.2. This serious case review used a mixed methods approach based on systems methodology. Individual Management Reviews (IMRs) and Chronologies were requested from the agencies that had provided services to Child A and the family. A panel of professionals from the Safeguarding Children Board Serious Case and Significant Incident subcommittee (SCSISC) met to quality assure the material that had been provided by agencies before onward circulation and again to review the overview report and provide a degree of governance to the review process. IMRs/Written Reports were received from (see further details 5.2) Clinical Commissioning Group (CCG) Area A (GP; Area of residence and Father’s GP) CCG Area B (GP; Mother and Children’s GP) Hospital Trust Area A (Health Visiting, Inpatient and community midwifery post-delivery, ante natal outpatients) Hospital Trust Area B (Accident and Emergency, Ante Natal Community Midwifery) Mental Health Team Area A (Psychiatric Liaison Serves to Hospital Area A) Mental Health Team Area B (Mental Health Services to Mother) Local Housing Group Local authority Area A (Children’s Social Care and Early Help) Police Ambulance Service Nil Returns were received from; Substance misuse services Children and Family Court Advisory and Support Service Probation Services Walk in Centres (Area A) 3.3. Members of the panel, practitioners and their line managers, report authors and safeguarding leads came together for two Practitioner Learning and Reflection Days (PLRD). It is of note, however, that many of the practitioners that were involved with the family during the timeframe of the review are no longer in post but all agencies were represented. Attendees at the first PLRD had an opportunity to review all the IMRs prior to and during the day. The PLRD also included group work whereby attendees identified areas where learning had occurred. The second day enabled a review of the emerging themes, learning and recommendations. In keeping with Working Together 2015 guidance, the PLRDs ensured full engagement from agencies who had provided services to the family and attempted to understand the systems that practitioners were working within to understand why practitioners practiced in the way that they did and how they made decisions. 5 4. The Reviewer 4.1. Karen Rees is an Independent Safeguarding Consultant with a nursing background. Karen worked in Safeguarding roles in the NHS for a number of years. Karen is completely independent of WSCB and its partner agencies. 5. Process and Scope 5.1. Full Terms of Reference and Project plan were agreed at a meeting of the SCSISC on 3rd August 2016 and are attached as Appendix 1. 5.2. For the purposes of this review health agencies will be known by the service that was provided and by area that it was provided from. The family lived close to the local authority border and health services were received from two areas. (Area A being the area in which the family resided and Area B being the neighbouring authority area). All other services either worked across borders e.g. Ambulance and Police or service was only received based on address e.g. Early Help, Children’s Social Care and housing provider. Agency Services Provided within the Scope of Review GP Area A Primary care to Father GP Area B Primary care to Mother and children Hospital Area A Inpatient and outpatient midwifery, post-natal community midwifery at home, health visiting to family. Hospital Area B Community midwifery at GP practice A and E service at time of death, health visiting Services to GP Practice Area B Mental Health Team Area A Psychiatric liaison Services to Hospital in Area A Mental Health Team Area B Commissioned to provide services to adults with Mental Health Issues who are registered with GPs in Area B (i.e. Mother) 6. Parallel Processes and Family Engagement 6.1. At the time of conducting this review there was an open coroner’s inquest and ongoing criminal investigations. The Coroner was made aware of the Serious Case Review. 6.2. The criminal investigation was in its early stages. The author contacted the officer in charge of the investigation in order to seek consent to provisionally speak to the family about their experience of the services they had received. Working Together 2015, states that family members should be invited to contribute to reviews. The author was mindful of guidance available from Association of Chief Police Officers and Crown Prosecution Service2 to support the liaison and information 2 Association of Chief Police Officers and CPS (2014) Liaison and information exchange when criminal 6 exchange when there are parallel processes. West Midlands Police consented to professionals taking part in the PLRD. 6.3. Although the guidance gives advice about how to involve family members without jeopardising the criminal proceedings, West Midlands Police did not give consent for the family to be approached by the author prior to the conclusion of the criminal investigation. This decision was respected and therefore arrangements to meet with the family were not possible leading to gaps in the ability to gather the views and perspectives of the family on information provided by professionals in the interim report. 6.4. The family were therefore informed about the review in writing and sent a leaflet about the method of conducting the review including the use of family records. Arrangements were made to meet with Mother and Father following the conclusion of the criminal justice processes. Mother and Father’s views are included in relevant sections throughout the report. 6.5. Both grandmothers were also contacted but It was not possible to engage with them and therefore their views are not included. 6.6. This review was initially written without involvement of the family and was interim until the family could be involved. This did not, however, prevent lessons being learned in how agencies worked together, nor did it prevent recommendations and learning being applied across agencies. 6.7. The IMR for the GP in Area B, who the mother and children were registered with, indicated that as consent from Mother could not be gained, the GP agreed to meet with the GP IMR author and share relevant and proportionate information to produce their IMR. This is in keeping with guidance obtained locally and nationally. 6.8. Following the first PLRD, the GP practice contacted Mother and gained her consent for her records to be used for the review, leading to more information available at the second PLRD. 7. Background Prior to Scoping Period 7.1. Much of the background of Child A’s family comes from the Police IMR. Child A was the second born to parents with the sibling having been born 13 months previously. Parents had been in a relationship for approximately 3 years. At the time that Child A died, the family were living in a two-bedroom ground floor flat rented from the local housing group. Information suggests that very soon after starting their relationship they became inseparable and before moving to their own property they lived with both extended households. Neither parent worked, relied on welfare benefits and lived in social housing. They are both White British and lived in an area where this population formed the largest single ethnic group. proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews 7 7.2. Mother concurred with this knowledge of the couple’s background and cited that they were like ‘Siamese twins’ and did everything together. Father also agreed that they were always together. 7.3. The family lived very close to the neighbouring authority border and this did present some complexity in the multi-agency working with services provided by both areas at differing times. 7.4. Mother had been known to Adult Mental Health Services in Mental Health Trust B since 2010 and previously known to Child and Adolescent Mental Health Services. She was initially diagnosed with paranoid schizophrenia3 and was known to the Early Intervention Psychosis Service4. Her care transferred to the Complex Care Team5 when her diagnosis was changed to borderline personality disorder6. This change in diagnosis and the impact of Mother’s mental health diagnosis on her parenting was subject to debate and discussion during the PLRD. This is subject to further analysis within this review (See Section 9.2). Maternal is recorded as a carer for Mother and this role later switched to Child A’s Father. 7.5. Agencies were not able to provide any background information related to Father, although it did come to light during the review that his GP was aware that he had a child by a previous relationship that he had no contact with. 8. Key Phases 8.1. For the purposes of this review the journey of the children’s story will be highlighted using relevant information in key phases that inform the later areas for analysis. Relevant information from the IMRs was extracted and discussed in the PLRD seeking to understand the multiagency working and learning. 8.2. It is of note that prior to the scoping period the family were not known to Children’s Social Care. Mother had been discharged from mental health services to the care of her GP, who reported that her mental health was stable and she remained very well. Key Phase 1: First pregnancy to delivery of first child (February to November 2014) 3 Paranoid schizophrenia is a sub-type of schizophrenia. It has been the most common type of schizophrenia. Schizophrenia is defined as “a chronic mental disorder in which a person loses touch with reality (psychosis). The clinical picture is dominated by relatively stable and often persecutory delusions that are usually accompanied by hallucinations, particularly of the auditory variety (hearing voices), and perceptual disturbances. These symptoms can have a huge effect on functioning and can negatively affect quality of life. Paranoid schizophrenia is a lifelong disease, but with proper treatment, a person with the illness can attain a higher quality of life. 4 Early Intervention Service – This team support young people and adults aged 14 to 35 who are going through a first episode of psychosis, or who seem at risk of going through a first episode of psychosis. 5 Complex Care Service - This service provides community support to people with severe and enduring mental health problems such as schizophrenia and bipolar disorder. The team is a multidisciplinary team that includes specialists in personality disorder. 6Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of ongoing instability in moods, behaviour, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships. A person with BPD may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days. Some people with BPD also have high rates of co-occurring mental disorders, such as mood disorders, anxiety disorders, and eating disorders, along with substance abuse, self-harm, suicidal thinking and behaviours, and suicide. While mental health experts now generally agree that the label "borderline personality disorder" is very misleading, a more accurate term does not exist yet. 8 8.3. The couple first came to the attention of services when an application for housing was made to a local social housing group. The online application was completed In April 2014 by Child A’s Mother. This stated that she was currently living with her mother and siblings and would need her own home as she was expecting her first child. Mother did not include any partner in this application. 8.4. During early and mid 2014 Child A’s Father consulted his GP with feelings of depression due to the breakdown of his previous relationship and not seeing his child. Father concurred that he struggled emotionally not seeing his child. In keeping with the practice protocol for mild depression7, he was given a self-help leaflet. The practice protocol also includes information being given to patients about the service of a Community Psychiatric Nurse within the practice. Child A’s Father did not access this facility. He attended later in 2014 when it was decided to commence medication. During this time, he was not reviewed by the GP and although sick notes were issued for depression, he did not have any further medication. In the latter part of 2014 Father attended his GP on another matter; depression was still noted. There was no exploration of Father’s current social situation. The practice was not aware of his new relationship or any children from that relationship, prior to notification of the childcare incident in 2016. 8.5. In May 2014 the Community Midwife from Area B forwarded an ante natal risk assessment to Area A Hospital (the local hospital for the area that Mother lived). The risk assessment detailed a diagnosis of paranoid schizophrenia. This constituted a referral for shared care between GP and consultant, in line with the mental health pathway for pregnant women. The assessment advised that Mother was currently not taking any medication. At this time, there was no other action. 8.6. Mother told the author that she was very happy to be pregnant. She stated that from the age of 19, she had wanted to have a baby and have her own family. Father also expressed this view and stated that he was excited to be a father. 8.7. A few weeks later the ambulance service was called to the address of Maternal Grandmother due to a report that Mother was 13 weeks pregnant, had fallen and was bleeding. The ambulance report stated that following a full assessment there was no reason to transport to hospital. It was agreed that she would self-present to Accident and Emergency for further examination. No other agency appears to have detailed this incident in their records; the IMRs for Area A and B hospitals do not detail an attendance at this time. It is therefore not known whether Mother attended another facility, or whether she changed her mind about attending Accident and Emergency. 8.8. In June 2014, the Named Midwife for Safeguarding at Area A Hospital received a call from the Community Midwife in Area B. The midwife expanded on the mental health history, she stated that mother had been diagnosed with Schizophrenia in 2010 and sectioned under the Mental Health Act. 7 Depression is a common mental health problem – it affects nearly 1 in 6 people in the UK. The main symptoms of depression are losing pleasure in things that were once enjoyable and losing interest in other people and usual activities. A person with depression may also commonly experience some of the following: feeling tearful, irritable or tired most of the time, changes in appetite, and problems with sleep, concentration and memory. Possible first treatments for mild to moderate depression include a self-help programme, a treatment called computerised cognitive behavioural therapy and a physical activity programme (exercise). - NICE Guidance 9 The information stated that the GP had not confirmed the diagnosis. It appeared that the GP would need to make a referral back to the mental health team, as Mother had not been seen by them for a considerable amount of time. 8.9. Information received from the GP practice, indicates that the referral was made in July 2014. This was following a conversation between the community midwife, the GP and a review with Mother. Mother had stopped her medication and was feeling well. The GP referral did not reference the diagnosis as she was well known to mental health services; the records showed the diagnosis of borderline personality disorder following the mental health review in 2013. 8.10. This referral back to mental health services when Mother became pregnant, was in line with the Perinatal Mental Health Pathway. The GP wrote a complex letter to the Mental Health Team. The referral was declined, as the GP referred due to concerns expressed by the midwife regarding the medication but had not detailed any concerns of a mental health nature. Indeed, information from the GP records state that Mother was clinically stable. 8.11. The information given to Area A Hospital by the midwife, did not give details of any concerning behaviours or concerns for current mental health state, that may have indicated a risk to an unborn baby at this point. Details from the GP record indicated that the midwife was contacting the GP about Mother stopping medication. It was clarified that she had done this because she was worried about the effect on the baby. Mother, on meeting the author, concurred that this decision had been her decision, that she felt very well and did not need her medication. She stated that the medication was an antidepressant and not an antipsychotic. 8.12. Because of the conversation detailed above, the Community Midwife agreed to make a referral to Children’s Social Care. There is no record that Mother knew about this referral; Mother and Father told the author that they were not told about this referral. The referral was received by the Multi Agency Screening Team in social care at the end of June 2014. It detailed concerns as above but indicated that the diagnosis, according to the GP records was psychosis, self-harm, overdose and personality disorder. It stated that Mother was not taking her medication and was not engaging with her GP. It is not clear what the ‘non-engagement’ related to as the GP records and IMR do not indicate this. It may have been that this was more about non-compliance from a medication perspective rather than non-engagement. The referral also detailed that Mother had stated that she had a previous miscarriage and had become upset when she detailed this. Records do not show any previous pregnancy. This added to the concern the Midwife was raising. There is not any mention of a partner or other family in this referral that would indicate the level of support that Mother had. 8.13. The duty social worker discussed this referral with the team manager. It was agreed that there would be no further action at this point and the Midwife would be advised to offer Early Help support to Mother. There is no record that this was communicated to the Midwife, even though the social care records indicated that it was agreed that the Early Help Coordinator would inform the named midwife for safeguarding of the advice for Early Help referral. This did not lead to any Early Help offer at this point. The PLRD events heard that feedback to referrers was an issue at this time but that following concerted work, there is now always a letter back to referrers detailing the outcome. 10 8.14. At the end of August 2014, Police were called to the home address of Paternal Grandmother. The log detailed an altercation between Child A’s parents and Paternal Grandmother with whom they had been residing. Paternal Grandmother had asked parents to leave as she felt that they had taken over her house. They had refused. Officers responded to this as a domestic abuse incident; they attended the property where they found that the couple had packed up and were in the process of leaving, stating that they had made arrangements to move to stay with Maternal Grandmother. Mother and Father both recall this incident as an argument over the financial contribution paid by Mother and Father to Paternal Grandmother for living costs. 8.15. This incident did not lead to a referral to the DART8 at the time as only incidences involving families where there were children, or a pregnancy were subject to this process. Given the nature of the incident and the absence of evidence of any children who could have been at risk, this was in accordance with policy. Mother did not appear to be pregnant to the officers and this was not disclosed as an issue by anyone at the address (she would have been 6 months pregnant at this point). There was a discussion at the PLRD that mother had a high Body Mass Index9 (BMI) and midwifery colleagues confirmed that pregnancy may not be noticeable in women with a high BMI. 8.16. The ambulance service received a call in October 2014 in respect of Mother, with a report of waters having broken and that she was experiencing contractions. Mother was found lying on the floor outside the property. She was conveyed to hospital. Hospital staff found no evidence of premature labour. It is not detailed by the Ambulance Service or the Hospital whether anyone was in attendance with Mother. Mother disclosed that she had been taken off her medication for schizophrenia by her GP. Mother also informed an unknown practitioner (there is a note in the records but it is not signed) that there was a domestic happening at home and stated there was lots of shouting. None of the information gathered related to mother lying on floor outside property, mental health medication or the reported ‘domestic at home’ was explored further by any of the staff who had contact with her during this episode. 8.17. Five days later, Mother was reviewed at Hospital A following the above attendance, she reported she was not taking her medication but planned to restart this after the birth. She stated that her mood was up and down but was feeling positive overall and that she did not feel the need to see a community psychiatric nurse. 8.18. The next time that Mother was seen is when she was admitted in premature labour on at the beginning of December 2014. Concerns were raised by Mother that she would not stay on the ward if her partner could not be with her. It was documented that she attended the ward for examinations and pain relief but stayed where she could be with her partner for the rest of the time. Father told the author that Mother liked him to be with her and that she often asked him not to go out if she was not going with him. 8 Domestic Abuse Response Team: at the time, all referrals were sent to the team for planning protection of children and victims. This was only where there were children or a pregnancy within the family 9 The body mass index (BMI) is a value derived from the mass (weight) and height of an individual. The BMI is an attempt to quantify the amount of tissue mass (muscle, fat, and bone) in an individual, and then categorize that person as underweight, normal weight, overweight, or obese based on that value. 11 8.19. When she did arrive on the delivery suite, she was reported to be emotional and had no belongings with her. Mother stated her partner could not go and collect them as they had no money. Mother was provided with a gown and other sundries that she needed. Mother again left the delivery suite on several occasions and had to be called back to be reviewed by the consultant. There was no exploration of the reasons for having attended hospital with no belongings or any further assessment of her social, financial or mental health situation at this point. Domestic abuse enquiry was not undertaken either as part of routine admission assessment or as a result of concerns noted. 8.20. On the same day, a midwife contacted the Health Visitor expressing concerns that Mother was due to deliver, had a diagnosis of schizophrenia and irrational behaviour but engaged with health. This liaison was good, and the health visiting records record the conversation. The records do not show the outcome of any assessment of this information or how this information would be used to inform the future health visiting offer to the family. It is not clear what the irrational behaviour referred to nor whether the midwife was referring to information from Mother self-reporting her diagnosis, from professional conversation or records. It is of note that it is not possible to tell from any records whether this was a community midwife from Area B or a hospital midwife from Area A. 8.21. Further concerns were recorded in midwifery records that Mother was asking to leave the ward for a cigarette whilst in labour. She was on an intravenous drip and advised that it was not appropriate to leave the ward during labour and she did not ask to leave again. Key Phase 2: Birth of Sibling to 2nd Pregnancy (November 2014- May 2015) 8.22. There was a lot of activity in this phase and the information below reports a summary of the events that occurred and the key points that will inform the analysis. 8.23. The period immediately following delivery of sibling showed further concerns expressed by midwifery staff of the parents being off the ward for extended periods of time. At the PLRD there were discussions related to this, leading to conclusions that the absences were over and above what would be expected to be usual for new parents. The baby was prescribed antibiotics as a preventative measure due to infection risk from prematurity and spontaneous rupture of membranes. The baby also required nursing on a ‘Cosy Therm’ mattress10. Parents, although aware of the need to take the baby to the special care baby unit for the medication and the times that medication was due, were not on the ward at this time. A midwife also recorded concerns of the parents’ ability to cope with the demands of parenting. There were also positive aspects noted on occasions with Mother giving appropriate care and when spoken to about being away from the ward parents did not leave again. There is no recording of which elements of parenting were of specific concern. A debate at the PLRD centred on whether the issues pointed to possible bonding concerns; it was agreed that there were some indicators of this but no real recorded evidence of ongoing concern. There was no exploration at this time of the support that the parents would have on discharge from family and friends. 8.24. When the baby was two days old a further telephone call was made by midwifery staff to Children’s Social Care expressing concerns that parents were leaving the baby. The Midwife was advised to 10 Cosy Therm mattress supplies regulated heat to prevent hypothermia in new-born babies. 12 observe. There is no exploration as to where or why parents were leaving the ward. It is not clear if parents were aware that contact was being made with Children’s Social Care. This contact resulted in advice to offer Early Help. 8.25. Mother told the author that she was very scared that her baby was ill and could not cope with seeing her baby receiving treatment under a lamp and with goggles on. Mother stated that no one asked her why she was leaving and that no one explained what was happening to her baby and she became emotional. Mother stated that it was her own mother who reassured her. 8.26. A midwife discussed the offer of Early Help support but Mother declined as she stated that she had good support at home from Maternal Grandmother who was also detailed as Mother’s carer.11 Carer would have been a term that Mother would have been used to during her time in mental health services. This was the first time that midwifery staff were aware that Mother had a carer. As Mother was well at this time it is likely that the carer role was minimal at this point. 8.27. During this inpatient admission, a doctor recognised that there had been no formal assessment of Mother’s mental health and duly referred to the Mental Health Team in Area A who provide a mental health liaison service to the hospital. The referral detailed concerns about a lady with schizophrenia who had stopped taking her medication during pregnancy and had no planned mental health follow up. The Community Nurse Specialist visited the ward and had a discussion with a midwife prior to seeing Mother. The Midwife reported no concerns with mental health and that Mother had been interacting and caring for her baby well. The Nurse Specialist saw Mother with Father and found her to be well with no obvious evidence of current mental illness. Mother declined a full mental health assessment but showed good insight into her illness and treatment and stated that she planned to see her GP to restart medication if necessary. She appeared to be open about her previous mental health illnesses and admissions but stated that she had been well for the last 18 months; Father concurred with this. Mother gave consent for the nurse to contact Maternal Grandmother, which she did; no concerns were identified. 8.28. The Nurse Specialist contacted the Mental Health Team in Area B who confirmed that Mother had remained well and care had been transferred to her GP. No contact was made with the GP by the Nurse Specialist for any further information. The Nurse Specialist was not made aware of the other concerns that had been raised by various midwives during this admission or previously. The Nurse specialist did not appear to know that further contact had been made with Children’s Social Care earlier that day or that Mother had declined the offer of Early Help. 8.29. The next day, further concerns were raised by a midwife as parents had stated they were tired. These were discussed with the parents and Mother stated that she would need her medication and would arrange for someone to bring it in. Mother said that although she now had her own property, she would be going home to Maternal Grandmother’s house and that her mother was a good source of support. Early Help was again offered and this time accepted. 11 A carer anyone who provides support for a relative, friend or neighbour. A carer is not paid for their role, and is different from a paid professional like a care worker or home help. 13 8.30. The next day an Early Help referral was received having been signed by Mother. Mother told the author that her own mother had advised her to accept the Early Help so that they could see she was a good parent and would not take her baby from her. 8.31. It appears that Mother and baby were discharged home to the home of Maternal Grandmother, at some point on the same day and the community midwife visited the family home the next day. It does not appear that there was any handover from the hospital of any concerns that the hospital had raised or about the referral to Early Help. The transfer sheet from the hospital to health visitor did detail an Early Help referral but not the detail as to why this was required. The Community Midwife saw Mother and baby on a few more occasions but did not detail any further recording of observations related to the concern that the hospital had raised. 8.32. The first contact with the Health Visitor was in accordance with the Healthy Child Programme (HCP)12 provided for those in receipt of Universal Services (at this time ante natal contact in Area A was not universally achieved). The Health Visitor recorded no concerns with the baby. The family were advised about not smoking around the baby and safe sleeping advice was given. The Health Visitor noted that Mother was very open about her mental health history and that she was due to see her GP to review her medication. The Health Visitor recorded no concerns regarding mental health and used her knowledge and skills from her previous role as a mental health nurse, recording that Mother engaged appropriately. There was no recording of the role that Father played or the home environment. Exploring this further at the PLRD, the Health Visitor stated that there were no concerns about the environment and that this was Maternal Grandmother’s home. Father and grandmother were noted to be present and therefore, following NICE guidance, routine domestic abuse screening was not completed. 8.33. The Early Help Family Support Worker contacted the family and visited the home. Recording detailed a warm and clean home and that the baby appeared well looked after and appropriately dressed but remained under the care of the midwife due to concerns about slow weight gain. Mother appeared to be open about her mental health and stated that she had started her anti depressant medication . She had not yet seen the GP. Mother stated that she did not recall signing the Early Help consent form and both her and Maternal Grandmother were clear that they did not require any support. Father was recorded as present but nothing else was recorded about him. The Early Help Support Worker contacted the Health Visitor following this visit. The health visitor affirmed that she had visited the family and that she had no concerns with no evidence on any impact of the concerns raised and that baby was well. 8.34. During this period the Early Help Support Worker continued to have contact with the family and liaised with her manager, the Health Visitor, the Mental Health Team in Area B and the GP. This was to ensure that Mother addressed the issue of her medication and that her mental health remained stable, even arranging for an appointment and accompanying her to the GP practice. This was 12 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk 14 despite the fact that the family did not consent to formal Early Help support but did not appear to mind the contact. The Health Visitor offered to talk to the family again about the Early Help offer and feedback to the support worker. She did this and again the family reaffirmed that they did not require this support. Mother told the author that she felt pressured into restarting her anti-depressant medication despite the fact that she felt well and did not feel that she needed it. Mother indicated that having her baby made her very happy and that she no longer felt any depressive symptoms. 8.35. Just before Christmas, the Health Visitor carried out the 6-8-week review, she noted that the baby was progressing as expected and recorded good attachment with Mother. This was the first real indication of the lived experience of the baby. Domestic abuse was again not assessed as Father was present. Mother was now reporting that she had a medication review with the GP and was taking an anti-psychotic and an anti-depressant. At the PLRD it was confirmed that the anti-psychotic was likely to have been used as relapse prevention rather than treatment of current psychosis. Mother was concerned that baby had a cough but that it was not affecting feeding and advice was given against smoking in the home. Nothing is recorded about Father or the home environment at this visit. Mother informed the Health Visitor that Early Help were still involved even though she did not want this service. 8.36. Following Mother’s attendance at the GP practice, the GP agreed to a referral to the Mental Health Team in Area B. Following a review of the previous notes and current identification in the referral of Mother remaining well with no concerns, the decision by the Mental Health Team was to take no further action and for her to remain under the care of her GP. 8.37. At the end of January, the Early Help Support Worker made further contact with an unannounced visit to the home of Maternal Grandmother after not getting a response by telephone earlier in the month. Mother was found to be doing well and stated she had settled well into her new home. There was no record of contact with the baby or Father at this visit. A further visit was scheduled for the next day. There is no record as to whether this visit took place. A final visit by the Early Help Support Worker took place the following week. Mother reported to be very well and seeing her GP regularly about her medication. The record shows that the baby was sitting in a baby chair and dressed appropriately for the weather. Mother was informed that she could contact Sure Start at any point if she needed further support. At this point, Early Help ended their intervention; records did not indicate that this was shared with any other professionals. 8.38. During this period the baby received immunisations as expected and no other concerns were raised. 8.39. The Health Visitor attended the family home to undertake the 3-4-month introduction to solids visit (HCP). Advice was given against adding rusk to the bottle. The home environment was recorded as being satisfactory and although an ashtray was evident with cigarette butts, Mother assured the Health Visitor that smoking only happened outside the property. The Health Visitor recorded that Mother’s mental health remained stable and described Mother as a confident lady who maintained eye contact and was appropriate in her conversation and responses. The Health Visitor advised about the benefits of floor play for the baby; at this point the family were reported to be saving for a carpet. 15 8.40. At the end of May 2015 that parents attended the GP practice as the baby had a rash. The GP recorded a ‘very happy child growing well’. This again references the lived experience of the baby and no concerns were highlighted. Key Phase 3: Pregnancy of Child A (knowledge of) to birth of Child A (June-December 2015) 8.41. The first contact in this phase was a telephone call in June 2015 from the Midwife to the Health Visitor. This was to advise that Mother was pregnant and had stopped all medication, but that Child A’s sibling was well looked after. Mother had told the midwife that she was well supported by her mother and partner and there were no concerns. No further detail of the conversation or actions related to relapse prevention or actions were recorded by the Health Visitor or the Midwife. The Health Visitor contacted Mother on the same day leaving a voicemail message requesting a call back to confirm the expected date of delivery and to book a developmental review for the sibling. 8.42. The GP made a timely referral to the Mental Health Team in Area B for review, monitoring and support with medication in this pregnancy. The Mental Health Team agreed to offer a routine outpatient appointment. 8.43. Mother attended her first ante natal appointment at Area A Hospital in July 2015 and was reviewed by a midwife and doctor. Concerns were raised about a high Body Mass Index and advice was given. Mother asked for support with stopping smoking and disclosed about her mental health and that she had stopped her medication due to her pregnancy. She informed the ante natal clinic doctor that she was seeing a community psychiatric nurse at the GP practice. This is not borne out in information obtained from the GP or the Mental Health Teams. A review of mental health was planned at 34 weeks’ gestation. No other communication occurred from the hospital at this point. 8.44. At this time, Area A hospital had introduced electronic records that had domestic abuse screening included in assessment questions. Questions related to previous and current domestic abuse can be answered by use of drop down pick lists of no/yes/declined to answer/ unable to ask. There is then a box to identify additional notes. On this occasion the ‘unable to ask’ was selected but no rationale was recorded. 8.45. In August 2015 officers from the housing group attended the family home to undertake a routine 9-month tenancy check. Every room was reviewed and the check was passed with no concerns reported. 8.46. The Health Visitor carried out a planned antenatal contact and a developmental review for Child A’s sibling at the beginning of September 2015. Sibling was reported to be meeting developmental milestones and growing as expected; it was noted that excellent interactions and attachment were observed between the parents and child. The home environment was recorded as satisfactory. Parents denied smoking in the property and support was requested to stop smoking; the Health Visitor gave a contact number for that support. Father was present so again, considering guidance, domestic abuse screening was not undertaken. The Health Visitor also completed an ante natal assessment. Mother disclosed about her schizophrenia and that she had stopped taking her medication due to pregnancy. There was no recording of any risk identified or any liaison with 16 midwifery services or GP following this contact. 8.47. Later in the month, Mother attended ante natal clinic at the hospital and was diagnosed with gestational diabetes. This resulted in a requirement to attend an educational session to learn about dietary management of diabetes, a transfer to a different consultant who specialises in managing diabetes in pregnancy and the booking of an ultra sound scan for October 2015. It was noted that there were no concerns for unborn Child A, that Mother’s mental health was stable and that she was due to see the Mental Health Team in November. 8.48. Two follow up ante natal appointments at the hospital were then defaulted that resulted in a telephone call to which Mother responded that she had been unwell. A further appointment was booked and attended by Mother and Father. There is no recording of what the reported illness was related to. Mother informed the consultant that she had not been testing her blood as required as she did not have any testing strips. Mother reported to the author that she did test her blood sugars during pregnancy and told the author how and when she did this. It was possible that she started doing this after she had been given testing strips. Father said that he remembered her testing her sugar levels. 8.49. Towards the end of October 2015 Mother attended the antenatal clinic at the hospital with concerns of a bump to the abdomen and reduced foetal movements. No further exploration was undertaken in respect of the nature of the ‘bump’. Routine domestic abuse screening was not undertaken as Father was in attendance. Mother attended for further follow up on seven days later and advice was given related to increased blood glucose and encouragement to stop smoking. Mental health was not discussed or recorded; routine domestic abuse screening was not undertaken and on this occasion, it is not clear why as Father is not recorded as being present. Mother attended again for a routine review in November and was again advised in relation to raised blood sugars. At a further follow up a week later it was recorded that Mother was not taking the medication to manage raised blood sugars that had been prescribed the previous week, as she thought that it was contraindicated in pregnancy. 8.50. At the end of October, mother had registered Father with the housing group as a person living with her at her tenancy but not as a joint tenant. 8.51. During this time the Mental Health Team had been trying to engage with Mother; she had defaulted an appointment in September which, in accordance with the Mental Health Trust Defaulted Appointment Policy, was followed up by telephone call from the duty worker to Mother. No concerns were noted therefore another routine appointment was offered for November. This too was defaulted and rearranged. There was no communication from the Mental Health Team to midwifery services or health visitor via the GP or otherwise. 8.52. At the end of November, at a routine appointment at the hospital, Mother was encouraged to opt for an elective caesarean section due to the gestational diabetes. Mother declined this as she preferred a normal delivery. The records noted that the schizophrenia and depression were reviewed and that Mother was coping without medication. The review did not include contact with any agency that was monitoring and supporting her mental health. At a further follow up in the first week of December it was noted that Child A was breech and therefore an elective section was 17 booked which Mother agreed to. Key Phase 4: Birth to Death of Child A (December 2015-June 2016) 8.53. Mother attended the hospital as planned for the scheduled caesarean section. It was not documented if Father was in attendance. 8.54. When Child A was born, there were immediate concerns; it was noted that the cord was around the neck and breathing needed to be aided. The heart rate was low as well as low blood sugars. Child A was transferred to the neonatal unit where good recovery was made. Mother attended the neonatal unit twice that evening and was updated by the doctor that Child A had recovered well and may transfer to the ward the next day. At this point, there was no mention of Father or the sibling. 8.55. The next day Father attended the hospital and was noted to be doing all feeds, Mother visited the neonatal unit as well. During the next two days both parents were reported to be caring for Child A. There were reports that the parents were missing from the ward on occasion but it is not clear if this was when they were visiting Child A on the neonatal unit. Mother and baby were discharged eight days after delivery. 8.56. The community midwife visited the following day as well as two days later and reviewed Child A and Mother. Apart from some slight jaundice there were no concerns noted. The final midwifery visit was at the end of December. Mother was recorded as being good emotionally but there was no obvious review of mental health or a discussion about medication. Father and sibling were not mentioned in the records; neither was the home environment or any issues noted about parenting of two very small children. No liaison took place with the GP or the mental health team who Mother had been referred to and it did not appear that the Midwife was aware of the defaulted mental health appointments. 8.57. The first visit of the Health Visitor had been planned but the family were not at home and a rearranged visit took place the following day. This was a different health visitor than had visited the family previously. At this visit Child A’s sibling was reviewed and noted to not yet be walking or pulling to stand (Sibling was now just under 14 months old). Parents were advised how to encourage motor development. They were also advised against adding rusks to the bottle, something that the previous health visitor had also advised about. There is no record of what arrangement was made to follow up this potential developmental delay. 8.58. Child A was noted to be well at this visit. The Health Visitor reviewed Mother’s mental health and Mother stated that the GP had advised to start her medication again for schizophrenia when she had finished her antibiotics. Mother reported that she was feeling well. The Health Visitor discussed that domestic abuse can be a feature within some relationships. This was a way of raising awareness of domestic abuse. The Health Visitor informed parents of the DART process and that health visitors offer support where there are incidents of domestic abuse; both parents were present. This is the first time domestic abuse had been discussed. The Health Visitor noted in the red book13 that the 13 The Personal Child Health Record (also known as the PCHR or 'red book') is a national standard health and development record given to parents/carers at a child's birth. The PCHR is the main record of a child's health 18 Midwife had recorded that the home environment was dirty. The Health Visitor discussed this with parents who became upset and had not seen what had been written. It was recorded by the Health Visitor that the home conditions at this visit were acceptable. Neither the Health Visitor nor the Midwife recorded descriptors as to the reason for their assessment of ‘dirty’ or ‘acceptable’. At the PLRD this was explored and the Health Visitor was able to state that Father explained the flat was untidy when the Midwife visited as he had not had time to wash the dishes and there were clothes on the floor waiting to go in the washing machine. 8.59. The Health Visitor undertook a routine 6-week check at home at the end of January as arranged; no concerns were identified. Sibling was not mentioned in recordings about this visit. The Health Visitor reviewed Mother’s physical and mental health and no concerns were noted. Mother was reminded to attend the GP surgery to discuss her medication. It did not appear that the Health Visitor liaised with the GP or the mental health team who were monitoring Mother’s medication and mental health. Father was not mentioned at this visit. The home conditions were reported to be much improved but there was no indication what had improved. Mother was asked to attend well baby clinic in three weeks’ time. At the second PLRD, the health visitor was able to recall that she had observed Father demonstrating to her that he had undertaken the strategies suggested at the previous visit by the health visitor, and that the sibling was now pulling to stand. 8.60. At the beginning of February 2016, the GP received a letter from the hospital detailing a defaulted appointment for a hip scan for Child A (routine following breech presentation). The letter requested referral back if any concern was identified. Child A was seen that day by the GP for a routine 6-8 week medical assessment. The assessment showed no concerns; hip examination is part of the routine screening at this assessment. Child A then received immunisations as expected at the GP practice when they became due in February, March and April 2016. 8.61. It was during this phase that there was an open referral from the GP to the mental health team in Area B. As detailed previously the referral was made in the ante natal period but appointments were defaulted. The appointment rearranged from November 2015 was to be for mid-January 2016. Records show that Mother phoned to cancel this appointment as she was recovering from a caesarean section. Mother was seeking a home visit if this was an option. A home visit was arranged for end of February. 8.62. The home visit was carried out by a doctor supported at the doctor’s request by an occupational therapist from the mental health team. Mother was not at home at the time of the visit but arrived home with Father and both children when contacted by phone; they had been shopping. Child A was asleep in the buggy but sibling was entertained and played with by Father. Both parents took part in the assessment. No mental health concerns were noted and Mother was to continue with the same treatment. No mention is made of the home conditions at this visit but on interview with the IMR author, the occupational therapist recalled that the flat was slightly unkempt but this was not of a level to cause concern. Although asking about abuse at any time in a patient’s life is part of the routine medical assessment of patients, the paperwork detailing this element is not in the records and development. The parent/carer retains the PCHR, and health professionals should update the record each time the child is seen in a healthcare setting. 19 for this visit. The recordings for this visit do identify that Mother was in a stable relationship with her current partner who was very supportive. 8.63. The outcome letter from this visit was not sent to the GP until April 2016. It was stated at the PLRD that this was due to significant capacity issues within the administration team and would not be usual. It was noted that after the death of Child A, the Mental Health Team Leader contacted the GP who informed the team leader that Mother had not taken any medication since May 2015 and that Mother had suffered no ill effects as a result. This is notwithstanding that the result of the assessment visit was to continue treatment. 8.64. A follow up appointment was arranged by the mental health team for May 2016, but this was not attended. This was followed up and a further appointment was made for a home visit on in June. 8.65. In June 2016, when Child A collapsed, father telephoned for an ambulance stating that Child A was not breathing. Details in the Police IMR indicated findings at the property suggestive of neglect i.e. “………. Furthermore, poor home conditions demonstrated by parental/adult failure to discard used nappies, items of clothing abandoned on floors culminates alongside the evidence of smoking with related paraphernalia easily accessible to children, grubby bedding, unhygienic toilets and an inaccessible second bedroom due to cluttered storage of items.” 8.66. The hospital in Area B, who carried out a child protection medical examination on Child A’s sibling also reported extensive nappy rash that had not been adequately treated that could have been indicative of neglect. 9. Thematic analysis 9.1. The individual management reviews and the discussions at the PLRD highlight several themes for further analysis. Focusing on the systems that practitioners were working in during the timeframe for this review leads to valuable learning. Mental Health of Parents 9.2. Much of the activity and concern within this review was related to the mental health of Mother. There are several aspects of this activity that provide insight into the information known to professionals, their understanding of Mother’s diagnosis and medication and the impact on her as a parent that give weight to further analysis leading to learning. 9.3. Father’s mental health problem was only known to his GP and it is not clear if he was ever asked about his health and well-being or his social history by any agency. He was present at both ante natal assessments by midwifery staff and there were no observed mental health concerns documented for Father. It is not clear if this was asked or if, when asked, there was no disclosure. Where parents have additional needs such as mental health a whole family/think family approach is required. An understanding that in fact there were two parents who had mental health problems should have refocussed attention to move to a whole family approach. 20 9.4. When the midwifery service first became aware that Mother had a mental health diagnosis and had stopped her medication there was immediate concern. This was raised initially by the Community Midwife in Area B and relayed to the Health Visitor and the hospital in Area A. Part of the reason was that the Mental Health Pathway for pregnant women indicates shared care between GP and consultant, but it was also suggested that there would be an impact on the unborn baby. 9.5. Following discussion with a safeguarding lead in the hospital in Area A, a referral was made by the Midwife in Area B to Children’s Social Care. The information shared was that Mother had a diagnosis of paranoid schizophrenia and that she had stopped her medication. Ultimately this led to the offer of Early Help and support, with a focus on restarting medication. There was little communication from those supporting Mother in her pregnancy and who were contacting Children’s Social Care to those professionals who had in depth knowledge of and were managing Mother’s mental health needs. Even when mental health professionals from Area A Mental Health Team carried out their assessment and found no concerns, this did not seem to have an impact and there was a continued pursuance of a focus on medication by Early Help when Mother and baby had been discharged. 9.6. The focus was on diagnosis and treatment rather than any impact on Mother, initially as a prospective parent through to being a parent of two small children. There was no assessment of her capacity to be a safe and effective parent. Practitioners were focussing on the medical treatment of mental health conditions as opposed to any presenting behaviours that may have impacted on parenting capacity. 9.7. There has been much written about parenting capacity and parental mental health. Cleaver et al 14 conclude that much research indicates that parents with a mental illness, as a single parental problem, can be effective and loving parents and do not present a risk of harm to their children. They also cite research that indicates many parents find that the bond can be especially strong and negative effects can be offset by good support networks. Mother told the author that she was very happy that she had become a parent and that this had a positive impact on her mental health. 9.8. Much of what is recorded about Mother’s diagnosis was taken by self-report with very little checking back with mental health professionals or GP. Mother never gave her current diagnosis, stating that she had a psychotic illness as opposed to personality disorder. It is not clear how well her change in diagnosis was communicated to her and at what point and whether she understood the differences. Some professionals knew of her more recent diagnosis, but this did not always appear to be applied consistently. Mother indicated to the author, several diagnoses that she had regarding her mental health; this included schizophrenia and personality disorder. 9.9. At the PLRD there was much discussion about this and it was included in the learning that emerged from the group work on the first day. Mental health colleagues were able to provide descriptions of the similarities and difference between the two conditions. The main issue arising out of this discussion was that in fact NICE Guidance related to borderline personality disorder, discourages prescribing for the condition. In cases of schizophrenia, medication is important and primary first 14 Cleaver, H., Unell, I. and Aldgate, J. (2011) Children's needs – parenting capacity: child abuse: parental mental illness, learning disability, substance misuse and domestic violence (2nd ed.) (PDF). London: The Stationery Office (TSO). 21 line of treatment. Mental health colleagues stated that it is usual to prescribe for individual symptoms associated with the borderline personality disorder. It can be seen therefore that the anti-depressant and anti-psychotic medications would have been to provide for symptomatic relief. 9.10. Mental health colleagues were also able to confirm that the decision to change diagnosis is not unusual. Symptoms initially may appear to be psychotic in nature but following a period of assessment can be found to be behavioural leading to a diagnosis review to borderline personality disorder. It was also confirmed that this change in diagnosis was discussed with Mother when she was transferred to the team that manage patients with this diagnosis. It is not clear how much Mother understood of this as she continued to inform professionals of her original diagnosis. 9.11. What may have provided for more thorough understanding of risk in this case would have been to concentrate on behaviours as they pertained to parenting capacity.15 This would have placed the focus on the future children within the family, taking a whole family approach. Use of theoretical frameworks in safeguarding children can provide a sound and evidence based assessment of risk. This may have provided Children’s Social Care with the clarity that they needed to understand the behaviours that may have posed a risk. For example, there were some indicators or cues that may have been linked to mental health but these were not explored further by any further questioning e.g. the concern about miscarriage that did not appear to feature in any medical records and the presentation reporting to being in early labour where there was no evidence of labour. These and other examples may not have been linked to her mental health diagnosis but were not explored and did not feature in any assessment. 9.12. Professionals did not articulate effectively if there was any specific risk posed by Mother’s mental health presentation, moreover there did not appear to be any documented mental health behaviour or presentation of any concern. Other than his GP, no professional documented any observation or assessment of Father’s mental health. 9.13. In trying to understand why practitioners were so wholly focussed on medication, professionals at the PLRD hypothesised that this was due to a lack of in-depth knowledge of mental health conditions. It was argued for more training for all staff in mental health. This was not necessarily wholly agreed with by all participants but use of the experts to check out the important points may have been helpful. 9.14. The hospital Trust in Area A has a Mental Health Guideline for all staff that work in Maternity Services. This was not applied robustly by the staff working within those services and the Trust made a recommendation in their IMR to address this issue. The guideline gives guidance to health visitors and GP requirements at ante natal and booking visits, but the guideline is not written for those staff. Indeed, in this case, Mother’s GP was over the border in Area B. Had this guideline been applied by the staff it is aimed at, there may have been a better understanding of Mother’s mental health diagnosis. There would have been a comprehensive plan of assessment and review of any mental health presentation at key points throughout her ante natal and immediate postnatal periods. The 15 Parenting Capacity: The ability to parent in a good enough manner long term from Conley, C. (2003). A review of parenting capacity assessment reports. Ontario Association of Children's Aid Societies (OACAS) Journal, 47(3): 16– 22 22 guideline could be strengthened specifically for women who have significant history of mental health conditions where there are no current mental health presentations of concern. 9.15. National guidance16 for all staff working with mothers where mental health is a concern, suggests that an integrated approach to care in the ante natal and post-natal period offers best practice in order that mothers and babies are afforded the best and safest care. 9.16. It appears that Mother’s decision to stop medication in pregnancy was not fully explored with her, her mental health team or GP. It is known that psychotropic medication taken in pregnancy can pose a risk to the unborn baby. There is a general caution to mothers-to-be about taking any medication in pregnancy and may have been the reason that Mother chose to stop her medication. Mother indicated to the author that she made the decision to stop her medication for fear of harming her baby. Indeed, mother did not take her medication for gestational diabetes either as she believed it would be contraindicated in pregnancy. Best practice in managing psychotic illness in pregnancy, indicates that the risks to the unborn of taking medication should be weighed up against the risks of relapse in maternal mental health by not taking it. Applying this practice within a multi-agency meeting alongside Mother may have provided an opportunity to have a more robust view of the risks, whilst working in partnership with the Mother. In this case, the evidence did not point to any negative impact on Mother’s behaviour or mental health by not taking medication. This was confirmed by two mental health teams and her GP as well as the Health Visitor. 9.17. In this case, given that the parents had mental health issues, it would have been helpful to apply a ‘think family’ approach to the possible impact of parental mental health on any children in the family e.g. using Falkov’s ‘Crossing Bridges Family Model’ outlined by the Social Care Institute for Excellence Guide 3017. This helps practitioners to identify protective factors and support networks against risk and vulnerability in the context of the parental mental health and child’s needs. It would 16 GUIDANCE DOCUMENT: Health Visiting Programme: Pathway to support professional practice and deliver new service offer Maternal mental health pathway 3 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212906/Maternal-mental-health-pathway-090812.pdf NICE Clinical Guide https://www.nice.org.uk/guidance/CG192/chapter/1-Recommendations#recognising-mental-health-problems-in-pregnancy-and-the-postnatal-period-and-referral-2 NICE Pathway https://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health 17 SCIE 2014 Think child, think parent, think family: a guide to parental mental health and child welfare http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf Learning Point 1: Not all professionals have the same level of expertise in all areas of professional practice. Use of those with expert knowledge in a given area (e.g. Mental Health) can support professionals to have more in depth understanding of their client/patient. ‘Checking out’ and ‘checking back’ are important elements when dealing with parental self-reports. (Recommendation 1) Learning Point 2: Use of national and local guidance related to Maternal Mental Health, by all health staff ensures that there is clarity of assessment and planning for women who have a history of mental health conditions who may or may not have a current presentation of concern. (Recommendation 5c) 23 have provided evidence of thorough assessment of these issues and any impact on the children (See Appendix 2). 9.18. Communication related to Mother’s mental health including defaulted appointments was not robust. Some of this may have been due to the complexities of cross border working. The community midwifery service for ante natal care came from Area B as it is based on GP practice. The post-natal community midwifery service came from Area A as it is based on the hospital of delivery. Midwifery services at Area A Hospital made no contact with the GP over concerns that had been raised with children’s social care about mother’s mental health The health visitor who worked in Area A made no contact with Area B GP The Mental Health Team in Area B made no contact with health visitor or midwifery service in Area A The Hospital Midwives in Area A did not communicate any concerns to the Community Midwives in Area A The communication pathway between community midwifery service antenatally in Area B and the post-natal community midwifery in Area A should have been via the patient held ‘Green Notes’ and the discharge summary. Neither of these contained the information about the concerns that had been expressed in the ante natal and immediate post-natal period. Domestic Abuse Routine Enquiry 9.19. There is no evidence that domestic abuse was a feature in this relationship. Due to the prevalence of domestic abuse being estimated at 1 in 4 women and that domestic abuse often starts or escalates in pregnancy18, it has long been advocated that all pregnant women should be screened for domestic abuse in a safe environment with access offered to support networks should they be required. This is reiterated in more recent NICE Guidance (2014)19 and NICE Pathway (2016)20 18 Department of Health (December 2005) Responding to domestic abuse: a handbook for health professionals 19 https://www.nice.org.uk/guidance/ph50 20 http://pathways.nice.org.uk/pathways/domestic-violence-and-abuse Learning Point 3: Application of theoretical frameworks can help to refocus assessments and provide an evidence base for concern, as well as providing good quality information for onward referrals related to specific issues of risk and vulnerability. (Recommendation 1 & 4) Learning Point 4: Robust communication is key in understanding concerns across all agencies and to afford prevention of harm. This can be particularly complex where there is cross border working. (Recommendation 5d) 24 9.20. It is also known that there is a greater risk of domestic abuse in relationships where one or both partners have mental health issues. Application of domestic abuse routine enquiry was therefore an important aspect of assessment to recognise any risk and vulnerability to the children in the family. 9.21. The absence of any thorough assessment of elements of domestic abuse as a feature within this relationship in line with NICE guidance and pathways, means it could not be ruled out. It could also be argued that no opportunities were given for disclosure by either parent. Research shows that it often takes several opportunities and enquiries before some victims will disclose, and some never do, suggesting that asking once is probably not enough to allow for a victim to come forward for support. Creating space to allow for screening and disclosure may have been an important aspect for both parents. 9.22. Managers and safeguarding leads at the PLRD identified varying levels of policy and practice related to the issue of routine enquiry. Midwifery and health visiting services indicated that it is policy and usual practice to ask the question. Mental health colleagues ask the question of all patients during routine assessment, however the evidence within the mental health records of this is missing in this case. The Mental Health Trust in Area B has a domestic abuse policy that covers this element of asking the question. The policy states that this would not necessarily happen on first contact, it does not detail the risks of asking it in front of partners or carers. The GP practice have policies and procedures alongside training for safeguarding. The GP IMR author for Area B, indicated that there was a training need for GPs related to domestic abuse enquiry and support for victims and included a recommendation to address this. 9.23. From discussions at the PLRD it appeared that there were several possible reasons why routine enquiry was not achieved in this case. 9.24. Practitioners are aware that they should not ask about domestic abuse in the presence of a partner. On many planned and routine assessment appointments, Father was present. In fact, comments earlier about the couple being inseparable from very early in their relationship and the fact that the couple were nearly always seen together, may have provided cues about coercive control.21 Coercive control has received much attention recently with a new law making coercive and controlling behaviour a criminal offence22 as it is a dangerous element of domestic abuse. Again, that is not to say that coercive control was an element in this relationship, but assessment and routine enquiry did not provide any opportunity for either disclosure or, to rule it out as a feature. 9.25. There is no evidence that arrangements were made to see Mother on her own as a routine part of achieving routine enquiry in the ante natal period. Opportunities were available when mother was seen alone but these did not lead to the question being asked as they were outside of the usual routine appointments and not seen as assessment opportunities e.g. when Mother was an inpatient in the ante natal period and Father was off the ward, or when seen following the bump to the 21 Coercive control is a term developed by Evan Stark to help us understand domestic abuse as more than a “fight”. It is a pattern of behaviour which seeks to take away the victim's liberty or freedom, to strip away their sense of self. It is not just women's bodily integrity which is violated but also their human rights. 22 Home Office (2015) Controlling or Coercive Behaviour in an Intimate or Family Relationship Statutory Guidance Framework 25 abdomen. 9.26. There were comments from all staff that knew Mother that she was a very confident lady, she appeared to be in control of managing her mental health and appeared to take the lead in the relationship. It is known that 1 in 6 men are thought to be victims of domestic abuse and that domestic abuse in males is underreported. Father should have been individually assessed as a parent, especially given his role in the family. That may have afforded opportunities to disclose domestic abuse should he have chosen/needed to. Father’s disclosure to the author regarding Mother not wanting him to go anywhere alone, may have become knowable to professionals if they had questioned why Mother kept leaving the ward. 9.27. Some practitioners stated that they did not feel confident to ask the question of the couple about experience of domestic violence or abuse or, had asked but in the presence of both parents. This would suggest that there may be further training requirement into the understanding of routine enquiry and coercive control as a feature of domestic abuse. 9.28. A discussion at the second PLRD provided more clarity as to the systems and organisational support for routine enquiry in domestic abuse: Police officers who are called to a domestic incident will always speak to both parties separately giving space for safe support and disclosure. Mental health staff have updated polices to include domestic abuse screening as part of their routine assessment. It is now included in training for staff, leading to a better understanding and application of the policy. The Royal College of General Practitioners provides guidance to GPs regarding domestic abuse. This does not advocate routine enquiry but does state that GPs should enquire sensitively where any indicators may be suggestive of violence or abuse. Area A Hospital Trust do not have a specific domestic abuse policy to support practitioners to undertake routine enquiry in line with national guidance. At the time of this case, they were using Safeguarding Children Procedures and NICE Guidance. This is being addressed and a policy is currently being written and will include mandatory use of DASH23 risk assessment. This will need to be followed up by training in the application routine enquiry and DASH risk assessment to give practitioners the skills and confidence to be able to apply the policy. 9.29. Professional curiosity was not applied to possible cues about domestic abuse. e.g. returning to the ward emotional in December.2014, in December 2014 mentioning a ‘domestic at home’ and on October 2015 when Mother presented with reduced foetal movements following a bump to the abdomen. These incidences did not lead to opportunistic screening of domestic abuse or any 23 DASH risk assessment: (domestic abuse, stalking and ‘honour’-based violence). Consists of a series of questions to work out the level of risk a victim is facing 26 further exploration as to the detail of those incidents. If Mother hinting at issues, had been testing out whether there was support around any disclosure of domestic abuse, these were missed. 9.30. Mother told the author that there was never a time when there was any domestic abuse. She indicated that they had usual squabbles, but that she never felt in fear of Father. Father indicated that he found it difficult that Mother did not want him going out by himself, even if that was to go to see his mother. 9.31. Recently published findings from a study of serious case reviews24 cites professional curiosity in many areas as a tool for safeguarding. In this case, there was a lack of professional curiosity to explore cues that may have related to domestic abuse. 9.32. The attendance by police officers to parental grandmothers’ home in August 2014 was discussed at the PLRD. Although it could be initially argued as a missed opportunity there are many factors that impacted on this. At the time only incidents involving children or an identified pregnancy were shared with multi agency partners using the Domestic Abuse Response Team. This was seen as a dispute between the parents and Paternal Grandmother and not a relationship issue and was rated as standard risk. With the current Multi Agency Safeguarding Hub approach to domestic abuse, all referrals related to domestic abuse are shared where there are children in the family. In this incident, the absence of a disclosure or knowledge of children or pregnancy, the information would not be shared. It was agreed that there is therefore no learning from this incident. Role of Father 9.33. One of the key themes throughout all the IMRs and noted at the PLRD was the lack of information, assessment and understanding of the role that the Father of Child A and sibling took within the family. The only knowledge of Father came from his GP who was able to give information about the nature and cause of Father’s depression. This was not shared with any other professional working with the family as the GP did not know that Father was in a new relationship and had two children. 9.34. All services appeared to focus on the needs of Mother and her mental health problems to the exclusion of any concern about whether Father was a positive or negative factor in the lives of his children and partner. 24 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education. Learning Point 5: NICE Guidance indicates that routine enquiry into domestic abuse should be undertaken. An environment for safe disclosure, alongside an embedded culture of professional curiosity that encourages opportunistic exploration of indicators, provides robust evidence that the issue has been thoroughly assessed. The outcome should be carefully and safely recorded. Without this, any possible impact on the lived experience of the children is not possible. Practitioners should be supported to apply these principles with policies and training that underpin practice (Recommendation 1) 27 9.35. Midwifery staff often commented on Father being present. There was no record of any information or assessment about him as a parent or any history when they carried out their ante natal risk assessment when Mother booked for antenatal services. 9.36. At the PLRD the health visitors that were present gave more information on how he interacted within the family home. After the birth of Child A’s sibling it was noted that Father was always present but that he was usually in the background undertaking household chores and was the one who apologised if the flat was not clean and/or tidy. After the birth of Child A it was noted that he was much more ‘hands on’ especially with Child A’s sibling. This was possibly due to the fact that Mother was recovering from major surgery having had a caesarean section and that there was now a toddler to look after. During a visit to Child A by the Health Visitor, Father was noted to be interacting well with the sibling. 9.37. There was no assessment of need of Father as a partner and parent that included an understanding of his history, other children and mental/physical health that would inform current risk and vulnerability. There was therefore no indicators of harm or protective factors. 9.38. Apart from the Area A GP, practitioners involved with the family, did not know that he was the father of a child that he did not see and that this had led to a depression that he was consulting his GP for. His GP did not explore his current social situation so was not aware that he was a father of two small children. 9.39. Mother informed the author that Father was a very good and caring father. It was he who did a lot of the hands-on child care. Mother stated that she was often fearful of handling the children in that she may do something wrong stating that Father was better at it. Mother stated that she was involved in all of the financial side of managing the household and made sure her children had everything that they needed. 9.40. Father concurred with this view and indicated that he loved being a Father and loved caring for the children. He agreed that he did most of the general childcare and household tasks. The lack of assessment of Father meant that this was not known by the professionals. All of the attention regarding caring for the children was centred on Mother when in fact, it was Father that carried out most of their care. 9.41. Engaging fathers has been the subject of focus in previous serious case reviews24 25. Where fathers are either not engaged or where their role in the family is not understood, professionals are not aware of what extent a father may be a risk or protective factor within a family. 9.42. In this case, nothing of concern was noted and no concerning behaviours were observed. There was, however, no comprehensive assessment of Father’s history, wishes and feelings as a parent, or as a possible support and carer of his partner who had a mental health diagnosis. There was also no robust assessment of him as a man who was being treated for his own depression and who was a main carer for his children. 25 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ 28 9.43. This was discussed at the PLRD in order to understand why Father did not feature in robust assessments. This case remained within universal services. At that time, even if the family agreed to an Early Help Assessment, it is unlikely that further assessment of Father would have occurred. The second PLRD heard that this has now much improved following a concerted move to include fathers in Early Help Assessments. Universal Services in health were either not aware that Father was a parent (GP) or were not concerned as to whether he was a risk or a protective factor, observing him to be an attentive partner and father. There does not appear to be an embedded culture of engaging directly with fathers and including them in assessments of needs in their own right or as a parent. 9.44. What is clear in this case, is that this father was not an absent carer, nor was hard to engage with but practitioners largely focussed on the needs of Mother. When practitioners were concerned about whether Mother should be taking her medication, his views and influences on her decision making were not explored or understood either positively or negatively. 9.45. Research by the University of Worcester and the Fatherhood Institute26 concluded that health visitors are well placed to include fathers in their work with families using the Healthy Child Programme. An evaluation of a training programme proved to have been positive in raising awareness in the importance of engaging with fathers and provided ideas of new and innovative ways to achieve this. 9.46. If an assessment had highlighted that Father had a previous child and that his separation from his child had led to depression, that he was the main carer for Child A and sibling, the level of need of the children in this family may have increased. It would have been known that both parents were experiencing mental health problems and the family may have been viewed from a health visiting perspective as having additional needs under Universal Plus (Health Visiting Programme)27 (discussed further in the next section). Family Support and Thresholds for 9.47. The result of the midwifery referral into Children’s Social Care was to offer Early Help support. This decision was based on the fact that Mother had a mental health diagnosis and was not taking her medication. At the time of the referral there was no checking with mental health services or the GP 26 Nolan, M (2014) Evaluation of a Training Programme and Toolkit to Assist Health Visitors and Community Practitioners to Engage with Fathers as Part of the Healthy Child Initiative: A developmental study using action research. University of Worcester 27 The Health Visiting Programme offers four levels of service as part of the Healthy Child Programme https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/407644/overview1-health-visit.pdf Learning Point 6: There are associated risks by not engaging and assessing the protection and support or potential threats that fathers may pose to children and/or their partner. Fathers’ needs are as important as mothers’, particularly where they live in the same household and provide equal parenting to children. Understanding both parental roles and needs can improve outcomes for children. (Recommendation 3) 29 as to whether this would pose any risk to any unborn or new-born baby. There was no further probing from Children’s Social Care as to what the specific concerns may be i.e. what behaviours were observed that indicated risk and what protective and resilience factors were in place. Children’s Social Care therefore, saw no role for statutory intervention (Section 4728) or invoking child in need (Section 1729). The Social Care IMR author questioned this decision and it was discussed at the PLRD. 9.48. Further exploration suggests there were differing Thresholds used to support this family by different agencies at the same time. 9.49. The Thresholds Guidance in place in 201330 (and this has not changed in the newer version in 2015) states that level 1 identifies that where no additional support needs are required needs are met by universal services. This would be managed from a health visiting perspective at Universal Level (Healthy Child Programme). Level 2 would be where there are additional needs but that they could be met by Universal services and a Health visitor may use Universal Plus (Health Visiting Programme) to meet those needs. 9.50. When the Early Help referral was made, it indicated that Early Help support could not be provided by a single agency (health) as the referral was for an Early Help Assessment and support from Early Help services so would be at level 3 according to the Thresholds Guidance. This did not lead to the Health Visitor re-evaluating the package of care and escalating intervention to Universal Plus (Health Visiting Programme) based on the fact that there were identified additional needs requiring Early Help Assessment. 9.51. Community midwives at the time were not aware of any referral for Early Help. 9.52. The Health Visitor received information about the Early Help referral in the transfer form from the hospital but this did not detail the reason for the referral. When the new birth contact was carried out, the Health Visitor did not mention this to Mother or explore any areas for Early Help. 9.53. Mother refused an Early Help Assessment and support since she did not see a role for it as she was in control of her mental health condition and had the support of her mother as her carer. Professionals did not explore the nature of the support offered by Maternal Grandmother either as a 28 Section 47 Children Act (1989): Local Authority duty to investigate where it is made aware that a child might be suffering or likely to suffer significant harm. 29 Section 17 Children Act (1989) Provision of services to children in need and their families 30 Walsall Safeguarding Children Board (2013) MULTI - AGENCY THRESHOLD GUIDANCE: Identifying Need and Analysing Risk when working with Children in Walsall Learning Point 7: Transfer of all information known to hospital maternity services, including reasons for any onward referrals, provides robust communication to enable community services to have information necessary for their ongoing interventions and care. (Recommendation 5a) 30 support with parenting or as a carer in respect of Mother’s mental health. 9.54. The Early Help support worker was tenacious in not giving up in ensuring that mother attended the GP and accessed her medication. She continued her contact even though Mother repeated that she did not want support, stated that she did not remember consenting to it and even told the Health Visitor that she did not want it. It is fair to say that at no time did the family refuse access to the Early Help worker nor were they dismissive of her. The service continued with the best intentions but with no robust consent. After Mother had been to the GP and without a further documented visit to the family in their own home, Early Help intervention ended. 9.55. Mother informed the Early Help support worker that she was in regular contact with her GP; although the support worker had previously contacted the GP, there was no further liaison at this point relying on Mother’s self-report. It was very early days for this new family in their own home. 9.56. There were several flaws in the level of support and how it was managed and these were contributed to by all of those involved. 9.57. The initial referral to Children’s Social Care and the ensuing Early Help offer was not based on all the known facts and there was a lack of robust assessment to inform that referral. Gaps in the referral were: Lack of information about Father No assessment of the financial difficulties that were seen when mother stated they had no money No recognition that parents were going to be moving from Maternal Grandmother’s home to their own property with a new baby No assessment of the reasons for parents’ absences from the ward for extended periods A reliance on Mother’s self-reporting of her mental health No robust understanding of the mental health diagnosis whether it did indeed pose any risk to a baby 9.58. It can be seen by exploration of the case, that it was indeed possibly a right decision that the case did not meet the Threshold for Children’s Social Care statutory intervention (level 4). It could be argued that assessment at level 3 was indicated with the health visiting service offering support at Universal Plus (Health Visiting Programme). 9.59. If Early Help had been offered for a different reason and to both parents and baby as a family, rather than the focus being purely on Mother’s medication and mental health, there may have been agreement from the family to receive additional support. Learning Point 8: The provision of comprehensive information to inform referrals is an important factor in the decision making related to thresholds for intervention (Recommendation 2) 31 9.60. The Thresholds Guidance quotes Working Together 201331 (Guidance in place at the time) “...if parents and/or the child do not consent to an early help assessment, then the lead professional should make a judgement as to whether, without help, the needs of the child will escalate. If so, a referral into local authority Children’s Social Care may be necessary.” There was no documentation that a judgement was made that was based on knowledge of all the issues and shared with other professionals in Universal Services. 9.61. It can be argued, therefore, that the needs of this family, at this point were at level 3. There should, therefore have been a lead professional identified. It would have been the role of that lead professional to instigate a multi-agency meeting to identify where all professionals felt that the Early Help offer needed to focus. Professionals could then have discussed whether or not the refusal of the service was an increased risk or whether the needs of the children could be met at level one. In this way it would have been noted that the Thresholds Guidance was not being applied in the same way across all agencies. 9.62. When Mother presented as pregnant with Child A, there were again concerns about her not taking mental health medication but this did not result in any conversation with, or referral to Children’s Social Care. There was no consideration that an Early Help referral was required. This was a very different approach to activity in the first pregnancy. 9.63. It could be argued that there were now increasing needs as Mother was also diagnosed with gestational diabetes and appeared to be non-compliant with monitoring and treatment of this. She also had a baby who was very young (at the time of Child A’s birth sibling was only 13 months old). The age of the children was an increased risk from a vulnerability perspective as research identifies that very young children feature in higher percentages in serious harm and serious case reviews. 9.64. The reasons for this not resulting in any onward referral at level 3 or any thought of a multi-agency meeting to collate and share all information were discussed at the PLRD. It was argued that the focus had moved away from mental health to physical health (i.e. gestational diabetes) and that this did not instil the same safeguarding concerns that mental health had done previously. It was also now known that there had been no apparently negative impact on Child A’s sibling, which may have provided confidence that parenting capacity was good enough. This was not offered or documented as evidence that no referral for Early Help was required or that Universal services were the appropriate level of intervention. 9.65. Multi Agency Statutory Guidance in place (both now and in 2013)2,25 states that early identification of levels of need and help to meet those needs is better than reacting later. 9.66. Throughout the journey of these children there was no robust multi agency communication. There were missed opportunities for agencies to come together for a formal review of the level of intervention that the assessment of the children’s needs required. Assessments did not appear to 31 HM Government (2013) Working Together to Safeguard Children 32 have focussed on what the lived experience of Child A and the sibling might be. This resulted in a lack of attention to the voice of the children in identifying levels of need. There were two specific times that could have led to a multi-agency review: The point of discharge after the birth of Child A’s sibling when there had been referral to Children’s Social Care and a psychiatric assessment of Mother. The information relayed to community services (Midwifery and health visiting) was poor. A discharge planning meeting may have led to better understanding of the concerns and a robust plan moving forward. Refusal by parents of Early help did not lead to a review of the level of need and intervention. A multi-agency meeting to discuss all the information known, alongside the family may have led to a more robust understanding of the needs of the whole family. This may have resulted in a more definite plan of care. 9.67. At the second PLRD it was agreed that at the time of this case there were difficulties with Thresholds Guidance not being applied consistently across all partners. Some were showing resistance to take the lead role. Following a training programme, recent audit has shown that the situation has improved. 9.68. There have been discussions and changes with some LSCBs related to the use of Thresholds Guidance. Written Thresholds Guidance was introduced to improve the understanding as to the required level of intervention to meet a child’s needs. Difficulties have arisen due to the complexity of many families and application of written thresholds being too prescriptive. This has taken away the support for professional judgment and agreements across partner agencies as to the best way of supporting individual families. A professional conversation about the specific issues faced by individual children and families to inform decision making and agreements as to the required level of intervention may provide for clarity. This would need to be alongside a culture of respectful challenge and escalation where agreement cannot be reached. 10. Good Practice 10.1. It is important to note that many practitioners offer a good level of service to their clients/patients and follow policies and procedures that are provided to guide practice. Whilst recognising gaps in practice, Serious Case Reviews can also provide evidence of this as well as practice that goes over and above what is expected. Attendees at the PLRDs were asked to identify these from their own and other agencies. It is important to highlight these as areas where learning can occur. The Early Help Support worker was tenacious in her visiting and went beyond what was expected to ensure Mother attended the GP. She contacted the GP to liaise about the need for medication review and to set up an appointment and accompanied Mother to the Learning Point 9: The application of standard thresholds across all agencies supports the robust assessment of children’s needs and can provide evidence to parents based on all available factors to support the argument for early help and support. Written Threshold guidance may be confusing and too prescriptive in some circumstances. (Recommendation 4) 33 surgery. The Mental Health duty worker made telephone contact with Mother following the defaulted appointment as per the Defaulted Appointments Policy. The Area B Mental Health Team, conducted a home visit when it was apparent that the reason for defaulted appointments was due to surgery. The doctor at Area A hospital ensured that the psychiatric liaison team reviewed Mother before discharge after the birth of Child A’s sibling. The Area A Psychiatric Liaison Nurse gathered information from the Midwife on the ward prior to speaking to Mother and liaised with the Mental Health Team in Area B. The Community Midwife, from Area B contacted the safeguarding named midwife in Area A and the Health Visitor about the concerns with Mother’s mental health and the ceasing of medication. The Health Visitor carried out an ante natal contact based on information received from the community midwife. The Health Visitor followed up the issue of the Midwife recording the home being dirty and was also able to advise on wound care when mother had been discharged from midwives. The health visitor used her knowledge and skills from her mental health training to effectively identify and record how mother presented and interacted. The GP (Area B) referred Mother to mental health services for a review of her mental health and medication due to concerns expressed by community midwife. The GP (Practice Area A) ensure that all patients seen for a mental health issue, are given the details of the Practice CPN. 11. Conclusions and Learning 11.1. From the material studied and the conversations and debates that took place in the process of reviewing this tragic case, no professional could have identified concerns to such a degree that would have given an opportunity to safeguard Child A from death. 11.2. It is clear, however, that cues may have been missed to further explore several elements of the lived experience of the two children in this family. 11.3. By using the model put forward in the Triennial Analysis of SCRs20 depicted in Appendix 3, it is possible to draw conclusions and learning in terms of ‘Pathways to Harm and Pathways to Protection’. 34 11.4. The events leading up to the death of Child A are unknown by professionals and therefore it is difficult to identify exactly which focus might have provided more insight into pathways to harm. During the process of the review, nothing came to light that would have indicated any risk of significant harm being identified so even using hindsight bias32 it is difficult to pinpoint where immediate protection could have been afforded. 11.5. In thinking about the ‘pathways to harm’ there were missed opportunities to gain a better understanding of the mental health of both parents as it pertained to parenting capacity, fully assess any domestic abuse, and an understanding of Father’s role. A further pathway to harm was the vulnerability of Child A due to being a baby under one in this unassessed environment. 11.6. Opportunities to provide the right level of support across a multi-agency arena can provide ‘pathways to protection’. 11.7. Application of professional curiosity to pick up on some of the cues that were available at various points, as well as maintaining a healthy scepticism of the self-reporting by family members that all was well, may have led to a robust Early Help offer. That in turn may have revealed more about the family functioning and parenting and the lived experience of the children. 11.8. Practitioners focussed on Mother’s mental health diagnosis and medication rather than on any behaviours that may have indicated pathways to harm. Observed behaviours in Father were not recorded possibly because his mental health issues were not known to practitioners that knew he was a parent. 11.9. Previous studies into serious case reviews nationally20, 33 have highlighted that professionals must maintain a healthy scepticism and respectful uncertainty to see beyond what is often being presented by parents. A process of ‘checking back’ with professional colleagues may provide opportunities to detect hidden issues and provide pathways to protection, particularly where the self-report is not in the professional’s area of expertise (e.g. Mental Health). 11.10. Maintaining a healthy scepticism of parents can be difficult to do and requires skill so that a trusting relationship can be built and maintained. Not all parents, or indeed these particular parents, are dishonest or hide what is really happening at home. Maintaining the professional curiosity and applying knowledge and skills to all cases and not just those where there are very apparent concerns leads to pathways to protect from harm (E.g. domestic abuse and role of fathers). 11.11. The lack of professional curiosity and not maintaining a healthy scepticism appear to have led to a significant gap in communication with the GP. Only the Early Help support worker contacted the GP. 32 Roese, N. J., & Vohs, K. D. (2012). "Hindsight bias". Perspectives on Psychological Science, 7, 411–426. Hindsight bias occurs when people feel that they “knew it all along,” that is, when they believe that an event is more predictable after it becomes known than it was before it became known. Hindsight bias embodies any combination of three aspects: memory distortion, beliefs about events’ objective likelihoods, or subjective beliefs about one’s own prediction abilities. 33 Laming, Lord (2003) The Victoria Climbié inquiry. Report of an inquiry by Lord Laming. Cm 5730, London: TSO. 35 Other health professionals who were expressing concern about the medication being stopped did not contact the GP to check out what Mother was saying. This led to lack of clarity about the impact of medication being stopped on mental health and therefore parenting. 11.12. It was reported in the GP IMR for Area B, that the practice would have been made aware of any safeguarding issues as a meeting was held regularly with the health visitors and that issues of this nature would be highlighted. It is not clear that this is robust for families that live over the border in Area A, as the health visiting service was received in Area A and not B. The GP in Area B has clarified that they are not aware if the health visitors cover both areas. (Recommendation 5b) 11.13. As stated above, robust application of thresholds for intervention at the right level also provides for pathways to protection. Early help was refused by mother. This should have led to a review of the need for this intervention and a multi-agency decision, coordinated by an identified lead professional. This would have led to a decision about whether to ‘step up’ the level of concern and intervention based on this refusal, as per the Thresholds Guidance and from learning from SCRs. The focus of the need for Children’s Social Care or early intervention and help should be based on all assessed needs and not on one specific area of concern. 11.14. It appears that many of the reasons why the frameworks and policies were not applied robustly was either due to a lack of knowledge and confidence or merely that as risk of harm to the children was not apparent. The need to apply frameworks robustly was not evident, thereby leading to lack of evidence that pathways to harm had been effectively assessed and therefore possibilities to intervene early for protection may have been missed. 12. Recommendations 12.1. The learning in this case provides a window on the system and it is believed that information that has come to light at the PLRD suggests that the issues that it has highlighted may not be applied only in this case and that there are implications for the wider system. The following recommendations therefore seek to address this. 12.2. This Serious Case Review covers two LSCB areas and therefore arrangements must be made to share the learning from this SCR with Area B LSCB. 12.3. Where agencies have made their own recommendations in their IMRs, both LSCBs should seek assurance that action plans and are underway and impact is assessed within those organisations. 1. Pathways to Harm (Learning Points 1,3 and 5) Walsall Safeguarding Children Board (WSCB) Serious Case and Significant Incident Sub Committee (SCSIC) must seek to embed the learning from this review and assess the impact across agencies. Amongst a range of issues are the following: Domestic Abuse routine enquiry and understanding of coercive control Hearing the voice of the child, particularly for younger children, where parental issues may be the more obvious focal point. Access to mental health expertise where that is not a professionals’ areas of knowledge 36 Assessment of social circumstances in primary care where adults are diagnosed with depression Think Family 2. Quality of Referrals (Learning Point 8) WSCB should seek assurance as to how widely training is being accessed across the partnership and learning applied from this case related to quality of referrals to Children’s Social Care and respectful challenge of referrers where there are gaps in information to support those referrals. 3. Engaging Fathers (Learning Point 6) a) WSCB must undertake an options appraisal to understand how relevant partner agencies will apply the learning in this case regarding the roles of fathers in their respective organisations and to include how information is shared to GPs when men become fathers and are not registered at the same practice as mothers (in the same/similar way to the notification to mothers’ GPs). b) WSCB should formulate guidance on the importance of engaging with fathers. This should include: the importance of gathering background information assessment of needs ensuring unmet needs are supported with appropriate offer of services and/or referrals 4. Thresholds (Learning Point 3 & 9) a) WSCB should seek assurance that all partner agencies understand the requirement for the Lead Professional in an Early Help Assessment or offer to be from the most relevant organisation and service in terms of the identified need. b) WSCB should seek assurance that all Early Help offers are robustly supported by the relevant Lead Professional. That assurance should also include that refusal of early help by parents is followed up in line with the Thresholds Guidance, coordinated by the Lead Professional, and that parents are made aware of the concerns leading to the need for the Early Help Offer. c) WSCB should reconsider the effectiveness of prescriptive thresholds guidance and identify if other models would be more effective e.g. professional conversation model 5. Communication a) WSCB should seek assurance that there is robust information shared from acute midwifery to community health services in respect of any safeguarding referrals that have been made during inpatient admission. (Learning Point 7) b) WSCB should seek assurance from the CCGs to ensure that where a GP practice is in a different CCG area to the Health Visitor, that there are robust systems in place for sharing of information related 37 to safeguarding concerns. (Para 11.12) c) WSCB should seek assurance from the CCGs that health providers in the locality strengthen the current Mental Health Pathway and that it is in use across all relevant health providers. Consideration should be given for opportunities to develop an integrated pathway in line with current best practice. (Learning Point 2) d) WSCB should consider implementing a communication model across partner agencies such as the example presented in Appendix 4. (Learning Point 4) Appendix 1: Terms of Reference 38 Better Together for Children www.wlscb.org.uk Serious Case Review Child A Terms of Reference 1. Introduction The request for a Serious Case Review was agreed by the Independent Chair of WLSCB on 19th July 2016. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2. Case summary Child A was the second child born to the parents. An ambulance was called to the family home by Father in June 2016. He informed the call handler that he had gone to get Child A’s bottle, came back and found him floppy. Child A was brought into the local Hospital’s Accident and Emergency Unit. Upon arrival, there were no signs of life. CPR was being performed by paramedics and resuscitation continued for about an hour unsuccessfully. Child A could not be revived and his time of death was recorded. On examination Child A had a very small bruise on the right side of his face. He had no major injuries but there was evidence of a bilateral haemorrhage in that both his eyes were cloudy. No other injuries were found. A forensic post-mortem was carried out; this confirmed that there was a severe bleed to Child A’s brain. He was six months old at the time of the incident; his sibling was 19 months old. 3. Scope of the Review The review will take into account agency involvement with Child A, his sibling and parents from the time that agencies were first aware of mother’s pregnancy with Child A’s sibling until the date of Child A’s death. The approximate timeframe will therefore be two years four months from February 2014. 4. Terms of Reference to be addressed by all agencies: In addition to production of a chronology and overall analysis of agency involvement and services offered to the child and family, the following specific questions should be addressed by all agencies. Appendix 1: Terms of Reference 39 a. In respect of domestic abuse routine enquiry: i. What assessment was carried out by your agency? ii. What was the result of those assessments? iii. What ongoing care and support was offered as a result? iv. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral? v. If routine enquiry was not achieved, please comment on why and what plans were made to follow up. b. In respect of mental health of parents: i. What assessment was carried out by your agency? ii. What was the result of those assessments? iii. What ongoing care and support was offered as a result? iv. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral? c. In respect of parental relationships with each other and the children: i. How did parental history inform your assessments? ii. What information did your assessments provide about parental history? iii. What did your assessment show about the role that mother and father took within the family? iv. What did your assessments identify that life was like for the children of the family? v. Was any additional care and support required or action was taken as a result of your assessments? vi. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral? d. In respect of wider family and community support: i. From your assessments, what did your agency understand of the support networks for this family? ii. What ongoing care and support was offered as a result? iii. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral? e. Risk, vulnerability and voice of the child: i. How were long term aspects of risk and vulnerability identified and how did these inform your agency support? ii. Please comment and provide analysis of evidence of the voice of the child and visibility of the children in this family. f. In respect of all assessments carried out by your agency: i. Were escalations pathways utilised and to what effect? ii. Were care plans SMART? iii. How was the impact on addressing identified needs monitored? iv. What arrangements were made for reviewing care plans? g. Cross border working: i. Were any cross border issues identified by your agency? ii. If so, how were these resolved? iii. How were any system issues dealt with (related to cross border working)? iv. Please comment on any positive/good practice identified with relation to any cross border working identified. h. Service arrangements/Case allocation: Appendix 1: Terms of Reference 40 How was this case allocated in your organisation? Please comment and analyse the impact of the following: Individual or team allocation Key worker (or equivalent) involvement How many practitioners/workers were involved or made assessments? i. Communication and information sharing: Other than what is already included above, what other communication did your agency have with others who were involved with the family? Please ensure that you cover what specific information was shared and how. Where there is no evidence, please comment on this. 5. Methodology Working Together 2015 states that: SCRs and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. This review will therefore use methodology that adheres to these principles by analysing agency involvement presented in Individual Management Reviews and engaging with practitioners that had direct involvement with the family. 6. Overview Author Walsall Safeguarding Children Board have commissioned Karen Rees, an Independent Safeguarding Consultant from 402k Consultancy Ltd. to undertake this SCR 7. Individual Management Reviews are Required from the following organisations: Area A NHS Trust: Health Visiting Midwifery Other hospital Departments e.g. Out patients and A & E General Practitioner (via Clinical Commissioning Groups) o Area A o Area B Area A Mental Health Foundation Trust Area B Foundation Trust (Adult Mental Health) Area A Metropolitan Borough Council o Children’s Social Care o Children’s Centres/Early Help Appendix 1: Terms of Reference 41 West Midlands Police Housing – Area A Housing Group 8. Timeline for Review Safeguarding Board decision and commissioning discussion 19th July 2016 Scoping Meeting 3rd August 2016 Terms of Reference agreed 3rd August 2016 Terms of reference, chronolator and IMR templates and guidance to authors w/c 8th August 2016 IMR Authors’ briefing 17th August 2016 IMRs / Chronology submitted 30th September 2016 QA & distribution to all Learning and Reflection Day attendees 7th October 2016 Practitioner Learning and Reflection Day 20th October 2016 1st Draft of Overview Report Distributed to all attendees 24th Nov 2016 2nd Review Learning and Reflection ½ Day 1st December 2016 Version 2 circulated 15th December 2016 Comments on V2 latest by 22nd December 2106 Version 3 to Board members 28th Dec 2016 Final Draft Overview report presented LSCB Jan 2017 9. Family engagement The family of Child A will be invited to contribute to the review by the author following consultation with the case Senior Investigating Officer from West Midlands Police. 42 Appendix 2: Falkov’s Crossing Bridges Model From SCIE Think Family Guide http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf 43 Appendix 3: Pathways to Harm, Pathways to Protection from Triennial Analysis of Serious Case Reviews Appendix 4: Example Communication Model Developed by Karen Rees and Ellen Footman, NHS Safeguarding Leads, in consultation with Worcestershire Health Safeguarding Forum 44 RECORD ASK Check back Check back SHARE DO Check back Make sure you have: Not made any assumptions Understood what you have been told Who else is working with the adult or family member/carer? Do they have concerns? Am I more or less worried? Who needs to know? Do I have or need consent to share information? Do I need advice? Make sure that you have: Not made any assumptions A shared understanding of the action to be taken. Agree what action will be taken, by whom and the time scales Consider escalating concerns if you disagree with the decision Make sure that: Your information has been heard and clearly understood by the recipient You have a shared understanding of the issues/ priorities Decide what you need to share and with whom Have all relevant detail available Be clear and concise using straight forward language and avoiding the use of jargon Provide examples where possible to illustrate what you mean Note whether information has been shared with or without consent and the rationale for doing so |
NC045590 | Death of a 4-month-old girl in October 2013, suspected to be caused by malnutrition. Mother was charged with causing or allowing the death of a child and the neglect of Jamilla and her two older siblings; she pleaded guilty to manslaughter and cruelty. Mother was born in the UK to a Somali mother and white British father. Mother was taken to live in Somaliland at 12-years-old where it is understood that she was forced into marriage at 13-years-old and experienced domestic abuse and rape. Mother returned to UK with the help of the Forced Marriage Unit (FMU) and her father when she was nearly 18-years-old and pregnant with Jamilla. Mother's care of Jamilla and siblings was assessed as good, despite her age and vulnerabilities. Identifies themes, including: the rapid deterioration of home circumstances, highlighting that neglect can lead to risk within a very short period of time for babies and young children; and the impact and potential addictive features of social network use on parenting capacity. Uses a locally developed systems approach, based on the Social Care Institute for Excellence (SCIE) model, to present findings, including: focus of assessments on current levels of functioning within families, with insufficient consideration of the potential risks of ongoing vulnerabilities; practitioners not obtaining an understanding of the implications for mother of being dual heritage and lack of knowledge of family's views to mother having escaped a forced marriage; and the need for challenging the myth of persistence in neglect. Makes recommendations covering agencies including the FMU and housing services.
| Title: ‘Jamilla’: serious case review. LSCB: Tower Hamlets Safeguarding Children Board Author: Edi Carmi Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. ‘Jamilla’ Serious Case Review Report Author Edi Carmi 08.11.14 1 Contents 1 EXECUTIVE SUMMARY 3 1.1 Context 3 1.2 Summary of Case 3 1.3 Summary of Main Findings 5 1.4 Could it happen again? 9 1.5 What will the LSCB do in response to this? 9 2 INTRODUCTION 10 2.1 Initiation of Serious Case Review 10 2.2 Methodology 10 2.3 Structure of the report 13 3 CONTEXT 14 3.1 Family composition 14 3.2 Knowledge of family by professionals prior to period under review 15 3.3 Additional information of the history prior to 2012 from family members 17 4 APPRAISAL OF PROFESSIONAL PRACTICE 18 4.1 Introduction 18 4.2 Key events 18 4.3 13th – 30th October 2012: Mother returns to the UK 19 4.4 Provision of temporary accommodation in Tower Hamlets: 30th – 31st October 2012 20 4.5 Temporary accommodation in Tower Hamlets: 31.10.12 – February 2013 21 4.6 New home prior to birth of Jamilla: March – mid May 2013 26 4.7 Birth of Jamilla: May 2013 28 4.8 Post natal period: mid-May – end of July 2013 29 4.9 August to October 2013 32 2 5 THEMATIC ANALYSIS 35 5.1 Introduction 35 5.2 Neglect 35 5.3 Threshold responses & assessments of need 38 5.4 Thresholds for children’s social care involvement 39 5.5 Use of history in determining agency responses 41 5.6 Health visiting service provision 41 5.7 Mother’s co-operation with health services 43 5.8 Lack of co-ordinated multi-agency provision 45 5.9 Health practitioners knowledge of police notifications 47 5.10 Task centred versus relationship based provision of support 48 5.11 Social isolation: family contact with extended family and community 49 5.12 Shortage of housing resources 52 5.13 Culture 54 5.14 Financial Problems 55 5.15 Addiction to social networking sites? 56 6 FINDINGS & RECOMMENDATIONS 58 6.1 Introduction 58 6.2 Findings and Recommendations 58 GLOSSARY OF TERMS & ABBREVIATIONS 68 APPENDIX 1: PANEL MEMBERS 69 APPENDIX 2: PRACTITIONERS INVOLVED IN THE SCR PROCESS 70 3 1 EXECUTIVE SUMMARY 1.1 Context 1.1.1 This serious case review was initiated by Tower Hamlets Local Safeguarding Children Board (LSCB) following notification that a four month old baby (referred to as Jamilla) had died in October 2013, following cardiac arrest, suspected to be caused by malnutrition. Her two older siblings were exhibiting signs of neglect and the family home was described by police as being in a poor condition. 1.1.2 This tragedy took professionals by surprise, as despite the mother’s youth and traumatic earlier experiences, the care of the children had always been assessed as being good, and she had presented as positive about the future and about the support she was understood to be receiving from family members. 1.1.3 Due to the lack of identified concerns about the children’s welfare the family was not in receipt of services from Children’s Social Care. At the time of Jamilla’s death, they had universal health services (GP and health visitor), as well as being an open case to the Gateway midwifery team1. There had previously been children’s centre involvement, but mother ceased to have her own allocated worker in March 2013 and had stopped attending any sessions shortly after Jamilla’s birth. 1.1.4 In the weeks prior to Jamilla’s death, a sibling had been registered at pre-school, but had only attended twice, both times in the company of his mother and siblings. The only concern identified at that stage was the smell of urine apparently coming from the children’s double buggy. 1.2 Summary of Case 1.2.1 Jamilla’s mother was born in the UK to a Somali mother and a white British father; her father had converted to Islam. She lived in London until the age of twelve2, when she and her younger siblings were taken by Jamilla’s maternal grandmother (MGM) to live in Somaliland3, the country from which the maternal family originated. 1 The Gateway midwifery team provide ante and post natal services for vulnerable women 2 The age is calculated from agency records of when Jamilla’s mother last attended school; but the mother herself understood she moved when she was aged eleven years old. 3 Somaliland is a former British protectorate which declared independence from Somalia (a former Italian colony) in 1991. Though not internationally recognised, Somaliland has a working political system, government institutions, a police force and its own currency. The territory has lobbied hard to win support for its claim to be a sovereign state. 4 1.2.2 Whilst in Somaliland it is understood that the mother of Jamilla was forced into a marriage at the age of 13 and suffered domestic violence and rape. She gave birth to two children whilst in Somaliland before managing to escape and return to the UK in 2012, with the help of the Forced Marriage Unit4 (FMU) and her own father. By this time Jamilla’s mother was nearly eighteen years old and pregnant with Jamilla. 1.2.3 In London, Jamilla’s mother and her two children stayed for a short period with mother’s father (MGF) and members of his family, before staying briefly with extended maternal family in Tower Hamlets. She was provided with housing in the borough and accessed local services for support. She also reported to practitioners from local agencies that her extended family were providing her with support. 1.2.4 In professional contacts with the family staff were impressed with the mother’s care of her children despite her youth. She received routine midwifery and health visiting appointments, and would have been provided with additional support had she requested. She did not however ask for more help. 1.2.5 Professional contact decreased after the birth of Jamilla as the mother was assessed to be coping well and (according to the midwife) chose not to attend the last midwifery post natal appointments (Mother though understood that the midwife would visit her). Mother ceased attending a Young Parents Group at the Children’s Centre: she had attended this regularly until the birth of Jamilla and subsequently on a few occasions. There was no health visitor or GP contact after early July, although the health visitor was planning to make contact in October. 1.2.6 In September 2013 the eldest child was registered at a local pre-school, but prior to the death of his sister he had not yet started to attend regularly. In the three pre-school contacts with the family in the days and weeks prior to Jamilla’s death, observations of the home, the children and their relationship with their mother did not give rise to specific concerns, other than a smell of urine from the children’s buggy. 1.2.7 In response to this concern, and the early indications of a lack of regular attendance, the pre-school were considering what support mother may need, whilst also trying to engage her to enable the son to attend. The manager involved mother’s previous family support worker (FSW), about who mother spoke positively. The FSW had provided support during the early months of mother’s return to the UK, when mother attended a children’s centre. Following contact with the pre-school manager, the FSW was attempting to make contact with mother. 4 The Forced Marriage Unit (FMU) is a joint Foreign and Commonwealth Office and Home Office unit which was set up in January 2005 to lead on the Government’s forced marriage policy, outreach and casework. It operates both inside the UK, where support is provided to any individual, and overseas, where consular assistance is provided to British nationals, including dual nationals. 5 1.2.8 Before the previous FSW had succeeded in getting a response from Jamilla’s mother, an ambulance was called to the family home and Jamilla was found to be in cardiac arrest. Jamilla’s siblings were found to be in a state of neglect and the conditions in their home were poor. 1.3 Summary of Main Findings Predictability 1.3.1 The death of Jamilla and the severe neglect of her siblings were not predictable. Professional contact with the family identified the mother’s vulnerability, due to her earlier life experiences, but led to consistent observations of a resilient young woman who was managing to provide her children with the love and care they needed. Preventability 1.3.2 It would have been difficult for professionals to have prevented the tragedy, due to the rapid deterioration in the home circumstances, mother not opening the door to callers in late September and her ability at pre-school, to project the appearance that she was still coping well with parenting her children, just four days prior to Jamilla’s death. The following sections suggest changes in service provision that may reduce the likelihood of similar tragedies in the future. Children’s health and welfare system does not routinely monitor pre-school children in the absence of identified needs 1.3.3 To have been able to prevent this unexpected and sudden tragedy, we would require a universal service with frequent family contacts, which is able to identify changes in the home circumstances and in mother’s parenting capacity, such as happened here. Current systems nationally do not by their nature intend to routinely monitor the health and/or welfare of children after they are 6 weeks old other than through voluntary developmental checks at subsequent points. When children reach school age they will be monitored when they attend school, with unexplained absences followed up. When children are younger and more vulnerable, their health and/or welfare will be monitored only if there are identified concerns, or if parent/s choose to bring the children to clinic appointments and/or to sessions at children’s centres, nurseries or pre-school. 6 1.3.4 In the case of this family, there were no concerns identified about the care of the children. The family had ceased to attend voluntary sessions at the children’s centre and although registered at the local pre-school, the eldest sibling had not yet begun to attend regularly. In the absence of babies and young children being seen regularly at community settings, we rely on family and neighbours to alert services if there are concerns. This did not happen in this case, partly because extended family, like professionals, thought mother was coping well and had themselves decreased contact and partly because of the family’s general social isolation. Focus of multi-agency assessment is on current levels of functioning 1.3.5 The focus of multi-agency assessment and subsequent response is based on current levels of functioning within families, with insufficient consideration of the potential risks arising from underlying vulnerabilities. The local Family Wellbeing Model (in line with the National Framework of Assessment) does not include such vulnerabilities in the trigger to undertake a multi-agency assessment, have a lead professional or team around the family. Local enhanced health visiting service does not provide criteria for level of service provision 1.3.6 The family were correctly assessed as needing both an enhanced health visiting service and the Gateway midwifery service, in recognition of mother’s vulnerability. However, the local arrangements for an enhanced health visiting service, whilst providing definitions of vulnerability, does not specify the minimum contact level with families or criteria to trigger follow up / additional visits: this is left to individual professional judgment. In this case a universal service was provided, with the added proviso that mother was able to request additional help. Given mother’s underlying vulnerability, such reliance on her to be able to understand she could request and then ask for help should her circumstances change may be over optimistic. Is there a role for a lead professional in the absence of current concerns, but where there are underlying vulnerabilities? 1.3.7 Because there were no identified concerns about the children, there was a lack of co-ordinated multi-agency input, so no one lead professional understood that mother had not brought her son for his developmental check, had not brought the children for their immunisations, had not attended her last two midwifery appointments and had ceased to attend the children’s centre. Whilst these are all voluntary activities and attendances, the pattern when taken together, was indicative of possible changes or even withdrawal from activities and contacts. 7 1.3.8 Given mother’s youth (18 years old) and vulnerability (and the difficulties for any single parent coping with three children under the age of 4 years old), such a pattern, if identified, should have led to follow up. The health visitor was planning to do this in October, on the basis of the missed developmental check and immunisations. This urgency is likely to have been greater had the health visitor also been aware that the family were no longer being seen at the children’s centre and had not attended the last two midwifery appointments. 1.3.9 Mother explained to the review author, that without a consistent relationship with any one professional she was unable to develop a trusting relationship and feel able to speak openly. An identified lead professional may have made a consistent relationship more likely. National Health Service: contrast between professional contact before the birth of baby, and after the baby is 6 weeks old 1.3.10 One of the features of the National Health Service is frequent contact with a pregnant woman during pregnancy, but then a marked decrease after the birth, unless the post birth visit by the health visitor assesses any additional needs. In this case whilst mother’s underlying vulnerability was identified, the assessment did not indicate any additional needs. 1.3.11 However, for some parents, the difficulties only become apparent later. This was the case for this family, with an 18 year old single parent with three children aged under 4 years old. The mother described to the author how soon after the birth of Jamilla the support she had from her family decreased and at the same time contact with professionals stopped. The rationale for this is that following the 6 week review, in the absence of identified concerns, it is left to parents to request help or to attend the clinic. It was though at this point when the responsibilities of caring for her new baby and two other young children seemed most onerous for this mother and she described feeling constantly tired. Potential weaknesses in identifying the presence of children arriving in the UK 1.3.12 This was not a problem in this case, but the circumstances have highlighted a potential weakness when families move to the UK from abroad, as there is no automatic information provided to universal services about the arrival of families and it is possible for the children’s existence to remain unknown. 1.3.13 In this case, the FMU were involved and informed Brent Children’s Social Care, who spoke to MGF, but did not inform health colleagues. Fortunately the family followed the advice provided and registered with a GP, so ensuring the children’s presence in the UK was identified. In Tower Hamlets, Children’s Social Care ensured the children’s presence was known and that the family was assessed for services. 8 Task centred versus relationship based provision of support 1.3.14 A challenge for practitioners nationally when undertaking assessments is the focus on achieving tasks as opposed to developing relationships. Moreover in the absence of identified concerns, contact normally takes place outside of the home, at clinics, children’s centres and schools. This contrasts with a generation ago when the universal health provision involved home visits by health visitors to households with pre-school children and midwives visiting the home for 10 consecutive days post birth. 1.3.15 This change to service delivery via clinics and children’s centres is more efficient and has the advantage of encouraging parental links with community resources and other parents. The disadvantage of this change may though be the ability to develop a trusting relationship with practitioners: this can impact on the quality of assessments undertaken as well as the chances that further help is requested. Weaknesses in the assessments undertaken 1.3.16 The assessments that were undertaken by health and children’s centres accepted mother’s self-reported accounts of intensive support from relatives. Without such help, she would have struggled to cope. What was missing from the assessments, and the ongoing work with the family, was an understanding of exactly what this support involved and its consistency and regularity over time. Other than the case worker from the FMU, no local practitioner met with any family members, even when a relative was present in the home during a home visit after the birth of Jamilla. 1.3.17 The assessments undertaken did not adequately seek to understand the implications for mother being of dual heritage and how this affected her experiences both currently and in the past; in particular what this may have meant within her extended maternal family. Given that she had fled a forced marriage arranged by her family this was a relevant area to explore, especially given mother’s reliance on these relatives for frequent and regular support. Housing provision 1.3.18 Mother was provided with a comparatively good housing service, given the resources available: she was immediately provided with temporary self-contained accommodation within Tower Hamlets and following her complaints was moved to an alternative temporary accommodation a few months later. 1.3.19 Unfortunately, the first flat was on the fourth floor of a building without a lift; this was a potential risk to a heavily pregnant woman and her two young children. However, given a steep rise in homeless applications and the portfolio of aging accommodation without lifts in the borough, this was the only available provision at the time. This lack of suitable resources is a continual problem both in the borough and elsewhere in London. 9 1.4 Could it happen again? 1.4.1 This tragedy was unexpected and could not have been predicted on the basis of the evidence practitioners had of mother’s parenting skills and her capacity to cope with obstacles in her life. 1.4.2 Given that services are provided in response to current problems and concerns, there will always be a risk that changes in parenting capacity are not later detected. Those children at highest risk are pre-school age children or those without regular children’s centre / pre-school attendance. 1.4.3 In consequence, services need to be sensitive to any changes or apparent withdrawal from services in families where children are not being regularly seen by professionals. The need for this is even greater when underlying parental vulnerabilities are already identified, as in this case. In these circumstances there should be multi-agency co-ordination of services by a lead professional, to maximise the possibility of: Developing a trusting relationship with the parent/s so as to be able to detect changes in parenting capacity Be aware of the overall pattern of behaviour by the family, including involvement and co-operation with all the service providers 1.5 What will the LSCB do in response to this? 1.5.1 At the end of each finding in section 6 recommendations have been made for the LSCB. The LSCB has prepared a separate document which describes the actions that are planned to strengthen practice in response to the findings and recommendations of this serious case review. 10 2 INTRODUCTION 2.1 Initiation of Serious Case Review 2.1.1 An ambulance was called to the home of four month old Jamilla in October 2013. Jamilla was found to be in cardiac arrest and was taken to the local Hospital where it was established that she was deceased: the suspected cause of the cardiac arrest was malnutrition. Her two older siblings appeared to be exhibiting signs of neglect and the family home was described by police as being in a poor condition. 2.1.2 The children's mother was subsequently arrested and charged with causing or allowing the death of a child and the neglect/ill treatment of all three children. She pleaded guilty to manslaughter of Jamilla and cruelty in relation to Jamilla’s elder siblings. 2.1.3 Following a recommendation from the Local Safeguarding Children Board (LSCB) Case Review Group, Sarah Baker, the Independent Chair of the LSCB, decided to initiate a serious case review (SCR) on the grounds that the circumstances met the criteria in accordance with Working Together to Safeguard Children 2013: ‘Abuse or neglect of a child is known or suspected and The child has died or been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child’. 2.1.4 The Department for Education and the National Serious Case Review Panel were informed on 29 October 2013. 2.2 Methodology 2.2.1 Statutory guidance5 requires SCRs to be conducted in such in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings 5 Working Together to Safeguard Children, 2013 Chapter 4 11 2.2.2 In order to comply with these requirements Tower Hamlets Safeguarding Children Board (referred to as the LSCB) developed a systems approach methodology to use for this case. This approach aims to understand professional practice in context, identifying the factors that influence the nature and quality of work with families and make it more or less likely that the quality of practice will be good or poor. The systems principles and data collection process in the Social Care Institute for Excellence Learning Together Systems Guidance6 has been used in developing this local approach. Period under review 2.2.3 The period under review is from the point when Jamilla’s mother approached UK authorities for help to return to the UK in 2012 until Jamilla died in October 2013. Information that was held by agencies about the mother’s family prior to this period provides a context of what was known or ‘knowable’ to practitioners during the period under review. Process 2.2.4 The process used involved: Agreement that the Independent LSCB chair Sarah Baker would be the chair of the serious case review panel A review panel of senior managers to oversee the process, meeting monthly (see appendix 1) Identification of agencies involved with the children in the family and their mother Collation of a detailed chronology of professional activity Obtaining information from Brent and Westminster LSCBs following the information that the family had lived initially in these 2 boroughs prior to moving to Tower Hamlets The appointment of an independent lead reviewer, Edi Carmi, to work collaboratively with the review panel, lead the analysis and write the review report The lead reviewer and panel members’ involvement in speaking to practitioners so as to understand what happened and why - the rationale for actions, inactions and decisions The review was undertaken from a multi-agency perspective from the outset: consequently individual management reviews from agencies were not requested NHS England expects health management reviews: the authors of these were part of the review panel and all health staff interviews were undertaken in collaboration with the lead reviewer The direct involvement of practitioners and managers through one individual and three group meetings to provide information and to participate in the findings of the review; including the thinking about what helps and hinders the safeguarding of children in such circumstances (see appendix 2 for details) Involvement of family members: mother and maternal grandfather agreed to participate in the process, once the criminal proceedings had ended 6 Learning Together, Fish, Munro & Bairstow SCIE 2008 12 Consideration of a variety of written records and reports undertaken as part of the ongoing work of practitioners and, as appropriate, as part of the criminal investigation and court proceedings including the witness statements obtained by the police as part of the criminal investigation, psychiatric and psychological reports undertaken as part of parallel legal processes Quality assurance process involving the scrutiny of the report by the overview author for another serious case review in a neighbouring borough (Barking & Dagenham), sharing the same Independent LSCB Chair Family participation 2.2.5 In order to enable mother to participate in the review, the report was delayed until she was able to speak with us, following the end of the criminal processes and when she was considered, by those professionals currently providing her with support, to be sufficiently settled to undertake this task. 2.2.6 Maternal grandfather also participated in the review once the criminal proceedings ended. 2.2.7 Attempts were made to contact the children’s maternal great aunt, but no response was received. Her witness statement to the police has been accessed and this has contributed an understanding of the support provided by the great aunt and other family members. 2.2.8 Subsequent delays occurred due to the time taken to enable mother to read and understand the contents of this report, with the help of a support worker. Mother was able to provide useful feedback which led to some additions, primarily acknowledging when her memory of events was different to that of practitioners. Limitations 2.2.9 The information about what happened to mother whilst living in Somaliland from the age of 12 – 17 years old has been obtained from statements mother and family members made to the police as part of the criminal investigation, information mother provided to the Forced Marriage Unit and information from interviews with mother and maternal grandfather . Some of this information is not clear, especially in terms of what injuries were involved and any involvement of family members, other than her husband, in the alleged abuse perpetrated against mother. Given that mother was a child herself at the time this is perhaps not surprising. 2.2.10 Mother spoke about receiving help from a family friend who worked for a local community organisation. This was not known until September 2014. The LSCB has attempted but been unable to obtain details of the service provided. 2.2.11 Mother chose not to complete reading this report prior to publication, so did not provide feedback to the second half of the document [section 5 onwards]. 13 2.3 Structure of the report 2.3.1 The report is structured as follows: Section 3 provides: o details of family members mentioned by the mother o historical information of professional involvement prior to the mother’s move to Somaliland in 2007 and o what family members understood about the mother’s history prior to her return to the UK Section 4 explains what happened from the perspective of those involved at the time, including both professionals and family members Section 5 provides an analysis of the themes emerging from the practice in this case Section 6 provides the overall findings and recommendations 14 3 CONTEXT 3.1 Family composition 3.1.1 Jamilla lived with her mother and 2 siblings in Tower Hamlets at the time of her death. Table 1: Household members Term used in report Relationship to Jamilla Age on 04.10.2013 Jamilla subject 4 months sibling 1 eldest sibling 3 years sibling 2 sibling 1 year 7 months Mother Mother of Jamilla 18 years 3.1.2 Whilst the composition of the household is known, it has been difficult to understand fully the structure of the extended family and significant people. 3.1.3 The children’s father lived, and remains in Somaliland. Also there are Jamilla’s maternal grandmother (MGM) and four maternal uncles/aunts. 3.1.4 The following table 2 shows other significant people mentioned by mother to practitioners and their locations during the period under review. All were family members. Table 2: Significant people as understood by practitioners at the time Term used in report Relationship to Jamilla Location on 04.10.13 Father Jamilla’s biological father Somaliland MGM Maternal grandmother Somaliland 3 Maternal uncle / aunts Jamilla’s mother’s half siblings Somaliland MGF Maternal grandfather LB Brent Maternal step-grandmother Jamilla’s maternal grandfather’s partner LB Westminster MGGM Maternal great grandmother LB Tower Hamlets Great aunt Maternal great aunt Not known Mother’s cousin 1 Jamilla’s mother’s cousins LB Tower Hamlets Mother’s cousin 2 LB Tower Hamlets Father’s cousin Jamilla’s father’s cousin London 3.1.5 Through reading police witness statements, further information has emerged of the family members. There is no evidence of mother having direct social contacts with anyone outside her family, except she mentioned one other woman with whom she had occasional contact who was the victim of forced marriage in Somalia. 3.1.6 Further significant people in contact have been identified from the police witness statements. However, the structure and members of the family are not totally clear. This confusion may arise from the cultural practice to call some family friends ‘cousins’, ‘aunties’ and ‘uncles’, as well as a desire to keep some privacy around family arrangements. 15 3.1.7 The witness statements highlight further family in Somaliland and London and in occasional contact with the family was a maternal great uncle, a large number of cousins and a further contact whose exact relationship is unclear. 3.2 Knowledge of family by professionals prior to period under review Introduction 3.2.1 The knowledge of the family prior to the period under review is when: Mother lived in London as a child, before she and her 2 siblings were taken to Somaliland by MGM in July 2007 - at that point mother was aged 12 years old and was near the end of Year 7 at school During the years she lived in Somaliland, when she was married as a child and gave birth to 2 children 3.2.2 This information gives a context of what happened before and was known or knowable to agencies. It is though prior to the scope of the serious case review, so the practice will not be subject to analysis. 3.2.3 The following information comes from agency records, witness statements that formed part of the criminal investigation, mother’s own accounts of her life given at various points to professionals and within the criminal investigation and interviews with mother and MGF for the purposes of this serious case review. 3.2.4 When individuals recounted memories of events on different occasions, the details provided were not always consistent, and the dates varied. Such inconsistencies are not explored as they are not significant in terms of either the mother’s experiences or the way agencies worked together during the period under review. Prior to move to Somaliland 3.2.5 Professional records of this period understood that MGM and her family were from Somalia but were living in London [mother has since explained they came from Saudi Arabia]. MGF is white British, and had converted to Islam. MGM and MGF separated when Jamilla’s mother was about 6 months old and it is understood that there was little subsequent contact between mother and MGF. 16 3.2.6 Prior to the family’s departure for Somaliland in 2007 there had been contact between MGM and the police due to reported incidents of domestic violence, between MGM and firstly MGF (during 2 contacts following their separation) and then several incidents between MGM and her second husband in 2003 and 2004. By 2004 the couple had separated and MGM spoke of being assaulted by her second husband on several occasions, including an allegation of being stabbed in her leg, as well as an allegation about his abuse of the younger children in the family. Police investigations were undertaken but did not substantiate the allegations and MGM’s second husband was not located. He was thought to have left the country7 . 3.2.7 By 2005 MGM and her three children had moved to Tower Hamlets, where mother attended the last year of primary school and first year of secondary school. Mother attended secondary school for 10 months; this was a difficult period for mother, with staff recalling her being bullied and the identification of her having a low reading age [6.08 years] and receiving extra literacy input. She also received help from a Somali support worker, who found mother to be shy with low self-esteem. Subsequently there were concerns about mother’s school attendance and her increasingly challenging behaviour. 3.2.8 Staff participating in this review recalled that mother looked much older than her age and had difficult relationships with some of her peers, especially the older Somali girls. It was understood that this was partly due to attitudes about her mixed heritage, but also due to communication difficulties, which led to misunderstandings. This was thought to be part of a language and communication learning difficulty, for which she was going to be referred to the educational psychologist for an assessment, but left the school prior to this happening. 3.2.9 In the months preceding the family’s departure there was involvement of police on two occasions when MGM reported her 12 year old daughter, Jamilla’s mother, as missing. On one occasion she was gone for a few days and on the second she was a few hours late home. 3.2.10 Children’s Social Care liaised with the school and MGM during the first episode, but did not become further involved. Mother was located at a maternal great aunt’s home after four days absence. The deputy head teacher recalled in interview for this review that mother sometimes stayed with an ‘auntie’ (possibly Jamilla’s maternal great aunt). 7 Further allegations have been made against this man as part of specialist assessments in legal proceedings. These have been reported to the police for further investigation, along with possible information about his whereabouts. 17 3.3 Additional information of the history prior to 2012 from family members 3.3.1 Police witness statements from family members provide additional history that was not known to professionals including: MGM, mother and siblings went to Somaliland on holiday, prior to MGGM deciding to live there MGM stopped mother’s contact with MGF during her 2nd marriage, but when MGM ceased living with her second husband contact resumed for about a year until MGM and her children went to Somaliland for a fortnight; subsequently they were never home when MGF called and he discovered eventually they had gone to Somaliland to live Great aunt and a cousin remembered relatives in the UK being shocked / upset to hear that mother was being married (variously said to be at the age of 13 or 14) and her husband was 20 years old, although another cousin heard she wanted to get married and was ‘in love’ Great aunt refers to MGM being worried about mother being ‘beaten up’ by her husband and ‘abused verbally’ but commented that ‘Somali women have no power’ so her sister [MGM] ‘could not do anything’ – on one occasion MGM reported to great aunt that mother had telephoned after being punched so hard in her face that it had loosened her front tooth and her mouth was bleeding Two cousins were aware of domestic violence and that mother was said to have had a miscarriage 3.3.2 Mother provided further allegations in interview including the loss of two pregnancies due to domestic violence, a complaint to Somaliland police following the loss of her tooth due to domestic violence and her attempt in Somaliland to escape to her MGM. Both police and MGM are understood to have returned mother to her husband. 18 4 APPRAISAL OF PROFESSIONAL PRACTICE 4.1 Introduction 4.1.1 Section 4 provides a commentary on professional practice during the period under review. 4.1.2 To understand the rationale for professional practice, what happened is described from the perspective of those involved at the time, professional staff and family members. The information is derived from agency records, interviews with staff and information from statements provided to the police after Jamilla’s death. 4.1.3 4.2 gives a brief table of the key events in what occurred and 4.3 – 4.9 gives the details of what happened, broken into time periods. The commentary within the shaded boxes at the end of each time period is an appraisal of professional practice. Where such appraisal and explanation reflects a recurrent theme regarding the service provided, there is a cross reference to subsequent analysis and/or findings. 4.2 Key events 4.2.1 The following table provides the key events during the period under review, which are then explained in more detail in the rest of section 5. Date Event October 2012 Mother and her 2 children arrive in London and are understood to move to MGF in Brent Brent Children’s Social Care advise MGF of services that mother could access 23.10.12 Mother’s pregnancy confirmed via GP in Westminster 30.10.12 Mother presented as homeless at Tower Hamlets and provided with temporary flat 31.10.12 Housing refer family to Children’s Social Care, who refer to the health visitor and Children’s Centre November 2012 Health visitor transfer in visit Family Support Worker, Children’s Centre visits home and agrees service Mother complains to Housing about being on the 4th floor without a lift Mother starts receiving regular midwifery services from the community midwife January 2013 Midwifery service from the Gateway team8 provided in light of mother’s age and vulnerability Mother starts to attend the Young Parents Group early February 2013 Health visitor sees family at clinic: 2nd health visitor contact End Feb. 2013 Family move to more suitable accommodation March 2013 Case closed at the children’s centre and mother declined referral to a Children’s Centre closer to her home – she continued though to attend the Young Parent’s Group 8 The Gateway team provides midwifery services for vulnerable women 19 April 2013 Unknown to staff MGGM leaves the UK and returns to Somaliland May 2013 Jamilla born Change of midwife : 2 home visits by new midwife and one clinic appointment June 2013 Health visitor’s new birth visit Mother attended 2 Young Parent’s Group sessions Mother DNA midwife appointment at the clinic July 2013 Mother attended post natal check at GP: last contact with health Jamilla seen by health visitor and GP for 6 week developmental check: last time Jamilla seen by health practitioners Mother and all children seen at pre-school for ‘settling in ‘ visit Mother does not attend midwife appointment at the clinic August 2013 No professional contact September 2013 Home visit by preschool staff on 6th Family attend one pre-school session on 19th – subsequently mother says sibling 1 unwell Family attend briefly again on 30th, but leave when explained mother will need to stay with sibling 1 as he is new to the pre-school (settling in period) 04.10.13 Mother speaks to pre-school and says that they have been staying with MGF Ambulance called to Jamilla 4.3 13th – 30th October 2012: Mother returns to the UK 4.3.1 In October 2012, mother (aged 17 years 11 months) came to the British Embassy in Addis Ababa, requesting passports for herself and her 2 children, aged 8 months and 2.5 years old. She had travelled with her husband from Somaliland. Mother explained her history to Consular staff including allegations that she was a victim of forced marriage at the age of thirteen and of domestic violence and rape from her husband. 4.3.2 Whilst consular staff undertook the Nationality Authentification Test (to confirm mother’s right of entry to the UK), she and her 2 children remained with her husband in a hotel for several days. The specialist caseworker of the Forced Marriage Unit (FMU) in the UK was told by Embassy staff that on one of days mother arrived with blood on her scarf, which she explained was the result of her husband hitting her. He signed the travel documents in the belief that mother would sponsor him subsequently to join her. 4.3.3 MGF liaised with the Forced Marriage Unit in London about mother’s circumstances. He purchased flight tickets for her and his grandchildren to travel to the UK; staff at the Unit understood the plan was for the family to stay with MGF in Brent. 4.3.4 The FMU Specialist Caseworker referred the family to Brent Children’s Social Care on 12.10.12 due to awareness of mother’s general vulnerability: aged under 18 years old, having endured a forced marriage, given birth at a very young age in difficult circumstances and whose children may have witnessed violence. 4.3.5 Although there were no specific concerns about the welfare of the children the FMU worker made the referral as ‘I wanted to check that her and her children were ok and felt they needed a professional (social services) assessment in case additional support was required.....’. 20 4.3.6 Brent Children’s Social Care telephoned MGF on 15.10.12 obtaining confirmation of the family’s return and offered advice about local services (Children’s Centre, GP, health visitor and Housing). Mother told the author she was present during the telephone conversation, but the social worker did not ask to speak with her. 4.3.7 MGF has explained that mother and children stayed with MGF’s ex-partner’s (maternal step-grandmother1) home in Westminster. A week after returning to the UK, mother consulted a GP in Westminster and following a pregnancy test it was confirmed that she was expecting a baby. She did not at this point disclose any history of forced marriage or domestic violence to the GP, who made a referral for antenatal care. Mother attended the local hospital accompanied by step grandmother1. Comment: Return to the UK Mother and children received a responsive sensitive service from staff at the Consulate and in the FMU, which took account of her precarious position and facilitated her return to the UK. The FMU does not generally provide a service once a victim is repatriated. If there are specific issues or concerns a referral is made to the relevant authorities. In this instance the referral to Children’s Social Care in Brent was appropriate given mother’s youth, vulnerability and perceived potential need for support. Because it was understood the family would stay with MGF, no referral was made to housing. Brent did follow up the contact made by the FMU by checking the family had arrived in the UK and signposting MGF to services. They did not though treat this as a ‘referral’, did not make any assessment of need, did not check if any services were accessed, or if health knew of the existence of the children in the UK. This is discussed in section 5.4. 4.4 Provision of temporary accommodation in Tower Hamlets: 30th – 31st October 2012 4.4.1 On 30.10.12 mother presented as homeless to Tower Hamlets, explaining she was familiar with the area before she went to Somaliland. She saw an Assessment Officer the next day, when she attended with her 2 children and described her forced marriage and return to the UK. Mother gave 2 addresses; the first was step grandmother’s home in Westminster and the second an aunt (maternal great aunt) in Tower Hamlets. 4.4.2 The Assessment Officer noticed that mother was fluent in English and ‘good with the children’. Sibling 1 was observed to be very active during the interview, whilst sibling 2 was carried by mother. She was affectionate with both children and sibling 1 gave his mother lots of kisses. 21 4.4.3 The Assessment Officer organised immediate temporary accommodation for mother and children in a flat on the 4th floor in a building, without a lift. She also organised emergency financial assistance to buy nappies and milk and informed the Housing Specialist at Children’s Social Care of mother’s situation (forced marriage, 18 years old, 2 children and 3 months pregnant) as she felt Children’s Social Care should ‘keep an eye on the family’ due to mother’s vulnerability. The Housing specialist within Children’s Social Care asked for a duty social worker to call mother the next morning and get her linked to the nearest Children’s Centre for support in sorting out her finances and furniture. Comment: Housing immediate response Housing provided an immediate and responsive service to mother and children. The provision of a flat was fortunate: the Assessment Officer commented this is often not available and families are then placed initially into Bed and Breakfast accommodation. The fact it was on the 4th floor without a lift is recognised to be far from ideal, but reflects the scarcity of temporary accommodation. This is discussed further in 5.12. The recognition of mother’s vulnerability and referral to Children’s Social Care was appropriate response. 4.5 Temporary accommodation in Tower Hamlets: 31.10.12 – February 2013 4.5.1 During the next 3 months mother lived in the 4th floor flat without a lift and had frequent contact with Housing, the GP, midwifery and children’s centre, as well as 2 contacts with health visiting services and a telephone contact with the FMU. Throughout this period professionals who saw the family were impressed with mother’s parenting of 2 small children and her overall positive and optimistic attitude to life. Children’s Social Care role 4.5.2 Children’s Social Care were not directly involved with mother, but responded to the referral from Housing by trying to speak to her on 31.10.12. In the face of a lack of response to a message left on the mobile number provided (belonging to a cousin of mother), the social worker made urgent referrals to the health visitor and Children’s Centre and advised that should there be any further concerns to contact Children’s Social Care. Both the health visitor (HV1) and the children’s centre made contact with Children’s Social Care that day and the Children’s Centre also allocated the referral to a Family Support Worker (FSW). Comment on LBTH Children’s Social Care role Children’s Social Care understood the vulnerability of mother and ensured that she received immediate support services via the Children’s Centre and the health visitor, but did not become directly engaged with the family. This is discussed further in 5.4. 22 Housing problems 4.5.3 From the outset, mother made it clear that she was unhappy living in a flat without a lift due to problems managing the four flights of stairs with two little children, a buggy and being pregnant. She complained in person to Housing within days of the move and followed advice from the Assessment Officer to put the complaint in writing (possibly with help from the Officer). Once again the Officer noticed positive interactions between mother and children, and a woman understood to be MGGM was seen in the distance. Mother continued to complain and got written support from the FSW at the Children’s Centre and the GP: the FSW received a written response that mother was on the transfer list, but that there was a shortage of temporary accommodation. 4.5.4 Meanwhile the Assessment Officer continued with background enquiries which indicated that because mother had left Tower Hamlets at age 12, she did not meet the criteria for a local connection, and because MGF lived in Brent it was judged that Brent held responsibility for housing mother and children. Mother was sent notification of this on in mid-November and her solicitor wrote to Tower Hamlets Housing two weeks later seeking a statutory review of the decision to refer to Brent. In early January 2013, Housing decided that the full homelessness duty rested with Tower Hamlets not Brent and on 26.02.13 the family moved to a new temporary tenancy. 4.5.5 It is of note that during the two months of negotiation with Housing, mother displayed admirable assertiveness as well as ability to co-ordinate the services in her support. She prompted the FSW as well as the GP to write to Housing to support her and also sought legal support. Housing Comment Mother and family received a comparably good service from Housing, in the light of current resources. However, the initial flat was unsuitable for a young isolated pregnant woman with 2 small children and this could have been perceived as a risk to their welfare. See section 5.12 for further discussion. Mother is likely to have experienced stress because of the initial decision that the homeless responsibility lay with Brent not Tower Hamlets. See 5.12 for further discussion. Children’s centre involvement 4.5.6 The Family Support Worker’s (FSW’s) involvement between November 2012 and February 2013 provided the most consistent professional contact during the period of the review. This consisted of 1 home visit, seeing the family when mother brought the children to play sessions at the local children’s centre and sometimes accompanying the family to the centre. From late January 2013 mother and children attended the Young Parent’s Group held at another Children’s Centre; the FSW was one of the staff involved with this group. 23 4.5.7 Throughout this contact mother presented as positive about the present and optimistic about the future, planning to continue her own education and wanting the best for her children. She was perceived to have a strong survival instinct and was ‘pretty canny for one so young’ (FSW description). 4.5.8 The children were observed to be well and to have a good relationship with their mother. Sibling 1 was very lively whilst sibling 2 was crawling and wanting to be near her mother. The home was clean and tidy and raised no concerns. 4.5.9 At the FSW’s supervision in mid- February it was decided to end the FSW’s allocated role with mother, as all objectives had been met and practical support and advice provided. The FSW would continue to see the family at the Young Persons Group and at sessions at the children’s centre. This was discussed with mother in early March. 4.5.10 The FSW was aware of the local family support, and understood that there was a cousin in the area and that MGGM lived locally and planned to stay with the family when the baby was born. The FSW never met any of these family members. Comment on children’s centre service The involvement of the FSW to help mother access practical benefits and facilitate her and the children’s involvement in the children’s centre activities was a positive service. Although it was judged that mother no longer needed an allocated FSW, the FSW continued to see mother regularly through on-going attendance at the Young Parent’s Group. This support was understood by other professionals as valued by mother and it is of note that because of the continuing involvement at the Centre mother still referred to herself having a FSW in her contacts with health professionals. Health visiting service 4.5.11 HV1 initially had some difficulty accessing the family as the contact telephone number provided, understood to belong to a cousin, had no voicemail. Moreover no-one was at home on two opportunistic visits. However the health visitor managed to speak with mother eventually and after some initial reluctance and suspicion mother agreed to be visited the next day. The health visitor arranged for an agency health visitor (HV2) to undertake this visit, highlighting the need to explore the family’s vulnerability. 4.5.12 On 09.11.12, HV2 visited the family. Mother spoke of her history including the forced marriage and domestic violence. She also spoke of being socially isolated, but having relatives living in the borough. HV2 noted that mother spoke to her children in a kind and loving manner, and they appeared ‘well cared for and thriving’. Their immunisations were not up to date and mother said the family were still registered with a GP in West London. A referral was made to the local children’s centre for assistance in obtaining financial help and for support. Mother’s vulnerability was noted within the record, but no arrangements made for any follow up home visits, possibly due to the fact that sibling 2 would be due her 8-12 month review 3 months after this visit. 24 4.5.13 HV1 saw both children at a clinic visit for sibling 2’s developmental review in early February 2013. Sibling 2 was on the 75th centile for height and just below that for weight. She was meeting all her developmental milestones. Sibling 1 was also observed to be well and healthy, with good interaction noted. He had started to be toilet trained. Mother was reminded to make an appointment for sibling 2’s 12 month immunisations, and HV1 planned to consult the GP about sibling 1’s immunisation status. The GP wrote to mother in late February following this up. 4.5.14 Mother told HV1 about her history, her current housing problems and that she had fallen on the stairs the previous week. A high level of vulnerability was noted, along with mother reporting she got a lot of help from the FSW at the children’s centre. Comment on health visiting service HV1 appropriately considered that the children were eligible for an enhanced health visiting service. However in practice due to a lack of specific concerns identified during the assessment process it was left open to the mother to access any service additional to the universal provision provided to all families. See 5.6 for discussion about the level of health visitor service provided. GP and midwifery 4.5.15 Mother’s ante-natal care was shared between the GP and community midwifery in the GP surgery and the Gateway team. There are weekly meetings attended by GPs and midwives, with monthly attendance by Gateway midwifery – this is the main form of communication. No concerns were ever identified, so the family was not discussed at this meeting. 4.5.16 The Tower Hamlets GP had his 1st contact with the family in November 2012, when mother brought sibling 2 as she had a chesty cough. She was noted to be a bright alert and happy baby. There was no mention made of forced marriage or domestic violence. Mother was also referred to the local hospital for antenatal care as the GP was advised this was the fastest way to get the care in place. Mother had received some ante-natal care in West London, but was unsure of which hospital and the GP had no electronic notes from the previous GP. The GP recalls mother as articulate, with a good understanding of the processes and the urgent need to see a midwife. 25 4.5.17 Mother had her 1st contact with midwifery in Tower Hamlets in early December 2012, after missing an appointment 2 weeks earlier (1st missed appointment or DNA for ante-natal care). The community midwife took a full medical, obstetric and social history and discovered that mother had previously been seen at St Mary’s Hospital, Paddington9. A referral was made to the Gateway team due to mother being a vulnerable teenager, having recently arrived from Somaliland. Mother replied ‘no’ to the question about domestic violence, but she was known to be in the UK without the father, living in temporary housing and moving around. 4.5.18 Following this appointment mother saw her GP again on 18.12.12 when she mentioned her history of domestic violence and forced marriage. The GP recalls his main concern was mother’s safety and support networks. He had the impression she was coping and saw nothing to alarm him in relation to her behaviour or interaction with her children; in fact her son was boisterous and she was able to calm him down effectively. 4.5.19 Mother attended scans and routine community midwifery appointments in December 2012 and January 2013, but missed her first appointment with the Gateway Team on 13.01.13 – she later explained she had not got the letter as had changed her address about this time (this was not in fact true). This was her 2nd DNA for ante-natal care. 4.5.20 Mother went on to miss 2 Glucose Tolerance Tests in February 2013 and explained this later to the midwife as difficulty fasting overnight. These were her 3rd and 4th DNAs. She did though keep her appointment with the Gateway midwife in mid-February (midwife 1), when she was 28 weeks pregnant and ‘obstetrically well’. This was a holistic appointment and mother spoke fully about her history as well as discussing her housing, her financial position, the support she received from the FSW, MGF and her extended family. Mother went on to keep her next routine community midwifery appointment a week later. 4.5.21 Midwife 1 recalled in discussions for this review that she observed mother’s appropriate and positive management of sibling 1’s behaviour, using distraction methods, encouraging him to listen to the baby’s heartbeat. Sibling 2 remained in her pushchair with a bottle. Comments on GP and midwifery service Initially mother did not disclose details of her past to the GP and midwife, but the midwife appropriately picked up her need to be identified as a vulnerable teenager and made the referral to the Gateway team, who undertook a holistic assessment. During this period of 4 months, mother did not attend 4 appointments relating to her ante-natal care. This is discussed in 5.7. 9 Despite contacting the relevant LSCB it has not been possible to locate any earlier ante-natal records for mother at St. Mary’s Hospital. This will be reported to the relevant LSCB. 26 Contact with FMU 4.5.22 In January mother contacted the FMU to express interest in helping to raise awareness of forced marriage in the Somali community. She reported to the specialist case worker she was doing well, in a flat and 6 months pregnant. This indicated to the case worker that mother was feeling very positively about her new life. 4.6 New home prior to birth of Jamilla: March – mid May 2013 4.6.1 The family moved to their new home at the end of February and Jamilla was born mid May 2013. There was regular contact with midwifery during this period and for a while the case worker from the FMU. Mother and children still attended the Young Parent’s Group, but contact with the FSW had decreased as there were no longer individual sessions with her and contact was solely at the Young Parents Group. Mother continued to be cheerful in contacts with practitioners and indicated she had lots of support from family as well as professionals, including the FSW, 4.6.2 At the beginning of March mother and children came to the children’s centre to discuss her move. She was offered a referral to a children’s centre near the new home to help her develop familiarity with the new area, but mother declined according to the FSW. Mother does not recall this service being offered. The case was then closed at the first children’s centre and both HV1 and Children’s Social Care informed. 4.6.3 Shortly after this, mother had her 5th health DNA when she missed an appointment with the Gateway team on 12.03.13. She later explained this was due to a family member being unwell. 4.6.4 Also on that day staff at the GP surgery alerted HV1 to fact that the children’s immunisations were not up to date and mother had missed several appointments. HV1 made contact by telephone that day with mother and advised her to make another appointment. It is not known whether she did so (see 5.7 for discussion about DNAs). 4.6.5 When mother attended her next midwifery appointment 3 days later, she explained that MGGM was now staying with her for support. Her mood was good and she was excited about her unborn baby. The glucose tolerance test was re-arranged. 4.6.6 Mother was visited by the specialist case worker from the FMU on 3 occasions in this period to discuss mother’s involvement in a film on forced marriage. On the second occasion the case worker was accompanied by a colleague who was providing advice about financial problems relating to child benefit. 27 4.6.7 On all 3 occasions the home was ‘immaculate’ and ‘spotless’. MGGM was there the first 2 visits. Mother’s relationship with her children was ‘impressive’. Sibling 1’s behaviour was demanding as he was very active and trying to play with electrical sockets, taking his sister’s toys and drinks. Sibling 2 had just started walking and was wobbly, quiet with lots of smiles. Mother appeared slightly immature, but the case worker thought this was a reflection of her youth and lack of the usual UK adolescent experiences. 4.6.8 Mother spoke to the case worker about her experiences of domestic violence and racism whilst in Somaliland. Mother spoke of MGF and that he visited once a week, but she did not refer to MGM. 4.6.9 It was agreed that mother should not be in the film about forced marriage due to possible risks to herself. Such risks were highlighted by mother’s description of being threatened locally by her husband’s relatives. The case worker reported this incident to the police, who visited the family. Mother explained that the incident had occurred several weeks earlier. She spoke of her husband’s uncle saying he could take the children to Somaliland. The incident had happened prior to her move, so mother felt confident that her new address was not known. 4.6.10 Police officers visited the home and found MGGM there with the family. Mother explained the incident was prior to her move and involved a threat to take the children to see their father unless she helped her husband come to the UK. The police assessed the risk as ‘standard’ and advice was provided. The police officer wrote that mother was ‘clearly a level headed and sensible young lady and has the utmost care and concern for her children.....aware of how to report any new matters that might arise.’ The PC wrote in his subsequent statement that mother apologised for the flat being untidy, but that in fact it appeared ‘clean and tidy’. Mother was described as being optimistic about her pregnancy, despite the trauma and circumstances of the baby’s conception. 4.6.11 Children’s Social Care was informed and a manager notes consideration given to referral to the children’s centre for additional support. Mother was telephoned and she reported being fine, knew what to do and listed all the people supporting her: a FSW at the children’s centre and MGGM often staying with her. No call was made to the children’s centre to ensure the FSW knew of the incident or to clarify what support was provided /needed and the case was closed. 4.6.12 The police notification of this incident was also sent to the consultant midwife and forwarded to community midwife and the Gateway team. The health visitor was unaware of this incident. 4.6.13 Mother continued to attend the Young Parents Group and on 20.03.13 attended a pathways to employment session. Although no longer allocated to the FSW, mother continued to see the FSW at the Young Parents Group and still referred to her as providing support when speaking to others (HV1, midwife 1 and Children’s Social Care). She continued to attend the Young Parents Group in late pregnancy and after the birth. 28 4.6.14 Mother attended her own health / maternity appointments in late pregnancy but did not bring sibling 1 for his planned 3.5 year health review at the end of April. This was the first recorded DNA relating to the children’s health appointments, but the health visitor was informed by GP staff in March that the children’s immunisations were not up to date and mother had not responded to letters inviting them to attend. Comment on service input March – April 2013 During this period mother slowly withdrew from children’s centre activities, although continued to attend the Young Parent’s Group meeting. She continued to exude cheerfulness and parenting capability in all her contacts with practitioners and spoke positively of the support of family and other services. It is this presentation of herself that re-assured practitioners and they felt confident that she would ask for help if required. With the exception of the FMU caseworker, no-one visited the home or met any of the family or learnt exact details of their involvement. However, the 3 visits by the FMU caseworker supported this professional perception. The police notification was sent to midwifery in accordance with the systems in place at the time. The systemic weaknesses within health services which did not ensure all involved health practitioners were aware of such incidents is discussed further in 5.9. There was no health visitor contact arranged during this period and none was expected. However, mother did not bring the children for immunisations or for sibling 1’s developmental check. There was no follow up to this, due to the lack of any identified concerns in her parenting. See 5.6 for further discussion. 4.7 Birth of Jamilla: May 2013 4.7.1 Jamilla was born mid May 2013. Mother continued to attend her midwifery appointments with the Gateway team and the Young Parents Group prior to the birth. 4.7.2 At a midwifery appointment on 10.05.13 mother attended with her children and her aunt: she was in a good mood, speaking of extended family support after the birth. Midwife 1 informed mother that midwife 2 would take over her care after the birth, as she covered the area where mother now lived. Mother was not happy with this decision and midwife 1 was also disappointed to transfer responsibility, but understood that this was usual practice. 4.7.3 Mother was admitted to the hospital for induction of labour on 16.05.13. Present with her was MGF, step grandmother and other family members. The delivery suite was busy at the time and the induction was re-arranged. Jamilla was born on 18.05.13. Mother and baby were discharged 2 days later. 29 4.7.4 The practitioners involved with the family at that time thought mother was receiving help and support from MGGM and that she was staying with the family: this was the plan she had shared with them. However, MGGM had moved to Somaliland in April and that level of support was never available subsequently. This change in circumstances was unknown to midwifery, health visiting or the workers at the Young Parent’s Group, although mother (in her participation in this review) believes she did tell them. 4.7.5 The police statement of a cousin indicates that by the time of the birth, the sources of support were far more haphazard and unpredictable. This cousin described being telephoned by mother and asked to look after siblings 1 and 2 when mother attended hospital for the birth. The cousin had not seen mother since her return to the UK and had never met the children. She turned up the evening before mother went to hospital to look after the children and described the home as ‘messy’ and the ‘place needed cleaning’. However, mother was described as ‘very loving’ to the children who ‘looked healthy’. 4.7.6 The cousin stayed for 3 ‘nights in total’ and in her statement she describes mother’s return from hospital as ‘she arrived alone by taxi’. MGF explained that he arranged her return home, putting her in a taxi at the hospital and followed her home. The next day MGF and his 7 year old son visited. 4.7.7 In interview for this review mother provided a different account, whereby the great aunt initially had one of the children and subsequently both. Comment The decision to transfer case responsibility between midwives after the birth is discussed in 5.8. The rationale for this change was the family’s move some 3 months earlier and that it is the usual practice, although exceptions could be made. In this instance mother did not wish to change and the midwife was also sad to transfer the case, but did not realise there was any discretion possible. 4.8 Post natal period: mid-May – end of July 2013 4.8.1 During the postnatal period there were no concerns about the care of Jamilla or about mother’s mood. She had 6 health contacts and 2 contacts with the pre-school: 3 contacts with midwife 2: 2 at home and 1 at the clinic 2 contacts with HV1 1 contact with the GP and 2 contacts with the pre-school 30 4.8.2 Midwife 2 visited the home the day after discharge, when Jamilla was 3 days old. Mother was caring for Jamilla upstairs, fully breastfeeding and interacting well. Downstairs could be heard children laughing and another adult’s voice. Two days later the midwife returned and no concerns were noted. Mother was keen to get out so the next appointment was made at the clinic, when Jamilla was 10 days old. Mother brought her to the children’s centre for that appointment and there were no concerns, the baby’s weight was above the birth weight and mother was still fully breastfeeding. Mother spoke of her plans to take the baby to the Young Parent’s Group (which she did). 4.8.3 Because HV1 was visiting the following week, midwife 2 arranged to see mother in 4 weeks, on 28.06.13 at the children’s centre. 4.8.4 During June and July 2013 there was some contact between mother and the FMU about her difficulties obtaining child benefit, due to doubts about her children’s birth certificates. The FMU wrote letters on mother’s behalf to explain the situation and asked her to get back to them if any problems continue. They did not hear any more. 4.8.5 The new birth visit by HV1 occurred on 04.06.13, when Jamilla was aged 16 days old. The visit was delayed due to communication difficulties between mother and the health visiting service and mother changing the appointments made. HV1 noted Jamilla was alert and active, exclusively breastfed, had regained birth weight, had colic, but also (and contradictorily) to be easy to manage and sleeping through the night. The baby was not weighed as the midwifery service remained involved and she had been weighed at the clinic. Mother was observed to be cuddling her baby and reported to be bonding well. Mother was very positive about Jamilla’s development (said to be smiling), reported she did not feel depressed and made references to extensive family support from MGF, aunts and MGGM, who was still understood to be living in the home10. The record also refers to visits from paternal grandfather, but it is not clear who this is. 4.8.6 This was recorded using a vulnerable child template and the plan was to offer an enhanced service and liaise with other agencies involved with the family. HV1 did liaise with midwife 2, who discussed the positive impression conveyed by the mother, a ‘mature’ young woman, managing her children well with support from extended family. She also mentioned the attendance at the young parents group as a positive factor. 10 NB Mother is adamant that she told practitioners that MGGM had gone to Somaliland, but this is not recalled by practitioners and is not in any agency records made at the time: it is possible that there was some confusion for practitioners about the distinction between MGGM and great aunt 31 4.8.7 HV1 also encountered the FSW at the health centre and mentioned concerns about sibling 1’s speech and language development. They agreed that the FSW write to mother to consider a referral at a children’s centre local to her address for structured play activities to support his speech development, and for the FSW to accompany her there. The next day mother attended the Young Parent’s Group (the last time she attended) and the FSW remembers that mother was happy showing her new baby to others. She had a 2-seater pram with the baby on top, sibling 1 walking and sibling 2 underneath the baby. Everything was clean and tidy. Mother was understood to decline a referral for the children’s centre, saying sibling 1 talked at home, so she was not concerned. Mother does not recall declining this. 4.8.8 Mother did not attend the planned appointment with midwife 2 on 28.06.13 (DNA 6 for mother’s appointments) and when contacted explained she was staying at her father’s address in West London and would be there for another 2-3 weeks. A new appointment was made for 23.07.13 and mother spoke about not being happy with HV1’s talk about the MMR vaccine. Information from MGF as part of this review confirms that mother and children stayed for a few days on 2 occasions during this period. 4.8.9 Mother did not attend the July appointment with the midwife (DNA7). She was never discharged but there was no further contact from the midwife, despite the midwife’s intention to contact mother in September and additionally receiving a missed call from mother in August. Mother’s memory of this is different and she is adamant that she did not miss any midwifery appointments and had a text from the midwife that she would send her date for an appointment. 4.8.10 Mother was however back in Tower Hamlets by early July, and attended a post natal appointment with her GP and HV1. Mother was observed to be fine and Jamilla was still breast fed, doing well, and smiling. HV1 undertook a mental health screening using a standard tool (PHQ9). Mother reported she was not depressed, was managing fairly well with support (misunderstood to be from MGGM). Jamilla was weighed and was gaining weight. The family remained on an enhanced service, but no further appointments were made. 4.8.11 Sometime in late June /early July mother came to the Pre-School to request a place for sibling 1 in September. The pre-school, had vacancies so a place was offered and a settling in visit arranged for mid-July. 4.8.12 The family attended the settling in visit. Sibling 1 was walking and the 2 younger children were in a double buggy. The family stayed for about 20 minutes, during which time sibling 1 played confidently, whilst the younger children remained in the buggy. Mother appeared confident and well presented. There were no concerns identified. 32 Comments As before mother continued to present impressively to practitioners, so despite identifying that she was vulnerable, she was not provided with any more services than a mother of 3 children aged under 4 without identified vulnerabilities. This was because of her observed competence and to her reports of family support, in particular of the MGGM’s role. In reality MGGM had by then left the UK. While all practitioners noted the family support, as disclosed by mother, no-one explored the detail i.e. which family members and how often they visited. Moreover no local practitioners met any family members, albeit one was in the home during the first home visit of midwife2, but was elsewhere in the flat with the siblings. This is not unusual, as a wider assessment involving families tends to be undertaken when there are concerns. 4.9 August to October 2013 4.9.1 There was no professional contact with mother and children during August, except for midwife1’s missing a call from mother on her mobile and mother’s call to Housing on 30.08.13 to inform of Jamilla’s birth and to elicit information on properties she had made a bid for. She agreed an appointment for 06.09.13 to bring in Jamilla’s birth certificate, but cancelled this on the day and failed to turn up on the re-arranged date of 09.09.13. 4.9.2 The subsequent contacts with practitioners were all with pre-school staff, at: a home visit on 05.09.13 At pre-school on 19.09.13 Telephone contact between manager and mother on 23.09.13 At pre-school on 30.09.13 Telephone contact between manager and mother on 04.10.13, the day of Jamilla’s death 4.9.3 The deputy manager of the pre-school visited mother and children on 05.09.13 along with a colleague. Mother presented as happy and confident, and spoke of MGF providing a stair gate. The deputy manager noticed the bedroom in passing was tidy and presentable. The lounge was reasonable. Sibling 1 was very active, whilst sibling 2 was shy and remained close to her mother. At one point the manager held Jamilla so mother could sign the forms. There was no concern about her or her siblings. 4.9.4 Mother spoke of being concerned about sibling 1’s speech and language skills and not always understanding what he was saying. She also spoke about still only receiving child benefits for the baby as the older two were not born in the UK. Mother explained about her past and that she received support from her family. She was not identifying herself as needing further support. 33 4.9.5 The only issue identified was a smell of urine and that the flat was warm. The manager did not raise this with mother as she wished to first establish a relationship with the family and was wary of scaring mother from engaging with the pre-school. She did though wonder if urine had soaked into the badly chipped laminate flooring which would then retain the odour. The deputy manager discussed this with the manager of the pre-school and agreed that given the mother’s self-reported history it was indicative of a need for support. However, in the context of mother and children’s positive presentation it was not perceived to be a safeguarding issue. 4.9.6 Sibling 1 started pre-school mid-September, 3 days after initially planned. Mother and children attended for the whole afternoon session. Mother mentioned that Jamilla had now progressed from breast feeding to formula milk and that sibling 1 was happy to attend the pre-school. All the family were well presented. 4.9.7 The manager recalled that towards the end of the day the room started to smell of urine and some staff members thought that this came from the pram. This prompted the manager to try to find out more about the family. With some detection work she located the FSW that mother had spoken about and communicated by email (as the FSW was out of the Centre). The FSW decided to make contact with mother to check on her welfare. 4.9.8 Meanwhile mother had not brought sibling 1 back again and on 23.09.13 telephoned to say he had a temperature. 4.9.9 On 30.09.13, mother brought sibling 1 to the pre-school and wanted to leave him saying that she had a health visitor’s appointment (in fact this was not correct and she had no appointment). Because sibling 1 had only attended once, staff explained that he could not stay without mother remaining. 4.9.10 Sibling 1 did not want to leave as he had just arrived and had started playing, but his mother remained calm and patiently managed his behaviour whilst she put on his coat again. The other two children were quiet. As on all other occasions, mother and children were well presented and mother’s ability to cope with all three was admired. However, as before, the double buggy smelt of urine. 4.9.11 On 02.10.13, the FSW wrote to mother having failed to be able to contact her by phone on 3 or 4 occasions. 4.9.12 The next day 03.10.10 sibling 1 was not brought to the pre-school and on 04.10.13, when the manager telephoned mother to enquire about his whereabouts, mother said they had been staying with MGF because of a ‘problem’ and would attend on 07.10.13. 34 4.9.13 Tragically later that afternoon an ambulance was called to the family home by neighbours, after mother asked for their help because her daughter was not breathing. Jamilla was taken to the local hospital’s emergency department. On arrival she was in asystolic cardiac arrest and after resuscitation attempts she was pronounced dead at 17.45. 4.9.14 During August and September it appears that mother’s contact with family members also reduced. The information for this is derived from the witness statements given to the police as part of the criminal investigation and from the interviews with mother and MGF. This demonstrates that over the summer mother was withdrawing socially, not answering the door to a cousin who tried to visit twice and not seen her father since July. Her regular week-end contact with great aunt also seems to have ended, with great aunt saying she had not visited for 3 weeks, but still spoke on the phone every 3 or 4 days. 4.9.15 Another extended family member also visited 3 weeks prior to Jamilla’s death and described the flat as clean and relatively tidy. Comment During the last 10 weeks of Jamilla’s life, there was very little professional contact with the family, and none with any of the professionals who knew mother, such as the health visitor, GP or the Young Parents’ Group, nor with the midwife who had kept the case open to the service, intending to make contact in the September. Mother had ceased to attend the Young Parents Group, so had no direct contact with the FSW, although the FSW had tried to contact mother in the days prior to Jamilla’s death. The only contact with professionals was in the 3 direct contacts with pre-school staff, who had not known the family earlier and were consequently not in a position to be able to ‘pick up’ any changes in mood and presentation of mother and children. The only source of concern at this point was the urine smell from the buggy. Pre-school staff registered this needed to be followed up and chose the FSW because mother spoke highly of her, she knew the family and would be in a good position to judge any changes. The FSW is to be commended for trying to reach out to the mother for the second time since Jamilla was born (previously had discussed the possibility of help for sibling 1’s speech development), despite mother no longer being a client of the FSW and of the first children’s centre. Whilst this was appropriate, the health visitor should have been consulted as she had ongoing responsibility for the family and would have been in a better position to act quickly. However, the lack of communication with the health visitor reflects the lack of an identified lead professional. 35 5 THEMATIC ANALYSIS 5.1 Introduction 5.1.1 Section 4 considers professional practice thematically, explaining why actions and decisions were taken in this case. Section 5 provides the systemic findings and recommendations arising from this analysis. 5.2 Neglect 5.2.1 The prosecution’s opening note at Crown Court in April 2014, mentions mother’s failure to feed her baby daughter and failure to seek medical attention, as well as failing to feed the elder siblings ‘properly’ and to keep them clean. 5.2.2 The practitioners who met this family were shocked and surprised at what had occurred. The universal perception of mother was of a young woman who had demonstrated her resilience in overcoming the abuse and trauma she had experienced as a child and teenager, who demonstrated good parenting capacity and who provided a good standard of care for her children. There was no professional knowledge whatsoever of any concerns around mother neglecting her children. 5.2.3 Family members largely shared this perception, albeit, around the period of Jamilla’s birth a few relatives described in their witness statements to police an untidy or ‘messy’ home. However, this would not be surprising given a single 18 year old mother, heavily pregnant with 2 young children, or caring for a new baby and 2 very young children. 5.2.4 For most of July and August mother had little social contact with family and none with professionals. She told the author that an incident occurred which led to her having ‘flash-backs’ of childhood abuse she had experienced. Along with this her husband kept telephoning from Somaliland, after MGGM gave him her telephone number. Mother recalls feeling ‘so tired’, ‘lonely, sad, unloved and ashamed of things that happened to her’. She thinks she became ‘somewhere else in my head’. 5.2.5 When the pre-school staff visited the home 4 weeks before Jamilla’s death, the home was reasonable and the only issue was the smell of urine. The children all were considered to be well. The last family members to see the family was great aunt and another female relative; they visited separately but both spoke of visiting the home 3 weeks previously, Great aunt did some cleaning in the lounge and kitchen. She was aware that mother was feeling ‘low’ and suffering from the ‘baby blues’ and had up till then been providing some support. 5.2.6 In the next 3 weeks, mother and children were seen twice at the pre-school and again, other than the smell of urine in the pram there was no concern about the children or mother. 36 5.2.7 Little is known about what was happening within the home in these last weeks, but unknown to the professionals, the family support previously understood to exist did not occur. From the police investigation as cited in the Crown Court Opening Notes, mother spent a great deal of time on Facebook, and in her communications with her new ‘virtual’ friends she described herself as living with her mother and her younger siblings. 5.2.8 One relative tried to visit the family in September a couple of times, but the door was not answered despite hearing a child crying inside, and mother did not answer her telephone. 5.2.9 Statements made by neighbours to the police include one that noted a smell when walking past the flat in September and another who had contact with mother the day before Jamilla died, due to mother being oblivious of a tap overflowing in to the neighbour’s flat. When the neighbour knocked on her door, there was no reply, and after 10 minutes of knocking on the door and shouting through the letter box, mother apologised but would not open the door. She later came to the neighbour’s flat and apologised. 5.2.10 The description by police and witnesses of the state of the family home following Jamilla’s death is a total contrast to that described by professionals and family members. The Crown Court Opening Statement gives a neighbour’s description of dirty and dishevelled children who ‘stank of stale urine’ and ‘dirt and sweat’...’place unfit even for livestock’. The police officers who went into the flat were quoted as encountering ‘an overpowering smell of faeces, urine and rotting food’ and ‘there was no edible food in the fridge’. Persistence & neglect 5.2.11 This case highlights the difference between the common perception of neglect (which whilst harmful to children over a long period) is not usually associated with such a sudden and life threatening impact on children. The common understanding of neglect is that the risk to children relates to a long term inadequacy of care. This is embodied in the definition of neglect provided by Working Together: ‘Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. 11 11 Working Together to Safeguard Children, DFE March 2013 37 5.2.12 Such a definition though is not congruent with the circumstances in this case, when there was an extremely quick and speedy deterioration in the home circumstances during the latter half of September. It is important that both professionals and public understand that neglect can lead to risk to children within a very short period of time, especially in relation to babies and young children. In this case, there were very few indicators known to professionals of the change in the home circumstances and to mother’s parenting capacity, other than the smell of urine from the children’s buggy. This rightly alerted the pre-school to make contact with those that knew mother, but in itself did not give rise to concerns about the immediate safety of the children. Research findings on fatal cases of malnutrition: invisible children 5.2.13 Brandon et al12, in a study of neglect and serious case reviews, points to how unusual this type of death is in their study: ‘The number of serious case reviews undertaken where the baby or child was dangerously emaciated has been low; typically only one or two per year. .... (there has) only been six serious case reviews undertaken in relation to fatal cases of malnutrition in a six-year period between 2005–11. In addition there were a small number of non-fatal cases, where malnutrition had been so severe that the child was within days of death, but had fortunately survived after intensive hospital treatment.’ 5.2.14 None of the 6 fatal cases of malnutrition in Brandon’s study involved children subject to a child protection plan, but what was common was that it involved children who were ‘invisible’ with parents that were withdrawing from services and children not seen by universal health services. 5.2.15 The question arises in this case: were the children in this family ‘invisible’ and the mother withdrawing from services in the way that Brandon et al describe? Until early July 2013, this was not the case. The children had been seen regularly during mother’s pregnancy and in the postnatal period, due primarily to mother’s contact with maternity services and the GP. 5.2.16 However, after the postnatal appointment early in July, the situation changed. It is of note that from the post natal appointment in early July, neither mother nor the children were seen by any professional who knew them. Mother ceased to attend the Children’s Centre Young Parent’s Group and failed to keep her appointment at the clinic with the midwife at the end of July. 5.2.17 Unknown to the health visitor and midwife, mother did initiate contact herself with the pre-school, but subsequent engagement was limited; without prior relationship with the family staff there were not in a good position to observe any changes. 12 Neglect and Serious Case Reviews, A report from the University of East Anglia commissioned by NSPCC Marian Brandon, Sue Bailey, Pippa Belderson and Birgit Larsson, 2013 38 5.2.18 Because there was no health visitor or further midwifery appointments provided over the summer (after the DNA in late July) and none in September, mother was not perceived as withdrawing from services. The children were in the minds of health practitioners, but were not actually seen and the family’s isolation was not identified. The midwife’s intention to contact mother in September did not happen and the health visitor’s plan to make contact in October had also not yet happened. It is not known whether mother would have responded had contact been made and appointments offered. However, the high level of contact with professionals the family had received prior and immediately after Jamilla’s birth, ceased. 5.2.19 This lack of visibility of the children over a period of 10 weeks is not a reflection on the individual members of staff, but is the usual service level provided in the absence of current concerns about mother and children. Staff planned to make contact, but there was no evidence of any urgent need to do so. 5.3 Threshold responses & assessments of need 5.3.1 The Tower Hamlets Family Wellbeing Model13 provides professional guidance on the tiers of need and the relevant thresholds for service provision for everyone who works with children, young people and parents /carers in Tower Hamlets. This provides comprehensive and detailed guidance on the required professional response to different levels of need. The version in force in 2012 / 2013 outlined 3 tiers of need: Tier 1: Universal, which described needs that can be met via universal services with at times ‘additional or differentiated support’, ‘minimal intervention’ and usually do not require an ‘integrated response’ Tier 2: Targeted, when needs are more complex or more intensive and additional specific support is required – in the 2014 model this has been revised to include ‘early help’ as well as targeted Tier 3: Specialist, when families / children are already experiencing poor outcomes and need ‘specialist and statutory support’ 5.3.2 The guidance provides indicators for each of the dimensions of the Framework of Assessment14 i.e. development of baby, child or young person; parent factors and family and environmental factors. These all focus on the current functioning of parents, and the health and development of their children. 5.3.3 In this case mother was open about her past and all practitioners recognised her vulnerabilities. However, all were impressed with her competence in parenting and her relationship with her children. Whilst it was noted that sibling 1 was extremely active and had possible speech and language difficulties, this was not on a level to raise concerns about his welfare. Sibling 2 was very quiet in comparison, but again there were no concerns about her health and development. 13 The Tower Hamlets Family Wellbeing Model 2012 14 The Framework for Assessment of Children in Need, originally DOH 2000 39 5.3.4 Agency records do not show the level of assessed need in terms of the 3 tiers, but with the exception of midwifery, the family were in practice provided with a tier 1 service. Moreover, the descriptors within each tier within the Family Wellbeing Model focus on current functioning and the fact of parental vulnerability in itself does not push a family into tier 2 provision, without evidence that the vulnerability is affecting the current parenting. Tier 1 provision does not require a CAF to be initiated, nor co-ordinated support and a lead professional. 5.3.5 Such a welfare model does not cope well with parental vulnerabilities, which may have different impacts on parenting at different times and rely on consistent practitioners with sufficient contact with the family to be able to have a holistic understanding of the family’s needs, knowledge of the overall multi-agency service provision and an ability to identify changes in need over time. 5.3.6 It is notable that in this case, in the absence of an identified lead professional, both the health visitor and the pre-school liaised with the FSW at the Children’s Centre over concerns (speech and language for sibling 1 and smell of urine respectively), despite the fact she had ceased to have a formal role many months previously. This was perhaps in recognition that the mother perceived the FSW as having been ‘her worker’ and also reflected the absence within the network of a ‘lead professional’. 5.4 Thresholds for children’s social care involvement 5.4.1 Mother and her 2 children were referred to Children’s Social Care on 3 occasions, firstly to Brent and Tower Hamlets in October 2012 and again to Tower Hamlets in March 2013. 5.4.2 The referrals to both local authorities Children’s Social Care in October 2012 were around the vulnerability of the family given mother’s very young age (nearly 18 for Brent and just 18 for Tower Hamlets), the trauma she had experienced since leaving the UK at age 12 and her heavy responsibilities of being a parent of two children aged under 3. Additionally Tower Hamlets were aware also of her third pregnancy. 5.4.3 Despite the recognition of vulnerability, there had been no concerns raised about mother’s care of her children, but the referrals made suggested that both the worker at the FMU and within housing recognised the potential risk if mother was not provided with support. 5.4.4 In Brent, mother was understood to be living with MGF, so it appears that an assumption was made that support was available and other than providing MGF with information of services, no contact was made directly with mother, no assessment made of her needs and no checks undertaken to see if the children’s existence was subsequently known about within health. The lack of speaking directly to mother is, according to her account, even more striking as she was present at the time of the social worker’s call. 40 5.4.5 Such a response of advice and signposting in the absence of identified concerns about the current welfare of children is consistent with a welfare model that relies on universal services to identify whether or not there is a need for targeted services. However, such a model relies on universal services able to identify the risks to children and families. This in turn is dependent on the children’s existence being known about by GPs and health visitors, who will then be able to assess whether any further support is needed. In this case, Brent Children’s Social Care did not ensure that: Universal services knew of the children’s existence nor that Universal health services knew of mother’s background and vulnerability nor that Any assessment was undertaken by the health visitor, in the absence of a social work assessment. 5.4.6 In Tower Hamlets, Children’s Social Care tried but did not manage to speak to mother, but financial assistance was provided (via Housing) and referrals were made to the children’s centre and health visitor to ensure that help was offered and that universal health services knew about the presence of the children in the borough. 5.4.7 This response ensured that the family would be offered support and that assessments would be undertaken both by the health visitor and the Children’s Centre. What it did not do was neither take any active part in deciding the type of assessment undertaken nor ensure that co-ordinated support was provided via a Team around the family. 5.4.8 Staff as part of this review reflected that when there are such parental vulnerabilities as indicated by mother’s youth and troubled history, practice has now changed and Children’s Social Care would take a greater role in ‘stepping down’ to universal services, so as to ensure a team around the family approach, with a lead practitioner and the undertaking of a Common Assessment (a CAF). 5.4.9 This would have provided an improved assessment of mother’s circumstances and consequently an improved understanding of her vulnerabilities over a longer period. However, it is not clear from the London Borough of Tower Hamlet’s Family Wellbeing Model that this would in fact occur (see section 5.3) or that a social worker is able to implement such an arrangement on other agencies. For this reason a recommendation is provided in section 6 about the use of the CAF and a lead professional in such circumstances. 41 5.5 Use of history in determining agency responses 5.5.1 Although mother lived in Tower Hamlets as a child, the knowledge of her childhood history was not accessed. In this case CSC history would have been limited to the knowledge about mother having been missing from home for a few days aged 12 years old. Such knowledge would have marginally increased the awareness of mother’s vulnerability, but would not have made a substantive difference to the decisions made at the time. CSC’s records would not have included all the information held by police about domestic violence prior to moving to Tower Hamlets, nor would mother’s educational difficulties have been in these records. 5.5.2 However, this case has highlighted the lack of checking of historical records, even though in this instance it is unlikely to have made a difference. Practitioners acknowledge that in 2012 this was not consistently undertaken due to: The high rate of referrals / contacts at that time meant that the screening role did not necessarily involve accessing of historical records Earlier records are less accessible due to the details not being on the current electronic system Not all practitioners have access to the old SWIFT and CRIS records, so the search for historical data is time consuming for a duty officer 5.5.3 Practitioners and managers were confident that the routine checking of historical records is now more consistently undertaken at the screening stage, but further research on this needs to be undertaken to be confident of such a change in practice. 5.6 Health visiting service provision 5.6.1 Health visitors provide universal / targeted interventions and referrals to other services such as Children’s Social Care according to the level of vulnerability identified. The Tower Hamlets Family Well-Being Model provides professional guidance on the tiers of need and the relevant thresholds for service provision. 5.6.2 The universal health service provision involves health visitors providing: ‘movement in’ visits to children and families who re-locate into the geographical area or register with a local GP so as to identify health needs, assess levels of vulnerability and signpost or support the family in meeting those needs by referring to local services New birth home visit – 10-14 days from birth 6-8 week review – undertaken in conjunction with the family’s GP at the surgery/clinic 8-12 month developmental review – clinic based 2 year developmental review – clinic based 42 5.6.3 All health visiting clients are encouraged to attend Child Health Clinics across the borough should additional support be required. Any intervention additional to this universal service, including further home visits is available for those assessed as requiring an enhanced health visiting offer. 5.6.4 Mother’s self-reported history at the transfer in visit with the agency health visitor provided sufficient information for her to be identified as vulnerable in the records. The health Individual Management Review considers that this should have led to the family being provided an enhanced service, although this was not specified by the agency health visitor. 5.6.5 At the clinic visit in early February 2013, HV1 (the allocated health visitor) noted mother’s history and high level of vulnerability. She explained, as part of this review, that an enhanced service was assessed, but that this would be provided via open access to additional services if mother wanted them. The rationale for this was mother’s competent parenting skills and apparent ability to cope. In practice without mother requesting additional help, the family received the universal health service offer and health visitor contact was limited to: the transfer in visit by the agency worker in November 2012 The clinic contact in February 2013 for the 8-12 month review for sibling 2 and The new birth visit in early June 2013 The joint 6/8 week post natal review at the GP surgery in July 2013 5.6.6 The lack of additional input arises from: The health visitor’s assessment of the family i.e. mother coping well despite her youth and history and demonstrating good parenting capacity The reliance on mother’s self-reporting about the provision of support from the family members and the FSW at the children’s centre The lack of definitive local guidance as to what constitutes an enhanced health visiting service, with the decision being left to the clinical judgement of the practitioner. The assessment that mother would have the insight and ability to request support if she required this 5.6.7 Until July 2013 the family had a high level of contact with health practitioners. However, by middle to late July: The high level of health contacts with the mother and baby had ceased (as is standard) following the end of the post natal period Mother had chosen not to see the midwife on two occasions Siblings 1’s developmental check remained outstanding The health visitor was aware of sibling 1’s possible speech and language problems, and that mother had declined the FSW’s offer to make a referral to a children’s centre The children’s immunisations remained outstanding and mother had not attended appointments for these 43 5.6.8 The service provided was entirely consistent with local requirements for an enhanced service, which does not necessarily involve additional input over a universal service. 5.6.9 In this case although there were no identified concerns about the children’s care, both the GP and health visitor were aware that immunisations and sibling 1’s developmental check had been missed. Also the health visitor was aware of sibling 1’s slow speech and language development and of the mother’s decision not to be referred to a children’s centre nearer home for group activity to help develop sibling 1’s language skills. 5.6.10 The health visitor had identified the need to follow up the children and planned to make contact in October. At the time the lack of any reported concerns from elsewhere meant that the priority to initiate contact was not perceived to be urgent. Had the health visitor known in September of the smell of urine in the flat and in the pram this may have increased the priority. 5.7 Mother’s co-operation with health services 5.7.1 Practitioners involved with the family were impressed at the time with how well the mother coped with the care of her small children and other than an initial resistance to seeing a health visitor in November 2012, she was thought to accept help and co-operate with professional plans and advice. 5.7.2 Table 4 shows the health appointments mother kept for her and the children and those which she did not attend (DNA). Also shown in the right hand column are her contacts with the children’s centre and pre-school. Table 4: Health and welfare face to face contact with family Month No of health appointments for mother No of health appointments for children Total health appointments kept Total health DNAs Children’s Centre / Pre-school attendances / home visits Appointments kept DNA Appointments kept DNA November 2012 6 1* 1 + 0 7 1 2 December 2012 3 0 0 0 3 0 1 January 2013 4 1* 0 0 5 0 3 February 2013 2 2 ~ 1 + 0 3 2 2 March 2013 2 2 #~ 0 0 2 2 2 April 2013 2 0 0 1 2 1 0 May 2013 6 + hospital for birth 0 0 1 6 1 2 June 2013 0 1* 1 + 0 1 1* 2 44 July 2013 1* 1* 0 0 1 1* 1 August 2013 0 0 0 0 0 0 0 September 2013 0 0 0 0 0 0 3 1st – 4th October 2013 0 0 0 0 0 0 0 TOTAL 26 8 3 2 29 10 *Midwife / GP ante / post natal appointments # GP unspecific appointment ~ glucose intolerance tests (which was subsequently completed) + 3 health visitor appointment s : transfer –in visit, clinic appointment included developmental assessment and new birth visit Mother’s appointments 5.7.3 Overall the number of health appointments kept by mother was 29, and she had 10 ‘DNAs’ i.e. a rate of nearly a quarter of missed appointments – 10 out of 39. Further analysis of this shows that All but one DNA concerned her health in pregnancy and post-natal, as opposed to the children’s appointments Very few health appointments were provided for the children – 4 were offered in total, and whilst she missed 2, one was re-arranged a few days later (the new birth visit for Jamilla). However sibling 1’s 3.5 year developmental check DNA was not followed up, despite subsequent awareness of concerns about his speech and language development and knowledge of lack of immunisations (see 4.7.6 for further discussion) Mother missed 8 appointments out of 26 health appointments for herself: 3 antenatal appointments with midwifery, 2 tests for glucose intolerance, an unspecified GP appointment and 2 post natal appointments with midwifery Gateway team 5.7.4 Staff interviewed for this review explained that given a young single pregnant woman with 2 children aged under 3 and then with 3 children aged under 4, such a DNA rate would not be unusual and was not perceived to be a risk indicator. In practice given that mother’s antenatal appointments were re-arranged and she attended the next ones, the ante-natal DNAs were not significant. 5.7.5 The CCG (Clinical Commissioning Group) aggregated root-cause analysis report 15 examines the missed appointments in this case and the authors conclude that: 15 Tower Hamlets CCG Aggregated Root Cause Analysis Report of the Health Provision for Jamilla; the subject of a Serious Case Review conducted by Tower Hamlets LSCB 2014, Authors: Rob Mills, Nurse Consultant Safeguarding Children and Dr Owen Hanmer, Designated Doctor Child Protection 45 ‘none of the DNA’s in this case proved to be significant in relation to the jeopardising of (mother’s) pregnancy or in contributing to the circumstances leading to the death of Jamilla. ‘ Children’s appointments 5.7.6 The issue with regard to the children’s appointments is more complex. Mother missed 2 of the 4 known appointments, but one was re-arranged, leaving only the 3.5 year developmental check outstanding. Given that this appointment was just before the birth of Jamilla, it is not surprising that mother did not attend, given the number of other health appointments she was keeping and having sole parenting of 2 small children. However, this appointment had not been re-arranged over the next months. 5.7.7 We do not know the extent to which mother did not attend nursing appointments at the GP surgery, as the routine recording of DNAs was for appointments missed with the GP and not for nursing. The health visitor was told she had missed her immunisation appointments, but the review does not know how many had been provided. This indicates a systemic recording problem within the GP surgery which has been addressed with a recommendation in the CCG Aggregated Root Cause Analysis Report of the Health Provision for Jamilla. Conclusion 5.7.8 The recognition of mother’s vulnerability by midwifery and health visiting did not lead to a holistic perspective which would have picked up that: From the end of June mother did not keep her 2 midwifery appointments AND She had not brought sibling 1 to his 3.5 year developmental check in April and had not brought the children to an unknown number of immunisations appointments 5.7.9 This lack of integrated working between different parts of the health service is discussed further in 5.8 below. 5.8 Lack of co-ordinated multi-agency provision 5.8.1 Mother received services from housing, children’s centres, a pre-school, midwifery, GP and health visitors. Despite the high level of professional contact in the early months, there was little communication evident between the various agencies and professionals, after the initial signposting between services. In line with tier 1 service provision as identified in the Family Well Being Model, no CAF was initiated, nor a lead professional identified. 5.8.2 The lack of any co-ordinated service input meant: That there was no communication about the service being provided to the family between the children’s centre and the health visitor and midwifery – so despite notification that the FSW had closed the case in March 2013, the health visitor continued under the misapprehension that the FSW was providing regular support 46 Lack of recognition of mother’s increasing isolation from family and professional contacts once the intensive health contact during pregnancy ceased Lack of understanding of the importance of providing mother with consistent input given her vulnerability and to avoid change of workers, i.e. change of midwife after the birth Lack of communication between pre-school and health visitor 5.8.3 Within health, there was very little direct communication between practitioners, especially health visitors and midwifery. The GP does hold regular monthly meetings which include the gateway midwife and the health visitor. The GP cannot recall any concerns raised about this family, but in the past the discussions were not noted on patient records (this has now changed so is not subject to a recommendation). 5.8.4 The lack of any ongoing assessment process meant that no practitioner had a grasp of the level of support mother received either from other agencies or from her own family. She did though at the time speak positively about the support she was receiving from services and from extended family members. See section 5.9 for further discussion about family. 5.8.5 The two professionals who had been a regular feature of the mother’s life ended contact around the birth, with a change in midwife following the birth and the regular contact with the FSW ceasing due to the mother’s withdrawal from the Young Parents Group after June 2013. It is telling that in interview for this review, mother spoke both about never getting to know any of the professionals, as well as at her distress at the change of midwife and ending of an allocated FSW. This apparent contradiction perhaps indicates her desire for having wanted an ongoing relationship with individual practitioners. 5.8.6 At this point, consistent with the tier 1 service provided there was no lead professional to understand that mother had started to withdraw from contacts, missing 2 post natal midwifery appointments, having no contact with the health visitor or GP following the post natal check at the beginning of July and ceasing to attend the Young Parents Group. During the next 3 months no practitioner who had previously met mother and children saw the family. 5.8.7 The pre-school had no previous contact with the family, and hence were not able to note any deterioration in the family’s functioning. They were though sufficiently concerned about the smell of urine and lack of regular pre-school attendance to make contact with the FSW and commendably (as she no longer had a professional role with the family) she agreed to try to intervene. Through the review process, staff from the pre-school realised that it may have been more appropriate and effective to have at that point liaised with the health visitor. This was not identified at the time, as the usual practice is for the first point of call to be within the early years services unless there are identified concerns. 47 5.8.8 Health members of the serious case review panel have clarified that the health visitor role (prior to a CAF and for cases held in health) is the “lead professional” for under 5s due to universality of service and a coordination and signposting role. There is no evidence within this case that such an understanding of the health visitor’s lead professional role existed in the professional network. There is a need for clarification about when and how the lead professional role operates within Tower Hamlets. 5.9 Health practitioners knowledge of police notifications 5.9.1 When children come to the notice of the Police, notifications of the event are sent to relevant partner agencies so that involved practitioners are aware of any risks to the children. This notification is called a Merlin by the Metropolitan Police Service. 5.9.2 Following an earlier serious case review recommendation in Tower Hamlets, in 2009, health (as well as social care) was routinely notified by the police of Merlins, when domestic abuse was the reason for the report being generated. The rationale for this was that whilst not all would meet a Children’s Social Care threshold, as health is a universal service there would be a health visitor record for all children subjects of such a notification. Health visitors could then decide whether to make contact with the family and offer early help and support or if such information, together with that held by health, warranted a referral to Children’s Social Care. Furthermore, such notification ensured that health staff undertaking home visits alone, were aware that there were potential risks to the visit. 5.9.3 A weakness of the system arose due to the way that health managed the information from the Merlin, if both midwifery and health visiting were involved. The information would be put only in the midwifery record with an expectation that the midwife would read the record and then inform the health visitor. 5.9.4 This case highlights the systemic weaknesses in such an arrangement. The Merlin was sent to advise health of the threats mother had received from a relative of the father and this information was entered into the mother’s midwifery record. However the midwife did not access the entry and the health visitor remained unaware of what had occurred. 5.9.5 Since September 2013, the Metropolitan Police Service (MPS) have decided that all Merlin reports should be processed via the newly developed MASH16 (the Multi-Agency Safeguarding Hub). However, since that time health has not been receiving any Merlins. This limits health practitioners’ ability to offer the early intervention service, as described in 5.9.2. This changed occurred across London and is addressed in a recommendation in section 6. 16 The MASH or Multi-Agency Safeguarding Hub is the single point of contact for all safeguarding concerns regarding children and young people. 48 5.10 Task centred versus relationship based provision of support 5.10.1 Barlow & Scott17 refer to the importance of building a trusting relationship ‘with clients has been acknowledged and emphasised by a range of helping professions, including social work, psychotherapy, nursing and medicine, but that there is a wide variation in the extent to which that relationship is regarded as central to professional practice’. A review of the evidence of effective interventions18, showed the importance of a ‘dependable professional relationship’ for parents and children, in particular with those families who conceal or minimise their difficulties. 5.10.2 Mother told the author of this serious case review that she did not know the practitioners who offered her support well enough to trust them. Whether this was always the case is not clear, but by July those she had developed a relationship with, the first midwife and the FSW at the children’s centre were no longer involved with the family. The health visitor continued to have an ongoing responsibility, but had only met mother and children on 3 occasions over 7 months, twice at the clinic and once at home. It is unlikely that such a level of contact would be able to provide a trusting relationship. However, such a level of contact is usual given the lack of assessed concerns. 5.10.3 It is of note that the FMU caseworker only met the mother on 3 occasions, but was able to learn more about her and her family in these contacts than other professionals. She learnt details about MGF’s personal circumstances which limited his contact at that time. She met MGGM and discussed her attitude to forced marriage. Most critically she identified there was a level of disconnection between the capable mother and her underlying immaturity and that she described the traumatic events in her life, as if they had happened to someone else. 5.10.4 It is likely that this difference in mother’s openness and to the FMU caseworker’s understanding relates to the 3 visits being undertaken within a short space of time, occurring within the home and being more relationship than ‘task focused’. 5.10.5 At one time universal health provision involved home visits by health visitors to households with pre-school children and midwives visiting the home for 10 consecutive days post birth, providing practitioners with a greater understanding of the family circumstances. A challenge for practitioners undertaking assessments in the current way services nationally are structured, is the focus on tasks as opposed to developing relationships and that usually contact takes place outside of the home. 17 Safeguarding in the 21st Century – Where to Now: Jane Barlow with Jane Scott. Research in Practice 2010 18 Effective Interventions for Complex Families where there are Concerns about, or Evidence of, a child suffering Significant Harm, Thoburn et al, 2009 49 5.10.6 The change to the contemporary picture of service delivery via clinics and children’s centres provides a more efficient use of scarce resources and has the advantage of encouraging mother’s to use community resources and get to know other parents. The disadvantage however, is in the ability to speak openly and develop a stronger relationship. This can impact on the quality of assessments undertaken as well as the potential to develop the trusting relationship in which parents feel able to express their worries and concerns. 5.11 Social isolation: family contact with extended family and community 5.11.1 The decrease in family support was not known by professionals and indeed their services were at the same time reducing following Jamilla’s birth and immediate well-being. 5.11.2 Practitioners in health and the children’s centre identified mother’s vulnerability but were re-assured by 2 main factors: Mother’s parenting capacity as observed by all and The support from extended family, in particular the regular input from MGGM and the intention for MGGM to stay with the family around the birth of Jamilla 5.11.3 Whilst mother’s initial accounts of the support from family members was accurate, the witness statements provided to the police indicate that mother and her three young children lived an increasingly isolated existence with sporadic support from extended family members, as opposed to a stable constant level of support (see 4.9). Other than family, there is no evidence that mother had any social contacts whatsoever. 5.11.4 This change in her circumstances remained unknown to professionals. None of the local practitioners met family members or verified the nature and extent of the support. Given the lack of current concerns, this would not be part of usual practice. MGM’s relatives in London 5.11.5 The FMU caseworker did meet MGGM and she was providing support to the family in March 2013. MGGM was also present when the police attended the flat that month. 5.11.6 After the birth of Jamilla, when the midwife visited the home, she heard the children playing downstairs and understood there was someone caring for them. Cousin 4 in her police statement mentions that the health visitor called when she was there, but they did not meet. It is more likely that this was the midwife. 5.11.7 Through reading the statements made to police, it is evident that whilst there was initially a high level of support from family members as described by mother, the situation changed and this was not understood by the various health clinicians still involved with the family (GP, midwifery and health visitor), nor by the workers at the young parents group. 50 5.11.8 The main change was that MGGM left to live in Somaliland in April 2013, before the birth of Jamilla and from that time onwards, social contacts and support provided became less consistent and regular from relatives, with assumptions being made that maternal great aunt and a great uncle were helping regularly. 5.11.9 Maternal great aunt remained in contact and saw mother and family regularly, most week-ends, according to her police statement, but did not stay over and mentioned that the only time she ever changed a nappy was during the days she cared for the siblings after the birth of Jamilla. She helped with cleaning, cooking and shopping and considered that mother was suffering with the ‘baby blues’, describing the situation as ‘like a baby having a baby’. However, she judged that mother, who was trying to ‘potty train’ sibling 1 at the time, was a ‘good mum’, ‘very mature for her age’ and ‘loved her children’. 5.11.10 Great aunt was aware of mother’s ongoing financial problems, only receiving child benefit for one of the 3 children and that she lacked any friends or contacts other than family. However, despite the financial hardships great aunt referred to mother as not asking for help as ‘she wasn’t English, she would not ask for anything’. 5.11.11 It appears that by September, this regular week-end visiting pattern had ceased and great aunt had not visited for about 3 weeks prior to the death of Jamilla, although she spoke to mother every 3 or 4 days on the phone. On her last visit to the home she did some cleaning, but said in her witness statement ‘about three weeks ago stopped going round’. 5.11.12 Great uncle, who others thought was providing support, did help the family to settle in Tower Hamlets and, according to his statement to the police, had 4 direct contacts with his niece – a visit to the first flat, escorting her to a solicitor (presumably about her housing problems), helping her move in February and on return from a trip to Somaliland at the end of May, the great uncle visited again in June / July – he was concerned about mother’s ability to shop for food, but she explained she did this via the internet. 5.11.13 Other family contacts as explained in police witness statements show a pattern of intermittent and largely decreasing visits following the birth of Jamilla: A cousin told police he spoke daily initially and saw mother 5 or 6 times, including at her home on 3 or 4 occasions – he described her as seeming ‘happy’ and looking after and loving the children, taking them he understood to playgroup: this cousin did not see the family after the birth of Jamilla Another cousin provided care for siblings 1 and 2 for 3 days when mother was in labour and giving birth, although mother says that great aunt did this not a cousin Another relative visited the family on 2 occasions, one before and one after the birth of Jamilla and attempted to see them again in September, but got no reply when called at the home or made telephone calls 51 Another cousin told police that mother stayed with her family for a few days at some point and helped them move into their flat – the cousin visited a few times but then lost touch An ‘auntie’ visited a couple of times before and after Jamilla’s birth and described the flat as looking clean, and mother was beast feeding Another cousin visited twice and described that on the second occasion the place was a ‘tip’ and they cleaned the flat – mother and children visited this relative in August, when mother seemed tired, but the children looked well Another cousin last saw the family when mother was 8 months pregnant and the flat was messy – prior to an argument the cousin had visited every Friday afternoon to help mother Maternal grandfather and family 5.11.14 Practitioners also understood that MGF and his family were providing support to the family. Certainly MGF assisted mother’s return to the UK and mother and children lived with his partner in Westminster. However, direct contact with MGF and other members of his family was limited once the family moved to Tower Hamlets and according to information provided in police witness statement by and in interview with MGF consisted of: MGF visiting the family a ‘few times’ in the beginning, but then not seeing each other for a ‘couple of months’ possibly after a ‘minor dispute’ but also from MGF’s perspective as both busy with their own lives Texting prior to birth of Jamilla Being present at the hospital during labour, but not at the birth Arranging a cab to bring mother and baby home A few visits following Jamilla’s birth Mother and children staying with his family in Westminster on 2 occasions after Jamilla was born A loss of contact for 3 months, before getting back via text messages, when mother said she was fine and taking the children to nursery Mother visited MGF’s mother a few times after the birth of Jamilla and they had telephone contact 5.11.15 Another female relative police she visited the flat on 3 or 4 occasions, the last being 3 weeks prior to Jamilla’s death – at that point the flat was clean and relatively tidy Summary of family contact 5.11.16 The information from the police statements confirms that the extended family were providing support to mother, but that the extent, regularity and consistency of this was declining over time, at the same point that professional contact declined. Mother would have spent days at a time without any social interaction with adults, living an isolated existence in the flat with her 3 very young children. 52 5.11.17 Information from family members also demonstrates the role of family members in cleaning and shopping activities to support mother, and some had noted a messy or dirty flat and according to the great aunt that mother was feeling low and having the ‘baby blues’. 5.12 Shortage of housing resources 5.12.1 As explained in the comment box at the end of 4.4, the family experienced an immediate and timely response from Housing, and were fortunate to be placed in a flat as opposed to Bed & Breakfast accommodation; such provision is often not available. When mother complained about the unsuitability of the first flat, they were again fortunate to be provided with more appropriate accommodation within 3 months. 5.12.2 It is recognised that given the housing shortage in London and Tower Hamlets this was a comparatively good outcome. The Service Head, Housing Options has provided the review with the information in the graph below on the significant rise in homeless applications this council (and the rest of London) has been experiencing and how the council’s accommodation responses are influenced by this. 5.12.3 Mother applied to the council in October 2012 and the decision to accept a full duty was made in January 2013. The graph above shows how homeless numbers was rising in Tower Hamlets, manifested by the (significant and growing) use of Temporary Accommodation. 53 5.12.4 In such a climate, the council is forced more and more to rely on bed and breakfast (B&B) accommodation. This is particularly significant in the context that Tower Hamlets was one of the first boroughs in London to originally end the use of B&B for families and consequently did not regularly record B&B usage for families, only starting in the November of 2012 when 45 families were recorded. Within 6 months, that had doubled. 5.12.5 Because of the desire to avoid placing families in B&B, all forms of self-contained accommodation is used, particularly if within the borough, in a desire to avoid exporting vulnerable and/or homeless households refers. Despite this the 6-week statutory maximum stay in a B&B is sometimes breached due to the lack of resources. 5.12.6 The use in this case of a walk-up block was a reflection of firstly the desire to avoid an initial B&B placement and secondly, in the context of an aging portfolio of properties in the borough such ‘walk-up blocks’ are not uncommon. These properties are deemed reasonable for occupation for permanent and secure housing so consequently their use for temporary homes is considered as reasonable. 5.12.7 The positive judgement of the service provided to mother and children is therefore based within the knowledge of this resource context. However it is worrying that the option to place a pregnant lone mother of 2 children aged under 3 years old in a 4th floor flat in a building without a lift is the best option available, despite potential risks to safety of mother and child. 5.12.8 Mother’s move to more suitable temporary accommodation relied on her having the ability to complain. When she did this, she was provided with support to put this in writing and was moved in a relatively fast time frame, albeit it might not have felt that fast to the family. Referral to Brent 5.12.9 Mother is likely to have suffered further anxiety due to the decision that Brent held responsibility for housing the family, as opposed to Tower Hamlets, on the basis that because MGF lived there this was her local connection. Whilst this is in accordance with The Housing Act 1996 and accepted practice in the UK, it would not have been in the family’s best interests as mother had never lived there and the family who provided her with the more regular support were based in East London. 5.12.10 In this case because mother engaged a lawyer who requested a statutory review of this decision a team manager reviewed the circumstances and decided that the process had been invalid as referral on family connection grounds should be undertaken after: Firstly a consultation with the applicant about their wishes and Secondly if the client wishes to be in the same area as the family connection 54 5.12.11 In this case neither of these conditions had been met, so the referral to Brent was withdrawn. The reason behind this mistake is understood to be due to the infrequency of such circumstances and a consequent lack of experience by the officer concerned. 5.13 Culture 5.13.1 Jamilla’s mother is of dual heritage, with a Somali mother and a white UK father; her father had converted to Islam. The mother had little contact with her father as a child and grew up as part of the extended Somali family living in East London. She was though, according to the police statement of cousin 2 ‘the first half Caucasian person in our family’. 5.13.2 It is not clear to what extent the mother’s dual heritage has caused her problems in being accepted within the local Somali community or within her extended maternal family, but there are indications that this fact has caused her a level of difficulties at times due to the reactions of others. 5.13.3 The psychiatric report undertaken as part of separate legal proceedings refers to mother’s account of conflict with her mother around the age of 10 and 11 years old because she did not wish to wear traditional Somali clothing to school. The secondary school recall that mother had some conflict with older Somali girls, possibly because she was different. The psychologist’s report mentions mother’s account of encountering cruelty and racism in Somaliland due to being ‘half white’. This was re-iterated in interview by mother for this review, and she spoke of both her husband’s negative attitude to her mixed heritage and that people in Somaliland would throw stones at her. 5.13.4 Since her return to the UK, until the death of Jamilla, mother was always dressed in traditional clothing with a scarf covering her head, and described as well groomed. The police witness statements from Somali neighbours though note her difference and describe her as a ‘white looking lady’’ or ‘white or mixed Arab type race’. 5.13.5 From the discussions held with practitioners, it does not appear that any explored the impact on the family of mother’s dual heritage. Only the caseworker from the FMU discussed with the mother the response of her maternal family members to her having left her husband. From the statements it appears that this was not a problem and there was a great deal of sympathy for her plight at being married at the age of 13 to a violent man. Cousin 4 said ‘It is not frowned upon to be a single mum within the Somali community’. 55 5.13.6 Practitioners have explained that the assessments that mother did not need additional services were based both on observations of her parenting skills and on her reports of family support. Given the identified vulnerabilities, any such assessment outcome, which relied on the support of others, needed to be based on a full understanding of the potential impact on family relationships of cultural factors, so as to take into account the: Impact for mother of being of dual heritage Impact of the abuse she had suffered Impact on her of being deprived of the teenage experiences she may have grown up expecting prior to her move to Somaliland at the age of 12 Attitude of the maternal family to mother given she had left her husband 5.14 Financial Problems 5.14.1 An ongoing problem for the family was financial hardship, due to not receiving child benefit for her two children born in Somaliland. This came over clearly in some of the witness statements to police and directly from mother. 5.14.2 The witness statements for this review show that the joint head of the FMU was trying to assist and had written to the Child Benefit Office in April and July. The problem was caused because the Somali birth certificates were not acceptable as proof the children belonged to mother and the letters therefore explained that national verification test had been undertaken and UK travel documents provided. 5.14.3 The joint head of the FMU did not hear from mother after July 2013, and consequently assumed that this problem had been sorted. Like all the other professionals, she expected mother to be able to telephone if the problem persisted. 5.14.4 However, what followed was the period when mother ‘shut down’ and her contact with the outside world decreased. At age 18, with 3 very young children she continued to face financial hardship and also had her application for tax credit refused because she had filled this in incorrectly. 56 5.15 Addiction to social networking sites? 5.15.1 One of the puzzling features of this case for the professionals involved was how this competent and loving mother changed her parenting behaviour to such an extent that she neglected her children to such an extent as to cause the death of Jamilla. 5.15.2 The review has established that from the beginning of July she had no contact with professionals who knew her or her children and her face to face family contact decreased and in the case of MGF ceased altogether. She has also explained that following an incident soon after Jamilla’s birth, flashbacks of earlier abuse in her life returned. Also that her husband started to ring her frequently and this worried and upset her. 5.15.3 The expert psychiatric opinion undertaken as part of the criminal proceedings indicate that during the period from July to October mother was suffering ‘...from a mental disorder characterised by dissociation....such that she was unable to predict risk to her children and ensure their basic needs were met’19. 5.15.4 It is known from the prosecution’s Opening Notes at the Crown Court that during this period mother spent increasing amounts of time on Facebook, where she developed an alternative identity of a student living with her mother and younger siblings. 5.15.5 There is now research into the phenomenon of addiction to Facebook and other social networking internet sites, which are being compared to addiction to gambling as well as to substance misuse. For example: ‘the internet and virtual social networks are new technologies that have had most impact on young people and have provided many benefits to their users. However, some people become obsessed with the internet, are unable to control their use of it, and may put their work and relationships in jeopardy. 20 5.15.6 The focus of the research tends to be about young people at educational establishments and the impact such addiction can have on their studies, but Kuss & Griffiths21 quotes Cohen 22 in “I’m an addict. I just get lost in Facebook” replies a young mother when asked why she does not see herself able to help her daughter with her homework. Instead of supporting her child, she spends her time chatting and browsing the social networking site (1’. 19 Psychiatric report, 17.12.13 20 Addiction to new technologies and to online social networking in young people: A new challenge, E Echeburúa, P de Corral, Adicciones, 2009 - europepmc.org 21 Online Social Networking and Addiction—A Review of the Psychological Literature Daria J. Kuss and Mark Griffiths International Gaming Research Unit, Psychology Division, Nottingham Trent University, 22 Cohen, E. Five Clues that You Are Addicted to Facebook; CNN Health: Atlanta, GA, USA, 2009; 57 5.15.7 This suggests that this case may not be unique in terms of social networking impacting on parenting capacity, to the extent of its addictive features. This is considered to be a greater risk for those with lower self-esteem (Kuss & Griffiths). 5.15.8 Other research links the risk to other mental disorders: Prior research has utilized the Zung Depression Inventory (ZDI) and found that moderate to severe rates of depression coexist with pathological Internet use.23 5.15.9 It is likely that given the trauma mother had suffered, her social isolation and difficulty in managing everyday life with very little support, the attraction of being a teenager without her responsibilities in a ‘virtual’ life would have been attractive. It is not clear to what extent this ‘hobby’ became an addiction which in itself contributed to the tragedy that occurred. 23 KIMBERLY S. YOUNG and ROBERT C. ROGERS. Cyber Psychology & Behaviour. SPRING 1998, 1(1): 25-28. doi:10.1089/cpb.1998.1.25. 58 6 FINDINGS & RECOMMENDATIONS 6.1 Introduction 6.1.1 This section contains the overall findings of this serious case review, with the associated recommendations for the LSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems through examining what happened to Jamilla and her siblings. 6.1.2 The LSCB has prepared a separate document with their responses to these findings and the plans to address the recommendations. 6.2 Findings and recommendations 1) Predictability and preventability 6.2.1 This serious case review concerns the tragic death of Jamilla in circumstances of extreme neglect in late September and early October 2013. Both her siblings also suffered neglect. 6.2.2 Prior to the death all the practitioners and most of the extended family members who came into contact with the family were impressed with how well the mother cared for her children and how they were flourishing. Even in the last few weeks in September, when the pre-school had contact with the family the concern (smell of urine from the children’s buggy and sibling 1 not yet attending voluntary pre-school consistently) was not of the level that the circumstances at home could have been predicted. 6.2.3 If a professional, a member of the family or a member of the public had gained access to the property during the last days of Jamilla’s life, had understood the level of neglect and its impact on the children and alerted the police and children’s social care it may have been possible to intervene and prevent the tragic death. However, by this point mother was not answering the door to visitors. 6.2.4 Had any family member or professional seen mother and identified the changes in her were a risk to the children it may have been possible to intervene, although the seemingly rapid deterioration in mother’s care may have made this unlikely. 59 2) The focus of multi-agency assessment and subsequent response is based on current levels of functioning within families, with insufficient consideration of the potential risks arising from ongoing vulnerabilities 6.2.5 The Tower Hamlets Family Wellbeing Model mirrors the Framework of Assessment in a focus on current family functioning and concerns, without giving sufficient attention to the role of ongoing parental vulnerability when considering the needs of the family. This approach, which forms the basis of service provision nationally, provides additional services in response to current needs. 6.2.6 Such an approach relies on the existence of a universal health and welfare system able to identify if and when parental vulnerabilities may re-surface, even when a parent has demonstrated her or his resilience in overcoming past traumas . This may work effectively for older children who attend schools and are seen regularly and for families who attend children’s centres. It also may have been reasonable at an earlier period when health visitor resources provided for regular home visits to younger children. However, the contemporary health visiting structure is based around open access to health visitors at clinics. The national specification provides after the 6 week review for two contacts: at 8-12 months and at 2 years. These are clinic based and if not attended rely on the individual health visitor to follow up. In the absence of identified concerns, any additional contact depends on parents voluntarily accessing clinics. Such a system will provide an effective and supportive service for the majority of the population, who cope with parenting and access help if required, but does risk the possibility of children who are not seen by any professionals for considerable periods of time and are reliant on family and neighbours to alert services if there are concerns. 6.2.7 The Family Wellbeing Model does not specify any level of additional support, such as undertaking a CAF24 or delivering multi-agency support with a team around the family (TAF) and an identified lead professional. Whilst health agencies may consider the health visitor to be the lead professional for children under 5 years of age, in the absence of a social worker, this case illustrated that this is not understood within the professional network. 6.2.8 Another aspect of the way that services were delivered is reflected in mother’s comment that she did not know the practitioners well enough to speak about her worries. Whilst this also may reflect the defences she has developed in her life, it is striking how she spoke more openly to the FMU caseworker than she did to local professionals. 24 The CAF is a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children's additional needs and promote co-ordinated service provision to meet them via a standardised approach to conducting an assessment of a child's additional needs and deciding how those needs should be met. 60 6.2.9 The FMU caseworker visited her at home and met MGGM. She discussed the attitude of MGGM to forced marriage and obtained more detail about MGF’s infrequent contact and family circumstances. She sensed the disconnect between mother’s exemplary parenting skills and her immaturity. She noticed that mother spoke about her past in a distant manner, as if recounting something that had happened to someone else. Had local practitioners experienced this, they may have been less confident about the mother’s ability to ask for help when required. 6.2.10 The ability of local practitioners to develop a relationship with mother which might have facilitated a deeper understanding of her capacity is limited by the setting (mainly out of the home at clinics and children’s centres) and possibly the task centred, as opposed to relationship focused, nature of their role. This is not a reflection on any individual practitioner, but of the nature of the services provided. Recommendations 1 - 3 1. The Children & Families Partnership to review the Tower Hamlets Family Wellbeing Model so as to clarify how, where there are underlying parental vulnerabilities which may impact on parenting in the future but no current concerns about parenting of pre-school age children, this is reflected in the classification of the level of need. This should result, if more than one agency is involved, in the provision of a co-ordinated multi-agency CAF, with a team around the child and a lead practitioner to ensure a holistic approach to the family and the development of sufficient a relationship to enable an in depth ongoing assessment of need. 2. Practitioners in all agencies should clarify within records the assessed tier of need within which services are being provided and the rationale for this. 3. The Family Wellbeing Steering Group to review the guidance on the lead professional role and strengthen the need for relationship building, as well as task focused work, and the use of home visiting to facilitate this. Please note: recommendation 6 also addresses the Family Wellbeing Model 3) Enhanced health service provision 6.2.11 The knowledge of mother’s vulnerability appropriately provided the family with a service from the Gateway midwifery team and an enhanced health visiting service. 6.2.12 The links between health provision and the Family Well Being model are not stated clearly in the Family Well Being model. The draft management report provided to the serious case review by the named nurse25 refers to: ‘This level of vulnerability and risk factors places (mother) and her children into Tier 2 Tower Hamlets Family well –being indicators’. 25 Draft comprehensive Investigation Report V3, Barts Health NHS Trust 61 6.2.13 Such a level of need would involve a CAF according to the Family Well Being model and single agency support if the needs are focused, or lead practitioner and team around the child if needs are complex. In this case it was considered that single agency support was appropriate. The CCG Nurse Consultant Safeguarding Children has advised that the assessments undertaken by health visitors are CAF compliant, so this would be consistent with tier 2 focused needs. 6.2.14 The Gateway midwifery team provide services for vulnerable pregnant women. The service was appropriate to health needs prior to the birth of Jamilla. It was unfortunate that there was a change of midwife following the birth, despite mother’s stated preference to remain with the practitioner. The rationale behind this change was that it was a consequence of the family’s move nearly 3 months earlier, and is the usual practice, misunderstood by the midwife concerned to be required practice. Whilst it is not known whether mother would have continued to keep optional midwifery appointments following Jamilla’s birth, it would have been more likely had there been continuity of the individual practitioner. Given that this is a service for vulnerable women, it would be sensible for ‘usual’ practice to be to retain continuity, unless there are good reasons to transfer responsibility. 6.2.15 After the birth, mother saw the midwife 3 times and then missed 2 appointments. Because this is a service for vulnerable women, the midwife did not discharge her from the service and planned to make contact in September. However this did not happen and the health visitor was not informed of the DNAs. Given that the service is designed for vulnerable young women, there is an argument for the following up of missed appointments, offering the possibility of a home visit, by either the midwife or the health visitor. 6.2.16 Whilst midwifery did provide focused single agency support in line with the Family Well Being model through the involvement of the Gateway team, the health visiting provision, although assessing the family as requiring an enhanced service, in practice provided the universal offer, with the added option for mother to ask for additional help. This relied on her to have the insight to ask for that help. She never requested additional help from health visiting services. 6.2.17 The reason behind this arises from the lack of local definitions about what constitutes an enhanced service, leaving it up to professional judgment. Evidence from this case suggests that in the circumstances when a family has been assessed as eligible for an enhanced service the avoidance of developmental checks should trigger timely follow up. 62 6.2.18 The lack of co-ordinated multi-agency input meant that no one lead professional understood that mother had not brought her son for his developmental check, had not attended her last 2 midwifery appointments and had ceased to attend the children’s centre. If this had been understood, there may have been attempts to follow up at home with mother during the summer. Recommendations 4-6 4. The Gateway midwifery team to provide consistency of the individual midwife for ante and post natal care as standard provision, except in circumstances when a change is judged to be in the interests of mother and baby. 5. When the health visiting provision is re-commissioned by the Council, the specification for an enhanced health visiting service to include: Minimum level of contact depending on age of child and parent / carer and vulnerability of family Need for timely follow up to non-attendance at developmental checks Liaison expectations with other practitioners, especially within the health service 6. The Children & Families Partnership to review the Tower Hamlets Family Wellbeing Model so as to clarify the linkage between health assessments and tiers of need: if the health assessment is CAF compliant how does it lead to multi-agency involvement, the formation of the team around the child and the identification of a lead professional? 4) Minimising risk of invisible children following moves into the UK or into a local authority 6.2.19 In this case, the Forced Marriage Unit informed Brent CSC of the family’s arrival in the UK, but did not tell the health services. The social care response of a telephone call to father did not ensure that the existence of the newly arrived children in the UK was known about by universal health services, so risking ‘invisible children’. Fortunately the mother herself did register with a GP. 6.2.20 Tower Hamlets CSC did liaise with other agencies and ensured that the presence of the children was known by universal health services as well as the local children’s centre. The practitioners, as part of this review, identified that they did not take a sufficiently pro-active role in ensuring that in the light of mother being potentially vulnerable there was an adequate assessment and co-ordination of services (a CAF, a team around the child and a lead professional). 6.2.21 The lesson from this is the need for Children’s Social Care to be more pro-active when signposting referrals to other services, so as to ensure that the ‘stepping down’ process results in sufficient assessment of need and co-ordination of services. It is understood that in both boroughs the arrangements for receiving referrals has changed since 2012 and that the current functioning of the ‘front door‘ service is likely to be more pro-active with the development of a Multi-Agency Safeguarding Hub . 63 Recommendations 7-9 7. Both Brent and Tower Hamlets LSCBs to undertake multi-agency audits of their front door processes to examine the following on those cases that do not meet the threshold for a social work assessment: The extent to which historical records are accessed How cases are ‘stepped down’ from Children’s Social Care and whether this includes any involvement in ensuring arrangements for a CAF and a lead professional when there are indications of parental vulnerability That action is taken to ensure the children’s presence within the local authority is known by universal health services, so as to help prevent ‘invisible’ children 8. The Forced Marriage Unit to inform local child health services whenever they are aware that children have moved into an area 9. The Children & Families Partnership should build upon the introduction of the MASH and the revised Family Wellbeing Model to introduce a clear process by which cases that do not cross the social care threshold can be passed to a lead professional who will take responsibility for coordinating the work of the "team around the child / family" - in some local authorities this role is described as that of the CAF Coordinator 5) Think Family Approach 6.2.22 Think Family was a cross-departmental programme introduced in 2009, jointly funded by the then DCSF, the Home Office, Ministry of Justice and the Department of Health, and supported by the Department of Communities and local government. The aim was to make sure that the support provided by children’s, adults' and family services is coordinated and takes account of how individual problems affect the whole family. 6.2.23 One of the features of this case is that only the case worker from the FMU met any family members and the assessments undertaken by practitioners did not involve obtaining much information about the family and the meaning and significance of the support that was being provided – even though without that support it would have been extremely difficult for mother to have been able to care for children without additional services. 6.2.24 Health practitioners and the Children’s Centre accepted that mother was getting support from her family, and that MGGM was living with her at the time of the birth of Jamilla. This was not in fact the case and in order to assess the risk to the children of a lone parent aged 18 with three young children under the age of four, it was important to understand the exact nature of the support available. 6.2.25 Judgements about needs were based on self-reported information relating to the involvement of extended family: such accounts may not be accurate and such levels of support may not be sustainable. If such support is critical for the family’s well-being, it needs to be verified by the inclusion of wider family within the assessment and the scope of service provision. 64 6.2.26 The midwife visited the family home after the birth and was aware of the children downstairs laughing and assumed this was with an adult. However, the focus of the home visit was mother and baby and the midwife did not see the other children or the adult thought to be with them. This was a missed opportunity to be able to check on both the welfare of all children, but also the veracity of self-reported information. Whilst perhaps not a part of the remit of the midwife’s current role, if the expectation is to ‘think family’ within adult services, then this is even more critical for practitioners within children’s services. Recommendation 10 10. The LSCB to consider how to change the broaden of working with families, so that practitioners take the opportunities to meet those extended family members who play a major part in supporting children and/or parents, through their involvement in assessments and ongoing services 6) Culture & Forced Marriage 6.2.27 Practitioners in this case did not obtain an understanding of the implications for mother of being of dual heritage and the significance this had within her family and within her community. Even more relevant was the lack of knowledge of the extended maternal family’s views to mother having escaped from a forced marriage in Somaliland. Given the assessment of the family’s needs was inextricably linked to the provision of support by relatives; this was a critical area to explore. 6.2.28 In this case it appears to have not made a difference to the level of extended family acceptance of mother and the children, but we do not know if it impacted on the support provided by any individuals. 6.2.29 Also what was not explored with mother was the impact on her of being deprived of the teenage experiences she possibly grew up expecting prior to her move to Somaliland at the age of 12. 6.2.30 A particular experience mother missed was a secondary education. Practitioners need to be aware with all service users, and especially those who come or return to the UK after periods abroad, that they may have difficulties reading, writing or comprehending verbal information, even when as in this case, mother was an English speaker. None of the practitioners was aware of mother’s literacy abilities and it is not known if her lack of secondary education contributed to her difficulties, nor if she had any other underlying communication difficulties. It is possible that some appointments may have been missed through such literacy problems. 65 6.2.31 A further difficulty for the family was the lack of financial resources as a consequence on the older children being considered to be not eligible for child benefit, due to the lack of birth certificates. This ongoing and apparently insoluble problem for the family was not known by local professionals and hence mother was left without anyone to advocate on her behalf. 6.2.32 Discussions with practitioners about the lack of such discussion with mother highlighted the reluctance to ask intrusive questions, when there is a lack of identified concerns. Also, the challenge of having such conversations when contact is in public places, such as clinics, as opposed to the home. 6.2.33 The incidence of Forced Marriage in 2012, as collected by the Forced Marriage Unit26, involved 1485 cases, of which 21% are in London. Given the ethnic composition of Tower Hamlets, which in 201127 had 47% 0f the population from BME groups, staff need to be equipped to speak openly with parents and children about issues of diversity and of forced marriage. Recommendations 11 and 12 11. The LSCB to review current multi-agency training and practice supervision on race, identity, forced marriage and other harmful practices to evaluate if this equips relevant practitioners with the understanding and skills to: Explore the implications of their race, ethnicity, culture and identity with parents and children Explore the impact with parents of having been subjected to a forced marriage or other harmful practice Consider safeguarding implications of parents experiences of harmful practices Be wary of the family support provided to victims by families who may have been involved in or supported the marriage Sensitively explore people’s literacy and comprehension, regardless of the ability to speak English Be aware of the role of Victim Support services in supporting victims of forced marriage and their ability to advocate to the benefits agency Consider financial needs for children arriving in the UK, without full documentation 12. To enable the use of specialist and appropriate services, the use of forced marriage needs to be routinely recorded as a data category by CSC and health practitioners: this will require these agencies to adapt their data collection records 7) Lack of housing resources within Tower Hamlets 6.2.34 Section 4.10 describes the significant rise in homeless applications being experienced within London boroughs, the consequent use of Bed and Breakfast accommodation so as to avoid exporting homeless families and the lack of suitable housing provision in a borough with a portfolio of aging accommodation in buildings without lifts. 26 https://www.gov.uk/forced-marriage#statistics-on-forced-marriage-collected-by-fmu 27 Tower Hamlets Research Briefing 2011-2016 file:///C:/Users/Edi/Downloads/RB%202011-06%20Population%20key%20facts.pdf 66 6.2.35 Within this context the family had a comparatively good service from Housing Options, being provided immediately with temporary housing, and being moved to more suitable accommodation in a relatively short space of time. 6.2.36 However, such judgment is purely in the light of available resources as opposed to what meets the needs of children and pregnant women. To be placed initially on the fourth floor without a lift could be a risk to the health and safety, even though it was undoubtedly preferential than other options. 6.2.37 Further stress was placed on mother through the decision to refer the family to Brent on the basis of a local connection. This action was mistakenly thought to be in accordance with The Housing Act 1996, but in fact contravened the need to only do so with the agreement of the parent. Once the mistake was identified the referral was deemed invalid. Recommendation 13 -14 13. The LSCB to consider how to take up the need for action on housing resources locally and within London, so that children and families are not placed in unsuitable accommodation, that could conceivable be perceived as a health and safety risk 14. Housing Options to provide guidance for their staff about the use of referrals to other boroughs, so as to avoid this being done without the tenant’s agreement 8) Challenging the Myth of persistence in neglect? 6.2.38 A factor in this case is the speed at which the home circumstances deteriorated, which is unusual and not consistent with common understandings of neglect as embodied in the definition of neglect provided by Working Together: ‘Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. 28 6.2.39 Such a definition does not fit with the circumstances in this case, when there was an extremely quick and speedy deterioration in the home circumstances . It is important that both professionals and public understand that neglect can lead to risk to children within a very short period of time, especially in relation to babies and young children, and as a result of single incidents of neglect, such as a lack of supervision. Recommendations 15 - 16 15. The LSCB to ensure that the new neglect strategy and training programme adequately reflects the risks of neglect in a short period of time, as in this case, or as a result of single incidents of neglect. 16. The LSCB to write to the DfE to challenge the current definition of neglect used in Working Together 2013, which refers to ‘persistent failure to meet a child’s basic needs’: such a definition can be misleading for both the public and professionals, and may risk under recognition of the extent of risk to children over short periods of time or in relation to single incidents of neglect such as lack of supervision in the bath. 28 Working Together to Safeguard Children, DFE March 2013 67 9) There continue to be systemic difficulties around ensuring that relevant information from MPS Merlins is provided to enable early interventions 6.2.40 During the period under review the weakness of the system for communicating information from Merlins29 to health practitioners stemmed from the restriction in being placed only within midwifery records and a reliance on an individual midwife to access information entered by others and communicate it to any other involved health practitioners. 6.2.41 Since that time the process has changed and Merlins are no longer sent to health agencies, but assessed within the MASH and shared as required. In practice this has led to the ending of such information sharing with health practitioners. 6.2.42 Moreover, within Tower Hamlets, schools have never been provided with such information, although the rationale of the potential for early intervention applies equally to education. In some instances such information sharing will add to knowledge held within universal services, which together will point to the need for Children’s Social Care involvement. Recommendation 17 17. The LSCB to ask the London SCB to urgently review the current information sharing arrangements around Merlins, so that universal services have access to such relevant information, especially around domestic abuse 29 Merlins are the MPS notification of a child coming to the attention of the police 68 GLOSSARY OF TERMS & ABBREVIATIONS CAF Common Assessment CCG Clinical Commissioning Group CSC Children’s Social Care DfE Department for Education DNA Missed health appointment – Does Not Attend ED Emergency Department of a hospital FMU Forced Marriage Unit FSW Family Support Worker at the children’s centre Gateway midwifery team The Gateway midwifery team provide ante and post natal services for vulnerable women GP General Practitioner HV Health Visitor LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub Merlin MPS notification that a child has come to the attention of the police MGF Maternal grandfather MGM Maternal grandmother MGGM Maternal great grandmother MPS Metropolitan Police Service TAF Team around the Family 69 APPENDIX 1: PANEL MEMBERS The review panel consisted of the following members: ROLE AGENCY Sarah Baker - SCR Panel Chair & Independent LSCB Chair (Tower Hamlets) Independent Edi Carmi, Lead Reviewer & Report Author Independent Interim Service Head – Children’s Social Care LB of Tower Hamlets Service Head – Learning and Achievement LB of Tower Hamlets Service Manager – Child Protection & Reviewing LB of Tower Hamlets Nurse Consultant Safeguarding Children & Designated Nurse Tower Hamlets Clinical Commissioning Group Lead Named Nurse for Safeguarding Children Barts Health NHS Trust Director of Nursing & Governance Barts Health NHS Trust Designated Doctor for Safeguarding Children Barts Health NHS Trust Service Head – Strategy, Regeneration & Sustainability (Housing) LB of Tower Hamlets Specialist Reviewing Officer Metropolitan Police Service LSCB Business Manager LB of Tower Hamlets 70 APPENDIX 2: PRACTITIONERS INVOLVED IN THE SCR PROCESS The following practitioners were involved in individual and group meetings with the lead reviewers and other panel members: ROLE AGENCY Specialist Case Worker Forced Marriage Unit Health Visitor Barts Health NHS Trust Gateway Midwives (Midwifery Team for Vulnerable Women) Barts Health NHS Trust General Practitioner Tower Hamlets Clinical Commissioning Group Team Manager LBTH Children’s Social Care Social Worker LBTH Children’s Social Care Family Support Worker LBTH Children’s Centre Family Support Work Practice Manager LBTH Children’s Centre Pre School – Manager and Designated Safeguarding Officer Independent Early Years’ Service Provider Pre School – Deputy Manager Independent Early Years’ Service Provider Pre School - Lead Practitioner for 2 year olds Independent Early Years’ Service Provider Senior Homeless and Housing Assessment Officer LBTH Homeless & Housing Service Head LBTH Housing Options Assistant Head Teacher (Designated Teacher) Secondary School |
NC52207 | Disclosure by a 14-year-old girl in January 2019 of four offences of rape by an adult male. Concerns that Child B was at risk of sexual exploitation had arisen a year earlier when Child B had travelled to a hotel to meet a man she had been in contact with over Facebook. Child B had been supported as a Child in Need and was later the subject of a Child Protection Plan, as well as being referred to CAMHS, Catch-22, and Barnardo's. There were concerns at school about bullying and Child B had moved to an Alternative Education placement. Further concerns about disguised compliance from Mother and Father's lack of engagement. Child B made several disclosures of grooming and sexual exploitation which resulted in Section 47 enquiries, and was accommodated under Section 20. Ethnicity and nationality not stated. Findings relate to: the multi-agency sexual exploitation process; child in need/child protection; the significance of neglect as a factor which underlies adolescent vulnerability; bullying; early intervention to prevent child sexual exploitation; information sharing; school nurse involvement; safeguarding roles and responsibilities; public awareness of child exploitation; the voice of Child B. Recommendations include: ensure that children and young people assessed as at high or medium risk of sexual exploitation are immediately flagged on the information systems of all agencies who are in contact with the child or young person; ensure that the support provided to children and young people at risk of sexual exploitation also considers the current and future needs of younger siblings living in the same household.
| Title: Child B. LSCB: St Helens Safeguarding Children Partnership Author: David Mellor Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child B Final Version: 9th March 2020 Strictly Confidential 1 St. Helens Safeguarding Children Partnership Serious Case Review Summary– Child B Contents Introduction 1 Summary of Case 2-3 Child B’s Views 3-4 Findings and Recommendations 5-11 References 11 Glossary 11-12 1.0 Introduction 1.1 In January 2019 a 14-year-old young person who will be referred to in this report as Child B disclosed four offences of rape by an adult male. Concerns that Child B was at a high risk of sexual exploitation had first arisen a year earlier and her case had been managed under the local multi-agency child exploitation process. Additionally, she had been supported as a Child in Need and later been the subject of a Child Protection Plan. As a result, a large number of agencies worked together to support Child B and her family in the year prior to her disclosures of rapes. 1.2 The then St. Helens Safeguarding Children Board, since succeeded by the St. Helens Safeguarding Children Partnership, decided to conduct a Serious Case Review (SCR) on the grounds that Child B had suffered significant harm and abuse was suspected. 1.3 St. Helens Safeguarding Children Board appointed Ann Dunne as chair of the SCR Panel established to oversee this review. She is the Senior Assistant Director, Children’s Safeguarding at St. Helens Council. David Mellor was commissioned as the independent reviewer for this SCR. He is a retired chief police officer and former independent chair of safeguarding children’s and adults’ boards who has no connection to any of the agencies involved in this case. 1.4 It is worthy of note that during the period covered by this SCR – January 2018 until January 2019 – there were two focussed visits to Children’s Services in St Helens by Ofsted which highlighted areas for improvement. Several of the findings of this SCR are consistent with the priority areas for improvement identified by Ofsted. Strictly Confidential 2 2.0 Brief Summary of Key Events and Agency Responses: January 2018 Concerns arose that Child B may be at risk of child sexual exploitation after she travelled to a hotel to meet an adult male she had been in contact with on Facebook. The hotel staff became suspicious and alerted Cheshire Police, in whose area the hotel was situated. Cheshire Police made a safeguarding referral. On receipt of the safeguarding referral from Cheshire Police, St. Helens Children’s Social Care initiated a Child & Family Assessment (C&FA) but there was a delay in completing the Pan Merseyside Child Exploitation referral form (CE1). February 2018 Child B was seen by Child and Adolescent Mental Health Services (CAMHS) following a referral by her GP. CAMHS referred Child B to Barnardo’s who provide Tier 2 (early help and targeted services) CAMHS support. CAMHS also contacted her school over concerns that Child B was being bullied by other pupils. March 2018 The C&FA was completed and it was agreed that Child B and her family would be supported under a Child in Need (CiN) plan. In late March the delayed CE1 Child Exploitation referral form was considered by a CE2 meeting, which is the meeting at which the CE2 multi-agency assessment tool is completed. Child B was assessed as being at high risk of child sexual exploitation. She was referred to Catch 22, which is a service which works with young people under 18 who are at risk of child sexual exploitation. April 2018 Child B’s case was discussed at the multi-agency child exploitation meeting (MACE), the purpose of which is to enable information sharing and action planning to tackle child exploitation. It was agreed that her case should be open to the MACE meeting and would be reviewed at the August MACE. May 2018 Catch 22 began working positively with Child B but Barnardo’s had been unable to contact Child B’s mother and wrote to her to say that they would close her daughter’s case unless contact was made. June 2018 A strategy meeting was held after Child B disclosed a sexual assault to the police. It was agreed that current support would continue and a Section 47 enquiry would be initiated. The Section 47 enquiry acknowledged the risks to Child B but concluded that she was not at continuing risk of significant harm and it was decided to continue to support Child B under the CiN plan. After CAMHS received a second GP referral in respect of Child B, Barnardo’s agreed to keep the earlier referral open. July 2018 Child B was referred to the young people’s drug and alcohol team (YPDAAT) who first made contact with her in September 2018. August 2018 Child B was involved in a road traffic accident in a car driven by a male said to be the boyfriend of her adult sister who was arrested for driving under the influence Strictly Confidential 3 of alcohol. Concern was expressed that Child B was being exposed to risk through her adult sister’s association with the driver of the car and other males. Barnardo’s closed Child B’s case as they had been unable to contact her parents. Child B made a number of disclosures of grooming and sexual exploitation by adult males which resulted in an emergency strategy meeting which led to a further Section 47 enquiry. September 2018 Child B was judged to be at continuing risk of significant harm and made subject to a child protection plan under the category of sexual abuse. October 2018 Child B’s case was considered at a further CE2 meeting where she continued to be assessed as being at high risk of child sexual exploitation. The action plan was updated and expanded. November 2018 A Legal Gateway Panel meeting was held and pre-proceedings were agreed in respect of Child B. (The aim of pre-proceedings is to try and support the family to address concerns before reaching the stage of legal care proceedings.) Child B had been supported to re-engage with school but was suspended and referred to Alternative Education provision. This provision was unable to manage the risk of child sexual exploitation to which she continued to be exposed. December 2018 A pre-proceedings meeting had to be rearranged when Child B’s mother did not attend. The rearranged meeting did not go ahead later in that month. January 2019 Child B was accommodated by St. Helens children’s social care under Section 20 Children Act 1989 after she disclosed four offences of rape by an adult male. 3.0 Child B’s Views on the Support she received from Agencies 3.1 Child B said she found the work she did with Catch 22 to be helpful, particularly their advice on how perpetrators groom children for sexual exploitation. She seemed to value and benefit from the Catch 22 advice that she should not blame herself for what happened to her. She felt that her self-confidence had increased during the time Catch 22 worked with her. 3.2 Child B was very critical of the High School she attended. She said that she was regularly bullied by female pupils in her year and lower. She said she had been ‘battered, bruised, nearly strangled and dragged around the school’. However, she felt that she was blamed for the incidents because she would ‘shout back’ at the pupils who were bullying her and, as a result, she was perceived by school staff to be the aggressor. She said the school believed those who bullied her. 3.3 She said that she had stayed off school ‘for about a year’ because of the bullying. Child B added that whenever the school contacted mother to discuss the bullying, she (mother) responded by saying that unless the school supported Child B, she would not bring her into school. Child B said that mother’s advice to her was to ‘put her head down and just ignore it’. She described the school as ‘horrible’. Strictly Confidential 4 3.4 Child B said that the school arranged for her to resume her education by initially attending on a part time basis (10am – noon daily) which she said was ‘alright’ although she said she was still being followed around school by pupils who were intent on being unpleasant to her and so she began missing school again. 3.5 She said her Alternative Education placement was ‘alright’ but she was disturbed to find that pupils from her school who had been involved in bullying her previously were also in the same Alternative Education placement. She added that they did not bully her during the Alternative Education placement. 3.6 Child B felt that YPDAAT had helped her to reduce her alcohol intake when she was out on a Friday and Saturday night. They helped her to appreciate that drinking excessively could increase her vulnerability to abuse. 3.7 Child B had only limited contact with CAMHS and Barnardo’s during the period under review and felt that their suggestions for preventing self-harming behaviour ‘didn’t work’. She said that Barnardo’s response to her efforts to access their online counselling service were not helpful. She contrasted the limited benefit she obtained from CAMHS and Barnardo’s with online support she had subsequently received from the ‘7cups’ website which, it is understood, allows users to anonymously connect with trained listeners in order to gain support for issues including mental health. There are different support options including individual listeners, chat rooms and forums. Child B said that this service ‘allowed her to get her feelings out’ and provided her with quite directive advice such as ‘don’t self-harm because the relief from doing so will last for only 2 minutes’, which she said she valued. 3.8 Child B made limited comments about the other agencies she and her family came into contact with. She said that the police had helped her to say what had happened to her and that the sexual health advice service had helped her to an extent. She initially said that she had no comments to make about children’s social care but as the conversation drew to a close she expressed dissatisfaction with the extent to which she was consulted over the decision to take her into care in January 2019. Although she said she was now thankful to mother for consenting to her becoming looked after, she felt that the process was quite abrupt. She said that the social worker visited her at her sister’s address and told her to ‘pack her bags’ and just dropped her off at the children’s home and ‘just left her there’. Child B felt that this process could have been managed more sympathetically. 3.9 Child B was asked if she had any views on how services worked together to support her and her family. She said that she didn’t think they worked together but was unable to enlarge on this view, possibly because she may have been unaware of what to expect from partnership working arrangements. 3.10 It had been hoped to invite Child B’s parents to contribute to this review but, at the time the SCR was being completed, they were facing a number of challenges which precluded contact at that time. Strictly Confidential 5 4.0 Findings and Recommendations 4.1 Despite the fact that Child B was assessed as at high risk of child sexual exploitation and her case managed through the Pan-Merseyside Multi-Agency Child Exploitation Protocol for twelve months and that, in parallel, she was first supported as a Child in Need and later subject of a Child Protection Plan, the risks to Child B from child sexual exploitation escalated to the point where urgent action was necessary to accommodate her under Section 20 of the Children Act. 4.2 Clearly, the Child Exploitation Protocol cannot eliminate the risk of child sexual exploitation and statutory child protection procedures cannot guarantee a positive outcome for the child concerned, but in this case, it became increasingly clear that despite the individual and collective efforts of a range of agencies, matters were not improving for Child B and the risks to which she was exposed were escalating. 4.3 The multi-agency child exploitation process in St Helens has continued to evolve since the period under review. The process is now led by the Complex Safeguarding Lead from St. Helens Children’s Services who has advised the independent reviewer of the changes including a greater emphasis on timescales in order to prevent drift and delay, although it is not known whether delays have been reduced, and an even stronger focus on reducing the risk of exploitation. Where the child or young person is also subject to Child in Need or Child Protection as well as the multi-agency child exploitation process, creative ways are being explored to better co-ordinate the two processes and manage the impact on practitioners of attending separate meetings for each process. However, this review focusses on Child B’s journey through the process during the twelve-month period beginning in January 2018. The Multi-Agency Sexual Exploitation Process 4.4 There were frequent and substantial delays in the progression of Child B’s case which prevented earlier intervention to support her and her family and left the risks to which she was exposed unattended to for a time. 4.5 The plans developed in the CE2 meetings contained an increasing number of actions and eventually became somewhat unwieldy. The plans did not identify, or afford priority to, all of the key issues which could have reduced the risk of child exploitation faced by Child B. In particular, repeated concerns that Child B’s unmet mental health needs may be increasing her vulnerability went largely unaddressed. 4.6 In Child B’s case, being open to the MACE meeting appeared to add little value. MACE did not provide strategic oversight; did not challenge issues such as the delays in progressing Child B’s case; did not ensure that the multi-agency sexual exploitation and the Child in Need/Child Protection plans complemented each other; did not challenge the fact that matters were not improving for Child B; and did not ensure that there was sufficient focus on outcomes for Child B. The latter point was picked up by practitioners involved in the case who attended a learning event to Strictly Confidential 6 inform this SCR. Many expressed the view that there was too much focus on the child exploitation process and insufficient attention paid to the outcomes for Child B. 4.7 However, the need to focus on outcomes is not solely the responsibility of the MACE meeting. An earlier serious case review into a case involving child sexual exploitation recommended that all practitioners needed to understand their responsibility to relentlessly pursue any concerns that the system was not working for any child (1). The system did not work well enough for Child B. Recommendation 1: That St. Helens Safeguarding Children Partnership obtains assurance that the MACE meeting provides strategic oversight of the multi-agency child exploitation process including • an overriding focus on outcomes for children and young people assessed as at high risk of exploitation, • challenging plans where the situation is not improving for a child or young person, • challenging delay and drift, • ensuring CE plans prioritise key issues essential to reducing risk and • ensuring CE plans and child in need/child protection plans are complementary. Child in Need/Child Protection 4.8 Child B’s case should have been escalated to child protection earlier than it was. Assessments were insufficiently informed by earlier children’s social care and early help involvement with the family and there was insufficient challenge to father’s complete lack of engagement or to the gap between mother’s words and deeds and the evidence of disguised compliance on her part. (Disguised compliance is a concept derived from learning from serious case reviews and consists of parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions and to allay concerns (2)). The vital parenting assessment should have been commenced earlier and, having been identified as a key task, was repeatedly delayed. Many of these issues were highlighted in focussed visits to St Helens Children’s Services by Ofsted in July and November 2018. The full Ofsted inspection which took place in September 2019 acknowledged progress made whilst highlighting the further developments required (3). 4.9 St. Helens Safeguarding Children Partnership may be able to obtain assurance in respect of the learning from this case about the manner in which Child B was supported, initially as a Child in Need and subsequently under a Child Protection Plan, from reports received in respect of the improvement programme established following the first of the Ofsted focussed visits in 2018. The specific issues on which the Partnership may wish to obtain assurance are: Strictly Confidential 7 • the extent to which child in need plans provide challenge and focus on change, capacity for change and the outcomes for the child or young person, • the extent to which section 47 enquiries fully consider historical information, parental capacity to safeguard and the possibility of disguised compliance, • that decisions to escalate to child protection are informed by escalating risks and fully consider relevant historical information, • that key elements of the Child Protection Plan, such as the parenting assessment in this case, are progressed expeditiously and • that timescales for key elements are monitored to avoid drift. Recommendation 2 That St. Helens Safeguarding Children Partnership obtains assurance in respect of: • the extent to which child in need plans provide challenge and focus on change, capacity for change and the outcomes for the child or young person, • the extent to which section 47 enquiries fully consider historical information, parental capacity to safeguard and the possibility of disguised compliance, • that decisions to escalate to child protection are informed by escalating risks and fully consider relevant historical information, • that key elements of the Child Protection Plan, such as the parenting assessment in this case, are progressed expeditiously and • that timescales for key elements are monitored to avoid drift. The significance of neglect as a factor which underlies adolescent vulnerability 4.10 The recurring concerns documented throughout Child B’s childhood, which included parental alcohol misuse; poor home conditions; lack of food in cupboards; lack of supervision; inconsistent school attendance; and lack of parental co-operation with agencies, makes painful reading. The inability of agencies to which Child B and her siblings were referred to intervene effectively because of a lack of challenge, lack of professional curiosity and a tendency to downplay concerns is equally disturbing. The picture is consistent with what was observed during the Ofsted focussed visit to children’s services in July 2018, when a high proportion of cases seen featured issues of long-standing neglect where too many children had been left in home circumstances where their health and well-being were compromised. Ofsted also observed that the cumulative impact on children was not sufficiently recognised by all workers or their managers, and the high tolerance to familial neglect was neither questioned nor challenged by effective management oversight or reflective supervision (4). 4.11 The long-term parental neglect both Child B and her elder sibling suffered left them both extremely vulnerable to exploitation as they entered their adolescent years. It is therefore recommended that St. Helens Safeguarding Children Partnership disseminate the learning from this case, including the long history of largely unaddressed parental neglect and the likely impact on the risk of sexual exploitation to which both Child B and her elder sibling were exposed. Dissemination Strictly Confidential 8 of learning from the review will provide an opportunity to emphasise the importance of the 2019-2024 St. Helens Neglect Strategy (5). It is also recommended that the 2019-2024 St. Helens Neglect strategy is amended to include child exploitation (sexual and criminal) as a contextual risk factor alongside domestic abuse, substance misuse, adult mental health, child poverty and youth homelessness. Recommendation 3: That St. Helens Safeguarding Children Partnership disseminates the learning from this case, including the long history of largely unaddressed parental neglect and the likely impact on the risk of sexual exploitation to which both Child B and her elder sibling were exposed. Dissemination of learning from the review will provide an opportunity to emphasise the importance of the 2019-2024 St. Helens Neglect Strategy. Recommendation 4: That the 2019-2024 St. Helens Neglect Strategy is amended to include child exploitation (sexual and criminal) as a contextual risk factor alongside domestic abuse, substance misuse, adult mental health, child poverty and youth homelessness. Bullying 4.12 Child B’s school generally perceived her to be the instigator of bullying whereas Child B strongly felt that she was often the victim. It is difficult to reconcile these opposing views although the long-term parental neglect suffered by Child B meant that she often presented as unkempt and later began caring for her younger sibling, factors which may have affected her ability to make friends amongst her peers. This case suggests that schools may need to look at bullying more holistically and consider the impact of neglect, particularly chronic long-term neglect, on pupils involved in bullying incidents whether perceived as instigators and/or victims. Recommendation 5: That St. Helens Safeguarding Children Partnership share the learning from this SCR with local schools and invite them to review their approach to bullying to ensure that the potential impact of neglect on those involved in bullying incidents is considered. Early intervention to prevent child sexual exploitation 4.13 Child B’s exposure to the risk of child sexual exploitation mirrored the experience of her elder sister five years earlier. Although it is understood that no interventions were put in place to support Child B’s sister at the time she may have been at risk of sexual exploitation, it may have been possible at the time that concerns arose in respect of her elder sibling to anticipate that Child B may also go on to be at risk of sexual exploitation. The common denominator in both of their lives was serious enduring parental neglect. Strictly Confidential 9 4.14 Therefore it is recommended that St. Helens Safeguarding Children Partnership obtain assurance that the support provided to children and young people at risk of sexual exploitation also considers the current and future needs of younger siblings living in the same household. Recommendation 6: That St. Helens Safeguarding Children Partnership obtain assurance that the support provided to children and young people at risk of sexual exploitation also considers the current and future needs of younger siblings living in the same household. Information sharing 4.15 Child B’s GP, CAMHS and Barnardo’s do not appear to have become aware that Child B was at high risk of sexual exploitation until after she was accommodated by the local authority in January 2019. The system by which partner agencies involved in the CE2 and MACE meetings flag their records in respect of children and young people at high or medium risk of sexual exploitation was insufficiently robust in this case and may therefore need to be strengthened. Recommendation 7: That St. Helens Safeguarding Children Partnership obtains assurance that children and young people assessed as at high or medium risk of sexual exploitation are immediately flagged on the information systems of all agencies who are in contact, or likely to come into contact with the child or young person. School nurse involvement 4.16 The school nurse service played a largely passive role in this case until Child B became subject to a Child Protection Plan in late August 2018. The school nurse service had been a repository of information shared in respect of the growing concerns relating to Child B but did not appear to consider whether there was a role for the service in safeguarding Child B prior to August 2018. Capacity issues may well have been a factor and so the Safeguarding Children Partnership may wish to seek assurance from North West Boroughs Healthcare NHS Foundation Trust (NWBH) as provider, over the steps they have taken to recruit and retain sufficient staff to deliver the four levels of school nurse service at community, universal, universal plus and universal partnership plus. Recommendation 8 That the St. Helens Safeguarding Children Partnership seeks assurance from North West Boroughs Healthcare NHS Foundation Trust (NWBH) as provider of school nursing services over the steps they have taken to recruit and retain sufficient staff to deliver the four levels of school nurse service at community, universal, universal plus and universal partnership plus. Strictly Confidential 10 Safeguarding roles and responsibilities 4.17 When this report was presented to the St. Helens Safeguarding Children Partnership Board, members observed that there were occasions when practitioners made assumptions that Child B’s needs were being met, when this was not the case. For example, agencies took comfort from Child B being ‘under CAMHS’ as she had been referred to that service, despite the fact that neither CAMHS nor Barnardo’s were able to provide a service to her. Members also observed that once a lead had been assigned, for example a social worker to lead on Child in Need support, there was sometimes a tendency for other partners to become less engaged in the process. In this case not all Child in Need meetings were well attended. 4.18 Members felt that it would be useful for partner agencies to be reminded of their responsibility to maintain their focus on safeguarding a child or young person and that this should not diminish simply because the child or young person had been referred to a partner agency or a partner agency had taken on a lead role. Recommendation 9 That St. Helens Safeguarding Children Partnership remind partner agencies of their responsibility to maintain a focus on safeguarding a child or young person, and that this should not diminish simply because a referral had been made to a partner agency or a partner agency had taken on a lead role. Public awareness of child exploitation 4.19 When Child B travelled to a hotel to meet an adult male in January 2018, staff became suspicious and contacted the police. This was an excellent piece of work by the hotel staff which helped to safeguard Child B and demonstrates the contribution that people in a wide variety of roles can play in preventing the sexual exploitation of children and young people. Recommendation 10 That St. Helens Safeguarding Children Partnership initiates a renewed public awareness campaign in respect of child sexual exploitation, with particular focus on key groups such as taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs. Given the likelihood of turnover of personnel in some of these sectors, it may be of value to provide guidance on how to embed messages on child sexual exploitation in staff training and development. Recommendation 11 That St. Helens Safeguarding Children Partnership acknowledges the positive intervention of the hotel chain who helped to safeguard Child B in this case by writing a letter of thanks. Strictly Confidential 11 The ‘voice’ of Child B 4.20 During the period under review Child B repeatedly sought help from agencies by visiting a local pharmacy to obtain antidepressants saying she wanted to ‘fall asleep and not wake up’, sitting down in the road so that traffic had to slow down to pass her, attending hospital ED on several occasions and twice attempting to access online counselling services from Barnardo’s after her parents did not take her to appointments with the latter service. What Child B appeared to be communicating to agencies through these behaviours was that her life was very difficult and she needed help. Despite the range of agencies in contact with her and her family she was unable to access help for her low mood and agencies did not appear to understand the significance of the help-seeking behaviours described above. Recommendation 12 When St. Helens Safeguarding Children Partnership disseminates the learning from this SCR, practitioners are encouraged to reflect on how Child B’s efforts to seek help for herself could have been responded to more effectively and what she was attempting to communicate noticed, and acted upon. References: (1) Retrieved from https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/filetransfer/2019AnonymousKatieOverview.pdf?filename=AA58F75CEDE68892A73FB681FE246B8371684F102152F0AA780A14959D3BCE5767137B3B2A935011CBAEC3068664FF681AA6D2524E357BAB96C006752CCD756759AD77BD1E389823A55CFAAE74B2EE64F46C611AD1724BE1AC50776135EAAAAFFECACF7BE0247BFC24B132894BF737ED6D2EE77EC0A82BFD51F9CB13BB656A5AEEB274B0D202E7F27F792337D2997A5F7B4930A36B46ED&DataSetName=LIVEDATA (2) Retrieved from https://learning.nspcc.org.uk/media/1334/learning-from-case-reviews_disguised-compliance.pdf (3) Retrieved from https://files.ofsted.gov.uk/v1/file/50010873 (4) Ibid (5) Retrieved from https://sthelenssafeguarding.org.uk/assets/1/neglect_strategyfinal.pdf Glossary Child and Adolescent Mental Health Services (CAMHS) Tiers: Strictly Confidential 12 Tier 1 provide early intervention and prevention services and are provided through schools and children’s centres; health visitors; school nurses; GPs; helplines; and websites. Tier 2 provides early help and targeted services. In St. Helens, these services are provided by Barnardo’s. Tier 3 provides specialist CAMHS, including eating disorder services. Tier 4 means specialised day and inpatient units, where people with more severe mental health problems can be assessed and treated. (CAMHS are moving from the Tiers approach to the THRIVE framework which is an integrated, person centred, and needs led approach to delivering mental health services for children, young people and their families. It conceptualises need in five categories; Thriving, Getting Advice and Signposting, Getting Help, Getting More Help and Getting Risk Support). A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Child and Family Assessment The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability. The Early Help Assessment Tool (EHAT) is a process for gathering and recording information about a child in respect of whom practitioners have concerns in which the needs of the child and how those needs can be met are identified. The term Early Help describes the process of taking action early and as soon as possible to tackle problems and issues emerging for children, young people and their families. Effective help may be needed for at any point in a child or young person's life. Section 47 Enquiry is required when children’s social care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. |
NC52449 | Death of a girl in 2021. Ellie's brother, a young adult, was subsequently found guilty of manslaughter. Learning themes include: assessment of children and young people as young carers; procedures to address domestic abuse in families where the child is a perpetrator of abuse; how capacity to parent a child is assessed when mental ill health has been identified in a parent; how the impact of parental mental ill health on a child is assessed; recognition and response to vulnerability in an adult who has parenting capacity; and availability of help and support for a person who has a diagnosis of autism. Recommendations include: adult and children's multi-agency services address transitional care between adult and children's services; children's social care provide evidence of robust procedures when closings cases, ensuring there is clear identification of the services continuing to support the child and family; social work assessments should include an effective consideration of history and parenting capacity that informs thorough analysis of risk; commissioners provide assurance on improving waiting lists for neurodevelopmental pathways timescales, so that children do no wait too long for support and diagnosis; review the availability of services and support for families who are waiting for an autism spectrum disorder (ASD) diagnosis and post diagnostic support; and the safeguarding children partnership seeks assurance on the effectiveness of interventions available for children with complex and challenging behaviours.
| Title: Local children’s safeguarding practice review: Ellie. LSCB: Tameside Safeguarding Children Partnership Author: Tameside Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. P a g e 1 | 17 Local Children’s Safeguarding Practice Review Child Name: Ellie Date of Report 12 October 2022 Date of referral to Panel 03/08/2021 Agency District Superintendent Police Assistant Director Children’s Services Youth Justice Service Operations Manager Head of Service, Early Help, Early Years and Neighbourhoods Specialist Nurse Advisor Hospital Named Nurse Safeguarding Children Head of Child Protection and Children in Need Acting Head of Service Childrens Designated Nurse Safeguarding CCG Named Nurse Safeguarding Children ( Mental Health) Access Manager Education Practice Improvement Manager Children’s Detective Inspector Police Administrator 1. Background Ellie died whilst on holiday. Her brother, Tom, a young adult, has been found guilty of manslaughter. Ellie and her family were known to various agencies since 2008. Concern related to parental mental health and the impact of this on the children. The family have experienced periods of difficulties for a majority of both children’s lives with ongoing and extensive service involvement throughout. Services with involvement include: Children’s social care (CSC) ; Young Carers; Health visiting; Early help services; Youth Offending services; GP services; Hospital services; Healthy Young Minds ; Forensic Adolescent Mental Health services; Police; Education (Special Education Need) ; MST; Education Psychology; SALT (Speech & language therapy); BLIS ( behaviour, learning & inclusion service); Consultant paediatrician; CLASS (communication, language & autistic spectrum support); Community mental health team. P a g e 2 | 17 Between 2009 and 2013, agencies recorded and shared concerns with CSC in respect of Tom’s escalating violent and aggressive behaviours. The outcome of contacts was no further action form CSC. An incident was referred to CSC in 2012 reporting that Tom had assaulted a member of staff at school and that Tom had become increasingly intimidating and aggressive at home, the target being his mother. At this time, the family were receiving support from the Young Carers Team. The outcome of the contact was for a CAF to be completed with School and Young Carers to lead. Tom had been presented at the Resolution Crime and Disorder Panel in response to the physical assault of his teacher and ongoing counselling was in place. In 2014 an assessment was completed by CSC in relation to Tom’s escalating behaviours that culminated in a period of Child in Need (CIN) support with the family. The CIN plan escalated to Child Protection Case Conference in April 2015 following an incident whereby Ellie was stabbed by Tom with scissors it was a Multi-Agency Decision that the children should be subject to Child Protection Plan (CP). During the course of Child Protection planning professionals and parents considered the family living arrangements and how they could be safely managed to reduce their assessed risk of harm to both Ellie and her mum. Practitioners did not have a shared assessment of risk of harm which Tom posed to his family. His family have expressed that Tom had a positive relationship with his sister and his mother and the violence was part of his overall presentation of autism. Mum made a decision to move out of the family home with Ellie, so that she and Ellie could live separately to Tom and Dad. This family separation occurred during 2017, and was identified by agencies involved as reducing the risk of future harm and was deemed effective at doing so. The case was subsequently stepped down from CP to CIN on 17th Oct 2017 and the case remained open to CSC until case closure in March 2018. Following the case closure there were no restrictions in place on for the family to work with or adhere to. During the childhood and early adult life of Tom he had ongoing assessment for autism, A diagnosis of this condition was made when Tom was 17 years old. Although he was signposted to other services who may have been able to offer help and support to Tom, the uptake of these was minimal. His family say that this was because Tom had difficulty with reading and writing and did not always understand how such services may have helped to support him. 2. The child Ellie has grown up in a family home where violence and aggressive behaviours have been present and where all family members have been physically harmed by Tom on many occasions. Both parents have suffered from poor mental health. Mother of Ellie pointed out that her low mood came after series of events in her life including bereavement and ill physical health. Mother of Ellie pointed out that she believed that professionals too often focused on violence within the home through a lens of domestic abuse rather than addressing violence as a response by Tom to frustration and anger, which were part of his autism. She also believed that Ellie and Tom enjoyed a positive sibling relationship and did not feel that any violent outbursts from Tom were directed at his sister. P a g e 3 | 17 It was confirmed by Midwifery services that Mum was treated for depression and prescribed medication whilst pregnant with Ellie. Ellie was delivered as a healthy baby and the Health Visitor worked intensively with mother due to mental health concerns. When Ellie was 2 and a half years old Mum was sectioned under the Mental Health Act in 2008 (Section 2 assessment & Section 3 treatment) and remained involved with CMHT (Community Mental Health Team) until 2015. Mum had episodes of mental health inpatient stays leaving both Ellie and Tom in the care of their father. Assessments carried out at the time identified Dad, had mental health and past alcohol issues, and there was evidence that this has impacted on his ability to meet his children’s emotional needs. The family had limited support from extended family and friends with little offer for support in caring for the children. Home conditions were recorded as being of concern at times. In addition to mental health needs, Mum has a chronic illness and has significant mobility difficulties requiring the use of crutches and a wheel chair. Ellie was identified as a young carer. Ellie was referred to Young Carers to receive support in groups and have time away from responsibilities at home. Ellie attended group sessions on a regular basis until she went to high school. Ellie engaged in art activities and attended holiday activities but was always quiet and withdrawn. Her parents said that one reason for her attending these groups was to build her confidence. Ellie had one to one work completed with her around self-confidence, Ellie would not talk about her situation or feelings but was happy to draw these. School reported an improvement in her confidence after this work. Once Ellie attended high school and started to attend after school clubs, she chose to attend these rather than Young carers group. Her parents cite the reason for non-attendance at the Young Carers meetings was because the transport did not arrive on an occasion and this made her anxious. Ellie had additional support with numeracy and literacy. Ellie had significant involvement with health services from the age of 7 years when she was referred for support in relation to low self-esteem and lack of confidence. A brief intervention was made. Ellie developed pains in heels and feet and was referred to Podiatry, physiotherapy and Orthopaedics. Ellie was assessed as having hyper-pronation of her foot and an infected in growing toe nail. Ellie was overweight in the latter part of her life. Her parents felt that she was very active and the family home had a number of photographs of Ellie undertaking activities. There was good compliance with health treatment for Ellie is documented. Ellie had 9 A&E attendances, 3 being recorded as injuries but there were no safeguarding concerns evident, all attendances were appropriate and evidenced that parents met reactive health care. There were no suspicious injuries and one attendance led on to foot surgery related to ongoing podiatry issues. Referral to paediatrics for recurring headaches was investigated, thought to be tension headaches, and no treatment required. Ellie had various health issues relating to eyes, ears and feet, which she had relevant treatment for. Concerns about Tom’s problematic and aggressive behaviour started to emerge in 2009. Tom attended specialist education provision after he was permanently excluded in February 2011, when he was in Year 4. This was due to his persistent aggressive behaviour towards other children and adults. Tameside Youth Justice Service were involved with Tom and the family between 2013 and 2017 with Tom being subject to both voluntary and Court orders (5 separate interventions in total). Work completed throughout interventions focussed on Domestic Violence, emotional regulation, carrying knives and weapons and support for his mental Health and Speech and language needs. Tom’s parents wished to point out that Tom did not normally carry knives and weapons but rather this was part of the overall P a g e 4 | 17 training programme he attended. There is evidence throughout of partnership working which in the main was positive. Many sessions were carried out with the support of school often physically carried out at school. Tom was diagnosed with Autism when he was 15 2 years from the point of referral for assessment. Tom was also registered as a young carer. Throughout CIN and CP, planning professionals remained committed to attending meetings and overall appropriate support and services were identified to work with the family. Parents attended and engaged with parenting support packages, but it is evident that they were not always willing to fully commit to changes proposed, such as consistently contacting the police when Tom has been violent. The family of Ellie felt that it was inappropriate to contact the Police after violent events had taken place in the home. They believed that to take this action would have been to escalate interfamilial conflict further and that the focus which they would have liked services to have provided was guidance around interventions to help Tom take measures in anger management linked to his autism. When Children’s services involvement ended with the family Ellie was residing with her mother whilst Tom resided with his father. Records indicate that mother and Ellie continued to attend appointments with Tom rather than father and so perceived risks to Ellie remained despite parents separating with the children. No further referrals were made to CSC from closure in March 2018 to the death of Ellie in 2021. The family expressed that although they recognise the problems within their family, they also wished to inform the Panel that they believed that their children had some positive experience of their childhoods including regular holidays and a family who cared and loved them. 3. Immediate Findings Panel members felt that Ellie was not the focus of services throughout the family’s various involvements with a large number of agencies. There appears to have been lack of exploration around Ellie’s daily lived experience during the initial periods of contacts made prior to CSC involvement, focus was on Tom and his mother’s vulnerability. Physical harm to Ellie does not appear to have been fully risk assessed. There were missed opportunities from professionals in response to obesity and self-esteem as a safeguarding concern. The Panel felt that the multi-agency team did not fully understand the underlying root causes and factors in this family. The family have since confirmed that they also believed that there was a lack of understanding of the needs of the family and would have liked more interventions to have been available to address the underlying causes of Tom’s violent behaviours. At the time when professionals were initially raising contacts and expressing concerns to CSC in the period 2009 - 2013, the response from CSC was that there were already sufficient services involved with the family. The children’s daily lived experiences appear to not have been fully considered and it is evident from records that there have been occasions when the children should have been seen. Ellie had self-esteem and confidence issues at an early age and found it hard to talk about her home life. Some work was undertaken by the young carer’s service and school nursing service but this does not appear to have been effective in the long term. There is evidence of non-verbal clues, there is some evidence of improvement in mood when initially separated from her brother and father but records detail that she misses them and her P a g e 5 | 17 behaviour becomes aggressive towards mum and children at school but this does not appear to have been assessed or appreciated at the time of the case closure. When the case was closed in 2018 agencies recognised that the risk of abuse remained and the panel felt the risks posed by Tom were underestimated. There is evidence that parents rationalised and minimised the abuse experienced and assessments did not fully explore the vulnerabilities of the family nor appreciate the lived experience of Ellie. Panel members questioned the processes for tracking meaningful change in a whole family. Did we achieve meaningful change or in fact only a change in circumstances? Did parents have the capacity for change? There was little consideration of parental mental health in assessments and the impact of this on parents’ ability to meet both their children’s needs. There was evidence that Tom’s behaviour continued to cause concern recorded in various multi-disciplinary team records in the period 2018-2021. In sept 2018 Tom was seen by mental health services, he wasn’t taking his medication and was identified as needing CSC input however there is no evidence this was actioned. The family emphasised that Tom stopped medication on the advice of his GP as he was experiencing side effects which were impacting on his daily living. A further opportunity was missed in October 2019 when the Mental Health Liaison Team recorded they would refer Tom to adult and children services. Again there is no evidence that this was actioned. In October 2019 Greater Manchester Police had records of response to an allegation of sexual assault towards Tom from a peer at the education provision. The GP recorded in Feb 2020 that Mum reported that Tom was ‘still hitting his father about 5-6 times per day. Tom denied this. There was no evidence that any of these concerns had been shared with CSC for further assessment /referral, the panel agreed that concerns should have been raised to secure multi-agency involvement. The Panel discussed the effectiveness of the ASD pathways & process and the interface with CAMHS. It was apparent that there was considerable delay in identifying the need for an autism assessment and then subsequently a diagnosis for Tom, which may have affected access to appropriate support and provision for the family. The panel also considered the impact of this on the parents and professionals ability to meet Tom’s social communication needs when they weren’t fully understood. Practitioners spoke of the delay in reaching diagnosis and subsequent difficulties in offering a response to support people and their families, where diagnosis has been made. Work is ongoing in the area between commissioning and provider services to ensure that there is a diverse and appropriate range of services available to support families. The mother of Ellie reported that she believed that she had noticed an improvement in services locally. Efforts were made to decriminalise Tom’s behaviour. Tom had been presented at the Resolution Crime and Disorder Panel and worked with Tameside Youth Justice Service in the period 2013 - 2017. Following an incident in 2015 Tom was arrested and a decision made to charge him with the offences after YOT advised Tom had 'exhausted all pre-sentencing diversion work'. Tom was subject to both voluntary and Court orders. He was discussed at the Mentally Vulnerable Offenders Panel (MVOP) panel. There is evidence throughout of partnership working which in the main was positive however there was evidence to be a lack of accountability and tracking of recommendations. Panel members questioned why a therapeutic placement outside of the family home was not found despite being recommended at the time. Interventions needed clearer management oversight. Complex cases would now be subject to more regular assessment and review and Tom would meet the criteria to be managed in the multi-agency Complex Case Panel (High risk process). P a g e 6 | 17 4. Analysis Tree EFFECTS: FOCAL POINT: ROOT CAUSES: Ellie lost life due to Tom assaulting her History of Domestic Abuse, trauma causes by ACEs, disability, autism and mental health issues. Tom to serve custodial sentence Community impact on Ellie’s family Parents lost daughter Ellie and impact of this on their own mental health and vulnerabilities Failure to assess the impact of poor parental mental health on parent’s ability to parent and protect their children. Risks Tom posed to Ellie and parents, Ellie has not been the focus of services. VOC expressed in behaviours lack of communication. Professional curiosity opportunities to ask those extra questions. The risk posed by Tom was not responded to at the earliest opportunity Lack of information sharing following key events in the last 3 years P a g e 7 | 17 5. What are we worried about? The Panel were concerned the case was closed too soon (following change to living circumstances 2017) and there was an over reliance on the family reporting improvement, there was complacency among agencies that Tom's behaviour had 'settled'. The panel felt it would have been prudent to see sustained change over longer period prior to closing the case. The Panel considered the quality of social work assessments. There was limited evidence that parental mental health was included in a holistic assessment of need considering broader factors that may have impacted on parenting ability and the impact that this had on the children. The family believed that the assessment focused on risk of harm from domestic violence rather than offering a service which could support family to intervene when Tom had violent outbursts. The Panel questioned overall accountability for monitoring progress and information sharing in cases where there is no CSC involvement after step down. Many services continued to see the family after statutory intervention stopped however, this appeared to be in silo and there was a lack of lead agency monitoring progress. The Panel identified a number of missed opportunities over the last 3 years that warranted a referral for further assessment and/or support, this may have supported a more joined up approach and identified escalating risk. The panel acknowledge the impact of Covid restrictions and the lack of visibility of this family during the pandemic however it is not clear what prevented professionals from sharing concerns given the extensive history of CSC involvement. There was evidence that police responded to some incidents in isolation and did not consider previous history and the impact on wider family members. Some of those incidents were not coded on police systems to indicate 'concern for child' therefore no Care Plans were raised for triage and consideration of safeguarding referral/s. Documentation and outcomes of strategy meetings was poor . The Panel considered if safeguarding was not considered due to Ellie and Mum living in separate accommodation. The Panel were concerned that children are waiting too long for ASD pathway and diagnosis and this is affecting the ability to meet needs. The SEND code of practice clearly states children should not wait for service whilst awaiting diagnosis but it appears over reliance on a diagnosis to effectively meet need. There were several referrals made to CAMHS that weren’t progressed, the panel questioned if these were these the right referrals. There is evidence that services did not understanding pathways for autism assessment and support with escalating behaviour and there was a lack of coordination of information sharing from CAMHS to wider multiagency to ensure when referrals were made key professionals are aware of waiting time and plan in interim. The panel were not clear what support and response is available for families who live with children who have social communication needs and present with aggressive behaviour, likewise what support is available for transition in to adulthood. The effectiveness of EHCP reviews post 16 were unclear. There is no evidence a review of Tom needs had been reviewed. This factor may have influenced the absence of a multi-disciplinary approach to obtaining an up to date overview of the young person’s holistic needs and the coordination required between services involved to identify the ongoing appropriateness of the current provision outlined within the EHCP. The availability of therapeutic placements for children with challenging behaviour has been identified in other local reviews, the panel are satisfied that learning has been reflected in those action plans. P a g e 8 | 17 6. What worked well? There is evidence of consistency in terms of the same professionals being involved in health and social care with the family. The children were well known and supported by their primary school. The family had a lot of support and input via a coordinated approach. The Neighbourhood Beat Officer offered consistent and multi-agency contact and support in place with good practice and partnership working. 7. Views of the Family The author of the review met with the mother of Ellie and Tom. Mum described her daughter as a very kind and quiet person. Mum said that her daughter had been a good support to her and was greatly missed. Mum described a close relationship between them. Mum said that although the family had separated to two households, they still regularly got together and spent family time together. Mum had been pleased about the proximity of the two addresses. Mum visits Tom regularly in a custodial placement. . Mum felt that mainly practitioners from services working with Tom had failed to understand how to respond to Tom’s behaviours. She described that a response of punishment of Tom was often made, expulsion from school at a young age and contacting the Police were specifically mentioned. Mum believed that Tom was perceived as a naughty child rather than one with autism who became overwhelmed in situations and needed to have adults around him who had skills to help him overcome anxiety brought on by his distress. The involvement of CAMHS was also viewed by the family in this way. Mum believed that there was a reluctance to work with Tom until his diagnosis of autism was made. Mum believed that his challenging behaviour and provision of support services to help him was not addressed by practitioners, although Mum believes that she has been able to see some learning especially from education in reviewing their response to children and young people who present with challenging behaviours. Mum believed that a change in approach of practitioners to people with autism would help to overcome some of the frustrations which they experience. Tom could barely read and write and so for practitioners to sign post him to services rather than making referral on his behalf was not effective in helping him to access services. Involvement from services within the family appeared to focus on the level of physical abuse perpetrated by Tom. Services addressed managing the risk to the family through the accepted routes of multi- agency policy and procedure to manage domestic abuse rather than regarding Tom’s behaviour as his inability to control emotions and hitting out as part of his autism diagnosis. The model of perpetrator/victim as in adult relationships was used to address the violence within the home which Mum believed did not improve the situation in which the family were living. Because of the focus of practitioners on domestic abuse within the home the P a g e 9 | 17 opportunity to help Tom to learn techniques to cope with his challenging behaviours was missed. Mum felt that the family’s decision to separate was because she was afraid that she would lose her children. Mum believed that she did set out to minimise the violent incidents but believed that Tom needed to be helped. She believed that if the children had been removed from her it would have meant that Tom would have felt abandoned, which was one of his fears. This would have made the situation worse. After the separation of the family into two households a decision was made to close the case for the family. Mum believed that this action meant that any available help and support was no longer offered. The family were still in contact with each other so the risk of harm did not go away. Mum also believed that at this time there are no services in Tameside to offer to those with a diagnosis of autism. Diagnosis is now being made but there does not appear to be any support available for individuals. Mum is supportive of developments in Tameside to address availability of therapeutic services for people with autism. P a g e 10 | 17 8. Further Learning - Practitioner Event Key lines of enquiry were identified in the rapid review and further discussion and consideration was made of these at a Practitioner Event. These were as follows: • How are children and young people assessed as suitable to be a young carer? • Procedures to address domestic abuse in families where the child is a perpetrator of abuse • How is capacity to parent a child assessed when mental ill health has been identified in the parent? • How is the impact of parental mental ill health on the child assessed? • Recognition and response to vulnerability in the adult who has parenting capacity • Availability of help and support for a person who has a diagnosis of autism Assessment of children and young people as young carers Children as carers of an adult, very often a parent, is recognised within the UK. The Children’s Society estimate that there are 800, 000 children in the UK who undertake this role and of those in the region of 30% of children report that they are unable to fully attend education or meet friends away from the home environment. Whilst other potential negative outcomes impacts of caring for an adult by a child has been well documented, the practice of children caring for their parents is accepted as necessary and every child has a right to carer’s assessment. Support is offered to children to support them in such caring roles. This is balanced with provision of interventions to promote childhood activities so that children and young people are able to have positive experiences. A local authority is required to carry out assessment of a young carer’s needs if that child is deemed to have support needs. A young person or their parent may also request a carer’s assessments from the local authority. “Such an assessment must consider whether it is appropriate or excessive for the young carer to provide care for the person in question, in light of the young carer’s needs and wishes. “The Young Carers’ (Needs Assessment) Regulations 2015/16 require local authorities to look at the needs of the whole family when carrying out a young carer’s needs assessment. Young carers’ assessments can be combined with assessments of adults in the household, with the agreement of the young carer and adults concerned.” WTTSC 2018 Both Ellie and her brother had been assessed by practitioners for being young carers. The children were supporting their mother due to her physical difficulties. Tom was assessed as his suitability to be a young carer at the age of 9 years old. The assessment identified that Tom was helping to bath his mother, to unload and load the washing machine and to generally “fetch and carry”. Concerns had been raised about Tom’s behaviour at school and these were known by the young carer’s team at that time. Whether the demonstration of such behaviours were potentially reflective of any distress which Tom was feeling about the expectations of his life were not linked. P a g e 11 | 17 Ellie was referred to Young Carers by her mother when she was aged 8 years. Information shared at the Practitioner event described Ellie as making breakfast and sandwiches, helping her mother get in and out of the shower and if mother was upset she would comfort her. The assessments of both children deemed them to have significant but not excessive caring responsibilities. The Young Carers team had been told by Ellie that she wished to carry out the care of her mother. Whilst the concerns about Tom’s behaviour was known by the team, the need to question how children who were already recognised as being in need of support and potential safeguards were able to carry out a caring function for an adult who had a key role in caring for them. The impact which the residence of an adult family member living within the household may have on assessing whether it was appropriate for children to carry out roles as young carers is not always considered. There was no evidence within the assessments of either child that the father’s role in caring for his wife and family had been assessed. There was an assessment made that he was at work at that time but the service identifies that the presence of other adults who may be more suitably able to carry out the caring role within the family was not made. The children’s father was not present at the time that either assessment of the children was carried out. It is unknown what role he played in caring for his wife within the home environment or how he supported his children in undertaking such support. This point highlights concerns which have been expressed in other reports such as The Myth of Invisible Men (National Panel 2021) In addition the need for the appropriateness of referring the adult to other local services such as Adult Social Care to access care and support to meet their need was not considered. This point is considered in more detail later. Procedures to address domestic abuse in families where the child is a perpetrator of abuse A significant amount of work has been undertaken by agencies to address responses and support for domestic abuse nationally, regionally and locally. To date much work is to support victims of domestic abuse, although recently there has been increasing drive to work with perpetrators, alongside victims. Support offered to domestic abuse victims who are adults still carries some gender bias with perceptions of female adults being victims and adult males being perpetrators. Whilst there is a wide range of literature which supports this view and statistical evidence would demonstrate an increased likelihood of the female victim, male perpetrator model, this sometimes impacts on the amount of support perceived to be necessary to support male victims or female perpetrators. Recent work within Tameside is increasingly addressing the needs of perpetrators. It remains focused, however on adult males as perpetrators. Tameside does commission child Independent Domestic violence Advocates (IDVA) but the role is focused on children as victims and witnesses of domestic abuse. In addition legislation and guidance tends to focus on domestic abuse from an adult perspective. Whilst the Domestic Abuse Act 2021 has improved the need to support children as victims in their own right from witnessing such violence there is little literature which identifies the prevalence of children as perpetrators of domestic violence. P a g e 12 | 17 Tom had been identified as having increasingly violent behaviour as a child from a very early age. This was initially identified during his primary school education and had led to his expulsion from the school when he was 8 years old. MARAC referral had been undertaken in 2014, when Tom was 14 years old after a violent attack against his mother had occurred. Practitioners described that Tom’s mother often “played down” the seriousness of the violence and believed that she did so as she wished to prevent her son from being taken into care. They believed that she under reported incidents because of this concern. Although practitioners suspected that Ellie was experiencing physical violence from her brother, on one occasion she had sustained a significant injury from him and practitioners described how Ellie had eluded to this in some conversations, there was no further action taken. There is no evidence that Ellie ever made direct disclosure to practitioners. Given that practitioners were seeing injuries to both mother and Ellie it is unclear why further action was not instigated without the need for direct disclosure. Mother of Ellie has denied that there was a risk of harm to Ellie from her sibling. Practitioners did not appear to assess the violence which the father of Tom and Ellie was experiencing. When the family separated and Tom lived with his father no action was taken despite Tom’s father reporting that it was “normal” for his son to be violent towards him about 5-6 times per day. After separation of the family Tom resided permanently with his father. The focus of children social care assessments had been on safety of the family due to Tom’s increasingly violent behaviour against his family. Other agencies, such as forensic psychology identified violence through their assessments. There appears to have been little work undertaken directly with Tom to establish any underlying reason for such behaviour or with Ellie to assess the impact which living in these circumstances was having. Some punitive measures were implemented early within the education settings without reviewing WHY such a young child was demonstrating such behaviours. There appeared to have been little intervention implemented to work with the family or Tom with the potential aim of reducing physical violence. An agreement for a therapeutic placement for Tom did not occur and practitioners expressed that this was a missed opportunity to potentially deescalate some of Tom’s violent behaviours. The family made decision to separate so that the risk of harm to Ellie and her mother could be reduced. Children’s Social Care stepped down the level of intervention after this event with the belief that the risk of harm had been reduced and then closed the case. There is some evidence, however that the family, although being separated by address still continued to be in close contact with each other. They continued to function as a family unit so the risk of harm remained. Whilst current local policy and national literature indicates that separation of perpetrators from victims does not reduce risk and indeed in some cases increases risk of harm to the victim, this is not always reflected in case management of domestic abuse by agencies. The risk of harm to the family from a child being the perpetrator of domestic abuse was assessed using current procedures and guidance based upon adults being perpetrators and victims. It was difficult to find national or local guidance for practitioners as to steps to be taken when a child has been identified as a perpetrator of domestic abuse. There is evidence that practitioners did try to address through the existing procedures for responding to adult abuse. There is a need, however, for review of both the Tameside domestic abuse strategy P a g e 13 | 17 and procedures to include how to respond to children who are perpetrators of domestic abuse. At this time the Panel has been informed that such work is underway. How is capacity of the adult to parent a child assessed when mental ill health has been identified in the parent? Both parents of Ellie had suffered from significant mental ill health both prior to the time that they had children and for a significant time in the children’s early lives. There is some evidence that the mother of Ellie had been so ill and this warranted inpatient mental health treatment. Some elements of mental ill health and chronic physical ill health of the adults in the household were prevalent throughout Ellie’s life. There is little evidence either from the rapid review undertaken or from the practitioner event that there is any formal assessment made, or that practitioners from any agency, except children’s social care, question how parental ill health impacts on an adult’s ability to parent their child or the impact which such ill health may have on the child. This appears to be assessed even less for a parent with chronic physical ill health. The Practitioner event highlighted some concerns which practitioners believed on reflection to be significant. For example behaviours such as parents not accompanying Tom to his health appointments were a cause for concern. This was shared with Children’s Social Care but there does not appear to have been any professional curiosity to ascertain why attendance was either not seen to be necessary or that there was some inability to attend. Practitioners also discussed the difficulty in making assessment of parenting capacity and the impact on a child. Health professionals expressed that the number of people with mental health difficulties who presented to them was very common, with varying features of behaviours and levels of ill health. The impact with which chronic mental or physical health is having on the life of the individual and/or others for whom they care should be routine enquiry. It is very difficult to understand how the most relevant intervention to support the individual can be chosen. In addition there was a perceived to be a high rate of non-engagement in assessments by parents for whom mental ill health has been identified. This did not appear to necessarily increase professional concerns about the impact of non- engagement on either their ability to provide suitable health pathways to support the child or the adult’s ability to care for them. Sharing of information about a parent with mental or physical chronic ill health was also identified. Education services illustrated that they have difficulties in their ability to respond to a child presenting with challenging behaviours which may be due to parental ill health. They believed that if this information was known then there would be opportunity to use alternative responses to support the family. Recognition and response to vulnerability in the adult who has parenting capacity The Practitioner event identified that on reflection both adults within the family ought to have been considered as vulnerable people who were had identified care and support needs (Care Act 2014). Mother of Ellie also has a degenerative physical health condition and there is some evidence that she was reliant on support from her children as young carers. Young carer’s assessments do not include assessment as to whether referral for support to external agencies are preferable to children carrying out care of their parent. In addition when assessment was made of Ellie as a carer her mother had felt that the support of the children to undertake identified tasks helped her to cope without the need for external help. P a g e 14 | 17 There is evidence that after an assessment for made by Children’s Social Care for the children in the household that a referral was made to adult social care. This was to gain some support for equipment to assist with mobility issues around the home. Discussion occurred as to whether it was routine practice for separate referral to be made to other agencies to address needs of the adult. Practitioners discussed that some referrals are made to other services but usually for the purpose of supporting a parent to improve their ability to function as a parent. For some period in which the family were receiving support from agencies as “child in need” and then later being subject to child protection plan, there does not appear to have been any referral for the adults for support in their own right. Availability of help and support for a person who has a diagnosis of autism At the rapid review the panel discussed the effectiveness of the ASD pathways & process and the interface with CAMHS. It was apparent that there was considerable delay in identifying the need for an autism assessment and then subsequently a diagnosis for Tom, which may have affected access to appropriate support and provision for the family. The panel also considered the impact of this on the parents’ and professionals’ ability to meet Tom’s social communication needs when they weren’t fully understood. At the practitioner event practitioners identified that that there is a two year period to make full assessment to formally diagnose autism. Once diagnosis is made there appears to be little provision of care and support in Tameside for individuals to help them overcome difficulties in their behaviour caused by autism. Practitioners spoke especially in service provision available for young people who are in the 16 to 18 age group. Diagnosis is made but interventions are not provided unless there are other identified mental health needs. Although CAMHS continued to “keep his case open” due to the autism diagnosis there is currently no available service in Tameside until the person reaches their 18th birthday. In addition there is no clear transition arrangements in place for young people with autism. Tom was closed to Children’s Social Care at the age of 16 years and although some health work from CAMHS continued at that time, there was a significant risk that he may have been lost to receiving the support available once he reached 18 years of age. Some services within other agencies did offer some interventions to Tom. These were education and vocational services. A trial of medication was also tried to assess whether this measure may reduce his level of aggression. This was unsuccessful and there was some difficulty in Tom engaging with these services. Practitioners expressed their frustration that a diagnosis of autism for a child currently means that the child will need to continue to seek support required through availability of traditional services. There is a need to identify a service which would be able to respond to specific needs of children with an autism diagnosis rather than trying to make traditional services fit. Practitioners also discussed that there is a clear gap in service in terms of support for autism within that age range, i.e. children’s services stopping at 16 years old and adult P a g e 15 | 17 services starting at 18 years old. The exception to this was if there are significant concerns in relation to learning disabilities identified. Tom was not considered to have a learning disability. The learning from the practitioner event with respect to autism has been captured in the recent Ofsted SEND inspection for Tameside and work is being undertaken to address concerns raised. (2021) P a g e 16 | 17 8. Recommmendations An all age task and finish group should be jointly initiated between adult and children’s multi agency services to address transitional care between adult and children’s services. Children’s Social Care should provide evidence of robust procedures when closings cases, ensuring clear step processes are followed and that there is clear identification of the services continuing to support the child and family. This should be recorded in a closure case summary. Closure letters should be sent to parents and all agencies involved with the family as to facilitate ongoing multi-agency support outlining the agreed step down plan. CSC should provide evidence that demonstrates social work assessments include an effective consideration of history and parenting capacity that informs thorough analysis of risk and ensures that assessments are updated regularly to reflect children’s changing needs and circumstances. Commissioners should provide assurance on plans to improve waiting lists for neuro developmental pathways timescale and update so that children do no wait too long for support and diagnosis. A working group should be established to review the availability of services & support available for families who are waiting an ASD diagnosis and post diagnostic support. The group should consider if pathways are clear for professionals and what supporting guidance is available to children and their families in understanding of ASD and social communication and interventions that help. Tameside Safeguarding Children Partnership to seek assurance on the effectiveness of interventions available for children with complex and challenging behaviours. The LA to provide assurance that ECHP reviews are carried out as a minimum every 12 months particularly for those in post 16 provision. There should be robust mechanisms in place to identify child & YP who have previous safeguarding concerns GMP to provide assurance there are robust systems for recording, identifying and referring child protection concerns. PCFT to provide assurance that children with complex needs who do not engage, are discussed with the MDT considering an impact assessment prior to discharging them. P a g e 17 | 17 . Further actions were identified from the Practitioner event these are as follows: Assessments of children as young carers needs to capture the child’s age, own development needs and their right to be parented. The potential of other adults living within the same household as a vulnerable adult needs to be assessed prior to the assessment of children as carers. The Tameside Domestic Abuse Strategy needs to include and identify pathways to recognise and respond to domestic abuse when children are perpetrators Multi agency routine enquiry should be made by practitioners about an individual’s capacity to parent with adults for whom mental and physical ill health has been identified. This is to ensure relevant support can be offered to enhance parenting capacity and to minimise risk of harm to the child. 1. |
NC52220 | Death of a 4-month-old infant in May 2018 whilst in the care of a family member overnight. Police initiated an investigation but no charges were made. Child A1 lived with her parents; Mother and Father were known to Early Help and Health Services in respect of antenatal and postnatal care. At the time of her death, Child A1 was being cared for by her paternal aunt, who placed her on the sofa and then fell asleep after consuming alcohol. When she woke up she found Child A1 lifeless. An ambulance was called, and Child A1 was confirmed dead at hospital. Paternal Aunt had two children; both were made subject to Child Protection Plans in March 2018 under the category of emotional and physical abuse. There were also concerns about alcohol misuse. Ethnicity or nationality not stated. Identifies an area of learning for Children's Services as to the extent to which the Child Protection Plan in respect of Paternal Aunt's household included any risk to other children. Recommendations: ensure that Special Circumstances Forms generated by midwifery services are shared by key agencies, such as general practitioners (GPs) and health visitors; ensure that information sharing and discussion take place routinely between midwifery and GP practices where issues are identified, and concerns are raised in order to understand the holistic family circumstances; where parental alcohol and substance misuse are risk factors, practitioners are able to consider any other caring responsibilities for children including babysitting arrangements.
| Title: Serious case review: Child A1. LSCB: Rochdale Borough Safeguarding Children Partnership Author: Rochdale Borough Safeguarding Children Partnership Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Rochdale Borough Safeguarding Children Board (now known as Rochdale Borough Safeguarding Children Partnership) Serious Case Review Child A1 Identifier Who A1 Child MA1 Mother FA1 Father PAA1 Paternal Aunt C1A1 Cousin C2A1 Cousin PGMA1 Paternal Grandmother PGFA1 Paternal Grandfather 2 1. Circumstances Leading up to the Serious Case Review 1.1 Child A1 was the first born child to MA1 and FA1. She was born in January 2018. Neither parent has any other children from previous relationships. 1.2 Child A1 was known to Early Help and Health Services in respect of ante and post- natal care. 1.3 Rochdale Children’s Social Care was not involved at any time throughout Child A1’s life. 1.4 Child A1 lived with her parents at the family home in Rochdale however at the time of her death she was being cared for by her paternal aunt (PAA1) overnight. Paternal grandfather (PGFA1) was in the family home at the time but was not believed to be part of the caring arrangements for A1. This was the first time that Child A1 had been cared for overnight by anyone other than by her parents. 1.5 PAA1 has two children, C1A1 and C2A1 who were known to Children’s Social Care in another area (LA1) due to concerns relating to Domestic Abuse between the parents, which were believed to be fuelled by alcohol. PAA1 was also believed to misuse alcohol. Children’s Services in LA1 became involved in February 2017 following a Domestic Abuse incident which resulted in the children becoming subject to a Child in Need Plan. This plan ended in August 2017. A further incident occurred in December 2017 which was reported by Greater Manchester Police (GMP) to Children’s Social Care in LA1. Further information was collated and a Child and Family Assessment undertaken which recommended a Strategy Meeting was convened. The meeting concluded that a S47 enquiry should be initiated and the outcome of this was to progress to an Initial Child Protection Conference. C1A1 and C2A1 were made subject to Child Protection Plans on 14th March 2018 under the category of emotional and physical abuse. Information shared within the Conference indicated that PAA1 had attended the nursery on 4 occasions where she had smelled of alcohol and her partner had stated that PAA1 drank a bottle of wine most nights. PAA1 denied that she used alcohol frequently or that she had a problem with alcohol. 1.6 On 27th May 2018 MA1 and FA1 attended a concert with PGMA1 and left A1 with PAA1 and PGFA1 overnight at the Paternal Grandparent’s home. C1A1 and C2A1 were also present. 3 1.7 A1 had been unsettled and wouldn’t take her bottle and PAA1 administered Nurofen to help her settle. PAA1 stated she kept taking A1 in and out of the travel cot provided by the parents but later settled A1 on the side / corner of the couch. 1.8 PAA1 drank wine from approximately 17.45 hours and fell asleep around 22.30 hours. 1.9 PAA1 woke sometime after 1am and found A1 cold and blue. She contacted the Ambulance who arrived at 02.07 hours but had tried to administer breaths to A until the ambulance arrived. The ambulance crew confirmed that A1 was in the arms of PAA1 and was cold, blue and stiff. 1.10 A1 was taken to hospital and time of death was confirmed at 02.56 hours. 1.11 MA1 and FA1 attended the hospital with other family members. 1.12 GMP initiated an investigation with regard to A1’s death, no charges have been authorised and no further police action will be taken. 2. Methodology and Key Lines of Enquiry 2.1 A Serious Case Review (SCR) Screening Referral Form was received from GMP on 05.06.2018 in respect of A1. 2.2 The screening panel was held in June 2018 and did not recommend to the Independent Chair of the RBSCB that a SCR should be convened. 2.3 The Independent Chair of the RBSCB agreed with the recommendation of the Panel and was of the view that the case did not meet criteria for a Serious Case Review as none of the records suggested that there were concerns regarding agencies working together. There was no agency involvement with the family in Rochdale other than Universal Services. It was considered that although PAA1 and her children were known to Children’s Social Care in LA1 for issues regarding alcohol abuse and domestic abuse, this was insufficient to initiate learning for Rochdale. It was acknowledged that it was not clear whether LA1 considered that it was inappropriate for PAA1 to babysit for A1. 4 2.4 A copy of the Screening Panel Minutes was shared with the Safeguarding Children Board in LA1 at the request of the RBSCB Independent Chair for consideration and any action it was felt appropriate due to LA1’s Children’s Social Care involvement. 2.5 The National Child Safeguarding Practice Review Panel (CSPRP) were notified of the above decision and considered A1 at their meeting on in August 2018. The CSPRP advised that in their opinion criteria for a SCR had been met as abuse or neglect was known or suspected and a child had died. 2.6 The response from CSPRP was also shared with the Safeguarding Children Board in LA1 and RBSCB Independent Chair corresponded with LA1’s Safeguarding Board Independent Chair due to the circumstances of the child’s death, i.e. in the care of PAA1. It was felt that if there were lessons to be learned from this child’s death, it would be in respect of services supporting the family in LA1 as only Universal Services were involved in Rochdale. RBSCB Independent Chair requested that this correspondence be treated as a referral for consideration of a SCR by LA1. 2.7 The Independent Chair of LA1’s Safeguarding Children Board responded in October 2018 to advise that a thorough review of the case had been undertaken by the Head of Quality Assurance for Safeguarding in LA1’s Children’s Social Care. The review noted that the concerns for C1A1 and C2A1 were not such that it was felt they should have been removed from their mother’s care. Concerns related to domestic abuse incidents where both parents were believed to be victim and perpetrator and the misuse of alcohol by both parents. Alcohol was believed to be a trigger for the domestic abuse incidents. 2.8 The review identified an area of learning for LA1’s Children’s Services as to the extent to which the Child Protection Plan in respect of PAA1’s household included any risk to other children. The Chair of the Initial Child Protection Conference directly asked both parents whether they were involved in the care of any other children; the parents advised they were not. It was noted that this was routine practice however this had not been recorded in the conference minutes. 2.9 It was the view of the LA1’s SCR Sub Group that any potential learning had been identified and addressed by the Service. It was also noted that usual practice would be for the Safeguarding Children Board or Partnership of the area in which the child resided to carry out a SCR if deemed necessary and that LA1 did not intend to 5 undertake the SCR in relation to A1. The Independent Chair did however support LA1’s participation in the SCR undertaken by Rochdale if required. 2.10 As a result of the above correspondence with both CSPRP and LA1’s Safeguarding Children’s Board it was agreed that Rochdale would undertake the SCR in respect of A1. 2.11 Requests for information were circulated to all agencies identified as being involved with A1 and the family, including LA1’s Children’s Social Care. 2.12 The timeframe for the SCR was agreed as 1st April 2017 to 4th June 2018. This timescale covered the pregnancy and life of A1. 2.13 The first panel meeting took place in January 2019. 2.14 The Panel members were limited due to Child A1 only being known to Universal Services however LA1’s Children’s Social Care were represented to contribute to the discussion and understand the key issues for consideration. 2.15 The SCR Panel was mindful of the revised statutory guidance within Working Together to Safeguard Children 2015. The new Working Together to Safeguard Children was published in early July 2018 which was after Child A1 had died. The screening initially was undertaken under Working Together to Safeguard Children 2015 however there are certain elements of the new guidance which will be taken into consideration with regard to the transition from LSCB to Multi-Agency Safeguarding Arrangements. 2.16 The Panel considered their responsibility in respect of collecting and analysing information about Child A1’s death with a view to providing an analysis of what happened in the case and why; what needs to happen in order to reduce the risk of recurrence, which is easily understood and suitable for publication and identified any key learning. 2.17 The key lines of enquiry identified with regard to A1 are as follows: - Information sharing between agencies and across Local Authority boundaries, including whether A1’s parents were aware that PAA1’s children were subject to a Child Protection Plan, whether A1’s parents had any understanding of PAA1’s suitability to care for their child Whether agencies had any opportunity to identify potential risks to A1 in respect of family member having children subject to CPP 6 To what extent FA1 was involved ante-natally with regard to discussions about safe sleeping etc 3. Planning the Review 3.1 As stated, the first SCR Panel meeting took place in January 2019. The chronology, key events and action plans had been completed by GMP, Early Years and Children’s Centres, Pennine Care Foundation Trust (Heywood, Middleton and Rochdale), Pennine Acute Hospital Trust, Heywood, Middleton and Rochdale Clinical Commissioning Group, Hopwood Hall College, National Probation Service and the Community Rehabilitation Company. 3.2 The Panel reviewed the timeframe set and noted that some agencies had provided information to their involvement where additional information was required. outside April 17 to June 2018. The combined chronology was reviewed and some areas of clarification were raised, which were required for a full understanding and contribution to learning. It was agreed that the author would liaise further with LA1’s Children’s Social Care with regard 3.3 The SCR Panel did not feel that a practitioner event was required due to the specific circumstances surrounding A1’s death. 4. Outline of how Child A1 was known to Agencies 4.1 Child A1 was first known to Early Help and Children Centres when MA1 accessed Midwifery Services and ante-natal care (Early Pregnancy Unit) at Children’s Centre 1 in June 2017 4.2 The Midwife recorded that MA1 was approximately 7 weeks gestation and discussed ante-natal screening tests, the importance of multivitamins and Group B Streptococcus Test information provided. Records also indicate that MA1 was accompanied to this appointment but does not indicate who that was. MA1 had a further ante-natal booking in July 2017 at 12 weeks gestation at which the dating scan was arranged. It is recorded that there were no concerns identified and routine bloods were taken. 7 4.3 MA1 and FA1 accessed ante-natal care at Children’s Centre 1 in August 2017 at 17 weeks gestation. MA1 reported to be well and no concerns were identified. The Midwife discussed whooping cough vaccine, multivitamins and hypnobirthing. 4.4 Further routine ante-natal contact was made with Mother at 20 weeks gestation during which the anomaly scan was completed with no issues identified or concerns raised. 4.5 In September 2017 MA1 presented at Maternity Triage with abdominal pain at 22 weeks gestation. 4.6 MA1 was seen by her GP due to indigestion towards the end of September 2017. She was 24 weeks gestation and had been experiencing reduced foetal movements. She had previously had an ultrasound scan, which was normal. MA1 was issued with a ‘fit to fly’ letter as she was going on holiday. 4.7 MA1 attended Children’s Centre 1 in October 2017 to access ante-natal appointment at 25 weeks gestation. There were no issues identified. It is noted that the Midwife had not made routine enquiries around domestic abuse. MA1 was advised to have whooping cough and flu vaccines at 28 weeks. 4.8 MA1 and FA1 attended Children’s Centre 1 in November 2017 to access ante-natal appointment at 28 weeks gestation. There were no issues identified. The Midwife referred MA1 to Health Visiting Services to confirm pregnancy progressing and that MA1 would require Health Visitor ante-natal contact. This is routine practice to notify Health Visiting service across the Trust in order for Health visiting teams to visit women in the antenatal period and vaccinations were booked. 4.9 MA1 and FA1 were seen again in November 2017 at Children’s Centre 1 at 31 weeks gestation; no concerns or issues were identified. It is recorded that a possible ectopic heartbeat was heard and this was to be reviewed at Maternity Triage at hospital. This was not confirmed at Triage and MA1 was reviewed by a doctor and discharged home with reassurance. 4.10 MA1 attended Children’s Centre 1 in December 2017 at 34 weeks gestation. The Midwife discussed breast feeding and skin to skin. MA1 and the Midwife planned to review again in 2 weeks and then again in 4 weeks at the hospital due to ectopic heartbeat being heard on 2 occasions. 8 4.11 A special circumstances form was generated in December 2017 following MA1 notifying the Midwife 1 week earlier, that FA1 was due to appear in court with regard to charge of assault following being involved in a fight in the City Centre whilst being out with friends at the beginning of MA1’s pregnancy. MA1 was asked and confirmed no issues in respect of Domestic Abuse. MA1 is said to have stated that this was FA1’s first offence or involvement with the Police. The Court hearing was due to take place just before Christmas 2017. 4.12 MA1 attended Children’s Centre 1 between Christmas and New Year 2017 during which the growth scan was completed and no concerns identified however 2 days later MA1 attended Maternity Triage with spontaneous rupture of membranes (SRoM). Trust Policy was followed which indicates that if labour does not start within 24 hours of SRoM, to return to triage. MA1 was given advice and advised to contact Triage if any further signs of labour were identified. A1 was born 2 days later at the beginning of January 2018 at 38 weeks by emergency caesarean section. 4.13 Child A1 was born with a fever and jaundice and was medicated and treatment provided. A1 was discharged from hospital within 24 hours of delivery but returned to the hospital following a home visit for treatment for high bilirubin levels. 4.14 A1 was achieving her milestones and had received all appropriate immunisations. 4.15 The breastfeeding and safe sleeping assessments were undertaken with MA1 and recorded in the Personal Child Health Record with no issues identified and was assessed as low risk. MA1 was breastfeeding A1 and continued to do so for 1 month when she moved onto bottle milk. 4.16 A discharge summary was sent from Pennine Acute to Pennine Care and a new birth letter was sent to MA1 by the GP, advising on the registration process for A1, immunisation schedule and 8 week check. 4.17 The midwife visited the day after A1 was discharged home and has recorded no problems reported, bloods taken with regard to the jaundice diagnosed. The blood levels were high therefore A1 was admitted to the Children’s Unit for treatment and discharged 3 days later. 4.18 It is recorded that MA1 was described as tearful during the Midwife visit; this is not unusual however it would be expected that the Midwife ask about mother’s emotional health at each contact and this may initiate a more formal assessment if required. It 9 was noted that there was no further reference to MA1 being tearful in subsequent visits. 4.19 There is no verbal handover between midwives and health visitors. The services overlap and unless there are significant concerns around maternal mental health or safeguarding. Health visitors and GP’s are notified of births and discharges by letter automatically generated by the hospitals maternity electronic system and if any concerns are highlighted a “special circumstances” form is generated which will be sent electronically to health visiting teams within the community. 4.20 Both MA1 and A1 were seen regularly throughout January 2018 with regard to their medical needs. The Health Visiting Service took over from the Midwifery Service and undertook a post-natal mental health check of MA1. It is recorded that MA1 was caring for the baby confidently and appropriately. MA1 stated she had excellent support and was assessed as requiring Universal Service. 4.21 A1 had an 8 week developmental check with MA1 at the GP practice which identified no concerns regarding her development. She received her 1st set of immunisations on the same date. 4.22 In March 2018 MA1 and A1 attended Children’s Centre 2 for Baby Clinic and Baby Play Session. 4.23 In April 2018 A1 received the 2nd set of immunisations whilst in her mother’s care and later that same month MA1 attended Well Baby clinic. The Health Visitor has recorded steady growth for A1 however MA1 reported that A1 is regularly sick after feeds. Advice was provided at that time. 4.24 On 01st May 2018 Child A1 was given her third set of immunisations with consent from MA1. 4.25 MA1, FA1 and PGMA1 attended a concert on 27th May 2018 and made arrangements for A1 to be cared for by PAA1 at the Paternal Grandparents home in May 2018. During the evening A1, PAA1, C1A1, C2A1 and PGFA1 were present in the home. The plan was for A1 to remain with PAA1 overnight. 4.26 On that evening North West Ambulance Service (NWAS) were called to the home of Paternal Grandparents on by PAA1. NWAS contacted GMP to advise them of a child being in cardiac arrest. 10 4.27 MA1 described A1 as being unsettled and not taking food however she did not have a temperature, rash or vomiting. PAA1 stated that A1 would not take her bottle and kept going in and out of sleep. PAA1 administered Nurofen to help A1 settle and moved her in and out of the travel cot in order to try and settle her. 4.28 PAA1 stated she had drank a bottle of wine plus a large glass of white wine which she started about 17.45 hours pm, and had not had anything to eat. She eventually settled A1 on the sofa next to her and PAA1 lay next to A1 facing inwards towards her when she fell asleep at approximately 22.30 hours. She awoke sometime after 1am and found A1 cold and blue. PAA1 contacted the NWAS and shouted her father (PGFA1). PAA1 administered breaths until the ambulance crew took over and commenced CPR. 4.29 A Police investigation commenced due to the circumstances of A1 death. PAA1 voluntarily attended a local Police Station the following day to provide a blood sample. On the 8th June 2018 PAA1 was interviewed by Police. 4.30 MA1 sought support from her GP following the death of her daughter and FA1 was supported following presentation at A&E by Adult Mental Health Home Treatment Team until July 2018. 4.31 Information identified following the death of Child A1 indicated that FA1 had a number of convictions which is contrary to the information shared by MA1 to the Midwife. These were identified as additional risk factors for FA1 and he was risk assessed by the Home Treatment Team on 24.06.18 as ‘Amber’ with support continuing. 4.32 The Sudden Unexpected Death of a Child (SUDC) meeting was held on 29th May 2019 and was well attended, including Consultant Paediatrician, GP Partner, the Assistant Practice Manager from Medical Centre, Deputy Manager from Early Help and Safeguarding Hub, Health Visitor, Safeguarding Specialist Nurse and Bereavement Nurse. Relevant information was shared which included information regarding LA1’s Children’s Services involvement with PAA1 and her children. 4.33 A Home Office Post Mortem took place in June 2018 which noted no specific injuries of assault and it was concluded that the death was unascertained. 5. Analysis of Practice 11 5.1 Whilst it is referenced that MA1 was known to Mental Health Services briefly in 2013, this was not identified as part of the ante-natal support. MA1 was a young mother however no other vulnerabilities were identified which resulted in her being in receipt of Universal Services. 5.2 In December 2017 MA1 notified the Midwife that FA1 was due to attend Court with regard to a charge following being involved in a fight whilst out with friends. MA1 is recorded to have stated that this was the first involvement by FA1 with the Police. 5.3 The issue of domestic abuse was discussed with MA1 and she stated that this was not an issue within her relationship with FA1. 5.4 Having reviewed the information available to the Midwife at the time of the pregnancy there was no information which would have indicated safeguarding concerns for Child A1 as an unborn child. A special circumstances form was completed with regard to the disclosure that FA1 was to attend a Court hearing and consideration was given to whether this would warrant a referral to Children’s Social Care. The special circumstances information sharing form was sent to Pennine Care Foundation Trust safeguarding team to be shared with the appropriate health visiting team. However there is no information as to whether this was shared with the Health Visiting Service at that time, which would have supported follow up. 5.5 It is noted that the information from MA1 to the Midwife with regard to FA1’s criminal history and forthcoming hearing was incorrect. There was no identified reason why the Midwifery Service would choose or have cause to disbelieve MA1 or explore this further in respect of FA1’s criminal history and involvement with GMP at that time. 5.6 A significant area of consideration by the SCR Panel related to whether MA1 and FA1 were aware that PAA1’s children were subject to a Child Protection Plan and the concerns identified. As stated LA1’s Children’s Services Review noted that the concerns were not such that it was felt that the children should be removed from their mother’s care or that she was unsafe to have care of a child. The review also raises the question as to whether the Child Protection Plan considered risks to any other children. This question was raised by the Conference Chair at the Initial Child Protection Review which was held on 14.03.18, at which time Child A1 was 2.5 months of age. 12 5.7 The majority of children subject to a Child Protection Plan continue to be cared for by a parent or person with parental responsibility. The arrangements in place and decision making in respect of a child subject to a Child Protection Plan would take into consideration their age and level of development. A1’s cousins were 2 – 3 years older however they would still have required a significant amount of care and supervision. The decision therefore for C1A1 and C2A1 to remain in their Mother’s care is relevant when considering her ability to babysit A1. 5.8 A further area of consideration was whether the paternal extended family, MA1 and FA1 were aware of the concerns underpinning the Child Protection Plan. LA1’s Children’s Social Care have recorded that extended family members attended meetings with PAA1. There is no reference as to whether a family tree or genogram was recorded and whether there was any discussion with PAA1 in respect of her contact with her brother and sister in law, or whether LA1’s Children’s Social Care were aware that MA1 was pregnant. It is noted that MA1 and FA1 were not referenced at the Initial Child Protection Conference. A family network meeting was held on 11th April 2018 at PAA1’s family home. In attendance at that time were PGMA1, FA1, MA1 and Child A1. The Family Network Meeting’s aim is to share concerns with family members and to assist in developing a plan to reduce the risks arising from the identified concerns. LA1 records indicate that the family agreed to report any issues or concerns to the Police and Children’s Services and that they would keep in contact with PAA1 on a daily basis. 5.9 PAA1 stated that she had consumed a bottle of white wine plus a large glass of white wine within an approximate period of 4 ¾ hours, and had not had anything to eat. Views may differ as to whether this is deemed an excessive amount of wine for one person within this timeframe however it is noted PAA1 would have been over the limit for driving an automobile. The important factor for consideration is that she was caring for a 4 month old child, who as reported by her MA1 and by PAA1 was unsettled and not taking her normal feed. 6. Learning from the Review 6.1 The Review has identified that there was no evidence within the ante-natal records that MA1 was asked about domestic abuse during her pregnancy however the 13 chronology identifies that MA1 reported there was no domestic abuse in her relationship when she notified the Midwife of FA1’s forthcoming court hearing. It is unclear whether the Midwife did make the routine enquiries and failed to record them or whether this did not occur as per policy and procedure. This has been addressed by Pennine Acute within their Action Plan and will be addressed via mandatory training sessions for all Midwives. Whilst there is no evidence of domestic abuse within the parent’s relationship, it is important to ensure that this issue is addressed within all ante-natal support sessions as this may support individuals who are experiencing domestic abuse to access services. 6.2 It is acknowledged that the Midwife had no cause not to believe the information provided by MA1 in respect of FA1’s criminal involvement, and would have required a clear reason to seek information from the Police in this regard. 6.3 Information sharing is identified by PAHT with regard to the timescales involved for the Special Circumstances form being completed, which was delayed. Mental Health Services also identified the need to ensure that relevant information is shared effectively with all relevant agencies. It is also noted that MA1’s brief history and involvement with Mental Health Services in 2013 was not considered during the ante-natal period of support. Historic information regarding MA1 would not have met the criteria for Mental Health services involvement. The Midwife would not have had access to historical mental health information as the providers are different and both have their own records and IT systems. 6.4 Information sharing and liaison with the GP is an area of learning and consideration. Special Circumstance forms are not shared with the GP and therefore whilst the GP may have known that MA1 was pregnant they did not know that there was any cause for concern. This is a learning point regarding communication between Midwifery service and GP practices. 6.5 Early Help and Schools highlighted that contact should have been made with the family when they failed to attend the baby massage session to ensure that they were offered another session and check whether support was required. 6.6 The issue of the quality of record keeping has been identified when undertaking this review by a number of agencies with regard to the detail and accuracy of information for example who was in attendance at the ante-natal meetings with the Midwife and 14 attending the Children’s Centres and what was discussed. Further issues with regard to record keeping is having an understanding of the family in its widest sense and addressing support networks as well as potential safeguarding risks. This would or could have identified issues as outlined with regard to PAA1 and her children. 6.7 A key area of focus related to the ability of PAA1 to care for A1 on the night she died. The significant issues for consideration related to PAA1’s children being subject to a Child Protection Plan as a result of domestic abuse and alcohol abuse by PAA1 and PAPA1, and PAA1 being under the influence whilst caring for A1 on the night she died. These matters are no longer under investigation by GMP and will be the subject of a Coroner’s Inquest therefore it is difficult to make any conclusions at this time. 6.8 It is important to note that C1A1 and C2A1 were subject to Child Protection Plans and were not removed from their mother’s care. It was clearly the view of LA1’s Children’s Services that whilst concerns were identified which indicated the children were at risk of actual or likelihood of significant harm, it was the view that by having the Child Protection Plan in place, this was sufficient to safeguard these children at that time. 6.9 LA1 Children’s Services had considered any other children within the household at the time of the Initial Child Protection Conference but had not ensured that this conversation was recorded within the Minutes of the Conference. 6.10 PAA1 had been referred to and attended an assessment session with LA1 Integrated Drug and Alcohol Service in April 2018 who advised the score on the alcohol audit was very low and had been given alcohol awareness and advice as a brief intervention. This was a self-reporting audit and it is noted that at the time of the Initial Child Protection Conference, PAA1 was denying misuse or frequent use of alcohol. It is questioned whether this provided sufficient reassurance that the issue of alcohol misuse was not a risk to the children. 6.11 The information provided by LA1 Children’s Services that the parents and paternal extended family were likely to be aware of the concerns being expressed with regard to the domestic abuse incidents and alcohol misuse as they had attended meetings where this information was discussed and had been part of the safety plan in respect of C1A1 and C2A1. 6.12 Learning has been identified by LA1 Children’s Services in respect of recording the discussion regarding other children PAA1 and her partner may have come into contact 15 with or had responsibility for within the Child Protection Conference. It is noted that Child A1 is recorded as being present with her mother MA1 at the Family Network Meeting and was therefore known to the allocated Social Worker for C1A1 and C2A1. 6.13 It is clear that LA1 Children’s Services were aware of PAA1’s alcohol misuse and had sought to put a safety plan in place to address the risks associated with this and the domestic abuse identified. As stated the risk assessment concluded that there was a low risk however this was based on self-reporting from PAA1 and indicates that PAA1 continued to deny that alcohol was an issue for her. 6.14 Due to the circumstances surrounding A1’s death, and in taking a proportionate approach, it was not felt that a practitioner event was required with regard to contributing to the content of the review. Agencies have identified individual areas of learning and developed single agency action plans which were actioned immediately. Agencies will also be supported in respect of the learning across the partnership via learning events and briefings. 7. Recommendations Where a Special Circumstances form is generated by Midwifery, this is shared with key agencies involved e.g. GP and Health Visiting Service Information sharing and discussion to take place routinely between Midwifery and GP practices where issues are identified, concerns are raised in order to understand the holistic family circumstances. Where parental alcohol and substance misuse are risk factors, practitioners are to consider any other caring responsibilities for children including babysitting arrangements Acronym Meaning LA1 Local Authority 1 RBSCB Rochdale Borough Safeguarding Children’s Board GMP Greater Manchester Police SCR Serious Case Review 16 CSPRP Child Safeguarding Practice Review Panel LSCB Local Safeguarding Children’s Board CPP Child Protection Plan GP General Practitioner SRoM Spontaneous Rupture of Membranes NWAS North West Ambulance Service CPR Cardiopulmonary resuscitation SUDC Sudden Unexpected Death in Childhood 17 Christine Foster-Alonge Service Manager, Safeguarding NB: Christine Foster-Alonge left the Local Authority in April 2019, amendments have been made to this report by Margaret Doe and the review panel |
NC52366 | Injuries to a girl aged under 12-months-old in 2020. Learning includes: professionals should be aware of the lived experiences of the family and create holistic assessments; where there are children within the family who have complex health needs requiring support from and across multiple services there should be a lead professional to coordinate the response of agencies that considers and assesses the needs and demands from within the family; all agencies should understand and recognise the impact that a previous sibling bereavement can have on a family; if a mother states that fathers or men are 'not involved', agencies should use professional curiosity to ensure that they fully explore those people who are associated with a family; when considering reducing or withdrawing any service to a family, health professionals should ensure that the service they are providing is consistent with the level of health pathway; considering historical information and cumulative impact allows professionals to fully understand the family context; holistic assessments need to include a wider picture of the potential stressors for the whole family. Recommendations include: develop a set of standards on early help; ensure that practitioners are appropriately trained in the use of genograms and family mapping; develop a pathway for children for complex health needs; ensure all agencies have an effective identification, assessment, and response to domestic abuse.
| Title: Local child safeguarding practice review: Child G. LSCB: St Helens Safeguarding Children Partnership Author: Wendy Wright and Andy Passey Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review Child G Review facilitated by: Wendy Wright – Safeguarding Coordinator Andy Passey – Safeguarding Coordinator OCTOBER 1, 2021 1 | P a g e Contents Page 1. Context 2 2. Methodology and Professionals Who Contributed to This Review 2 3. Family Structure 3 4. Background 4 5. What did agencies understand about the children’s living arrangements at the point of which the review period begins. Did these arrangements change during the review period? 5 6. What was understood by agencies about mothers’ vulnerabilities? (Terms of reference 3) 5 7. What did agencies understand about the family’s circumstances and the caring roles within the family? (including the role of biological fathers, Partners & Grandparents) (Terms of reference 4 & 5) 7 8. What services were provided to family members by the agencies involved, during the review period & did the number of agencies working with the family influence the outcomes and impact on the lived experience of Child G and her siblings? (Terms of reference 2, 9, 10) 8 9. How were Child G’s needs and the risk of harm to which she and her sibling were exposed understood by practitioners and how effective were the actions taken? (Terms of reference 1, 7, 11) 10 10. How effective was single and multi-agency communication during the review period and how effective were agencies in understanding and overcoming any barriers to engaging with Child Gs family? (Terms of reference 6, 8) 11 11. To what extent do agencies feel Neglect played a part in this case? If so, what was offered in terms of support? (Terms of reference 12) 12 12. Did the COVID-19 Pandemic have an effect on the services provided or the family? (Terms of reference 13) 13 13. Summary 14 14. Recommendations 14 15. Appendix 15 2 | P a g e 1. Context: This review has been completed further to a referral to the Local Safeguarding Children Partnership Board (LSCP) in mid-2020 by Children’s Social Care as per the processes that are in place. The referral was completed following Child G being admitted to hospital with two skull fractures and multiple bleeds to the brain. To date there has been a number of accounts provided as to how the injuries occurred, none of which have been deemed consistent with the injuries caused. During the production of this report Child G has made a full recovery. As a direct result of the incident Child G and her siblings were removed from the care of their mother and placed with extended family and Local Authority foster carers having become subject to interim care orders. At the time of writing this report care proceedings remain ongoing within the family court alongside a finding of fact hearing in relation to the case. The LSCP Rapid Review Panel agreed that the threshold was met for a Local Child Safeguarding Practice Review to be conducted. The identified timelines were the partnerships involvement during the 18 months prior to and including the period of Child G sustaining the fractures to her skull. From the initial scoping information, the rapid review group identified the following areas to be considered as part of this review: How were the Child G’s needs and the risk of harm to which she was exposed understood by practitioners and managers? Child G and her mother were receiving the support of a number of agencies. How integrated were agencies plans to meet Child G’s needs? To what extent did agencies understand mothers’ vulnerabilities? What understanding did agencies have about the fathers of the children and mothers’ subsequent partners? How thorough was agency understanding in terms of the grandparent’s role within family circumstances especially in relation to the children? How effective was single and multi-agency communication during the review period? How effective were single and multi-agency services in promoting Child G’s welfare and in keeping her and her siblings safe? How effective were agencies in overcoming any barriers to engaging with Child Gs family? Did the number of agencies working with Child G’s family influence outcomes? To what extent was Child G’s voice and that of her siblings heard and the lived experience understood? To what extent was Domestic Abuse a contributory factor in this case? And were agencies overly optimistic about mother’s new partners ability to change? Where professionals aware of neglect within this family and what was done to support the family? Was COVID-19 an influencing factor within this case? 2. Methodology and Professionals Who Contributed to This Review: The information available to the review included notes from the Rapid Review Group, merged multi agency chronology, learning summaries provided by all agencies involved with the family and information gathered from a practitioner’s day held in November 2020. Agencies were requested to complete individual learning summaries which comprised of 14 questions identified by the Local Child Safeguarding Practice Rapid Review Panel. The following is a list of professionals who contributed to this review by completing the Single Agency Learning Summary Proformas. Children’s Social Care PVPU Police Children’s Hospital Trust Local Hospital Trust Adult Mental Health Services GP Practice Primary School Nursery Community Health Service 3 | P a g e 3. Family Structure The relevant family members in this review are: Family Member To be referred to as Subject Child Child G Twin Sibling 1 Sibling A Sibling 2 Sibling B Sibling 3 Sibling C Sibling 4 Sibling D Mother Mother Father of Sibling B (No longer in relationship with Mother) Father 1 Father of Sibling C & D (No longer in relationship with Mother) Father 2 Father of Child G & Sibling A (No longer in a relationship with Mother) Father 3 Mothers Partner (no biological link to Child G or Siblings) Partner Maternal Grandfather to Child G & Siblings Maternal Grandfather / Grandfather When not being cared for in a hospital setting, Child G and Sibling A resided at their home address with their mother and their siblings. Child G’s Mothers Partner also resided at the address on a number of occasions although the exact frequency of his residency remains unclear. Child G and her siblings had no ongoing contact with their biological fathers during the time period subject to this review. On occasion when Child G & Sibling A were in hospital Maternal Grandfather would take on the caring role for Sibling B & Sibling D. The family had suffered the bereavement of Sibling C prior to the births of Child G, Sibling A and Sibling D. Child G is a female child, and she was under 12 months of age at the time she sustained the injury that resulted in this review being undertaken. Her ethnicity is recorded as being white and British. Learning point 1: When establishing an understanding of the family structure the reviewers compiled a genogram and held discussions around the family structure within the practitioners meeting. The reviewers found that no agency had a clear recording or understanding of the family structure in its entirety. Through the development of a clear genogram the complexities of the family make up in this case became evident. The review found that despite agencies involvement no agency recorded the full details of father 1 or father 3 this is in direct contrast to practice standards that some organisations are required to work to. The remaining organisations did not have standards in place. Additionally, the reviewers established that there were a number of unassessed risks within the family network which had not been identified, considered, or appropriately flagged within agencies records. This factor increases the likelihood of risks being overlooked, inaccurate assessment and for the children appropriate support from within a safe family environment not being identified. Using genograms in social work practice by Hannah Scott (2021) details that a study by Laird et al. (2012) indicated that whilst not used in a high number of cases, those workers who co-created a handwritten genogram with a family (in contrast to the worker completing the system genogram) would include more extensive wider family members. This can be particularly helpful for safety planning using the family network, including Family Group Conferences or exploring Lifelong Links. However, workers must consider the importance of seeking to understand beyond biological family members and the role of family friends and peer relationships, particularly where concerns are present regarding exploitation and extra-familial harm (Firmin, 2019) 4 | P a g e 3.1 The views of the family Within any Local Child Safeguarding Practice Review, consideration is always given to obtaining the views of the family in relation to their experiences of working with the agencies involved. In Child G’s case there have been a number of factors that have resulted in the decision being taken not to directly seek the views of Child G or her mother. For Child G, due to her age the Rapid Review Panel took the decision not to directly speak to her as part of the review. In relation to Child G’s mother and her partner, ongoing investigations, and legal proceedings at the time of completing the report have meant that it has not been possible to involve them directly in the review. However, the mother has been notified of the fact that the review is being undertaken and will be given the opportunity to read the final report prior to publication. 4. Background At the time of the incident the family were not open to CSC, however Child G, her mother and her siblings were being supported by a significant number of Health professionals working across several Health providers. In addition to this school and nursery were involved with Child G’s older siblings but the family were not open to a coordinated package of Level 2 support. The family of Child G and her siblings have been known to the multi-agency partnership including Children’s Social Care (CSC) since 2010 just prior to the birth of the eldest sibling. Between 2010 – 2020 there have been 11 referrals made to CSC covering the following areas of concern: Homelessness / teenage pregnancy Domestic Abuse between mother and her sibling Over Chastisement of Sibling B by Aunt. Risk Uncle poses in relation to alleged sexual abuse (the alleged sexual abuse did not relate to any child subject to this review). Mother corresponding with a prisoner known for significant Domestic Abuse. Fabricated/Induced Illness Loss of a child (Sibling C) Sibling B being assaulted by Aunt. Mother being in a relationship with a male whose ex-partner had made allegations of domestic abuse and harassment. Child G sustaining significant head injury (incident that has led to this review) These referrals have resulted in a range of outcomes from Child and Family assessments (C&F), Early Help interventions, information signposting and in some cases, there were no further services offered. However, organisations constituting the multiagency partnership over this time period had offered other support and Level 2 support. The multi-agency partnership from the learning summary, chronologies and practitioner event were aware of a number of factors as listed below: Mothers mental health, diagnosis of Obsessive-Compulsive Disorder (OCD), depression, and anxiety The impact on mother of bereavement (Sibling C) The impact on Sibling B of bereavement (Sibling C) Mother managing the presenting behaviours of Sibling B Medical and caring needs of Child G and her twin Sibling A due to prematurity and complex health needs. Numerous repeated admissions for Child G and Sibling A across two separate hospitals. Repeated rejection of Early Help Intervention and support Mother having to live away from the family home whilst Child G and Sibling A were in hospital resulting in Sibling B and Sibling D being cared for by their Grandfather. Impact on Sibling B’s emotional well-being as a result of mother being away from the family home. 5 | P a g e The additional needs of Child G’s older siblings. Not all agencies were aware of the entirety of the factors affecting the family, as such no one single agency had a full picture of the lived experiences of the children and the family and how these have impacted on the day to day lives given the family were already under a great deal of pressure managing the care of the premature twins who had significant health needs, requiring regular hospital attendance. Learning point 2: If all agencies had been aware of the picture/lived experiences of the family, this should have led to assessments being completed that were holistic in nature and which clearly evidenced the needs of each family member and any associated risks when needs were not addressed. Resulting in a more tailored package of support being offered to mother and the children. 5. What did agencies understand about the children’s living arrangements at the point of which the review period begins. Did these arrangements change during the review period? The majority of agencies reported that they generally “believed” the children lived in the family home with mother, and with maternal grandfather on the occasions when the twins were admitted to hospital. Children’s Social Care (CSC) understood that the new partner was also staying in the family home, if not residing there. It was, also acknowledged the twin’s older brothers (Sibling D and Sibling B) had spent large periods of time cared for by Maternal Grandfather historically. When mother was in hospital with the twins maternal Grandfather moved into his daughters’ home to care for Sibling B and Sibling D. Learning point 3: It is clear from conducting this review that although agencies were aware of different people being involved with the family, no agency could clearly define who resided in the property at the specific times of their contact from within the review period. Agencies were also unable to identify who held caring responsibilities for the children as this did change on number of occasions between 2019 / 2020. 6. What was understood by agencies about mothers’ vulnerabilities? (Terms of reference 3) The majority of professionals involved during the timeframe of this review were predominantly Health professionals who represented a wide range of specialist health provisions. When asked about mother’s vulnerabilities all Health professionals were able to identify those related to her mental health, namely anxiety, depression, OCD, and bereavement in relation to the loss of Sibling C. However, information provided to the review identified that the other agencies involved with the family did not have overarching awareness of mother’s vulnerabilities. This was predominately due to the nature and timing of their contact with the family of Child G. Despite services being aware of many of mother’s vulnerabilities, little was done to coordinate a package of support for her. It is recognised that the health visitor referred mother to homestart services, however mother declined this service. Also, on one occasion contacted the GP on mother’s behalf, following her running out of medication. Health visitor contacted the GP ensuring a prescription would be available. However, in summary agencies understood mother’s vulnerabilities but didn’t see the impact of those vulnerabilities on the day-to-day parenting of Child G and her siblings. In conclusion there was a lack of professional curiosity by agencies in relation to the presenting vulnerabilities of mother. The one area that appears to have galvanised the partnership into working together to understand mother’s vulnerability was focused on the receipt of a referral to CSC suggesting she was at risk of domestic abuse by her partner. 6 | P a g e This resulted in the agreement of the need for a Claire’s Law disclosure and agreement to share information held to ensure that she had adequate information to make informed choices. The referral also required a C&F (Children and Families assessment) to be completed requiring multi agency consultation and collaboration. The assessment recognised that the relationship was relatively new and was recorded by the social worker as being in its “honeymoon period”. Research would suggest that professionals at this stage should have been alerted to the fact that this was a period of high risk and increased vulnerability due to a number of factors which are highlighted within both the MERIT (Merseyside Risk Identification Toolkit) and Barnardo’s Domestic Violence Risk Identification Matrix. In addition to this the 2016 article Starting a New Relationship After Abuse by DomesticShelters.org, highlights the increased risk when starting a relationship with someone who has previously been a perpetrator of domestic abuse. The article states: “There isn’t a simple checklist that guarantees a potential partner will be safe, abusive partners are, by definition, manipulative. They can come across as charming and caring. No matter how charming a person seems, a history of abusive behaviour is cause for concern, as are other red flags. Abuse is a learned behaviour, which means until it is unlearned, a person is likely to have a pattern of abusing multiple partners.” Within the C&F assessment the focus was on mothers’ partners previous relationships and did not focus on mother’s relationship history to identify any domestic abuse that may have gone unreported which could increase the risk of domestic abuse in future relationships. In addition, the C&F focused on the risk posed to the children in relation to witnessing possible incidents of domestic abuse but did not consider any risk of the children being subjected to violence themselves, or any other forms of abuse or neglect that may become evident. Furthermore, the review found that during the completion of the C&F significant sources of information were not sought. This may have provided practitioners with an insight in relation to whether there were any concerns during times of increased stress for the family. Learning point 4: In late 2019, during a discussion regarding the discharge of the twins from hospital it was identified that there were concerns around mother’s presentation and need for additional mental health support through a referral to mental health services. The review found no evidence of this referral being completed despite the identified need. Furthermore, the review found consideration for a re-referral to mental health services was not given any further consideration by the agencies involved with the family in the time period following, even though there were clear signs of mothers increasing stress and anxiety impacting her mental health. Learning point 5: All agencies should understand/recognise the impact that a previous Sibling Bereavement can have on a family. This should take into consideration not just the impact it may have on their ability to care for other children at the time of the bereavement but also how it may impact the care afforded to any future children. Health services should consider and assess this specifically during any future pregnancies in order to identify any support needs at the earliest opportunity. Learning point 6: There was no information submitted to the review to demonstrate that Health providers had completed routine enquiries into possible domestic abuse despite these forming part of NICE guidelines and organisational practice guidance. In addition to this during the screening of the referral regarding possible domestic abuse there is no evidence to substantiate that Health providers were specifically asked by CSC about whether routine enquiries around domestic abuse had been completed with mother and what information Health had recorded in response to the enquiries. The 2014 NICE guidelines on Domestic violence and abuse: multi-agency working details that Health and CSC should ask service users whether they have experienced domestic violence and abuse. This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse. 7 | P a g e 7. What did agencies understand about the family’s circumstances and the caring roles within the family? (including the role of biological fathers, Partners & Grandparents) (Terms of reference 4 & 5) Agencies contributing to this review, had limited knowledge of the children’s biological fathers and reported that it was thought there was no ongoing contact between the children and their respective fathers. The review found that when mother informed agencies that the children’s biological fathers were not involved with the children, agencies did not sufficiently explore the circumstances of mother’s relationships, what had led to the relationships ending or what if any support the fathers provided or could provide to the children? However, School reported that they had previously explored this issue when Sibling B was in an earlier year group. At the time mother stated that his father did not want to be involved in his upbringing. One key missed opportunity for further exploration by school was when Sibling B discussed not seeing his father during a wellbeing session. This could have been a significant factor in terms of his emotional wellbeing and was an opportunity to increase the support network around Sibling B’s mother. The review found that during Sibling B’s counselling sessions Sibling B explored with his counsellor, the people who were a positive influence within his life. It was identified that his grandfather was an important male role model. The report by the NSPCC Hidden men: learning from case reviews - Summary of risk factors and learning for improved practice around ‘hidden’ men (April 2015) highlights the importance of exploring all hidden males within a family and details that men play a very important role in children’s lives and have a great influence on the children they care for. Despite this, they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers/female carers. This was also the case when it came to mothers’ partner, no agency had a clear understanding of mother’s partners circumstances or the specific role that he played in relation to caring for the children. The review found that across agencies there was an awareness of the concerns in relation to the previous allegations of domestic abuse, raised by his ex-partner. However, this was only as a result of the referral that was made, and agencies being contacted in relation to the Child and Families (C&F) assessment and was not through any enquiries agencies had made during any contact with the family prior to the referral being submitted. CSC completed a C&F assessment in relation to the potential Domestic Abuse risk posed by mother’s partner, however failed to explore the exact role this partner played in caring for the children. This assessment focused on the circumstances of the referral (the risk he posed to mother) rather than looking at the wider picture. CSC acknowledge within their learning summary that mother’s relationship history was not really understood, and this remains an area that requires further understanding. The review found that there was also conflicting information between agencies in relation to mother’s partner. For example, Children’s Hospital Trust believed mothers partner was an on/off partner, it was acknowledged he stayed at Children’s Hospital Trust on a number of occasions, but he was reported as not appearing to play a caring role within the family. Whereas 0-19 service and the Local Hospital Trust detailed that mother’s partner seemed to play a much more active role in caring for the children with the mother of Child G referring to him as “Dad”. The more active role that mother’s partner played was also reflected in schools learning summary who stated that Sibling B had spoken of enjoying spending time with mothers’ partner and had been away for weekends with him. Two of the agencies involved in this review (School and Nursery) had a clear understanding of the role that Grandfather played in supporting and caring for Sibling B and Sibling D whilst their siblings were in hospital. The other agencies that were involved had an awareness of the fact that Grandfather played a supporting role however did not have a clear understanding of the extent of this role. In conclusion without an understanding of persons involved in the family and their relevant roles in caring for the children the need for support and potential risks cannot be accurately assessed. This gap in assessment then results in the opportunity to provide a tailored support package being missed. 8 | P a g e Learning point 7: The theme of hidden males and absent fathers was evident in this case solely due to a lack of professional curiosity. This reflects similar findings within both national/local reviews and the Boroughs multi-agency audits. Agencies need to ensure that they fully explore those people who are associated with a family, the caring roles they may have, circumstances of previous relationships, and the support that absent partners may be able to provide (either physical, emotional, or financial). If a mother states that “they are not involved” agencies should use professional curiosity to develop the discussion around this topic. 8. What services were provided to family members by the agencies involved, during the review period & did the number of agencies working with the family influence the outcomes and impact on the lived experience of Child G and her siblings? (Terms of reference 2, 9, 10) During the review period there were a number of services provided and offered to the family. The majority of which were in relation to Child G and her twin with little focus on the wider siblings Sibling B and Sibling D. Community Health services provided support to the family in the form of the health visiting, school nurse, speech and language, physiotherapy, and community dietetics services. The Health Visiting Service provided safe sleep advice, weight monitoring, arrangement of immunisations, development checks, and safe child handling advice all of which was in relation to Child G and her twin. This service included more frequent home visits due to the twin’s level of health need being classed as Universal Plus in line with the Healthy Child Programme (http://www.healthychildprogramme.com). The Local Hospital Trust provided ante natal care, ongoing support around feeding following the initial discharge from hospital of the twins. This took the form of telephone support, regular home visits, attendance at pre discharge meetings and relevant referrals to other services when necessary. The children’s hospital trust provided support during the twin’s attendances at hospital via the medical team and provided support via the complex discharge team. The complex discharge team arranged and managed all of the Multi-Disciplinary Discharge meetings for Child G and her twin (Sibling A). Throughout the time identified within the review and up until the reported head injuries CSC did not provide a direct service, other than to assess the family. The outcome of assessment was that support at Level 2 should be offered, this was declined by the family. The Level 2 offer was to include awareness raising about domestic abuse. One of the key messages identified by the 2021 National Panel Annual Report on LCSPRs was that services should consider the reasons for non-engagement in the family and in the response of practitioners and agencies and how to engage, rather than close due to non-engagement. Progress should be evidenced prior to closure, the reasons for closure should be clear and closure should not be viewed simply as the end, that is, there should be clarity about what to do if new concerns emerge. The GP provided primary care support for the whole family; this included the issuing of prescriptions/advice, and supporting the Secondary Care provision for the twins and Sibling B. Sibling B was in receipt of Universal Plus School Nursing Service provision and was under the care of Consultant Paediatrician at the Children’s Hospital Trust for asthma. However school provided the main service for Sibling B, recognising the need to support his emotional health due to the impact of bereavement within the family which was felt to be further compounded by mothers absence whilst responding to the health needs of the Child G and her twin (Sibling A). This support was in the form of weekly wellbeing sessions. School referred Sibling B to an external counselling service however his mother was unable to get him to the sessions and Sibling B also refused to attend. As a result, school found a suitable child counsellor for Sibling B to have weekly counselling sessions in school. 9 | P a g e The review established that Sibling D appeared to have significant health needs that were being addressed by primary, secondary, and tertiary health services culminating in an assessment to establish if there were any additional needs. Referrals to SALT and community dietetics were made as a result of the assessment findings however, in early 2019 Sibling D was discharged from the Community Dietetics as a direct result of not being taken to appointments and by mid 2019 there was no service offer to him. This appears to be as a direct result of not being taken to appointments. Additionally, there were no professionals able to demonstrate an understanding of Sibling D’s needs with the exception of nursery who report that Grandad was his main carer, and it was established that any concerns they discussed with him were addressed. It is the opinion of the reviewers that Sibling D was very much a “hidden child” further to the birth of the twins in 2019. The review found that when Early Help was offered by Schools, 0-19 Service, and CSC it was predominantly offered in isolation with no previous understanding of when or what had been offered by other services. When this support was declined as mother stated that she had sufficient professionals involved little further exploration was completed to overcome the barriers to accepting the support. Information submitted to the review demonstrated that Health Services were the predominant service provider throughout the review period specifically in relation to the twins. It is clear that there was limited coordination to support the family to navigate the complexity and competing demands placed on them by Health providers who in the main worked in isolation. The one opportunity that did arise to provide this coordination was missed as further discussions across Health agencies concluded that it was not warranted as the family had sufficient support. This decision did not recognise that mother was pulled between the caring roles of the twins and the caring needs for Sibling B and Sibling D i.e. there was no consideration given by the professionals involved in relation to the logistics of how mother was managing to meet and address all the needs within the family. The reviewers are of the opinion that had this been considered by professionals and a coordinated approach introduced the pressures on the family and anxieties could have been reduced. The reflection at the practitioner event concluded similarly; noting that without a coordinated approach the number of professionals involved does not necessarily equate to successful intervention or positive outcomes for a family as was the case in this review. Therefore, it was concluded that it would have been best practice to have identified a lead professional from within the Health Services to ensure that the services being provided were understood and coordinated. The review found that despite the complex health needs of Child G and her twin Sibling A, agencies did not consider that a referral to the Children with Disabilities team was needed. Such a referral may have allowed for mother to gain access to specialist support including respite, housing needs, finances, and access to associated charities. The review identified that the 0-19 service reduced their level of contact with the family in mid 2020. The 0-19 service following discussions with mother ceased their weekly visits and agreed that their next contact with the family would be when Child G and her twin (Sibling A) required their 10-month developmental checks. The level of contact agreed was found to be inconsistent with the health pathway to which they were open (namely Universal Plus). In summary the large number of services involved with the family did not have a negative impact on Child G. However, when looking at the needs of the older siblings the review found they were at times overlooked following the birth of the twins, with no one agency clearly understanding their lived experience. The reviewers felt that health services were predominantly focused on the complex health needs of the twins. Learning point 8: Where there are children within the family who have complex health needs requiring support from and across multiple services there should be a Lead Professional to coordinate the response of agencies that considers and assesses the needs/demands from within the family. This approach should ensure that all outcomes for all children within a family are met. 10 | P a g e Learning point 9: When considering reducing or withdrawing any service to a family, Health professionals should ensure that the service they are providing is consistent with the level of Health pathway to which the family are open (as defined by the Healthy Child Programme). Any decision to change the level of Health pathway that a family is open to should be supported through appropriate assessment and management oversight. 9. How were Child G’s needs and the risk of harm to which she and her sibling were exposed understood by practitioners and how effective were the actions taken? (Terms of reference 1, 7, 11) Child Gs health needs are clearly documented, and she is known to have complex health needs originating at birth. No agency had identified this family to be at risk of harm and were in the main receiving single agency support above that of universal need. Information available to the review shows that there were potential risk factors as follows: physical abuse, Domestic Abuse and mental health issues affecting both mother and one of the siblings. The Rapid Review Group identified the possibility of neglect being a feature within the family, this is discussed later in the report. Physical Abuse: In early 2020 a referral was made to CSC in relation to Sibling B sustaining injuries following falling off his uncles’ bike; the referral also detailed that his Aunt had caused a separate injury by digging her nails in to his arm. No further action was recorded, however the circumstances around Aunt causing the injury were not explored nor recorded. This was a missed opportunity by CSC to assess and understand any risk to which the children were exposed to within the wider family network. Following school being notified by CSC that the referral would not reach Level 3, school did speak with Sibling B’s mother in regard to an EHAT, however, this was declined. Domestic Abuse: Good practice would state that when practitioners assess a case in relation to domestic abuse, they should use their organisational policies such as routine enquiries. The review found no evidence that such routine enquiries had been completed in the case of Child G. When looking at Domestic Abuse (DA) no agency as part of their learning summaries or from the practitioner day identified DA as being a part of the identified risk relating to the family. This was up until receiving the referral from a neighbouring Local Authority in early 2020 where there were concerns raised around domestic abuse perpetrated by mother’s partner in his previous relationship. CSC acted appropriately in that the family received an assessment. The assessment concluded that threshold was not met for statutory intervention as there was no evidence that the children had been exposed to any form of domestic abuse with no reported incidents. The social worker (SW) did acknowledge within the assessment that the risk in relation to the partner should not be dismissed but that this relationship was in the early phases and that abuse may not have yet manifested itself. As such, mother was supported to request and receive information under the Claires Law Disclosure. The family were offered Level 2 support which was refused; all information was shared with partner agencies. Mental Health issues: Both mother and Sibling B suffered from Mental Health issues. Agencies had an awareness of mother’s mental health (OCD, depression and anxiety) yet no agency reported that they had clearly assessed how these concerns may or may not have impacted the care afforded to Child G or her siblings. The review established that across the agencies the indicators of increasing stress for mother such as, an inability to cope with the twins’ health issues and a heavy reliance on Health professionals was not clearly understood or assessed from a single or multi agency perspective in terms of how they impacted on mothers’ ability to parent Child G and her siblings. 11 | P a g e The information presented shows Sibling B intermittently presented with aggressive behaviour. This suggests there may have been mental health difficulties, but it does not appear to have been considered by agencies in terms of its increased impact on the family. Counselling was put in place by School however a full assessment may have been more appropriate. School took steps to address this by completing a referral to CAMHS for an assessment and support, however, this referral was rejected. The review notes that the anxiety of Sibling B would appear to correlate with the birth of the twins - the impact of the twin’s complex health needs may have led to Sibling B being overlooked. Learning point 10: The completion of Accurate risk assessments means a more effective agency response and ultimately better outcomes for children and families. Considering historical information and cumulative impact allows professionals to fully understand the family context. 10. How effective was single and multi-agency communication during the review period and how effective were agencies in understanding and overcoming any barriers to engaging with Child Gs family? (Terms of reference 6, 8) The learning summaries reflected that, agencies generally worked well together to ensure that the safety and health needs of the children were met. At the time of the incident all agencies worked together to ensure that all children were immediately safeguarded. Previous audits and reviews would evidence that this is reflective of practice in St Helens. The agencies involved acted efficiently and effectively, the fact that the incident occurred during a weekend period did not impact or lead to drift or delay in this case. In the past national serious case reviews have talked about the difficulties experienced when dealing with an incident during the “out of hours” period however, this was not evident in this case. Sibling B’s school detailed that the multi-agency communication was impacted by the fact that the younger siblings did not attend school. As there was no EHAT in place for the family school did not receive or request information from partner agencies. The way in which they overcame this barrier was to speak directly to mother or through communicating with the Education Welfare Officer who had direct involvement with the family. Sibling D’s nursery had limited communication with outside agencies other than when assessments or screening was completed by CSC. The nursery adhered robustly to their safeguarding procedures and this meant that they would only communicate with outside agencies when specific safeguarding concerns were raised. Within the nursery there were daily conversations held between staff where concerns would be discussed, reported, and recorded. Children Social Care was found to have liaised with all professionals currently involved with the family during the two assessment periods. CSC sought information for the completion of screening/ assessments however the outcomes of the these were not consistently fed back to the agencies from whom the information had been sought. In relation to the health services involved with the family there were some examples of good communication within health services which was specifically in relation to the twins. These examples of effective communication were achieved through multi-disciplinary discharge meetings that were arranged and managed via the Children’s Hospital Trust. The paediatric liaison service was also used to facilitate communication in this case. This service shared information with the Health Visitors, Midwives, GP’s, and the Family Nurse Partnership following attendances at A&E, acute services and discharge from hospital to support the continuity of care. The review found that Child G, her siblings, and mother crossed primary, secondary, and tertiary care services with numerous health providers all using different electronic health record systems with no one single system collating all of the information. When we look at information sharing with some organisations as in this case the HV, SN and adult mental health all had the same electronic system however did not triangulate any of that information. 12 | P a g e Due to these complexities and the barriers that that they create, there is a reliance on a health professional as in this case taking the lead for the child and families health needs to support a co-ordinated plan working with the parents. What should have happened in this case is that health practitioners knew the difficulties the family experienced, the level of health need and the potential stress and pressures on the family but didn’t work with mother to pull that together in a joint health EHAT enabling all to see the bigger picture around the need for support. The reviewers found barriers to communication and information sharing to be a factor in relation to Fabricated or Induced Illness (FII). In 2018 concerns of FII were raised in relation to Sibling D and again in 2019 in relation to Child G and Sibling A. The initial concern by the children’s hospital trust resulted in there being no evidence to substantiate a finding of FII. The screening of the further anonymous referral in 2019 made no mention or reference to the FII referral or outcome for Sibling D in 2018. This demonstrates that there was no triangulation of the information held within the different health systems. The review found no evidence of communication or coordination between the different internal departments within the Children’s Hospital Trust which during the time period of this review had all of the children within the family open to their hospital services. When looking at communication between agencies it was also evident that General Data Protection Regulation (GDPR), and consent acted as a barrier to communication. Agencies become hesitant to request and share information as Child G’s mother had declined Level 2 support and there was no EHAT in place. The Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers (July 2018) details that GDPR, Data Protection Act 2018 and human rights law are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately. The review also identified that when one of the predominant health services involved with the family reduced their level of contact ceasing the weekly visits to the family there was no documented contact with other agencies (in particular other health services) involved to inform them of the fact that they would be reducing their involvement, or to inform them of the advice that they had given to the mother during their last contact. Learning point 11: Practitioners within CSC should ensure that they share the outcomes of any assessment with the agencies who they have sought information from as part of the assessment. This should then be clearly documented within each agency relevant systems detailing what has been shared, who it was by, who it was shared with and why. Learning point 12: Agencies should ensure that they utilise the information they hold on their own recording systems in relation to the whole family and not just the information they hold in relation to the member of the family that they ongoing involvement with. 11. To what extent do agencies feel Neglect played a part in this case? If so, what was offered in terms of support? (Terms of reference 12) The Rapid Review Panel felt that the case presented elements of chronic neglect, this was not identified within multi agency learning summaries or within the practitioner’s event. None of the agencies identified any concerns around neglect throughout their involvement as such no specific support was offered in relation to neglect. This is not to say that neglect wasn’t a feature within this case, and it is worthy of note that agencies; particularly health, did not consider the wider picture that would have led to the possibility of neglect being a feature. The search for health needs and the facilitation to meet those needs is a fundamental principle within the provision of health services. However, in this case it is evident that there is a lack of this principle in places. For instance, not assessing the impact of mother’s mental health on her ability to meet the demands of caring for premature twins, the burden of premature baby feeding regimes, SEND issues and the ever-growing demands upon mother as main carer for the children. There was 13 | P a g e little professional oversight in relation to giving thought to the added weight of mother having to deal with her own health issues whilst co-ordinating and attending to the array of health needs and interventions that that children were experiencing. In conclusion professionals assumed that neglect was not a feature in this case however this assumption was not based in sound assessment utilising locally agreed tools and resources such as EHAT, GCP2 to support analysis. Health agencies held information which should have prompted practitioners to explore themes such as possible neglect i.e. around the children’s growth charts to identify where they were residing at the times when there were peaks and drops in weight (home vs hospital), missed maternal mental health appointments, missed child health appointments and the root cause of sibling’s behavioural issues. As these factors were not fully explored the reviewers were unable to conclude whether the children were subjected to neglect and whether any possible neglect was through omission or commission. Learning point 13: To be holistic assessments need to include a wider picture of the potential stressors for the whole family. Where there are identified levels of health and development needs and gaps in those needs being met practitioners should recognise these as possible indicators of neglect. This should then be assessed through the use of locally agreed tools and resources such as EHAT and GCP2. 12. Did the COVID-19 Pandemic have an effect on the services provided or the family? (Terms of reference 13) In relation to the impact of the COVID-19 pandemic on the services provided the review found that generally critical business was maintained by services for the family, in some cases the service maintained direct visits to the family and in other cases this took place virtually. The 0-19 service stated that the Health Visitor had direct contact with the family during home visits however, these then predominately became by telephone during the COVID-19 Pandemic prior to level of intervention by the Health Visitor being reduced in mid 2020. This change in direct contact was consistent with the processes put in place by the 0-19 service as at the time there was no compelling clinical or safeguarding need identified in relation to the family of Child G. Upon reflection it was identified that this would have impacted on Health Visitor observing/assessing the children in the care of their mother in the family home. Coupled with this, given the recent referral around alleged domestic abuse in relation to mothers partner the reduction of direct contact also reduced the opportunity for the Health Visitor to go into the property and observe any possible increased tensions within the household which may have been an indicator of domestic abuse. The April 2020 report Family violence and COVID-19: Increased vulnerability and reduced options for support by Kim Usher et al explores this factor and states: “Isolation paired with psychological and economic stressors accompanying the pandemic as well as potential increases in negative coping mechanisms (e.g. excessive alcohol consumption) can come together in a perfect storm to trigger an unprecedented wave of family violence (van Gelder et al. 2020). Substance misuse, financial strain, and isolation are all well-known domestic abuse risk factors (Richards 2009). During isolation, there are also fewer opportunities for people living with family violence to call for help. Isolation also helps to keep the abuse hidden with physical or emotional signs of family violence and abuse less visible to others (Stark 2009).” Within the practitioner’s event it was identified that during the COVID-19 pandemic the family of Child G did not meet the threshold as a priority family for the Community Nurse Service as they were not in need of clinical nursing intervention. This threshold was implemented by the Community Nurse team to manage which families needed to have continued face to face visits. Despite this the nurse involved with the family of Child G was not constrained by process or procedure and used her professional judgement to override this and continue to complete face to face visits to ensure that the support received by the family was maintained. During the COVID-19 pandemic Child G’s mother made the decision to keep her older children off nursery and school provision due to the vulnerability of the twins. School endeavoured to continue to try and maintain regular visual contact with Sibling B working together with EWO to provide almost daily 14 | P a g e visits to the family. The wellbeing sessions for Sibling B did not take place during COVID-19 pandemic due to the ongoing restrictions. The COVID-19 pandemic resulted in a reduction of the oversight professionals had of the family. Not all professionals explored how the pandemic may have impacted the family directly. Given mothers history of mental health specifically in relation to her high level of anxiety and intrusive thoughts of the family becoming ill and dying, the COVID-19 crisis would have had significant impact which should have been explored as it may have identified increased risk around her ability to care for her children. This exploration would have enabled services to assess whether there was any need for additional support. This factor was also evident in relation to Sibling B who’s wellbeing sessions were not completed due to the pandemic. Given the concerns around Sibling B’s emotional wellbeing, plans should have been put into place by practitioners to allow the emotional wellbeing sessions to continue either via telephone or virtually. The review does however, acknowledge that EWO did continue to make home visits and phone calls during this period to enable them to check on the wellbeing of Sibling B. Practitioners should ensure that they take into account how external factors may impact on a family either directly or indirectly. 13. Summary From reviewing the evidence contained within the learning summaries, the practitioner event it is clear this was a family who needed help and support. There was a lack of multi-agency coordination and understanding of what the lack of engagement with the early help provision meant to the family and how this may have increased stressors within the family. Due to insufficient professional curiosity, not all practitioners in this case had a clear understanding of the factors that cumulatively impacted on the family. Factors such as the number of health appointments, maternal mental health needs, including the death of her child all had significant impact. When coupled with the emotional and health needs of the siblings this would have increased mother’s anxieties reducing her ability to respond to the needs of the children. It is the opinion of the reviewers that the family would have benefitted from the allocation of a lead professional who would have been able to coordinate services, relative to the children’s complex needs. No single agency appeared to have had a clear understanding of who the family members were, or significant the others involved with these children and what caring roles were provided and by who. Neglect was not clearly identified by practitioners involved in the case which resulted in a significant area of unassessed and unaddressed risk. Practitioners should be aware that Neglect does not always present in the typical forms and in some cases will need further exploration past these forms before it can be discounted. 14. Recommendations Recommendation 1 For the Safeguarding Children Partnership to facilitate the development of a set of practice standards when it comes to how we offer early help across the multi-agency partnership. As a minimum these standards should detail the need for practitioners to discuss with a family and appropriately record the key points outlined below: What exactly Early Help is and any common misconceptions. Why Early Help is being offered (Signs of Safety format)? What support can be offered and the possible format it will take? What the potential impact on the children and the family may be if no support is accepted? The reason why Early Help has been declined by the family and what efforts were made to overcome this barrier? Recommendation 2 15 | P a g e The Safeguarding Children Partnership working with the Health Forum should identify an ongoing training and refresher training program to ensure all front-line practitioners across the multiple health services are trained in the Early Help provision and EHAT completion. This should be supported through an auditing process of cases that have been identified for Early Help. Recommendation 3 The Safeguarding Children Partnership working in conjunction with the Health Forum (and ultimately commissioning services) should look to develop a pathway for children and families with complex health needs to ensure that when there is a relevant need an allocated lead health professional is identified. This will then ensure a coordinated approach from Health providers and enable a greater understanding of how the health needs of all of the children impact the family holistically. It would also provide a single point of contact for partner agencies when they are seeking information around a family. Recommendation 4 For the Safeguarding Children Partnership to seek assurance from all agencies that practitioners are appropriately trained in the use of genograms/family mapping (as per Signs of Safety model). This should be supported through an ongoing audit process within each agency to ensure that genograms/family mapping are being utilised and updated across cases in accordance with organisational practice standards. This will support an understanding of significant relationships within a family. Recommendation 5 For the Safeguarding Children Partnership to seek assurance from all agencies about their practice in relation to the identification, assessment, and response to domestic abuse. For health service this would be to include adherence to NICE guidance and routine enquiries. Recommendation 6 For the Safeguarding Children Partnership to seek assurance from 0-19 service and integrated commissioners that the correct application of the Healthy Child Programme threshold is consistently applied with oversight from team leaders. This should then be reflected within the Health records and any changes to the levels of intervention i.e. step up or step down to be recorded with clear rationale (this should be supported through a programme of audit/dip sample). 15. Appendix Working with the whole family: What case files tell us about social work practices. Laird, S., Morris, K., Archard, P., & Clawson, R. (2017) https://doi.org/10.1111/cfs.12349 From genograms to peer group mapping: introducing peer relationships into social work assessment and intervention, Families, Relationships and Societies by Firmin, C (2019) - https://www.ingentaconnect.com/content/tpp/frs/2019/00000008/00000002/art00004 Using genograms in social work practice 18/02/2021 by Hannah Scott - https://www.researchinpractice.org.uk/children/news-views/2021/february/using-genograms-in-social-work-practice/ Healthy Child Programme - http://www.healthychildprogramme.com Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers July 2018 - 16 | P a g e https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721581/Information_sharing_advice_practitioners_safeguarding_services.pdf Request information under Clare's Law: Make a Domestic Violence Disclosure Scheme (DVDS) application - https://www.merseyside.police.uk/advice/advice-and-information/daa/domestic-abuse/alpha2/request-information-under-clares-law/ NSPCC Domestic abuse: learning from case review – June 2020 https://learning.nspcc.org.uk/media/1335/learning-from-case-reviews_domestic-abuse.pdf Annual review of LCSPRs and rapid reviews by Jonathan Dickens, Julie Taylor, Joanna Garstang, Nutmeg Hallett, Natasha Rennolds & Penny Sorensen - March 2021 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984770/Annual_review_of_LCSPRs_and_rapid_reviews.pdf Hidden men: learning from case reviews - Summary of risk factors and learning for improved practice around ‘hidden’ men - April 2015 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf Family violence and COVID-19: Increased vulnerability and reduced options for support by Kim Usher AM, RN PhD FACMHN, Navjot Bhullar BA(Hons) MA, MPhil, PhD MAPS, Joanne Durkin PgDip MA, Naomi Gyamfi BSc (Hons) MSc, Debra Jackson AO, RN PhD FACN SFHEA MRSNZ - April 2020 https://onlinelibrary.wiley.com/doi/full/10.1111/inm.12735 Barnardo’s Domestic Violence Risk Identification Matrix https://www.cafcass.gov.uk/download/6629/ NICE Recognising and responding to domestic violence and abuse https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/recognising-and-responding-to-domestic-violence-and-abuse https://www.nice.org.uk/Media/Default/About/NICE-Communities/Social-care/quick-guides/recognising-responding-domestic-violence-abuse-quick-guide.pdf NICE guidelines on Domestic violence and abuse: multi-agency working - 2014 https://www.nice.org.uk/guidance/ph50 Starting a New Relationship After Abuse by DomesticShelters.org - May 2016 https://www.domesticshelters.org/articles/relationships/starting-a-new-relationship-after-abuse |
NC048216 | Death of a 7-month old child of British and Pakistani background in January 2014. A post mortem indicated failure to thrive, dehydration and malnutrition as contributory factors. The mother and maternal grandmother were later found guilty of child cruelty. Child E was born prematurely and lived with the mother and two older siblings in the maternal grandmother's home. The father did not live with the family. There was contact with midwives, health visitors, the GP and hospital services including Accident and Emergency dating from before Child E's birth until the death. Hospital and GP appointments were missed and a number of home visits denied. Concerns were expressed by health visitors about cigarette smoke, a cluttered and dirty home environment and bed sharing. Findings include: failure to recognise a young mother struggling to cope with parenting; assessment tools were not implemented; lack of coordination in transferring cases between health visitors; the mother's failure to engage with services was not noticed; an intervention would have either helped Child E get better care or highlighted the true level of risk. Recommendations were made for Cambridgeshire County Services (CCS) and Luton and Dunstable University Hospital (LDUH), Luton Children and Learning Department and Luton LSCB. These include being aware of the importance of weight gain over time in premature babies and recording this; professionals working in Luton should be able to implement a multi-agency strategy for the assessment of neglect which sets practice standards for the use of assessment frameworks and tools.
| Title: Serious case review report in respect of: Child E LSCB: Luton Local Safeguarding Children Board Author: Kevin Ball Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Luton Local Safeguarding Children Board Learning & improving Serious Case Review report in respect of: Child E Independent Lead Reviewer: Kevin Ball, NSPCC Senior Consultant This report has been commissioned and written on behalf of: Luton Local Safeguarding Children Board This report has been anonymised in order to protect the identity of individuals. 2 Contents Page 1.Introduction 3 - The reason for this case being subject to review - Audience for this review 3 3 2. Brief synopsis of the case 3 3. The Serious Case Review process 4 - Methodology for this Serious Case Review - Scope of this Serious Case Review - Involvement of the child, family & carers in this review - Limitations of this review 4 6 7 7 4. Summary account of professional contact with Child E (including siblings) & family members 8 5. Outcome statements 11 6. Review and analysis of single agency contacts, including findings 12 - Luton & Dunstable University Hospital - Cambridgeshire Community Services - Luton Borough Council: Children & Learning Department - General Practitioner and Surgery - School 12 15 22 23 24 7. Summary of emerging themes 26 8. Local operating context for statutory agencies 26 9. Assessment opportunities & the use of assessment tools to understand the child’s experience 28 10. Threshold and professional intervention 32 11. Organisational arrangements to promote safeguarding practice 34 - Training - Supervision - Caseload management issues 34 35 38 12. Summarised account of review findings 39 13. Lessons learnt from this review 40 14. Recommendations and challenges to Luton LSCB & partners 42 Appendices: - Appendix 1: Membership of SCR Reference Group - Appendix 2: Professionals who have been interviewed for this review or who have contributed to the review process 3 1. Introduction 1.1. Statutory guidance1 states that “professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others”. Case reviews provide a valuable opportunity to reflect on the quality of services and practice. Guidance also cites Regulation 5 of the Local Safeguarding Children Board Regulations 2006, that a Serious Case Review (SCR) should be undertaken where abuse or neglect is known or suspected and either; a child dies; or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. The reason for this case being subject to review 1.2. In January 2014 Child E was found dead in the family home. Following the initial police investigation concerns were raised about the circumstances surrounding the death. An early review of the case showed that Child E had lived, and died, in neglectful conditions prompting concerns about how statutory agencies worked together to safeguard and protect Child E’s welfare. Audience for this review report 1.3. The primary audience for this report is Luton LSCB, local services and professionals. The report may be of interest to the public and a broader professional audience where there may be similarities in findings and where learning and improvement may be considered at a regional or national level. 2. Brief synopsis of the case Child E: age seven months – English Pakistani Mother: English Sibling 1: age four years– English Pakistani Grandmother: English Sibling 2: age two years – English Pakistani Father: Pakistani Sibling 3: born post Child E’s death – English Pakistani 2.1. At the time of death Child E was a seven month old infant. The household in which Child E lived comprised the mother, maternal grandmother and two older siblings, both of whom were under four years of age. The children’s father had no role in caring for the children although it is believed that he may have visited occasionally. 2.2. Child E’s mother had received antenatal care for all of her children from local hospital services. Additionally, she and each of the children had been provided with postnatal care from community based services including the GP, although this universal support offer was not always accepted. Both hospital and community based services raised concerns about the neglectful home environment and conditions in which the children were living from around the summer of 2010. Concerns included; a house full of ‘clutter’, often 1 This SCR was commissioned under Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, March 2013, HM Government. Subsequently, HM Government issued a revised version in 2015. 4 dirty due to pet bird droppings, safety hazards around the house, smoke filled due to heavy smoking, cramped living conditions, and bed sharing. 2.3. The local authority Children & Learning Department (Children’s Social Care) became aware of the concerns through a referral from the hospital but also discussions with the Health Visiting Service. An agreed plan between agencies (Specialist Family Support service of the Children & Learning Department and the Health Visiting Service) was for the Health Visitor to monitor and work with the family. 2.4. At the birth of each child similar concerns about the conditions of the home environment were raised and yet limited professional input was provided. In part, this was due to the limited engagement by the mother with professionals. Various formal assessment opportunities were either considered or attempted but these had no impact. In turn, improvements to the home conditions were limited and had little positive impact. The mother’s capacity to parent and care for three young children was never fully assessed. 2.5. In late 2013 when Child E was 26 weeks old (approximately four weeks prior to death) Child E was noted to be suffering from nappy rash during a scheduled hospital review. Additionally it was noted that Child E’s weight gain was erratic; advice was given to the mother about weaning and a feeding regime. These two issues became a focus for the GP and Health Visiting Service to address. Despite very clear professional advice, the nappy rash went untreated by the mother and became more serious. Advice about weaning and feeding was also not followed. 2.6. At around this time, the mother became pregnant; no professional was aware of this. Child E was found dead in the family home in January 2014. A post mortem was conducted and whilst unable to ascertain a definite cause of death it has highlighted a range of contributory factors about the cause of death. These were indicative of a significant failure to thrive. 3. The Serious Case Review process Methodology for this Serious Case Review 3.1. Throughout, this review has remained mindful of the principles outlined in statutory guidance2 for conducting reviews. It has endeavoured to examine the case in a manner which is both proportionate whilst balancing the public interest in the outcome. The methodology for this review has therefore comprised of; The formation of a Serious Case Review Reference Group in order to contribute to the gathering and analysis of information as well as ensure the smooth and timely completion of the review. Reference Group members were responsible for commissioning and seeking their own respective agency information for submission to the review. Members of this Reference Group were independent of line management responsibility for any member of staff involved in this case thereby ensuring a sufficient level of impartiality. Due to a known potential conflict of interest within one agency under review (Cambridgeshire Community Services: Health Visiting Service) an Independent Consultant 2 Principles for learning and improvement: a culture of continuous learning and improvement, proportionality, independence, seeking the involvement of professionals, seeking the contribution of children and families, ensuring reports are published, and ensuring sustained improvements, p.66/67, Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, March 2013, HM Government 5 was commissioned to review the contribution and actions of this agency. This provided a sufficient level of impartiality. This group met six times between June 2014 and April 2015. Membership of this group is shown in Appendix 1; The Independent Chair of Luton LSCB appointed Kevin Ball, NSPCC Senior Consultant as the Independent Lead Reviewer for this Serious Case Review. Neither the Independent Lead Reviewer, nor the NSPCC, had any involvement with the subject of this review or members of the family and the professional network; The appointment of an Independent Chair of the SCR Reference Group – Keith Ibbetson – to oversee and facilitate the smooth and timely completion of the review process; The use of a methodology which adhered to the principles set out in statutory guidance and which aimed to critically examine the episodes of professional contact where there was the greatest value in pursuing learning, understanding what happened and the reasons why individuals and agencies acted as they did; Obtaining single agency chronologies of involvement with the child and family3 (taken from individual agency records) and single agency tabular time-lines4 (taken from individual agency records, interviews held internally and reflection on the practice that took place) which identify key practice episodes5; Examination of other relevant working documents which informed the review process e.g. policies and procedures (from the range of agencies involved), case evidence and information (from the range of agencies involved), and other pertinent documentation such as other local SCRs, Ofsted reports, research and LSCB documents/reports; Individual conversations and interviews (via phone and face to face) with key professionals who were involved in the case, where possible, and interviews with family members (where possible). In order to ensure transparency and fairness6 professionals interviewed were provided with information about the review purpose and process; 3 Chronology detailing all contacts with the child and family from 20/07/09 to 17/01/14, including background contextual information 4 Tabular time-lines: Adapted from a Root Cause Analysis investigative approach devised by the National Patient Safety Agency (NHS), 2011 5 Key practice episodes: concept drawn from work undertaken by SCIE (Social Care Institute for Excellence) Learning Together model, to describe events “… that seem to be points at which actions were taken that had a decisive effect on the future course of the case, an effect sometimes positive and sometimes negative”, SCIE, Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Report 19, 2008, p 78, Fish, Munro & Bairstow 6 Ensuring fairness, 2013, p.13, Improving the quality of Children’s Serious Case Reviews through support & training, NSPCC, Sequeli, Action for Children, Department for Education, 2013 6 Requesting single agency action plans at the outset of the review as well as at the conclusion of the review process as a way of encouraging continuous learning and improvement7; Being respectful of parallel proceedings taking place alongside this case review, namely a police investigation and associated criminal proceedings but also care proceedings, and working collaboratively with those conducting those proceedings. Scope of this Serious Case Review 3.2. The scope of the review was intentionally set wide to begin with. This allowed the Independent Reviewer in collaboration with the Reference Group to consider the data presented and examine emerging themes. From this, further refinement of the scope, where useful, was possible. The terms of reference for this review were set as; 1. To initially review events between July 2009 and January 2014 whilst also considering any relevant background contextual information prior to this defined period of time; 2. To review the actions of the agencies that came into contact with Child E and family; 3. To review key practice episodes, within the above timeframe, up to the date of Child E’s death; 4. To specifically consider the following issues: the use of the Common Assessment Framework (CAF), the use of the Graded Care Profile, thresholds for intervention, professionals holding information but not seeming to act on it, assessments, service provision, communication across agencies, and the interaction with parents; 5. To seek to involve parents, carers and other family members, in the review, as appropriate; 6. To produce a final report which: a) Provides a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence, b) Is written in plain English and in a way that can be easily understood by professionals and the public alike, and, c) Is suitable for publication without needing to be amended or redacted, d) Is completed within appropriate timeframes. These were initially set within a six month period (June 2014 – December 2014) however due to the police and criminal investigation this was delayed. 3.3. The review methodology has balanced an investigative approach with a wider understanding about the system in which agencies and professionals were operating. The process has often required certain agencies 7 New learning from serious case reviews: a two year report for 2009-2011, Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson, Centre for Research on the Child and Family in the School of Social Work and Psychology, University of East Anglia/Health Sciences Research Institute, Warwick Medical School, University of Warwick 7 to undertake a further analysis of specific information following a period of interrogation by the Independent Reviewer and the Reference Group. This approach has encouraged greater local analysis, improved local ownership and accountability and a deeper appreciation of why events occurred as they did. Involvement of the child, family & carers in this review 3.4. The contribution of family members to this review was desired from the outset. Research8 has shown there to be added value when this can happen particularly in respect of promoting a child centred review and seeking key information from those closest to the child. 3.5. The mother, grandmother and father were informed of the review at the outset. Due to the Police investigation there was an inevitable delay in seeking the contribution of family members. An agreed and joint strategy was formulated between the Police and Independent Reviewer as to how best secure the participation of family members in the review process. Letters were sent, via Special Delivery, to the three family members. The mother and father made no contact with the Independent Reviewer. The grandmother made contact and expressed an interest in contributing however did not follow this through with action despite subsequent attempts to speak over the phone. On this basis, it has not been possible to secure the family’s contribution to the review within the timeframes agreed by the LSCB. Limitations of this review 3.6. A number of professionals who were involved in this case no longer work for their respective agencies. Whilst these practitioners have not contributed to the review the Independent Reviewer is satisfied that sufficient information has been gathered to understand practice at the time, capture learning and inform improvements. 3.7. As already stated, family members were offered the opportunity to contribute to the review. Regrettably this was not taken up. In turn, this has limited the Reference Group’s understanding about how professionals attempted to work with family members. 3.8. The review has identified practice challenges for agencies with the multi-agency understanding of thresholds for intervening when there may be concerns about a child’s welfare. Ofsted9 noted many positives in local safeguarding arrangements in 2012. It is beyond the specific scope of this review to consider, in any depth, changes that may have occurred since this Ofsted finding in 2012. It will be the responsibility of the LSCB to consider the specific findings of this review in the context of its wider understanding of local safeguarding arrangements and thresholds. 8 A study of family involvement in case reviews: Messages for policy and practice, Morris, K., Brandon, M., Tudor, P., BASPCAN 9 Ofsted, 2012, Inspection of safeguarding and looked after children services Luton Borough 8 4. Summary professional contact with Child E (including siblings) & family members 4.1. For ease of reference, Table 1 provides a substantially summarised account of professional contact with Child E’s siblings. This information has been extracted from a combined chronology of agency involvement with the family. A similar table for Child E has also been produced. They have been separated as it allows the review to consider patterns of behaviour and engagement by the mother with professional services in respect of each child; this aids analysis and findings. Table 1: Summary chronology of relevant & key professional contacts with Child E’s siblings: Siblings 1 & 2 Key to agencies: LDUH – Luton & Dunstable University Hospital CCS – Cambridgeshire Community Services C&L – Local authority Children & Learning Department GP – General Practitioner Sibling Contact with agency & professional Sibling 1 (2009) LDUH: Pregnancy booked with the Community Midwife responsible for teenage pregnancies. Mother aged 17 years. No significant history noted. Routine appointments completed at 10, 15, 22, 26, 28, 32, 35, 40 weeks. Within this period Surestart Midwife and Connexions worker visited to discuss support available at local Children’s Centre. Sibling 1 (02/10) LDUH: Sibling 1 born. No concerns noted. Sibling 1 (03/10) LDUH: Postnatal care provided by Community Midwife from teenage caseload team. There were two occasions of no access during this period of midwife care. Routine discharge to Health Visitor. Sibling 1 (04/10) CCS: Six week check at GP Practice. First primary immunisations given. Sibling 1 (09/10) CCS: Second primary immunisations given at GP Practice (overdue). Sibling 1 (02/11) CCS: One year development check cancelled by mother. Sibling 1 (05/11) CCS: Third primary immunisations given at GP Practice (overdue). Pregnancy (06/11) LDUH & CCS: Pregnancy failure noted on file. Safeguarding concerns were raised about the mother (aged 18 years) who had a one year old child, was living in poor housing conditions which were unsuitable for a child or new-born, home cluttered, smoke filled, bird droppings. Sibling 1 (06/11) CCS: Booster immunisations given at GP Practice. Siblings 1 & 2 (08/11) CCS: Health visiting service informed of concerns expressed by LDUH. Records indicate that Midwifery would complete Common Assessment Framework (CAF). Records also indicate that three months pass where no action was taken by either CCS or LDUH in respect of the CAF or follow up to concerns. Sibling 2 (11/11) LDUH: Formal booking at home visit of third pregnancy (Sibling 2). House noted to be smoky and very untidy. Sibling 2 LDUH: Routine antenatal care appointments completed at 16, 20, 24, 28, 29, 32 weeks. During this period the Health Visitor was denied access to the home a number of times 9 (including attempts to speak over the phone which were also cut off). The mother declined a visit by the Midwife. Further support was also declined. Sibling 2 (03/12) LDUH: Mother attended hospital and was seen smacking and shouting at Sibling 1, allowing her to wander; mother also appeared unkempt. Information was shared by LDUH with the Health Visitors. Sibling 2 (05/12) LDUH: Sibling 2 born (premature). Sibling 2 (05/12) LDUH & CCS: Separate home visits during the same day – LDUH granted access, CCS denied. Further access denied later in the same month. Sibling 2 (05/12) LDUH & C&L: Sibling 2 admitted to hospital (at 11 days old) due to poor feeding and weight loss. C&L informed as mother had been difficult to contact, did not appear to interact well with the baby and there were concerns about her care of the baby. Social Worker conducted two home visits, home conditions reported as ‘very untidy’ (via an independent assessment commissioned by C&L), and the home conditions were perceived to have slightly improve. Sibling 2 (06/12) CCS: Opportunistic home visit conducted by Health Visitor. Home conditions reported as cluttered but ‘fairly clean’. Further advice given and appointment made. Sibling 2 (06/12) CCS: Health Visitor conducted a new birth visit. Risk assessment completed and discussion about a further assessment being completed. Sibling 1 CCS: Mother encouraged to attend a local Stay and Play group for Sibling 1. Further visits over the next four weeks found the children clean and well-dressed. The home conditions continued to be very cluttered and dirty but with some improvements. Further visits cancelled by mother. Siblings 1 & 2 (08 – 11/12) CCS: Opportunistic visit by the Health Visitor to home. Home smelt strongly of cigarette smoke, remained very cluttered and dirty, floor covered in rubbish, safety hazards. Home safety assessment completed. Mother planned to register Sibling 1 at local Nursery. Further assessment to be completed. No access when further visits were attempted. Health Visitor 1 contacted C&L to express concerns. Agreed that CCS would continue to monitor. Consideration of using the CAF. Child E (01/13) LDUH: Pregnancy booking in respect of Child E. Refer to Table 2. Sibling 1 (09/13) Nursery/School: Sibling 1 begins school. 4.2. Table 2, similarly, provides a substantially summarised account of professional contact with Child E. This information has been extracted from a combined chronology of agency involvement with the child and family. Table 2: Summary chronology of relevant and key professional contacts during Child E’s lifetime Key to agencies: LDUH – Luton & Dunstable University Hospital CCS – Cambridgeshire Community Services C&L – Local authority Children & Learning Department GP – General Practitioner Weeks Contact with agency & professional -20 weeks LDUH: Community Midwife books pregnancy at Aunt’s home as the grandmother was not 10 from birth (01 -02/13) happy with the pregnancy and did not want the Midwife in her home. Information shared (including information held about previous similar concerns in respect of the two older siblings) with Health Visitor. Mother refused to sign a CAF. -18 weeks (02/13) CCS: Planned home visit in respect of sibling 2. Home appeared cleaner, strong smell of cigarette smoke, stairs clutter free. Home safety advice given. Further assessment not completed due to perceived improvements. Review in one month. -11 to -3 weeks from birth (04 – 05/13) LDUH: Mother attended hospital on nine separate occasions over an approximate nine week period. Routine medical advice and treatment provided. 0 (06/13) LDUH: Child E born prematurely at 30 weeks gestation. Weeks 0 – 8 (06 – 08/13) LDUH: Child E remained in hospital due to prematurity initially receiving high dependency care and then special care. During this time the mother was contacted by CCS to arrange a new birth home visit. Week 8 (08/13) LDUH & CCS: Child E discharged from hospital and returned to family home. New birth visit conducted by Health Visitor 1. Family assessment completed. Week 10 (08/13) CCS: Review home visit conducted by Health Visitor. Suggested weighing of Child E to take place by Community Nursery Nurse and two year check for sibling 2. Week 11 (09/13) CCS: Community Nursery Nurse conducted home visit. Child E weighed. Concerns noted about home conditions; very cluttered, limited space, strong smell of cigarette smoke, unable to manoeuvre adequately. Advice given. Concerns shared with Health Visitor 2. Week 11 (09/13) GP: 8 week GP check. No significant concerns noted. Week 14 (09/13) LDUH: Scheduled attendance at Outpatients Department for review by a senior staff grade paediatrician. No concerns noted. Review recommended in 10 weeks (December). Child E and mother also seen by LDUH neonatal physiotherapist. Unable to complete full assessment due to baby being unsettled. Further appointment made. Week 15 (10/13) LDUH: Mother did not attend follow up appointment with Neonatal Physiotherapist. Letter sent from LDUH to the mother and CCS informing them of this. Week 15 (10/13) CCS and LDUH: Mother did not attend clinic appointments. Week 18 (10/13) LDUH & GP: Attendance in Emergency Department for Sibling 2 and then next day by GP for a respiratory tract infection. LDUH prescribe an inhaler. Concerns noted about the quality of parent – child interaction with Sibling 2 and dirty presentation. Information shared with C&L and Health Visitor 2. Request for health promotion advice to be given. Concerns expressed about home conditions and potential impact on Child E due to his prematurity. Week 18 (10/13) CCS: Home visit. Concerns about sleeping arrangements were raised. Week 18 (10/13) GP: Mother attends GP surgery for Child E’s first set of primary immunisations CCS attempt a home visit; no access. Week 19 (10/13) CCS: Attempted home visit by Health Visitor 2. Grandmother deceived Health Visitor and Community Nursery Nurse about presence of children in the house. No access. Health Visitor returned for home visit and gained access. Week 19 (10/13) CCS & C&L: Announced home visit by Health Visitor 2 and Community Nursery Nurse. Depression assessment offered but declined. No concerns noted. Child E not seen – informed by mother he was sleeping. Advice given. C&L contact Health Visitor 2 to discuss concerns expressed by LDUH. Health Visitor advised that any developments would be reported back to the department. It was reported that, although there were issues, the Health Visitor held no concerns for the children. 11 Week 22 (11/13) CCS: Home visit by Health Visitor 2. Concerns were discussed. Mother still in pyjamas at 11.30am. States she is scared to leave the house due to local gun crime, lacks confidence. Grandmother will not agree to a further assessment being conducted. Discussion about attending local play group. Health Visitor 2 made contact with Nursery/School. Week 22 (11/13) CCS: Telephone call to mother as she did not attend the Children’s Centre as agreed. Further offer of an assessment of the mother’s mental health; declined. Week 25 (12/13) LDUH: Mother attended neonatal physiotherapy appointment with Child E. No concerns noted with baby developing appropriately. Week 26 (12/13) LDUH: Child E seen in hospital for a Consultant review. Advice given about nappy rash and oral thrush. Mother uncertain about immunisations. GP to prescribe for Candida. Health Visitor 2 to monitor weight as it had dropped a centile. Discussion about weaning onto different formula. Growth on 2nd – 9th centile; mother advised to change milk from specialist formula to Cow & Gate and to start weaning. Plan to review in 3 months. Dietetic follow up not carried out. Week 29 (12/13) CCS: Health Visitor 2 & Community Nursery Nurse conduct a home visit. Mother did not followed advice about nappy rash. Week 30 (01/14) CCS: Health Visitor 2 leaves a message for the mother reminding her about the need to collect prescription and treat nappy rash as she had failed to do so. Week 30 (01/14) LDUH: Ambulance called to home. Child E found dead. 4.3. Prior to all of the above contacts in respect of Siblings 1 and 2 and Child E, evidence submitted to this review indicates that Luton Borough Council Housing Department formally expressed concerns to their tenants about the poor condition of the garden at the family home in 2006 (rubbish and dog faeces in the garden). No further action was taken. 4.4. Additionally, at the outset of this review process being commissioned it was discovered that the mother was pregnant with her fourth child. It is believed that the mother would have known about being pregnant at the time of Child E’s death. Agencies were unaware of this pregnancy until the mother booked into antenatal services at 20 weeks. 5. Outcome statements 5.1. The cause of Child E’s death is undetermined however the findings of the post mortem indicate a significant failure to thrive, highlighting dehydration and malnutrition as significant contributory factors. 5.2. Child E’s mother and grandmother was both found guilty of cruelty to a person under 16 years of age under the Children and Young Persons Act 1933 and guilty of causing or allowing the death of a child under the Domestic Violence, Crime and Victims Act 2004 – and sentenced accordingly. 5.3. Following the death of Child E all of the siblings were removed from the mother’s care by Order of the Court. For this to happen, a threshold of significant harm, or the likelihood of significant harm must have been proven. Care proceedings have concluded and the three siblings are now subjects of Special Guardianship Orders and living with members of the extended family. They are all reported to be making positive progress. 12 6. Review and analysis of single agency contact, including findings 6.1. Information from all the agencies that had contact with Child E and family has been collated as part of this review process. This has allowed a unique opportunity for the Independent Reviewer and the SCR Reference Group to see the entirety of agency involvement. In turn, this has prompted agencies to understand where they can learn about improvements in practice. Findings10 are presented throughout which are then used to inform a thematic analysis in section 6. Luton & Dunstable University Hospital (LDUH) 6.2. Submissions to this review reveal that the hospital’s first contact was with the mother when she was 17 years old and pregnant with her first child (Sibling 1). During this pregnancy there was nothing of significance noted, with appropriate support being provided by the team responsible for teenage pregnancies. Midwives met with the mother on a number of occasions (see Table 1). Practitioners have described visiting the family home and observing ‘stuff’ and having concerns about the cigarette smoke (July 2009 to March 2010). Evidence submitted shows that there were appointments missed by the mother when midwives attempted to visit with no access gained but also developmental checks were cancelled by the mother. Primary immunisations were not given as scheduled. 6.3. Finding: Information gathered during this period was not shared by LDUH with other key agencies e.g. the health visiting service or the local authority children’s services, as there were no safeguarding concerns identified. 6.4. A failed pregnancy in June 2011 prompted internal communication (via a cause for concern letter) which was then prioritised by the hospital safeguarding team. In turn this prompted the Midwifery Service (LDUH) to share information externally with Cambridgeshire Community Services Health Visiting Service, highlighting cigarette smoking, a cluttered house, and bird droppings from a pet bird. The resultant plan of action was that the Health Visiting Service would make contact with the mother to assess the situation. 6.5. Evidence reveals a similar pattern of engagement by the mother during the second successful pregnancy and subsequent birth of Sibling 2 (this included a short period of Sibling 2 being re-admitted to hospital three days after initial discharge). Similar conditions in the home environment were noted by the Midwifery Service as well as limited parenting skills and poor hygiene when feeding the young infant. On this occasion, this information was shared through an electronic safeguarding alert system with the Health Visiting Service but also the Children & Learning Department (November 2011 to June 2012). 6.6. Finding: At this point information was appropriately shared with other agencies by LDUH given the known history and presenting issues. 6.7. Although we see a similar pattern of engagement by the mother during the pregnancy for Child E, it is evident that this pregnancy appeared more difficult and stressful for her. She attended the hospital on nine separate occasions (April to May 2013). During this pregnancy records indicate that midwives observed and discussed with the mother concerns about the home environment, housing issues, risks of smoking in the 10 Finding: a judgement or conclusion about a particular aspect of professional practice (positive or negative) where there may be learning. 13 house with children present (Siblings 1 & 2) and general support needs. The mother refused to consent to a Common Assessment Framework (CAF) being completed. 6.8. Records show that these concerns were also shared with the Health Visiting Service (May 2013). Appropriately (based on research and national learning from serious case reviews11), domestic abuse was considered by the hospital given the multiple admissions to hospital during this time, despite there being no explicit evidence it was an issue. 6.9. Finding: This information was appropriately shared internally by LDUH with the Safeguarding Midwife and externally to the Health Visiting Service. 6.10. Following Child E’s birth (10 weeks prematurely), positives were noted by maternity staff in as much as staff observed the mother being confident and caring with Child E whilst in hospital, although her visiting was late in the day due to caring for the older siblings. There were no concerns about her interactions with Child E at this time. 6.11. Child E was discharged home seven weeks after birth (August 2013). Review of records show there was a delay by LDUH in informing Cambridgeshire Community Service Health Visiting Service about the birth (CCS received a letter six days after birth and then a notification 13 days after birth). Given that Child E remained in hospital during this period and the care of Child E was noted to be satisfactory, the need to share information immediately was less critical. During this period there were a series of telephone exchanges between staff at the hospital, Health Visitor 2 and the mother. Health Visitor 2 was kept informed of the delays in discharge. 6.12. Finding: The telephone contact between staff on the neonatal intensive care unit in hospital and Health Visitor 2 indicates good practice. 6.13. In September Child E attended hospital for a routine outpatient’s appointment, being seen by a Doctor and the neonatal physiotherapist. No significant concerns were noted, particularly regarding weight gain. 6.14. Concerns were raised by LDUH when Sibling 2 was brought to the hospital in October 2013. Sibling 2 was described as dirty and wearing dirty clothing and it was felt that the mother was not coping well with three young children. This resulted in a further electronic safeguarding alert being completed and shared with the Health Visiting Service. Information was shared by Health Visitor 2 to the Safeguarding Nurse for children in the hospital about the maternal grandmother smoking heavily and hoarding. Information was relayed back to hospital staff that the home environment may pose a risk to a premature baby. Information was also shared with local authority Specialist Family Support service. A plan was agreed between LDUH and the Health Visiting Service that a referral would be sent highlighting the need for assessment by the Specialist Family Support service but also support from the Health Visiting Service. 6.15. Finding: This was an appropriate course of action by LDUH; concerning information had been gathered by the hospital about all three children and shared with other agencies. Alerts were raised in June 2012, May and October 2013. 11 NSPCC Briefing, Domestic abuse: learning from case reviews: What case reviews tell us about domestic abuse, November 2013 14 6.16. At this point in time the mother, aged 22 years had care of three children all under the age of 3 years 8 months. This would be a significant task for any capable and well-resourced adult, let alone a young single mother in less than advantageous circumstances. 6.17. The final contact LDUH had with Child E, prior to death, concerned a routine series of appointments with the Consultant and the Neonatal Physiotherapy Team (December 2013). No significant concerns were raised by either professional about Child E’s weight or appearance. However, Candida nappy rash was noted and the mother was clearly advised to see her GP, obtain medication to treat the condition, and have it reviewed. Child E’s weight was to be monitored by the Health Visitor and GP as it had dropped on the centile chart. Advice on weaning and feeding was also given. A letter was written by the Consultant to the GP outlining these findings. This letter was typed the day after the consultation and received by the GP three days later. 6.18. Finding: Independent and expert medical opinions12 obtained for the purpose of this review have noted that, based on documentary review, there was evidence of Child E failing to consistently gain weight from the point of discharge in August. Although this opinion has been gained with the benefit of hindsight and with all information to hand, the failure to consistently gain weight would have been apparent at the consultation in December. The reason this was not spotted was due to a professional failure to compare individual measurements of growth against an overall trend. This would have revealed a downward trajectory and would have been sufficient to trigger prompt action. An additional contributory factor, of a procedural nature, was that there was an inappropriately wide 12 week gap between two reviews of Child E (particularly given prematurity) where there was an identified weight gain problem. Finding: It would have been more helpful for LDUH to have issued the medication or at least the prescription to the mother from the hospital at that time in December, rather than transfer the issue of a prescription to the GP practice. This would have ensured the mother had the correct treatment and could begin applying it immediately. 6.19. Of note, at the time of the mother’s final visit to the hospital in December 2013 she would have been 10 weeks pregnant. This pregnancy was not however known about by agencies at the time. 6.20. Also of note, throughout the involvement of the hospital with these three pregnancies the children’s father was never seen. No information has been submitted to this review to indicate that there was any questioning about the father. Until very recently, the routine asking of information about a prospective father has not been sought. This is changing and the Midwifery Team is currently developing a new booking application which will seek information about fathers e.g. names, date of birth, address, contact arrangements, mental health/drug misuse, other children. It is planned that this will become procedural by the summer of 2015. 6.21. In summary, firstly evidence indicates that LDUH Midwifery Services acted appropriately with information they had gathered in the course of their involvement with the mother and children with the exception of not sharing information with other agencies during the first pregnancy in 2009. Information was gathered and used to inform an assessment of the level of individual vulnerability and potential risk to each 12 Independent and expert medical opinion gathered from three sources: 1) The former Designated Doctor for Safeguarding Children & Young People, 2) The current Consultant Community Paediatrician and Designated Doctor for Safeguarding, 3) Professor and Consultant Neonatologist appointed for legal proceedings. 15 of the children; this was achieved in a timely manner. Electronic database systems were used by LDUH to share this information and these appear to have been effective. These findings should be considered in the context of inspection findings made three months following Child E’s birth. The inspection by the Care Quality Commission13 noted that “… there were enough qualified, skilled and experienced staff to meet people's needs in the main hospital, however in the Maternity Unit staffing levels were not in line with national expectations which meant staff were working under increased pressure …”. Despite these pressures expected policy and procedure were followed. Secondly, two opportunities were missed by medical staff in September and December 2013 to effectively respond to Child E’s failure to consistently gain weight. Cambridgeshire Community Services (CCS Health Visiting Service) 6.22. Cambridgeshire Community Services has submitted a detailed and comprehensive chronology of key practice episodes. It is evident from these submissions that there were a number of opportunities for the community health service to gather information, make assessments and respond. 6.23. CCS first had contact with Sibling 1 at a routine new birth visit. Further developmental checks were cancelled by the mother and there were delays in Sibling 1 receiving primary immunisations due to the mother not attending appointments. No records of these contacts exist on the CCS electronic database which may be due to it not being fully implemented at this time. No concerns about the home conditions at this point in time are therefore logged. 6.24. A further pregnancy in June 2011 prompted liaison between the Midwifery Service (LDUH) and CCS, resulting in a cause for concern letter (June & July 2011) being shared. This pregnancy failed but the mother soon became pregnant again prompting a further sharing of information between professionals highlighting cigarette smoking, a cluttered house and bird droppings from a pet bird. The resultant planned action of this sharing of information was that the Health Visiting Service would make contact with the mother. Concerns were shared to the CCS Safeguarding Team14 via the electronic share mechanism (August 2011). An electronic ‘share’ is an on-line mechanism where one person can request another to view information; dependent on the content the sharer may, or may not, be seeking advice. 6.25. Finding: The sharing of information about a further pregnancy to the CCS Safeguarding Team was an appropriate course of action given the level of concerns expressed. However, this review has shown that front line practitioners in CCS and members of the Safeguarding Team had differing expectations about how information would be responded to. 6.26. There were a series of exchanges between the Midwifery Service and the Health Visiting Service over a four month period from the point when professionals were alerted to the failed pregnancy (June to October 2011). Records reveal that attempts by the Health Visiting Service to visit or contact the mother were first made from October 2011. Other attempts were made over this period by the Midwifery Service but these either failed or showed that home conditions had not improved. There were also five liaisons between the Midwife and Health Visitors (June to December 2011), indicating a high level of contact beyond that which would routinely be expected during a pregnancy. 13 Care Quality Commission, Inspection report for Luton & Dunstable Hospital, published October 2013 14 CCS Safeguarding Team: A team of experienced and specialist practitioners who do not hold a specific caseload or undertake health visiting duties. They provide supervision, support and additional expertise to Health Visitors. 16 6.27. Finding: As well as seeing an increasing number of risk factors we can also see a developing picture of failure to engage with services and non-compliance by the mother. It is reasonable to conclude that these risk factors could have been identified and considered at the time. 6.28. Evidence submitted also reveals confused practice by the Health Visiting Service during this time period; uncertainty whether a CAF had been completed, two separate Health Visitors making home visits on the same day with no apparent coordination, and liaison with two separate Midwives. It has not been possible to interrogate these episodes further to explore the reasons for the above confusion as the individuals involved are no longer employed by CCS. The review has found that, at this stage, there was no expectation that the Safeguarding Team would take any action in terms of providing advice as the ‘share’ to the Team was for information only. This Team have reported that there are too many cases shared to make reading of each case sustainable and practicable. 6.29. Finding: Notwithstanding assessment and information sharing by LDUH Midwifery Service, the response by CCS Health Visiting Service around December 2011 was fragmented and lacked coordination. 6.30. A further cause for concern letter was raised (April 2012) by the Midwifery Service to the Health Visiting Service and local authority Children & Learning Department as the mother was observed to be unkempt, had been seen shouting and smacking Sibling 1, and failing to provide appropriate supervision. At this point the mother was pregnant with Sibling 2. The next recorded contact by the Health Visiting Service was in May 2012 at a new-birth visit for Sibling 2. 6.31. Finding: There is no recorded explanation or apparent resolution about actions taken as a result of this cause for concern letter being shared in April 2012, other than an unsuccessful home visit by the Health Visiting Service. 6.32. Of note, information was ‘shared’ with the CCS Safeguarding Team. As stated earlier, evidence indicates (written submission and interviews) differing expectations about what action might be taken once information is ‘shared’. This period of time reveals further situational risks – potential self-neglect by the mother during pregnancy, a failure to respond to Sibling 1’s health needs by not attending routine appointments, a failure or inability to appropriately supervise or manage Sibling 1, experiencing stress resulting in shouting and smacking, a disclosure of historical sexual assault by the mother and a refusal of home visits by the mother. These factors clearly indicate an escalation of potential risks to Sibling 1 and the unborn Sibling 2. At this point in time it is possible to see a developing picture where a more robust style of early intervention would have been entirely reasonable in order to promote the children’s welfare. 6.33. In May 2012 Sibling 2 was born prematurely at just over 35 weeks. Home visits by the Health Visiting Service were either declined or failed. Sibling 2 was admitted to hospital 11 days after birth due to feeding problems and weight loss. This prompted information to be shared with the local authority Children & Learning Department by LDUH, as there were concerns about the mother’s care of the baby whilst in hospital. This will be examined more closely in the section on Children & Learning Department. 17 6.34. Additionally, two home visits were achieved by Health Visitor 1 during this time – one in which a vulnerability risk assessment15 was completed. This revealed a number of risk factors which were previously known by the Health Visiting Service. Records reveal that Health Visitor 1 also discussed with the mother the use of the Graded Care Profile assessment framework16. 6.35. An appropriate plan of intervention and support was initiated during this time period – the use of a risk assessment framework, the suggestion of using a further assessment framework (Graded Care Profile), a suggested plan for a Community Nursery Nurse to visit on a weekly basis, advice being given about issues such as hygiene when feeding, prevention of SIDS17 , risks associated with smoking and needing to ensure a clean and tidy home environment, and the commissioning by Specialist Family Support of additional support. 6.36. Finding: Using hindsight to our advantage, this review finds that this period of time (May to June 2012) offered a valuable opportunity. As well as managing the immediate and presenting concerns affecting Sibling 1 and 2, ongoing support could have been considered. The opportunity of early and coordinated intervention was not maximised because there was no one single agency taking a lead on overseeing case management; agencies were working in relative isolation of one another. The natural opportunity presented to the Children & Learning Department to take this lead was not taken up because the Health Visiting Service considered that they had a greater role in working with the family and did not see the need for shared management. 6.37. Over the following weeks home conditions fluctuated, sometimes with slight improvements and at other time’s conditions falling back. Some compliance was demonstrated by the mother with access to the home achieved, an overdue developmental check being completed for Sibling 1 and developmental checks being completed for Sibling 2. 6.38. The intention of using the Graded Care Profile was never followed through with action because of the perceived improvement in home conditions. Records also reveal that there was no further contact with the family until November 2012 when Health Visitor 1, opportunistically, achieved a successful home visit. Home conditions were observed to have deteriorated with a strong smell of cigarette smoke, dirty carpets with rubbish on the floor, and inappropriate bed sharing arrangements. Additionally, Sibling 2 had only received one set of immunisations and was now behind the recommended schedule of immunisations. Further mention of completing a Graded Care Profile was raised – but again this does not appear to have been followed through because Health Visitor 1 did not gain access to the home. Health Visitor 1 did share information about this deterioration with the Team Lead. The advice given included, completing an internal initial assessment pro-forma to consider seeking additional support to manage the case, but also to contact Specialist Family Support. 6.39. Finding: The response by Health Visitor 1 to share the concerns to the CCS Safeguarding Team was appropriate. The Health Visitor, on the advice of the CCS Safeguarding Team, did contact Specialist Family Support who confirmed that they were not actively involved with the family. The Health Visitor shared the concerns but also detailed a plan of action to be led by the Health Visiting Service. The agreed plan of action 15 A locally developed assessment tool that is designed to be used in conjunction with the Graded Care Profile as a means of initially identifying a child at risk of neglect through a range of listed factors which are associated with vulnerability 16 Graded Care Profile, http://lutonlscb.org.uk/graded.html 17 Sudden infant death syndrome (SIDS): the sudden, unexpected and unexplained death of an apparently well baby 18 (as above), unless a further formal referral was received, relied on the Health Visiting Service to take the lead with there being no role for Specialist Family Support. This was a missed opportunity. 6.40. In February 2013 the grandmother was seen at an opportunistic home visit by Health Visitor 1. A further home visit took place three days later and home conditions were noted to be similar although less cluttered. The level of smoking remained an issue. The use of the Graded Care Profile was raised again but due to the perceived improvement by the Health Visitor, this was not followed through. This reflects a level of professional optimism18 in that small changes were deemed acceptable but failed to acknowledge the history and wider concerns for the welfare of the children. Calder (200819) discusses optimism, noting that practitioners often “… over-estimate the level of progress made, fail to consider the significance of past agency experiences of dealing with the family and make decisions based upon opinion rather than fact …”. A further appointment was to be made for one month. This did not happen due to Health Visitor 1 going on extended sick leave. The next time the Health Visiting Service made contact with the mother was five and a half months later when the case was transferred to Health Visitor 2. The case was not picked up by the Health Visiting Service during this intervening period. 6.41. Finding: There was an unhelpful level of professional optimism by Health Visitor 1 about the changes and improvements made by this mother. The case (and therefore concerns and risks) was allowed to drift for over five months before being re-allocated to Health Visitor 2. 6.42. When Child E was born, prematurely, the LDUH appropriately referred their concerns to CCS. At this point the current (and newly appointed) Health Visitor 2 considered that the home conditions had improved, with the exception being the level of cigarette smoking. Action about beginning a Graded Care Profile had still not been taken. As stated earlier, Child E was in hospital for seven weeks until discharge. During this period, the review has noted good practice by the hospital in communicating with Health Visitor 2 (until the actual point of discharge). 6.43. Finding: Records highlight good practice by Health Visitor 2 in making contact, or attempting to make contact, with the mother whilst Child E remained in hospital. 6.44. At the time of Child E’s birth, Health Visitor 2 had been registered as a Health Visitor for less than a year and was still under guidance from a preceptor20. Health Visitor 2 had five child protection cases to manage (cases where children were subject to Child Protection Plans). No other team member had more than six child protection cases at this point in time. This seems to be an excessive number of high risk cases for a recently qualified practitioner. 6.45. From interview, handover arrangements between Health Visitors at this time have been described as less than satisfactory. Health Visitor 2 has described cases being ‘swapped’ between Health Visitors rather 18 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., Black, J., Research report: DCSF RR023, 19 Calder, M., 2008, Professional dangerousness: Causes and contemporary features , p 67, in Contemporary risk assessment in safeguarding children, Russell House publishing 20 Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals, 2010, p 10: Defining preceptorship: “A foundation period for practitioners at the start of their careers which will help them begin the journey from novice to expert.”, Department of Health, HM Government 19 than being transferred on a more considered and formalised basis. More experienced practitioners ‘swapped’ complex cases with less experienced colleagues. One interviewee recounted “… in other [locality] areas it would have been down to the Team Lead to make the decision about a swap. As a result of it being up to me the swap was sometimes unfair. One case would not be swapped like for like. The people I was swapping with were, generally, more experienced than me … this was a case we swapped because it was a new birth, the previous Health Visitor did not feel she was getting anywhere and it needed a new fresh pair of eyes. I was aware that the mother had declined a CAF …. Although I was told about the issues I suppose I wasn’t aware, in my naivety, what I was taking on. Having a completed paper handover form would have helped so that I got the details and likely issues …”. 6.46. Finding: Health Visitor 2 had a very limited amount of experience of dealing with cases where child protection was a feature and appeared to carry a comparative caseload to other, more experienced practitioners. Transfer arrangements between practitioners were not as tightly managed as they could have been which led to cases being inappropriately allocated to less experienced practitioners. 6.47. Visits by the Health Visiting Service were achieved although there were also failed attempts to gain access to the home and see the children. Health Visitor 2 and the Community Nursery Nurse made strenuous efforts to make contact with the mother between June and September 2013 but met continued non-compliance from the mother. 6.48. One Community Nursery Nurse, has described “… experiencing great difficulty in finding any space to undertake the developmental checks on both Sibling 1 and 2 and finding the environment psychologically claustrophobic … it was difficult to engage with the mother and grandmother regarding the home environment and, in particular, their smoking and healthy eating for the children despite the mother appearing to be attentive …”. The Community Nursery Nurse felt “… that she could not challenge some of the behaviours she was witnessing i.e. children being given a constant supply of sweets and sugared drinks particularly in the presence of the grandmother … she also felt that any decision to make a child protection referral had to be the responsibility of the Health Visitor”. 6.49. Finding: The Community Nursery Nurse has described differing levels of experience, qualification and perceived status, including being viewed as less ‘qualified’ within the organisational structure as a barrier to making safeguarding referrals but also challenging the mother over her care. 6.50. In October 2013 the mother attended LDUH with Sibling 2 due to a cough. Staff were however concerned about the quality of the relationship between the mother and the child but also about the grubby appearance of the child. Whilst this prompted a referral to be made to the Children & Learning Department by LDUH the matter was also followed up by the CCS Rapid Response Team (a team that can accept referrals from A&E, Walk in Centre and respond to acute health needs or follow up treatment). Concerns about the quality of the interaction between the mother and Sibling 2, but also the sleeping arrangements for Child E were observed. Further contact and visits were attempted during October 2013 but were either met without success or declined by the mother. One such attempt encountered a level of deceit by the grandmother who stated that the children were not at home, just as Sibling 1 came to the door. 6.51. Health Visitor 2 has reflected on their involvement in this case during the early stages of managing the case “… I didn’t start from where the previous Health Visitor left off – I started from afresh …”. Reflection on this case has also prompted the Health Visitor to consider that “Since Specialist Family Support had received 20 the referral it would have been very helpful for a joint visit. It would have been better if I had made a paper referral to Specialist Family Support with a list of all the activities and with a chronology”. This is a useful reflection from a practitioner with limited experience and one that does seem entirely reasonable given the presenting circumstances; it does also however rely on the Health Visitor to use their interpersonal skills and share information in a manner which sufficiently engages and alerts a Social Worker to respond accordingly. This did not happen. 6.52. Finding: The mother and grandmother failed to comply, and attempted to deceive professionals. Attempts by professionals to engage and assist this family were thwarted. 6.53. Finding: Health Visitor 2 has described ‘starting again’ with this family. Brandon et al (2008, p11)21 refers to this “… one common way of dealing with the overwhelming information and the feelings of helplessness generated in workers by the families, was to put aside knowledge of the past and focus on the present, adopting what we refer to as the ‘start again syndrome’…. The ‘start again syndrome’ prevents practitioners thinking and acting systematically in cases of long standing neglect”. 6.54. A further opportunistic joint visit by Health Visitor 2 and the Community Nursery Nurse took place at the end of October 2013. This further visit was intended to be as a follow up to the referral made to Specialist Family Support. The mother was seen and the children were reported to be present in the house but only Sibling 2 was seen. Child E was not seen and was said to be sleeping and to have a cold. This was a missed opportunity to exercise some professional curiosity22 and observe whether Child E was safe, view the sleeping arrangements for all children as well as see the condition of the upstairs area of the family home. On reflection, Health Visitor 2 has appreciated that this was a missed opportunity but has described challenges that affected judgement. In particular, these relate to being “… very conscious I was a male health visitor going into a woman’s house and asking if I can see the bedroom …” to see the infant’s sleeping arrangements. 6.55. Finding: The home visit in October 2013 was a missed opportunity to see and check Child E’s health, weight and development. 6.56. A number of issues were discussed with the mother including the quality of the attachment to Sibling 2, lack of immunisations, impact of the environment and lack of stimulation on the children’s development, attendance at the Stay and Play Group for Sibling 2 and attendance at the clinic/GP for Child E, the mother’s mental health and housing. The mother declined the offer to complete a depression assessment (Whooley Depression assessment23). 6.57. Following this visit Health Visitor 2 contacted Specialist Family Support to inform them of the findings. It was reported that there were no concerns for the children but that a Graded Care Profile would be 21 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005, Brandon, M,. Belderson, P,. Warren, C,. Howe, D,. Gardner, R,. Dodsworth, J,. Black,, J,. Research Report DCSF-RR023, DCSF 22 For the purpose of this review professional curiosity is defined as the ability to exercise a sufficient level of questioning and challenge in order to fully understand or appreciate a situation or event. The ability to exercise professional curiosity may develop with experience. 23 NICE, 2007, Antenatal and postnatal mental health: Clinical management and service guidance, now replaced with NICE guidelines [CG192], 2014 21 undertaken. The Health Visitors views about there being no concerns were further reinforced when he made contact with the Nursery School and was told that there were no concerns about Sibling 1. 6.58. Finding: Health Visitor 2 appropriately made contact with the Nursery/ School but did not use the opportunity to its greatest advantage. 6.59. Finding: The opportunity to discuss the family and share concerns about the level of vulnerability and risk by the Health Visitor with Specialist Family Support was not maximised. The follow up contact by the Health Visitor to Specialist Family Support gave a false assurance about the children’s circumstances. 6.60. Health Visitor 2 made arrangements with the mother to meet her away from the home in order to ‘gather information’ as the practitioner felt the grandmother was an unhelpful influence on the mother during attempts to discuss issues in the family home. This took place and records indicate that a list of concerns was covered in this meeting. The mother declined the use of a CAF and the Graded Care Profile. The mother also described being scared of leaving the home due to local crime. 6.61. Finding: Health Visitor 2 usefully attempted to engage with the mother outside of her usual circumstances, recognising a potentially damaging dynamic between the mother and grandmother. 6.62. In December 2013 Child E attended a routine paediatric outpatient appointment. Child E was found to have mild oral thrush and Candida nappy rash. The mother was advised to make an appointment with the GP for a review, obtain a prescription, as well as seek advice about weaning. The consultation at the hospital also advised that the Health Visitor should monitor Child E’s weight as it had dropped a percentile. An unannounced home visit by Health Visitor 2 and Community Nursery Nurse took place three weeks later in January 2014 and found a very smoky house and Child E had not gained sufficient weight. The prescribed medication for nappy rash had not been collected. Weaning arrangements for Child E were also noted to be unsatisfactory. Siblings 1 and 2 were however noted to be clean. Evidence highlights that the mother was asked to present Child E for weighing in 3-4 weeks. The mother’s response was “ … this would depend on how she was feeling …”. Child E had serious nappy rash but had also not been transferred onto the appropriate feeding formula. The mother had begun weaning and was using bought jars of baby food. The mother declined advice about using family made foods. A follow up unannounced home visit two days later in January failed. One further telephone contact was attempted but without success. Child E died four weeks later. 6.63. Finding: This review has found that the percentile charts used by the Health Visitor to chart Child E’s weight development was the one found in the Red Book (record for individual child health given to all children following discharge from hospital). This records weight/height gain from 32 weeks. Child E was born prematurely and the percentile chart used in the hospital setting was different. Health Visitor 2 adjusted the weight gain from 32 weeks and not 30 weeks. This would have exaggerated Child E’s failure to gain weight; there was no analysis and interpretation of Child E’s weight and growth data. 6.64. We now know that at this time the mother would have 10 weeks pregnant. This was not known about by agencies at the time and was unlikely to be evident. 6.65. In summary, evidence indicates that the Health Visiting Service was in a prime position to take a lead on gathering information, make an assessment of the children’s circumstances and pass this on to the local authority Children & Learning Department requesting a more coordinated and robust approach. 22 Luton Borough Council: Children & Learning Department (Comprising of the Specialist Family Support service - which covers social care functions and referral and assessment and Prevention and Early Intervention service - which covers the CAF coordinating function) 6.66. Documentary evidence reveals that their first contact with this family was shortly following the birth of Sibling 2 (June 2012). The LDUH had made a referral as, following a home visit by the Midwifery Service, concerns were expressed about the conditions of the home but also the ability of the mother to care for the baby. This resulted in a visit to the family home via an independent social care provider. This service was initially sent by the Emergency Duty Team (EDT provided by a neighbouring authority – Central Bedfordshire) to complete a welfare check on Sibling 1. The house was found to be clean but with various hazards around the home, and it being ‘cluttered’. The family were advised to clean it up. A return visit was completed the following day by the independent social care provider and improvements were noted but the family were assessed as ‘struggling’. Based on this assessment, EDT agreed that Sibling 2 could return to the family home from hospital. Central Bedfordshire EDT referred this information to the Luton Referral and Assessment Team of the Specialist Family Support service recommending a follow up the next day. This follow up visit did not happen and no explanation can be provided for this omission. Essentially the brief assessment was a temporary and uncoordinated intervention to a more chronic situation which needed a more coherent and sustained response. 6.67. Finding: The Referral and Assessment Team missed a valuable opportunity to follow up concerns, but also to make further assessments on the family, despite recommendations from EDT and concerns being raised by the independent social care provider. No reason can be provided for this omission. This gave the impression to CCS (and Health Visitor 2) that the concerns were either not at a level that warranted further intervention from the Specialist Family Support service or there was no role for them as part of a multi-agency approach to dealing with the concerns. 6.68. The Specialist Family Support service’s second contact with other professionals was approximately four months after Child E’s birth (October 2013). This contact arose following a referral to them by the LDUH who expressed concerns about the care and treatment of Sibling 2. This resulted in an appropriate and pro-active exchange of information between the hospital, the Specialist Family Support service and Health Visitor 2 about the care of the children, including the home conditions and parenting issues. 6.69. The Specialist Family Support service made a clear and reasoned decision to not take any further action based on the information they were presented with. The Health Visiting Service was engaged with the family, were visiting regularly and was cognisant of the need to complete further assessments (specifically regarding both mental health and neglect). Progress on these plans was provided by the Health Visiting Service, including information about the mother’s failure to follow advice and refusal to participate in assessment work. However, this failure to comply was tempered with the Health Visiting Service detailing that there were no concerns about the children and that a further update would be provided to the Specialist Family Support service if it was deemed necessary. Records indicate that no information about recent historical concerns was shared. On this basis, the Specialist Family Support service did not undertake any further assessment nor gather any additional information, but instead closed the case. 6.70. Finding: This review finds that the Specialist Family Support service considered that they had a clear rationale to close the case. This was based on the fact that another professional (Health Visitor 2) was having 23 regular contact with the family and there appeared to be a clear plan of action which included the need to return to Specialist Family Support should further assistance be needed. Perhaps crucially, the Health Visitor had expressed no concerns about the children based on the content of the original referral. As there had been no follow up of their involvement in 2012 the Specialist Family Support service’s rationale was based on incomplete information. 6.71. Evidence submitted to the review reveals there to be a reoccurring issue of uncertainty, presented in both the LDUH and the CCS submissions about whether a CAF was ever completed. The local authority Prevention and Early Intervention service would routinely take the lead on coordinating a CAF. Evidence submitted to the review reveals that there are no records submitted to Prevention and Early Intervention service to indicate that a CAF was ever completed. This therefore leaves a question about why LDUH and CCS ever thought a CAF had been completed. No explanation can be provided about this. 6.72. In summary, we see attempts to engage the local authority Children & Learning Department through the sharing of information by the LDUH and the Health Visiting Services. The Specialist Family Support service gave reasoned judgements about why they would not become involved in 2013. However, the review has also discovered that the Specialist Family Support service missed an important and valuable opportunity to engage with this family and professionals in 2012. General Practitioner and Surgery 6.73. A chronology of contact and key episodes with the GP and Surgery has been submitted to this review. Practitioners have described a positive working relationship with the mother, who appeared similarly to any other typical young mother. Appointments were generally kept, there were no particular or remarkable health concerns known about - physical or mental – and there was no known history of domestic abuse, substance misuse or criminality. 6.74. Records indicate a mixed picture of attendance at the nominated Surgery by the mother, with seven attendances to actually see a GP between February 2010 and December 2013. There are also records of the mother seeing an out of hours GP, but also seeing a GP at a local NHS Walk in Centre three times in 2013. Otherwise, documentary evidence reveals a considerable amount of information held by the GP and Surgery that relates to other health professional contact with the mother e.g. health visiting and midwifery. These records are simply an account of what those professionals were doing, or had done, rather than specific contacts with or interventions by the GP. 6.75. It is important to consider the context in which GPs and Surgeries operate in order to appreciate their involvement with children and families. GPs provide a spectrum of care within a local community and deal with a diverse range of problems including those with physical, psychological and social aspects. 6.76. A theme emerges about how information was not used to aid a more rounded understanding about how this mother was living her life and, in turn, how this might have affected her children. This information could have been gathered together in a coherent way, over a period of time. This is highlighted by research24 (2014) which refers to some of the strengths of GP practice “… the most cited benefits of recording wider information about the child and maltreatment related concerns in general practice are making children with 24 The GP’s role in responding to child maltreatment: Time for a rethink? An overview of policy, practice and research, July 2014, pp 18 – 25, NSPCC, Royal College of General Practitioners, UCL and University of Surrey, 24 concerns ‘findable’ on the system, building up a cumulative picture of a family where a series of minor concerns might indicate a serious problem and making concerns known to colleagues …”. In this case, from chronological records submitted it is possible to see how this cumulative picture could have been formed by the GP reviewing records with a safeguarding mind-set. This did not happen. This could have been strengthened by there being better documentation of possible neglect and correct coding on the GPs electronic database. This would reflect an appreciation that there was a number of low level concerns regarding the home conditions and that these could have been shared. A discussion between the Health Visitor and GP would also have provided similar insights. Again, there is no evidence to indicate that this happened. 6.77. The above points suggest that the GP and GP Surgery could have taken a greater role in prompting a more holistic assessment of the mother and children. Whilst this may be seen as an ideal, the aspiration warrants consideration, particularly given the unique role GPs have within their local community. The author for the GP submission has also reflected on how this may be achieved; There should have been greater vigilance about the missed immunisation appointments. This is a wider issue for GP Surgeries. There was no specific and direct contact between the Health Visitor and GP or GP Surgery in this case. Access by the Surgery to the local database (System One) would have helped information sharing. Information sharing of this nature relies on permissions being given to different users dependent on their role. In this case, permissions were not in place. The issue of how GPs respond to young mothers and offering advice about contraception has been raised. This young mother had four pregnancies and gave birth to three children (one resulted in a miscarriage) before the age of 23 years. This undoubtedly placed pressure and stress on the mother to care for three young children as a single parent whilst living in less than favourable conditions. This would be a significant task for anyone. When considered against the local levels of deprivation and limiting life chances it magnifies risk and vulnerability considerably. The GP was well placed to explore this with the mother. 6.78. A proactive safeguarding mind-set would need to be prompted by a trigger event. On this occasion there was no explicit event but rather multiple births in a relatively short period of time. Whilst multiple births, in itself, may not ordinarily be a problem, when combined with information that was held electronically, it may have prompted a wider analysis of family circumstances. 6.79. Finding: This review finds that on the basis of the information immediately available to the GP, given the involvement of other health professionals at the time, there was no evidence or need to consider any additional monitoring or assessment. School 6.80. Sibling 1 joined the local primary school in the autumn term of 2013. Prior to this Sibling 1 had sporadically attended a Stay and Play Group in the school; this was a drop-in arrangement. Family Workers delivering the sessions have reflected that there was nothing in the presentation of either the child or mother to cause alarm or concern despite Sibling 1 functioning below age expected levels. When Sibling 1 joined Reception class this picture did not alter. The child presented in appropriate uniform, was clean, and 25 appeared well fed. Sibling 1’s attendance was acceptable at 86% (although Sibling 1 was under school age and there is no requirement about school attendance). Absences appeared routine and the school was notified by the mother when they occurred. No notable information was provided on the admission documentation to prompt further enquiry by the School. Early assessment indicated that Sibling 1 made steady progress once in the school and attained age expected levels across a range of areas comparative with other children from similar social and economic backgrounds. There was also nothing in the manner in which the mother communicated with either the child or staff to cause alarm or concern. 6.81. Finding: On the basis of the presentation by both child and mother the School had no evidence or need to consider any additional monitoring, assessment or information gathering in respect of safeguarding concerns. 6.82. The School has however identified a significant learning point in the course of this review25. It is general School practice to provide a non-statutory home visit prior to a child starting school. The School had routinely undertaken these visits so as to provide teachers and staff with an opportunity to see children in their own home environment where they are likely to be more comfortable. This also enabled pre-school paperwork to be completed. It is an information gathering and assessment opportunity. 6.83. On this occasion no home visit took place. This was due to extenuating circumstances at the time and all home visits for admissions over the start of the autumn term 2013 being suspended. This decision was taken by the Head Teacher with School Governor support. The extenuating circumstances involved the significant escalation of gun and knife crime in the local neighbourhood around this time period. This led to armed Police being deployed in the neighbourhood for a short period of time. Understandably, this appeared to have a direct impact on the stability of the local area. Residents were fearful and local service providers were encouraged to manage safety in all areas. This corresponds with the mother’s report about feeling scared of leaving the family home around early winter time 2013. However, it is important to note that no specific directive was given by the Police that local services should not go about their daily business. The decision to not undertake home visits was taken by the School as a way of them managing potential risks to staff. The local area does have a history of unrest with high crime rates over a number of years. 6.84. This meant that Sibling 1’s home environment was not seen, and School staff were unaware of the living conditions. Using hindsight to our advantage, practitioners have reported during the course of this review that, had they been aware of the condition of the home environment, it would have prompted them to share information and involve other agencies. Using experience, they would also have been able to benchmark their findings against other home environments they visit to inform a judgement about whether a threshold had been reached to warrant a referral to the Children & Learning Department. 6.85. Staff members vaguely recollect a phone call made by Health Visitor 2 to the School in November 2013 though not its exact purpose. No record was made of the call because it seemed to be an enquiry about the general welfare of Sibling 1 during which no specific concerns were shared. The School report that they frequently receive multiple general enquiries, not all which would be logged. It is now understood that the call was part of an attempt by Health Visitor 2 to conduct a more holistic assessment of the family in order to 25 Overview analysis of single agency key practice episodes, Education, Safeguarding in Education Manager, 25/08/14 26 then report back to the Specialist Family Support service and that he was enquiring about the quality of attachments rather than the wider concerns about neglect. 6.86. Finding: This review finds that the opportunity to form a dialogue with the School in order to inform the assessment was not maximised by Health Visitor 2. 7. Summary of emerging themes 7.1. The analysis of single agency involvement has made a series of findings from evidence submitted. These findings have prompted agencies to review their practice across a number of areas and have informed what they have learnt as a result of this review. Three themes emerge from analysis of key practice episodes, documentation, interviews and findings. These are; 1) Assessment opportunities and the use of assessment tools to understand the child’s experience, 2) Thresholds and professional intervention, 3) Organisational arrangements to promote safeguarding practice, comprising of; Training Supervision Caseload management issues 7.2. Section 9 will examine these three themes in an attempt to help us further understand what happened in this case, and importantly, develop our understanding about the underlying reasons that led individuals and organisations to act as they did. Before doing this, valuable information about the local operating context for professionals is provided. 8. Local operating context for statutory agencies 8.1. The findings of this review, and in particular the actions and responses by statutory services, do need to be considered within a wider context. In 2010 Luton was ranked as the 69th (out of 326) most deprived local authority areas. Trend analysis shows a worsening picture when in 2004 it was ranked as 101st and in 2007 it was ranked as 87th. Of significance to this review, is that the family lived in an area where it is ranked as being in the top 10% most deprived areas in the country. This includes the very highest levels of deprivation across a range of fundamental areas which impact on life chances; housing and access to services (including overcrowding, affordability, homelessness and geographical distance to local amenities), crime (including burglary, violent crime, theft and criminal damage), education (considering educational attainment from primary to higher education), employment, health (including illness, disability ratios, measurements of premature death and the rate of adults suffering mood or anxiety disorders), living environment (both indoor and outdoor), income deprivation affecting children, and income deprivation affecting older people26. The specific geographical area connected to this review has a high fertility rate, a high rate of low birth 26 Luton Borough Council, Research and geospatial information, 2010 indices of multiple deprivation, August 2011 27 weight babies, high incidence of stillbirths compared to England average, high rate of women with post natal depression, and lone parent households with dependent children27. 8.2. The independent author of the CCS submission to this review has also outlined highly relevant information which describes the operating context for Cambridgeshire Community Services, “In 2011 the Government published the Call to Action Health Visiting Implementation Plan 2011 – 2015. The purpose of this was to herald a new approach to the development and provision of Health Visiting Services to children and families. Part of this plan was to increase Health Visitor numbers by training more and Cambridgeshire Community Services, as other Trusts, embraced this and actively recruited from its own workforce and externally, student Health Visitors. It is currently on its fourth tranche. However, although the increase in Health Visitors is a positive it has also brought with it a number of risks. Firstly, there is the increased work load on the newly qualified Health Visitors during the students training and supervised practice, secondly, resources to provide clinical supervision and safeguarding supervision to newly qualified Health Visitors do not necessarily increase incrementally, and thirdly, the organisation has a large percentage of its workforce as newly qualified and inexperienced Health Visitors. There is also the issue of retention in that, despite recruiting CCS has found it difficult to retain newly qualified Health Visitors as Luton, and in particular [the specific locality area in this case], are seen as a high risk place to work due to the level of complex social issues. There is also a view that those who come forward to train as Health Visitors are not necessarily of the calibre required to deal with the reality of working as a Health Visitor in areas of high need. CCS is aware of these issues and has placed the Health Visitor Service on the CCS Risk Register”. 8.3. Single agency progress reports by CCS submitted to Luton LSCB provide valuable information about the organisational working context in which frontline health practitioners were operating at the time28. Of relevance to this review, health visiting capacity, training and the provision of supervision are highlighted as challenges. Evidence submitted to the review indicates that in order to meet targets of increasing frontline health practitioners (and in turn meet local need) there will be a shortfall in practice teachers and mentors for students. This will undoubtedly challenge the current supervisory requirements and the need to support, what is likely to be, a high level of inexperienced practitioners. This indicates a risk, not only to the organisation, but also those practitioners who attempt to operate in less than favourable conditions. In turn, this potentially leaves children at risk. Similar concerns (amongst the positives) were noted by Ofsted29 in Luton’s most recent inspection “There has been good progress in attracting student health visitors with the aim that once qualified that they will join the understaffed Luton teams. Capacity is stretched with caseloads double that of the required standard.” 8.4. The level of local need and deprivation clearly poses challenges to local statutory services and practitioners. For Cambridgeshire Community Services - a service working closely with children and families in deprived neighbourhoods - these challenges are obviously compounded by capacity and resourcing. 27 Cambridgeshire Community Services submission to the SCR Reference Group, 25/09/1 28 Luton LSCB and Cambridgeshire Community Service single agency highlight reports (Aug/Sept 2012, Sept/Oct 2012, 20/04/13 – 31/08/13, 22/05/13 – 31/08/13, 01/12/13 – 28/02/14) and Health Visiting Service: update on progress against the Health Visitor implementation report (not dated) 29 Ofsted, 2012, Inspection of safeguarding and looked after children services Luton Borough 28 9. Assessment opportunities & the use of assessment tools to understand the child’s experience 9.1. Statutory guidance30 explicitly refers to keeping the child in focus and ensuring a child centred approach, “… failings in safeguarding systems are too often the result of losing sight of the needs and views of the children within them, or placing the interests of adults ahead of the needs of children”. This is supported by research and inquiry31. Horwath (2010)32 describes the assessment process as being a dual activity alongside actions and interventions, but that practitioners should have “… identified whether the child is at risk of harm … established the developmental needs of the child … have a comprehensive overview of the family’s past history and carers patterns of behaviours, information about family strengths and relevant family and environmental factors …” 9.2. This review has already noted the opportunities for agencies to gather information and undertake assessments in respect of Siblings 1 and 2 and Child E, and where these could have used to greater effect. A number of professionals used, or attempted (or considered) to use formalised risk assessment frameworks but were very limited in their success. These activities occurred in isolation with no collective assessment and synthesis of information. 9.3. The use of such frameworks reduces the need for individual practitioners to make subjective, and what may be perceived as personal judgements. This is especially so where the assessment tool permits the service user to self-assess. For many practitioners, the use of tools and frameworks can make it easier to ask probing and uncomfortable questions particularly when faced with more challenging and complex scenarios. Importantly they promote evidence based interventions which can be child focused and their initiation and/or completion should not prevent intervention (where necessary during the process) or be viewed as the final action. The following tools/frameworks were used or attempted in this case; 9.4. Pre-CAF and CAF: “ … the CAF is designed to be used when someone is worried about how well a child or young person is progressing (e.g. concerns about their health, development, welfare, behaviour, progress in learning or any other aspect of their wellbeing)and/or; a child or young person, or their parent/carer, raises a concern with a practitioner and/or; a child's or young person's needs are unclear, or broader than the current service can address and require additional support …”33. It provides commonality across services and can assist in facilitating early intervention. A Pre-CAF is a tool that helps practitioners identify when a full CAF might be useful and can be used internally rather than as a multi-agency assessment tool. 9.5. A CAF was considered but never used by either LDUH or CCS. LDUH did however share information via another appropriate mechanism (June 2011 and April/May 2013). 9.6. There are a number of references in the documentary evidence submitted to this review which reveal uncertainty or confusion about whether a CAF had been completed, either by the Midwifery Service or by CCS. The fact that there was uncertainty or confusion about this is a significant finding in itself. This 30 Working together to safeguard children, 2010 & 2013, HM Government 31 a) The Victoria Climbié Inquiry Report, p 208, HMSO, London & b) Ofsted, Learning lessons from serious case reviews 2009–2010 & c) Ofsted, The voice of the child: learning lessons from serious case reviews, 2011 32 Horwath, J,. The Child’s World, 2nd Edition, The comprehensive guide to assessing children in need, 2010, p 69, Jessica Kingsley 33 https://www.luton.gov.uk/Health_and_social_care/children_and_family_services/earlyhelp/Pages/CAF 29 uncertainty, whilst discovered with the benefit of hindsight, could have been relatively easily solved by someone checking (either LDUH Midwifery or CCS Health Visiting Service, or CCS Safeguarding Team), and being curious, with the Specialist Family Support service. This did not happen. 9.7. This review has also highlighted continued confusion about the overall usage of Pre-CAF and CAF, with agency representatives on the Reference Group highlighting confusion and uncertainty about if, how and when these mechanisms are used. This will be an issue for the LSCB to consider. 9.8. This case has also highlighted that if a parent/carer refuses consent for a CAF to be used there is a need for practitioners to understand the implications of this refusal and consider whether their worries or concerns need escalating or dealing with via another route. It certainly indicates a need to closely monitor the child’s circumstances rather than simply accepting the parent’s wish. The refusal of consent does not eliminate or reduce risks to children; they remain as does the need to respond to them. 9.9. Home conditions did not noticeably improve and any improvements were very minor and temporary. Engagement with professionals remained limited and all the pre-disposing risk factors (young mother, poor housing, limited resources, and three young children) remained. This should have prompted those professionals involved with the family, particularly around May/June 2012 and then again in October 2013, to increase their concern to a higher level of activity and contact i.e. through a Child in Need or child protection assessment route, which should then have prompted a more robust multi-agency response. This potentially reflects professional optimism and a willingness to accept small changes as a sign that risks were reduced or eliminated. 9.10. Graded Care Profile (GCP): “… a practice tool which gives an objective measure of the quality of care in terms of a parent/carer's commitment. The quality of care, both negative and positive, is measured across 4 different domains of a child or young person needs - physical, safety, love and esteem. The GCP has been developed to quantify care neglect by objectively displaying both the strengths and weaknesses in different grades (1 to 5), to inform judgements by professionals and parents/carers working together about the intervention required and to measure progress”34 9.11. The use of this tool was mentioned by two health practitioners on several occasions, but never applied. Contributing factors to these missed opportunities include: - practitioners incorrectly believed that consent was needed in order to use it; consent was never given. - Health Visitor 1 had received formal training on it as a student and it was discussed during one group supervision session that Health Visitor 2 attended, but otherwise Health Visitor 2 had not received any training on how to use it. - Formal training via the Luton LSCB had been available in January, May, July, September and November 2012 and January, March 2013. No further training was provided during the time of Health Visitor 2’s involvement with this family as the training offer had been withdrawn by the LSCB because of the low take up of training by agencies. 9.12. During an interview with Health Visitor 1 about their involvement in this case and their use of assessment frameworks, the following reflections were noted, “…the Health Visitor view was that [the 34 Graded Care Profile, http://lutonlscb.org.uk/graded.html 30 Graded Care Profile] was a wordy document, called for subjective judgements to be made and required the consent of the parent … the Health Visitor was unsure whether she had built a good relationship with [the mother], wondering whether [the mother] had ‘not liked her’ but also referred to feeling like she was ‘hitting a brick wall’ and wondering where she went from here. [the Health Visitor] also appeared uncomfortable about making what were perceived as ‘subjective judgement’s’ as to what was considered ‘good enough’ seeing this as comparing standards with someone else’s”. Research into other serious case reviews35 has found similar discomfort by professionals “… efforts not to be judgemental becoming a failure to exercise professional judgement …”. Whilst this reflects a lack of confidence in applying an assessment framework (that is specifically designed to counter these individual barriers), the CCS submission states that this is not an unusual issue for newly qualified or inexperienced professionals and one which should be addressed through supervision. 9.13 Whooley depression assessment: A series of questions designed to identify and assess post natal depression. Clinical guidance36 recommends that healthcare professionals ask two questions at a woman’s first contact with primary care, again at her booking visit, and again post-natally (usually at 4-6 weeks and 3-4 months): 1) During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2) During the past month, have you often been bothered by little interest or pleasure in doing things? A third question should be considered if the woman answers “yes” to either of the initial questions: 3) Is this something you feel you need or want help with? 9.14. This was considered and offered. However because the mother did not indicate that she was feeling depressed in any way after answering the first question it was unnecessary to continue with the remainder of the assessment. Whilst this may be considered a legitimate method for assessing mental health post-natally, it is an adult focused assessment and fails to recognise the wider circumstances in which a child may be living, as well as other pressures the mother may be experiencing. Had the mother’s response to this assessment been considered alongside actual evidence of home conditions and the care arrangements for the individual children it may have prompted the Health Visitor to be more curious about how well the mother was coping. 9.15. Vulnerability risk assessment: A locally developed single agency assessment tool that is designed to be used in conjunction with the Graded Care Profile as a means of initially identifying a child at risk of neglect through a range of listed factors which are associated with vulnerability37. This is used by CCS. 9.16. This was applied by Health Visitor 1. This review has examined the guidance documents in place for health practitioners for using this tool and finds them confusing and misleading. It refers to needing to understand the Graded Care Profile and seems to complicate the process of analysis. In this case, the findings were never synthesized to have any impact or effective use, nor communicated with other agencies in a manner or style that prompted more robust intervention. 9.17. Home safety assessment: A basic safety assessment of a family home conducted by a Children’s Centre worker or a member of the Fire & Rescue Service to identify practical health and safety issues. 35 Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., & Black, J., Understanding Serious Case Reviews and their impact: A biennial analysis of serious case reviews 2005 – 07, p.47, DCSF 36 NICE, 2007, Antenatal and postnatal mental health: Clinical management and service guidance, now replaced with NICE guidelines [CG192], 2014 37 Vulnerability risk factors tool: health practitioners guide, 13/09/10 V3 31 9.18. This was completed in November 2012. Although a potentially useful assessment the findings needed to be incorporated into a wider and more holistic understanding of the children’s day to day experiences. This did not happen and there was no joined up assessment and analysis of environmental, child and parenting factors. Additional assessment activity and considerations: 9.19. Central Bedfordshire Emergency Duty Team (on behalf of Luton Borough Council Children & Learning Department) requested an assessment through an independent provider. Notes and records passed to Luton Children and Learning Department indicate that this was a welfare check visit with some recommended actions. Follow on action by Luton Children and Learning Department, was not maximised 9.20. As stated earlier, Health Visitor 2 shared a view about ‘starting from afresh’ with the family. This mind-set has to be seen alongside the Specialist Family Support service’s failure to follow up an assessment opportunity and the implicit message that this gave to the Health Visitor about how much weight to attach to the concerns. In turn, this impacted on the impetus and style of intervention adopted by Health Visitor 2 to the extent that the Health Visitor felt the case could be managed in isolation. 9.21. Opportunities for assessing the mother’s commitment to ensure the children’s health needs were not maximised. Firstly, evidence of the mother either missing scheduled appointments/immunisations or declining appointments is apparent. It is unclear from the evidence submitted whether these missed appointments were due to the failure by the mother to recognise the importance of the appointment, forgetfulness, being overwhelmed and disorganised or deliberate non-attendance. This is coupled with a mother (and grandmother) who either attempted to deceive professionals, or who were not prepared to engage with professionals to serve the best interests of the children. Exercising some level of professional curiosity and healthy scepticism about these issues from practitioners at successful visits would have been appropriate. Secondly, the advice given to the mother to treat Candida and nappy rash was not followed through. Weaning advice was also not followed. Health visitor 2 has reflected that, with the benefit of hindsight, a referral to the Specialist Family Support service would have been appropriate in respect of the mother’s failure to treat the Candida and nappy rash. Research (2013)38 about neglect and serious case reviews highlights “… Professionals tended not to challenge parents’ behaviour when medication was given erratically or consider reasons for parents’ reduced compliance with advice … Undue professional optimism can mean that the impact of medical neglect and the danger for the child is missed and thus no referral is ever made to children’s social care …”. 9.22. On a positive note completing opportunistic home visits seems, on balance, to have been more successful in this case than scheduled appointments. This positive aspect of assessment practice should not be lost and there is valuable learning to transfer from this case to other cases where non-engagement or non-compliance by service users may be a characteristic. 9.23. Given the findings, it follows that there was no ‘making sense’ of information gathered in a multi-agency context and no coordinated decision making about effective early help. Evidence presented paints a picture of a mother (and grandmother) who engaged with statutory agencies to an absolute minimum and not with a view to promoting the welfare of the children. In this case, no comprehensive or holistic 38 Neglect and Serious Case Reviews, 2013, p. 12, University of East Anglia & NSPCC 32 information was gathered or synthesized by any one single agency or range of agencies over a four year period. Fragments of information were gathered but shared in an episodic manner. 9.24. In summary, the review has found that pre-existing mechanisms for professionals to communicate risk which may then prompt assessment were not used. CCS practitioners lacked the confidence or training to appropriately use formal risk assessment tools and the Specialist Family Support service failed to have sufficiently robust commissioning arrangements to effectively use assessment services to the benefit of those children whose welfare was being assessed. Assessment activity lacked a focus on the child’s day to day experiences. 10. Threshold and professional intervention 10.1. Two versions of statutory guidance (2010 and 2013)39 which cover the timeframe for this review provide broadly similar definitions of neglect, serving as a threshold for professionals to determine ‘good enough’ care arrangements. Key facets of this statutory definition of neglect relate to the persistence of concerns and cover acts of both omission and commission when caring for a child. Research40 highlights the critical impact of inadequate care during early childhood on later development. Whilst the review may find some sympathy for any parent with limited resources managing three young children, it is apparent that the level of care afforded these children occasionally reached a ‘good enough’ standard. Three issues emerge; 10.2. Firstly, the care giving context is important. It is evident that the mother lived in an area of high deprivation with limiting life chances. The local community in which Child E and siblings lived created (and continue to do so) daily challenges for those with parenting responsibilities. Neglect as a result of impoverished circumstances is one contributory factor in this case. Horwath (2007)41 considers this as a challenge for professionals when examining neglect and the care-giving context; that of “…. distinguishing between low standards of care resulting from deprivation and low standards because of the ability and motivation of the carer …”. This review has found that there was no explicit exploration by professionals with the mother (and grandmother who also had a significant caring role for Child E) which attempted to assess or distinguish between the ability to care for a vulnerable child and the circumstances in which parenting was taking place. The omissions in care by the mother/grandmother, which were predominantly perceived to be linked to housing conditions, were not viewed as serious or serious enough to warrant statutory intervention to protect any one of the children. Health Visitor 2 has recounted “… the conditions I saw were not unusual in this area. It is not unusual to see clutter, for parents to not keep appointments, for housing conditions to be dirty and for left-over food and dirty nappies to be left lying around …”. This suggests a level of acclimatisation and tolerance by practitioners to information they observe during the course of home visiting. Evidence submitted to this review by the School states “Practitioners identify the threshold for intervention is high and that when need is consistently high, the principle of ‘good enough’, is applied in order 39 Working Together to safeguard children, 2010, HM Government & Working Together to safeguard children, 2013, HM Government 40 1) Neglect: research evidence to inform practice Dr Patricia Moran, Action for Children Consultancy Services, Action for Children, 2009, 2) Early Intervention: The Next Steps: An Independent Report to Her Majesty’s Government Graham Allen MP, 2011, HM Government, 3) NSPCC: CORE-INFO: Emotional neglect and emotional abuse in pre-school children, May 2012 41 Horwath, J., Child neglect: Identification and assessment, 2007, p. 113, Palgrave MacMillan. 33 to determine if one family presents as more in need than another. Staff note that there is potential for acclimatisation when working with high levels of deprivation on a daily basis”. 10.3. Secondly, in this case, we see a worsening picture of neglectful parenting; not one-off incidents or accidents but events which, when looked at as a whole, indicate deteriorating circumstances. These events reflect a persistence of concerns and indicate an emerging chronicity rather than isolated and acute episodes of struggling to care for a child/children. Horwath42 (2007) considers different categories of neglect which reinforce the findings of this review and the developing chronic picture of neglect. Child E and siblings experienced medical neglect (the failure to protect a child through scheduled immunisations and administering medication when needed e.g. for Candida and nappy rash), nutritional neglect (the failure to follow advice and appropriately feed and wean Child E), physical neglect (the failure the provide a safe, clean and adequate living environment as well as exposing premature infants to a smoke filled house) and a failure to consistently provide adequate supervision and guidance (Sibling 2 whilst at hospital). These features point towards acts of omission by Child E’s mother and grandmother. 10.4. Finding: The benchmark or threshold of what constituted ‘good enough’ care was clouded by a focus on immediate, tangible and observable physical risks to the children. This appeared to mask the difficulties that the mother was experiencing in parenting three young children in less than favourable conditions and failed to adequately assess the impact on the children’s overall welfare in a more holistic way. The persistence of risk factors in Child E’s life, when considered alongside the experiences of Siblings 1 and 2, were not explicitly or systematically considered and weighted by any professional who came into contact with this family. 10.5. Finally, in order to assist the review understand the failings of the assessment process, but importantly the difficulty for professionals setting an acceptable threshold for intervening, there are a number of contributory factors to consider; - Information often suggested positive aspects of parenting. There was information presented to professionals which conflicted with the developing picture of neglect. The School note in their submission “Sibling 1 attended in the appropriate uniform, did not present hungry, or overly smelling of cigarette smoke that was noticeable to staff. At no point did Sibling 1 make any disclosure prior to the death of Child E about … home or familial situation …. Given what information the school directly held, it is unlikely that any concern, and note that none were raised, would have triggered a response. On a front facing basis, Sibling 1 presented no differently to … peers, practitioners note that on the whole Sibling 1 presented better” 43. Such conflicting information makes assessment and intervention more challenging for practitioners. - There was often conflicting information. Based on the original referring issue from LDUH of potential attachment difficulties with Sibling 1 and the mother, Health Visitor 2 contacted the School to make enquiries. He was informed that the School had no concerns about Sibling 1. The Health Visitor did not use this opportunity to convey his wider concerns back to the school to prompt a dialogue about general welfare. This interaction reflects two issues. Firstly, a relatively fixed view of risk by the Health Visitor (also reflected in the view that home visits often did not reveal any immediate risks to the children) rather than seeing the more pervasive and chronic impact of neglectful parenting. 42 Horwath, J., Child neglect: Identification and assessment, 2007, p. 113, Palgrave MacMillan 43 Nursery Group & School submission, 25/08/14v2 34 Secondly a failure to be curious about a possible mismatch in evidence presented by the School with known information held by the Health Visitor. All of these issues may, not unreasonably, be due to limited experience and skill in working with complex dynamics but do affect perceptions around thresholds and intervention. - CCS have also commented on thresholds but with an additional view about how this affects referrals and access to services “… fixed perceptions also led to difficulty in challenging and escalating this case into child protection …. However, there was also evidence that the thresholds in health may also have risen and accommodated the social issues present within [the local area]”. One practitioner commented that “ … the circumstances of this family were not unusual … many families living in [this area] present with similar issues …” and that she was “ … not confident that, had a referral been made to the Referral and Assessment Team, any action would have been taken … based on a recent case that … was not dissimilar to this family …” - The Community Nursery Nurse felt “… any decision to make a child protection referral had to be the responsibility of the Health Visitor …”44. This has been linked to experience, qualification and perceived status within an organisational structure but is clearly a concern. 10.6. Research45 (2013) highlights threshold dilemmas as a common feature “Professionals were tolerant of dangerous conditions and poor care …” and “… there was a drift and lack of sense of urgency …” . The findings of this review reflect these dilemmas. 11. Organisational arrangements to promote safeguarding practice 11.1. Statutory guidance (2010 & 2013) respectively state that organisations should have “… arrangements to ensure that all staff undertake appropriate training to equip them to carry out their responsibilities effectively …” and “ … creating an environment where staff feel able to raise concerns and feel supported in their safeguarding role …”. 11.2. Three organisational factors had a negative impact on the delivery of services for Child E. Most notably, these relate to the contribution of Cambridgeshire Community Services. Training 11.3. As previously stated Health Visitor 2 was recently qualified - less than a year – but had attended mandatory training in child protection at levels 1, 2 and 3 based on the Inter-Collegiate guidance46. These were courses provided internally by CCS. Review of training records also shows a range of other training courses attended. It is clear from interview that Health Visitor 2 did not feel fully equipped to deal with the complexity of cases held despite having attended training courses. This raises questions for CCS about whether their current training provision adequately equips relatively inexperienced practitioners to deal with the level of need and often complex family situations they will encounter on a day to day basis. It has 44 Cambridgeshire Community Services submission to the SCR Reference Group, 25/09/14 45 Neglect and Serious Case Reviews, 2013, p. 12, University of East Anglia & NSPCC 46 Safeguarding children and young people: roles and competences for health care staff: Intercollegiate document published by the Royal College of Paediatrics and Child Health, September 2010 & Third edition March 2014 35 also become apparent that there is a potential misunderstanding by Health Visitors in training provision. CCS offer a level 3 training course (which is based on the Inter-Collegiate guidance) and the LSCB also offer a level 3 training course (which is targeted at those in management or designated positions), but which has a different content. The use of the same headline description may have caused some misunderstanding and has the potential to create confusion. This is an area that the LSCB will need to examine. 11.4. The report has already covered when training was provided on the Graded Care Profile (see 9.10) and when it was withdrawn by the LSCB. The ability to understand a particular tool/framework and then apply it in practice is clearly a fundamental requirement for all practitioners who are required to assess child welfare arrangements. A failure to understand and apply the Graded Care Profile has been noted as a contributory factor to the manner in which this case was managed. Supervision 11.5. Statutory guidance47 (2010 & 2013) highlights the importance of effective staff support and supervision. Supervision is one mechanism through which organisations can support practitioners to discharge their duties. Owen and Pritchard (1993)48 state “Supervision implies overseeing appropriate functioning of the worker …. It also implies guidance, advice, correction, encouragement, teaching and support … The content and the quality of work will be determined by the workers’ level of knowledge, their skills, judgement, confidence, stamina and the support and help given to them to do the job effectively and efficiently …” . 11.6. Two CCS supervision policies were implemented during the time period under review, one in 2010 and then a second in 201249. A further policy has since been introduced in 2014. 11.7. Health Visitors had/have access to three forms of supervision; safeguarding supervision50, management supervision51 and clinical supervision52 . These could all be delivered by different supervisors. Whilst there is an organisational framework that outlines the different forms of supervision this case review has highlighted that it is not obvious to Health Visitors or the Reference Group how advice and support offered by each interact and offer a coherent accountability structure; it is reliant of the individual practitioner to make the links. It is possible that those practitioners moving through the preceptorship framework could also have a fourth person offering support and guidance. 47 Working Together to safeguard children, 2010, HM Government & Working Together to safeguard children, 2013, HM Government 48 Good practice in child protection: A manual for professionals, Owen. H, and Pritchard. J, (1993) p.203, Jessica Kingsley 49 CCS Supervision Policy 2010 & CCS Supervision Policy, 2012 50 Safeguarding children supervision offers a formal process of professional support and learning for practitioners working with children, young people and their parents/ carers. Safeguarding children supervision is about the ‘how’ of safeguarding/ child protection practice; it provides a framework for examining and reflecting on a case from different perspectives. It also facilitates the analysis of the risk and protective (resilience) factors involved by enabling discussion of cases of actual or suspected child abuse and those at varying levels of concern from high risk, to cases with very early potential indicators in order to ensure safe practice, Cambridgeshire Community Services, Supervision framework, January 2014 51 The purpose of management supervision is to provide support and oversee performance, Cambridgeshire Community Services, Supervision framework, January 2014 52 Clinical supervision provides an opportunity to discuss clinical cases in more detail, provide support and challenge and contributes to professional and personal development, Cambridgeshire Community Services, Supervision framework, January 2014 36 11.8. The 2010 policy prescribed 1:1 safeguarding supervision with a trained child protection supervisor for experienced practitioners on a three monthly basis and two monthly for newly qualified practitioners. The revised policy in 2012 moved away from 1:1 safeguarding supervision towards group supervision on a three monthly basis; a significant reduction. Additional individual safeguarding supervision would have been available on more complex cases under both the 2010 and the 2012 policies, but this would be at the individual practitioner’s request. 11.9. Finding: Records indicate that both Health Visitors 1 and 2 followed policy and procedure in seeking safeguarding supervision at various times. 11.10. In this case, supervision would have been the ideal forum for Health Visitor 1 to discuss issues such as how it felt to make ‘subjective judgements’ about parenting, what else to do with the case due to feeling stuck having ‘hit a brick wall’, and the impact of feeling disliked by the mother. Based on the descriptions of these three forms of supervision it is difficult to see which forum would have been most useful to have discussed such a practical but very real dilemma. Evidence submitted to this review reveals that Health Visitor 1 had individual safeguarding supervision although actual records on the content discussed cannot be located. Based on interview, concrete solutions were discussed. Without records it is impossible for this review to draw a conclusion about the quality of these sessions but also how useful it was to the individual practitioner. However, it does appear to have had limited impact on the effectiveness of Health Visitor 1’s approach to the family “… and that she had achieved little with the family and the case may benefit from a fresh pair of eyes …”53. 11.11. Records indicate that Health Visitor 2 received clinical supervision five times between January and October 2013, attended five safeguarding supervisions between June 2013 and January 2014 (two of which were individual sessions) and received one management supervision during the timeframe of this review. 11.12. Records show that safeguarding issues were discussed during the group safeguarding supervision sessions e.g. assessment frameworks, working with families where non-compliance was an issue, LSCB neglect procedures. All of the topics that are recorded as being discussed appear highly relevant to the features of this case. Following on from these sessions there appears to be no evidence to suggest that learning from supervision on these particular topics was put into practice. 11.13. Health Visitor 2 appropriately sought 1:1 safeguarding supervision in October 2013. This resulted in a plan of action. Records indicate that attempts were made to follow through this plan, but with limited success due to the non-engagement by the mother. 11.14. Looking at this issue from a wider organisational and systemic perspective, this review has found a number of contributory factors which undoubtedly affected individual practitioners and managers. At the time Health Visitor 2 took over responsibility for the case, the safeguarding practice of the Team Leader responsible for providing management supervision to Health Visitor 2 was investigated internally by CCS. Of note, this Team Lead had also provided Health Visitor 2 with support and preceptorship whilst a student. Whilst it may not be appropriate for this review to examine the detail of this internal investigation, it is clear that there must have been legitimate concerns for such 53 Cambridgeshire Community Services submission to the SCR Reference Group, 25/09/1 37 a process to be instigated. In the interim, ‘care-taker’ Team Leads were appointed, which had mixed levels of success. The CCS Safeguarding Team, as presently resourced with three whole time equivalent posts, provides safeguarding supervision (group and individual) to 93 practitioners, which included 26 practitioners who work with children with additional needs. In addition to this practitioners could/can alert the Safeguarding Team about a case via a ‘share’. This can be seen as a way of flagging complex cases that require safeguarding input or additional expertise however due to the high volume of ‘shares’ this challenges the Team’s capacity to respond to every ‘share’. The review has found that the CCS Safeguarding Team does not have an explicit role in checking and overseeing whether actions discussed as part of a safeguarding supervision session have been followed through. Nor do they have a responsibility for taking action based on information being ‘shared’ by a practitioner. They provide an advisory function to practitioners on safeguarding matters. Whilst the opportunity to consult or seek advice about a particular case may arise at subsequent supervision sessions, the responsibility for taking action rests with the individual practitioner and then with their respective manager to check. 11.15. Finding: This review finds that given the identified deficits and challenges faced by the Safeguarding Team, the accountability arrangements for individual practitioners when faced with child protection concerns could be strengthened. 11.16. In this case, we see a recently qualified and relatively inexperienced practitioner taking responsibility for reviewing his own child protection practice, having to request 1:1 safeguarding supervision following a period of being managed by a Team Lead whose judgements were called into question. These circumstances highlight a level of personal and organisational vulnerability. 11.17. A revised model of delivering safeguarding children supervision has been implemented in February 2014, maintaining the emphasis on group supervision. The independently authored CCS submission to this review has appropriately challenged the sole use of group supervision in effectively meeting the needs of practitioners, particularly concerning child protection practice. Whilst the opportunity for individual practitioners to access individual safeguarding supervision is available this relies on the individual to know they need some support. This seems inherently risky and, as this case has illustrated, is not reliable and potentially places children at risk. 11.18. Health practitioners from CCS who have contributed to this review have referred to a potential disconnect between the CCS Safeguarding Team and health practitioners. Although practitioners have described the Team as accessible, advice given was often considered to be “… prescriptive and left some practitioners feeling ‘ordered about’ … “. Alongside this, there is a potential tension that, given the Safeguarding Team does not have a responsibility for checking that actions/advice has been followed it places an expectation back on the Team Lead to undertake this check. This creates additional work. This finding has to be considered with the knowledge that the Safeguarding Team is under pressure (both time and resource) which may create particular ways of working as a means of managing demand. 38 11.19. Whilst this review appreciates the limitations on capacity, workload pressures and financial constraints, it is concerned with wishing to promote effective safeguarding practice – especially given the known local levels of deprivation and the inherent risks this brings for children. Effective safeguarding practice has to be seen and considered in the wider context of support for practitioners to effectively discharge their duties i.e. recruitment of a high quality workforce, training, the overall provision of supervision, and ongoing support. In discussing organisational dangerousness, Calder (2008, p.147)54 cites Davis (2001) who argues that “ … one of the most significant liaisons that needs to be strengthened in acknowledging, supporting and responding to the inherent emotional currents of the work is the supervisory relationship …”. The need to create fertile conditions in which practice improvements occur cannot be underestimated. This becomes even more critical when, as in this case, CCS has struggled to recruit and retain sufficient numbers of experienced and trained Health Visitors. The local Health Visitor workforce in this area has doubled in the last three years which, whilst providing a greater resource has meant the overall skill mix has lowered due to the relative levels of knowledge and experience. Alongside this, demands on the Safeguarding Team and the need for increased supervision have increased, but without additional resourcing being made available. The findings in this case are reflected by research (2013)55 about neglect and serious case reviews, notes “Drift and confusion becomes a systemic problem due to overwhelming workloads, high staff turnover and high vacancy rates …” Caseload management 11.20. Of significance is the finding that Health Visitor 2 carried five child protection cases as a newly qualified practitioner whilst still undergoing the preceptor programme. In this instance it has been confirmed that these were cases where children have been formally identified as at risk and who were subject to child protection plans. Although there have been attempts and discussions to quantify Health Visitor caseload size for a number of years56 nationally there appears to have been no specific guidance to inform the size and profile of case load a Health Visitor should have, particularly in respect of holding cases with child protection issues; local determination is expected. For practitioners in Luton, at around September 2013 caseload sizes decreased from 600 to 455 for those working full time. The target is 243 cases based on an under 5 years population of 17,000 children and 70 whole time equivalent Health Visitors reflecting the level of challenge those delivering health visiting services face. 11.21. Given the problems CCS have experienced with staff recruitment and retention Health Visitors have been given a mixed caseload as an attempt to maintain core service delivery. Such an approach seems reasonable if individual practitioners are capable and appropriately supported (through management support but also training and supervision). However in this case we have also seen local custom and practice developing due to a lack of management oversight with the ‘swapping’ of cases between Health Visitors and a mind-set that a ‘fresh pair of eyes ‘ might make a difference. Such a mind-set may have merit57 but only 54 Calder, M., Organisational dangerousness: Causes, consequences and correctives, in Contemporary risk assessment in safeguarding children, 2008, Russell House publishing 55 Neglect and Serious Case Reviews, 2013, University of East Anglia & NSPCC 56 A) A funding model for Health Visiting: baseline requirements - part 1. Community Practitioner, 2007, 80(11): 18-24 B) A funding model for Health Visiting: impact and implementation - part 2. Community Practitioner 2007: 80(12): 24-31, C) The Protection of Children in England: A Progress Report, The Lord Laming March 2009, p 11 57 The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? Burton, S., National Children’s Bureau, November 2009, C4EO 39 when applied in a systematic and coordinated manner and used alongside effective supervision. In this case, that did not happen; we see that the support system was not as robust as it should have been. 11.22. Recently issued guidance58 for those delivering health visiting services suggests that practitioners are “… Not to have sole responsibility for safeguarding families in the first 6 months …” and refers to shadowing and co-working opportunities in respect of safeguarding cases. 11.23. The size and profile of caseloads is clearly an issue which those with responsibility for delivering health visiting services in the Luton area will need to consider in the future given the operational challenges they face in the recruitment and retention of Health Visitors. 12. Summarised account of review findings The following section represents a summary of the main findings from this review; 1. Indicators of a mother struggling to cope with parenting three young children in less than favourable conditions were not recognised. In turn this placed all of the children at risk of further neglect and emotional harm, 2. No one single agency took an assertive lead on the management, assessment and intervention of this case, despite opportunities being presented to do so. Although information was shared this did not lead to a coordinated multi-agency response, 3. LDUH shared information appropriately with CCS and the Children & Learning Department having identified concerns at every stage of their involvement, 4. Attempts were made by the Health Visiting Service to engage the mother. These attempts included planned and unannounced home visits plus offers of support and assistance, 5. Assessment frameworks and tools were considered but not implemented by practitioners who had direct contact with this family, 6. Case information was shared by Health Visitors to the CCS Safeguarding Team appropriately as a route for seeking additional support and advice however the review has shown that arrangements were not as robust as they could have been and there were differing expectations by those sharing information and those receiving information about action needed. These differing expectations were caused by local custom and practice evolving over time as a result of an unclear policy but also an overwhelming workload, 7. The overall response by CCS Health Visiting Service was fragmented, lacked coordination and was hampered by inexperienced practitioners who lacked specific child protection experience, and specific training. 8. Crucially, this occurred in a challenging organisational operating climate for CCS Health Visiting Service where resources were stretched, workforce capability was compromised and service delivery was unable to respond to high levels of deprivation at a local level. The requirements of the Call to Action initiative placed the service under pressure to recruit large number of Health Visitors, provide training in order to respond to the Healthy Child Programme plan and offer management support. Additionally, due to organisational restructuring the implementation of different management 58 A National Preceptorship Framework for Health Visiting: The First 2 Years, 2014, Developed by the Institute of Health Visiting on behalf of Health Education England and the Department of Health 40 structures meant that oversight and governance of Health Visiting was not as robust as it could have been. 9. Child E’s critical needs were not sufficiently recognised at a time when there was an emerging picture of the mother failing to engage with services which occurred alongside Child E failing to gain adequate weight following discharge from hospital. This was coupled with a level of deceit by the mother and grandmother, professional optimism and a failure by the professional network to appreciate the history of the mother’s vulnerability. 10. A more robust intervention could have been made which, if the mother and grandmother had cooperated, would have ensured that Child E received adequate care and nutrition. If this cooperation had not been forthcoming, and there had been greater clarity about the level of risk, there would have been evidence to enable the local authority Children & Learning Department to intervene. On that basis, this review concludes that Child E’s death was preventable. 13. Lessons learnt from this review The following section outlines what individual agencies have identified and learnt as a result of conducting this review. As a result of this review individual agencies have learnt the following; Luton & Dunstable University Hospital 1. Outpatient staff should inform Doctors and other health professionals of anything out of the ordinary seen when attending to children in the outpatients department, 2. There is a need to continue with information sharing in the event of a pregnancy that does not continue to full term, 3. There is a need to ensure, on discharge, growth charts are known about and understood by all health professionals who may apply them in the community, especially for pre-term infants, 4. There needs to be improved systems that are failsafe for community dietetic follow-up for neonatal discharges. Cambridgeshire Community Services 1. A high number of inexperienced, newly qualified Health Visitors brings with it an increased risk to the organisation and the service families receive, 2. A high attrition rate brings with it an increased risk to the organisation and the service families receive, 3. The current model of provision of safeguarding supervision may not be suited to the high levels of newly qualified practitioners, 4. The current model of safeguarding supervision may not be suited to the high level of vulnerability within the caseloads, 41 5. The purpose and expected outcome from the SystemOne ‘share’ with the Safeguarding Team is not clear to those who refer matters to the Safeguarding Team, 6. Health needs assessments of the child and family are inconsistent across the service. Historical and current health needs and progress are not being robustly assessed. This increases the risk of poor decision making and care planning leading to poorer outcomes for children, 7. The standard of record keeping does not demonstrate a robust assessment, analysis and evaluation process to inform decision making, 8. The current practice around allocation of families coming onto health visitor caseload is not sensitive enough to the complexity of families and the available skills in the team, 9. The current process for transfer of cases between caseloads/colleagues is not as robust as it needs to be, 10. There is a mix of percentile charts in use across agencies and this is a risk when assessing the growth of babies, particularly when pre-term, 11. There is an acceptance of high thresholds and tolerance of risk factors due to the demographics of the resident population, 12. There is a perception that thresholds within Children’s Social Care are set too high, 13. The role and accountability of all CCS children’s services staff with regard to leadership, professional accountability and safeguarding is not clearly understood, 14. There is a lack of acknowledgement of the roles and responsibilities and collaborative working between health visiting and the responsible professional during the antenatal period. 15. The organisational framework which includes all types of supervision was not robustly implemented or quality assured across children’s services. This resulted in weak leadership and role modelling and poor professional practice, 16. Information sharing processes between the Health Visiting Service and maternity/SCBU (Special care baby unit) were not robust. 17. The diversity of clinical experience of new HVs coming into the profession may mean that they do not have the skills and competencies to assess when a child is not thriving or unwell, 18. The leadership capacity required to manage strategic change can cause loss of focus on governance. Luton Borough Council: Children & Learning Department 1. There is a need to identify the key factors when adults do not engage or comply, and for professionals to be clear about the level of response and action that can be taken in such situations, 42 2. There is a need to ensure issues of neglect are not seen in isolation, 3. The Graded Care Profile should be completed and repeated in all cases where neglect concerns are present. This should be shared with all agencies. General Practitioner and Surgery 1. There is a need to follow up missed appointments for immunisations, 2. Health Visitor and GP practice information sharing needs to be through hand over as well as SystemOne, 3. The SystemOne sharing with 0 – 19 team of the GP record should be automatic as opposed to a discretionary opt in. Nursery Group & School 1. For professionals to be more curious and questioning when receiving query calls in relation to families from other agencies and to record the content of such contacts. 2. To develop formal supervision opportunities for front line case workers which are clearly linked to case files. All of the above agencies have submitted an Action Plan to the LSCB to address these issues. 14. Recommendations and challenges to Luton LSCB and partners Individual agencies involved in this case have each submitted an action plan to remedy the deficits and omissions identified in this review. The implementation and progress of these actions will need to be monitored by Luton LSCB. In addition to the action plans submitted, the Independent Reviewer has agreed the following specific recommendations and challenges. Individual agency recommendations Cambridgeshire Community Services: 1 To review the arrangements for the transfer of cases between practitioners to ensure there is a fair and formal procedure in place, which includes a visible management footprint. 2 To review the role, remit and purpose of the Safeguarding Team. Specifically, this review should include; • Whether the expectations of the Team – by practitioners and Team Leads – match the service provided, and to seek solutions in order to overcome any mismatch discovered, • To review whether the Safeguarding Team has a role in the follow up of actions agreed in supervision sessions with practitioners. • The current levels of resourcing for the team and whether this is sufficient to meet need and demand of practitioners involved in working with vulnerable children and families, • An audit of the arrangements for practitioners to share alerts with the Safeguarding Team and the capacity of the Team to respond. This audit should include an examination of the process of alerting 43 the Team as well as the quality of the content referred to see if any improvements can be made, • Whether the Safeguarding Team is adequately trained, resourced and capable of delivering safeguarding supervision to practitioners based on the current policy and model of supervision, 3 To review case recording practices for Health Visitors and managers/supervisors where there are child protection/safeguarding concerns to ensure recording accurately reflects the circumstances and professional activities of the case. 4 To audit the use of chronologies where cases have been transferred to another health practitioner and identify where there are missed/failed appointments and immunisations. This audit activity should also include checking the visibility of management input. 5 To review the practice of allocating child protection cases to newly qualified Health Visitors in their first six months/year of practice. 6 To review the developmental needs of the diverse range of health practitioners in the local area to ensure that supervision arrangements are fit for purpose, especially for newly qualified Health Visitors. 7 To review the use of, and guidance for, the Vulnerability Risk Assessment tool, to ensure it is user friendly. 8 To ensure all health practitioners, at whatever level they may operate within the organisation, feel empowered to act on information or concerns they may have about a child’s welfare. 9 To review the supervision policy and ensure it provides clarity about how the different forms of supervision available to health practitioners form a coherent and whole accountability framework. Luton & Dunstable University Hospital: 1 Improve the screening arrangements on fathers/males connected to new pregnancy bookings. 2 LDUH, in collaboration with CCS to ensure there is a clear understanding about which percentile charts are being used by health professionals following the discharge of premature babies. Training should be provided to all those professionals who may use these charts to ensure there is absolute clarity about how they should be applied to premature babies once discharged into the community. 3 Parents of children under one year should be given the option of collecting prescriptions from the hospital pharmacy if the medication is not held in the Outpatient Department. This is especially so if there is a chance of a considerable delay in obtaining it from a community pharmacist by the parent. 4 To review the effectiveness of the Outpatient Department policy and procedure for monitoring the weight gain of infants and potential for failure to thrive, particularly those born prematurely. Luton Children & Learning Department 1 Luton Children and Learning Department should, in conjunction with Luton LSCB should ensure that documentation on the Early Help Assessment, graded care profile and other assessment frameworks makes clear to professionals how they should address refusal of consent. Luton LSCB 1 The LSCB should ensure that professionals working in Luton have access to and can understand and implement a coherent multi-agency strategy for the assessment of neglect which sets clear practice standards about the use of assessment frameworks and tools such as the Graded Care Profile 2 The LSCB should consider how best to ensure that professional acclimatisation to the high levels of poverty and deprivation in Luton does not lead to accommodation to the neglect of children 3 The LSCB should ensure that its multi-agency training programme on neglect deals fully with known vulnerabilities in practice such as professional optimism, disguised/lack of parental compliance, ‘start again syndrome’ and professional curiosity/healthy scepticism. The Board should set clear 44 expectations about mandatory attendance at learning events and hold agencies to account over this. 4 Luton LSCB should ensure that its structures and processes enable it to have an accurate understanding of risks to service provision in member agencies and strategies to address them. 5 Luton LSCB should ensure that professionals working with vulnerable children have a consistent understanding of thresholds for intervention and service provision at all levels of entry, including thresholds and triggers for referring concerns about a child’s welfare to the Children and Learning Department. 6 Luton LSCB should in conjunction with Children and Learning Department ensure that documentation on the Early Help Assessment, graded care profile and other assessment frameworks makes clear to professionals how they should address refusal of consent. 7 Luton LSCB should emphasise the importance of weight gain in infants as being a critical indicator of health and development. This may include a) an alert to all relevant professionals to record the infant’s weight on a regular, but also opportunistic, basis b) being mindful of weight being recorded by different professionals and held in different locations and the need to cross reference information where there may be faltering growth c) ensuring all relevant professionals can interpret growth charts, particularly for premature infants and d) the need for faltering weight to be closely monitored in line with best practice. 45 Appendix 1: Membership of SCR Reference Group Agency name Reference Group membership Designation Agency submission Author designation Practitioner interviews conducted NSPCC Yes Independent Reviewer Overview author Independent Reviewer Yes Luton LSCB Yes SCR Independent Chair No Not applicable Not applicable Luton LSCB Yes LSCB Business Manager No Not applicable Not applicable Luton LSCB Yes LSCB Administrator No Not applicable Not applicable Luton Care Commissioning Group Yes Designated Doctor for Luton CCG Yes Designated Doctor Yes Luton Care Commissioning Group Yes Named GP for safeguarding children & adults Yes Named GP for safeguarding children & adults Yes Luton Care Commissioning Group Yes Assistant Director & Designated Nurse Yes Designated Doctor and Named GP Yes Luton & Dunstable University Hospital Yes General Manager Safeguarding Midwife Yes General Manager and assisted by Safeguarding Midwife, Safeguarding Nurse, Lead Nurse (NICU) Yes Education Services Yes Safeguarding in Education Manager Yes – Primary School A Safeguarding in Education Manager Yes Luton Borough Council Children & Learning Department: Yes Interim Safeguarding & Quality Assurance Manager Yes Independent Reviewing Officer: Luton Borough Council Yes Bedfordshire Police Yes Detective Superintendent Yes – Hertfordshire Police Review Officer No Luton Community Care Services Yes Children’s Services Manager Yes Independent Management Review author Yes 46 Appendix 2: Professionals who have been interviewed for this review or who have contributed to the review process Agency Designation Cambridgeshire Community Services Named Nurse: child protection Specialist Nurse: Safeguarding Clinical Lead: Health Visiting Children’s Service Manager: 0 -19 Team Health Visitor Community Nursery Nurse Rapid Response Team Primary School Family worker & Designated Safeguarding Lead Family worker Transition Administrator SENCO & Looked after Children Designated Teacher Luton Borough Council: Children & Learning Department Social Workers (x2) CAF & Stronger Families Manager: Prevention & Early Intervention Luton & Dunstable University Hospital Teenage Caseload Midwives Community Midwife Safeguarding Nurse Safeguarding Midwife Community Neonatal Sister Nursery Nurse Lead Nurse: NICU Neonatal Consultant Neonatal Physiotherapist Luton Care Commissioning Group General Practitioner Central Bedfordshire Council Emergency Duty Team Emergency Duty Team Manager |
NC047869 | Review of the responses of agencies between 1 January 2012 and 31 January 2014 to a young girl who was found to have contracted two sexually transmitted infections whilst in local authority foster care. "Claire" was known to multi-agency services from the age of five months, and had previously been the subject of a child protection plan. At six-years-old she was sexually abused by a member of the household and became a looked after child (LAC) in the care of her paternal grandmother. This placement broke down and Claire was placed in foster care. The female foster carer raised concerns about her ability to care for Claire, after which the male foster carer became Claire's main carer. Claire was removed from the placement after 15 months, when she was diagnosed with chlamydia and gonorrhoea. Issues include: lack of assessment, support and guidance for kinship foster carers; absence of scrutiny and challenge when assessing and approving new foster carers; lack of collaboration between social workers representing different teams within the LAC service; the importance placed on performance indicators compromised the role of the Independent Reviewing Officer. Uses the Social Care Institute for Excellence (SCIE) methodology to identify findings, including: strengthen the contribution of family members in LAC reviews and child protection conferences; review how agencies are kept informed of planned changes for a child and consider adapting processes to facilitate the involvement of partner agencies; put processes in place to embed challenge as an accepted responsibility in safeguarding children.
| Title: Serious case review: ‘Claire’. LSCB: Croydon Safeguarding Children Board Author: Bridget Griffin Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Croydon Safeguarding Children Board Serious Case Review ‘Claire’ Author: Bridget Griffin 2 1. Executive Summary Context At the heart of all safeguarding work is a hope that when, making a difficult decision to remove a child from the care of their family, the system can better safeguard the child and improve their outcomes. This commitment is enshrined in legislation and statutory guidance, it is supported by research and embedded within systems and processes, and it is intrinsic to the work carried out every day by professionals across the country. For children who cannot be adopted or provided with permanent care by their family or kinship network1, the care provided by foster carers remains the best possible environment where children can be enabled to establish healthy secure attachments with a trusted, caring adult (or adults) and assisted to reach their potential. The vast majority of children placed in foster care in the UK benefit from this care every day and for the duration of their childhood, but for a small minority of children the care they receive is harmful. Whilst there has been recent attention given by the media to the abuse of children by adults in a position of trust, the focus of this has been largely in relation to children who are the victim of sexual exploitation. There have been fewer cases that have caught the attention of the media in relation to children in foster care, and we know very little about the extent and nature of abuse or neglect by adult caregivers in foster and residential care today. In 2014, the NSPCC2 attempted to address this lack of research and in doing so looked at allegations of abuse made against foster carers and residential workers, concluding that: The vast majority of children entering foster care are provided with safe family placements, but in approximately 450–550 cases, children across the UK do experience harm each year from those responsible for their care. This is likely to underestimate the true extent of the problem as well over half of unsubstantiated allegations could not be proven one way or the other. In a small number of very serious cases involving the persistent neglect, emotional and/or sexual abuse of children, it was clear that the foster carers concerned should never have been recruited. High quality assessment, recruitment and review procedures are needed to prevent these individuals being able to harm children. This serious case review examines the recruitment, assessment and approval of foster carers, but goes further than this to examine the way in which multi-agency systems safeguard children over time in the provision of a wide range of services. Croydon Safeguarding Children Board identified that reviewing this case had the potential to shed light on particular areas of practice and raised the following questions: How do services work together to assess carers and match children with carers? How do multi-agencies work in partnership to support children with complex needs? How effective are multi-agency partnerships in protecting children from sexual abuse? How does existing partnership working (within and between systems, teams and agencies) improve outcomes for looked after children after? 1 Statutory guidance now refers to kinship carers as ‘connected persons’ thereby including all adults in a child’s network 2 Keeping Children Safe: Allegations concerning the abuse or neglect of children in care: research into child abuse allegations against foster carers and residential care workers. University of York & NCPCC 2014 3 This review set out to understand what happened to Claire and why. The SCIE3 methodology was chosen as it was believed to be the most appropriate to help answer the above questions, and to provide a window on the current safeguarding system. The review has explored why things happened, and provides Croydon Safeguarding Children Board (CSCB) with a number of findings to consider. What happened? This case involves the responses of agencies between 1st of January 2012 and the 31st of January 2014. This time period was selected to provide the most useful learning about current safeguarding systems. At the request of CSCB, this review has also provided comment on an earlier period of time (when Claire was the subject of a child protection plan in her early years), as it was felt this was a critical period of multi-agency service provision that could not be overlooked. Claire was known to multi-agency services from the age of five months. At this time, there were concerns about the misuse of drugs and alcohol in the household and domestic violence. Claire was made the subject of a child protection plan under the categories of emotional harm and neglect, and remained on this plan for a number of years. A range of multi-agency services were provided, and her safeguarding was the subject of regular monitoring and review. When Claire was six, she was sexually abused by a member of the household; shortly after this she came into the care of the local authority and was placed in the care of her paternal grandmother. After a number of months, this placement broke down and she was placed in the care of foster carers, who had been approved by the local authority. Fifteen months later, Claire was found to have contracted two sexually transmitted infections and she was removed from this placement. Claire received services from a wide range of multi-agency professionals, and her needs were considered within multiple processes. Overall, the review identified that the multi-agency system was not always effective in translating the extensive available legislation, guidance and procedures to frontline delivery of services in the following areas: Rigorous assessment and approval of foster carers Involvement of kinship in the care and safeguarding of a child Practice based decision making when matching a child with carers Achieving full multi-agency working when seeking to protect children from harm Comprehensive multi-agency involvement when a child is looked after Why it happened The detailed description of what happened and the appraisal of practice is provided in section 4. Section 5 of this report provides the underlying systemic findings that give a deeper understanding of the reasons for the practice shortcomings that are described in section 4. 3 Social Care Institute for Excellence 4 Background An inspection of safeguarding and looked after services in Croydon took place in June 2012. At this time, Ofsted judged safeguarding and looked after children services to be adequate (overall) with good partnership working, and good capacity to improve. It was recognised that services in Croydon contended with considerable pressure on resources in attempting to meet the needs of a large population: Croydon is the London borough that has the highest number of children under the age of 15. The time under review includes the period Ofsted were conducting their inspection, and the 18-month period after this inspection concluded. Findings There are eleven findings in this review, the first of which relates to how kinship care is not sufficiently valued. Whilst the benefits of such placements are understood in principle, in practice this does not translate to an approach that consistently supports these carers to the same level as foster carers recruited by the local authority. The next three findings are focussed on the systems in place during the assessment and approval of foster carers, and the safeguards in place that support decision making on the question of suitability. Finding 4 examines an established practice in relation to male foster carers, and how this custom and practice (as it exists) has no value in either safeguarding children from harm, or supporting carers. Finding 5 raises questions about how children are matched with carers at an early stage, and the remaining findings focus on how different agencies, services and teams work with each other, and with members of a child’s family, to safeguard looked after children and meet their needs. An area of additional learning is presented at the end of the report: this relates to the role of managers from across services and agencies and their responsibility to provide satisfactory supervision and guidance and, critically, to challenge each other, and escalate concerns, where disagreements remain unresolved. Could it happen again? The findings in section 5 explain the underlying strengths and vulnerabilities in the multi-agency systems, and patterns of working relating to the circumstances in this case. Whilst the abuse of a child by foster carers is rare, the wider circumstances of this case are not. The findings address these wider circumstances and suggest that if these issues are not addressed, the multi-agency safeguarding system will continue to have the weaknesses described, and the same practice and shortcomings could occur again. What will the CSCB do in response? At the end of each finding in section 5, considerations have been listed for CSCB. At the request of CSCB, this report goes further and raises questions for relevant agencies. These questions are aimed at assisting the Board and individual agencies to decide on the optimum action to take; they are not an exhaustive list. The intention of these questions is to prompt debate and challenge, within and across agencies, about how improvements will be realised. In response to this serious case review, CSCB has prepared a separate document outlining the work that is to be taken forward. 5 2. Introduction Why this case was chosen to be reviewed. Croydon Safeguarding Children Board Serious Case Review Sub-Group considered the circumstances of this case in November 2013, when it was agreed that agencies would examine their case records and bring information back to the sub-group. The sub-group considered the case again in January 2014 and March 2014 and a decision was taken that the case did not meet the threshold criteria for a serious case review; instead Children’s Social Care agreed to undertake an ‘Individual Management Review’ (IMR). The National Panel of Experts were critical of this decision and asked to see the IMR when it was completed. A draft IMR was presented to the July 2014 sub-group and was re-presented to the Croydon Serious Case Review Panel on the 25th of September 2014. The circumstances of this case were reconsidered, and the previous decision reviewed. It was agreed that the criteria, outlined in statutory guidance4 for undertaking a serious case review, had been met. On the 7th of October 2014 Croydon Safeguarding Children Board (CSCB) decided to review this case using The Social Care Institute for Excellence (SCIE), Learning Together Case Review methodology5. The National Panel were notified of the decision on the 1st of October 2014 and the 31st of October 2014. Summary of the Case Claire’s family had been known to Children’s Social Care (CSC) since 2005. Her mother had three children, of whom Claire was the youngest. The concerns in 2005 related to domestic violence, drug and alcohol misuse, and were of such concern that all the children were placed on child protection plans from 2006 until 2010, under the categories of neglect and emotional abuse. The case was closed in 2010, after it was decided that Claire no longer needed to be the subject of a child protection plan. Shortly after this, when Claire was four, she was found alone wandering in the street as she had been locked out of the family home. The case was re-opened to CSC and an Initial Assessment completed. Claire was deemed to be a ‘child in need’ and support services were provided to the family. In January 2012, whilst Claire was sleeping in bed with her mother, she was sexually abused by a family friend. Two days later, mother contacted the police and a child protection investigation commenced, followed by a child protection case conference. Claire was made the subject of a child protection plan for neglect and sexual abuse. Those at the conference felt Claire should be removed from the family home as a matter of urgency. An application for an Emergency Protection Order was lodged at court in January 2012, and then withdrawn. Later that month, Claire was accommodated6 and became a ‘looked after child: she was placed within the care of her paternal grandmother. Two months later, paternal grandmother reported she was unable to cope with Claire’s behaviour and a local authority foster placement was sought. 4 Working Together to Safeguard Children. HMG 2013 5 Fish, Munro & Bairstow 2010 6 Sc20 Children Act 1989 6 A couple, newly approved by the fostering panel, were considered as a potential placement for Claire and, after introductory visits, Claire was placed with these carers. Early concerns expressed by the female foster carer about the demands of the fostering role led to the provision of a range of support services. Over the duration of Claire’s placement, a number of concerns emerged about the carers but overall it was felt the placement was going well; Claire’s permanent care within this family was thought to be the likely long term outcome. An Interim Care Order was granted in August 2012, and a Care Order in June 2013. Later that year, in August 2013, Claire was removed from this placement after contracting gonorrhoea and chlamydia, and she was placed in an emergency foster placement. In November 2013, Claire moved to live with specialist carers and remains in this placement to date. Organisational Learning and Improvement Statutory guidance7 on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews, states: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that are needed and to consolidate good practice. LSCB’s and their partner organisations should translate the findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children’. Structure of the report The report is structured as follows: Section 3 explains the methodology used for this serious case review Section 4 explains what happened, why and gives an appraisal of practice in this case Section 5 provides the findings and suggests what needs to happen in the multi-agency safeguarding systems to reduce the risk of recurrence A glossary of terms and abbreviations used is provided at the end of the report 3. Methodology Introduction Statutory guidance (Working Together 2015) requires that serious case reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 7 Working Together to Safeguard Children 2015 7 In order to comply with these expectations and requirements CSCB has used the full version of the SCIE Learning Together Systems model8 for this review. This approach endeavours to understand professional practice in context, identifying the factors in the system that influence the nature and quality of work with families, and make it more or less likely that the quality pf practice will be good or poor. Solutions then focus on redesigning the system to make it easier for professionals to safeguard children well and harder to safeguard children poorly. Review team and independence The process has been led by Bridget Griffin and Ghislaine Miller; the final report was written by Bridget Griffin. Both are independent reviewers with significant experience of writing serious case reviews and they are accredited by SCIE to lead serious case reviews using the Learning Together methodology. These lead reviewers worked closely with a review team consisting of a group of senior managers who worked collaboratively with the lead reviewers in reading documentation, talking to staff, and analysing data. The review team were also able to provide useful information regarding the practice in this case, and evidence about whether the issues relevant to this case had wider significance. Those involved were: Manager, Croydon Safeguarding Children Board Head of Service, LAC and Resources Croydon LA Specialist Crime Review Group, Met Police Head of Safeguarding, Designated Nurse Safeguarding Children, Croydon CCG Designated Nurse LAC, Croydon Health Services Croydon Education Safeguarding Leads Designated Doctor for Child Protection, Croydon CCG The lead reviewers received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and the reliability of the findings as rooted in evidence. Data collection: practitioners and records Understanding practice in context requires reviewers to engage those people who were directly involved in the case in a collaborative process of dialogue, as well as drawing on the formal documentation as a source of data. Input from the key practitioners (called the ‘case group’) has been generated via individual conversations, supplemented by two case group meetings, when practitioners were given the opportunity to discuss, correct, amplify and challenge the accuracy of the facts identified, and the interpretations made, by the review team, and to share their knowledge of the systems as a whole. In total, 27 conversations were held, 8 meetings took place, and over 60 documents reviewed. Membership of the multi-agency case group and the review team numbered over 45 and included, but was not exclusive to, the following members of staff: 8 Fish, Munro and Bairstow, 2010 8 Social Workers x 5 Team Managers x 5 Primary School Teachers x 2 Teaching Assistant GP Health Visitors x 2 Paediatrician Police x 3 Independent Reviewing Officer Child and Adolescent Mental Health Services x 2 Independent Fostering Agency Supervising Social Worker and Team Manager Children’s Guardian (CAFCASS) Local Authority Designated Officer Delivery Managers (Children’s Social Care) x 2 Fostering Panel Advisor (at the time) Independent Fostering Panel Chair Agency decision maker (Fostering) Representatives from the Business Resource Team (Children’s Social Care) Data from Family Members The lead reviewers met with Claire’s paternal grandmother, her aunt and her mother. All family members clearly welcomed the opportunity to express their views. The information they provided was critical, and can be seen in several of the findings. In particular, their perspectives have contributed to the formulation of findings 1 and 11. Understandably, members of Claire’s family are deeply distressed by what they have learnt about Claire’s experiences. They had all believed that ‘by giving Claire up to be cared for by the state’ (none of the family members contested the Care Proceedings), they were placing her in the care of a trusted system that would be of long term benefit to Claire. To learn of Claire’s experiences has clearly brought about feelings of anger and regret, and deep sadness for Claire. The review team are immensely grateful to members of Claire’s family for agreeing to participate in this review. Methodological Comment and Limitations When initially considering membership of the review team, there were four professionals who had a possible conflict of interest as they had had some contact with Claire or decision-making in the process. However, as Claire was a child who had been the subject of extensive multi-agency involvement, it was concluded that it would be difficult to identify review team members who had not been involved in the case in some shape or form. Following a period of discussion and challenge, it was agreed that these possible conflicts would be acknowledged through the process and that peer challenge and scrutiny would be a welcome feature of this review. 9 4. Appraisal of professional practice Introduction This case involves the response of agencies between January 2012 and January 2014 to a young child who was receiving universal and specialist services as a child in need, a child in need of protection, and a looked after child. There were a multitude of professionals involved in providing services to Claire under the review timeline, she was the subject of many assessments, carried out by staff across a range of disciplines and services, and her needs were considered within a range of multi- agency assessments and processes. Working at the front line of a complex system, with children who have suffered harm or who are suffering harm, is extremely challenging. It goes without saying that the events of this case had a significant impact on professionals involved, both at the time the events were happening and during this serious case review. That said, practitioners and managers who were directly involved in providing services to Claire engaged well with this review. The nature of the Learning Together methodology allows front-line practitioners to reflect on their work and to strengthen their knowledge of multi-agency systems and processes, as well as providing an opportunity to promote their professional learning. Many have commented that being part of this review has allowed them to achieve a depth of learning that will have a lasting impact on their professional work in safeguarding children. This section provides an overview of what happened in this case and why. Sometimes the explanations for why will be explained in the findings section of the report and a cross reference will be provided in this section. Along with the explanation of what happened, the following makes explicit the view of the review team about the timeliness and effectiveness of the responses provided to Claire and her family, including where practice was below expected standards. Such judgements are made in light of what was known and was knowable at that point in time. The name of the child, foster carers and professionals that were involved, have been anonymized. Local Context During the last Ofsted inspection of looked after services and safeguarding arrangements in Croydon in June 2012, Ofsted judged services to be adequate (overall) with good partnership working, and good capacity to improve. The Ofsted report made the following observation of Croydon: Croydon is the second most populous borough in London, with a population of 345,600, including approximately 89,200 children aged 0-19. Croydon is a socio-economically diverse borough. The borough is ranked 19th out of 32 London boroughs in terms of overall deprivation and 107th out of 326 local authorities in England. The local authority and multi-agency partners contend with considerable pressure on resources: Croydon remains the second highest populated borough in London with 84,000 young people under the age of 15, the largest number of any other borough. It has the highest number of looked after children compared to all other London boroughs and consistently has a higher number of unaccompanied asylum seekers than any other local authority. In terms of the CSC workforce, the local authority struggled for some time to recruit permanent members of staff and as research shows this can have a significant impact on the quality of work that can be achieved. At the time Claire was first placed on a child protection plan in 2009, only 40% of the staff were permanent and, although this number improved to 85% in 2012, it was observed by Ofsted that “many of the social workers are relatively newly qualified”. 10 The report adds that “[t]he quality of service is improving, but from a low base. Some known weaknesses, such as the quality of work with children in need, have yet to be fully tackled to improve the performance of front line social work services”. Significant dates in the period under review Date Event 7.1.12 Claire is sexually assaulted by a 32-year-old friend of her eldest brother. 9.1.12 Mother contacts the Police after Claire discloses sexual abuse to mother’s friend. 10.1.12 Child protection medical; significant bruising found and additional concerns are identified in relation to neglect. 12.1.12 Police and Children’s Social Care commence a joint child protection investigation (Section 47, Children Act 1989). 25.1.12 Initial Child Protection Conference. Professionals voice frustration that Claire is still living at home. 25.1.12 Foster Care Assessor concludes the assessment of Mr and Mrs George. 26.1.12 LA lodges an Emergency Protection Order (EPO) application with the court; EPO is not progressed. Mother agrees to Claire and Sibling 2 being accommodated by the LA. Claire is placed with her paternal grandmother and Sibling 2 with a different paternal grandmother. 14.1.12 Fostering Panel review the assessment of Mr and Mrs George; Mr and Mrs George are approved as foster carers. 14.1.12 First Looked after Child (LAC) Review. 21.2.12 Claire is interviewed by the police and discloses sexual abuse. Police suspect this is not an isolated event. 20.3.12 For a number of weeks, Claire’s paternal grandmother expresses concern that without support she is unable to care for Claire. After 2 months an alternative placement is requested. 28.3.12 Review Child Protection (CP) Conference for Claire and Sibling 2. Children’s names are removed from a CP plan as they are now both looked after by the local authority. April/May ‘12 Mr and Mrs George are identified as possible foster carers for Claire; a period of introduction commences. 23.4.12 Pre-Placement Planning Meeting: Mr George and Mrs George are advised that males in the house, including Mr George, must not be alone with Claire. 27.4.12 Letter of intent (local authority’s intention to apply for an Interim Care Order) is sent to Mother and Father. 9.5.12 Claire’s spends her first overnight stay with Mr and Mrs George (part of planned introduction). Second LAC Review held: Care Plan confirmed as long term fostering. 10.5.12 Child protection referral is made by Claire’s school expressing concerns about Claire. 11.5.12 Mr and Mrs George are told of concerns reported by the school: Mr George responds angrily. 14.5.12 Claire is placed with Mr and Mrs George. 15.5.12 Mrs George found to be in distress: she is struggling to care for Claire and requests her removal from the foster carer’s home. 16.5.12 – 6.6.12 Mrs George makes regular contact with CSC stating she no longer wants to be a foster carer. She identifies Claire’s behaviour as the source of her distress and requests Claire is immediately removed from the placement. 7.6.12 Mr and Mrs George report Mr George is now taking a more active role in caring for Claire; as a result, placement is regarded as stabilising. 2.7.12 Problems with Claire’s bedtime routine are reported by carers; Claire’s school reports concern that Claire is assaulting other children. 11 31.8.12 Interim Care Order is granted. Parents do not contest proceedings. Father previously expressed a wish to care for Claire but provided no formal response as part of the proceedings; mother told the court she was unable to care for Claire. 3.10.12 Third LAC Review held at Claire’s foster placement with Mr and Mrs George. 15.10.12 Case transferred to a different social work team, the Looked After Children (LAC) Team. 19.3.13 Annual Review of Foster Carers. Fostering Panel express concerns about Mr and Mrs George; particular concerns relate to Mrs George’s ambivalence towards Claire, and her own unresolved emotional needs. Decision about continued approval is deferred. 20.3.13 Fourth LAC Review held. 14.5.13 Fostering Panel review approval of Mr and Mrs George. Panel receive updated information about the suitability of Mr and Mrs George and recommend continued approval. 24.6.13 Care Order granted for Claire (Section 31, Children Act 1989). 8.8.13 Mrs George telephones the GP regarding Claire having vaginal soreness and asks for cream to be prescribed.GP examines Claire and is concerned that Claire has a sexually transmitted infection. Swabs are taken and CSC contacted; GP expresses concern that Claire is unsafe; Mrs George is informed. Decision is taken by CSC not to take any action until swab results known. 12.8.13 Swab results confirm Claire has gonorrhoea and chlamydia; GP confirms results with CSC. Allocated social worker and foster carers’ supervising social worker visit the placement; Mr George leaves the family home overnight and Claire remains in placement. 13.8.13 Local Authority Designated Officer (LADO) Strategy meeting: police express significant concerns that Claire remains at significant risk. Child protection investigation is initiated; Claire is removed from the placement and placed in an emergency foster placement. 23.8.13 Police interview Mr and Mrs George; nothing of significance emerges. 4.9.13 ABE interview with Claire; Claire does not disclose abuse. 12.9.13 Second LADO strategy meeting: Mrs George tested positive for gonorrhoea and Mr George tested positive for chlamydia; it was felt Mr George may have received treatment for gonorrhoea before test was done. 18.9.13 Third LADO Strategy Meeting. 30.11.13 Claire moves to live with specialist carers. 21.1.14 First LAC Review in new placement. Claire has settled well; placement noted to meet her needs. Appraisal of Practice Linked to the Findings The Learning Together methodology intentionally focusses on a period of time that is most relevant to current practice and systems. The reason for this is that practice and systems can change rapidly over time in response to learning and improvement, changes in the workforce, and wider local or national changes of government, legislation and associated guidance. Therefore, the period under review (1st January 2012 to 31st January 2014) was selected as the period most relevant to current systems learning. However, CSCB felt it was important to comment on the early period of Claire’s life, in order to understand more about Claire’s early years and to identify any possible learning that may still be relevant. 12 The period prior to the time under review Shortly after Claire’s birth, the children in the family were made the subject of Child Protection Plans under the category of emotional abuse, and remained on Child Protection Plans for four years. The case notes over this period of time have not been scrutinised as part of this review, but from the account given by Claire’s mother (when she was spoken to as part of this review) it is clear that during this time Claire witnessed frequent violence which at times was extreme. The names of the children were removed from Child Protection Plans when it was believed Claire’s mother had made a number of improvements in her parenting, and after four months the case was closed to CSC. Seven months later, Claire was found wandering the streets as she had been locked out of the family home; concerns were expressed about drug and alcohol misuse and violence within the household. This prompted the re-involvement of CSC, and a child in need service was provided to the family under section 17 of the Children Act 1989 Appraisal: The length of time Claire was the subject of a Child Protection Plan was unacceptable: the impact of early trauma on children has been well researched and the effects of this trauma are likely to remain with Claire throughout adulthood. A much earlier decision should have been taken to remove Claire from this household. Had there been adequate consideration of Claire’s future, it would have been clear that Claire’s paternal grandmother was willing to provide care, but this was never explored. The ending of Claire’s Child Protection Plan may well have been indicated at the time, although without analysis of the records it is not possible to know this with certainty. Given that only a few months later the original concerns returned it seems highly likely that the assessment which concluded sufficient changes had been made was overly optimistic and not predicated on a sound evidential base. When speaking to Claire’s mother as part of this review, she was invited to reflect on this period of time: I was in relationships with men that were regularly violent…..sometimes this violence was extreme, I could not break out of these relationships; this is what I needed help with, but help was not given. I found the help for myself in the end and attended a self- help group. I now understand that I was in a cycle I could not break out of…. when I went to court at the time I told them I was not a fit mother. After getting the right help I am now in a relationship with a man that is not violent. Since this time, there have been a number of significant changes in the length of time children are the subject of a Child Protection Plan, with an increased emphasis on children remaining on Plans for a maximum of two years. Performance and quality assurance measures are in place to enable this data to be reported to senior managers, and compliance is the subject of regular review. Therefore, the considerable practice changes to this safeguarding work since 2005 means that no findings are made in relation to this period: the changes in practice, existing quality assurance and reporting mechanisms are understood to be adequate. The period under review Allegation of sexual abuse and child protection medical, January 2012: The history of the family was one of emotional abuse and neglect; the circumstances of the sexual abuse allegation (including information that mother was drunk at the time) demonstrated that there had been no sustainable changes in mother’s ability to protect her children from abuse. Despite this, Claire remained living at home for twenty days after the allegation of sexual abuse was made. The social worker to the family was newly qualified. This social worker was committed to her work with the family, had a good relationship with mother and felt that mother would make every effort to protect Claire: she ensured mother signed a written agreement to this effect. 13 The use of a written agreement to seek assurances from parents is common practice; they are promoted by managers, and their use is often endorsed by legal advice, but their efficacy has not been the subject of review. Management supervision should have challenged the optimistic view of this newly qualified social worker, and the use of a written agreement, particularly in circumstances such as this where a parent is known to misuse alcohol, should not have been encouraged. This practice was not based on a sound evidence base, and was not the subject of sufficient management support or guidance. This is discussed further in the additional learning. The child protection medical was carried out by an experienced clinician and was good practice. It was well documented and made clear findings and important observations about neglect. Initial Child Protection Conference, January 2012: The Initial Child Protection Conference was timely, well attended and well chaired. Members of the multi-agency group rightly voiced concern that Claire remained living at home and the conference correctly made a recommendation that Claire should be the subject of an Emergency Protection Order (EPO). After the conference, the social worker lodged an application for an EPO hearing with the court; this was good practice. However, the EPO was not pursued, because mother agreed to Claire being accommodated by the local authority. This is in line with expected practice: legal proceedings should be avoided if parental agreement to a child’s care can be gained. However, it was the view of the multi-agency group that in Claire’s specific circumstances, a court order was required to allow the local authority to share parental responsibility for Claire. Despite being informed that this recommendation was not followed, members of the multi-agency group, including the conference chair, did not escalate their concerns. This fell below expected practice: a safe system requires multi-agency partners to challenge practice where it falls below expected standards. Issues regarding the absence of multi-agency engagement in decision making for children in the care of the local authority are explored in finding 8. Issues regarding the absence of multi-agency challenge are explored further in the additional learning. Claire’s accommodation and placement with paternal grandmother, January 2012: On removal, Claire was placed with her paternal grandmother under Section 20 of the Children Act 1989. This was good practice as children should be secured within their birth families whenever possible and Claire was close to her grandmother: she spent every weekend in her care and had her own bedroom in the house. The social worker rightly completed a viability assessment, but the full assessment that was required (a Regulation 24 assessment) was not completed. This should have been started immediately; failure to do this meant that there was no assessment of the paternal grandmother’s capacity to care for Claire, no assessment of the support she required and no assessment of any potential risk the birth father may have posed. 9 The lack of support provided to the paternal grandmother had a direct impact on the placement later breaking down. This practice fell below expected standards and, had the correct level of support been provided, it may have been entirely possible that Claire could have remained within the care of her extended family. Claire’s social worker was newly qualified and she was a busy front line first response social worker dealing with the immediate protection of children on a daily basis. She did not understand that the assessment needed to be passed to a different social work team, and she was not appropriately guided in her work. In addition, the organisational culture that appeared to prevail was that kinship care was not valued in the same way that care provided by in-house foster carers was and this, combined with the limited integration of the different social work teams working with the needs of looked after children, contributed to this placement breaking down. 9 The lack of clarity in relation to the possible risks posed by birth father contributed to later confusions during a time when critical decisions needed to be made about Claire’s protection. 14 The issues in relation to how kinship placements are valued are explored in finding 1, issues in relation to the integration of different social work teams are explored in finding 9, and the quality of management supervision and guidance is explored in the additional learning. First LAC Review, 14th February 2012: This first review was critical: it was an opportunity to intervene early to avert the potential of drift and delay in care planning. The review was correctly held within the required timeframe. The social worker was late in letting the LAC Review Service know of the need to convene a LAC Review, the social worker had no experience of working with looked after children and existing processes in place meant that it was the allocated social worker, rather that the LAC Review Service, who were responsible for making arrangements for LAC Reviews. The Independent Reviewing Officer (IRO) knew that the timeliness of reviews was an important performance indicator, so the review was arranged quickly at the social worker’s office. There was no consultation with Claire, Claire’s parents, her paternal grandmother or with any other agency: this contravened statutory guidance. Issues in relation to how the contribution of family members is valued in the life of a looked after child are explored further in finding 11. The IRO was allocated seventy to eighty cases; this case load exceeded national guidance and left the IRO with little time to think or reflect on Claire’s case. The IRO was keenly aware which performance indicators had to be covered within the review and made sure they were properly covered; as a result the meeting focussed on performance indicators relating to Claire’s health and education. Claire’s complex emotional needs, her placement with her paternal grandmother and her legal status and care plan were not discussed in any meaningful way. The care plan described in the review (as Claire remaining with her paternal grandmother long-term under section 20) should have been the subject of challenge: Claire was a very young child, her permanent care through adoption or through a Special Guardianship Order should have been thoroughly explored. The quality assurance systems in place measured particular performance indicators in respect to LAC Reviews; quality was not measured against the IRO regulations, and IROs were under pressure to ensure that these specific performance measures were covered; this narrowed the IRO’s focus. These issues are explored further in finding 10. Assessment and approval of Mr and Mrs George as foster carers, 14th February 2012: The assessment of Mr and Mrs George was completed using a standard Form F assessment tool. The tool is in widespread use across the country and the format ensures all required fostering competencies are covered. Although the assessing social worker was new to the role, all obligatory areas were covered within the assessment and a great deal of information was provided to evidence the competencies. However, the form did not promote sufficient critical appraisal of the information gathered, and as a result there was an absence of analysis. These issues are explored further in finding 2. The assessing social worker was employed on an independent sessional basis by the local authority; it is not unusual for fostering assessments to be completed by independently employed sessional workers. However, this meant that the social worker did not have accesses to routine management guidance or supervision. Before the assessment went to panel, the assessment was seen by a manager. This manager did not identify the absence of analysis as, in line with expected standards, the focus of quality assurance was not on the quality of analysis but on whether the required competencies had been properly covered. The social worker attended the fostering panel with Mr and Mrs George. Panel members asked very few questions about the content of the assessment, but did ask Mr George how he would manage allegations made against him. He responded saying he would not be left alone with a female foster child and his answer was accepted without question. The assessment was agreed by the panel and Mr and Mrs George were approved as foster carers. 15 Within the Form F information was presented that required further exploration, scrutiny and analysis by the various managers and panel members responsible for quality assuring such assessments. Had this happened questions would have been raised about the truthfulness of the couple, their emotional stability and their resulting suitability to foster. The Form F assessments routinely seen by the panel contain a list of competencies, and the assessing social worker provides information to evidence these competencies; this allows panel members to focus on whether the required competencies have been met, and is in line with expected practice. It is not uncommon for there to be limited analysis of the information provided; it is not something that panel members routinely scrutinise or challenge, hence it was not obvious to the panel that there was information within the Form F that required further scrutiny. It was clear Mr and Mrs George met the competency check list, and this governed decision making. These issues are explored further in finding 3. The question asked by the panel about how the couple would manage allegations made against them was an inappropriate question; it is unclear what assurances the panel were seeking in posing this question, although it is acknowledged that this question is routinely asked by the panel, and is believed to be an accepted way in which allegations against carers can be successfully avoided. However, the panel’s confidence in accepting the assurances given by Mr George was misplaced because, even if this was the expected answer or practice, a plan for Mr George to avoid being alone with a female child could not be monitored and his assurances could not be guaranteed. These issues are explored further in finding 4. The identification of Mr and Mrs George as a suitable placement for Claire, March 2012: In response to concerns raised by Claire’s paternal grandmother that she was struggling to provide care to Claire, the social worker made a referral to the team responsible for identifying placements for children. This involved completing a referral form; it was an appropriate referral that included all the information requested. The social worker was committed to Claire and very keen to find a placement that would provide Claire with safety and love; her commitment to Claire was commendable. The team responsible for identifying placements was the Business Relationship Team (BRT). This team is responsible for finding placements that will meet the needs of a child on the basis of the information provided by the child’s allocated social worker. Mr. and Mrs. George were identified as being newly approved and as having no children placed in their care and the placement was efficiently identified as suitable for Claire. This process is not a practice based matching process. Matching is achieved through another, practice based, process that happens after a child has been in a placement for a year. This process involves a series of assessments and reports that articulate the needs of a child, and the abilities of identified carers to meet these needs. The match is carefully considered through a series of meetings, and decision making takes place at the fostering panel; this is known as ‘the matching process’. However, for a variety of understandable reasons, more often than not, children are matched with the carers with whom they are first placed; as a result it is this initial ‘business’ process that becomes the critical matching process. There is no practice based matching process within existing systems for children who are entering local authority care, and whilst this is understandable for children who need to be placed in an emergency, it is not understandable for children who are entering care in a planned way, as in Claire’s case. The lack of a practice based matching process at the initial stage of placement mitigated against Claire being placed with carers who were able to meet her needs. Finding 5 explores the relevant issues. 16 Review Child Protection Conference, 28th March 2012: At this time, Claire was the subject of a Child Protection Plan under the categories of neglect and sexual abuse. The Conference heard from the social worker that after receiving legal advice there had been a decision not to proceed with an application for a court order; the decision to proceed with a voluntary agreement with parents rather than pursue a legal route was in line with preferred practice. At the Conference, members rightly raised significant concerns that Claire had not been made the subject of legal proceedings. Additional concerns were expressed about her placement with her paternal grandmother, and the unassessed risks potentially posed by Claire’s birth father. However, in line with expected practice, as Claire was now looked after, a decision was taken that her Child Protection Plan would end and that no further Conferences would take place. The logic that informs this expected practice is that if a child is looked after they are adequately safeguarded, because they are the subject of additional processes such as court proceedings and Looked After Children reviews: it is assumed that these provide the required safeguarding mechanisms. Hence, having an additional Conference process in place is regarded as superfluous, and an unnecessary drain on resources that are already over-stretched. This is understandable, and is an approach widely taken across the country. However, in cases where a child is not the subject of court proceedings, and where risks remain unresolved, this blanket approach is unsafe. In addition, the expectation that the LAC Review process will involve the required multi-agency representation and adequately interrogate the safety of a child, was not borne out in practice. Despite significant concerns being expressed by multi-agency partners during the conference, there was no effective challenge to the decision to end Claire’s Child Protection Plan. The absence of effective multi-agency challenge fell short of expected practice, is contrary to procedures, and did not provide adequate safeguards. These issues are explored further in finding 6 and in the additional learning. Second Looked After Review meeting, 9th May 2012: This second LAC Review followed the same format as the first LAC Review. In addition, the membership, venue and timing of this review were contrary to the IRO Regulations and the relevant section of the child protection procedures was not followed; this practice did not provide adequate safeguards and fell below expected standards. The competing demands and the organisational pressures experienced by IROs (resulting in a dilution of their responsibilities under the IRO Regulations), have already been outlined and are explored further in finding 10. In addition, the assumption that existing processes will provide adequate safeguards for a child was not embedded within established practice or process and as a result was not borne out in practice. These issues are further discussed in finding 6. Pre-placement planning meeting, 23rd April 2012: In line with expected practice and procedure, a pre-placement planning meeting was held at the home of Mr and Mrs George. The foster carer’s supervising social worker attended alone and although this is not uncommon, it would have been best practice if Claire’s social worker had been invited. The purpose of the meeting was to plan how Claire’s needs would be met in the placement, and to identify what support the carers may need. During this meeting, the fostering social worker told Mr George that he must be careful not to be alone with Claire; Mr George agreed. This was not an unexpected request as Mr George had already given assurances to the fostering panel to this effect. Although the requirement that Mr George should not be alone with Claire was a routine request made of male foster carers caring for a child who has been the victim of sexual abuse, and was supported by management guidance, it was an unreasonable request that could not be adequately monitored or assured. These issues are further explored in finding 4. 17 After the meeting the supervising social worker returned to her office and, in line with routine practice, placed the notes of the meeting in the fostering file. There was no communication with Claire’s social worker and, as Claire’s social worker did not have access to these notes, she was unaware of the meeting, or of the requirement that Mr George was not to be alone with Claire. This lack of joint working fell below expected practice, led to disunity in the frontline teams and created gaps in the understanding and meeting of Claire’s needs. The reasons for these practice shortcomings are outlined below and explored further in finding 9. Multi-agency responses to concerns about Claire, 10th May 2012: After Claire had spent her first overnight stay with Mr and Mrs George, as part of a planned introduction to the placement, she was observed at school to be walking ‘splay legged’ and complained that her vagina was sore. School staff knew her well as she had been at the school since her reception year, and this behaviour was uncharacteristic. The school contacted the social worker and suggested that a strategy meeting was needed. The social worker was newly qualified and she appropriately sought advice from her manager about this request. The manager felt that Claire’s behaviour may have been linked to her previous abuse and, as Claire had not made a disclosure, it was decided that a strategy meeting was not needed, but that Claire’s paternal grandmother should be asked to take Claire to the GP. The school were informed of this decision; they were unhappy with the response but were not sure what else they could do. Issues in relation to management guidance and multi-agency challenge are explored further in the additional learning. No strategy meeting took place, there was no child protection medical and there was no child protection investigation. This was contrary to the child protection procedures and fell below expected practice. This approach was indicative of a poorly developed understanding of the value of strategy meetings. These issues are explored further in finding 7. Response to concerns in placement, 15th May to 7th June 2012: The day after Claire’s was placed with Mr and Mrs George, Mrs George telephoned her supervising social worker in a distressed state; she told her social worker that she was unable to care for Claire and wanted her to be immediately removed from the placement. The supervising social worker arranged to visit the placement the next day; this was a timely visit. During the visit, Mrs George became distressed and spoke about how difficult she was finding the fostering role. The supervising social worker spoke to her manager about this. It was the manager’s view, informed by significant experience in the fostering service, that this was not an unusual reaction for a couple who were new to fostering. A good package of support was offered to the carers in response to Mrs George’s concerns. Two weeks later, the couple confirmed that things had settled down; it was reported that Mr George was now caring for Claire until their adult daughter took over care when she came back from work, thus relieving Mrs George. The communication between the supervising social worker and Claire’s social worker over this period was minimal. The words used by Mrs George when describing how she felt about caring for Claire should have prompted far greater curiosity and analysis by the fostering team, and should have been shared with Claire’s social worker, but this did not happen. In addition, there was no challenge to the information received that Mr George was now playing a key role in Claire’s care, and again this information was not shared with Claire’s social worker. The social worker and the supervising social worker worked in different teams; they had different roles and responsibilities; were managed by different line managers; and used different data recording systems. Close working relationships between these social workers was therefore difficult to achieve and, whilst there were no structural barriers to achieving a close working relationship, the structures in place did not sufficiently facilitate this relationship. 18 In practice, close working relationships were largely dependent on the relationships achieved by individual workers. These issues are explored further in finding 9. Third Looked after Review Meeting Mr and Mrs George’s home, 3rd October 2012: There are no minutes on file of this meeting; the reason for this is not known. The absence of such an important record falls below expected practice standards. During the course of this review it was understood that by this time Claire’s medical had taken place and a number of health needs had been identified. However, there was no representation of the LAC nurse at this meeting. In addition, by now Claire had been the subject of significant multi-agency involvement and specialist assessment and intervention, but despite the close involvement of agencies in Claire’s day to day life, including Claire’s school, none of these professionals or agencies were represented at this important planning meeting. This left decisions solely in the hands of the local authority and this single agency approach did not meet Claire’s complex needs. It was understood that this is often a feature of LAC Reviews and planning meetings for looked after children and, whilst there is a strategic multi-agency commitment to sharing responsibility for looked after children and their outcomes, there is little in place to facilitate this on the front line in a way that makes a difference to children. These issues are further explored in finding 8. Renewal of Mr and Mrs George’s approval as foster carers, 19th March to 14th May 2013: The approval of Mr and Mrs George as foster carers was the subject of a routine annual review on the 19th March 2013. During this review, panel members were rightly concerned about the suitability of Mr and Mrs George as foster carers. Concerns were focussed, not on the role of Mr George, who it was argued had a strong commitment to caring for Claire in the long term, but on concerns about the emotional health of Mrs George, her ambivalence towards Claire, and towards her fostering role. Information provided to the panel by the fostering team on these issues was inadequate, and as a result panel members had differing views: four panel members recommended the decision should be deferred until more information was made available, three panel members recommended the carers should be de-registered and two recommended the carers should not be re-approved. The panel chair made the decision to defer concluding the matter until more information was available. Claire’s social worker was unaware of the concerns held by panel and was unaware of the panel’s decision. The reasons for this are outlined previously and explored further in finding 9. At the next panel meeting on 14th May 2012, Mr and Mrs George attended. A revised report was provided by the fostering team and Mr and Mrs George answered questions put by the panel. The panel were told that Mr and Mrs George were now both fully committed to Claire, and to their fostering role. Information provided by the fostering team in support of the recommendation for continued approval included confirmation that Mr George was now playing an active role in caring for Claire. Additional information was provided that Mrs George was taking medication for panic attacks and was on the waiting list for counselling, and as a result her emotional health had improved. On this basis of this new information, the panel recommended continued approval. The information provided to the panel stated not only that Mr George was actively caring for Claire, but that he was often alone in her company. Despite the existing agreement that Mr George should not be alone with Claire, this was not questioned by the supervising social worker, or by the manager who signed off the report, or by the Panel or later by the Agency Decision Maker. The lack of sufficient scrutiny of the information provided to support the continued approval of Mr and Mrs George by managers and panel members meant that decision about the suitability of Mr and Mrs George was highly questionable. The issues raised previously, in relation to the poorly developed quality assurance mechanisms in place when deciding foster carer suitability, are explored further in finding 3. 19 Professional response to the GP’s concerns about Claire, 7th August 2012. Mrs George noted Claire had a vaginal discharge; she bought some cream from a pharmacy but there was no improvement. She then contacted her GP asking for some cream to be prescribed. The GP asked for Claire to be brought to the surgery that day; this was good practice. The GP examined Claire and took a number of swabs, she was very concerned by what she observed and about Claire’s immediate safety; she spoke to Claire in the presence of a chaperone: this was good practice. She informed Mrs George she would be contacting CSC as she was concerned for Claire’s safety and made immediate contact with CSC and spoke to the social worker; this was good practice. On receiving the call, the social worker was extremely concerned: as she was not in the office because she was responding to an urgent matter on another case, she asked the GP to contact her manager and also contacted the manager herself; this was in line with expected practice. The GP contacted the manager and gave her opinion that Claire had a sexually transmitted infection and was at risk. After discussion with another manager, a decision was taken to await the swab results before taking any other action. The manager informed the GP of this decision; the GP correctly told the manager she was extremely concerned by this response and went on to make numerous phone calls to health colleagues in an attempt to elicit a different response from CSC. The perseverance of the GP was commendable but, despite the number of calls made by the GP, health professional colleagues were unable to escalate the concerns effectively and there was no strategy meeting and no child protection investigation. The reason for this is believed to be directly related to a misunderstanding about the value of strategy meetings when a child is looked after. These issues are discussed further in finding 7. The next day the Local Authority Designated Officer (LADO) was contacted by the manager; the LADO agreed with the decision to await the swab results before taking any action. The response by CSC managers (including the LADO) and the lack of action taken was contrary to the child protection procedures, left Claire at risk of harm and fell well below expected practice. The reasons for this are linked to the issues outlined in finding 7 and were compounded by the issues explored in the additional learning. Professional response to the swab results, 12th to 13th August 2013: On 13th August 2013, the GP contacted the social worker confirming that Claire had chlamydia and gonorrhoea. The social worker was shocked by what she was told. She was not in the office that day but made immediate contact with a senior manager and made arrangements to return quickly to the office; this was good practice. The senior manager had limited experience of child protection work and so the child protection procedures were not well known to her; she also had limited knowledge of sexually transmitted infections and so when she was contacted by the GP she sought assurances that the infection could not be caught from something other than sexual contact/abuse. She was not convinced by the answers she was given, or that Claire was unsafe in her placement. She spoke to a colleague in the fostering team and together they reached a view that as Claire’s father was a Schedule One offender, and Claire was spending alternate weekends in the care of her paternal grandmother, there was a chance that she may have been infected by someone outside the placement, or that the infections had remained dormant from when Claire had been sexually abused whilst living with her mother. A decision was made that the social worker and the supervising social worker would visit the placement, speak to Claire and the carers with the view to removing Claire from the placement. The social worker returned to the office and sent a police notification form and a Local Authority Designated Officer referral form to the senior manager and, together with the supervising social worker, visited the placement. The reaction of Mr and Mrs George to the information that Claire had sexually transmitted infections was one of anger. 20 Mr George became particularly angry and abusive; Claire witnessed this anger and was distressed. As directed by the senior manager Claire was spoken to alone by the social worker; she did not make any disclosures. The social worker made regular calls to the senior manager; she was expecting the police to arrive at the house to assist but when they did not arrive, and the situation became increasingly untenable, she asked the senior manager for the police to be called. The senior manager had not contacted the police because she did not think they would be in the office as it was out of normal office hours; furthermore, she was not keen to have the police visit the home of a foster carer. Eventually, in an effort to minimise further disruption for Claire, a decision was taken by the senior manager that Claire would remain in the placement and Mr George would spend the night in another household. This was contrary to advice given by the Head of Service at an earlier point that Claire should be removed from the household. However, it was late in the evening, the senior manager was aware that her decision making was trusted by the Head of Service and an extreme situation had been reached, so she felt in a position where a judgement call needed to be made. The social worker was not happy with this decision or with the way in which the situation had been managed by the senior manager: she felt very concerned for Claire and did not want to leave her in the placement, but it was now very late at night and she felt she had been left with no alternative. The social worker was new to her role and although a competent and committed practitioner she felt she had no option other than to follow the direction and guidance of the senior manager. She did not know what else she was able to do. The issues in relation to management supervision and guidance are explored further in the additional learning. It was the view of an experienced Director of Children’s Social Care who was in post at the time these events occurred, that the decision not to remove Claire was a judgement call that did not contravene existing child protection procedures. There remains a divergence of views about this: it was the view of a number of review team members that the guidance provided by CSC managers, the lack of a strategy discussion with the police and the lack of joint action with the police fell below expected practice, was contrary to child protection procedures and to statutory guidance, and compromised Claire’s emotional wellbeing and safety. That said, in the absence of required action in response to the concerns raised the previous week, in the absence of a strategy meeting or discussion that day, and in circumstances where a child is experiencing considerable emotional distress caused by witnessing anger and hostility within a household for some considerable time, to reach an agreement that a male carer will leave the house rather than remove a child is a judgement call, and on balance, in these extreme circumstances, is one that is arguably justifiable. Issues relating to how strategy meetings are valued are explored further in finding 7. Strategy Meeting, 13th August 2012: On the advice of the LADO, a strategy meeting was held the next day. This was well attended by professionals representing the police, health services and CSC and a decision was taken to remove Claire from her placement that day; this was the correct decision. Claire was immediately removed to a place of safety; this was expected practice. Information was held by Claire’s school, but this information was not sought. If contact had been made with the school, information would have come to light at an early stage that would have informed a better understanding of Claire’s experiences. 21 Claire’s paternal grandmother had recently provided respite care for Claire. She had important information about Claire’s discharge and had also been given information by Mrs George about a previous visit to the doctor and a diagnosis of thrush: this information was in fact untrue. . As the paternal grandmother was not contacted as part of the strategy meeting process, she was not able to share this information: this fell below expected practice. The contribution family members can make in the protection of children is understood but not fully realised, and this has a significant impact on how information held by family members is sought and used to inform safeguarding decision making. These issues are explored further in finding 11. 5. The Findings Introduction Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of re-occurrence10. Section 4 provides the analysis of what happened and why; section 5 provides the findings relating to what needs to happen in the multi-agency safeguarding systems to reduce the risks of re-occurrence. The SCIE Learning Together systems approach uses what has been learnt about an individual case to provide a ‘window on the system’ into how well the local multi-agency safeguarding systems are operating. In what way does this case provide a useful window on our systems? CSCB was understandably very concerned about what had happened to Claire and sought to understand her experiences as a child who had been in receipt of many multi-agency services from a very early age. It was felt vital not only to learn about what had happened in this case (as described in section 4), but also to consider what this tells us more generally about the way agencies in Croydon individually and collectively respond to safeguarding children when they are a looked after. The contextual information provided in section 4 provides a general picture of judgments made in Croydon’s Ofsted inspection and of improvements made at that time, but the judgements do not address the specific circumstances seen this case. This case provides evidence of multi-agency working after the period under inspection and covers a number of areas that have previously not been the subject of investigation, audit or analysis. Summary of findings This section contains eleven priority findings that have emerged from the serious case review. The findings explain why professional practice was not more effective. Each finding lays out the evidence identified by the review team that indicates that these are not one-off issues. Evidence is provided to show how each finding is indicative of potential risks to other children in future cases, because they undermine the reliability with which professionals can do their jobs. It does this by considering patterns that are supportive of good quality work and patterns that introduce or increase the risk to the reliability with which we can expect professionals to achieve good quality work. 10 Working Together to Safeguard Children DfE 2015 22 The eleven priority findings relate to five underlying patterns within multi-agency safeguarding systems. No single finding can explain the outcome; all the findings are interrelated: one impacts on the other and the other impacts on the next and so on. The evidence for the findings comes from the knowledge and experience of the review team and case group, from the records relating to this case, case documentation and from relevant research evidence. Quotes from the case group and the review team are used in the findings; these are direct quotes taken from the words of an individual professional, and are chosen because they are felt to best represent a view expressed by a number of case group and review team members during the course of this review. The remainder of this section explores the eleven Findings. Findings in detail Finding 1: Patterns of interaction with family members The difference in how connected carers are valued, and so supported, in contrast to ‘in house foster carers’, increases the likelihood that children are unable to grow up in the care of connected carers/family members. Introduction When a child becomes looked after by the local authority a decision must be taken about where the child is best placed in order for their needs to be met. There are a number of options that are considered in making this decision: for younger children either a foster placement, or a placement with members of the extended family or with connected persons, are the placements of choice. In an emergency, children can be placed with connected persons or family members who have previously not been assessed, as long as a viability assessment is completed. Following this, these carers are subject to an assessment and approval process that largely mirrors the assessment and approval process of other foster carers. In the same way, these carers are joined in all relevant processes, procedures, standards and quality assurance mechanisms as applied to all children’s placements in foster care. Likewise, these carers are equally entitled to the same financial assistance, training and support packages that are provided to other foster carers. The challenges of caring for looked after children, who have frequently suffered abuse and/or neglect in early childhood, are often significant and the support provided to their carers is pivotal in enabling such placements to be successful. This case has shown that there is a difference in the way these different carers are valued and supported. How did this feature in this case? When a decision was taken to remove Claire from her mother’s care and accommodate her within the care of the local authority, Claire’s mother agreed to her paternal grandmother looking after Claire. The social worker completed a viability assessment and Claire was placed in her care. Paternal grandmother did not understand that Claire was now a looked after child; she simply assumed that Claire was staying with her as she usually did every weekend and every school holiday, but that this time her stay included weekdays. The bin liner of clothes that she came with was found to contain dirty ill-fitting clothes. The paternal grandmother bought her new clothes and a school uniform. Money was tight and all incoming money was already accounted for, so the additional financial pressures proved to be difficult to manage. 23 The paternal grandmother was not aware that she was able to gain financial support: she was not told of this and so did not ask for it. The demands of the paternal grandmother’s job meant that she worked long days, and often worked for six days of the week: it was a struggle for her to meet the practicalities of caring for a young child. Claire’s behaviour was challenging, she was exhibiting emotional distress and her behaviour was difficult to understand. The paternal grandmother often asked CSC for support; she was seen as very demanding. Eventually, the demands of caring for Claire became too difficult for the paternal grandmother to manage and she informed the social worker that she was no longer able to cope with her care. By this time Claire had been with her paternal grandmother for almost four months, but no formal connected person’s assessment had been completed, no therapeutic services or guidance had been provided, and no financial assistance had been given. In contrast, when Claire moved to live with Mr and Mrs George, who had been assessed and approved as professional foster carers by the local authority, the carers were provided with a weekly financial allowance and a clothing allowance to meet her needs. Respite care was provided every other weekend, child care was provided to allow the foster carers to go on holiday, after school activities, breakfast club, and summer camps were funded, and the carers were provided with the support of a mentor. There were regular visits by Claire’s social worker and the carers received support from their fostering supervising social worker; a CAMHS tier 4 team provided therapeutic support to the carers. How do we know it is not unique to this case? Members of the case group were clear that statutory guidance promotes the placement of a child within the care of extended birth family members, and efforts should be made to support these arrangements. Whilst it was understood that this is the starting position, it was felt that this did not necessarily translate to the same level of support as that provided to foster carers recruited by the local authority: We do not invest enough in family, it is potentially the best option for a child and is more cost effective (front line practitioner). In terms of why this might be the case, members spoke about differences in the processes in place for the assessment of family members, and the additional work that is inherent in supporting birth family members as carers. In the case of in house carers, the necessary work at the early stage of recruitment is completed by the fostering teams and a supporting social worker is allocated (the supervising social worker). For family carers or connected persons, the checks and the initial viability assessment are completed by the child’s allocated social worker before the case is passed to the Fostering Team and allocated to a supervising social worker. This is both sensible and reasonable, as it is this child’s social worker who often knows the child and family best. However, this work can be difficult to prioritise for social workers and they may de-prioritise full completion of this early stage of work, in a working environment where the immediate need to achieve safety for a child dominates much of their work. It was understood that this can cause delays in completing the work needed to transfer the case to the fostering teams, as it did in this case. 24 Whilst these practical difficulties were widely acknowledged as very real obstacles, it was felt that this was not the central nub of what may lie beneath the differences in the support provided to the two different kinds of carer. What came across was a sense of a distinctly different attitude towards family carers in comparison to other foster carers, a view that family carers do not require the same support as other foster carers because the child is believed to be known well by these family members, and a belief that families have a moral obligation to provide care. It was concluded that this leads to workers sometimes not perceiving the provision of support to family/connected person carers to be urgent. When combined with the impact of practical differences inherent within existing processes, this leads to these carers being valued, and consequently supported, in a very different way. How widespread and prevalent is the issue? There are numerous pieces of national research examining this issue, and unanimous agreement that there is a real difference in the support offered to connected persons, as compared to in house carers: It is clear from the research that the support offered to kinship foster carers varies greatly and the support, finance and training available to kinship carers is often of inferior quality to that offered to non-kinship carers.11 In 2013, The Buttle Trust12 reviewed relevant research and interviewed 80 children and kinship carers. This research found that the lack of support to kinship remains a concerning trend: Despite taking on a huge burden from the state by looking after children who would otherwise end up in the care system, kinship carers and the children they look after are still an overlooked group who experience high levels of poverty and disadvantage with little or no statutory support. Government statistics on the numbers of children in formal connected persons care show that at 31st March 2013, 11% of children (over 7,000) looked after in England were fostered by a relative or friend (DfE, 2013). No data is available in relation to the levels of support provided to connected persons. Between January 2013 and December 2014 in Croydon, ninety carers were approved as foster carers; fourteen of these were connected persons (15.55%). There is no data available on the number of connected persons placements that break down as a result of lack of support, or the number of placements that are made where financial or other support is (or is not) provided. Consequently, it is not possible to provide statistical data in relation to how connected persons/carers are supported in Croydon. 11 How do kinship (family and friends) foster carers experience their role and working relationships within the children’s workforce? CWDC 2009 12 “The Poor Relations? Children and informal carers speak out”: The Buttle Trust 25 What are the implications for the reliability of the multi-agency safeguarding system? There is a widespread recognition that children who cannot live with their birth parents should be given the chance to be looked after by family members/connected persons rather than strangers, if this is in the child’s best interests. If placements with connected persons are properly resourced and supported they have the potential to offer children permanence, stability and a sense of belonging which other kinds of care placement cannot always provide. In a system that is working to preserve children’s care with their birth families, efforts will be made to establish mutually respectful relationships with birth family members as soon as they become known to the local authority, so that a positive working relationship can be established and a tailored package of financial, practical and emotional support provided to enable them to offer the best possible care to their child. However, connected persons face many challenges, often linked to their own circumstances, the complex emotional and behavioural needs of the child they are caring for, the financial demands of caring for a child, and the difficult dynamic that can exist between them and the child’s parents. If a system does not properly recognise and promote the benefits for looked after children of finding permanence within their birth families or the support for connected persons is not adequate, connected persons are likely to struggle with the challenges of caring for their child and may ultimately find this so overwhelming that the child’s placement breaks down. 26 Finding 1: The difference in how connected carers are valued, and so supported, in contrast to ‘in house foster carers’, increases the likelihood that children are unable to grow up in the care of connected carers/family members. Summary: Legislative guidance, backed by research findings, is clear: wherever possible children should be placed within the care of their birth family because such placements have clear lifelong benefits for a child. However, supporting connected persons carers can be complex. The mixed organisational messages about the value of connected persons, if not resolved, can leave practitioners trying to resolve these contradictions on the front line. Without the necessary organisational supports in place, such efforts will inevitably have little impact. Issues for the Board and Individual Agencies Children’s Social Care How will the support currently provided to existing connected carers be reviewed and evaluated? What steps will be taken by CSC to identify any cultural attitudes or beliefs or organisational obstacles that may get in the way of providing sufficient support to connected carers and how will improvements be made? Does innovative practice exist elsewhere and can this be built upon in Croydon? Is it possible to conduct a focus group with family carers to better understand what support they need and how this is best delivered? Do current arrangements provided to support in house carers need to be adapted so they meet the needs of family carers- Would a more tailored approach be helpful? What training is currently provided about the value of family placements and how such placements can be identified and best supported? What data should now be collected in relation to connected carers and what quality assurance measures need to be in place to examine this area of work? How are placement disruptions currently managed? And how can the learning from any breakdowns or disruptions be used to inform future developments? Are there any systems issues, in relation to both supervision and the electronic systems in use that guide the flow of work (ICS), that could be adapted to embed changes that will support practitioners and managers in the timeliness of assessments and in the provision of support? Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board CSCB to decide where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. 27 Assessment and approval of Foster Carers (Findings 2 & 3) The assessment and approval of foster carers takes place within a tried and trusted process that involves the completion of an assessment form and a process of scrutiny and quality assurance provided by suitably experienced managers, and an independent panel. The following two findings are two aspects of this system and, whilst inextricably linked, are separate aspects of the system and need to be considered in their own right. Therefore, these findings are presented separately. Finding 2: Tools The tool used in the assessment of foster carers appropriately encourages the gathering of information guided by fostering standards. However, this is not sufficiently balanced by a focus on critical appraisal and this has a detrimental impact on the quality of analysis in the assessment of potential foster carers. Introduction When prospective foster carers are assessed in relation to suitability, statutory guidance13 provides the broad framework for assessment, detailing the areas that must be covered and the information that must be gathered during this assessment. The guidance states that [t]here are no specific requirements about the way in which assessment information must be collected or presented to panel. Assessments are routinely undertaken using a standard template known as the ‘Form F’. This template was designed by the British Association for Adoption and Fostering (BAAF)14. A licence is paid to BAAF in order for the form to be used and this form is in routine use across the country (to such an extent that the term ‘BAAF Form F’ is synonymous with ‘a fostering assessment’); no other forms are known to be in use. Whilst the associated guidance states the need for scrutiny and analysis of the information gathered, the form does not provide explicit prompts to facilitate this; it is assumed this will be completed by the assessor or will be picked up by the quality assurance mechanisms in place. This finding illustrates how, in the use of an assessment form primarily focussed on a list of competencies, the decision making about suitability can become inadvertently led by a need to ensure these competencies have been met, rather than assessment and decision making involving critical appraisal and analysis that may reveal important information on the question of suitability. 13 Assessment and approval of foster carers: Amendments to the Children Act 1989 Guidance and Regulations Volume 4: Fostering Services July 2013 14 Prospective Foster Carer(s) Report (Form F) (England) BAAF 28 How did this feature in this case? The Form F provided a great deal of information about Mr and Mrs George. The information provided followed the standard structure of a Form F, charting how Mr and Mrs George met the necessary fostering competencies and foster care standards. The information covered a wide variety of areas pertaining to Mr and Mrs George, with the vast majority of information taken directly from the words of the couple. As a result, the information presented in the assessment took the form of descriptive accounts; there was an absence of critical appraisal and analysis and this impacted on decision making in respect to suitability. This is illustrated in a variety of ways within the Form F. The following information provides two examples. The Form F contains long quotes from Mr and Mrs George about their own childhoods: the couple describe these childhoods in very positive terms. Phrases such as having a great life and having a happy childhood are used interchangeably by both Mr and Mrs George. However, from both carers’ accounts, there were indications that these childhoods were not quite as they were described. For Mrs George there were clear issues regarding her relationship with her birth father and her step-father, both of whom left the family home when she was a child. There were unanswered questions concerning the identity of her birth father, and there remained issues relating to secrecy and truth in relation to this important issue. These issues remained unresolved at the time of the assessment and were not commented on or explored during the assessment. In addition, Mrs George was known to have a serious life threatening health condition which, although being successfully treated, was something she was continuing to emotionally process; this was not the subject of sufficient exploration. Mr George spoke in glowing terms about his childhood. However, within the narrative there were clues concerning a number of emotional issues that remained unrecognised and so potentially unresolved. These included descriptions of his mother being emotionally unavailable to him – she was not physically affectionate… She put up with me – and of his father: He was not an emotionally warm or affectionate man who would not like him (Mr George) showing his feeling or crying…to this day Mr George finds it hard to talk about his feelings when he is upset, and never cries. These accounts appear as a narrative of facts and the conclusion in the report is that Mr George has experienced a stable, committed family and he has experienced reliable, loving and caring parenting. The structure of the Form F encouraged an approach that appeared primarily to focus on making sure the eighteen competencies and seven standards had been met, by posing questions throughout the form inviting information to be provided to evidence these competencies and standards. Analysis is only prompted at the end of the form and this appears to encourage a summary of how the competencies and standards have been met, rather than prompting critical appraisal and analysis. How do we know it is not unique to this case? The messages from the case group and from conversations with managers, practitioners and panel members responsible for the completion, review and scrutiny of Form Fs, were consistent: 29 Form Fs are a reputable tool used to assess the suitability of foster carers; they have been use for a number of years and so are an established bedrock in the assessment of foster carers and, apart from an increased focus on foster carer competencies, they have changed very little over the last ten years. There was a strong reluctance to question the format and use of the Form F: it was clear that its use is so part and parcel of the culture that questioning this bedrock led to many challenges and a desire to draw the focus of enquiry towards the individuals involved. Whilst the notion that this may be a one off (an issue peculiar only to this case) was considered, the fact that the assessment went through a number of different quality assurance layers, involving individuals at different levels of management hierarchy, and involving a panel of independent members, led to the conclusion that this finding was not peculiar to this case. Indeed, the unanimous view of the case group and review team, who were familiar with Form Fs, was that this assessment was of a ‘good quality’ (it was no different to the quality of the Form Fs routinely seen by the Fostering Service, the Panel, and the Agency Decision Maker). A number of case group members spoke about how Form Fs have come to be seen as just a ‘means to an end’, in relation to the approval of foster carers. There was information to suggest they are not routinely read or used to inform the ongoing work with carers, or to inform how a child’s needs will be met in the placement, and it was generically felt that apart from listing how the fostering competencies have been met, these forms had no other value. A member of the review team expressed their professional view, based on many years of experience in fostering services, that the emphasis of the Fostering Standards (2011) has drawn local authorities into a position where the form F is disproportionally slanted to an assessment process that leads down a path of using the form to assess foster carers to become foster carers. Hence, the result is an emphasis on gathering information in order to complete a check list of competencies, rather than an emphasis on information scrutiny, based on critical appraisal and analysis. How widespread and prevalent is the issue? BAAF Form Fs are the only forms in use in Croydon for the purpose of foster care assessment, and are widely used across the country to inform the assessment and approval of foster carers. Despite calls to improve the quality of fostering assessments, and recommendations to move to a ‘value based’ or ‘adult attachment style’ of assessment (NSPCC 2013), there is no research and no local or national data on this issue. However, it is perhaps noteworthy that serious case reviews examining the abuse of a child in a position of trust over recent years15 have highlighted the need to have in place assessments that prioritise information gathering characterised by close careful appraisal and analysis, over information gathering led primarily by the need to show whether or not competencies have been met. 15 There have been a number of inquiries into abuse in foster care, including the inquiries into the deaths of Shirley Woodcock (1984), Chelsey Essex (2007), and into cases where foster carers have been imprisoned for the abuse of foster children, including Eunice Spry, Kenneth Norton and two foster carers in Wakefield who sexually abused a succession of foster children (Parrott et al., 2007). More recently the report of a court case, A and S (Children) v Lancashire County Council [2012], documented the physical abuse of two siblings in two of the many foster placements they had lived in over an 11-year period (Conroy, 2012). 30 What are the implications for the reliability of the multi-agency safeguarding system? The assessment of foster carers is part and parcel of the way in which vulnerable children are safeguarded and their needs met within the care of the Local Authority. The safe and effective assessment of foster carers for this critical caring role is carried out daily across the country in order that children who are unable to live within the care of their birth family can make secure attachments and grow up to reach their potential in the care of a substitute family. If foster care assessments get beneath the narrative by exploring values and motivations, and conclusions are predicated on critical appraisal of the information gathered and analysis, the question of suitability can be properly determined and suitable carers recruited. Information gathering in order to evidence how standards are met, whilst useful, is only one part of the assessment process. Adults who intend to sexually abuse children are often sophisticated in their attempts to be in a position where they may gain the opportunity to carry out this abuse and they will look for ways of outmanoeuvring whatever assessment processes are in place to avoid detection. If foster carer assessments are led by a format that promotes gathering information to evidence whether a list of competencies have been met and does not balance this with a format that facilitates robust critical appraisal and analysis, this creates a potential loophole that risks manipulation by adults who are potentially unsuitable, thus undermining the systems designed to protect children from harm. 31 Finding 2: The tool used in the assessment of foster carers appropriately encourages the gathering of information guided by fostering standards, however this is not sufficiently balanced with a focus on critical appraisal and this has a detrimental impact on the quality of analysis in the assessment of potential foster carers. Summary: The assessment and approval of foster carers is a critical cornerstone in how children are safeguarded, and how their needs met. Many foster carers are successfully recruited across the country and provide a high standard of care to vulnerable children. The assessment form in use lists the foster care standards and competencies required by national guidance, and this is appropriate. However, the lack of emphasis on critical appraisal and analysis of this information creates potential loopholes that undermine the quality of decision making when question of suitability is decided. Issues for the Board and Individual Agencies Children’s Social Care How might the assessment tool in use be adapted to promote strengthened critical appraisal and analysis? Is there innovative practice elsewhere that can built upon? How might the benefits of using the principles of value based motivational interviewing be considered when assessing foster carers? Have the benefits of an adult attachment interview been considered in the assessment of foster carers? How might the training of assessing social workers be strengthened to promote critical appraisal and analysis of the information gathered? Could agencies be better engaged in the assessment of foster carers in a way that supports analysis of the information gathered (such as the involvement of a mental health professional)? Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board CSCB to decide where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. 32 Finding 3: Management Systems There are a number of quality assurance measures in place to enable the successful assessment and approval of foster carers, but these measures are inhibited by an absence of sufficient scrutiny and challenge. This compromises decision making on the question of suitability. Introduction The completion of a foster care assessment is only the start of an established process of review and decision making before the question of approval is concluded. This process involves a manager responsible for foster care assessments, a Panel made up of experienced independent members, and a nominated ‘Agency Decision Maker’ (usually a senior manager). The Agency Decision Maker has the final say in foster care approval. Accordingly, this strict process is a core quality assurance mechanism that facilitates how the question of foster carer suitability can be decided. In order for this to work well, the process must be predicated on robust challenge, scrutiny and analysis. This case has shown that when these features are absent, the approval of foster carers is compromised. How did this feature in this case? There was information contained within the assessment of Mr and Mrs George that was presented to Panel which suggested this was a family where secrets and dishonesties were an accepted part of life. As described in the previous finding, this was something Mrs George had grown up with. The assessment completed by the assessing social worker identified that the parents had not told the truth to their children about Mr George’s previous marriage. In this assessment there was additional information provided that the couple had not told their children the truth about their own marriage: the children had been led to believe the parents had been married at an earlier point in their relationship, so when Mr and Mrs George told them they were getting married the children were really angry…… they felt they had been lied to. There were significant discrepancies in the dates given by the couple regarding when they had met and started an intimate relationship. These dates were significant as Mr George was married when the couple met and, given the birth date of their eldest child, it was entirely possible that an intimate relationship commenced within months of his first marriage (when Mr George was still living with his wife in the marital home). The number of discrepancies in the dates given by the couple suggested the couple were keen to ensure that the truth about this was not the subject of exploration, and indeed it was not. All of this information was clear to see within the assessment, and within this assessment there were other areas of the couple’s life that should have posed questions in relation to their honesty (e.g. suggested fraudulent use of a disabled ‘blue badge’ parking certificate). The responsible manager picked up on the issue of Mr George’s previous marriage and the fact that his children had not been informed, but apart from this none of these issues were raised by managers, panel members, or by the Agency Decision Maker. Consequently, there was no interrogation of these secrets and dishonesties, and no analysis of the possible implications. 33 How do we know it is not unique to this case? Conversations were held with a number of the case group members who held responsibility for the assessment and approval of foster carers: these included the Panel Chair, Panel Adviser, and the Agency Decision Maker. Collectively, these members had many years of experience in the assessment and approval of foster carers. The view of these members was that the carers looked good on paper, the assessment was of the same quality as the majority of assessments that go to panel, and in hindsight there was nothing memorable about the information provided in the assessment. The assessing social worker told members of the review team of recent discussions with colleagues about attendance at panel; their experiences suggested a consistent absence of in depth scrutiny and challenge, and a view that panel members were focused on typing errors, or on more practical aspects of the assessment in relation to such things as the financial status of the couple and whether the required fostering competencies had been covered. How widespread and prevalent is the issue? Although there is no local or national data or research relevant to this particular finding, it is noteworthy that research and serious case reviews examining the safe recruitment of adults in a position of trust emphasise the need for sufficient scrutiny and analysis to be present, not just in the completion of an assessment but in all stages of the recruitment process: In a small number of very serious cases involving the persistent neglect, emotional and/or sexual abuse of children, it was clear that the foster carers concerned should never have been recruited. High quality assessment, recruitment and review procedures are needed to prevent these individuals being able to harm children.16 An experienced senior manager expressed the view that assessment is disproportionally slanted to approving foster carers, and so it may be of relevance to note that in Croydon between January and December 2013, there were 37 foster carer assessments presented to panel, all carers (100%) were approved. In 2014, 56 carers were presented to panel, 54 were approved (96%). What are the implications for the reliability of the multi-agency safeguarding system? There are over 63,000 children placed in foster care in the UK. The vast majority of children entering foster care are provided with safe family placements; this is achieved through a tried and tested process of assessment and approval that includes suitably experienced managers, independent experts, and multi-agency specialists, with the ultimate decision resting with an experienced senior manager. In a system that is working well, the suitability of potential carers is determined by assessment and decision making characterised by robust analysis, scrutiny, debate and challenge. In the absence of these features, unsuitable adults will be in a position of caring for vulnerable children, compounding existing problems that the child may have, and causing further harm. High profile cases17 of children abused by adults in a position of trust has shown that when the rigour of the recruitment process is comprised, this makes it more likely that unsuitable adults will be able to manipulate these gaps in order to have access to children. 16 Keeping Children Safe: Allegations concerning the abuse or neglect of children in care: research into child abuse allegations against foster carers and residential care workers. University of York & NCPCC 2014 17 Bichard Warner Utting et al 34 Finding 3: There are a number of quality assurance measures in place to enable the successful assessment and approval of foster carers. These measures are inhibited by an absence of sufficient scrutiny and challenge, and this compromises decision making on the question of suitability. Summary: Foster carers are tasked with the safe care and nurture of vulnerable children. The assessment of ‘in-house’ foster carers falls to the local authority: approval is the subject multi-disciplinary review and decisions are made within a carefully established process that includes the involvement of independent panel members. For this system to work safely, in approving suitable foster carers and protecting children from harm, the vital role played by scrutiny and challenge must be fully realised and consistently delivered. Issues for the Board and Individual Agencies Fostering Panel What are the obstacles to achieving scrutiny and challenge of foster care assessments? Is the Fostering Panel made up of the necessary expertise to allow informed analysis of the information provided? How do panel members gain specialist advice when needed? What is the role of the Panel Advisor and how are any potential conflicts of interest understood and managed? What quality assurance mechanisms are in place to review and evaluate the work of the Panel? How is performance measured? How is the Independent Chair supported in raising and resolving any concerns in relation to the work of the panel? Fostering Panel learning and development plan to reflect the learning from this finding and issues to be taken forward. Fostering Panel to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Children’s Social Care What are the obstacles to achieving high quality assessments? How is quality assurance (under the current arrangements for commissioning assessments) provided? Are these arrangements adequate? What is the role of the Agency Decision Maker? Are there any obstacles in how this role is fulfilled? Are there any potential conflicts of interest? CSC Learning and Development Plan to reflect the learning from this finding and issues to be taken forward. CSC to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. 35 Issues for Croydon Safeguarding Children Board CSCB to decide where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Finding 4: Patterns of multi-agency working in longer-term work The established norm of seeking a commitment from male foster carer that they will not have unsupervised contact with a female child in their care to avoid allegations being made, provides a veneer of assurances that the child and carer are safeguarded. Introduction Statutory guidance contained within Working Together18, sets out the responsibilities of Local Authorities and multi-agency partners in dealing with allegations made against staff in a position of trust. Allegations made against foster carers, whilst not a significantly prevalent issue, are not uncommon: a recent study by the NSPCC reports a UK estimate of approximately 2,000–2,500 allegations per year. Between one-fifth and one-quarter of these allegations (22–23 per cent depending on year) were confirmed as abuse or neglect. The majority of allegations were therefore not substantiated. In a sub sample of 85 local authorities 26 per cent of all allegations were confirmed and 30 per cent were considered to be unfounded. However, 43 per cent of allegations were unsubstantiated due to a lack of evidence to either prove or disprove them. Since the 1980s, the Fostering Network and its predecessor the National Foster Care Association (NFCA), have drawn attention to allegations of abuse against foster carers,19 describing how unfounded allegations can be profoundly upsetting for foster carers, can lead to the removal of children from their care, and may result in some carers giving up fostering. It is therefore unsurprising that fostering teams and panels are mindful of this issue when working with foster carers. The response to this issue by fostering services and panels is varied; in Croydon a particular approach has been taken and this approach has become a routine part of practice. How did this feature in this case? In line with expected practice, Mr and Mrs George attended the fostering panel to answer questions put by the panel to assist the panel in making a decision about their approval. Within the assessment information was provided outlining how the couple would share the care of a child: Mrs George would care for the child until Mr George returned from work…. He would then be able to do what was needed for the child while Mrs George was at work. Prior to approval being recommended, Mr George was asked how he would manage the potential of allegations being made against him by a child in his care; he responded by saying that he would ensure he was ‘never alone with a female placement’ and the panel accepted this answer. The panel made a recommendation to the Agency 18 Working Together to Safeguard Children, DfE 2013 & 2015 19 The Fostering Network, 2006, The Fostering Network, 2004a, Nixon and Verity, 1996, Swain, 2006a, Hicks and Nixon, 1989). 36 Decision Maker that Mr and Mrs George should be approved as foster carers. This recommendation was signed off by the Agency Decision Maker, and Mr and Mrs George became approved foster carers for Croydon. Subsequently, Claire was placed in their care. Prior to this placement being made, a ‘Pre-Placement Planning Meeting’ was held. During this meeting Mr George was asked for assurances that he would not be alone with Claire; these assurances were given, and accepted without question. During the early days of Claire’s placement, Mrs George struggled with her fostering role and made a number of requests for Claire to be removed from the placement. Subsequently, it was confirmed by Mr and Mrs George that in response to these difficulties Mr George was taking an active role in supporting his wife in caring for Claire. As a result it was unsurprising when it was confirmed that Mr George took Claire to her contact with birth mother, and when visiting the carers at their home the supervising social worker found Mr George home alone with Claire. This change in the arrangement was reported to the Fostering Panel in support of their continued registration, and was accepted without question. How do we know it is not unique to this case? Information gathered during conversations and meetings with case group members confirmed that there was a standard requirement for male foster carers to make a commitment never to be alone with children who had been the victim of sexual abuse: it is standard safeguarding practice (manager). It is an expectation routinely set by fostering teams, and is regarded by the Fostering Panel as an acceptable way in which allegations against carers can be managed. When the Review team dug beneath this issue, it was equally clear that this is an expectation that in reality is unreasonable and that no one expects to be followed: Everyone would have known it was unworkable, it is an extreme position... No one thought it would be followed and so no one was surprised when it wasn’t. (Manager). How widespread and prevalent is the issue? As stated above, this expectation is set as a requirement for every foster placement made in Croydon for a child who has been the victim of sexual abuse. When drawing from the experiences that the case group had had with fostering panels, and fostering services more widely across other local authorities, it was understood this is not unique to Croydon. This expectation is set up in this way, not on the basis that the male carer would pose a risk, but in order to protect foster carers from potential allegations of sexual abuse being made by a child. It is not an area that has been the subject of audit either locally or nationally and as a result there is no relevant research or data available. 37 What are the implications for the reliability of the multi-agency safeguarding system? Many children who have been the victim of sexual abuse are provided with safe nurturing care within the care of families that include male members in a caring role. The role modelling by male family members of an appropriate loving relationship based on clear boundaries and a love that is unconditional (not based on what the child can provide to the adult, or on a relationship tainted by grooming or abuse), provides an optimal environment where a child can heal the wounds of past trauma caused by sexual abuse. There is no doubt that a child who has experienced such significant trauma can present unique challenges to carers in their attempts to meet the child’s considerable needs. To meet these challenges by setting unrealistic expectations of foster carers has the potential of setting foster carers up to fail, places unreasonable demands on carers, and puts in place a veneer of assurances that the child is adequately safeguarded and carers are protected from allegations being made against them. Finding 4: The established norm of seeking a commitment from male foster carer that they will not have unsupervised contact with a female child in their care to avoid allegations being made, provides a veneer of assurances that the child and carer are safeguarded. Summary: A safe system needs to balance the need to protect vulnerable children from foster carers who may harm, and foster carers from false allegations of causing harm. There is no simple solution to this but a tokenistic response, such as highlighted in this finding, risks neither parties benefiting at all. Issues for the Board and Individual Agencies Fostering Panel The Safe Caring Family Policy that is included as part of the foster carer assessment pack to be reviewed by Panel members to ensure greater emphasis is placed on how the individual circumstances of a child are considered in safe caring arrangements and how carers will be supported. Panel to explore the intention behind the question posed to foster carers about how they will manage allegations made against them and re-consider what ( if any) questions are asked on this issue at panel. Panel to consider adopting any innovative practice that exists elsewhere on this issue. Panel to receive training from the LADO (or appropriately experienced trainer) on key findings from serious case reviews and research that has been conducted with adults who abuse their position of trust. Panel to consider what support can be offered to carers when they are caring for a child who has previously been the victim of sexual abuse. Fostering Panel learning and development plan to reflect the learning from this finding and issues to be taken forward. Fostering Panel to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. 38 Children’s Social Care Fostering teams and assessing social workers to receive training from the LADO (or appropriately experienced trainer) on key findings from serious case reviews and work that has been conducted with adults who abuse their position of trust Audit of fostering files to be conducted to review the extent to which this requirement has been stated as part of a fostering or placement agreement and to consider how this will be addressed. Fostering teams to explore what innovative practice exists elsewhere in relation to this issue. Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. CSC to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board CSCB to decide where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. CSCB to consider how this finding will be incorporated into the existing learning that has emerged from audit findings or case reviews in relation to how the role of fathers or male figures is understood and valued in the life of children. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Finding 5: Management systems There is an efficient placement allocation process for children in need of a placement that is managed through a business process. The absence of a practice based matching process at this early stage of placement risks decision making that compromises a child’s needs. Introduction The process of matching a child’s needs to carers is understood to be the formal process of meetings and decision making, led by the Fostering Panel. This process applies to all children where a long term match is being considered; a similar practice based matching process for children entering care does not exist. When a child enters care and requires a placement, whether in an emergency or not, the decisions about where a child will be placed are made by referring to the Business Relationship Team (BRT), which is responsible for identifying a placement. 39 Although the term ‘matching’ is not used in relation to the initial placement of a child, it was not possible to identify any other process apart from the process of referral to the BRT that considered Claire’s needs and the suitability of Mr and Mrs George to meet these needs. It is a process where, for understandable reasons, resource pressures associated with availability of placement options and budgetary constraints play a significant part in deciding a child’s placement. The review team learnt that for perfectly rational reasons, relating to a desire to provide stability for a child and the absence of available foster placements from which to choose, the initial placement often becomes the long term placement for a child. Hence, although there was a challenge put to the lead reviewers that the term ‘matching’ only applies to decisions in relation to long term placements of children (where there is a clear practice based decision making process in place), because these initial placements often become the long term placement for a child, by default the initial decisions made through the BRT process are the critical matching decisions. How did this feature in this case? The care plan for Claire was long term fostering: she needed permanency within a family where she could develop a positive identity, form healthy attachments and where her needs would be understood and met. The history of multi-agency involvement with her birth mother clearly indicated that this permanency could not be achieved within the mother’s care. Adoption was ruled out because Claire was felt to be too old for permanency to be achieved in this way and there was a view that permanency could not be achieved in familial care. Consequently, a search for a foster placement commenced. Identifying a suitable placement involved a referral to the Adolescent Resource Team (now known as ‘The Business Relationship Team’). This referral was made by the social worker, and later followed up with an email stating that due to Claire’s complex needs, a specialist foster placement may be needed. The BRT is made up of a staff team who are responsible for identifying resources for children in need of placements and the referral of Claire was considered by a member of the team. Their aim is to find placements quickly and effectively; cost is an understandable consideration and in-house foster carers are the placement of choice. It was identified that Mr and Mrs George had been recently approved as foster carers and were waiting to have a child placed in their care; they were approved to take a child of Claire’s age, lived in the local area, and were able to take and collect Claire from school. A member of the fostering team was briefly consulted, Claire was ‘matched’ to the placement and subsequently placed. Claire was a young child with early trauma and complex needs: her behaviour in the care of her paternal grandmother, including spontaneous screaming for long periods, frequent agitation, and difficulties sleeping, indicated that she was suffering from the effects of significant early trauma. The review team attempted to understand how her needs were considered in matching her needs to these carers. This was not an emergency placement: Claire had been living within the care of the local authority for four months and she had been known to the local authority since birth. Apart from the referral sent to the BRT, it was not possible to identify any other paper work or practice based decision making processes where Claire’s needs were described in a way that would facilitate decisions on matching. Under the review timeline, Claire had not been in placement with Mr and Mrs George long enough for the routine practice based matching process to commence, as this normally commences a year after initial placement. However, in line with normal practice: It was assumed that if it went well with ‘Mr and Mrs George’ this would be a long term placement (practitioners and managers). 40 How do we know it is not unique to this case? As stated above, the case group were clear: matching a child’s needs to carers does not take place through the referral to the BRT. Time and again it was said that this was a ‘business process’, governed by the resource constraints of budget and resource availability. Matching a child to carers takes place through a different ‘matching process’: this is a practice based process involving assessment and Panel approval. However, practitioners were also consistent in saying that if a child is in a placement longer than a year then this is considered as the long term placement for the child and that permanency decisions are based on how well the child settles in placement, and whether the carers are prepared to care for the child long term. Feedback from those involved in the formal matching process confirmed this position20. It was clear to the review team that there are two distinct processes in place in placement decision making, one that makes decisions about where a child should be placed based primarily on resource availability and cost, and one that is a practice based decision making process that matches a child to placement based on a child’s needs. There was a divergence of views amongst staff members from the different teams about where matching a child’s needs to carers takes place. Those practitioners who had experience of the practice based matching process were clear: the initial decision taken when a child is first placed with carers is in reality the fundamental matching decision. When speaking about the BRT process, social workers and their managers referred to this as a ‘matching process’; members of the BRT were equally clear: the referral to the BRT team is not a matching process. It was demonstrated that this confusion generates frustration between the different staff teams: matching a child definitely causes tensions between the LAC social worker and everyone else involved. I have often got frustrated that people were putting resources rather than the child’s needs first (front line practitioner). And, in relation to what takes priority when placements are being sought: you have to take what you are given… there is no choice (case group member); it is pot luck what is the budget available, and what is available on the day (manager). How widespread and prevalent is the issue? In discussing this finding, members of the review team and case group drew on their experiences of working in numerous local authorities throughout their respective careers. They confirmed that although the extent of choice about placement options varied (according to different budgetary pressures, levels of demand for placements and availability of placements), their experiences suggested that the absence of a practice based matching process, in the early stages of placement, meant that the initial placement decision is significantly influenced by business considerations. Further, they commented that it is common for initial placements to become the long term placement for a child. 20 Claire was in placement with Mr and Mrs George for 15 months, it was unclear why this formal matching process did not take place. 41 There is no national data available on how many children are affected by this pattern and there has been no specific data collected in Croydon that is relevant to this finding. Whilst it is acknowledged that it is possible that not all looked after children are affected by this pattern, it is equally accepted that a sizable number of children are potentially affected. The numbers of looked after children in Croydon are relevant: In 2014 there were 79021 looked after children in Croydon. Croydon has the highest number of looked after children across inner and outer London (the nearest local authority being Greenwich which, in 2014, had a population of 540 looked after children). In addition, it is relevant to note the significant pressures on local authorities to reduce spending, and placements are a high cost pressure: local authorities in England were looking after 68,110 children on 31 March 2013, and in 2012-13, authorities spent £2.5 billion on costs associated with children’s placements. A report by The National Audit Office in 201422 examining services provided to looked after children reported that Local authorities we visited base decisions on children’s placements on short-term affordability rather than long-term strategies to meet needs assessments. What are the implications for the reliability of the multi-agency safeguarding system? Many looked after children have complex needs arising from their experience of abuse, neglect, separation and loss. Matching a child with a foster carer is one of the ‘turning points’23 in a child’s life. When decisions are made about where a child’s needs are best met and a decision about their placement is based on a rigorous practice based matching process that is not compromised by considerations of cost, this placement has the best potential of meeting their needs and supporting them to overcome previous trauma. If this system is not working children may be placed with carers who do not have the skills or resources to meet their needs, and in these circumstances placements are likely to break down. Placement breakdowns can be devastating for children in care, replicating the trauma of their separation from their birth parents, giving rise to feelings of rejection and anger, and causing further damage to already insecure attachment patterns. Furthermore, placements that are not meeting a child’s needs are often a drain on local authority resources, preventing resources being used more creatively and effectively to improve outcomes for the child, and leading to social workers’ time and energy being focussed on managing short term problems and crises rather than on the long term best interests of the child. 21 Department for Education Statistics 2014 22 Department for Education: Children in care, National Audit Office: 2014 23 Schofield et al 2011: Care Planning for Permanence in Foster Care, University of East Anglia 42 Finding 5: There is an efficient placement allocation process for children in need of a placement that is managed through a business process. The absence of a practice based matching process at this early stage of placement risks decision making that compromises a child’s needs. Summary: A safe system will promote decisions based on a clear understanding of children’s needs, and these needs will take priority in any decisions. Although resources are a consideration for all local authorities, if these are balanced by a strong focus on the needs of a child, and a commitment to investing in a child’s long term future, then this has the best potential to enable a child to grow up with consistent carers, establish secure attachments and flourish. Issues for the Board and Individual Agencies Children’s Social Care Matching a child through the BRT processes to be further examined to consider what changes may need to be made to allow the needs of child to be better considered when making placement decisions. For decisions that have to be made in an emergency, services to consider what opportunities are in place to fully scrutinise this match and consider any changes that need to be made (including what additional support may be required in the placement). For decisions that do not have to be made in an emergency, services to consider how a practice based matching process can be strengthened. Systems changes, including how the current ICS system and supervisory arrangements may need to be adapted to embed practice based decision making, to be explored. Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Designated governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board CSCB to consider where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. The following two findings (6 & 7) are linked but they are presented separately because each finding raises distinct issues within safeguarding systems and, whilst they may well interrelate, they are of considerable importance in their own right. 43 Finding 6: Patterns of communication and collaboration in longer term work When a child is looked after there is a shared assumption across the multi-agency network that the child is safe and that existing processes will provide adequate protection; this assumption is unsafe and leads to a lack of partnership working. Introduction In recent years, there has been understandable pressure to take a pragmatic approach to children who are the subject of a Child Protection Plan and who are looked after, the thinking being that a dual process (of a child being subject to a Child Protection Plan and to LAC Reviews) is not needed. The practice reasoning behind this position is that existing processes in place for children who are looked after (such as the LAC Review process) is able to provide adequate safeguards. The London Child Protection Procedures published in 2010 and the revised version published in 2015, provides clarity on this issue: If a child subject of a child protection plan becomes looked after under s20, their legal situation is not permanently secure and the next child protection review conference should consider the child’s safety in the light of the possibility that the parent can simply request their removal from the local authority’s care. The child protection review conference must be sure that the looked after child care plan provides adequate security for the child and sufficiently reduces or eliminates the risk of significant harm identified by the initial child protection conference24. This finding has shown that in Croydon, a blanket approach has been taken to removing the names of children from a Child Protection Plan who are looked after, on the assumption that existing processes for a child looked after will automatically ensure a child’s safety. This assumption is shared by the multi-agency network but it is an assumption that is unsafe. How did this feature in this case? Prior to Claire’s removal from the care of her birth mother, there had been an Initial Child Protection Case Conference at which she was made the subject of a Plan under the categories of neglect and sexual abuse. Subsequently, Claire was placed within the care of her paternal grandmother as a child in care. The Review Child Protection Case Conference that followed made a decision that, as Claire was in the care of the local authority, she was adequately safeguarded. Her Child Protection Plan was ended, and no further Conferences were held. This was despite information shared at the conference that Claire was in fact in care under a voluntary agreement: the local authority did not share parental responsibility with Claire’s birth mother (who was within her rights to return Claire to her care if she so wished). In addition, information shared at the Conference suggested that Claire may not be safe within this placement as there was a potential of Claire’s birth father (who was a Schedule One offender25) having contact with her and there were concerns that this risk had not been adequately assessed. 24 London Child Protection Procedures 2010 25 The types of offences against children or young person’s up to the age of 18 years, usually referred to as ‘Schedule 1 Offences’ are set out in Schedule 1 of the Children and Young Persons Act 1993. Briefly, they include: • All forms of child abuse; • Any form of sexual assault; • All other forms of maltreatment including murder, manslaughter, infanticide, incest, violence, neglect or cruelty. 44 Despite Case Conference members being aware of these potential risks and voicing concerns, there was no objection to the decision that she should no longer be the subject of a Child Protection Plan and no agencies took any action to follow up on the concerns they had voiced.26 There were no subsequent multi-agency forums in place that focussed on Claire’s safety. How do we know it is not unique to this case? Information provided during the follow on meetings with the case group suggested the assumption that children in the care of the local authority are safe is a commonly held assumption. Case group and review team members spoke about the difficulties in thinking the unthinkable. They spoke of a blindness about this issue and asked where do you draw the line? You have to assume safety somewhere otherwise how can you do the job. Members of the case group spoke about the work involved in the two processes, which was felt to be repetitive, and about how, in order to comply with the demands imposed by the LAC Review and Child Protection Conference process, a considerable amount of form filling and report writing is required: this can add to the considerable pressure felt by front line multi-agency services in meeting the demands of their safeguarding role. Hence, an approach that ensures only one of these processes is involved at any one time, founded on an assumption that if a child is looked after they are, by the nature of being looked after, safe, has enabled a pragmatic approach to be taken to reduce work load and rationalise finite resources. It was argued that in principle LAC Reviews, chaired by an Independent Reviewing Officer, should have a responsibility to take on this role for children who are looked after. Indeed this requirement is detailed in the London Child Protection Procedures. However, feedback from the case group and from the documentation reviewed revealed that in practice LAC Reviews are not a substitute for child protection case conferences: the focus of these meetings is not on protection; it is on care planning. Risk and safeguarding issues are not routinely discussed and the full multi-agency group is not included, as evidenced in this case. Hence, the assumption that the LAC Review process would be the forum for risk management and safety planning is an assumption that, in the experience of case group members, is not borne out in practice. How widespread and prevalent is the issue? It is now common practice to remove the name of a child from a child protection plan when they become looked after by the local authority or county council. It is a practice that has grown up and become commonplace across the county over the past few years. It is not known how different authorities have approached this issue, as no relevant research has been conducted and no data collected. In March 2014 there were 790 looked after children in Croydon. In line with routine practice none of these children were the subject of Child Protection Plans and this remains the current position. There has been no local or national auditing or research examining the quality of LAC Reviews in relation to risk assessment and risk planning. 26 Subsequently, the lack of clarity about the risks posed by birth father, and the suspicion that he may have had contact with her, whilst in the care of paternal grandmother, was put forward as a possible reason as to how Claire may have contracted gonorrhoea and chlamydia, and influenced the decision to leave her in the care of Mr and Mrs George. 45 What are the implications for the reliability of the multi-agency safeguarding system? A child is best protected when multi-agency processes, set up to prevent harm to a child, are operating well and (regardless of the child’s legal status, home environment or carers) there are no assumptions made that the child is ‘safe’. Multi-agency meetings, characterised by a clear child protection focus, robust sharing of information, and clear lines of communication throughout and across the respective organisations, are proven to safeguard children successfully. If multi-agency partners are not working in this kind of system, they may develop the dangerous assumption that a child is safe because he or she is looked after. With this approach comes the risk that the multi-agency network will not work in a way that is informed by a child protection focus or knowledge, information that seems to suggest that something is not right for the child will not be challenged and assumptions will be made. This approach is likely to lead to failures to respond when a child is at risk of significant harm, and does not recognise that looked after children deserve the same protection as all other children. 46 Finding 6: When a child is looked after there is a shared assumption across the multi-agency network that the child is safe and that existing processes will provide adequate protection; this assumption is unsafe and leads to a lack of partnership working. Summary: In the challenging work of safeguarding children and protecting them from harm, making any assumptions poses a risk to a child’s safety. When a child is looked after by the local authority and when concerns remain about the safety of that child, to assume that the child is safe, or to assume that other existing processes will effectively take the place of established child protection multi-agency working, poses a risk. Issues for the Board and Individual Agencies All relevant agencies Agencies to review how challenge is effectively raised about the safety of children, with particular reference to this practice in child protection case conferences. Agencies to explore how practice in this area will be strengthened. Agencies to put in place an internal (agency specific) process that embeds challenge as an accepted responsibility of respective agency practice in safeguarding children. Agencies to consider how they will contribute to information sharing, risk assessment and decision making, when a child is looked after. Agencies to consider any systems changes that may be needed to embed practice (including but not exclusive to: supervisory arrangements, recording practices and changes to databases). Learning and development plans for respective agencies to reflect the learning from this finding and issues to be taken forward. Respective agencies to identify an internal governance body or designated lead responsible for maintaining an overview of planned actions, changes that have been made, and the impact of these changes. Designated lead or governance body to be accountable to CSCB and keep CSCB updated of progress. Looked after Reviews and Child Protection Conferences Relevant service areas to examine how these planning processes link together, so, where needed, responsible chairs and IROs share information and integrate relevant processes. LAC Review documentation, including the agenda of the Review and minutes of the meeting to be reviewed to explore how a strengthened focus on safeguarding will be achieved (including discussion of risk and planning for a child’s protection). Responsible service area to explore further how multi-agency representatives will be consulted with, and involved in decision making and planning, in safeguarding looked after children. Relevant heads of service to review how child protection chairs and IROs provide effective challenge to practitioners and to partner agencies in safeguarding children and how effective escalation is achieved. Systems changes to be explored, including how the current ICS system and supervisory arrangements may need to be adapted to embed changes in practice. Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. 47 Responsible service areas to report to the internal designated governance body on planned actions, changes that have been made, and the impact of these changes. Internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board Is CSCB satisfied that the blanket approach of removing the name of a looked after child from a Child Protection Plan is justifiable in all cases? Could there be exceptions to this rule when risks remain? How will CSCB be satisfied that the LAC Review process will effectively involve multi-agency partners and manage risks? How can CSCB assist in strengthening a culture of challenge and debate across agencies in safeguarding children? Are the current escalation processes robust and how does the board know whether they are used routinely and effectively? CSCB to consider how they will be kept informed of progress by partner agencies and consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Finding 7: Patterns of multi-agency working in response to incidents and crises When a child is looked after the value of multi-agency strategy meetings/discussions and the crucial part played by professional challenge is not understood; this inhibits effective multi-agency safeguarding work and leaves children vulnerable. Introduction In line with primary legislation (Section 47 of the Children Act 1989) and procedural guidelines27, multi-agency strategy discussions and meetings are required to take place in response to concerns that a child is in need of protection. The purpose of these discussions or meetings is to share information and to make multi-agency decisions about the steps that need to be taken to protect a child from harm. It has been argued that, in this case, safeguarding action was taken, and indeed it was, but there is a distinct difference between safeguarding action and child protection action: safeguarding action can apply to a wide range of steps taken to safeguard a child from harm and to promote good outcomes across a range of areas in a child’s life; the action taken in Claire’s case was not a child protection response and was not in in line with procedural requirements. As a result, Claire was not adequately protected. 27 London Child protection Procedures 2010 & 2015 48 How did this feature in this case? In order to demonstrate the seriousness of this finding a number of examples are given. The first example relates to concerns raised by Claire’s school. At this time, Claire was looked after by the local authority and was placed in the care of her paternal grandmother. The social work team allocated to Claire at the time was the Child in Need Team, as her case had not yet been transferred to the LAC Team. After spending her first overnight stay with Mr and Mrs George, as part of a planned introduction to her new placement, Claire arrived at school the next day. It was noticed that she was walking with her legs splayed open throughout the school day: this behaviour was not characteristic of Claire; she had never walked in this way before. When asked why she was walking in this way, Claire told her learning assistant that she hurt inside and when asked about what this meant, she demonstrated with her hands and told her teaching assistant that she was hurting inside her vagina. School staff were very concerned, and after they had had discussions with the Deputy Head (Safeguarding Lead), the Deputy Head called CSC to express their concerns. Later in the day, the social worker contacted the Deputy Head and reported: I have consulted with management in relation to the information you have disclosed, as Claire has not identified or directed the disclosure at any person in particular we will not be referring the information to the police. No investigation followed and no strategy meeting was held. School staff did not take any action to escalate this matter to ensure a multi-agency strategy meeting took place. A second example occurred several months later. For some time Mrs George had noticed that Claire had a thick vaginal discharge; she tried treating the discharge with cream bought from the local pharmacy but without success, so she contacted the GP. At the request of the GP, Claire was brought to the surgery by Mrs George. On examination, the GP identified that the skin around Claire’s vagina was red and inflamed and observed a prurient green discharge pouring out of her vagina. The opinion of the GP was that Claire had a sexually transmitted infection; gonorrhoea was suspected and swabs were taken. The GP was aware that the disease attacks the pelvic organs and can result in infertility; she was very concerned and was keen for immediate action to be taken. The concerns were shared with the social worker and with the social worker’s line manager. After a discussion with the LADO (a staff member responsible for managing allegations against staff) a decision was taken by CSC to wait for the swab results; no child protection action was taken. Five days later, the results from the swabs showed that Claire had gonorrhoea and chlamydia. The GP contacted the LAC social worker, who immediately consulted with a senior manager. The social worker was told to visit Claire in her placement, to inform Mr and Mrs George and to talk to Claire. A number of actions were taken that could arguably be regarded as safeguarding action, but no child protection action was taken on this day and no multi- agency partners were consulted. Claire remained in placement until the following day. 49 How do we know it is not unique to this case? When the conversations were held with the multi-agency practitioners, and when the ‘View from the Tunnel’28 was shared with the case group, there was a very strong reaction to this issue. Case group members were taken aback by the lack of child protection action taken: for many it provoked an emotional response evoking feelings of rage and blame, and for many there was just a sense of feeling overwhelmed and of deep despondency. Various suggestions to account for why things happened the way they did were put forward and tested. The first suggestion that was tested was whether the underlying issues outlined in finding 6, were the nub of the issue. Whilst it was felt this may have had a part to play, it was concluded this was not the central underlying pattern. As the conversations with case group members continued, it was found that at the heart of the issue was this finding. Information gathered pointed to a lack of clarity about the purpose and value of strategy meetings; this was demonstrated in the decisions taken in response to the three incidents described above involving a range of managers within the local authority, the lack of successful multi-agency challenge of these decisions, and the subsequent lack of multi-agency involvement in the action that was taken. During the conversations held with front line practitioners and their managers within the multi-agency network, it became clear that a shared understanding of the intrinsic value of multi-agency strategy meetings was not embedded, nor was the responsibility of multi-agency partners to provide effective challenge. In addition, there seemed to be a mind-set about strategy meetings in relation to looked after children that influenced decision making – you would have to take the position that the local authority was in some way responsible for the harm suffered as they are in the parenting role – and this was felt to be an uncomfortable position to take. How widespread and prevalent is the issue? Research29 by the NSPCC recognises that when a child is looked after, this can impact on the decision making by professionals in relation to concerns about the care they are receiving: Communication and information sharing between agencies was not always sufficient. The media have widely reported on cases involving the sexual abuse of children (many of whom have included children who are looked after) where the necessary multi-agency child protection investigation and action has not taken place; these cases do not have to be repeated here. Research30 focussing on the response to children who are looked after and who are victims of sexual exploitation, suggests there is a reluctance to instigate child protection procedures in the form of multi-agency strategy meetings, as the intrinsic value of these multi-agency forums in assessing risk and planning a strategy of intervention for these children is not realised. 28 View from the Tunnel: Multi-agency perspectives drawn from conversations with case group members (held as part of the SCIE LT Case Review Model). 29 Keeping Children Safe: NSPCC 2014 30 What’s Going On? Jago, Arocha et al University of Bedfordshire 2011 50 Local data shows that the number of strategy discussions taking place during 2011-2012, in respect to looked after children, represented 10.68% of the overall number of strategy discussions held. A similar percentage is seen in the years 2012-2013 and 2013-2014. No detailed interrogation of this data has taken place and so it is difficult to draw firm conclusions however, given the high number of looked after children in Croydon and the particular vulnerabilities of this group, this figure seems relatively low. The review team were unable to source relevant local multi-agency data in relation to this issue. What are the implications for the reliability of the multi-agency safeguarding system? Strategy meetings are the bedrock of multi-agency safeguarding practice, where assessments, assumptions and judgements made by individual professionals can be tested and developed, the responsibility for planning and risk management can be shared, and an accountable plan developed to investigate concerns and to protect the child. A safe system is characterised by professionals who value strategy meetings and are clear when and why strategy meetings are held, and understand the important contribution they are required to make regardless of whether or not a child is looked after. Understanding what to expect of partner agencies, and taking robust action to challenge and escalate concerns, forms part of the child protection responsibilities expected of all agencies and if used to good effect creates a healthy child protection system. If the value of strategy meetings, as a forum with legislative powers to share information and expertise and to coordinate a multi-agency child protection response, is not understood, the section 47 process will be drained of its power to protect children. If professionals fail to challenge each other in this complex work, it is likely that an ineffective, reactive, muddled, single agency response will be provided to address situations of serious risk. This leaves an unfair and dangerous level of responsibility in the hands of social workers, who will be investigating these risky situations without a coherent plan informed by multi-agency expertise, and without full knowledge of the child’s circumstances. This can lead to children remaining in unsafe situations, and evidence which may need to be used in a criminal investigation being contaminated, individuals who pose a risk to children may go undetected and may continue to cause harm. 51 Finding 7: When a child is looked after the value of multi-agency strategy meetings/discussions and the crucial part played by professional challenge is not understood; this inhibits effective multi-agency safeguarding work and leaves children vulnerable. Summary: Understanding the value of information sharing and decision making within a formal multi-agency strategy meeting/discussion is critical if children, regardless of whether or not they are looked after, are to be protected from harm. In order for this to work safely and effectively, multi-agency challenge and escalation must form part and parcel of the everyday work. If these components are not culturally embedded within safeguarding systems, the protection of children will be compromised. Issues for Croydon Safeguarding Children Board The issues raised in respect to how agencies promote challenge within their respective organisations are represented in the finding above and are relevant to this finding. The issues in this finding are of such urgency that the issues set out are for consideration by the Board in the first instance: How will CSCB be informed of the training and tools that may be needed by the multi-agency workforce to develop knowledge and expertise in relation to the requirements of section 47 of the Children Act 1989, and to strengthen the ability of professionals to respond effectively when they are concerned about a child’s safety? Does a training programme need to be developed to specifically support social workers practising in Looked After teams to continually improve their knowledge of the assessment of risk and the conduct of section 47 investigations? How can a culture that encourages discussion and challenge in safeguarding children be fostered throughout organisations and what would such a culture look like? Do changes in the relationship between agencies, departments and teams, need to take place to facilitate this? How does CSCB and individuals in positions of responsibility and authority, effectively demonstrate a healthy attitude towards debate and professional challenge? How is the expertise of designated safeguarding professionals, and those in the role of quality assurance such as CP chairs and the LADO, embedded in safeguarding decision making? How will CSCB members evidence how the lessons learnt are integrated into the learning and development plans of partner agencies? How will CSCB be kept informed of progress by partner agencies, and how will progress be evaluated and challenge provided? Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. 52 Finding 8: Patterns of communication and collaboration in longer term work Multi-agency partners are not sufficiently engaged in supporting the local authority to make decisions about the care of a looked after child. This impacts on how the local authority is able to fulfil its parental responsibilities when meeting a looked after child’s needs. Introduction In line with all relevant legislation31, when a child becomes looked after by the local authority under a Care Order, as set out in The Children Act 1989, the local authority holds parental responsibility for the child. Parental responsibility is defined in the Act as: all the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child and his property. In terms of duties: The local authority has a duty to safeguard and promote the welfare of the children in its care. The child, parents and other relevant people should be consulted in the decision-making process regarding a child being taken into care and during their time under local authority care. This finding suggests that in practice the interpretation of the term ‘relevant people’ does not include the involvement of multi-agency partners, and that formal partnerships are not in place in a way that holds sufficient weight or meaning in how decisions are made about the care of a looked after child. How did this feature in this case? Claire was a child with complex needs; she had been the subject of a Child Protection Plan for the duration of her early childhood and was again the subject of significant harm when she was 6 years old. She had experienced multiple early trauma that included long term neglect, exposure to domestic violence, and sexual abuse. As a looked after child, she was the subject of multiple assessments completed by partners across a range of agencies and services. One of these assessments included a LAC Medical. Completion of this medical is a basic requirement for all children who are looked after; this medical was over 4 weeks late. There were several health needs identified in this assessment that required prompt follow up; apart from sending this assessment to the LAC social worker nothing else was done by the designated health professional to ensure Claire’s health needs were met. A significant number of multi-agency assessments were dutifully provided to the social worker, but none of the partners made any attempt to be actively involved in decision making and none of the many care planning meetings held by the local authority involved multi-agency partners. Claire had such complex needs that her care required the active involvement of the respective specialists to ensure her needs were met. This did not happen and instead her care was left solely in the hands of the local authority. 31 Children Act 1989 and 2004 53 How do we know it is not unique to this case? During case group meetings involving practitioners and managers from across the multi-agency network, there was a very clear position taken by those representing the local authority and articulated by case group members in the following ways: I think most professionals understand they have a role to play in a looked after child’s life but they don’t see themselves in a parenting role like the social worker does, or see this as part of their professional identity (frontline practitioner). …. I think other professionals often try to avoid playing a role in managing or carrying decision making for children who are looked after and see this as the social worker’s job (front line practitioner). Multi-agency practitioners gave examples of when they were not included in decision making or consulted with sufficiently in relation to children who are looked after with whom they are involved, but equally spoke about being unable to prioritise attendance at meetings where the planning for these children takes place. Examining what may lie beneath this lack of prioritisation revealed that if a child is living at home as part of a Child Protection Plan their case is prioritised above that of a looked after child. This thinking is based on the notion that the remit for involvement in professional decision making about a child living at home was clear, whereas the rights professionals have to be involved in making a contribution to decisions about the care of a looked after child was less clear. Members of the case group representing a range of agencies, services and disciplines, understood the strategic commitment held at a senior level to this joint working, were aware of guidance and knew of some initiatives within their own agencies that focussed on meeting the needs of looked after children. However, it was clear that these initiatives were often agency specific, and integration of the strategic commitment to share the responsibilities for improving outcomes for looked after children is not integrated into the day to day delivery of services. How widespread and prevalent is the issue? Over recent years, there have been a number of initiatives to improve partnership working in relation to Looked After Children. Generally, these initiatives have focussed on two specific areas of a child’s development (education and health): there are long standing quality assurance measures in place in relation to these areas of a child’s life but, aside from these measures, there is no quantitative data available (locally or nationally) that interrogates the true nature of the partnership working that takes place for looked after children. These issues are explored in the recent Croydon IRO Report submitted to CSCB in July 2015. Whilst no data is presented about this issue, the report makes helpful reference to the aspirations of the IRO service in relation to how partners can be joined in parenting a looked after child: The writing of this report has provided an opportunity to reflect on the IRO service delivery, outcomes for Looked After Children and the responsibilities of Corporate Parents. The Children’s Act 1989 Guidance and Regulations states: the role of the corporate parent is to act as the best possible parent for each child they look after and to advocate on his/her behalf to secure the best possible outcomes. The guidance goes further and states; however, they cannot fulfil this responsibility without the full co-operation and support of a range of other agencies which provide services to children and their families. …. 54 …As Corporate parents we are obliged to be the best we can be…We must be committed to our Looked after Children achieving to their full potential. In order to do that, we must be willing to have difficult conversations, commitment appropriate resources and hold each other accountable. What are the implications for the reliability of the multi-agency safeguarding system? Many looked after children have complex emotional and behavioural needs and need support from a large network of professionals. If this network is working effectively, information about the child can be shared and multi-agency expertise used to develop the child’s care plan, with each member of the network understanding how their work contributes to the overall plan. Clear and reliable lines of communication between everyone in the network and a collaborative and supportive attitude towards taking a responsibility for promoting positive outcomes allows the complex task of parenting a looked after child to take place, and increases the likelihood that a child will achieve their potential. If the network is not engaged in making decisions about a child, professionals will be working in isolation, professional knowledge and expertise will not be shared, potential risks may be missed, and the chances of the network being able to safeguard and support the child in reaching their potential will be reduced. There is also a risk that individuals will be working towards different goals, and professional disagreements or differences of opinion will not be resolved, leading to splits in the network. Children are likely to pick up on these splits, which may cause them anxiety and confusion and a sense that the adults in their lives cannot help them. This approach is unlikely to improve outcomes for looked after children. 55 Finding 8: Multi-agency partners are not sufficiently engaged in supporting the local authority to make decisions about the care of a looked after child. This impacts on how the local authority is able to fulfil its parental responsibilities when meeting a looked after child’s needs. Summary: Legislation, statutory guidance and procedure, outline the responsibilities of local authorities and partners in the care of children who are looked after. Ensuring the correct balance between the leadership role of the local authority and the other responsibilities shared by partners is a challenge. At a strategic level, multi-agency ambitions for looked after children are shared, but, as this case has shown, there are challenges on the front line in achieving these ambitions in practice in the lives of individual children. Issues for the Board and Individual Agencies Health (including mental health services) and Education Agencies to review how they currently contribute to care planning meetings (including looked after reviews), and examine whether the quality of this contribution is sufficient. Agencies to identify obstacles that may inhibit this contribution, and identify what could be put in place to improve practice in this area. Agencies to review whether members of staff are aware of the responsibilities they hold in relation to looked after children, and identify possible changes that could be made within the organisation to facilitate better engagement. Learning and development plans for respective agencies and services to reflect the learning from this finding and the issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Respective internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Children’s Social Care (including Looked after Reviews) Services or teams to identify any current obstacles that may be inhibiting effective partnerships with agencies or other professionals, when planning for a child’s needs. Relevant service areas to examine how the different roles of the social worker and carer (s) complement each other in achieving effective partnerships with involved agencies. Good practice to be identified and used to assist service wide learning and development. Responsible services to review how agencies are kept informed of planned changes for a child, and whether existing processes and planning meetings need to be adapted to facilitate the involvement of partner agencies. Audit to be conducted looking at the effectiveness of LAC Reviews in achieving multi-agency engagement and consultation, including how the minutes and outcomes of LAC Reviews are shared with agencies. Any areas of improvement to be identified and to form part of an improvement plan for this service area. Systems changes to be explored, including how the current ICS system, meeting formats and supervisory arrangements, may need to be adapted to embed changes in practice and processes. Learning and development plans for respective teams and for the relevant service areas to reflect the learning from this finding and issues to be taken forward. 56 Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board Is CSCB satisfied that the formal partnerships in place with multi-agency partners for parenting a looked after child are sufficient? How will CSCB oversee the work of the Corporate Parenting Panel to facilitate improved partnership working and shared responsibility for improving outcomes for children who are looked after? How will CSCB work together with the Corporate Parenting Panel to identify and address any obstacles in achieving this shared responsibility at the front line? How is the culture of healthy challenge and debate, in order to achieve the best possible outcomes for looked after children, facilitated by CSCB? CSCB to consider how they will be kept informed of progress by partner agencies, and consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Finding 9: Patterns of communication and collaboration in longer term work. There is pattern of social workers and managers representing different teams within the local authority LAC service working in relative isolation. This has a negative impact on the way in which looked after children are safeguarded and affects how their needs are met. Introduction Established primary and secondary legislation, guidance and regulations32 dictate the different responsibilities of the local authority in meeting the needs of looked after children; local authorities have responded structurally to these regulations by establishing various teams which, in line with these regulations, hold responsibility to provide specific services to children who are looked after. The two teams that have regular direct contact with the child and with foster carers are the LAC social worker team, which holds responsibilities in relation to the child, and the Fostering social work team, which hold responsibilities for providing support to foster carers. The teams are overseen by the same senior line manager but are divided according to their respective roles and responsibilities and so report to different line managers within a specific service area. On an operational basis, there are differences in their job descriptions, supervisory arrangements, and targets and performance indicators; furthermore, the teams are often located separately. Whilst this has, understandably, been put in place by local authorities to ensure that all duties are properly carried out, unless systems are in place to promote a unity in the work, this relative isolation risks compromising a joint approach to meeting the needs of looked after children. 32 Including but not exclusive to: Children Act 1989, Children and Young People’s Act 2008, associated guidance and regulations 57 How did this feature in this case? During the timeline under review it was difficult to find occasions when Claire’s social worker and the social worker from the Fostering Team met together, visited the family together, or attended the same meetings. This limited communication and lack of joint working led to a number of occasions when important information known to one social worker was not known to the other. The following are two illustrations: At the Fostering Panel, and later at the pre-placement planning meeting, Mr George gave assurances that he would not be alone when caring for Claire. The documents containing this information were placed on the local authority fostering database, but Claire’s social worker did not have access to the fostering file, as this was held in a separate database. There were no discussions between the two social workers about this agreement with Mr George, no meetings were held when they were both present and where this information could have been shared, and so Claire’s social worker was unaware of this requirement. The day after Claire’s placement with Mr and Mrs George, Mrs George contacted the Fostering Service. She told the fostering social worker: I do not want this child, and asked for Claire to be immediately removed from the home. In the recording on the fostering data base it was stated: she does not want to go home to face Claire and that: she has not eaten or slept for four days (since Claire had an introductory overnight stay with the carers). The fostering social worker consulted with her manager and visited the carers the next day. She noticed that: Mrs George looks drawn and she has lost weight... She looked like she had been crying… as soon as she is faced with Claire she becomes tearful… she says that she looks at Claire and feels guilty. This information was placed on the fostering database but it was not shared with Claire’s social worker. This meant that Claire’s social worker was not given an opportunity to consider the meaning of these statements or what impact this might be having on Claire; as a result, Claire’s wellbeing was not properly considered. Throughout Claire’s placement with Mr and Mrs George (one year and three months), apart from the visit made at the end of the placement when the swab results were confirmed, there were no meetings or visits that included the fostering social worker and Claire’s social worker. In addition, the separate nature of the databases, the different information recorded in these databases, and the fact that Claire’s social worker could not access either database, meant that important information was not considered. This has a negative impact on how Claire’s needs were thought about and met. How do we know it is not unique to this case? During discussions with the case group and during conversations with social workers and their managers from different teams, it became clear that this was not particular to Claire’s case. Whilst there were examples given of fostering and looked after social workers working together well, it was apparent that the key to successful joint working was as a result of the individual relationship between specific workers representing the different teams, not as a result of the opportunities inherent within existing structures, systems, or processes. As a result, joint working is variable and largely characterised by work that takes place in parallel rather than in unity. Case members spoke about how their different roles and responsibilities lead to separate meetings, and about how information and case recordings about the foster carers and the child are kept in separate databases. 58 It was generally agreed that due to the limits of recording, and a confusion about what information should be stored where, social workers and their managers could not rely on the information they had access to within the different databases to comprehensively inform their work with children and carers. The review team heard about many internal meetings held as part of planning and decision making processes for looked after children (such as LAC Reviews and Permanency Planning Meetings), and a number of other meetings held by fostering teams. It is commonplace for these meetings to involve only one social worker (either the looked after social worker or the fostering social worker). A member of the review team advised that: there are no structural obstacles to this joint working, and reported that there have been a number of initiatives (such as joint training) to facilitate this relationship. However, evidence from the various documents seen in this case and from information gathered during the conversations held with a range of practitioners representing the LAC social work teams and the fostering teams, it was clear that in practice this joint working is not embedded. How widespread and prevalent is the issue? Due to the complexities of fulfilling the duties of a corporate parent, through necessity all local authorities split the parenting role and associated tasks, placing these roles and tasks into different areas of responsibility and into different processes. Different workers in different teams with different roles and responsibilities undertake this parenting role, and distinct processes allow the completion of parenting tasks. Although there is no research on this issue, experience suggests that this is common place across the country. There is no local or national data or research examining how these teams work together to fulfil the parenting role. What are the implications for the reliability of the multi-agency safeguarding system? Children placed in foster care need to be looked after within a family that is able to offer love, nurture, stability and containment. Providing this kind of care to children who may have complex emotional and behavioural needs, is a challenging and emotionally demanding job. Two key professionals who are in close contact with the child and family are the child’s social worker and the foster carer’s supervising social worker. In a system that is working well, together these professionals will hold the history of the child and the family in mind, have regular joint contact with the child and the carer(s) and frequent communication, thereby providing a strong support network and a unified approach in meeting the child’s needs and supporting the carers to meet these needs. Establishing such a relationship nurtures a mutual understanding that the two professionals share the job of promoting the safety and well-being of the child, whose needs lie at the heart of the work they are doing. This collaboration allows observations and concerns about the care the child is receiving, and about any challenges or stressors that the foster carer may be facing, to be identified, shared, and promptly addressed in a way that is supportive to the carer and is focused on the wellbeing of the child. If the two workers are working in isolation and important information is not shared, a child’s needs risk being unmet and concerns about the standard of care that the child is receiving may be missed. In addition, if carers are struggling with the complexities of their caring role and a lack of unity is sensed between the workers, this is likely to compound their difficulties, can threaten the safety and stability of the child’s placement, and can result in the child’s needs being compromised. 59 Finding 9: There is pattern of social workers and managers representing different teams within the local authority LAC service working in relative isolation. This has a negative impact on the way in which looked after children are safeguarded and affects how their needs are met. Summary: Various local authority teams are in place to carry out the corporate parenting duties bestowed on local authorities and county councils by legislation and guidance. This means that there can be numerous teams involved directly or indirectly with a looked after child. If systems and processes are in place that promote integration and unity, these structural separations should not prevent these teams from work well together in the best interests of the child. However, if there are limited organisational opportunities to embed this approach, if there is disunity in relationships or if the various processes and systems are not fully integrated, work will take place in parallel and a consistent joint approach to meeting the needs of children and carers is unlikely to happen. This will have a negative impact on how children safeguarded and how their needs met. Issues for the Board and Individual Agencies Children’s Social Care Heads of service to explore the current relationship between the social work teams, examining any systemic organisational factors that may be having a detrimental impact on this relationship. Heads of service to identify examples of good practice and to examine what factors are in place that facilitates this relationship. Learning to be shared across the services to promote improvements. Services to examine current meetings in place across the LAC and Fostering teams, establishing which of these meetings must involve both social workers, and taking steps to improve this area of work. Heads of service to review current guidance on this joint working and to make any necessary changes (including any changes to existing supervisory arrangements) to promote this joint working. Current data storage systems to be reviewed; any required changes to recording and access to be made and clarity to be provided on how information should be recorded and shared. Systems changes to be explored, including how the current ICS system, meeting formats, and supervisory arrangements may need to be adapted to embed changes in practice. Learning and development plans for respective teams and for the service to reflect the learning from this finding and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. 60 Issues for Croydon Safeguarding Children Board CSCB to consider where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how the Board will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Finding 10: Management systems The importance placed on performance indicators has led to a pattern whereby the Independent Reviewing Officer (IRO) Regulations take second place to these indicators; this compromises the role of the IRO and the quality of care planning. Introduction The Independent Reviewing Officer’s Handbook33 (IRO Handbook), and related regulations34 and procedures35, provide the statutory guidance for IROs and local authorities in relation to the case management and review of the care provided to looked after children. There are two clear and separate aspects to the function of the IRO: chairing the child’s review and monitoring the child’s case on an ongoing basis. In exercising both parts of this role, the IRO Handbook outlines the responsibilities of the IRO in relation to a wide range of areas including, but not exclusive to: Facilitating consultation with a wide range of parties, promoting the voice of the child; ensuring that plans for looked after children are based on a detailed and informed assessment, are up to date, effective and provide a real and genuine response to each child’s needs. And: Offering a safeguard to prevent any ‘drift’ in care planning and as part of the monitoring function IROs have a legal requirement to monitor the local authority’s performance in respect of reviews. The intention is to enable the IRO to have an effective independent oversight of the child’s case, and ensure that the child’s interests are protected throughout the care planning process. For a number of years, the way in which local authorities have been judged in relation to their capacity to meet the needs of looked after children has been predicated on the performance data local authorities have provided to government. This data remains an important part of the inspection regime. As a result, these indicators have become an established part of the routine quality assurance reporting mechanisms within local authorities. 33 IRO Handbook Statutory guidance for independent reviewing officers and local authorities on their functions in relation to case management and review for looked after children DCSF 34 Care Planning, Placement and Case Review (England) Regulations 2010 and the accompanying statutory guidance Putting Care into Practice 35 London Child Protection Procedures 2010 & 2015 61 Distinct data recording processes are in place to collect the data and to report on this data, and this work remains very much part of the organisational culture. All local authority staff who are working with looked after children are well aware of their responsibilities in relation to meeting performance indicators: these indicators often form part and parcel of supervision and target setting. However, there are no such quality assurance indicators in place that measure the quality of LAC Reviews in line with the IRO regulations. Measuring compliance with these regulations is down to the discretion of the local area and/or the individual IRO. In times of high volume, or when the system is under pressure, it is the established performance indicators that take precedence. This can lead to the unique role of the IRO being compromised, and this has an impact on the quality of care provided to looked after children. How did this feature in this case? Claire’s initial review was held at the social worker’s office, and was attended only by the social worker and the IRO. No consultation took place with paternal grandmother, Claire, or multi-agency partners. The minutes are a descriptive account of events leading to Claire’s placement in care. Recommendations are a statement of position; some relate to tasks that needed to happen; these tasks related only to health appointments that needed to be actioned by the paternal grandmother: Grandmother will make an appointment with the dentist and optician’ and Grandmother will ensure that any other health appointment are kept. The minutes of the meeting were not received by the paternal grandmother and so it is unclear whether she was aware of these tasks but the record of the review demonstrated that, in theory, the associated performance indicators were covered. In line with the core regulations and statutory guidance, the critical questions that needed to be asked at the Review related to the care plan for Claire. The plan articulated was that Claire would remain in long term fostering in the care of her paternal grandmother; the question of achieving permanency planning for Claire under relevant legal orders was not discussed. At the second review, Claire was still living within the care of her paternal grandmother, the review should have taken place in Claire’s home with her grandmother but the review was held at the home of Mr and Mrs George. The venue and membership of the meeting was contrary to existing guidance, the permanent plan for Claire was not discussed, and the procedural duties laid out in the child protection procedures, in relation to risk management and safety planning, were not considered. However, there were clear recommendations made in relation to Claire’s dental checks, her personal education plan and her health assessment, all of which are directly linked to existing performance indicators. How do we know it is not unique to this case? Discussions with the case group about the purpose of LAC Reviews in the life of a looked after child revealed a general sense of lethargy about these meetings. There seemed to be no investment in these reviews as a process that improved outcomes for children. They were felt to be just ‘an added thing that needed to be done’; to be ticked off in a long list of process requirements that hampered rather than helped the busy life of a front line social work team. Case group members spoke about LAC Reviews being focussed on process rather than practice: LAC Reviews are 100% about process. This view was shared by a number of front line social workers and their managers. 62 In wider discussions with the multi-agency group, the perspective of partners evidenced a clear confusion over the purpose of a LAC Review and, on further discussion, many professionals struggled to see themselves as having a role or responsibility in relation to these meetings. From the perspective of the various teams within the local authority, there was a sense of ambivalence about the value of LAC Reviews and the role of the IRO. From the perspective of the IRO, there was a strong sense that the IROs were working in a sausage factory, where quality was not valued (only keeping to process); ensuring reviews were held on time and that performance indicators were covered were felt to be the key quality measures that are prioritised: No one cares…… not even Ofsted…… all they are interested in is the PI’s, there is no systematic interrogation of quality, there are no PI’s on quality and no audits on compliance with IRO regulations” (CSC manager). An IRO case load is in excess of the guidance and this drives IRO’s down a process led by the Performance Indicators” (CSC manager). How widespread and prevalent is the issue? IROs were introduced on a statutory basis in 2004, and the Care Matters Green Paper consultation in 2006-2007 provided an opportunity to take stock of the new role. The key issues to emerge were that IROs were not sufficiently robust in challenging decisions made by local authorities, even in cases where professional practice was obviously poor and not in the interests of the child. Not every statutory review was being conducted in a way that encouraged a challenging analysis of the proposals for meeting the child’s needs, and insufficient weight was given to the views of the child, to those of his or her parents or carers, and to other professionals with a role in securing his or her welfare: Unless care plans are rigorously examined the review is no longer an opportunity for informed reflection on the child’s progress and planning for the child’s future; instead it becomes merely a sterile ‘box ticking’ exercise. The changes to legislation, supported by changes to the IRO guidance, were made with the intention of taking forward the Government’s commitment to secure significant improvements in the contribution IROs can make to improving care planning and securing better outcomes for looked after children. These changes are yet to be evaluated by Government, although it is noteworthy that research in 201436 conducted by the National Children’s Bureau states: It is 10 years since IROs were created in response to widespread concern about children in care being lost to sight. Yet the key conclusion of this study is that the IRO role in ensuring high-quality care planning is still to be fully realised. The report is full of examples of what can be achieved by a well-organised service, but it also uncovers the widespread problems that still exist. The requirement that all looked after children must have regular reviews of their care led by an IRO means that during 2014-15, 802 children in Croydon were the subject of regular LAC Reviews. In terms of the wider population, the UK figure is 93,000. It is not known how many children are the subject of poor quality Reviews that have an overriding focus on the timeliness of the process and targets linked to performance indicators, but the research above suggests this group may well be significant. 36 The role of Independent Reviewing Officers (IROs) in England: Final report Helena Jelicic, Ivana La Valle and Di Hart, with Lisa Holmes from the Centre for Child and Family Research, Loughborough University National Children’s Bureau: working with children, for children. 63 In Croydon, in line with IRO regulations, an IRO report was submitted to CSCB in July 2015. This report outlines the work of the IROs with the current population of 802 Looked after Children. Within this report, it is clear that the quality assurance measurements for LAC Reviews relate only to the timeliness of reviews, completion of health related action, and the educational performance of looked after children; there are no quality assurance measures or audits in relation to compliance with the IRO regulations. The report makes the following comments: For too long there has been an over emphasis on [the role of the IRO] in relation to compliance and performance timescales. Whilst recognising the importance of a timely response to the needs of children and families, the IRO quality assurance role needs to be more focussed on the quality of the work undertaken by Children Social Care and partner agencies as part of the Looked after Children review process.37 What are the implications for the reliability of the multi-agency safeguarding system? LAC Reviews provide a mechanism for reviewing how effectively children’s care plans are meeting their needs, for addressing poor planning or drift, and for identifying any safeguarding action that needs to be taken. When LAC Reviews are working effectively, the IRO will hold a thorough understanding of the child’s needs and journey through care. The IRO will chair a meeting informed by a process of consultation with the child and with those who know the child best, and will bring the child’s network together to identify whether or not the child’s care plan is working, whether the child is adequately safeguarded, and the actions that need to take place to address any gaps. In a system that is working well, IROs make a significant contribution to service wide quality assurance, effectively confronting systemic poor practice and challenging the local authority where drift or delay in care planning exists, or where a child is at risk of harm. If the IRO is constrained by a need to keep rigidly to existing performance indicators, or is constrained by the need to keep to process or to a tick boxing exercise as an overriding priority, the IRO will not have a comprehensive understanding of the child’s needs or a motivation to make a real, challenging, creative contribution to the child’s life, and the safety net that the Review process should provide for children will not exist. In this system, it is likely that gaps in children’s care plans will go unaddressed, drift will occur, and false reassurance will be given that the child is safe and desired outcomes are being reached because statutory tasks have been completed and performance indicators met. 37 Croydon Annual Reviewing Officer Report 2014-2015 64 Finding 10: The importance placed on performance indicators has led to a pattern whereby the Independent Reviewing Officer (IRO) regulations take second place to these indicators. This compromises the role of the IRO and the quality of care planning. Summary: Independent Reviewing Officers occupy a unique place in the work of a local authority, holding a critical responsibility to take an independent overview of the care a looked after child is receiving, to take action to ensure a child’s needs are met, and to hold the local authority to account (if necessary through court action). Over the years, a narrow focus on a handful of performance indicators has had a significant impact on the LAC Review process and resulted in diluting the core functions of the IRO in the life of the child. As a result, the potential for IROs to make a significant contribution to children’s care plans, and to service wide quality assurance and development, has not been sufficiently realised. Issues for the Board and Individual Agencies Children’s Social Care – Looked after Reviews Do current performance indicators in place that measure the quality of LAC Reviews need to be revisited and revised in light of this finding? How is compliance with the IRO handbook, and associated regulations, reviewed and quality assured? What are the mechanisms in place for IROs to challenge care planning and to take steps to achieve any required improvements? Is there anything within the organisational culture that inhibits the IRO in championing the needs of a child and in making a significant contribution to care planning? How are LAC Reviews regarded within the wider service? Is it felt that LAC Reviews make a significant contribution to how children’s needs are met, or have they become largely an administrative exercise that brings no extra value to an already overburdened system? Systems changes to be explored, including how the current ICS system, meeting formats and supervisory arrangements, may need to be adapted to embed changes in practice. Learning and development plans for respective teams within the service to reflect the learning from this finding, and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board How does CSCB propose to respond to the recent IRO report received by the Board? CSCB to consider where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress, and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. 65 Finding 11: Patterns of communication and collaboration in longer term work When a child is looked after, the principle that family members can make a valuable contribution to a child’s care and protection is understood but not fully realised. This has an impact on the quality of care and protection provided to children. Introduction Preserving children’s links with their birth families, valuing these relationships and the contribution that family members can make to decision making, planning and interventions, can strengthen the way in which a child is safeguarded and positive outcomes achieved. The involvement of family members in the lives of looked after children has been the subject of extensive research and training and is well covered in legislation38 and associated guidance. The principles behind this are therefore well understood. This case has shown that translating these principles into practice is more difficult, and this results in the potential benefits of involving family members in the care and protection of a child being missed. How did this feature in this case? When the lead reviewers met with Claire’s paternal grandmother and paternal aunt, they were shown a photograph album. In this album were photographs depicting Claire’s life story: photographs showing her time spent with extended family members on her birthdays and holidays, and her relationships with significant members of her kinship. The occasions depicted were numerous. It was clear her paternal grandmother and aunt knew her well: they knew her likes and dislikes, her favourite things, her fears, her sadness and her joy. They held her life story in these photographs, and in their shared memories. For the duration of Claire’s care within the local authority during the time under review, there was only minimal consultation with paternal grandmother and paternal aunt about Claire’s needs, and little involvement in care planning. Their knowledge and memories of Claire were not sought, and so professionals never had the benefit of learning from this. When Claire was placed with Mr and Mrs George, Claire stayed with her paternal grandmother every other weekend, in order to provide ‘respite’ to the carers. As a result, both the paternal grandmother and paternal aunt held information that was critical in understanding Claire’s experiences in the care of Mr and Mrs George. For example; they spoke about Mr George being very active in the care of Claire, and of occasions when he was alone in the home when they returned Claire after a weekend. They had important details to share in relation to the discharge they observed when she was in their care, and about the accounts given by Mrs George in respect to the diagnosis and treatment she claimed Claire was receiving, which were in fact untrue. There was no attempt to seek any information from the paternal grandmother about these issues, and it was only after she was spoken to as part of this review that this information was revealed. 38 The Children Act 1989 66 How do we know it is not unique to this case? When the review team spoke to the case group during conversations and case group meetings, it was clear they understood the theoretical basis underpinning why such a contribution is so important. However, for many this contribution was seen as being established only through ensuring contact arrangements were set up and reviewed. As the review team dug deeper into this issue, it was difficult to find information to show how family members were supported to make a significant contribution to a child’s life in a way that informed assessments, care planning and decision making. A number of reasons were put forward as to why this might be the case: these reasons indicated how responsibility for enabling this significant contribution fell, in practice, to the child’s social worker. This is time-consuming work, and is often negatively impacted by what was felt to be an adversarial relationship between the local authority and family members (particularly where care proceedings have taken place). In addition, case group members spoke about how complicated it can be to negotiate meaningful contact with birth family members, and to ensure that this happens in practice. They spoke about the complicated emotional responses of some children to contact, and of foster carers sometimes ‘getting in the way’ of sustaining this lifelong connection. In terms of seeking information from relatives to inform a child protection investigation, this was an area that seemed to be fraught with obstacles. Many of these obstacles posed very real complications that were difficult to unpick and get round. Case group members spoke about family members who may have a vested interest in providing biased information, and how the constraints in relation to data protection and confidentiality, and fears about information sharing, can cause confusion. This can have an impact on how family members are meaningfully involved in risk assessments and decision making in the life of a looked after child. In relation to how information held by family members is used to assist work with a looked after child to promote an understanding of their life story and identity, there was a view that this information is sought, but it seemed to the reviewers that this was often only when a life story book or life story work was being completed with a child. It was not seen as information that could be collected dynamically and used frequently, in a professional’s day to day work with a child. How widespread and prevalent is the issue? Research and literature39 in this area is well established. The Care Inquiry, 201340 (literature review of research into permanency options for children) comments on the critical nature of nurturing the meaningful connection of children with birth family members. This inquiry cites research and literature evidencing the need for this meaningful connection, and the paucity of this connection in the lives of children looked after away from familial care. In terms of gathering, and placing importance, on the information held by family members research suggests that: Insufficient weight is given to information from family, friends and neighbours and that: there is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk.41 There are no relevant local audits or any data available on this issue. 39 To name a few: Keeping in touch” (A report of children’s experience by the Children’s Rights Director for England 2009. Children and Young People’s Views on Being in Care A Literature Review Hadley Centre for Adoption and Foster Care Studies Coram Voice 2015 40 Understanding permanence for looked after children: A review of research for the Care Inquiry Janet Boddy 41 Ten pitfalls and how to avoid them. What research tells us? Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln NSPCC September 201O 67 What are the implications for the reliability of the multi-agency safeguarding system? In a system that is working well birth family members are enabled to make a valuable contribution to the lives of children placed in care, supporting children who may have little or no contact with their birth parents to retain links with their family of origin, and giving professionals information about the child’s story which might otherwise be lost. This is then used to inform assessments and in the day to day work with a child, assisting professionals and carers to understand the child’s needs and supporting children to develop a coherent and positive sense of their own identity. Birth family members who are meaningfully engaged often provide practical support to care leavers, reducing their vulnerability as they enter adulthood and their network of professional support falls away. In making use of this support, organisations foster a culture of valuing family members and including them in planning for the child, wherever this is safe and appropriate for the child; inviting birth family members to LAC Reviews, involving them in assessments and life story work, and supporting them to have the right level of contact with the child. In an organisation where the important contribution of the kinship network is not appreciated, children are likely to be seen outside of the context of their birth families, there will be a narrow focus on supporting them through professional intervention alone and significant information that could strengthen how a child is safeguarded will be lost. Key pieces of information or artefacts which would be familiar to children living within their birth families may not be preserved and relationships which could sustain children for years to come will not flourish. Finding 11: When a child is looked after, the principle that family members can make a valuable contribution to a child’s care and protection is understood but not fully realised. This has an impact on the quality of care and protection provided to children. Summary: The importance of family members and kinship in the life of a looked after child is well known. However, if this does not translate in practice to work that meaningfully involves family members and kinship in assessments, care planning and protection, the care provided to children by professionals will not be sufficiently informed and the immediate and long term outcomes for a child will be compromised. Issues for all agencies Agencies to explore whether there are any cultural attitudes, beliefs or organisational obstacles that inhibit how family members are facilitated in making a contribution to the assessment of risk and care planning. Agencies to consider how they might assist in making improvements in this area. Relevant agencies who have regular contact with family members (such as schools) to consider how information provided by family members can be usefully shared. Where there is an absence of family involvement, supervision to provide challenge, and explore reasons for this absence. 68 Issues for Children’s Social Care (including Looked after Reviews) Services to explore whether there are any cultural attitudes, beliefs or organisational obstacles that inhibit how family members are facilitated in making a contribution to the assessment of risk and care planning. Services to explore the role of the IRO and child protection chair in this area, and examine how LAC Reviews and CP Conferences could be adapted to strengthen the contribution of family members, and establish how engagement in a child’s life can be achieved wider than the confines of contact arrangements. Risk assessments to include information from family members, and to provide clear evidence to support why information either has not been sought or should be treated with caution. Services to explore how current meetings can better facilitate the involvement of family members and include the knowledge they hold about a child. Services to explore how life story work is completed and take steps to facilitate the dynamic nature of information gathering about a child’s life and family (that is not confined solely to the completion of a life story book) so that information is sought, and information shared with a child as part of an ongoing process of strengthening a child’s sense of identity. Systems changes to be explored, including how the current ICS system, meeting formats and supervisory arrangements, may need to be adapted to embed changes in practice. Learning and development plans for respective teams within the service to reflect the learning from this finding and issues to be taken forward. Responsible service areas to report to the designated internal governance body on planned actions, changes that have been made, and the impact of these changes. Internal governance body to report to CSCB on planned actions, changes that have been made, and the impact of these changes. Issues for Croydon Safeguarding Children Board CSCB to consider where accountability will be held for maintaining detailed monitoring and evaluation of the learning and development. CSCB to consider how they will be best informed of progress and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. Additional Learning This additional learning is not presented as a finding as it was not possible to uncover the systemic reasons that may lie behind the issues. That said, the importance of this learning should not be underestimated. It is strongly recommended that it should part of the future work of the Board and relevant agencies, to identify what needs to happen to achieve improvements in this area. Management guidance and use of authority Throughout the review the review team were struck by the number of front line staff who were relatively inexperienced, and were undertaking a piece of work in the case for the first time. These front line practitioners were critical, they included the CIN social worker, the LAC social worker, 69 Claire’s Teaching Assistant, the assessing Fostering social worker, and the GP. This was a complex case, and the delivery of services on behalf of their agencies was in their hands. These practitioners understood the gravity of the work they were doing, and the need to ‘get it right,’ and so they all appropriately sought advice and guidance from managers and service leads. For a number of these practitioners, the advice and guidance they received at critical points in the case, was unhelpful, and for some of them, the advice they received was misguided, this placed practitioners in very difficult, and on occasions compromised, positions and had a direct impact on how Claire was safeguarded. Overall, management guidance appeared to be characterised by decisions based on the ‘here and now’. There was little evidence of reflective supervision, or of a form of supervision that supported the workers to manage the emotional cost of the work. Importantly when managers, including on some occasions senior members of staff, were directly involved in the case, or were made aware of concerns about the decisions that had been taken by their partner agencies, despite some significant energy and commitment being put into attempting to resolve the issues by partner agencies, multi-agency challenge was ineffective. The CSCB escalation policy was not clear at the time, and this mitigated against a satisfactory conclusion being reached. It is understood that sufficient clarity has now been provided and this is helpful. On occasions, as the appraisal of practice has shown, the limits of appropriate management guidance was relevant to a number of services, and applicable to managers across the management hierarchy throughout the time under review. Several reasons were suggested as to why this might be the case, these included: Lack of an accepted culture of challenge and debate across the multi-agency network, and a poor understanding of the procedural duties of all professionals to provide robust challenge. Under developed practice in the provision of reflective supervision. Volume of the work, leading to a culture where poor practice is tolerated. Composition of the workforce within CSC (where a significant number of front line practitioners are newly qualified, thereby requiring additional management support). Fear of challenge, and a lack of understanding about the intrinsic value of challenge to children and colleagues in safeguarding work. Lack of relevant experience and training. Issues for Croydon Safeguarding Children Board CSCB to review existing and previous serious case reviews to examine whether the issues identified are systemic. CSCB to consider where accountability will be held for maintaining detailed monitoring and evaluation of any learning and development identified. CSCB to consider how they will be best informed of any improvements needed and progress made, and to consider how challenge will be provided. Findings and planned improvements to be integrated into the CSCB Learning and Development Plan. 70 Conclusions As a child with an early history of abuse and trauma, who received services as a child in need, a child in need of protection and a child looked after, Claire is not unique. Many children who are known to multiple agencies have needs such as Claire’s, and many practitioners and managers across agencies and systems are involved in delivering a service to these children. This means that there is a complex and interrelated web of systems and individuals dealing with complex problems and providing multiple services to individuals and families, who all have their own unique needs. There is no shortage of legislation, guidance, procedures, policies and protocols governing how agencies and services should work together to safeguard children and promote positive outcomes. Complicated processes are in place to support and assist this complex, challenging work. A crucial health check of any organisation is to understand how existing cultures, processes and practices help or hinder service delivery at the front line. CSCB has undertaken this systems review in an attempt to understand multi-agency service delivery from the perspective of Claire, and the front line practitioner. It has been a long review and it has not been easy; the information that has emerged, and the findings that have been reached, have evoked many emotions, the work has been immensely time consuming for all involved. CSCB are committed to take forward the learning from this review. 71 Appendix One: Glossary ABE: Achieving Best Evidence (police led interview with a child) ART: Adolescent Resource Team BRT: Business Relationship Team CAFCASS: Children and Family Court Advisory and Support Service CAMHS: Child and Adolescent Mental Health Services CIN: Child in Need CSC: Children’s Social Care (local authority social work teams) CP: Child Protection CSCB: Croydon Safeguarding Children Board DCS: Director of Children’s Services EPO: Emergency Protection Order (made under section 44 of the Children Act 1989; an Order conferring limited parental responsibility on the applicant, to allow a child to be protected in a place of safety on a short term basis) IMR: Independent Management Review IRO: Independent Reviewing Officer LAC: Looked after child LAC social worker: a looked after child’s allocated social worker LADO: Local Authority Designated officer (responsible for the management of allegations against staff who employed within the children’s workforce) LAC Review: Looked After Child Review meeting LT: Learning Together SCIE: Social Care Institute for Excellence Section 47: Section 47 of the Children Act 1989 (the duty to carry out a child protection investigation to investigate the possibility that a child may be suffering or have suffered significant harm) Section 20: Section 20 of the Children Act 1989 (the provision for a child to be voluntarily placed by his or her parents in accommodation provided by the local authority; in this instance, parental responsibility remains with the parents and is not shared by the local authority) Supervising social worker: a foster carer’s social worker TA: Teaching assistant TM: Team manager |
NC52357 | Death of an infant girl in 2020 found to be an accident, linked to an unplanned unsafe sleeping environment. Ruby was on a child protection plan due to risk of neglect when she died. Learning focuses on: awareness of a parent's history; considering and involving fathers; assessing wider family members who play a key role in supporting or safeguarding a child; sharing concerns about the impact on a child of changes of circumstances; the impact of alcohol and substance misuse on children and unborn babies; safer sleeping advice; using virtual technology for key meetings; strengths based models of assessment and planning; avoiding over-optimism and losing focus on the child; knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed. Recommendations include: promote the involvement of fathers; ensure that the implementation of sleep assessments includes bespoke explicit and detailed safer sleep advice, including an explanation of why vulnerable babies are more at risk of sudden unexpected death in infancy (SUDI); ensure that key meetings such as child protection conferences being held by video conference or telephone have the optimum involvement of parents; ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of escalation policies; consider how to ensure that accurate information about medication being prescribed to a pregnant woman is available to all health professionals working with the family.
| Serious Case Review No: 2022/C9248 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Child Safeguarding Practice Review Ruby REVIEW REPORT Contents 1 Introduction and summary of the learning Page 1 2 Process Page 1 3 The child being considered Page 2 4 Learning identified Page 2 5 Conclusion and recommendations Page 16 1 Introduction and summary of the learning from this review1 1.1 This Child Safeguarding Practice Review (CSPR) was undertaken in order to find learning through considering practice and systems with the family of a young baby who died in 2020. The child will be referred to as Ruby2. An inquest3 found that Ruby’s death was accidental. Ruby was on a Child Protection Plan (CPP) due to risk of neglect when she died. 1.2 Learning was identified in the following areas by considering this case: Awareness of a parent’s history Considering and involving fathers Assessing wider family members who play a key role in supporting or safeguarding a child Sharing concerns about the impact on a child of changes of circumstances The impact of alcohol and substance misuse on children and unborn babies Safer sleeping advice Using virtual technology for key meetings Strengths based models of assessment and planning Avoiding over-optimism and losing focus on the child Knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed 1 It was agreed to remove any indicator of the area where Ruby lived. However the learning will be widely disseminated locally. 2 The name Ruby was chosen by the Partnership to provide anonymity for the child and family. The family support this choice. 3 A parallel police investigation was undertaken in regard to Ruby’s death. No further action is being taken. 2 2 Process 2.1 It was agreed that the review would be undertaken using the Significant Incident Learning Process (SILP) methodology, which engages frontline staff and their managers who were involved in the case being considered, avoids hindsight bias or individual blame, identifies opportunities for improvement within systems for safeguarding children and promotes good practice. An independent lead reviewer was commissioned to undertake the review4. Due to Covid-19, engagement with professionals was via video technology. 2.2 The lead reviewer spoke to Ruby’s mother who was supported by her mother, Ruby’s maternal grandmother (MGM). The learning identified from this engagement is included in the report where relevant. There was no involvement with Ruby’s father during the pregnancy or after her birth. Her mother identified him following Ruby’s death. He has been informed of the learning from the review. The man who was thought to be the sibling’s father at the time did not engage with the review. 3 The child being considered 3.1 Ruby was vulnerable due to her mother’s history of serious mental health difficulties and domestic abuse in her relationship with the man thought to be her older child’s father5. Ruby’s mother had been known to services as a teenager due to family relationships, substance misuse and what we can now see was a risk to her of abuse through exploitation. When Ruby’s sibling was born, a child in need plan was made. The concerns were largely in regard to domestic abuse between the sibling’s parents, emerging parental substance misuse concerns and the potential for a relapse in the mother’s mental health. 3.3 During the pregnancy with Ruby, a child and family assessment was undertaken by CSC. There were a number of concerns at the time after the mother left her mother’s home with her child and accepted a tenancy in another town where she had no family support. There were potential risks from new acquaintances of the mother, on one occasion the sibling was found alone on the street and was taken into police protection6. There were a number of missed appointments and allegations of mother’s increasing alcohol7 and substance use. Both unborn Ruby and her sibling were made the subject of Child Protection Plans. 4 Learning 4.1 The review has identified learning following consideration of the following areas of practice that were identified during the rapid review process, highlighted within the agency reports, discussed at the learning events and from speaking to family members. Areas of learning Knowing the history Child’s lived experience Impact of Covid-19 Professional challenge of self and others 4 Nicki Pettitt is an experienced safeguarding professional and lead reviewer who is entirely independent of the Partnership and all agencies 5 Following Ruby’s death it was established that he was not the father. 6 The Children Act 1989 section 46 empowers a police officer to remove a child to suitable accommodation or prevent the removal of a child from a hospital or other place in which that child is being accommodated. When these powers are exercised, the child is considered to be in police protection 7 Problematic alcohol use is evident. There does not appear to be a clear pattern of use however which had an impact on the assessment of this by those involved at the time 3 Knowing the history 4.2 A large number of case reviews completed in recent years have highlighted the importance of considering, understanding and sharing details of a parent’s history if it may have an impact on the care of their child. It is known that when children and young people are subjected to difficult experiences, it can have an effect both at the time and when they become parents themselves. Research into Adverse Childhood Experiences (ACEs) states that the more additional ACEs a child experiences and the longer they experience them for, the worse their physical, mental and social outcomes are likely to be. This includes the possibility that their own children will be known to safeguarding services, and that their longer-term mental health will be adversely impacted8. In respect of Ruby’s mother, there was good awareness across agencies of her significant mental health history and other more recent and current vulnerabilities. 4.3 During the pregnancy with Ruby’s older sibling it was apparent that the relationship between the baby’s parents was abusive. The sibling spent time on a child in need plan, which Mother largely cooperated with. The plan closed when the couple’s relationship ended, and although there were concerns in the year that followed these were not felt to meet the threshold for CSC involvement. It appears however that these concerns were not considered together but as individual incidents, meaning they did not meet the recognised threshold. Had they been considered together, along with the known history, there may have been the need for a social work assessment. The national Safeguarding Practice Review Panel’s Annual Report published in May 20219 states that ‘the recognition of cumulative neglect and its impact continues to be a key challenge for practitioners’ nationally. The fact that the mother and child were living with the maternal grandmother was also seen as a protective factor for Ruby’s sibling. When the mother left the grandmother’s home where the family had been living, and secured a tenancy in a different town, concerns for Ruby’s sibling, and then unborn Ruby, began to escalate. 4.4 Those professionals who know Mother well described her as naive and trusting. She was also said to be impulsive. Her move, early in the first Covid-19 lockdown, was not well planned and was advised against by her family and the professionals involved. The move led to a number of changes of professionals, including the family GP, health visitor, community and hospital midwifery care and mental health professionals. The mother told the review that this was particularly difficult for her. The review found evidence of good information sharing at the time of the move, including verbal handovers that highlighted current concerns and the background to the case. The exception to this was due to Mother not immediately registering with a new GP. When she did it took a significant amount of time for the records to transfer, with the new GP not actually receiving the family records until after Ruby died. There is no evidence that any other professional informed the GP of the family history. 4.5 Delays in receiving GP records are an issue across the area and have been highlighted in other case reviews nationally. The GP surgery that the mother and Ruby’s sibling registered with asked Mother to fill out a new patient information form. While a good starting point, this relies on the parent providing accurate and honest information, and the right questions being asked. The review has found that the form completed in this case was not the most up-to-date version and did not include a question about whether there was social work involvement with the family. This question was relatively recently introduced onto the form in the area to provide 8 For some adults who have experienced ACEs, there may be protective factors and individual levels of resilience so negative outcomes should not be assumed. However they always need to be considered on a case by case basis. 9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf 4 an indicator to the GP surgery about whether they needed to prioritise information seeking about a family newly registered at their surgery. Work has since been undertaken to ensure the GP surgery involved are using the correct form and discussions are underway about the requirement that they have an administrator with specific responsibility for safeguarding. 4.6 There is little doubt that many of those working with them knew the maternal family well. There was an admirable commitment to ensuring that Ruby’s mother was not labelled by her history, but a recognition that she required support (from family members and potentially professionals) to enable her to positively parent her children. Mother told the review that she had excellent support from a number of professionals, including the children’s social worker. Less was known by professionals about the relevant males. Ruby’s mother had separated from the man she believed was the father of the sibling by the time she became pregnant with Ruby, but he had on-going involvement due to his contact with his child and what appears to be a degree of mutual dependency between them. Private law proceedings in respect of the sibling had been instigated by the mother around the time of her move, as she wanted to ensure that there was a clear plan for contact, which had not always been the case. The police and CSC were occasionally involved due to allegations made by both parents about the other one’s care of the child, on-going domestic abuse and contact disputes. The social worker told the review she was unsuccessful in her attempts to engage with the sibling’s father, this is disputed by the father. There was limited involvement with him in the assessments and plans. The social worker remembers inviting him verbally to meetings and that he chose not to attend. This was not recorded, and it appears no letter or formal invitations were sent other than to the Initial Child Protection Conference, which he did not attend. 4.7 For family members who do not engage, putting information in writing can be helpful. The man thought to be the sibling’s father claimed that his mother was supportive, but reportedly he resisted her being approached by professionals. This appears to have been accepted by professionals as a lack of interest by him in his child’s care, and it seems that his intimidating behaviour to them and reportedly to Ruby’s mother also had an impact. His probation officer shared with the review that he told her that he was very concerned about his child however and that she made contact with children’s social care about this, requesting that his concerns were robustly explored. Reportedly as the concerns about her care of the sibling were denied by the mother, no further action was taken. The probation officer did not use the escalation policy to challenge this, as she was not aware that this was a possibility. The other agencies involved tend to rely on CSC to make contact with fathers who do not live with the child, and there was no evidence of any challenge about the lack of involvement from Ruby’s sibling’s father, even when she was on a CP plan and core group meetings were being held. A recommendation has been made to ensure that all professionals take responsibility to both involve fathers and challenge their colleagues if there is no involvement, even when this seems to be complex or difficult. 4.8 Professionals were not confident about who the father of Ruby was. Mother said that she was not sure and that she was reluctant to find out – stating that her experience with the sibling’s father had made her wary of further contact disputes. She did give a name to a number of professionals, including the midwife, but was very clear they were not in a relationship and that she had no on-going contact with the man in question. This was accepted by those involved and mother’s wishes were respected. Ruby’s mother experienced domestic abuse both in her childhood and in her past relationship/s, and the professionals working with her were aware of this. It is right that professionals are sensitive to this issue and respectful of the mother’s wishes regarding information sharing with partners/ex-partners. The World Health Organisation states that medical professionals must guarantee security and confidentiality to 5 women who may be subjected to domestic abuse10, and this is established practice in the UK. Those involved with Ruby’s mother during her pregnancy did not feel that it would be appropriate to pressurise her to disclose who the father was or might be. This does pose a dilemma to professionals however, who would want to involve a child’s father in assessments and plans and key meetings such as child protections conferences. 4.9 It was clear that Ruby’s mother had a lot of support from her family, but that she wished to be more independent and less reliant on them. There was professional concern about how she would cope as a single mother of two young children, as her mood was ‘low’ and she was known to be isolated in her new home, particularly during the Covid-19 lockdown. Due to her history of mental health concerns Ruby’s mother was on antidepressants and anti-psychotic medication11. It is believed that she stopped taking the antidepressants after the pregnancy with Ruby was confirmed. The review has identified however that there was not a clear overview of what medication Ruby’s mother was prescribed or taking, other than from her self-report. This appears to be a systemic issue that needs further exploration. Both the GP and the psychiatrist were prescribing to Ruby’s mother, and it would have been helpful if there had been a review of this when Ruby’s mother was referred for obstetric care and to the substance use and domestic abuse midwives. Ongoing mental health support was provided and this continued following her move. Although she was considered to be mentally well in recent years, it is good practice that at the time of a new pregnancy that this support remained in place. 4.10 As well as considering the history of the parents, it is important that professionals consider any known predisposing risks from wider family members who have caring responsibilities for a child. MGM was a critical part of the plan following Ruby’s birth, with the expectation that she, along with other maternal family members, would provide support and monitor the mother’s mental health for four weeks. The review has found this was not straightforward and that there were some concerns shared at the time about this support and the wider family’s own issues. Learning: There remains a need in the area for professionals to consistently consider and apply the impact of cumulative harm and a parent’s own history to the current situation. Father’s should not be missed or an after-thought – at every meeting father’s need to be considered as a potential risk or protective factor to a child. The wider paternal family should also be considered as well as the maternal side. All professionals have a responsibility to engage with fathers or question any apparent lack of engagement from other agencies. This includes putting key information in writing. If an expectant mother is taking prescribed medication from her GP and a psychiatrist, it is good practice to seek permission to speak to the prescribers. When relying on the support provided by wider family members to reduce any risk to a child, it is important to make checks and assess their suitability for the role. Child’s lived experience 4.11 When there is a parent who is vulnerable, as Ruby’s mother was, it can be difficult to vigilantly consider the child’s lived experience while providing support and advice to the parent. Mother’s own needs could dominate conversations with and between professionals. An awareness of and focus on the risks to the child from the parent’s vulnerabilities is essential. In 10 https://www.who.int/news-room/fact-sheets/detail/violence-against-women 11 Aripiprazole and Sertraline 6 this case there were concerns about the impact on the children of maternal mental health, drug and alcohol use and domestic abuse. Along with this there were the added risks of a move to a new area where there was no support from family and a need for new professional involvements. This was particularly concerning during a pandemic where a number of services were not actively providing support such as play settings and group family support. 4.12 Ruby’s sibling was also spending time with the man thought to be her father, yet very little was known about him or her life experience when staying with him. The focus of professionals, including when considering if a child protection plan was required at the ICPC, was on Ruby’s mother’s care. Ruby’s sibling had lived for much of her life with her MGM along with her mother. In March 2020, her mother’s decision for them to move out and get a flat would have been a big change for the child. Although her mother stated that difficult tensions in the home were making it untenable for them to remain living with extended family, this would still have been a big adjustment for Ruby’s sibling, who was used to living with a number of adults. There were benefits to Ruby’s sibling and mother from living with MGM, which included support with child care and financial support. MGM was also able to facilitate contact between Ruby’s sibling and their father. The move placed more responsibility on Ruby’s mother to care for herself and her child, and coincided with her pregnancy. Although the distance between her previous home with MGM and her new property was not excessive, the public transport available was slow and limited. The plan was mostly based around family members travelling to the new home however as this was thought to best meet Ruby’s siblings needs. 4.13 Following Ruby’s mother’s move with sibling to their new home in another town, there were increasing concerns about the company that mother was keeping. Information was shared that she appeared to be allowing her accommodation to be used by people who were drinking and taking drugs. Home visits by a number of professionals, including the police, described men asleep or ‘passed out’ in the living area. Despite this, the mother was always described as sober and able to care for Ruby’s sibling. Ruby’s mother had a history of being exploited when younger and those who knew her believed she would struggle to say no to those who wished to use her in this way. Ruby’s mother told the review that her child was not at risk and that any visitors only came after the child had gone to bed. 4.14 Not long after the move there was police involvement due to a domestic abuse incident between Ruby’s sibling’s parents. Both made allegations of assault against the other, and police officers were concerned about mother’s demeanour – describing her as erratic and extremely distressed. She said that she was not taking her medication due to her pregnancy and this was understood to be the reason for her behaviour. Due to these concerns it was agreed by the police that Ruby’s sibling remain in her father’s care that day, as her mother was felt not to be able to look after herself and certainly not a two year old. The police informed the Safeguarding HUB, the IDVA service (as the DASH was medium risk) and an email was sent to the midwifery service, the health visitor and to a named social worker who was listed on the system, despite it not being allocated at the time. No further action was taken by the Safeguarding HUB following the police referral. However a later referral was received from Victim Support about the same incident, sharing concerning allegations made by Ruby’s mother about physical assaults from Ruby’s sibling’s father. A worker from the safeguarding HUB had spoken to Ruby’s mother and suggested a Child and Family (C&F) Assessment be undertaken by a social worker but she declined to give consent for this, only agreeing to an early help assessment. 4.15 This was the second time that Ruby’s mother had refused a C&F assessment in as many months. It does not appear that the HUB considered all other known history when agreeing 7 that early help was appropriate at this stage. This incident, combined with the known concerns, met the threshold for a child protection response for Ruby’s sister, who had been present at the time of the domestic abuse. Ruby’s mother wanted her community midwife to lead on the early help support. The planned ‘team around the family’ included mother’s mental health nurse and Ruby’s sibling’s health visitor, as well as mother and MGM. There was a plan to involve Family Action & the area Family Support, but the response to COVID 19 limited what was available. 4.16 All assessments and meetings in regard to early help plans at the time had to be held virtually and this had an impact on their effectiveness. The community midwife in this case contacted the HUB with concerns about the recommended early help plan, particularly with the limited opportunities for face to face contact at the time. The HUB advised that either the midwife or mother refer again if concerns increased. 4.17 There is evidence that Ruby’s mother was exploited financially by at least one of her new associates and there were concerns shared that Ruby’s mother was drinking and using drugs. Professionals reflected that Ruby’s mother was sometimes ‘out of her depth’ when having to deal with difficult situations. An example of this was when she allowed a friend and her children to stay at her accommodation. The friend was escaping domestic abuse and her children were open to children’s social care in another area. There was no evidence of the professionals involved with the other family considering the impact on Ruby’s sibling of these guests. In fact there was a safety plan in place for these children that supported the move. There was also no communication with Ruby’s sibling’s allocated social worker, who only found out about the plan on a home visit. At the time there should have been robust planning for all of the children in the home that considered the impact on them all of Ruby’s mother’s decision to provide refuge to her friend. The impact on the child/ren of inappropriate visitors and guests in their home needs to be considered, shared and part of planning, particularly where drug and alcohol abuse features, as it did in this case. 4.18 An incident where Ruby’s sibling was taken into police protection following her being found alone on the street in May 2020 should have indicated worries for her care and supervision however. (This incident is considered further below.) The observed warm relationship between Ruby’s sibling and her mother led those who knew them to underestimate the impact on the child of the house guests as well as Ruby’s mother’s vulnerability. 4.19 It was in August 2020 that Ruby’s mother was seen at the hospital and was described by staff as unkempt, disinhibited and behaving erratically. When interviewed she stated that she was drinking around half a litre of vodka plus wine and cider on a daily basis with the friend who was living with her temporarily. It emerged during the review that those involved at the time did not entirely believe that this was actually the case, but there is no evidence that this disbelief was explored with mother or that they had any idea why she would lie about something as serious as this. It was not until the care proceedings on Ruby’s sister following Ruby’s death that hair strand testing was undertaken, which confirmed long term drug and alcohol use, but not at the time of the child’s death. At the time of the hospital presentation a breathalyser was negative and mother refused a blood test for drugs. Although she later informed the substance use midwife that she had used cocaine and cannabis once during the pregnancy. At the time it appears there was no consensus amongst the professionals involved regarding what levels of alcohol and drug misuse were suspected. 4.20 The response to mother’s disclosure was a child protection conference in respect of unborn Ruby and her sister, as there was recognition that both children would be at risk of neglect due to the vulnerability of Ruby’s mother, her risky associates and friends, her chaotic 8 presentation and behaviours, the isolation resulting from having moved away from her support network and her reported heavy drinking. This was a good decision and application of thresholds. A funded nursery place for the sibling and a referral to substance misuse service, a substance misuse service, were part of the plan following the conference. A core group was formed and was responsible for the plan. There was a lot of evidence to suggest that alcohol use was an ongoing issue for the mother throughout her pregnancy with Ruby. This is not reflected as a significant issue in either of the Child and Family assessments completed or in the Child Protection Plan following the ICPC in September 2020 however. This was likely due to optimism from those involved about mother’s ’honesty,’ the fact that she had not been seen under the influence of alcohol, and her reported determination to stop drinking. However the involvement of the substance misuse midwife was positive and they provided both challenge and support to Ruby’s mother. 4.21 Following Ruby’s death there was a rapid post-mortem. There were however delays in the initial toxicology testing, due to Covid-19. This led to the issue being taken to the GOLD group12 to fast track the tests - due to the need to have information to effectively protect Ruby’s sibling and to limit the impact of the delays. A further round of toxicology was then required to consider the impact of the prescribed medication that Ruby’s mother was taking at the time. In the meantime the on-going safeguarding of the sibling was being considered and there was challenge from partner agencies in respect of this. Learning: Any change of circumstances or sharing of concerns must consider, first and foremost, the impact on the child. Professionals need to balance supporting a vulnerable parent with clear child focused challenge about the potential for a negative impact on the child. Professionals need to be clear about the impact of chaotic alcohol and substance misuse on children and unborn babies, including on the parent/carers ability to protect their child from harm. Consideration should always be given to who is in the family home when considering a child’s lived experience. Even if the parent is thought to not be using drugs or alcohol, if the parent allows the home to be used for drinking and drug taking it is a child protection matter. Impact of Covid-19 4.22 It was the view of the rapid review meeting that was held shortly after Ruby’s death that there was no evidence to suggest that the Covid-19 pandemic directly caused or contributed to the tragedy, although it was acknowledged that it did exacerbate some of the issues faced by this family and the professionals involved. This CSPR has also found this. All agencies needed to adapt their practice swiftly to ensure that they were able to provide services to all vulnerable families, including Ruby’s. The pandemic undoubtedly had an impact on the engagement of professionals with the family, on the ability of some services to make complete assessments rather than basing them on self-reporting, on the need to reinforce case specific advice regarding issues like safer sleeping whilst ensuring Covid-19 safe practice for staff and service users alike. 4.23 The second national review commissioned by the Child Safeguarding Practice Review Panel and published in 202013 states that infants dying suddenly and unexpectedly represents one of 12 A Gold Group can advise, guide or otherwise support the management of an effective response to an identified incident, crime or other matter and is chaired by a senior police officer. It is positive that in this case the toxicology was fast tracked. 13 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. 2020 9 the largest groups of cases notified to the panel. In light of this, engaging with parents about safer sleeping and safer handling is important both before a child is born and afterwards. Unsafe sleeping environments are one of the infant care factors most commonly associated with Sudden Unexpected Death in Infancy (SUDI)14 along with co-sleeping on a sofa or in a bed, including after drinking alcohol and/or taking drugs15, and co-sleeping with babies who are premature or low birth weight and where there was poor antenatal care and where there was use of alcohol or drugs during pregnancy is a greater risk. The last point is particularly important in this case. 4.24 Provision of advice regarding safer sleeping is provided verbally and in written form (e.g. a leaflet) at key points during antenatal and postnatal care and is expected practice nationally. It isn’t straightforward however. The Lullaby Trust state that ‘for some in more vulnerable situations, additional support in understanding and implementing safer sleep practices is required.’ The Serious Case Reviews that were considered in the Child Safeguarding Practice Review Panel’s report suggested that largely parents do not find the interactions with professionals about safer sleeping meaningful and that they tend to think that the goal is to follow the advice most of the time, rather than always. The report concludes that a more sophisticated multi-agency practice model (“prevent and protect”) is needed to support families living in challenging circumstances to ‘understand the reasons behind the safe sleeping advice and anticipate reasons why this might not always be easy to follow consistently.’ This was likely to have been required by Ruby’s mother, even as an experienced parent. The challenge of managing two children alone added to the potential risks, along with mother’s drinking during the pregnancy. There is evidence that safe sleeping advice was given was in the hospital and that the community midwife discussed safe sleeping with Ruby’s mother twice postnatally, including on her first home visit to Ruby where she saw two Moses baskets that were for the baby to sleep in. The social worker also observed the sleeping arrangements. 4.25 The Lullaby Trust published a recent survey in March 2021 which showed ‘a concerning indication that lockdown restrictions combined with the increased pressure placed on public health services by Covid-19, means less support and information for new parents, which is putting babies at risk.’ In Ruby’s case there was a lot to consider in the days following her birth. There was a multi-agency focus on the plan for support from family members with the care of both children, and the need to monitor mother’s mental health due to the increased risk of a postnatal breakdown. There is a clear protocol for unborn babies that are subject to a CPP that a ‘birth plan’ is completed by the core group and that this considers both the hospital stay and the discharge from hospital. When the child is subject of a child protection plan, as Ruby was, a discharge meeting should be held following the birth which includes the key professionals and the family to discuss the expectations of all, including the professional visiting schedules. This did not happen in this case as those involved at the time felt there was an appropriate plan in place in respect of baby Ruby and her family. There is no expectation of specific consideration in either the birth plan or at a discharge meeting of the consideration of safer sleeping. Those involved in this case reflected that a leaflet and checking where a baby is supposed to be sleeping is not enough when a parent and their children are vulnerable. 4.26 A neighbouring area has implemented ‘sleep assessments’ which start during the pregnancy and are completed by midwives following the child’s birth. They take into consideration particular circumstances and vulnerabilities. There is a plan to implement these in the area. This review has made a recommendation to ask that this is extended to ensure that all 14 https://www.lullabytrust.org.uk/research/evidence-base/ 15 Toxicology results following Ruby’s death showed no recent consumption of alcohol or illegal substances by her mother. 10 professionals, not just midwives, are aware of the need to reinforce safer sleeping advice to the more vulnerable families and where there are particular risks, as there were in this case. 4.27 The home move during the pandemic had worried professionals. The substance misuse midwife was particularly concerned due to the new area being known for its high level of substance misuse. When the mother then missed a number of appointments with her, and was said to have no money immediately after getting benefits - requiring a referral to the food bank, the midwife spoke to the social worker, questioning whether a strategy meeting was required and whether the child in need plan was sufficient. When this was not agreed there was no formal escalation by the midwifery service or any consideration of formally requesting a strategy meeting. 4.28 The social worker recognised Ruby’s mother’s on-going vulnerabilities and her involvement following the CPP being made focused on the need to make the home a safe place for the children, and mother’s need to enforce a ‘closed door’ policy. Covid-19 was very difficult for the family, as their relatives were some distance away and the mother felt isolated and restricted. The professionals involved recognised that it was a balance between ensuring that Ruby’s mother was developing friendships in the new area but ensuring that those attending the home were not a risk to the children. Local support services had very limited offerings due to the pandemic. Key professionals remained involved however and there was no impact on this case of health staff being redeployed to Covid-19 duties. Initial support was provided by the Universal health visiting service (with a transfer when Ruby’s mother and sibling moved home in March 2020.) Strengthening Families took over the health visiting role after a child in need plan was made in June 2020. They undertook a number of direct visits to Ruby’s mother, and developed a good relationship. This allowed the strengthening families worker to challenge mother, including about the risk to her unborn baby from drinking. There was a verbal handover from the community midwife service in respect of Ruby when she was 10 days old and the Strengthening Families worker was informed there were no concerns about the baby. 4.29 For any mother the postnatal period is a vulnerable time where they require high levels of support. A study published in May 202116 acknowledges that a lack of social support increases the risk of depression in new mothers and that this was exacerbated by the Covid-19 lockdowns. It was fortunate for Ruby’s mother that it was during the period between full lockdowns that Ruby was born, and the core group were able to put a package of support from family members in place for Ruby and her mother and sibling. Those involved were aware of the potential vulnerabilities that could lead to deterioration in mother’s mental health and the concerns about her excess drinking during the pregnancy. 4.30 Maternal alcohol use and substance misuse were at the centre of the assessments and discussions between Ruby’s mother and substance misuse service. It was recognised that she was likely to be under reporting or denying use, and that this might not be the full picture. She stated that after the hospital admittance that she was not drinking at all. They were also aware that her changing her prescribed medication during the pregnancy may have led to symptoms that she was using alcohol or other substances to manage. However due to the Covid-19 pandemic face to face appointments were not occurring in all cases and for Ruby’s mother contact was completed over the telephone. This lack of face to face contact limited the ability of substance misuse service workers to assess firsthand her demeanour and any potential intoxication. 16 Communication Across Maternal Social Networks During England’s First National Lockdown and Postnatal Depressive Symptoms. Myers and Emmott. University College London 11 4.31 Covid-19 risk assessments were undertaken regularly by all relevant agencies in the area. Most were designed to specifically consider the ability of professionals to visit and undertake work in a service user’s home. In the case of CSC this case was Covid-19 risk assessed regularly, and was described as ‘dynamic’ and considered the changing needs of the family. In August for example the visits from the social worker increased to weekly due to concerns about the mother’s drinking. The review acknowledged the fine line between ensuring that professionals are safe but also the need to see the most vulnerable children at home, and appreciates that it was positive practice that face to face visits continued to Ruby’s sibling and then Ruby herself. 4.32 When the Initial Child Protection Conference (ICPC) was held in respect of unborn Ruby and her older sibling, there were technology issues that had an impact on the process, particularly for Ruby’s mother. The meeting was held via Teams technology, which all the professionals had access to. Ruby’s mother was unable to access the meeting via video however and had to dial in. This meant that she could not see who was speaking. She was reportedly distressed by this at the time. The IRO did not postpone the conference due to this, as they believed it was in the best interests of the children for the conference to proceed. The IRO told the review that Ruby’s mother had a clear understanding of the concerns, was able to voice her views and was involved appropriately in the conference. 4.33 Ruby’s mother was at a further disadvantage at the conference as the ICPC report (which takes the form of a child and family assessment) and proposed plan was not written in advance of the meeting and was therefore not shared with her, as is expected practice. They were also not shared with the other professionals in advance of the Conference, as is the procedure. This deficit was not challenged by any professional, including the IRO. The social worker allocated to Ruby and her sibling was new to the team and the role, and had started just before the first lockdown. This was the first time she had taken a case to an ICPC. The system should ensure that the lack of a report is challenged prior to or during the conference, particularly where there are new staff who require information and support when completing tasks for the first time. Learning: Safer sleeping advice needs to be robust and bespoke for families where there are additional vulnerabilities. It needs to consider in detail the increased risks in each case and involve the multi-agency professionals working with the child and family. When undertaking important meetings virtually or by telephone, such a child protection conference, there needs to be optimum planning, pre-meets and recognition of the difficulties this may bring to vulnerable service users. The planning needs to include support to enable them to attend and be fully prepared for the meeting, including seeing the key reports in advance. Professional challenge of self and others. 4.34 Signs of Safety was used in this case to consider both the strengths and the risks. The positive aspects of the mother’s care of sibling and then Ruby were based on this, which is good. The strengths identified included breast feeding, positive interactions, a clean home, and so on. This needed to be balanced with the child’s lived experience however, which considered the disruption due to mother’s lifestyle, lack of supervision and care due to alcohol and substance misuse, and the risks posed by visitors to the home. The focus of signs of safety is on how strengths can become safety over time to reduce the risk of the dangers/harms identified. In this case there was the planned use of the family network as part of the safety plan. It is important that there are clear bottom lines however, with robust testing of the plan which 12 includes the skilful use of authority and a transparent focus on risk. This should ensure that the multiagency team around the child considers evidence and avoids over-optimism, including regarding what strengths and protection family members may bring to the case. Practice in this area is said to be evolving and improving. 4.35 Ruby’s mother and the extended family network were aware of the concerns of professionals. The social worker reported that she related these back to the impact on sibling and that both the physical and emotional impact was considered. This was not entirely the case however. When Ruby’s sibling was found wandering the streets alone in May 2020. Her mother’s explanation was too readily accepted by those who were working closely with her. The police, on the other hand, arrested her mother for child neglect and imposed bail conditions that prevented her caring for her child for a number of weeks. Concerns were noted by the police about Ruby’s mother’s presentation and attitude towards Ruby’s sibling at the time. The review has found that there were discrepancies in the accounts given; including how long Ruby’s sibling was actually missing for. However there were also issues with the information sharing regarding the incident. For example the social worker emailed one of the officers in attendance for further information and he did not share the concerns about Ruby’s mother’s presentation that were included in the report from the night. It was known however that there was evidence of heavy alcohol use at the property, and a male was present at the time who was known to the police due to his drug use. This detail does not appear to have been considered by professionals who decided that a child protection response was not required at the time, and there was limited sharing of the information with other professionals. Even without the required information being shared by the officer involved, the incident was seen in isolation. For example information was available that Ruby’s mother had missed a number of antenatal appointments (eleven in all) and this was not considered. 4.36 It is also of significance that the police had been called the night before the missing incident. They had been told that the adults in the house were drinking and taking drugs. There was a systems issue identified in that the police notification was completed the day after the incident but not signed off by a police manager until two days after the incident as it was a bank holiday weekend, so it was not placed onto the CSC system until after the response to the missing incident had been decided. There is no evidence the response was reconsidered in light of this additional information, or that the officers involved in the second incident considered what had happened the previous night. This lead to decisions being made without the full information and incident led practice. the area Police have been asked to consider how they can ensure that information is shared in a timely way on bank holiday weekends. 4.37 The knowledge and combination of the two police notifications may have led to a more robust response. As well as this, the learning event discussion highlighted that very few professionals are aware that a strategy meeting should always follow a child being made subject of police protection. Ruby’s mother was spoken to by those involved from CSC following the incident and a degree of optimism about what happened and mother’s role in not supervising the toddler was evident. Mother gave what was considered to be a plausible explanation to the social worker and the email from the police officers involved at the time did not provide information to dispute this. MGM was present during the conversation with CSC and was pledging support which was reassuring to CSC. MGM was caring for Ruby’s sibling while mother was on bail for the matter and she appeared fine despite her ordeal. Professionals reflected that it can be hard to challenge family members when they are articulate and professionals have a good relationship with them, as was the case with Ruby’s mother and grandmother. A strategy meeting would have ensured that all of the available information was considered. It is also helpful to go back to the professional source of the 13 information or concerns to discuss the conclusion of any assessment to ensure it fits with what actually happened at the time. It is acknowledged that the police later decided to take no further action in this matter, which along with the email correspondence at the time also provided reassurance to CSC. It should always be remembered however that the criminal justice system works to a different standard of proof than is required when considering a safeguarding response. 4.38 There were practice issues that could have been challenged by those working with the family at the time. This included the lack of multi-agency meetings and absence of recordings/minutes of those that were held. Some professionals are clear that some meetings, for example child in need meetings, were held, but acknowledge that there is no evidence that this was the case. There is also no evidence of management oversight in respect of the lack of evidence of key meetings. Even the most experienced practitioners should consult procedures to clarify what is expected and focus thinking when deciding on a course of action. All professionals need to be aware of the expectations when there is a plan in place for a child including the frequency of meetings, the requirements to provide reports and record the outcomes, and the production of a plan which is also shared with the family. If there is any doubt or disagreement, advice should be sought from others within organisations, such as safeguarding leads, senior managers, child protection conference chairs and legal services. They can then be clear about when a challenge is required if these expectations are not met. 4.39 In order to ensure that a safeguarding system is able to provide professionals with the ability to challenge and address concerns, there also needs to be good information sharing and seeking. Small things like the need to use a team email address instead of a direct email for a professional were identified as learning, as when a professional is off, key information can be lost, meetings can be missed and professionals can then be kept out of the loop for future meetings. This was an issue for the mental health worker and the substance misuse service worker. There were other areas identified in this case where information was not shared as would be expected. For example, in July 2020 the police informed CSC that they had received a call alleging that Ruby’s mother had been using amphetamines while caring for her child. The police undertook a welfare check and reported that two other adults in the home were clearly under the influence of substances but that there was no evidence that Ruby’s mother was under the influence of any substances or alcohol and her child was asleep in bed at the time of the visit. There is no evidence this was shared with other professionals by CSC. Had the other professionals involved in the case been aware of this allegation, and the police involvement the night before the incident where the sibling had been out alone, there may have been a challenge or escalation of concern requesting a safeguarding response. 4.40 After Ruby’s death there were concerns about how her mother was coping. It was understandable that she was shocked and grieving, and consideration was given to the impact of this on her care of the older child. Some of the professionals involved also struggled with the death of Ruby, which is completely understandable. Circumstances such as these can have an impact on decision-making in respect of surviving siblings and the review was told that some of the professionals involved at the time were worried that concerns about Ruby’s mother’s mental state may have had an impact on the focus on the sibling’s needs following Ruby’s death. The Strategy Meeting held to discuss Ruby’s death decided that Ruby’s sibling should remain in her mother’s care but that a family member would supervise at all times. The fact that the previous plan had not been adhered to was discussed. It was stated by Children’s Services that this plan was more enforceable as a ‘bottom line’ and that the family had reassured CSC that they would adhere to it this time. 14 4.41 It was initially agreed that there should be no unsupervised contact between Ruby’s sibling and her mother, however the plan then changed and it was decided that Ruby’s sibling could return to her mother’s sole care. The review was told that the decision making was undertaken almost entirely by CSC without seeking and hearing the views of other professionals, particularly those working in adult mental health where there were serious concerns about the on-going contact and the proposed plan for reunification. CSC dispute this, but mental health professionals involved at the time told the review they were only aware of what was happening because the family told them. This was challenged at the time, but the concerns were apparently not responded to. This was likely due to the amount of tasks that needed to be prioritised by CSC, including taking legal advice. It would have benefited the case if the Partnership escalation policy had been used by other agencies about these concerns. Care proceedings have since been undertaken in respect of Ruby’s sibling. 4.42 It has also been identified during the course of this review that staff involved in cases that require a child safeguarding practice review need support and regular updates on the processes that are being undertaken. When a child has died or is seriously injured, there needs to be responsive structures in place to support staff through this ordeal that does not rely on self-referral for welfare support. Health agencies have a robust debrief process in place for staff following a death or significant incident, including debrief meetings after events held as part of a CSPR, however this is not in place for all agencies which can lead to anxiety. A recommendation has been made in relation to this issue. Learning Strengths based models of assessment and planning for children need to have a clear focus on risk and ensure that all available information is considered when deciding on the safety plan for a child. Written safeguarding procedures need to be considered by professionals at key points in a case. This includes when there is an incident, when a case requires a strategy meeting or a conference, and when there is a disagreement between agencies. All professionals need to be confident about what is in the multi-agency safeguarding procedures. This includes expectations about frequency of meetings, requirements to provide reports, recording of meetings, production of a plan, and so on. This confidence will ensure that they challenge colleagues when expectations are not met. Professionals need to ensure that having a positive relationship with family members does not lead them to lose focus or be over optimistic about the potential for harm to a child. 5 Conclusion and recommendations 5.1 Ruby’s death was a tragic accident, linked to an unplanned unsafe sleeping environment. The Partnership recognised however that there were lessons to be learned for the way that agencies worked together in this case and the way that they engaged with Ruby’s mother in respect of her predisposing vulnerabilities and the risks these might pose to her children. 5.2 There has been a high degree of cooperation and engagement from agencies in the area with the review, including the completion of single agency reports that identified learning and made appropriate and timely action plans. These have resulted in changes being made, like those identified above for the GP surgery, and substance misuse service reviewing their Covid-19 procedures for pregnant service users. Learning regarding both assessments of family members and the need for balance within strength’s based practice are included in the CSC agency report. Much of the wider learning identified within this report has been 15 addressed by the single agency actions plans. For example children’s social care are working to ensure that gaps in case recording are identified and rectified. 5.3 The purpose of providing additional recommendations is to ensure that the Partnership are confident that any areas identified as being of particular concern and not included in the single agency plans, are addressed. In respect of Recommendation 4, the review is aware that this is an issue that has been identified in other case reviews in the area, and remains an ongoing concern. The Partnership aspires to ensure that there is robust and persistent challenging of professionals in cases where there are concerns about professional practice with a child and family. A recommendation was made in a recent serious case review. Ruby’s case shows that this remains a concern and the partnership are asked to make renewed efforts to ensure improved practice in this area. Recommendation 1: The Partnership to make promoting the involvement of fathers a key focus of its work. Recommendation 2: The Partnership to ensure that the implementation of Sleep Assessments in the area includes bespoke explicit and detailed safer sleep advice, involves all adults who will have responsibility for the care of the baby, and that all professionals working with the family are aware of and reinforce the sleep plan. The plan should include the advice that it must be adhered to all of the time and includes an explanation of why vulnerable babies are more at risk of SUDI17, using case specific information. Recommendation 3: The Partnership to request that the relevant partner reviews both expectations and practice to ensure that key meetings such as child protection conferences being held by video conference or telephone ensure the optimum involvement of parents. Recommendation 4: The Partnership to ask partner agencies to reconsider how they ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of the escalation policy, as this case shows that this issue remains a concern. Consideration needs to be given to all key meetings, such as child protection conferences, promoting positive challenge. Recommendation 5: The relevant partner agencies to be asked to consider how they can be sure that accurate information about medication being prescribed to a pregnant woman, is available to all of the health professionals working with the family. Recommendation 6: The Partnership to request that clear protocols are developed by all partner agencies to ensure that staff working with a child who dies, or is the subject of review, receive timely and ongoing information and support until the conclusions of any investigations or processes. 17 Sudden unexplained death of an infant |
NC50887 | Non-accidental injury, believed to be caused by shaking, to Natalie, a 6--week-old baby in 2016. Natalie has significant special needs as a result of her injuries. Neither parent could provide an explanation for the injuries, and neither were found culpable of causing the injuries to Natalie. Natalie lived with her mother and her 28-month-old sibling. Her parents had been in an 'on/ off' relationship for three to four years. GP records show that father known to be involved in violent assaults and had a history of drug and alcohol misuse. Reports of domestic abuse by father in a previous relationship and a verbal altercation between parents recorded by police in August 2014. When 28 weeks pregnant Natalie's mother attended the Maternity Assessment Unit with trauma to the abdomen and cramping. Evidence for domestic abuse was not shared and there was no disclosure from mother at booking appointment. Father was not present at any contacts or assessments. Findings include: the need to evaluate information shared about domestic abuse notification for ongoing assessment; the importance of engaging with fathers. Uses the Significant Incident Learning Process (SILP). Recommendations include: ensuring that there is guidance/policy related to the response to receipt of domestic abuse notifications, that partner agencies who carry out assessments of need ensure that processes and practice provide adequate scope to include all relevant family history, especially for absent parents and carers.
| Executive summary of the Serious Case Review using the Significant Incident Learning Process of the circumstances concerning Natalie Independent reviewer: Karen Rees Proportionate Serious Case Review Summary: Developed by Margaret Tench Designated Nurse, Northumberland Clinical Commissioning Group and Robin Harper-Coulson Northumberland Safeguarding Children Board Businesss Manager, October 2018 2 Contents 1. Introduction 3 2. Parallel Proceedings and Family Involvement 3 3. Background 4 4. Key Episodes 5 5. Analysis by theme 9 6. Good Practice 15 7. Conclusions and Lessons Learned 16 8. Recommendations 17 3 1. Introduction 1.1. This Proportionate Serious Case Review Summary was developed from the full serious case review by the Designated Nurse for Safeguarding Children Margaret Tench and the NSCB Business Manager Robin Harper-Coulson following guidance from the National Panel. 1.2. Natalie was a six-week-old baby who lived with her Mother and 28-month-old sibling. In 2016 Mother contacted the 111 service reporting that Natalie was unresponsive. Natalie was transported to the Acute Hospital by paramedic ambulance with Mother. Assessment at the hospital indicated serious concerns. Investigations revealed injuries belied to be caused by shaking. The situation moved from concerns about an ill baby to concern about non-accidental injuries. Natalie now has significant special needs as a result of her injuries. Neither parent could provide an explanation for the injuries. 1.3. The Serious Case Review was undertaken following a notification of the childcare incident to Ofsted on 04.05.2016 and subsequent discussions with the National Panel which concluded that the criteria for a Serious Case Review was met. 1.4. The request for a Serious Case Review was agreed by the Independent Chair of the NSCB on the 15.08.2016 following discussions with the National Panel. 1.5. The NSCB agreed to undertake this review using the Significant Incident Learning Process (SILP), a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. Process 1.6. Following the decision by NSCB to commission a SCR, a scoping meeting and authors’ briefing took place on the 8th November 2016 to agree the Terms of Reference with representatives for NSCB and to introduce the SILP model process and expectations to authors of agency reports. 2. Parallel Proceedings And Family Involvement 2.1. During the review there were ongoing criminal investigations and care proceedings. 2.2. Northumbria Police did not give consent for the family to be approached by the author prior to the conclusion of the criminal investigation. This decision was respected and therefore arrangements to meet with the family were not possible. This led to gaps in the in the interim report concerning the views and perspectives of the family on information provided by professionals and the services they received. 2.3. The status of the criminal process at the time of writing the initial overview report and from knowledge and information gathered in undertaking this review, provided no 4 indicator as to what happened either at the time of or leading to the injuries to Natalie. This review is therefore written without that knowledge initially and will have been updated as information became available and the family could be involved. This did not, however, prevent lessons being learned on how agencies worked together, nor has it prevented recommendations and learning being applied across agencies. At the time of the updated report, recommendations and actions are largely completed or nearing completion. 2.4. The criminal proceedings were concluded in the early part of 2018. Neither parent was found culpable of causing the injuries to Natalie. There were ongoing care proceedings. In order to allow full involvement of parents. Following the conclusion of criminal and care proceedings, the parents were offered the opportunity to share their experiences of agency involvement during the scope of the review. 2.5. For the purposes of this executive summary, the family will be known in the following way: Family member: To be called: Mother of Natalie Mother Father of Natalie Father Natalie’s sibling Natalie’s sibling or sibling Half siblings of Natalie Father’s older children Father’s previous partner Father’s previous partner 3. BACKGROUND PRIOR TO THE SCOPED PERIOD 3.1. Very little is known about Mother prior to the scoping period and no agency had knowledge of any significant involvement. The GP report from Area A indicated that Mother had been known to the practice since her early teens. The GP described her as not unlike many other young women registered with the practice; she did not stand out in any way. 3.2. Information held within Police and GP records indicate that Father had been known to be involved with violent assaults, experimentation with class A & B drugs1, prescription medication and alcohol prior to the scoping period and that he had 1Under the Misuse of Drugs Act 1971, illegal drugs are placed into one of 3 classes - A, B or C. This is broadly based on the harms they cause either to the user or to society when they are misused. • Class A drugs include: heroin (diamorphine), cocaine (including crack), methadone, ecstasy (MDMA), LSD, and magic mushrooms Class B includes: amphetamines, barbiturates, codeine, cannabis, cathinones (including mephedrone) and synthetic cannabinoids. • …. cont. ….cont. Class C includes: benzodiazepines (tranquilisers), GHB/GBL, ketamine, anabolic steroids and benzylpiperazines (BZP).http://www.talktofrank.com/faq/what-drug-classification-system 5 been registered with the same GP practice since birth. 3.3. Father’s contact with agencies does provide some useful and important background and, although originally not set as part of the scope of the review, it was felt to be important enough to be brought into scope and therefore forms Key Episode One. 4. KEY EPISODES Key Episode One: History of Father and knowledge by agencies 4.1. This episode focuses on what agencies knew of Father’s history in Area B, There was a history of interventions related to violence and domestic abuse with a previous partner. 4.2. There was a clear pattern of escalating reports of domestic abuse in Father’s previous relationship known to the Police across Area A and B (same force area) and to CSC in Area B. However the history from Area B was unknown until this review. 4.3. Information was held by fathers GP in Area A. Key Episode Two: Parental Relationship and Family Life 4.4. Information recorded on a health assessment by the health visitor after the birth of Natalie and contained within the GP record for Mother, indicates that the couple had been in an ‘on/ off’ relationship for three to four years. 4.5. Mother came into contact for health reasons with her GP, Walk in Centre, Accident & Emergency and Maternity Unit. 4.6. These attendances at various health settings provided an insight that Mum’s GP and other health services did not have a full understanding of the relationship. 4.7. Documentation by both the midwife and health visitor during the ante natal period for Natalie’s sibling then indicated that Mother informed practitioners that she was not in a relationship with the Father but that he would be supporting her. 4.8. Father was not registered at the same GP practice and therefore the midwife did not have direct access to information regarding Father’s older children. Routine domestic abuse screening was undertaken, and no disclosures were made. 6 4.9. The health visitor carried out the Tynedale Health Needs Assessment (THNAT) at the ante natal contact as per the Healthy Child Programme (HCP)2, again history was detailed as above, and no disclosures of domestic abuse were made. Mother was nineteen years old at the time and consented to a referral to the teenage pregnancy team. At that time all pregnant mothers under 20 years old were referred to the Teenage Pregnancy Team3. Mother indicated that she had good family support and would not require the additional support offered. 4.10. As was usual practice, the midwife visited three times postnatally and no concerns were highlighted. It is not documented who was present at any of these visits. 4.11. At the new birth visit to Natalie’s sibling by the health visitor, as per HCP, baby was observed to be well, gaining weight and positive interaction was noted between mother and baby. Maternal Grandmother was present and was noted to be caring towards her daughter and baby. Father was not present at any contacts at this time. 4.12. During this time, there is little mention of the Father or the parental relationship. 4.13. In August 2014, when sibling was seven months old, there was a verbal altercation that resulted in a CCN to Area A CSC. As this was a significant incident in understanding the lives of the family, it has been identified as a Key Episode and is explored further below (4.18). 4.14. At the booking appointment with the second pregnancy, with the midwife, routine screening for domestic abuse was carried out and there was no disclosure. The midwife was not aware of the domestic incident the previous August. This is discussed further in the next Key Episode and analysis. 4.15. At 28 weeks’ gestation, Mother attended the Maternity Assessment Unit at Area C hospital with trauma to the abdomen and cramping. Mother reported that she had an accident at work and hit her ‘bump’. This explanation was accepted, and examination identified no concerns for the baby. This incident was documented in the GP records by the community midwife in Area A when she had been notified by Mother about her attendance. The recording by the midwife related to the fact that Anti D4 had been given due to this incident as opposed to the mode of the incident in itself. 2 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk 3 Teenage Pregnancy Team: With consent, referrals were made for all under 20’s. Contact would be made to identify any support that may be required. 4 Giving Ant D can help to avoid a process known as sensitisation, which is when a woman with RhD negative blood is exposed to RhD positive blood and develops an immune response to it. Pregnant women are offered anti-D immunoglobulin if it's thought there's a risk that RhD antigens from the baby have entered the mother’s blood – for example, in the event of any abdominal injury. http://www.nhs.uk/Conditions/Rhesus-disease/Pages/Prevention.aspx 7 4.16. Postnatally, assessments by midwife and health visitor did not raise any concerns. The health visitor met the Father for the first time as it was noted that, although the couple did not live together, he was there to offer support due to the traumatic delivery and immediate post-natal complications. 4.17. During this period Father was attending his own GP with issues that none of the agencies working with Mother and children were aware of. Father’s GP was not aware that he was a Father or that he had been an alleged perpetrator of domestic abuse in his previous or current relationship. Father continued to be reported to reside with his parents in Area B and accessed his GP in Area B. 4.18. In September 2013 Father attended his GP on two occasions. The first time he saw a locum GP as he had been advised by his ‘bosses’ to seek help as he had slept in, was not dressing well and was not himself. It was also recorded that he had money issues and a third child on the way, which the locum recorded that Father had felt that he had reluctantly accepted. This is the first time that Father was identified as a parent. Counselling was offered but not readily accepted and a suggestion by the GP of time away from work was not accepted due to money issues. 4.19. During the timescale of the review, Father’s GP recorded several attendances and contacts related to musculoskeletal pains in the back, for which Father was seeking codeine5. This was not always prescribed and on 2 occasions, Father re-contacted the surgery stating that the prescribed medication did not work and then codeine was prescribed. On the final occasion a stronger codeine dose was requested, and this was agreed. 4.20. Father also sought help for smoking cessation and records indicated that this was successful as the recorded levels of Carbon Monoxide had reduced. In March 2016, Father had reported to the practice nurse that he had no problems with the smoking cessation programme stating he was ‘a little grumpy but manageable’. 4.21. One of the significant issues discussed at the Learning Event relates to the NSPCC programme called ‘Coping with Crying’ that has been adopted in Area A. This programme includes a requirement from the NSPCC during its research, that it is best practice for all parents to be shown the DVD and given a leaflet about how to soothe crying babies and points out the dangers of shaking a baby. In this case, the programme was not in place at the time of Natalie’s sibling’s antenatal and post-natal period. Both parents were present, however, when the leaflet was shared after Natalie’s birth, but the health visitor did not have access to a DVD player or any 5 Codeine is a moderately strong opiate drug that is used in pain relief and for the suppression of coughs. But strong or weak, it is still an addictive drug with many symptoms of use in common with other opiates. http://www.narcononuk.org.uk/drug-abuse/codeine-signs-symptoms.html 8 alternative method of the parents viewing the film. This issue and the difficulties with practical application of this programme are discussed further in the analysis. Key Episode Three: Domestic incident August 2014 4.22. There was only one occasion where any domestic abuse in the parental relationship came to the attention of agencies and therefore to ensure that any learning from this incident is recognised it forms a separate Key Episode. 4.23. In August 2014, police were called to an incident involving a verbal altercation between the couple at Mother’s address. There were several people socialising at the address when the police arrived. Officers attending assessed the incident using the DASH6 risk assessment as standard risk. Police officers asked Father to leave the premises, which he did, and no further action was taken as no offences were disclosed. Mother was offered services of Independent Domestic Violence Advisor (IDVA)7 support if required but this was declined. Information also indicated that the couple were no longer in a relationship. 4.24. A CCN was sent to CSC in Area A. There was a discrepancy in the understanding of the presence of a child at this incident. At the Learning Events the police confirmed that the generation of the CCN would infer that a child was present but that the conversation between the social worker and the health visitor (see below 4.21) was that there was no indication detailed in the CCN of where the child was at the time. This notification detailed the previous history of Father and domestic incidents that had taken place with the former partner but that this incident was the only one in the last 12 months. No contact was made with the police by the duty social worker considering the incident to explore more about the previous domestic incidents or clarification as to the whereabouts of the sibling at the time. 4.25. Because of the notification, the social work team manager instructed the duty social worker to make a visit. There were two failed attempts to see the family. On the day of the second failed visit, the social worker contacted the health visitor. The health visitor informed the social worker that there were no concerns about the family and 6 DASH stands for domestic abuse, stalking and ‘honour’-based violence. It is based on research about the indicators of high-risk domestic abuse. The simple series of questions makes it easy to work out the risk a victim is facing. A high score means the victim is at high risk of murder and/or serious injury and needs urgent help. http://www.safelives.org.uk 7 The main purpose of independent domestic violence advisors (IDVA) is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans. http://www.safelives.org.uk/ 9 that Mother engaged well with clinics and groups. The health visitor and the social worker did not discuss if the health visitor had met Father. 4.26. At this point Area A CSC were not aware of the previous involvement of CSC in Area B related to Father’s older children who resided there. No further action was taken by Area A CSC. 4.27. In line with the process at the time, the CCN was shared verbally with the health visitor for information but without the information related to the previous incidents. The health visitor did not know of the previous incidents in Area B. As a result of her own knowledge of the family, the fact that the current incident was risk assessed as standard, that CSC were taking no further action and that this was a verbal altercation at a ‘party’, the health visitor did not follow this incident up with the parents. 4.28. When Mother became pregnant again, the THNAT was not completed by the health visitor antenatally due to Mother’s work commitments and scheduling issues for the health visitor and was commenced at the first visit to Natalie. Although all newly pregnant women are discussed between the midwife and health visitor, the domestic incident of August 2014 was not raised at this time, the midwife was not aware of the incident, but it was recorded on the GP record by the heath visitor. It is not clear if the midwife was aware of the information on the record at the booking visit as this was a relief midwife who did not have access to the GP record system in the same way that the regular midwife does. 4.29. At the new birth and follow up visits to Natalie, when the THNAT was undertaken, the issue of the domestic incident could not be raised as Father was present, nor was the usual domestic abuse enquiry question asked for the same reason. The health visitor did intend to address this as soon as she had the opportunity but the injuries to Natalie occurred before further contact could be arranged. 4.30. Following the domestic abuse incident, no checks were made by any agency with the GP for Father, therefore the fact that he had disclosed about his anxiety about becoming a Father for the third time and his potential depression remained unknown. 5. ANALYSIS BY THEME History informing assessment 5.1. From the information gathered during the process of this review it is clear that very little was known about Natalie and her family. They only became known to services in Area A when Mother presented in her first pregnancy. All assessments at that time were indicative of a family who would not have any additional needs and therefore remained in universal services initially in health and more latterly in the Early Years 10 setting. These assessments were based solely on what was known about Mother and the observations of the family as a unit which mostly excluded Father. 5.2. In Area A, health visitors use the THNAT which is a robust assessment tool used to discern the level of need. HCP Guidance indicates that, especially in first pregnancy where parents are not known, there are indicators that can be useful in identifying early identification of risk and need. 5.3. It is apparent in hindsight that although information was available it remained largely unknown and unassessed by the practitioners offering universal services in Area A. 5.4. The importance of Father and his history being included in assessment becomes very clear. Without this it is easy to see why risk indicators or protective factors were not recognised. 5.5. The observations that the practitioners made were of a young mother who had good family support. Mother was also observed, once children were born, to be an engaged and caring mother. The impact of the reported on/off relationship was not explored nor were the reasons considered for any difficulties that this may indicate in the relationship. 5.6. The importance of being cognisant and curious of history when undertaking assessments has been a feature of previous serious case reviews nationally.8 9 10. Understanding Domestic Abuse 5.7. Whilst it is not clear how Natalie’s injuries were sustained, research into significant harm and severe maltreatment suffered by children shows clear links with domestic abuse.9 10 11 It is therefore important to consider this in agencies’ assessment and responses to understand any possible impact on the lived experiences of Natalie and her sibling. 5.8. It is important to note that Mother has made no disclosures of domestic abuse to date. Apart from the verbal altercation that took place in August 2014 there were 8 Child N Northamptonshire Safeguarding Children Board 2016 9 Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC 10 Brandon, M., Belderson, P., et al (2008) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003–5. London: Department for Children, Schools and Families. 11 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education Learning Point 1: Assessment guidelines provide clarity about breadth and purpose. Gathering historical information to inform that assessment provides rigour to the outcome and informs the level of need as well as understanding, risk and vulnerability. Recommendation 1 11 no other obvious indicators. The midwife and health visitor asked about domestic abuse as part of routine enquiry in both pregnancies and at the new birth visit to the sibling and there were no disclosures. 5.9. There was a clear pattern of escalating reports of domestic abuse in Father’s previous relationship known to the Police across Area A and B (same force area) and to CSC in Area B. Father accepted that this was a volatile relationship and not a positive one. The incident in January 2011 was recorded and processed as a verbal incident in CSC records. In fact, the Police information stated that this was a physical assault that resulted in a caution. This incident was therefore a physical assault witnessed by a child of the relationship and took place at a time that may have been reasonably close to the start of the new relationship. 5.10. It is of note that in both Father’s known relationships there was a feature of the ‘on/off’ nature of the relationships being reported to Police and CSC. This appeared to lead to an over optimistic view of the reduced risk to the children. Decisions were based on the fact that the volatile nature of the relationship would not be impacting on the children because the relationship was over. There was indeed evidence to the contrary as in both relationships there were further incidents where Father and the previous partner, or Father and Mother were together at the time that the incidents occurred. Had professional curiosity been applied regarding the on/off relationships they would have ascertained that in the first relationship this was volatile and on and off but that in the relationship with Father and Mother, this was due to concerns about benefits. 5.11. There was no understanding as to whether Father would pose a risk in any future relationships. Assessments did not include Father, no one spoke to Father after these incidents and assumptions may have been made. To ensure accurate risk assessment of domestic abuse impact on children, information needs to be fully explored and shared in order to discern if alleged perpetrators are a risk. Appropriate interventions and further assessments can then be based on all knowable information. 5.12. There were several ways that the history of domestic abuse could have been identified, understood and used for assessment of risk within the new family. 5.13. At no time during the interventions for domestic abuse in Area B, was the GP of Father contacted. The GP held relevant information related to Father’s history of substance misuse and alcohol use but did not have information that he was an alleged perpetrator of domestic abuse. At a discussion at the Learning Event, it was argued that GPs will not give information to other agencies unless it is for Section 4712 12 Section 47 Children Act (1989): Local Authority duty to investigate where it is made aware that a child might be suffering or likely to suffer significant harm. 12 enquiry. This is not always the case and usually when there are other clear reasons to share information, in the interests of safeguarding. 5.14. When Area A CSC received notification of the incident in August 2014, as part of the information gathering and risk assessment, contact could have again been made with Father’s GP. Whilst the GP would not have known about previous domestic abuse, as he had not been notified, he would have had significant recent history about possible depression and money concerns as well as more historic information that may have been relevant. He would also then have known that he was a Father and an alleged perpetrator of domestic abuse and this may well have been considered for any further presenting issues. 5.15. A full check back with Area B CSC by Area A CSC about the previous incidents would also have provided more details about any possible abuse in the past relationship and therefore any current risk thus encouraging more pursuit of contact with Mother and deciding as to whether it was appropriate to commence a child and family assessment. 5.16. Use of The Domestic Violence Disclosure Scheme (Clare’s Law)13 may also have been a further opportunity to identify if there was a risk. Clare’s Law was launched nationwide in March 2014. Mother was given information about the IDVA service. There was also the possibility for Mother and for the others at the house to be made aware of Clare’s Law. A leaflet to Mother or others at that point may have encouraged further information being sought that may have led Mother to find out about Father’s history. 5.17. When it was known that Mother was again pregnant, the information pertaining to the first domestic incident was not shared with the midwife by the health visitor, nor did the midwife identify the incident from the GP records. This resulted in both the health visitor and the midwife continuing to offer service at a universal level as history of previous domestic abuse was not considered in the assessments they carried out. 5.18. More recently, processes regarding domestic incidents have been amended and police now share CCNs with the health visitors directly. A pathway has been developed to offer guidance to health visitors regarding responses to those notifications. It is of note, however, that the CCN does not provide any history of previous domestic incidents, therefore there is a reliance on the professional in receipt of information to check back for other notifications received. 5.19. The police have since clarified that the history is not included in information sent to other professionals due to the nature and relationships that the notification may 13 The Domestic Violence Disclosure Scheme is a national scheme that has been set up to give members of the public a formal mechanism to make enquiries to Police about an individual who they are in a relationship with, or who is in a relationship with someone they know, and there is a concern that the individual may be abusive towards their partner. 13 relate to e.g. the alleged perpetrator may not be associated with the children involved in the incident on an ongoing basis and this information may be recorded in children’s records. This is an important issue that adds weight to learning highlighted above (Learning Pont 2). 5.20. Notwithstanding hindsight bias14 discussions at the Learning Event also focussed on how more professional curiosity may have provided cues as to what may have been happening within the relationship. The Agency Report Author for the GP practice in Area A was concerned at the number of attendances related to personal health issues and considered that this was over and above the norm. This was alongside a consultation regarding uncertainty about continuing with a pregnancy and attendances at various health services (e.g. Walk in Centres, GP practice and maternity unit). 5.21. A further opportunity for professional curiosity was related to the attendance at the Maternity Assessment Unit with abdominal trauma in the second pregnancy. This was after the first incident of domestic abuse had been identified. The information and detail of the incident on its own may well have been feasible. 5.22. Research regarding intimate partner violence15 16 has identified that women experiencing abuse are three times more likely to access emergency departments than non-abused women and seek health services from primary care and women’s services more often. It is therefore important to offer opportunities for safe disclosure and make use of selective enquiry where there are cues or indicators such as those presented in this review. Role of Father and Think Family 5.23. The work by the author of the CCG Agency Report in relation to the issues of the presentation by Mother for various health issues and at various places, has resulted in learning for GP practices. This will be taken forward into training with GPs and an anonymised version of the facts in this case will be used for scenario-based training. 5.24. One of the key themes throughout all the Agency Reports and noted at the Learning Event, was the lack of information, assessment and understanding by those working with Mother, Natalie and her sibling of the role that Father of took within the 14 Roese, N. J., & Vohs, K. D. (2012). "Hindsight bias". Perspectives on Psychological Science, 7, 411–426. Hindsight bias occurs when people feel that they “knew it all along,” that is, when they believe that an event is more predictable after it becomes known than it was before it became known. Hindsight bias embodies any combination of three aspects: memory distortion, beliefs about events’ objective likelihoods, or subjective beliefs about one’s own prediction abilities. 15 Campbell, J. C .(2002) Health consequences of intimate partner violence. The Lancet; Vol 359 • April 13, 1331-1336 16 Plichta, S. (1992) The effects of woman abuse on health care utilization and health status: A literature review. Women's Health Issues, Volume 2, Issue 3, 154 - 163 14 family. 5.25. Universal health services in Area A focussed on the needs of Mother and her children. They did not have very much contact with Father, so he did not feature in assessments that were carried out. 5.26. Engaging fathers has been the subject of focus in previous serious case reviews17. When fathers are either not engaged or where their role in the family is not understood, professionals are left not knowing to what extent a father may be a risk or protective factor within a family. In this case, nothing of concern was noted and no concerning behaviours were observed. 5.27. Where parents have a mental health issue and are accessing support for that, it is important that professionals identify the adult that they are seeing as a parent and 17 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/ Learning Point 2: Risk assessment following domestic abuse incidents must be based on accurate and full relevant information being shared and robust assessment of all information and history in order to achieve best outcomes for children and adult victims. Alleged perpetrators should also be considered and spoken to in follow up and assessment. Recommendation 1 & 2a Learning Point 3: Where CCNs are shared it is important that practitioners understand what response is required of them. Recommendation 1& 2b Learning Point 4: Professional curiosity and further assessment of the nature of reported on/off relationships, particularly where evidence would suggest otherwise, may afford greater understanding of any risk to children (or not) exposed to domestic abuse. Recommendation 1 & 5b Learning Point 5: GPs of perpetrators of domestic abuse may hold valuable information to inform risk assessment and protect children. GPs may be the constant service offered to domestic abuse perpetrators and require robust information to inform their assessment and information sharing. It is important for GPs to know and record males who are fathers in order that the significance of that information can be weighed up against the reasons for consultation. Recommendation 1 & 3a-c Learning Point 6: Where national initiatives such as Claire’s Law may not be widely understood by members of the public it is important for professionals to be knowledgeable about these e.g. including information in briefings and training so that professionals can promote these in order that they can be effective. Recommendation 4 15 adopt a ‘Think Family’ approach to understand the possible impact of parental mental health on any children in the family. This helps practitioners to identify protective factors and support networks against risk and vulnerability in the context of the parental mental health and children’s needs. It would have provided evidence of thorough assessment of these issues and any impact on the children. Further probing by the Father’s GP may have identified his partner and children and enabled information sharing between health services in Area A and Area B. 5.28. Results from the NSPCC research18 into the Coping with Crying programme have shown positive results. When parents have seen the film, they have an increased understanding about infant crying, are more likely to respond positively to their baby’s crying and are more confident in seeking support and help. 6. GOOD PRACTICE It is important to note that most practitioners offer a good level of service to their clients/patients and follow policies and procedures that are provided to guide practice. Whilst recognising gaps in practice, Serious Case Reviews can also provide evidence of this as well as practice that goes over and above what is expected. Agency Reports and attendees at the Learning Events were asked to identify these from their own and other agencies. It is important to highlight these as areas where learning can occur and to recognise good practice. CSC in Area A decided to contact Mother despite there only being one incident of domestic abuse notified Police attended the incident in 2014 and recognised it as a domestic incident and risk assessed it appropriately. 18 https://www.nspcc.org.uk/ Learning Point 7: There are associated risks by not engaging with and assessing potential threats that fathers may pose to children and/or their partner as well as understanding any protection and support they may offer. Fathers’ needs are as important as mothers. Where fathers are absent, actively engaging them and exploring with the mother the role that fathers play in the lives of children is important. Understanding both parental roles and needs can improve outcomes for children. Recommendation 1, 5a &c Learning Point 8: Application of theoretical frameworks can help to refocus assessments and provide an evidence base for concern, as well as providing good quality information for onward referrals related to specific issues of risk and vulnerability. Recommendation 1 Learning Point 9: Where practitioners are required to undertake an intervention, it is important that barriers to compliance are addressed in order that families receive the information that has been established as a benefit in the protection of children. In the case of the Coping with Crying programme, a fresh approach to implementation may increase the numbers of parents that view the DVD. Recommendation 6 16 A consistent service was offered by midwifery and health visiting teams with practitioners remaining the same throughout the timescale of this review Throughout the review it was noted that domestic abuse routine enquiry was understood and carried out by health services following NICE Guidance. The THNAT was used and provided a good basis for understanding the needs of Mother and the children Good communication from the health visitor identified an updated address for CSC to contact Mother. GP practices in Area A have regular safeguarding meetings with health visitors and midwives with templates for the meetings and a robust referral system for cases that require information sharing. An administrator attends these meetings and adds appropriate ‘read codes’ to GP records following the meetings. The Safeguarding Lead GP at Mother’s GP practice has developed an automatic trigger system for cases that need discussion via a ‘hit the red button’ system. 7. CONCLUSIONS AND LESSONS LEARNED 7.1. The events leading up to the injuries to Natalie are unknown by professionals and therefore it is difficult to identify exactly which focus might have provided more insight into pathways to harm. 7.2. Previous studies into serious case reviews nationally, have highlighted that professionals must maintain a healthy scepticism and respectful uncertainty to see beyond what is often being presented by parents. A process of ‘checking back’ with professional colleagues may provide opportunities to detect hidden issues and further provide pathways to protection. Use of the Pathways to Harm model helps to identify where more professional curiosity and application of evidence-based practice may have afforded pathways to protection. 7.3. In this, case various indicators of harm were related to: Father’s history, his potential significant untreated depression. Father being an alleged perpetrator of domestic abuse in his previous relationship. Age and therefore vulnerability of the children especially Natalie. Young parents. 7.4. Good information sharing and contacting the professionals that may well hold key information about a whole family and use of Think Family approaches may have afforded the right information to inform robust assessments of elements of risk and therefore inform the level of service that would possibly provide prevention from harm. 17 7.5. If Father’s GP had known that he was an alleged perpetrator of domestic abuse and a father of four children, given the diagnosis of significant depression, this may have caused contact at least with the health visitor or GP for the Mother and children and could have led to a reassessment of the current situation and more support for the family. 7.6. Exploration by CSC in Area B about the nature of the last episode of domestic abuse in the first relationship being one of a physical assault in front of a child may have led to more assessment and probing into Father’s background and contact with his GP. 7.7. Information being shared with the health visitor about the nature of previous incidents that Father had been involved in may have led to a more robust assessment of Mother and opportunity to for her talk more about any issues in her the relationship. 7.8. If Mother’s GP had opportunities to reflect on the number of issues that she was presenting with and the number of places she was accessing for advice and treatment it may have been an alert to probe further about why this was and share information with other health professionals that were seeing her in order to offer any support she needed. 7.9. It is important that as well as individual professionals’ curiosity, to consider how systems and policies can support prevention and protection. 7.10. The system of information sharing related to domestic abuse across the locality needs to be reviewed so that the understanding and assessment within families by all professionals is robust and is informed by all the information that is available and therefore leads to recommendations for the LSCB to consider. 7.11. It is the case that in some instances Serious Case Review meetings between family and authors have been successfully undertaken without prejudicing other proceedings. Use and knowledge of disclosure issues are an important factor that need to be understood. Engagement from families much later in the process can limit the effectiveness of the review process and therefore the learning. 8. RECOMMENDATIONS 8.1. The learning in this case provides a window on the system. Information gathered during this review suggests that the issues that it has highlighted may have Learning Point 10: Delays due to criminal or other proceedings lead to limited engagement with families much later in the process and limit learning and improvement. Understanding and challenging that SCR processes are also mandated under legislation and can sometimes be undertaken simultaneously should encourage challenge and further discussion. Reassurance regarding SCR process and understanding of issues that should lead to disclosure can be helpful. Recommendation 7 18 implications for the wider system. The following recommendations therefore seek to address this. 8.2. This Serious Case Review covers services offered within 3 LSCB areas; professionals from those areas were fully engaged with the SCR. Arrangements must be made to share relevant learning from this SCR with Area B and C LSCB. 8.3. Where agencies have made their own recommendations in their Agency Reports, the three LSCBs should seek assurance that action plans and are underway and outcomes are impact assessed within those organisations. 8.4. The following recommendations are made as a result of the learning in this case and require that NSCB seeks assurance from the appropriate partners that the following are addressed: 1. That partner agencies who carry out assessments of need ensure that processes and practice provide adequate scope to include all relevant history pertaining to family history especially for absent parents and carers as well as drawing on ‘Think Family’ approaches (Learning Point 1-5, & 7- 8). 2. That partner agencies across the NSCB area: a. Evaluate the information that is shared regarding domestic abuse notifications to ensure it provides robust information for on-going assessment (Learning Point 2). b. Ensure that there is guidance/policy related to the response to receipt of domestic abuse notifications (Learning Point 3). 3. a. That information related to domestic abuse incidents is shared with GPs for the perpetrator as well as for the children and victims (Learning Point 5). b. That practitioners who are assessing risk for victims and children ensure that they contact GPs of both victims and perpetrators to include relevant information in order to safeguard children and in the public interest. (Learning Point 5). c. That GPs record where male patients in their practice are fathers, especially when their partner and children are registered at a different practice or area. (Learning Point 5). 4. All agencies who encounter domestic abuse victims should promote Claire’s Law; consideration should be given to the production of a leaflet 19 highlighting this where an incident has occurred, and police have been called (in the same way as IDVAs are recommended) (Learning Point 6). 5. a. That partner agencies will provide detail of how they will apply the learning in this case regarding assessment and engagement with fathers in their respective organisations and to include how information is shared to GPs when men become fathers and are not registered at the same practice as mothers (in the same/similar way to the notification to mothers’ GPs). (Learning Point 7). b. NSCB, through its learning and development activity and case auditing, and partner agencies through their supervision, ensure that healthy scepticism and professional curiosity are encouraged and evidenced in practice. (Learning Point 4) c. NSCB should formulate guidance on the importance of engaging with fathers. This should include: the importance of gathering background information assessment of needs ensuring unmet needs are supported with appropriate offer of services and/or referrals (Learning Point 7) 6. That NSCB considers interagency support to enhance the roll out of the Coping with Crying programme in light of the learning from this review (Learning Point 9). 7. In recognition that not all cases are the same, NSCB should engage in full discussions and escalate concerns where learning from Serious Case Reviews is affected by ongoing Criminal Processes (In line with CPS Guidance1920). 19 https://www.cps.gov.uk/sites/default/files/documents/publications/liaison_and_information_exchange.pdf 20 https://www.cps.gov.uk/legal-guidance/serious-case-review |
NC50852 | Death of a 16-year-old boy by apparent suicide in February 2018. Mario initially lived with mother and maternal grandmother with siblings 1 and 3 and moved in with father and sibling 2 a year later; his parents had divorced in 2010. All four siblings were subject to child protection plans in April 2013 due to emotional abuse arising from parental conflict and domestic abuse, with Mario's case closing in April 2014. School raised concerns over Mario's mood due to defacing school equipment and a teacher overhearing him discussing suicide; referred him to an in-school counselling service. Mario disclosed physical abuse by father on two occasions and the school contacted the multi-agency safeguarding hub (MASH) for advice. Sibling 1 reported that Mario was possibly anorexic to MASH and had seen Mario self-harming at his father's house. Mario used school computers for web searches relating to suicide and self-harm which were blocked but not reported to school. Ethnicity/nationality unknown. Findings include: practitioners viewed Mario in isolation from concerns about his wider family; advice provided to school by MASH was not consistent with safeguarding policy and practice; Mario was not linked to domestic abuse incidents at his mother's house; and the counselling service's safeguarding policy and practice requires development. Makes recommendations including: increase awareness of the antecedents of suicide amongst children and young people; share learning with schools in the local authority; and ensure assessments consider the needs of siblings not living in the household.
| Title: Mario (Case A18): serious case review: overview report. LSCB: Bury Safeguarding Children Board Author: David Mellor Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Bury Safeguarding Children Board Serious Case Review Mario (Case A18) SERIOUS CASE REVIEW OVERVIEW REPORT Report Author: David Mellor Date: 26 October 2018 Commissioned by: Bury Safeguarding Children Board 2 Contents 1.0 Introduction ............................................................................... 4 2.0 Terms of Reference ..................................................................... 4 Lines of enquiry ..............................................................................4 3.0 Glossary ...................................................................................... 5 4.0 Synopsis ..................................................................................... 7 Significant events which took place prior to October 2016 ....................8 October 2016 to 4th February 2018 .................................................. 12 2017 ........................................................................................... 16 2018 ........................................................................................... 22 5.0 Views of Family ......................................................................... 23 6.0 Analysis .................................................................................... 29 How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario? ....................................................... 29 To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family? .................................................... 32 To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response? ................................. 35 To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario? . 36 To what extent were agency interventions with Mario informed by relevant prior concerns? ................................................................. 38 To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family? .............................................. 38 To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood? ...................................... 39 To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family?. ............ 40 To what extent were safeguarding children procedures followed? ........ 41 Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, Mario. ............................................ 43 Good practice ............................................................................... 44 7.0 Findings and Recommendations ............................................... 44 Awareness of suicide antecedents ................................................... 44 Recommendation 1 .......................................................................... 46 Dissemination of learning to schools ................................................ 47 Recommendation 2 .......................................................................... 47 3 Suicide Prevention ......................................................................... 47 Recommendation 3 .......................................................................... 47 ‘Think Family’ ............................................................................... 47 Recommendation 4 .......................................................................... 48 Recommendation 5 .......................................................................... 49 Recommendation 6 .......................................................................... 49 Recommendation 7 .......................................................................... 49 MASH response to disclosure of physical abuse ................................. 49 Recommendation 8 .......................................................................... 49 Access to harmful websites............................................................. 49 Recommendation 9 .......................................................................... 50 Doki Doki Game ............................................................................ 50 Information Sharing ...................................................................... 51 Recommendation 10 ........................................................................ 51 Safeguarding policy and practice ..................................................... 51 (Single Agency) Recommendation 11 .............................................. 51 Recommendation 12 ........................................................................ 52 References ....................................................................................... 52 Appendix A ...................................................................................... 53 Single Agency Recommendations .................................................... 53 Appendix B ...................................................................................... 55 Process by which SCR completed and membership of the SCR Panel .... 55 4 1.0 Introduction 1.1 On 4th February 2018 a young person who will be referred to in this report as Mario died after apparently taking his own life. 1.2 Following Mario’s death, Bury Safeguarding Children Board decided to conduct a serious case review (SCR) on the grounds that a child had died and that there were lessons to be learned from the way in which agencies worked together with the child and his family. 1.3 The Safeguarding Children Board commissioned David Mellor to be the independent lead reviewer for this SCR. David is a retired chief police officer and former independent chair of safeguarding children and adults boards who has over six years experience of conducting SCRs and other statutory reviews. He has no connection to Bury or any of the agencies involved in this case. An SCR panel was established to oversee this review and membership of this group and a description of the process by which this SCR was carried out is shown in Appendix B. 1.4 An inquest into the death of Mario will take place in due course. 2.0 Terms of Reference 2.1 The period covered by this SCR is from October 2016, when serious concerns about the impact of domestic abuse on Mario’s wider family arose, until the date of Mario’s death on 4th February 2018. Significant events which took place prior to October 2016 are also included within the scope of the review. 2.2 It was also decided that the SCR would explore the following key lines of enquiry: Lines of enquiry To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family? To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario? 5 To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family? To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood? How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario? To what extent were safeguarding children procedures followed? To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response? To what extent were agency interventions with Mario informed by relevant prior concerns? To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family? How effectively was Mario’s suicide related internet use monitored? Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, their son. 3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Child and Family Assessment (CAFA) The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability. Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members 6 regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological physical sexual
financial emotional Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour. Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Independent Domestic Violence Advisor (IDVA) Their main purpose is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members in order to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans. Multi Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality. 7 (SafeLives) DASH (Domestic Abuse, Stalking and “Honour”-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi Agency Risk Assessment Conference (MARAC) and what other support might be required. Sanctuary Scheme is a multi-agency victim centred initiative which aims to enable households at risk of violence to remain in their own homes and reduce repeat victimisation through the provision of enhanced security measures and support. Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. Team Around the Child (TAC) This approach brings together relevant practitioners to address the needs of the child or young person. The team works together to plan coordinated support from agencies to address problems in a holistic way. The TAC process is focused on children and young people before they reach the threshold for social care intervention. 4.0 Synopsis 4.1 Mario was born in 2002 and was the youngest of four siblings born to mother and father. Mario’s elder siblings will be referred to chronologically as siblings 1, 2 and 3. After Mario’s mother and father divorced in 2012, mother subsequently gave birth to another child with a different partner who will be referred to as child 5. 4.2 As previously stated the primary focus of this SCR is on relevant events which took place during the period from October 2016 until Mario’s death on 4th February 2018. However, significant events which took place prior to October 2016 will also be addressed. 8 Significant events which took place prior to October 2016 4.3 Mother and father separated in 2012. Initially mother and siblings 1, 3 and Mario moved in with maternal grandmother whilst sibling 2 remained with father. The separation of mother and father was acrimonious and mother was referred to a Multi-Agency Risk Assessment Conference (MARAC) in October 2012 after several incidents in which father was regarded as the perpetrator and mother as the victim of domestic abuse. 4.4 Children’s social care became involved with Mario in November 2012. At that time Mario was missing sibling 2, experiencing some difficulties in his relationship with mother’s new partner (partner 1), and struggling with literacy at school where he was behaving disruptively at times. He was frequently described as ‘angry’ and began staying with his maternal grandmother. (Mother, siblings 1, 3 and Mario had moved out of maternal grandmother’s home by this time). 4.5 Around March 2013 Mario left mother and moved to live with father and sibling 2. It was said that all the children resented partner 1, particularly Mario. (Father’s address was approximately five miles from mother’s address). 4.6 In April 2013 all four siblings were made subject to child protection plans under the category of emotional abuse arising from continuing parental conflict and domestic abuse. It was agreed that Mario and sibling 2 would be referred to Child and Adolescent Mental Health Services (CAMHS) although father questioned both this referral and their further engagement with children’s social care. Although Mario appeared quite resistant to engaging with his social worker, by September 2013 he was perceived to be ‘safe and well’ in his father’s care and doing well at school. During a review child protection conference meeting held the same month improvements were noted in respect of Mario and sibling 2, whilst less progress was considered to have been achieved in respect of siblings 1 and 3. Also in September 2013 mother was again referred to MARAC as a victim and father as the perpetrator of domestic abuse. 4.7 In February 2014 Mario and sibling 2 were ‘stepped down’ from child protection plans to monitoring as children in need as their needs no longer 9 justified child protection arrangements. They both continued to reside with father where the atmosphere was described as ‘calm and relaxed’. In April 2014 the cases of Mario and sibling 2 were closed to children’s social care. 4.8 Mario transferred to his secondary school in September 2014. Mario’s primary school head teacher appears to have shared some information about Mario’s history, specifically that he was living with his father and had been removed from a child protection plan whilst the siblings who were living with mother remained on a child protection plan. By October 2014 siblings 1 and 3 had also been removed from their child protection plan after a positive assessment of mother’s parenting capacity. 4.9 During September 2014 conflict between father and sibling 2 led to the latter moving back to mother leaving Mario as the only sibling living with father. Sibling 2 alleged that father had assaulted him. The police were involved but decided to take no further action. During that month father took Mario to hospital A&E where he was treated for pain to his ribs said to have been the result of an assault by sibling 2. After X-rays revealed no fractures, Mario was discharged home. Following the departure of sibling 2, all of Mario’s siblings were then attending a different school to him. 4.10 Following his return to live with mother, sibling 2 became involved in a domestic incident with mother’s new partner (partner 2) in December 2014 to which the police were called. Team Around the Child (TAC) arrangements were put in place to support the family at this time and sibling 2 went to live with maternal grandmother for a period. 4.11 In early 2015 concerns arose over Mario’s school attendance and under achievement in a number of subjects. He received support in school for literacy difficulties. Father was finding it difficult to attend parents’ evenings and when separate appointments were made he cancelled them on more than one occasion because of work commitments. 4.12 During May 2015 Mario was found to have been damaging school computer keyboards and a monitor. This led to concerns about Mario’s low mood and his 10 habit of picking at the skin on his fingers. He was provided with a ‘doodle pad’ to try and prevent him defacing school equipment. Later that month Mario commented in class that his holiday destination would be ‘to go to Hell’. His teacher also overheard a discussion between Mario and a fellow pupil in which committing suicide was referred to. The teacher judged that Mario was not saying he intended to commit suicide. From discussions with Mario, teaching staff formed the view that he was experiencing low mood as a result of an accumulation of issues including feelings of failure, getting into trouble at school and fear of how his father would respond to the news that he had been damaging school computer equipment. The school decided to offer Mario pastoral support in the hope that a trusting relationship would develop which could allow Mario to be more forthcoming about his worries. 4.13 The following month Mario was excluded from school for two days after swearing at a member of staff. When Mario’s father was informed he expressed the view that his son had not been treated fairly. 4.14 In January 2016 concerns arose over Mario’s school attendance record although it was noted that two of his main absences were due to a ‘gastro bug’. 4.15 On 16th March 2016 Mario damaged a computer mouse at school. When spoken to by his head of year, Mario expressed concern about what his father would say when he found out he was in trouble again. He disclosed that his father shouted at him and had hit him and grabbed him in the past. He was also worried about being removed from father’s care. Mario disclosed that he had three siblings who lived with mother, that he worried about mother, that her partner (partner 2) had been ‘kicked out’, that the partner had ‘smashed her car up’, that his mother and father had split up 3 or 4 years previously ‘due to fighting’ and that ‘social services had been involved’. 4.16 The school contacted Bury Multi-Agency Safeguarding Hub (MASH) for advice on how to proceed. The MASH noted Mario’s allegation that father had hit him and informed the school that Mario’s siblings were open to children’s social care although Mario was not. The advice from the MASH was for the school to further explore Mario’s relationship with his father and to arrange a further 11 consultation with MASH if required. The head of year spoke to Mario again who reiterated that father shouted and hit him and had slapped him on the cheek in the past. However, Mario appeared to become more settled and when a second contact was made with the MASH, their advice to the school head of year was to ring father and ‘judge his response’ before deciding on what action to take, including further contact with the MASH if necessary. 4.17 The school contacted father who was said to have adopted a supportive tone towards Mario. Mario later confirmed that he had gone home and had a ‘good chat’ with his father who had admitted he sometimes went overboard with his shouting and would try and control this in future. Mario agreed to a referral to Relateen, an in-school counselling service provided by the Relationship Hub. The referral form stated that the reason for making it was ‘anxieties – lets worries build up’. The referral form also stated that Mario’s father was aware of the referral. Mario was placed on a waiting list. 4.18 During April 2016 mother contacted the police to say that her ex-partner (partner 2) was harassing her by texting and calling her. When the police attended mother alleged that partner 2 had taken her car without consent in January 2016 and crashed it. She alleged that he had forced her to take responsibility for the crash. Fearful of partner 2, mother said she made a false report to her car insurance company stating that she had been the driver of the car at the time of the incident. The insurance company had recently contacted her to advise that they had become aware that she had made a false statement about the incident. This news had prompted her to contact the police. A DASH (Domestic Abuse, Stalking and “Honour”-based violence) risk assessment was completed which assessed mother as being at ‘high’ risk of domestic abuse. The case was referred to MARAC and referrals were made to children’s social care and other partner agencies. The referrals linked Mario to mother. Partner 2 was arrested the same day. 4.19 Also during April 2016 Mario was placed on report as a result of concerns about his academic progress. 12 4.20 On 4th May 2016 MARAC considered the domestic abuse incident involving mother and partner 2. MARAC was informed that there was a history of violent and controlling behaviour by partner 2. Bail conditions were in place although partner 2’s parents lived near mother’s home. Mother was said to have rejected the suggestion that she and her children move elsewhere. Mother stated that she was no longer in a relationship with partner 2, had no contact with him and was exploring obtaining a restraining order. MARAC was informed that mother’s children were open* to children’s social care and that the service was attempting to complete a children and families assessment (CAFA) but mother was said not to be engaging in this process. (*Mario was not open to children’s social care at that time so it seems that he was not included in the CAFA). 4.21 On 29th May 2016 sibling 1 contacted the police to report that eight males including partner 2 had attended mother’s house and had assaulted mother. The police attended and mother, who was visibly upset, refused to disclose what had happened. Sibling 1 repeated her allegation that men had turned up at the address and attacked mother and had since left. The officer assessed the risk as ‘standard’ and made no referrals. Mario was not linked to this incident. 4.22 On 14th September 2016 Mario received a school detention after an altercation with another pupil. Mario became distressed and was seen by a school first aider to whom he disclosed that he was afraid of how father would respond when told about the incident. He said he was worried about father hitting him and disclosed that he had hit him on the previous Sunday (three days earlier). The school reflected on the advice previously received from the MASH and sought more information from Mario, who said he had ‘back-chatted’ father who had then grabbed his arm which caused Mario to bump his eye on the sofa. Mario had no visible marks as a result of the incident. The school then telephoned father in Mario’s presence and decided that it was safe for Mario to return home that evening. October 2016 to 4th February 2018 4.23 During the early hours of Sunday 9th October 2016 mother was assaulted by partner 2 whilst they were staying in a hotel in Blackpool with child 5. At the 13 time partner 2 was on pre-charge bail in respect of the earlier assault on mother in the Greater Manchester Police area (Paragraph 4.18). Partner 2 was subject to bail conditions in respect of this earlier assault which stated he was not to contact mother or enter the road on which she lived in Bury. 4.24 Mother reported the incident to Lancashire Constabulary but declined to make any complaint against partner 2. She was noted to have recent marks on her face and bruising to her eyes which was fading. Partner 2 had left the scene prior to police arrival. Mother and child 5 were moved to another room in the same hotel. Mother co-operated with a DASH risk assessment during which she disclosed that partner 2 had previously assaulted her, that the violence was getting worse and that he had made threats to kill himself during previous arguments. Mother was assessed as being at ‘high’ risk of domestic abuse and this information was passed to Greater Manchester Police (GMP) to facilitate a local MARAC referral. 4.25 Two days later partner 2 made counter allegations of assault against mother. He was located and arrested by GMP for his alleged assault on mother in Blackpool. He was then transferred to the custody of Lancashire Constabulary. No details of any outcome of this arrest have been shared with this SCR. 4.26 Mother returned to her home in Bury on Sunday 9th October 2016 and was visited by officers from GMP who repeated the DASH risk assessment, also concluding that mother was at ‘high’ risk. Mother provided a statement of complaint to GMP which stated that following an argument over money, partner 2 repeatedly punched and kicked her resulting in bruising to her eyes and arms. Mother was referred to MARAC and referrals were also made to children’s social care and ‘health’. A safety plan was put in place for mother. In the documentation completed for GMP’s Public Protection Investigation Unit (PPIU) no reference was made to Mario. 4.27 A strategy meeting took place on 11th or 12th October 2016 following concerns that mother was maintaining a relationship with partner 2 and, as a result, this was exposing sibling 2, 3 and child 5 to the risk of domestic abuse. (Sibling 1 was an adult by this time). The outcome of the strategy meeting was 14 that sibling 2, 3 and child 5 were to be referred to an initial child protection conference (ICPC). 4.28 On 2nd November 2016 the referral in respect of the assault on mother was discussed at a MARAC meeting. The outcome was for the Independent Domestic Violence Advisor (IDVA) to contact mother and establish whether partner 2 had access to mother’s home address, in particular whether he had keys to the address. It appears that no further action was being taken in respect of the Blackpool incident ‘due to injuries to both parties’. 4.29 On 3rd November 2016 Mario attended an initial meeting with a Relateen counsellor at school at which there was a brief exploration of his worries and feelings. 4.30 A week later Mario attended a second meeting with the counsellor during which there was more time available to explore issues. He reported being angry around people. He disclosed that his parents had separated when he was younger and he lived with father. He said he rarely had contact with mother with whom he was angry for being in abusive relationships and had told her this. He was also said to be angry with mother for not contacting him. He said he had good relationships with father, an aunt and his maternal grandmother. 4.31 At the next meeting with the counsellor on 17th November 2016, Mario spoke of meeting with his mother who had a black eye which she told him had been caused by falling out of bed. Mario questioned the truthfulness of his mother’s explanation and expressed concern that she was seeing an ex-boyfriend who he had heard had been released from prison. (Presumed to be partner 2) Mario said he was worried about child 5 witnessing domestic violence ‘because she (child 5) was hitting out’. Following this session, the counsellor discussed Mario’s case in supervision and it was decided that the counsellor would speak with Mario about sharing his concerns with the school safeguarding lead or head of year. 4.32 One week later (24th November 2016) Mario saw his counsellor again and said that he thought his family did not consider his feelings important and so he 15 didn’t want to talk to them about his feelings. The counsellor spoke with her supervisor over the telephone and subsequently spoke to the head of year at Mario’s school about the concerns raised by Mario during the counselling meeting dated 17th November 2016 (Paragraph 4.31). The school state that this conversation did not take place until 23rd January 2017 (Paragraph 4.42). However, Relateen state that this conversation with the school head of year had taken place by 24th November 2017 although the concerns raised by Mario were not put in writing until 26th January 2017 (Paragraph 4.44). 4.33 On 28th November 2016 an attendance improvement support report was completed in respect of Mario. This would enable a programme of support to be put in place to improve his school attendance which was categorised as ‘poor’. 4.34 A further meeting took place between Mario and his counsellor on 1st December 2016 at which Mario expressed anxiety about meeting mother ‘and family’ and how he would talk to them. The counsellor responded by giving Mario an exercise to complete at home which was intended to help Mario with ‘emotions and positive thoughts’. The counsellor subsequently discussed the case in supervision once again where the possibility of inviting Mario’s father to a counselling meeting was discussed. It was thought that it would be helpful for Mario to discuss his worries about his mother with his father. 4.35 On 5th December 2016 Mario was seen by his GP in company with father. Mario had an upper respiratory tract infection and had had a frontal headache since the previous day. He had a dry, sore throat and said he felt sick. Father said Mario had lost weight recently. The GP arranged for a blood test to investigate the weight loss. The possibility that Mario was suffering from a viral illness was also considered by the GP. Two days later Mario’s blood results came back as ‘essentially normal’. The blood tests were to be repeated in 4-6 weeks but Mario did not attend the GP practice for these tests. There is no indication that Mario’s weight was monitored over time. 4.36 On 15th December 2016 Mario met his counsellor and spoke of his worries about no-one wanting to employ him. He agreed that it would help if father came to a counselling meeting. 16 2017 4.37 On 13th January 2017 children’s social care completed Section 47 enquiries (which had presumably been initiated following the 11th or 12th October 2016 strategy meeting (Paragraph 4.27)) and concluded that as child 5 had been present when partner 2 assaulted mother on 9th October 2016, the case should progress to an initial child protection conference (ICPC). 4.38 On 18th January 2017 a school nurse carried out a home visit to mother’s address in order to share information from her report to the forthcoming ICPC. 4.39 The following day Mario saw his counsellor for the first meeting of the new year. He said he had had a good Christmas break and had spoken to father about coming to a future meeting to discuss his mother’s safety ‘and domestic violence’ but thought father might be too busy with his work. The counsellor was to seek the permission of the school for the involvement of father. 4.40 On 20th January 2017 the ICPC took place. According to the children’s social care chronology sibling 3 and child 5 were made subject to child protection plans under the category of emotional abuse as a result of domestic violence. According to school nurse and police records sibling 2 was also made subject to a child protection plan. Mario was identified as a sibling in the school nurse report but was noted to have resided with father for some time and his contact with his siblings was said to be ‘not known’. The police record of the ICPC states that Mario was designated as a ’significant other’. Police markers were placed on the addresses of mother, father and maternal grandmother. 4.41 On 23rd January 2017 a school nurse completed a health assessment in respect of sibling 3 as part of the child protection plan. Sibling 3 reported low mood for which mother was said to be contacting their GP for support. Sibling 3 expressed concerns about mother’s ex-partner who he said had ‘abused and terrorised’ his mother. Sibling 3 was accessing mental health services and had open access to his school nurse drop in. The school nurse subsequently liaised with sibling 3’s school who intended to refer him to the Relateen counselling service. 17 4.42 On the same date, Mario’s counsellor contacted the school head of year to discuss the safeguarding concerns first disclosed by Mario on 17th November 2016 (Paragraph 4.31). These concerns were articulated as Mario used to live with mother but went to live with father after witnessing domestic violence. Mario was said to maintain contact with his mother who was said to have had a number of abusive relationships. Mario was said to have never witnessed domestic abuse but had noticed that his mother had a black eye which she had claimed had been caused by falling out of bed. He had heard father and his maternal grandmother discussing the domestic abuse. He believed that ‘when things got bad’ mother and child 5 went to stay with maternal grandmother. Mario was concerned that child 5, who was two years old, was witnessing domestic violence. After receiving this information, the head of year was advised by school senior management to telephone the MASH, speak to the school nurse and request they contact the health visitor. The school is unable to confirm whether Mario was in fact referred to the school nurse. The counsellor was asked to write up the concerns she had shared in respect of Mario so that they could be passed to the school’s safeguarding lead. 4.43 The next day (24th January 2017) Mario’s counsellor informed the school that she was sending the safeguarding concerns in respect of Mario to her line manager to read through. The school responded by saying that the written details of the safeguarding concerns were needed as soon as possible as the MASH was said to be waiting for them. 4.44 On 26th January 2017 the written safeguarding concerns in respect of Mario were shared with the school head of year. Later that day the school contacted the MASH by telephone to confirm the contents of the report provided by Relateen. A children’s social care contact note dated the following day recorded that they had been informed by Mario’s school that he had seen mother with a black eye and suspected that her partner was responsible although mother claimed that she had fallen out of bed. This information was shared with the social workers supporting sibling 3 and child 5’s social worker. On the same day, Mario met his counsellor and said he had not seen his family for a month. He said 18 he worried about his own future relationships. The counsellor informed Mario of the actions she had taken in response of his disclosures about the impact of domestic abuse on his mother and child 5 and Mario was said to be pleased about this. 4.45 On 30th January 2017 Mario’s counsellor asked the head of year whether he was allowed to ‘fiddle with blu tac in class, and the head of year confirmed that he was. 4.46 On 2nd February 2017 Mario’s counsellor reviewed the value of the counselling with him. Mario said that the counselling wasn’t making things better or worse but that he wanted it to continue. During the meeting Mario disclosed that he spent a lot of time staring at the ceiling at weekends. (Father said that Mario often stared at the ceilings whilst lying down on his bed or the settee and listening to music on his headphones. He didn’t perceive this as an indication of low mood). 4.47 On 6th February 2017 sibling 3 attended the school nurse drop at his school and during the course of the conversation said that mother was experiencing some difficulties in seeing Mario. However, in his next counselling meeting three days later, Mario said he was looking forward to going for a walk with mother. 4.48 On 16th February 2017 Mario met his counsellor and said he had enjoyed his walk with mother. He was invited to consider places where he felt safe and his response was ‘at his friends’. Mario was also invited to consider his hopes for the future which he said were a ‘dog and a family’. 4.49 On 27th February 2017 partner 2 contacted the police via 999 to report that mother had stolen his phone. He said he was ringing from his parent’s address. He said he was tired and wished to go to bed and so the response to the incident was delayed. An officer subsequently attended and a DASH risk assessment was completed which assessed risk as ‘medium’. When reviewed by a specialist officer the risk was adjusted to ‘standard’. 4.50 Later the same date sibling 3 attended A&E with ‘disturbed thoughts’ and was seen by CAMHS. The following day (28th February 2017) sibling 3 was taken 19 to hospital by the ambulance service after he had contacted them to say that he felt suicidal and could do ‘something stupid’ following a family argument. Sibling 3 was later discharged. The hospital notified the school nurse of his school and a referral was sent to the Healthy Young Minds (HYM) service. HYM noted that sibling 3 was subject to a child protection plan and that a risk management plan was in place for him of which his social worker was aware. 4.51 On 2nd March 2017 Mario saw his counsellor who told him that children’s social care ‘had decided that no further action was needed with mother’, about which Mario was said to be relieved. It appears that Mario was misinformed by the counsellor. The school had apparently advised the counsellor that ‘no further action’ was required of her in respect of documenting Mario’s concerns. It appears that the counsellor had understood the term ‘no further action’ to refer to outcome of Mario’s concerns. The counselling sessions were again reviewed and Mario said he thought they were helping and wanted them to continue. 4.52 On 6th March 2017 sibling 3 was seen by HYM and told them that he did not have any thoughts of self-harm or suicide. After discussion with sibling 3’s social worker, it was decided that CAMHS would monitor his mental health thereafter. 4.53 The following day sibling 1 telephoned the MASH to express concern that Mario was anorexic. Enquiries were made with school, health services and father. Mario was described as a ‘nervy young man’ who bit his nails. Father said that Mario was having a growth spurt, that he had already taken him to the GP and planned to take him again before Easter. (There is no record of father taking Mario to the GP at that time). The MASH asked the school head of year to speak with Mario. When spoken to Mario said that ‘things were a lot better’. The MASH decided to take no further action. Mario was invited to the school nurse drop in at his school but did not attend. 4.54 On 9th March 2017 Mario attended counselling and said he had plans to go hiking with friends during the school holidays, adding that he wanted to ‘feel peaceful away from everyone’. 20 4.55 On 14th March 2017 the school nurse discussed sibling 2 and sibling 3 in safeguarding supervision. Sibling 3 was reported to be living with his maternal grandmother and sibling 2 was reported to be living with his girlfriend. Mario was also discussed and was noted to continue to live with father. The emotional impact of domestic abuse on the children was discussed. 4.56 On 16th March 2017 Mario met his counsellor and discussed his shyness with people. In response the counsellor outlined strategies for coping with this. 4.57 On 23rd March 2017 Mario saw his counsellor and expressed concern that people might think he was ‘weird’ and therefore not like him. The counsellor helped him reflect on the friends who knew and liked him. 4.58 On 4th April 2017 a review child protection conference took place at which it was decided that sibling 2 and 3 and child 5 would continue on a child protection plan under the category of emotional abuse. Mario was mentioned as a significant other but mother was said to have ‘very limited contact’ with him. 4.59 On 19th April 2017 a MARAC meeting took place at which sibling 1 was referred as a victim and partner A as the perpetrator. Partner A was said to be in prison and his release date was to be ascertained. Concerns about this relationship continued for a number of months. Amongst the concerns raised was possible contact between partner A and sibling 1’s siblings. Mario was included in the list of siblings considered. 4.60 On 4th May 2017 Mario met his counsellor and disclosed that he had been avoiding coming to the meetings (last session attended was on 23rd March 2017) because he ‘got nervous talking’ but wished to continue the meetings. He went on to disclose that a friend had self-harmed in February. The counsellor advised Mario that she may have to report this disclosure. The counsellor subsequently discussed the matter in supervision where it was agreed that the counsellor would talk to Mario about helping the friend, who Mario had now identified by name, talk to an adult or possibly talk to Mario as an alternative. Another option discussed was for the counsellor to report the incident to school. 21 4.61 On 7th May 2017 mother contacted the police via 999 to report that her ex-partner (partner 2) had visited her address and been banging on the door. She described him to be drunk and aggressive. The police attended and concluded that no offences had been disclosed. The incident was risk assessed as ‘medium’ and later adjusted to ‘standard’ when reviewed by a specialist officer. Referrals were sent to children’s social care, ‘education’ (not including Mario’s school) and ‘health’. 4.62 On 18th May 2017 Mario met his counsellor and it was agreed that the counsellor would report the self-harm incident involving his friend to the school head of year. Mario was said to be struggling to understand why his friend had self-harmed. 4.63 On 24th May 2017 father contacted school to say that Mario was too upset to attend school that day as sibling 2’s girlfriend had given birth the previous night and that the child had died shortly after birth. Various members of school staff were advised but it is unclear whether Mario’s counsellor was informed at this point. On the same date mother contacted her health visitor ‘in a distressed state’ to pass on the same news. The health visitor planned to make a home visit to mother to offer emotional support and discuss the emotional impact on sibling 2 and child 5. 4.64 On 15th June 2017 Mario attended a meeting with his counsellor. Two meetings had been cancelled owing to the counsellor being unwell. A discussion took place about working towards ending the counselling when the current school academic year came to an end. Mario said he wanted to work on self-confidence and dealing with anxiety until then. Apparently it is usual practice to end counselling before the school summer holidays. 4.65 On 20th June 2017 a school nurse saw sibling 2 at his girlfriend’s house for checks on his growth, hearing and vision. He disclosed that the recent loss of the baby had had an impact upon him emotionally and he had suffered anxiety and panic attacks. He was advised to self-refer to his GP and the Healthy Minds service. 22 4.66 On the same date a core group meeting in relation to the child protection plan for sibling 2, 3 and child 5 was cancelled because of unavailability of staff. The meeting was rearranged for 5th July 2017 but no details of the meeting have been shared with this review. 4.67 On 11th July 2017 Mario and another pupil were warned after homophobic bullying and name calling another pupil. The head of year was to monitor the situation. 4.68 Two days later Mario attended his final counselling appointment after missing three successive meetings, although two of these were because special events were taking place within the school. Mario said he thought the counselling had helped but was happy to end the sessions. He disclosed that he had had some time off school as a result of a family bereavement. He indicated that this difficult experience had somehow helped him to feel more mature and confident. 4.69 A review child protection conference took place on 20th September 2017 at which it was decided that siblings 2, 3 and child 5 were no longer to be subject to child protection plans. They were to be monitored for a short period as children in need. Siblings 2 and 3 had moved back to live with mother. Sibling 2 was hoping to study engineering and sibling 3 had achieved well in his GCSEs and had recently started college. Once again, mother was reported to have very little contact with Mario. 4.70 The first child in need meeting in respect of siblings 2, 3 and 5, which had been scheduled to take place on 24th October 2017, was cancelled and on 27th November 2017 their cases were closed to children’s social care. 4.71 On 28th November 2017 Mario attended his GP in company with father. He complained of having general aches and pains for almost three weeks and said he felt dizzy on standing at times. Blood samples were taken for testing and found to be normal. 2018 4.72 On 12th January 2018 Mario attempted to make a series of web searches on school computers relating to ‘how to kill myself’ and ‘how to tie a noose’. All 23 searches were blocked by Smoothwall which is a system which prevents access to inappropriate websites. At that time, the system was unable to flag up searches on the school computer which gave rise to concern and so Mario’s searches were not escalated. 4.73 On 17th January 2018 Mario and other pupils were involved in a name calling incident during class which led to sanctions being issued to some of the pupils. No sanction was issued to Mario. 4.74 On 18th January 2018 Mario attempted to make a series of web searches on school computers relating to ‘why shouldn’t I commit suicide?’ and ‘Kill me’. Mario had attempted to disguise the ‘why shouldn’t I commit suicide?’ searches by randomly adding numbers to the text of the question. He succeeded in gaining access to page setting out sources of support. The ‘kill me’ searches were again blocked by Smoothwall. 4.75 The following day Mario attempted to make a series of web searches relating to ‘suicide tablets’ which generated images of tablets. 4.76 On 4th February 2018 Mario was found dead at his home address after apparently hanging himself. Mario had been alone in the house at the time. 5.0 Views of Family 5.1 Mario’s mother, father and maternal grandmother chose to contribute to this SCR. It had been decided not to invite Mario’s siblings to contribute to the review on the grounds that they may find the experience distressing. However, when the independent lead reviewer visited mother to enable her to read the final SCR report, sibling 1 was present and wished to contribute to the review. 5.2 Father said that Mario had lived with him for a number of years and so he saw him every day. Both parents said that Mario loved computer games, the outdoors including climbing, swimming, hot tubs, the sea and the beach. Father described Mario as happy in his life, adding that though his son had good and bad days at school he would set off early for school each day and always return home happy. 24 5.3 Father had a slight concern that Mario had to make all the effort in order to meet up with his friends. They didn’t call on him. He called on them and he would often return home early from visiting a friend and say that the friend had not been available because he was doing something else. However, he said that much of Mario’s contact with friends and his siblings was online. Father said he would often walk past Mario’s bedroom in the evening and hear him talking and laughing with one of his brothers over skype whilst simultaneously playing a computer game with them. 5.4 Mother said she generally saw Mario at her mother’s home two or three times a week. She said that Mario’s maternal grandmother often collected him from the home he shared with his father and drove him to the metro station from which he caught a tram to school. She would also collect him from the same metro station at the end of the school day. If mother was visiting her mother’s home, Mario would often call in to see his mother after being collected from the tram station at the end of the school day. 5.5 In the last two years of Mario’s life, mother said she had found it difficult to encourage him to visit her at her home. She attributed his reluctance to visit her to the fact that he was going through his teenage years and would rather ‘be with his mates’. 5.6 Mother said that Mario had a good relationship with his maternal grandmother, with whom he would have conversations whilst she was transporting him back and forward to the metro station. Mother said that her mother recalled Mario asking her questions about the ‘afterlife’ after his paternal grandfather died in November 2017. 5.7 The death of his paternal grandfather was one of two bereavements Mario experienced in 2017. As well as being present alongside other family members when his paternal grandfather died, Mario also arrived just after his nephew (sibling 2’s son) died shortly after birth in May 2017. His parents said that the death of his nephew ‘broke Mario’s heart’. They said that after suffering these two bereavements, Mario began questioning ‘why deaths had to happen’. 25 5.8 Mother disclosed that both Mario’s elder siblings were aware that he was self-harming by cutting his arms. Mother added that sibling 1 had seen him cutting his arm in the bathroom at father’s house. This was later confirmed by sibling 1 who said she had seen Mario cutting his wrist with a razor blade around the beginning of 2017. Mother said that she had been unaware of Mario self-harming. Father said that sibling 1 had had told him that Mario had cut his arms but that when he (father) spoke to Mario about it, he denied that he had cut himself and let his father check his arms for marks on that occasion. Father said he monitored the situation thereafter but never saw any marks on Mario. Maternal grandmother saw marks on Mario’s wrist in the month before he died which she suspected were self-harm cuts. (Mario did not disclose self-harming behaviour to any practitioner although several fellow pupils interviewed by the police after Mario’s death said that they were aware that he cut his arms). 5.9 Father said that Mario’s secondary school had provided him with learning support as a result of his dyslexia but that this had stopped at the end of year 9. He said he was expecting the support to resume in January or February 2018. He said he didn’t know why the support had been interrupted but had assumed it was something to do with resources (See Paragraph 6.41 for the school explanation that Mario no longer met the criteria for Special Educational Needs (SEN) support. The school adds that Mario had not been diagnosed with dyslexia). 5.10 Mario’s parents said that he enjoyed art and had expressed an interest in a career in animation. He spent a lot of time drawing at the kitchen table at home. Father added that Mario began drawing the characters from the Doki Doki computer game although he (father) didn’t know anything about the game or the characters until after Mario’s death. Both parents expressed concern about the themes of the game having a dangerous impact on children who played the game. Mother said she believed Mario purchased the Doki Doki game soon after it became commercially available in September 2017. 5.11 When asked if they had any other concerns about Mario, mother said that he had had a ‘self-image problem’ in that he didn’t like the way he looked and 26 often said he was ugly. She added that Mario had felt this way for a number of years. Both mother and father said that Mario was thin, with ‘no fat on him’, despite ‘eating like a horse’. Father said he took him to see the GP twice about this issue and that blood tests were taken which were found to be normal. The GP was reassuring and said that Mario was thin because of a growth spurt. His parents said he was 6’ 1” in height at the time of his death. Mother said that she felt that it was not unusual for teenagers to worry about their self-image and had expected Mario to pass through this phase in his life. 5.12 Father and mother added that Mario had a fear of going into shops on his own and was very reluctant to do so. His mother attributed this to ‘social anxiety’. 5.13 Both parents said that they felt let down by Mario’s school and the counselling service to which the school referred him. They said that his school had not told them about Mario talking about suicide and had not told them that they had referred him to Relateen. Father said he was the parent with whom Mario’s school had contact and would have expected them to have told him about the above issues (The school acknowledges that father was not informed about the conversation in which Mario mentioned suicide, but state that he was advised of Mario’s referral to counselling – see Paragraph 6.42). His parents were also concerned that Mario’s attempts to access suicide related websites on school computers had not led to immediate action (See Paragraphs 6.50 to 6.53. The school adds that ‘immediate action’ was taken to block Mario’s access to the websites). Mother added that she didn’t really have a relationship with Mario’s school as all of his siblings had attended a different secondary school. 5.14 Maternal grandmother said that she saw Mario most days during school term time as she would often drive him to the Metro station to catch the tram to school. She would often pick him up at the end of the school day. If mother was visiting maternal grandmother’s house with child 5, Mario would sometimes call in and spend time with them at the end of the school day. 5.15 Maternal grandmother said that in her opinion Mario was in fear of father. He worried about doing anything which would get him into trouble with father. 27 She said that Mario was even worried about letting father know that she (maternal grandmother) had given him a lift to or from school in case that angered father. She said that father discouraged Mario from visiting mother and also restricted him from seeing his siblings. She felt he did this in order to continue to exercise some control over mother. Maternal grandmother said that Mario had told her that father had said he would kill himself if Mario left him to return to mother. (Father said that he never discouraged Mario from visiting mother’s house, adding that sometimes Mario did not enjoy his visits to mother). 5.16 She said she became very worried about Mario’s weight loss when she saw him in September 2017. This was straight after the school summer holidays during which she had seen less of him. She says she was shocked at how much weight he had lost. He seemed to have had a growth spurt but this could not account for how thin Mario appeared. Maternal grandmother expressed her concerns to other family members but added that father wasn’t very good at taking Mario to see his GP. She mentioned an example of Mario having a persistent nose bleed which she said he needed to see his GP about. She says she kept asking Mario if his father had arranged a GP appointment yet and Mario said he hadn’t. 5.17 Maternal grandmother said she was aware that Mario often missed out on breakfast and so she would carry some breakfast bars in her car so that he could eat them whilst she drove him to the Metro station. She added that he would sometimes bring home the sandwiches he had taken to school for lunch. He would ask her to get rid of the sandwiches for him before he left her house to go home to his father at the end of the school day. She said that she would ask him why he hadn’t eaten his sandwiches and he replied that he didn’t like them. When she said that he should tell his father so father could make him sandwiches he liked, Mario said that doing this would only get him in trouble. (Father responded to these comments by saying that Mario chose not to eat breakfast from time to time and had sometimes told father he had eaten breakfast when this was not the case. Father said he also became aware that Mario had thrown away his lunchtime sandwiches. He added that Mario had asked for school 28 dinners instead but father had told him that he could not afford to pay for them. Father said he took Mario to see his GP about weight loss and that this had been ‘all sorted’. (See Paragraph 4.35)) 5.18 During the month before his death, maternal grandmother noticed a number of cuts on Mario’s wrist. She said that one of the cuts looked quite deep. She said that Mario had been trying to cover up the cuts with the sleeve of his school blazer. When she asked Mario about the cuts he said that they had been accidentally caused by a bush. She said that she didn’t think this explanation was true. 5.19 Sibling 1 briefly contributed to this review. She said that father was physically abusive to Mario and that she had seen him hit Mario and sibling 2. She added that when Mario and sibling 2 were living with father, they had told her that father had told them to say nothing to the social workers who were working with them at that time. 5.20 She also said that she had become very worried that Mario had developed an eating disorder and that this had prompted her to contact the MASH in March 2017 (Paragraph 4.53). 5.21 Mother and father were given the opportunity to read and comment on the final draft of this report. Mother read the report and said she was satisfied with the report and its findings. The only comment she made was that she had worried about how sibling 2 and Mario would get on in their father’s care. She said she based her worry on how strict father had been with the children prior to the divorce and the threats of violence he had made against her which had led to his referrals to MARAC. She said that she had raised her concerns with a social worker but that no action had been taken. Father separately read the report and also said he was satisfied with the report and the findings. He commented that he felt that ‘physical abuse’ had been over-emphasised. He acknowledged that he sometimes lost his temper with Mario and ‘clipped him around the ear’ and slapped him. However, he said that Mario was ‘never beaten’. 29 6.0 Analysis 6.1 In this section of the report the terms of reference questions for this SCR will be considered in turn. How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario? 6.2 During May 2015 Mario commented in class that his holiday destination would be ‘to go to Hell’. His teacher also overheard a discussion between Mario and a peer in which committing suicide was referred to (Paragraph 4.12). From discussions with Mario, teaching staff formed the view that Mario was not saying he intended to commit suicide but was experiencing low mood as a result of an accumulation of issues including feelings of failure, getting into trouble at school and fear of how his father would respond to the news that he had been damaging computer keyboards and a monitor at school. The school decided to offer Mario pastoral support in the hope that a trusting relationship would develop which could allow Mario to be more forthcoming about his worries. Given, the school’s lack of awareness of the wider family issues which may have been affecting Mario at that time, the school’s response was appropriate, although Mario’s father is critical of the decision not to inform him that Mario had discussed suicide (Paragraph 5.13). The school had a telephone conversation with father in response to this incident in which some of Mario’s difficulties at school were discussed. It would have been helpful if that discussion had included reference to Mario’s comments about suicide. 6.3 In March and September 2016 Mario made separate disclosures of physical abuse by father to members of school staff. Both disclosures appeared to have been prompted by Mario’s fear of father’s reaction to him getting into trouble at school. In the first disclosure Mario alleged that his father had hit and slapped him in the past (Paragraph 4.16). This prompted dialogue between the school and the MASH which ultimately led to the matter being resolved by Mario’s head of year speaking with father over the telephone. The positive tone of this conversation 30 gave the school confidence that Mario could be allowed to return home at the end of the school day and a follow up conversation with Mario the next day appeared to confirm that he and his father had had a positive exchange in which father had said he would try and restrain his tendency to ‘go overboard’ in future. However, sharing Mario’s disclosure with the person who was alleged to have abused him, had exposed Mario to the risk of further abuse from father. 6.4 Children’s social care now take the view that the MASH response was not appropriate as Mario’s behaviour had deteriorated in school, he was clearly worried about how his father was going to respond and had stated that he had been hit by father previously. Consideration should have been given to initiating child protection enquiries under Section 47 of the Children Act. The MASH had a much fuller knowledge of wider family concerns than the school at this point, although Mario did begin to disclose some of these concerns to his head of year at this time. The school was unaware that father had previously been referred to MARAC for domestic abuse (Paragraph 4.3) and it is unclear whether MASH took this fact into account when advising the school how to respond. 6.5 The second disclosure of physical abuse in September 2016 (Paragraph 4.22) was more serious because on this occasion Mario gave a recent date for the physical abuse and this incident represented an escalation. Father had been advised by the school following the March 2016 incident and had apparently committed to adjusting his behaviour towards Mario. Yet six months later Mario alleged he had been assaulted by father again. However, the school decided that as this incident was similar to the previous incident, the approach they adopted to the first incident would be followed. No contact was made with the MASH on this occasion but the approach which had emerged from the discussion between the school and the MASH in respect of the March 2016 incident was replicated. 6.6 It seems clear that the approach adopted by the MASH in March 2016 de-escalated the response to Mario’s first disclosure of physical abuse and strongly influenced the school’s response to his second disclosure. The possibility that the MASH may be in possession of relevant information about Mario and/or his wider family which could have had a bearing on deciding how to respond to Mario’s 31 second disclosure did not apparently occur to the school. Nor did the school apparently give sufficient weight to the information Mario had shared with them about his family circumstances when he made his first disclosure of physical abuse in March 2016 (see Paragraph 4.15). 6.7 On 17th November 2016 Mario disclosed to his Relateen counsellor his suspicion that mother had been assaulted by a former partner and not been truthful about the cause of an injury Mario had noticed. Mario expressed particular concern about the impact of child 5 witnessing domestic violence involving mother and her ex-partner. After consulting with her supervisor, the counsellor discussed the disclosure with Mario’s head of year. Relateen state that this discussion took place by 24th November 2016 whilst the school state that the discussion did not take place until 23rd January 2017 (Paragraph 4.32). Whichever version is correct, there was an exceedingly long delay in alerting the MASH to the concerns raised by Mario. The concerns were not put in writing by Relateen until 26th January 2017 (Paragraph 4.44). 6.8 It appears that the focus of Relateen may have been primarily on the impact of the domestic abuse on Mario and that the urgency of making a safeguarding referral in respect of child 5 (then aged two) received less emphasis. At the time that Mario made the disclosure to his counsellor in November 2016 agencies were aware of the domestic abuse and siblings 2, 3 and child 5 had been referred to ICPC and Section 47 enquiries initiated (Paragraph 4.27). Mario had not been considered by partner agencies to be at risk. A prompt referral at that time may have drawn Mario and the potential impact of the domestic abuse on him to the attention of agencies, although when Mario’s disclosure was belatedly referred to MASH in January 2017, it did not achieve the effect of raising the awareness of agencies to the potential impact of domestic abuse in mother’s household on Mario (Paragraph 4.44). 6.9 A further issue Mario disclosed to his counsellor was self-harm by a friend (Paragraph 4.60). This again raised concern about their safeguarding practice in that some emphasis was placed on Mario consenting to the sharing of information relating to the pupil with school. And the suggestion that Mario might 32 be asked to encourage the other pupil to report self-harm did not appear to have much to commend it. The pupil needed professional adult intervention and there was the issue of how further exposure to his friend’s distress might affect Mario. 6.10 In March 2017 a concern was expressed on behalf of Mario by sibling 1 (Paragraph 4.53) who reported to the MASH that Mario might be anorexic. Enquiries were made with the school, Mario’s school health practitioner and father. No evidence was identified to substantiate sibling 1’s concerns about her brother. Father was advised to take Mario to see his GP and responded by saying that he had already done this and was planning a follow up appointment before Easter. He added that Mario was experiencing a growth spurt. Father had taken Mario to see his GP in December 2016 (Paragraph 4.35) when he told the GP that his son had lost weight recently. Blood tests were ‘essentially normal’ but there is no evidence that the blood tests were repeated after 4-6 weeks as planned nor is there evidence that Mario’s weight was monitored subsequently. Father did not take Mario to see his GP ‘before Easter’ 2017. He did not take Mario to see his GP until November 2017 (Paragraph 4.71) when anorexia was not raised as an issue. On that occasion blood tests revealed nothing abnormal. 6.11 The disclosure from sibling 1 did not result in enquiries being made with Mario’s GP which was a missed opportunity. The MASH did contact Mario’s school health practitioner who invited him to a school health drop in which Mario did not attend and, in respect of which, no follow up action was taken. This was a missed opportunity for the school health practitioner to proactively engage with Mario. To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family? 6.12 Either of Mario’s disclosures of physical abuse could have led to an assessment. Had any assessment been carried out it seems likely to have shed light on the range of concerns affecting his wider family which may have been impacting on Mario’s health and wellbeing. Given the missed opportunities to carry out assessments of Mario, the challenge for agencies in contact with his wider family was to fully consider the impact of these concerns on Mario. 33 6.13 There were several occasions when risks to Mario were considered by practitioners. Mario was linked to the allegation of domestic abuse mother made against partner 2 in April 2016 (Paragraph 4.18) but was not included in the CAFA completed by children’s social care in response to this incident (Paragraph 4.20). The police placed markers on the addresses of mother, maternal grandmother and father after mother’s domestic abuse allegations against partner 2 in October 2016 (Paragraph 4.40). Mario was identified as a sibling in the school nurse report prepared for the ICPC in January 2017 and Mario was also noted to be a ‘significant other’ in the police record of the same meeting. (Paragraph 4.40) He was included in the list of sibling’s concern was expressed about, as a result of the relationship between sibling 1 and partner A (Paragraph 4.59). 6.14 On other occasions, risks to Mario were not considered. He was not linked to the domestic abuse incident involving mother and partner 2 reported to the police in May 2016 (Paragraph 4.21) nor was he initially linked to the domestic abuse incident which took place in Lancashire in October 2016 (Paragraph 4.26) or considered as part of the Section 47 enquiries which followed. Mario was not linked to further domestic abuse incidents involving mother and partner 2 in February 2017 (Paragraph 4.49) and May 2017 (Paragraph 4.61). 6.15 However, when Mario was linked to concerns affecting mother and his siblings there was an assumption that he had very limited contact with mother (Paragraphs 4.58 and 4.69) or the level of contact was not enquired into. Agencies generally appeared to take an unhelpfully narrow view of what constituted ‘contact’ between mother and Mario, focusing on the frequency of physical visits to her address. In her contribution to this review, mother has acknowledged her difficulty in encouraging Mario to visit her address (Paragraph 5.5) but says she saw him regularly at his maternal grandmother’s address (Paragraph 5.4). Additionally, it seems clear that Mario enjoyed substantial contact with some of his siblings through skype and playing computer games online (Paragraph 5.3). It is also clear that he was sensitive to concerns affecting 34 the lives of his siblings from the disclosures he made to his Relateen counsellor in respect of child 5 (Paragraph 4.31). 6.16 Another factor in the risks to Mario being overlooked or downplayed was the judgement that because he was not resident with mother, he was at no immediate risk of harm. This was a valid judgement to make. It was right for the primary focus to be on the siblings who were resident with mother and therefore at immediate risk of emotional abuse arising from domestic abuse. However, having excluded Mario from risk considerations because the risk to him was not immediate, Mario remained excluded when agencies moved beyond consideration of the immediate risks. In the final two years of Mario’s life a considerable number of non-immediate risks were beginning to accumulate which did not become visible to practitioners. 6.17 Mario’s needs may have received greater attention had father been involved in child protection meetings in respect of Mario’s siblings. He retained parental responsibility for sibling 2 and Mario but did not appear to have been formally invited to participate in decision making in respect of them. 6.18 Health visiting, school nursing and Healthy Young Minds had a varying amount of contact with Mario’s siblings. Mario was evidenced in all his siblings’ health records as part of the family composition but there was little enquiry into his wellbeing. Once again, the fact that he was living at a different address appears to have diminished professional curiosity in respect of Mario. 6.19 Mario had a different school health practitioner to his siblings. Therefore, whist the school health practitioner for his siblings was aware of the challenges the children were facing when living at mother’s address, Mario’s school health practitioner was not privy to that information. Mario is clearly evident in the genogram which forms part of the (school health practitioner) safeguarding supervision documentation in respect of his siblings but the impact on Mario of the challenges faced by his siblings was not considered in safeguarding supervision. 35 To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response? 6.20 A 2012 children’s social care assessment identified that siblings 1, 2, 3 and Mario had all been emotionally affected by their exposure to historic domestic abuse and the ongoing conflict between mother and father. Exposure to domestic abuse can causes serious physical and psychological harm to children (1). However, research studies tend to focus on children living in a household in which domestic abuse is present. Mario and his siblings were exposed to domestic abuse between mother and father but Mario was no longer a member of the household during the period in which there was domestic abuse between partner 2 and mother. Physical distance from the household in which the domestic abuse was taking place may have reduced the impact on Mario although he benefitted less from the potential protective factor of immediate sibling support. 6.21 After moving to live with father, the police only intermittently recorded Mario as an affected sibling in respect of domestic incidents involving mother and partner 2. The omission of Mario may have been influenced by the wording of DASH guidance and the phrasing of the questions contained within the DASH risk assessment. The safelives guidance on DASH completion refers to the ‘presence’ of children whilst additional questions which GMP has added to the DASH refer to children who ‘live in the household’. Whilst this seems appropriate to enable immediate risks to be identified, there is a risk that the DASH wording diverts attention away from children not present or living within the household. 6.22 A direct impact of omitting Mario from referrals arising from domestic abuse incidents is that no information was sought from Mario’s school health practitioner. 6.23 When Mario moved to live with father and sibling 2 in March 2013 there is no indication that this generated any professional concern arising from father’s prior referral to MARAC as a perpetrator of domestic abuse in November 2012 and his subsequent such referral in September 2013. From September 2014 Mario was the only sibling living with father. Mario’s maternal grandmother has 36 advised this review that in her opinion, father limited Mario’s access to mother and his siblings. Mario voiced fear of father’s reaction when he got into trouble at school and his maternal grandmother also expressed the view that Mario was in fear of father. It seems possible that Mario may have exchanged one household in which he experienced a difficult relationship with mother’s then partner for a household in which he may have been in fear of, or experienced, physical abuse. To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario? 6.24 As Mario accessed universal services only from the point at which his case was closed to children’s social care in April 2014, the agency which provided the majority of support to Mario was the secondary school which he attended from September 2014 until his death. 6.25 When Mario transferred to his secondary school in September 2014 his transfer documentation included no information about prior safeguarding concerns and stated that no agencies were currently engaged with him. However, Mario’s primary school head teacher shared limited information about his history, specifically that he was living with his father and had been removed from a child protection plan whilst his siblings who were living with mother remained on a child protection plan (Paragraph 4.8). (This wasn’t completely accurate information as sibling 2’s case had also been closed to children’s social care in April 2014). 6.26 It is not known how much further information Mario’s primary school was aware of. Mario’s case had been closed by children’s social care five months prior to his transfer to secondary school so it would have been correct to say that there were no agencies involved with him at the time of his transfer. His parents were under no obligation to share information about the family’s contact with agencies with Mario’s primary or secondary school. 6.27 However, as Mario’s siblings attended a different secondary school, were known to a different school health practitioner, and Mario’s school had no contact with mother, the concerns in respect of Mario’s wider family were largely 37 unknown to Mario’s school until March 2016. From that point on, his school’s awareness of concerns relating to Mario’s wider family gradually increased. When Mario made his first disclosure of physical abuse by his father in March 2016 (Paragraph 4.16) he told his head of year that he had three siblings who lived with mother, that he worried about mother, that her partner (partner 2) had been ‘kicked out’, that the partner had ‘smashed her car up’, that his mother and father had split up 3 or 4 years previously ‘due to fighting’ and that ‘social services had been involved’. 6.28 Mario’s school acquired further insight into issues affecting Mario in January 2017 when Relateen shared their report about the disclosure made to his counsellor in November 2016 (Paragraph 4.31). At this point the school was advised that Mario maintained contact with his mother who was said to have had a series of abusive relationships. Mario had noticed that his mother had a black eye which she had claimed had been caused by falling out of bed. He had heard father and his maternal grandmother discussing the domestic abuse. Mario believed that ‘when things got bad’ mother and child 5 went to stay with maternal grandmother. Mario was concerned that child 5, who was two years old, was witnessing domestic violence. 6.29 Although the school had little information formally shared with them, they had become informally aware of many of the concerns affecting Mario by January 2017 and had also dealt with Mario’s two disclosures of physical abuse by his father. The school had referred Mario to Relateen but there is no indication that all the information they had accumulated about the concerns affecting Mario were brought together, examined as a whole and informed action taken to support him thereafter. Nor was the information obtained about Mario by the school shared with the Relateen counsellor. The formal opportunity for the school to share information with Relateen is via the referral form but the referral form in respect of Mario contained only a very brief justification for the referral. The school has advised this review that opportunities for informal sharing of information about pupils receiving counselling are limited by workload pressures. 38 6.30 The school appears to have shared no information about Mario with his school health practitioner. To what extent were agency interventions with Mario informed by relevant prior concerns? 6.31 Prior allegations of domestic abuse against father were unknown to Mario’s school when he made his two disclosures of physical abuse by father. When the school discussed Mario’s first disclosure of physical abuse with the MASH, it is unclear whether the MASH considered prior allegations of domestic abuse against father but there is no indication that they shared these with the school. To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family? 6.32 Since 2008, when the Cabinet Office published Think Family, a literature review of whole family approaches (2), a more holistic understanding of people’s lives and more joined-up approaches to delivering services – especially for those families who are experiencing multiple challenges - has been encouraged. The Think Family approach places an emphasis on ensuring that the support provided by children’s, adults’ and family services is well co-ordinated and focused on the problems affecting the whole family. 6.33 It follows from this that when helping individual family members, it is important to take wider family needs into account. In respect of Mario this was often not the case. He was frequently seen as a child who lived with his father the nature of whose contact with mother and his other siblings was either not considered or insufficiently explored. This is a key area of learning which emerges from this review. 6.34 The question of whether practitioners should have considered making an adult safeguarding referral in respect of mother was discussed by the SCR Panel established to oversee this review. Mother was referred to MARAC as a victim of domestic abuse on several occasions. This SCR has insufficient information about any care and support needs mother may have had to make an informed 39 judgement about what might have been the outcome of any adult safeguarding referral in respect of mother. 6.35 To better inform this SCR, a learning event was arranged to which practitioners who had had contact with Mario and his family were invited. This was a well attended event at which practitioners provided valuable insights. However, awareness of the Think Family agenda appeared undeveloped. To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood? 6.36 The decision to refer Mario to Relateen provided Mario with an opportunity to discuss issues of concern to him confidentially in a supportive environment. A degree of trust appeared to be built up because he began to make disclosures about issues which were worrying him from an early stage. The first disclosure related to his concern that child 5 was being adversely affected by the domestic violence and abuse he suspected a former partner had inflicted on mother. This was the clearest possible indication that Mario was profoundly affected by events which were taking place in mother’s household. 6.37 The manner in which this disclosure was responded to in safeguarding terms will be considered later in this report, but Mario appeared to be communicating something of great importance; that despite the fact that he lived separately from mother and his siblings, events which took place in their household had a substantial effect on Mario’s emotional health and wellbeing. 6.38 Mario’s two disclosures about his fears of father were not raised in the counselling meetings but came to light after he got into trouble at school and became worried about how father would react. The first of these disclosures led directly to the referral to Relateen and the counselling began around two months after the second disclosure. However, the opportunity to further explore Mario’s disclosures about father in the counselling meetings was not taken because there is no indication that the school shared this information with Relateen. 6.39 It could also have been of value to further explore Mario’s damaging of school computer equipment in the counselling meetings as behaviour is a means 40 of communication. Again, information about the computer damage does not appear to have been shared with Relateen. 6.40 The school noticed a reduction in what were considered to be signs of anxiety in Mario, such as ‘doodling’ ‘fiddling’ and ‘picking the skin on his fingers’. Mentoring support, the referral to Relateen and being provided with blu tac to ‘fiddle with’ were all believed to have contributed to progress in this area. 6.41 The school has advised the review that Mario was on the Special Educational Needs (SEN) register in respect of ‘learning difficulties’. He was supported by a Special Learning Difficulties teacher in respect of literacy skills for a period but this ceased when his literacy skills improved to the point at which he no longer met the criterial for SEN support. He continued to receive learning mentor support to assist him to make greater progress in some subject areas. 6.42 Mario’s school attendance was of concern throughout his time at secondary school. There was a period of improvement in 2014-15 following his referral to the school attendance team. However, Mario’s overall attendance remained around 86%. The school regards any attendance under 96% to be ‘poor’. It is unclear whether any underlying reasons for unsatisfactory school attendance emerged from the intervention of the school attendance team. To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family. 6.43 There were some difficulties engaging with Mario and his family in earlier years (Paragraph 4.6). Mario’s school experienced some issues in engaging with father at times (Paragraph 4.11) and never had any contact with mother. 6.44 As previously stated father says that he was unaware of Mario’s referral to Relateen. School records indicate otherwise but are not conclusive on this point. The possibility of inviting father to attend a counselling meeting was explored for a time. When considering this possibility as an option, it seems likely that his Relateen counsellor was unaware of Mario’s earlier allegations of physical abuse by father. 41 6.45 The decision to end Mario’s counselling with Relateen appears to have been influenced in part by the end of the school year. Given that Relateen provide an in-school counselling service one can understand that the six weeks school holiday period would represent a disruption in a regular programme of meetings but Mario had made a number of disclosures during the counselling meetings, had demonstrated low mood throughout the period in counselling, had just experienced a bereavement (Paragraph 4.63 and 4.65) and had been involved in homophobic bullying two days prior to the final counselling meeting. Although Mario said that he had taken something positive from his experience of bereavement, it might have been prudent to re-engage with Mario after the school holidays to see whether he needed to continue with counselling. However, the counsellor advised Mario that should he need to return to counselling in the future he could access the service by speaking to his head of year. This review has been advised that demand for in-school counselling services is high and that there is always a waiting list. More urgent referrals to counselling are given higher priority however. 6.46 The Relateen counsellor had been concerned about Mario’s continuing low mood, which had shown no improvement over the period he had participated in counselling. Relateen considered referring Mario to Healthy Young Minds but decided that he did not meet the threshold. Relateen uses a young person’s evaluation system for monitoring mental health and well-being. This evaluation system was introduced by Relateen after a previous SCR and was designed by the Child Outcomes Research Consortium (CORC) and monitors anxiety, depression, self-harm and trauma session by session. Mario was consistently monitored as having no thoughts of self-harm and considered to be in the range of ‘mild to moderate’ difficulties. No referral to his GP appeared to have been considered. To what extent were safeguarding children procedures followed? 6.47 As previously discussed, Mario’s first disclosure in respect of father merited a formal safeguarding response (Paragraph 6.4) and his second disclosure should have been referred to the MASH by his school. 42 6.48 The contact with MASH by sibling 1 on Mario’s behalf resulted in a response which was limited in some respects. No contact was made with Mario’s GP and there was no follow up when Mario did not attend the school drop in offered by the school health practitioner. 6.49 Mario’s disclosure to Relateen about his fears for child 5 was not referred to the MASH for over two months. There is some dispute over when this disclosure was shared with the school by Relateen but the practices of Relateen were not conducive to prompt safeguarding referrals as they made the safeguarding referral through the school rather than directly themselves and a report needed to be prepared by the counsellor’s supervisor before a referral could be made. These practices do not appear to be consistent with effective safeguarding policy. Additionally, in responding to this disclosure Relateen appeared to focus insufficiently on the possibility that the two year old child 5 could be at immediate risk. 6.50 Relateen has advised the review that the reason why any safeguarding referral is made through the school is that the school is likely to have much more information about the pupil and the pupil’s family than a counsellor. Whilst it is likely to be the case that the school will have a fuller picture of the pupil’s needs than the counsellor and the school is likely to have greater familiarity and contact with specialist safeguarding services, in this case the practice of making a safeguarding referral through the school led to an unacceptable delay in making the referral. 6.51 Additionally, Mario’s counsellor appears to have incorrectly advised Mario that no further action was being taken in respect of Mario’s concerns about Child 5 (Paragraph 4.51). It is questionable whether it was appropriate for one potential response to Mario’s disclosure that a friend had self-harmed was for Mario to talk to him (Paragraph 4.60). How effectively was Mario’s suicide related internet use monitored? 6.52 Between 12th and 19th January 2018 Mario attempted to search the internet for suicide related material on school computers (Paragraph 4.72, 4.74 43 and 4.75). It is not known specifically what prompted Mario to attempt these searches. 6.53 The school advises that computer use in class is generally monitored by the teacher using ‘AB Tutor’ which allows the teacher to view all screens in use. If a pupil searches for inappropriate or explicit content, the aforementioned Smoothwall system would redirect the user to a blocked internet page and log the search as a blocked searched term. AB Tutor allows the classroom teacher to monitor the usage of all active screens in the room. However, it does not flag up search content. 6.54 School technical staff can monitor pupil’s internet searches on request from staff in response to any concerns. There was no reason for the school to have been monitoring Mario’s internet searches during that period. At that time there was no system in place to monitor blocked pupil internet searches due to the high volume of blockages taking place. The school has advised the SCR that on one day there were over twelve thousand attempts to access blocked content. 6.55 In March 2018 Smoothwall upgraded the functionality of the school’s system allowing notifications to be made of blocked pupil internet searches in high risk safeguarding categories, including areas such as criminal activity, abuse, adult content, bullying, radicalisation, substance abuse and suicide. Real time alerts are now made to the school safeguarding team in respect of high risk internet searches. Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, Mario. 6.56 The school maintained contact only with father. Mother’s details were not provided to the school and mother made no contact with Mario’s school herself. Although contact was made with father after Mario’s conversation with another pupil about suicide (Paragraph 4.12), Mario’s reference to suicide does not appear to have been disclosed to father at that time. Additionally, father states that he was unaware of Mario’s referral to Relateen. The school referral to 44 Relateen states that father had been informed. Mario’s parents were also concerned that Mario’s internet searches of suicide related websites had not been prevented by the school. As previously stated, the school had a system in place to block access to harmful sites but no system to highlight pupil attempts to access the most concerning websites at that time. Good practice 6.57 This review disclosed a number of examples of good practice: The school head of year managed to elicit significant information about wider family concerns from Mario. The school’s decision to refer Mario to Relateen provided Mario with an opportunity to discuss issues which were worrying him in a supportive and confidential environment. There were several occasions when Mario was linked to concerns affecting the children in mother’s household including the decision to place a police marker on the address where Mario lived with father following domestic abuse concerns arising from mother’s relationship with partner 2. 7.0 Findings and Recommendations 7.1 In order to maximise learning from this SCR it has been necessary to consider some of the difficulties experienced within Mario’s family. No judgement of Mario’s family is intended. All families experience difficulties from time to time. Many families need help and support. The reason it has been necessary to focus on the dynamics of Mario’s family is to highlight the need for practitioners working to support families to consider all children in the family even where one or more siblings may be living elsewhere. Awareness of suicide antecedents 7.2 Key factors in self-harm and suicide in adolescents include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion (an increase in suicidal behaviours through 45 exposure to suicide in one’s family, peer group or through media reports) are also important, with the internet having an important contemporary role (3). 7.3 To his parents and to the practitioners in contact with Mario, his death was completely unexpected. A 2017 University of Manchester study Suicide by children and young people (4) categorised a number of suicides of children and young people as ‘out of the blue’ deaths in that there had been ‘no contact with any services or agencies, no history of self-harm, no indication of suicidal thoughts or intent, and never seen by a GP or at A&E for mental health problems or for self-harm’. 7.4 However, Mario’s apparent suicide was not an ‘out of the blue’ event. On closer inspection, several of the antecedents of suicide in children and young people had been present to an extent in Mario’s case. The University of Manchester study identified the following antecedents of suicide in people under the age of twenty (5): Contact with social care/local authority services Contact with CAMHS (at any time) Self-harm by cutting Psychiatric diagnosis Looked after Child Bereaved Experienced abuse Bullied Self-harm by self-poisoning Contact with Youth Justice/Police (at any time) Excessive alcohol use Illicit drug use No service contact 7.5 In Mario’s case he had been in contact with social care when subject to child protection measures and in subsequent referrals to the MASH; he had been referred to CAMHS some years prior to his death; whilst no practitioner in contact with Mario was aware of any self-harm, sibling 1 noticed that Mario cut himself 46 around a year prior to his death and made father aware of this and Mario’s maternal grandmother noticed cuts to his wrist in the month prior to his death; he suffered two bereavements during the year prior to his death and he experienced emotional abuse as a result of domestic abuse and also experienced physical abuse. 7.6 Additionally, Mario demonstrated consistently low mood during his counselling meetings, was affected by concerns about his mother and siblings, was worried about his body image, was subject to family concerns about anorexia and began to actively explore suicide in the month prior to his death. He had also been playing the Doki Doki computer game during the months prior to his death in which one of the potential endings involves self-harm and suicide. 7.7 Unfortunately, no practitioner in contact with Mario or his family was aware of all of these issues. In general, practitioners viewed Mario in isolation from the concerns about his wider family. Had any assessment of Mario been completed when opportunities arose after his two disclosures of physical abuse and after sibling 1 contacted the MASH to express concerns about anorexia, it may have been possible to better understand the many issues which had begun to impact upon Mario’s emotional health and wellbeing. 7.8 The first recommendation arising from this review is that it would be of benefit to practitioners to have increased awareness of the antecedents of suicide in children and young people in order that their efforts to provide support to children are informed by these antecedents. It is therefore recommended that this SCR is used as a case study to, amongst other things, increase awareness of the antecedents of suicide amongst children and young people. Recommendation 1 That Bury Safeguarding Children Board make use of this SCR as a case study to, amongst other things, increase awareness of the antecedents of suicide amongst children and young people. 47 Dissemination of learning to schools 7.9 Additionally, Mario’s school has identified significant learning from this case which is indicated in their single agency action plan (Single Agency Recommendations are shown in Appendix A). It would be of value to all secondary schools in the local authority area to benefit from Mario’s school’s learning. It is therefore recommended that Bury Safeguarding Children Board ensure that the dissemination of learning from this SCR includes the sharing of Mario’s school’s learning with all secondary schools in the local authority area. Recommendation 2 That Bury Safeguarding Children Board ensure that the dissemination of learning from this SCR includes the sharing of Mario’s school’s learning from the case with all secondary schools in the local authority area. Suicide Prevention 7.10 The government strategy for preventing suicide in England (6) requires each local area to put a suicide prevention plan in place. It is understood that the Bury suicide prevention strategy is nearing completion. Public Health England’s guidance on local suicide prevention planning emphasises the need for the local plan to provide better information and support to those bereaved or affected by suicide (7). The Head Teacher of Mario’s school is very critical of the lack of support the school received from the local authority following Mario’s death. It is therefore recommended that this SCR report is shared with Bury Suicide Prevention Group in order that the learning arising from the SCR can inform local efforts on suicide prevention. Recommendation 3 That Bury Safeguarding Children Board shares this SCR overview report with Bury Suicide Prevention Group in order that the learning arising from the SCR can inform local efforts on suicide prevention including the local action plan. ‘Think Family’ 7.11 Mario’s needs were generally considered in isolation from the concerns affecting his wider family. He was the only one of his siblings who lived with his 48 father following the return to mother of sibling 2. When concerns arose in respect of mother and Mario’s siblings, the potential impact on Mario was often overlooked. When his needs were considered he was not unreasonably perceived to be at no immediate risk, but risks to Mario beyond the immediate were rarely considered. His contact with mother and his siblings went largely unexplored and when it was considered, an unhelpfully narrow view of what constituted contact was taken. Links did not appear to be made between Mario’s disclosures of physical abuse by father and father’s domestic abuse history. 7.12 Many practitioners at the learning event which informed this SCR did not appear to be entirely familiar with the Think Family approach. This approach might well have helped practitioners in contact with Mario and his wider family to have taken a more holistic view of Mario’s needs. It is therefore recommended that Bury Safeguarding Children Board and partners consider how to embed the Think Family approach in the way in which partner agencies work to support families in Bury and consider what systems need to be enhanced or put in place to support practitioners in this. This SCR could be a valuable case study to assist in raising practitioner awareness of Think Family. Recommendation 4 That Bury Safeguarding Children Board and partners consider how to embed the Think Family approach in the manner in which partner agencies work to support families in Bury and consider what systems need to be enhanced or put in place to support practitioners in this. 7.13 Consistent with the Think Family approach, it is also recommended that children and family assessments should include consultation with both parents with parental responsibility. This review has received no indication that father was involved in assessments of the children residing with mother for whom he had parental responsibility. It is also recommended that children and family assessments should consider the needs of siblings even if not resident within the household where concerns have arisen. It is also recommended that MARAC should consider the impact of domestic violence and abuse on all siblings even if not resident in the immediately affected household. 49 Recommendation 5 That Bury Safeguarding Children Board obtain assurance that children and family assessments will include consultation with both parents with parental responsibility. Recommendation 6 That Bury Safeguarding Children Board obtain assurance that children and family assessments will consider the needs of siblings even if not resident within the household where concerns have arisen. Recommendation 7 That Bury Safeguarding Children Board share a copy of this report with the local Community Safety Partnership in order that the latter partnership can obtain assurance that MARAC will consider the impact of domestic violence and abuse on all siblings even if not resident in the immediately affected household. MASH response to disclosure of physical abuse 7.14 When Mario’s school contacted the MASH following his first disclosure of physical abuse by father (Paragraph 4.16), the advice the MASH provided to the school was not consistent with safeguarding children policy and practice and unhelpfully de-escalated the situation. The advice provided by the MASH on this occasion also strongly influenced the school’s unsatisfactory response to Mario’s second disclosure of physical abuse by father (Paragraphs 6.3 – 6.6). Therefore, Bury Safeguarding Children Board may wish to gain assurance that the advice provided to partner agencies by the MASH is consistently sound. Recommendation 8 That Bury Safeguarding Children Board obtains assurance that the advice provided to partner agencies which contact the MASH is consistently sound. Access to harmful websites 7.15 Mario’s attempts to visit suicide related internet websites on school computers in the month prior to his death represented an opportunity to intervene and could conceivably have been a ‘cry for help’ from Mario although 50 he attempted to disguise some of the searches. However, at the time Mario made the internet searches the school had a system for blocking access but no system for flagging up searches of harmful websites. The school has now remedied this by enhancing the functionality of their system (Paragraph 6.55). It is therefore recommended that Bury Safeguarding Children Board obtains assurance about the effectiveness of the additional functionality introduced in Mario’s school, recommends and promotes the introduction of such functionality throughout secondary schools in Bury and gains assurance that secondary schools have a robust process in place to intervene when pupils attempt to access suicide related websites. Recommendation 9 That Bury Safeguarding Children Board obtains assurance about the effectiveness of the additional functionality introduced in Mario’s school, recommends and promotes the introduction of such functionality throughout secondary schools in Bury, including the independent school sector and gains assurance that secondary schools have a robust process in place to intervene when pupils attempt to access suicide related websites. Doki Doki Game 7.16 Concerns have been expressed in Bury and elsewhere about the impact of the Doki Doki game on children who play it. Practitioners in contact with Mario were unaware of his access to the game and would probably have been unaware of the concerns about the game at that time. It is not known whether the Doki Doki game was a factor in Mario’s death. His parents fear that this may have been the case. The Coroner for Bury has taken steps to ensure that concerns about the game have been circulated to practitioners. In view of the absence of evidence of the impact of the game arising from this review, and the evidence that there were many other factors which could have impacted upon Mario’s apparent decision to end his own life, it is not felt appropriate to make a recommendation unless further information comes to light. 51 Information Sharing 7.17 Mario’s school felt that they had insufficient information about the concerns affecting Mario’s wider family to safeguard him effectively. Although some information was passed to them on Mario’s transfer from primary school the formal transition document contained no information about the prior involvement of services with Mario and his family. The school gradually became aware of concerns affecting Mario’s wider family but this SCR identifies a concern about how fully information relevant to safeguarding pupils is shared at the point at which pupils transfer in to secondary schools, from primary school or when moving secondary schools. It is therefore recommended that Bury Safeguarding Children Board seek assurance that information about safeguarding concerns is appropriately shared at the point at which pupils transfer into secondary schools. Recommendation 10 That Bury Safeguarding Children Board seeks assurance that information about safeguarding concerns is appropriately shared at the point at which pupils transfer between schools. Safeguarding policy and practice 7.18 Relateen provide in school counselling for pupils at Mario’s school and other schools. This SCR indicates that Relateen’s safeguarding children policy and practice requires some development to ensure it is consistent with best practice. It is therefore recommended that Bury Safeguarding Children Board obtain assurance from Relateen that their safeguarding policy and practice, supported by staff training, is improved in order to address the learning arising from this SCR. This is a single agency recommendation but Relateen provide a service to a number of schools. (Single Agency) Recommendation 11 That Bury Safeguarding Children Board obtains assurance from Relateen that their safeguarding policy and practice, supported by staff training, has been improved in order to address the learning arising from this SCR. 52 7.19 Relateen would have been better equipped to support Mario had fuller information about the concerns the school had about Mario been shared with Relateen at the time of initial referral and subsequently. It is therefore recommended that Mario’s school consider adding a recommendation to the single agency recommendations to which they have already committed. This additional single agency recommendation would be to improve information sharing with Relateen at the point of initial referral and during the period of counselling provided to the pupil concerned. 7.20 Bury Safeguarding Children Board may also wish to gain an awareness of the counselling services which schools in the local authority area commission for their pupils and obtain assurance that schools are offered guidance on the commissioning of such services. Any guidance offered by the local authority could address issues such as the counselling service’s safeguarding policy, information sharing etc. Recommendation 12 That Bury Safeguarding Children Board gains an awareness of the counselling services which schools in the local authority area commission for their pupils and obtain assurance that schools are offered guidance on the commissioning of such services. References: (1) Retrieved from http://www.safelives.org.uk/sites/default/files/resources/Final%20policy%20report%20In%20plain%20sight%20-%20effective%20help%20for%20children%20exposed%20to%20domestic%20abuse.pdf (2) Morris, K, Hughes, N, Clarke, H, Tew, J, Mason, P, Galvani, S, Lewis, A and Loveless, L (2008) Think family: a literature review of whole family approaches. Cabinet Office Social Exclusion Task Force. (3) Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22726518 53 (4) Retrieved from http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/cyp_2017_report.pdf (5) ibid (6) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/430720/Preventing-Suicide-.pdf (7) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585411/PHE_local_suicide_prevention_planning_practice_resource.pdf Appendix A Single Agency Recommendations Children’s Social Care Social Work assessments should be strengthened to routinely include the “think family” approach. Children should not be seen in isolation. Consideration needs to be given in regards to siblings living at separate addresses when children are made subject to Child Protection plans. The conference should consider children who regularly visit the household and how they will be protected from Domestic Violence and the emotional impact of it. Greater Manchester Police Recording details of strategy discussions prior to Initial Child Protection Case Conference. Consider the impact of DA on children who are not present at the incident or who do not reside at the address on a permanent basis but who may visit frequently. 54 Pennine Care NHS Foundation Trust (school health practitioners) To support PCFT practitioners to adopt a ‘think family’ approach when working with families where siblings are living in different addresses and attending different schools. To ensure PCFT health visiting and school health documentation includes enquiry about contact with siblings who are living in different households is considered and evidenced with records to enable a comprehensive risk assessment and support being put in place for children and there are robust information sharing pathways between different PCFT practitioners working with siblings, To ensure PCFT Safeguarding Supervision documentation identified siblings living at different addresses are included in the process. To ensure the PCFT request for health information for MARAC Pathway includes previous requests are considered in the response so each request is not considered in isolation. To ensure the PCFT MASH request for health information pathway is robust particularly where there has been an allegation by a child. To ensure PCFT safeguarding supervision documentation to ensure siblings living at a different addresses are included in the process. Relationship Hub To incorporate questions about video games or suicide forums as part of our practice. To arrange a continuous professional development meeting with practitioners to look at issues around: - liaison with school staff; - requesting written feedback from the school following a referral to external agencies as to action taken - for that written information to be shared with counsellors 55 School IT systems to include real time alerts when pupils access inappropriate material. At least two points of contact for each pupil on management information system. Telephone MASH when any disclosure made by a pupil. Improve safeguarding record keeping to enable a full chronology to be viewed when concerns arise. Improved information about pupil’s family circumstances on transition to the school. Schools to have consistency in the pastoral system staffing (Head of Year to remain with their year group as they move through school where possible). Safeguarding policies to include specific guidance on expectations regarding self-harm. Schools to ensure access to inappropriate games is blocked where possible. Improved communication between agencies. Social Housing Provider Provider should obtain/record details of any children not living within the tenancy household to enable comprehensive data sharing when appropriate. Provider should ensure the voice of the child is considered when completing a Sanctuary Safety Plan. Appendix B Process by which SCR completed and membership of the SCR Panel. An SCR Panel of senior managers from partner agencies was established to oversee the SCR which was chaired by the independent lead reviewer. The membership of the panel was as follows: Strategic Lead, Children’s Social Care. 56 Head of Safeguarding and Designated Nurse, Bury Clinical Commissioning Group. Detective Sergeant, Greater Manchester Police. Lead Officer, Early Years Service. Head Teacher, Mario’s Secondary School. Designated Teacher Safeguarding Children, Mario’s Secondary School. Named Nurse for Safeguarding, Pennine Care NHS Foundation Trust Manager, the Relationship Hub Consultant in Public Health Strategic Lead, Education Manager, Social Housing Provider Senior Administrative Support Worker, Bury Safeguarding Children Board David Mellor, Independent Lead Reviewer It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports including chronologies which described and analysed relevant contacts with Mario and his family were completed by the following agencies: Bury Children’s Services Secondary School attended by Mario The Relationship Hub Pennine Care NHS Foundation Trust Greater Manchester Police Social Housing Provider 57 Additional reports were also provided by Bury NHS Clinical Commissioning Group and Lancashire Constabulary. The Coroner also shared information gathered by the Coroner’s Officer which was relevant to the SCR. The SCR Panel analysed the chronologies and identified issues to explore with practitioners and managers at the learning event facilitated by the lead reviewer. This event was well attended by representatives of the various disciplines involved in this case. The lead reviewer then developed a draft report which reflected the chronologies and the contributions of practitioners and managers who had attended the learning event. With the assistance of the SCR Panel, the report was further developed into a final version and presented to Bury Safeguarding Children Board. Mario’s mother, father, maternal grandmother and, to a limited extent, sibling 1 contributed to this review and were also provided with an opportunity to read and comment on the final draft of this SCR overview report. |
NC049440 | Death of a 3-year-old child, from an asthma attack. Child K1 had been diagnosed with brittle asthma and was on a child protection plan for neglect. Child K1 was living with their father and paternal grandmother who was the main carer at the time of death. Child K1's mother was suffering from depression and was unable to care for Child K1. Child K1's father was known to youth offending services, CAMHS and Connexions, and had a history of depression. Child K1 had had many health appointments related to asthma and had been admitted to hospital 9 times between 2013 and 2015 for asthma attacks. Learning includes: professionals need to take into account safeguarding concerns such as the impact of smoking and home environment; health professionals need to ensure they have a good understanding around the concept good enough care for a child with a chronic illness; consider the father's role in caring for a child; involving the housing provider in child protection meetings where there are rent arrears and neglect. Recommendations include: lead health professionals to be identified for all children with a chronic health problem with clear communication systems in place for information sharing. Uses a systems approach based on the Manchester methodology.
| Title: Child K1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Anne Morgan Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD K1 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14th December 2017 INDEPENDENT LEAD REVIEWER: Anne Morgan July 2017 MSCB Child K1 SCR Page i Contents 1.0 INTRODUCTION .................................................................................................................... 1 2.0 RATIONALE FOR CARRYING OUT A SCR ............................................................................... 1 3.0 REVIEW PROCESS ................................................................................................................. 1 4.0 CHILDHOOD ASTHMA .......................................................................................................... 3 5.0 CASE SUMMARY ................................................................................................................... 7 6.0 ANALYSIS OF PRACTICE ...................................................................................................... 14 7.0 FINDINGS ............................................................................................................................ 20 8.0 ADDITIONAL LEARNING ..................................................................................................... 23 9.0 WERE THERE ANY AREAS OF GOOD PRACTICE? ................................................................ 25 10.0 RECOMMENDATIONS THE BOARD MAY WANT TO CONSIDER ........................................ 25 11.0 CONCLUSION .................................................................................................................... 26 12.0 APPENDICES ..................................................................................................................... 27 MSCB Child K1 SCR Page 1 of 27 1.0 INTRODUCTION 1.1 Child K1 was three years old at the time of death, following an asthma attack on the 21st June 2016. At the time, Child K1 had been diagnosed with brittle asthma and was on a Child Protection plan for neglect. Child K1 was living with father, and paternal grandmother who was their main carer at the time of death. 2.0 RATIONALE FOR CARRYING OUT A SCR 2.1 Two meetings in July and August 2016 of Manchester Safeguarding Children Board’s Serious Case Review (SCR) Panel were held to discuss the care provided to Child K1 before death in June 2016. A decision was made to recommend carrying out a SCR. This decision was ratified by the Independent Chair of Manchester Safeguarding Children Board (MSCB) in August 2016. This decision was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)1, which refers to Regulation 5 of the LSCB Regulations 2006. Regulation 5 (2) states that; “a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either; (b)(i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the… (agencies)… have worked together to safeguard the child”. “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii) must always trigger an SCR”. Child K1’s death met regulation 5(2) (a), abuse is suspected, and 5(2)(b)(i), the child has died 2.2 Following this decision an SCR was commissioned. There was a discussion about proportionality and the focus of the review. The panel agreed that the terms of reference and scope should concentrate on the impact of neglect on a child with asthma. The review is therefore focusing on that area but does also consider professional practice more generally. 3.0 REVIEW PROCESS 3.1 Scope and focus of the Serious Case Review 3.1.1. The SCR panel identified the following key areas to be explored as part of the review. They were: To gain an improved knowledge of neglect and the role of smoking and poor home conditions (dirt, clutter) in exacerbating illnesses such as asthma, thereby increasing the risks of illness and death. 1 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75: DfE MSCB Child K1 SCR Page 2 of 27 To gain an improved understanding of current research and findings around smoking and environmental factors and their effect. To gain an improved knowledge of the management of cases where neglect factors may impact on chronic health conditions. To gain a better understanding around the concept of when care is/is not good enough for the needs of a specific child and how this should inform case planning. 3.2 Time period to be covered 3.2.1 The review covers the period of time from the 1st January 2016 to June 30th 2016, but has used what was known of Child K1’s history prior to that time to inform review findings where appropriate. 3.3. Organisations involved in the Review 3.3.1 It was agreed that the following agencies would be required to contribute to the serious case review: Children’s Social Care New Charter Housing Families First GP Practice Nursery Early Help Alder Hey Children’s Hospital NHS Trust (chronology for prior to period under review) North West Ambulance Service Central Manchester University Hospital NHS Foundation NHS Trust Acute and Community Services Pennine Acute NHS Trust Greater Manchester Police. 3.4 Methodology 3.4.1 Chapter 4 of Working Together2 identifies the purpose of a Serious Case Review and sets out the principles to be used for learning and improvement. It identifies that Serious Case Reviews and other case reviews should be conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; 2 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of Children March 2015 children p75 DfE MSCB Child K1 SCR Page 3 of 27 is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. Working Together also identifies the need for LSCBs to use a systems methodology in carrying out such reviews3 which should be ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’... 3.4.2 This review was carried out in line with those principles and is proportionate to the case under review. The model used was a systems approach based on the Manchester methodology. Ms Anne Morgan was appointed to be the Independent author and chair of the review. Anne Morgan is an Independent Safeguarding Children Consultant with a background in paediatric quality assurance and safeguarding. She has extensive experience in carrying out reviews and is trained in the use of a systems approach. She was supported by a review team made up of senior Safeguarding Children Board representatives (Appendix 1) none of whom had any involvement in the case. 3.4.3 A chronology was produced by the agencies involved and the professionals working with the family identified. Professionals working with the family at the time under review were involved through practitioner groups and email correspondence where that was not possible. A separate meeting was held to gain background information from CAMHS. The final meeting with practitioners was used as an opportunity for them to review the findings and consider the recommendations. 3.4.4 The author and the Safeguarding Children Board Business Manager met Child K1’s paternal grandmother and mother to help inform the review process and their input has been incorporated into the final report. Child K1’s father did not feel able to contribute at that time. 4.0 CHILDHOOD ASTHMA 4.1 To understand the impact of asthma and professional concerns relating to the care provided to Child K1 it is necessary to understand what asthma is and what the expected management of asthma looks like. 4.2 Asthma 4.2.1 Asthma is a common chronic respiratory disease that can affect people of all ages which can start in childhood. Symptoms of asthma include a wheeze, breathlessness, chest tightness and cough. Symptoms can vary between one child and another and if left untreated it can be life threatening. Symptoms are usually episodic and may vary over time. 4.2.1. Asthma is triggered by many factors, including: viral infections; exercise; substances (called allergens) that cause allergic reactions, either aero-allergens (such as house dust mites, pollens, MSCB Child K1 SCR Page 4 of 27 fungal spores or animal dander) or oral allergens (such as eggs, fish, milk or nuts). Other triggers include medicines, including aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), e.g. ibuprofen and naproxen, and environmental factors such as tobacco smoke, dust, fumes, and air pollutants, as well as climatic variation. 4.3 The Impact of Environmental Tobacco Smoke (ETS) (also called passive smoking second-hand or third-hand smoke) 4.3.1 There has been significant evidence available since the middle of the 1990s that exposure to environmental tobacco smoke has an impact on a child’s health as well as exacerbating childhood asthma4. ETS is the smoke a smoker breathes out and that comes from the tip of burning cigarettes, pipes, and cigars. It contains about 4,000 chemicals including carbon monoxide. Carbon monoxide makes it harder for oxygen to circulate round the body. In addition many of these chemicals are dangerous; more than 50 are known to cause cancer. Each time children breathe in second-hand smoke they are exposed to these chemicals. Third-hand smoke is the smoke left behind in places where people have smoked previously. The harmful toxins found in third hand smoke can be found in the walls and furniture of a house, pillows and sheets, or even a child's hair after a caregiver smokes near the child. 4.4 Impact of ETS on a child’s health 4.4.1 Babies and children take more smoke into their lungs than adults. Because they are still growing and their immune system is not fully developed yet, they are at greater risk from the toxins given out in the smoke. They are more likely to get ear and respiratory infections and tooth decay and may miss more school than their peers who are not subjected to the effects of ETS. Infants have a higher risk of SIDS if they are exposed to ETS, particularly if co-sleeping. 4.4.2 Children with asthma are especially sensitive to ETS. It may cause more asthma attacks and the attacks may be more severe, requiring hospitalisation. This is because the chemicals in tobacco smoke irritate the airways and the lungs and trigger or exacerbate asthma reducing the body’s ability to circulate oxygen effectively5. 4.5 Psychosocial aspects 4.5.1There is a well-recognised link between asthma and psychosocial problems. In Sandberg et al6 18 month prospective study of children with asthma, the experience of an acute negative life event (e.g. death of a close family member) increased the risk of a subsequent asthma attack by nearly two-fold. The impact of an acute negative event was accentuated when it occurred in the context of chronic stress. Children exposed to high levels of acute and chronic stress showed a three-fold increase in risk for an attack in the two weeks that followed the acute event. Four further studies 4 Parental smoking and childhood asthma: longitudinal and case-control studies David P Strachan, Derek G Cook Thorax 1998;53:204–212 5 Asthma UK web-page access 13.03.2016 6 Asthma exacerbations in children immediately following stressful life events: a Cox’s hierarchical regression S Sandberg, S Jarvenpaa, A Penttinen, J Y Paton, D C McCann Thorax 2004; 59:1046–1051. doi: 10.1136/thx.2004.024604 MSCB Child K1 SCR Page 5 of 27 have reported that children exposed to domestic abuse were more likely than their peers to develop asthma7. 4.6 Epidemiology of asthma in the UK 4.6.1 The number of people affected by asthma in the UK is amongst the highest in the world. According to Asthma UK and other sources, up to 5.4 million people in the UK are currently receiving treatment for asthma8.During 2011–12 there were over 65,000 hospital admissions for asthma in the UK, of these 25,073 were 0-14 years old. 4.7 Asthma deaths in the UK 4.7.1 Comparisons of international asthma death rates for 5- to 34-year-olds during 2001–10 show that the UK asthma mortality is one of the highest in Europe, and comparable with those for Australia, New Zealand and the USA9. Between February 2012 and 31 January 2013 there were 195 deaths due to asthma, of which 14% were aged 19 years and under10. The report “Why Children Die” 11 relates this higher percentage of deaths to differences in social equality found in the UK, good primary care services and the differing public health services and policies in other European countries. It identifies changes which could significantly prevent deaths in the longer term, improving health and quality of life. Tobacco control is one of the areas identified as being an important area for preventing disease and promoting health. Whilst the UK scores highly on population-based implementation of legislation and guidance (no smoking in public places, no smoking in cars where children are passengers, fostering regulations etc.) compared with many other European countries, health promotion in relation to smoking cessation has not been as effective. These factors need to be taken into account when considering the management of asthma. 4.8 Management of Asthma 4.8.1 The goal of management is for people to be free from symptoms and able to lead a normal, active life. This is achieved partly through treatment tailored to the person, and partly by people getting to know what provokes their symptoms and avoiding these triggers as much as possible. The NICE Guidelines 201312 clearly identifies the quality markers identified in diagnosing and managing asthma effectively (Appendix 2). 4.9 Asthma in Manchester 4.9.1 Central Manchester has the highest number of asthma admissions in children aged 0-14 in the country at 937 per 100,000 of the population. This compares to a national average of 7 The relationship between intimate partner violence and children's asthma in 10 US states/territories. Breiding MJ, Ziembroski JS. Pediatr Allergy Immunology. 2011 Feb; 22 (1 Pt 2):e95-100. doi: 10.1111/j.1399-3038.2010.01087.x. E7 8 Health and Social Care Information Centre. Quality and Outcomes Framework: GP practice results. 2014. www.qof.hscic.gov.uk/index.asp pub 2010 Aug 24 9 Department of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. www.gov.uk/government/publications/an-outcomes-strategy-for-people-withchronic-obstructive-pulmonary-disease-copd-and-asthma-in-england 10 The national review of asthma deaths (NRAD) 2011-12 complete ref 11 Cnattingius, S. The epidemiology of smoking during pregnancy: smoking prevalence, maternal circumstances, and pregnancy outcome. Nicotine Tob Res. 2004; 6(supp 2):S125-40.cited in Why children die: death in infants, children and young people in the UK Part A May 2014 12 Asthma Quality standard Published: 21 February 2013 nice.org.uk/guidance/qs25 MSCB Child K1 SCR Page 6 of 27 approximately 200 per 100,000 and has a clear correlation with levels of poverty, socio-economic deprivation high levels of smoking as identified in 'Why Children Die'13. Asthma and Neglect 4.9.2 Neglect is defined in Working Together to Safeguard Children 201514 as “the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development……. Once a child is born, neglect may involve a parent or carer failing to: provide adequate food, clothing and shelter (including exclusion from home or abandonment); protect a child from physical and emotional harm or danger; ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. 4.9.3 When concerned about neglect and whether it has an impact on a child’s asthma the neglect needs to be considered on a case by case basis. The assessment should take into account the care provided, based on the child’s health and development including any environmental and social economic factors that impact on that health and development as well as the carer’s ability to make the necessary changes. When considering neglect in relation to asthma and smoking the severity of the asthma will also need to be considered, as well as the care-giver’s ability to reduce or stop smoking and whether the asthma is triggered or exacerbated by the smoking. 13 Why Children Die: Death In Infants, Children And Young People In The Uk Part A May 2014 Ingrid Wolfe Alison Macfarlane Angela Donkin Michael Marmot Russell Viner Royal College Of Paediatrics And Child Health National Children’s Bureau British Association For Child And Adolescent Public Health 14 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of Children March 2015 children p93 MSCB Child K1 SCR Page 7 of 27 5.0 CASE SUMMARY 5.1 Family Composition at time of K1’s death Age Relationship Ethnicity Under 4 Subject (Child K1) White British 20-25 Mother White British 20-25 Father White British 40-45 Paternal Grandmother White British 5.2 Summary of Case prior to Review Period 5.2.1 This period preceded the scope of the review; however, it may be considered relevant in relation to setting the scene in relation to the environment that Child K1 was living in. 5.2.2 Child K1 was born in August 2012. Child K1's mother was twenty-one years old at the time and their father, was sixteen. This was Child K1’s mother’s second child and Child K1’s father’s first. Child K1’s mother suffered from asthma and Child K1’s father with eczema. 5.2.3 Soon after Child K1’s birth both parents moved to live with K1's paternal grandmother. Child K1's mother at this time was depressed and unable to care for Child K1. 5.2.4 Children’s Social Care (CSC) became involved with the family at this time, supporting grandmother in caring for Child K1. The health visiting service also provided additional support to the family. 5.2.5 During December 2012 Child K1’s mother made several calls to the police reporting domestic abuse by Child K1’s father. He was not charged due to the retraction of allegations and lack of supporting evidence. 5.2.6 Child K1’s father was known to Youth Offending Services, Child and Adolescent Mental Health (CAMHS) and Connexions at varying times between 2012 and 2015. They worked with him to try and engage him in varying training schemes. Due to the birth of Child K1, and his “depression” for which he was treated this did not happen. He was however reported to be fully engaged with the support provided in relation to him being a parent. 5.2.7 In May 2013, following a referral from the health visitor, Child K1 was made a child in need. As part of the support package Child K1 was offered a nursery place which started in October 2013. 5.2.8 Child K1 was first seen for asthma on the 02/05/2013, when nine months old. Between August 2013 and August 2015 Child K1 attended A&E nine times with asthma; being admitted four times in respiratory arrest. Following the August admission Child K1 was diagnosed with “brittle asthma”. At an appointment with the Respiratory consultant at the Royal Manchester Children's Hospital (RMCH) in May 2015 Child K1’s grandmother reported that she had parental responsibility (she did not) and was Child K1’s main carer due to her son’s age. At this, and at all hospital attendances, Child K1’s grandmother inhaler technique was checked and she was advised to reduce MSCB Child K1 SCR Page 8 of 27 her and her partner’s smoking (reported to be 5 and 2 cigarettes respectively) due to the adverse effect on Child K1’s health. Child K1 was referred to the asthma nurse in May 2014. There is no discussion recorded in relation to Child K1’s father’s smoking. 5.2.9 Between June and December 2015 Nursery, Early Help and Housing raised concerns in relation to Child K1’s presentation and home environment. 5.3 Case Summary January 2016 to June 2016 (the period under review) 5.3.1 Child K1 was admitted to the North Manchester General Hospital (NMGH) on the 18/01/2016 following a respiratory arrest. The ambulance records noted that Child K1 had been short of breath for the previous six hours. Children’s Social Care were made aware of the admission. Child K1’s grandmother was taught CPR prior to discharge and the asthma nurse informed. Prior to this admission and subsequently not all Child K1’s appointments with the asthma nurse were kept. 5.3.2 Child K1 was seen at home on the 25/01/2016 by the health visitor and asthma nurse who made a referral back to Early Help identifying concerns relating to the environment and the impact it was having on Child K1’s health, the risk from sharing a room with grandmother and living in a smoky and cluttered environment. A referral was also made to the dental team and speech and language therapy. 5.3.3 On the 02/02/2016 Child K1 had a follow up appointment at the RMCH. No social concerns were identified, although Child K1’s grandmother’s smoking rate remained the same. On the same day Early Help visited the home. The worker could see Child K1 unsupervised downstairs. There was no carpet in the hall and a strong unidentified smell coming from the house, alcohol bottles were outside. An adult spoke to the support worker from an upstairs window and refused access. There had previously been difficulty accessing the family, in part because Child K1’s grandmother’s partner did not want a male support worker. Early Help referred the case back to Children’s Social Care. 5.3.4 On the 03/02/2016 the social worker (SW) did a home visit to assess conditions. Child K1 was clean and well presented. The house however needed to be cleaned. It smelt strongly of dog faeces. The social worker advised that the dog needed to be found a home and Child K1 provided with a bed. The SW also discussed their concerns that Child K1’s father may be using cannabis. The social worker was not allowed upstairs or allowed access to Child K1 and grandmother’s bedroom, which grandmother said was messy. The alcohol bottles were reported to be her son’s. The social worker attempted to arrange another visit but Child K1’s grandmother said she could not confirm a date due to the number of health appointments Child K1 had. 5.3.5 On the 10/02/2016 the social worker rang Child K1’s grandmother to arrange a home visit. Grandmother said that her mother had just died. The social worker agreed to ring in a week’s time. The asthma nurse also rang and re-arranged their visit for the next week. 5.3.6 On the 11/02/2016 the social worker had supervision and raised concerns about grandmother’s compliance with care and the need to hold a strategy meeting. On the same day a warrant was authorised by the housing provider for ongoing rent arrears. MSCB Child K1 SCR Page 9 of 27 5.3.7 Also on that date an ambulance was called by Child K1’s grandmother and Child K1 was taken the Emergency Department at NMGH where they were intubated and then transferred to RMCH Paediatric Intensive Care Unit. Child K1 was ventilated overnight before being transferred to a ward. Ambulance records note that Child K1 had been given antibiotics three days ago but these had not been started. They also recorded that Child K1 was in a dirty vest and no other clothes and that the house was dirty. A referral to children’s social care was made by the ambulance service. On the ward staff were concerned about Child K1’s father and grandmother’s attitude towards Child K1, especially their lack of response to K1's medical needs and contacted Children’s Social Care. The social worker advised the ward that a home visit needed to be carried out before Child K1 returned home. On the 16/02/2016 Child K1 was transferred to North Manchester General Hospital (NMGH) prior to discharge. On the 17/02/2016 the consultant’s records note that Child K1’s cubicle was dirty and smelling of smoke and that there were concerns regarding grandmother’s compliance with Child K1’s care. It is not clear whether this information was shared with Children’s Social Care although there was a conversation between the consultant and a social worker regarding their concerns in relation to Child K1. There was an agreement that Child K1 was to stay in hospital until a strategy meeting and/or a discharge planning meeting had occurred. Child K1’s grandmother was angry and upset about this decision and following discussion with the social worker Child K1 was discharged home on the 19/02/2016 with support from the community nursing team over the weekend. 5.3.8 On the 23/02/2016 the asthma nurse made a planned visit but was not allowed access although she saw Child K1 through the bedroom window. Child K1 was also not taken to the GP for follow up, despite being asked to contact the surgery in line with the asthma protocol. There is no evidence that this occurred following any of Child K1’s admissions 5.3.9 On the 24/02/2016 Child K1 was seen to be inadequately supervised by father by one of the nursery workers. A decision was made by the Nursery to talk to Child K1’s grandmother. The social worker was not informed. It was however highlighted at the Initial Child Protection Conference (ICPC). 5.3.10 On the 25/02/2016 the social worker rang Child K1’s grandmother and was told she couldn’t speak to her as it was her mother’s funeral that day. Attempts were made to contact Child K1’s grandmother later that week without success. The social worker carried out a home visit on the 02/03/2016. The house had been cleaned and clutter removed and good interaction was noted between Child K1 and Child K1’s grandmother. 5.3.11 The social worker contacted Early Help on the 04/03/2016 with a view to engaging their help in supporting the family. The case was accepted on the 08/03/2016. The plan included engaging Child K1’s father in Child K1’s care, providing financial advice and budgeting and helping with Child K1’s grandmother’s housing needs, monitor alcohol use within the household, to improve home conditions and support Child K1’s grandmother with Child K1’s care. The case was allocated to an Early Help worker on the 01/04/2016. 5.3.12 On the 10/03/2016 the eviction planned for the 11/03/2016 was withdrawn following payment of some of the rent arrears. MSCB Child K1 SCR Page 10 of 27 5.3.13 On the 14/03/2016 Child K1’s grandmother contacted the police to say her television had been stolen. She then realised it had been taken by her son and withdrew the complaint. 5.3.14 On the 04/04/2016 the social worker rang Child K1’s grandmother to arrange a home visit. She said the SW could not visit due to the large number of health appointments and that she needed help with a school placement as she had missed the deadline for this; the education case worker agreed to support Child K1’s grandmother who was informed and a visit planned for the next day. At that visit on the 05/04/2016 Child K1’s grandmother told the social worker that Child K1’s father was helping more, however the social worker noted that the condition of the house had deteriorated and that Child K1 whilst happy was grubby and was wearing dirty clothes. Child K1’s grandmother informed the social worker that K1”gets tired easily and lacks motivation”. She informed the social worker that she had a GP appointment late that day. The social worker advised Child K1’s grandmother that she needed to clean the house and that the social worker would visit the next day to ensure this had happened. Child K1’s grandmother was advised that due to the deterioration in care the social worker may need to proceed to a child protection conference. 5.3.15 Child K1’s grandmother attended the GP later that day (05/04/2016) following an NHS check invitation. She had a one month history of anxiety and panic attacks and had lost her mother two months ago. She was smoking 1-9 cigarettes a day, she was referred to the practice nurse for smoking cessation and for follow up by the GP. On the same day Child K1’s father also attended the GP. He is recorded as smoking 15 cigarettes a day and wishing to give up. He had stopped smoking cannabis a week ago. He was also suffering from anxiety with depression, and had had a low mood for the previous four to five years. He had been on antidepressants which he had stopped some time ago and was now requesting Mirtrazapine. This was prescribed and a referral made to the practice nurse for smoking cessation. 5.3.16 On the 06/04/2016 the social worker liaised with the support worker and advised that the case had escalated and was likely to go to an Initial Child Protection Conference. The SW also visited Child K1’s grandmother and informed her of the decision due to the ongoing concerns regarding the house and Child K1’s care. A strategy meeting took place on the 07/04/2016 and it was agreed to proceed to conference. Child K1’s mother was advised of current concerns and the plan for a child protection conference. 5.3.17 On the 18/04/2016 the Paediatric Consultant at NMGH invited professionals working with the family to a professionals meeting planned for the 04/05/2016 identifying in the invitation the concerns relating to Child K1. Invitees included RMCH and NMCH safeguarding nurses, the GP, social worker, the respiratory and asthma nurse and HV. This meeting was cancelled on the 20/04/2016 when the Paediatric Consultant was informed of the Initial Child Protection Conference planned for the 03/05/2016. 5.3.18 A planned visit by the social worker on the 20/04/2016 was cancelled by Child K1’s grandmother and re-arranged for the 25/04/2016. Improvements regarding the house cleanliness were noted and some decoration had taken place. Child K1’s father was reported to be helping more and was playing with Child K1 at the time of the visit. Child K1’s grandmother said she was not getting support from CSC and was feeling very stressed. She said that she was trying to reduce her smoking and was seeing the GP that day. The social worker completed the assessment and shared it MSCB Child K1 SCR Page 11 of 27 with Child K1’s grandmother. The recent bereavement and the impact of that on the family was not discussed or included within the report. 5.3.19 On the 03/05/2016 an initial Child Protection Conference was held. It was attended by Child K1’s grandmother, social workers, health visitor, asthma nurse, nursery and the police. A report was received from the GP and hospital consultant who were not able to attend. The consultant's report however clearly identified their concerns and the risks to Child K1. The conference decision was that Child K1 was at risk of significant harm and K1 was placed on a Child Protection Plan, category Neglect. This decision was unanimous. The main risk factors identified at the conference were the smoky environment within the house; fluctuating home conditions; the clutter and dirt within the house; the fact that Child K1 was co-sleeping with grandmother who was a smoker; the ongoing risk of criminality from Child K1’s father; and the fact that Child K1’s grandmother minimised professionals’ concerns. The plan also included a social work assessment of Child K1’s father and the support he was able to offer in caring for Child K1. The case was transferred to a different team and the social worker changed as Child K1 was now on a plan. At this time Child K1’s grandmother was reportedly smoking ten to nineteen cigarettes a day and Child K1’s father was smoking fifteen cigarettes a day. Child K1’s father was also being treated for depression. These facts were not included in the GP report or shared at the conference. The consultant from the RMCH was not invited and not aware of the concerns identified within the community. 5.3.20 On the 05/05/2016 the housing provider could not gain access to the property to carry out a planned gas safety check. They were also contacting Child K1’s grandmother at this time regarding her rent arrears. Further contacts were made in May without success. 5.3.21 The same day (05/05/2016) Child K1’s grandmother attended the GP surgery to see the practice nurse. She reported that she had cut down to about six a day; she was provided with nicotine replacement therapy. On a visit to the GP on the 10/05/2016 she informed the GP she was smoking ten to nineteen cigarettes a day. When this was discussed with Child K1’s grandmother as part of this review she reported that her smoking was fluctuating at this time due to stress. 5.3.22 On the 13/05/2016 a joint home visit was carried out by the previous and new social worker. The house condition was improved although Child K1 was still not in her own bed. When this was discussed with Child K1’s grandmother as part of this review, she reported that Child K1 would reach out for her in the night for comfort and did not want to sleep in a separate bed. It was also agreed at the visit that the social worker would have more involvement with Child K1’s father to which he agreed. Child K1’s grandmother reported that she was unhappy with health staff saying at the conference that home conditions made Child K1’s asthma worse as Child K1 was not allergic to mites or dog or cat hair. 5.3.23 The core group meeting took place on the 16/05/2016. It was attended by the health visitor, nursery, social worker and Child K1’s grandmother. Grandmother reported that Child K1’s father was unwell. Some improvements were noted and a bed was now available for Child K1. Actions were identified to progress the plan and a referral was made to Families First15. The health visitor shared the outcome of the core group with asthma nurse. 15 Families First is an intensive evidence based family support intervention MSCB Child K1 SCR Page 12 of 27 5.3.24 On the 19/05/2016 the Families First worker met with Child K1’s grandmother to agree a contract regarding Families First intervention. Within this plan were two items relating to Child K1’s father who was not at the meeting. One related to the Family First practitioner having an honest relationship with Child K1’s father in relation to his possible using or dealing of drugs; the other was to take on a more active role in the care of Child K1. At a further visit Child K1’s grandmother reported that she was not feeling well. She was grieving for her mother and reported that she was also stressed and anxious that Child K1 would be removed from her care. She cancelled the meeting for the following day. She also cancelled the asthma nurse’s visit planned for the 25/05/2016 and asked her to cancel the social worker’s visit planned for that day. 5.3.25 On the 03/06/2016 Child K1’s nursery contacted Children’s Social Care as K1 had a bruise on their arm. Child K1 had said “daddy hurt me”. The social worker arranged for a child protection medical and contacted the police for a strategy discussion. Following a visit to nursery the social worker reported that it was not a bruise but a scratch and having spoken to Child K1’s father and grandmother no further action was to be taken. On the same day, Child K1’s grandmother found out that Child K1’s father had tested positive for heroin and took him to a drug rehabilitation centre for advice and treatment. She cancelled a home visit by the Families First worker as she was too upset. The social worker received this information the following Monday (06/06/2016) and carried out a home visit that day with the Family First worker. The social worker saw Child K1’s father and grandmother and discussed the concerns that had been identified with them. The SW contacted the drugs team to check Child K1’s father’s attendance and the nursery to say that Child K1’s father was not to have unsupervised access to Child K1. The social worker also expressed concern with Child K1’s grandmother that Child K1’s bed had still not been assembled. 5.3.26 Both the health visitor and asthma nurse were in ongoing contact with the family during this time providing advice and support in relation to Child K1’s asthma, missed audiology and dental appointments and other general health and developmental concerns. 5.3.27 On the 13/05/2016 a second core group meeting was held. This was attended by Child K1’s grandmother, the social worker, Family First worker, asthma nurse and community nursery nurse (HV team). Child K1 was reported to have a cough and cold and been prescribed medication by the GP; medicine advice was re-enforced by the asthma nurse. Child K1 was seen to be a good colour and breathing well. Child K1’s grandmother and Child K1’s father were reported to be engaging with Families First. Child K1’s grandmother had not assembled the bed, she said Child K1 would not sleep alone. She said she would stop Child K1’s bottle now K1 was feeling better and make appointments for audiology and the dentist. 5.3.28 On the 16/06/2016 Child K1 attended a clinic appointment and saw the respiratory medicine consultant. Child K1’s grandmother advised that Child K1 had been well until recently when the weather changed. Child K1 was prescribed a five-day course of steroids and advised to attend hospital if at all unwell. A bronchoscopy appointment was made for the end of June. 5.3.29 On the 17/06/2016, following attempts to contact Child K1’s grandmother by phone regarding rent areas and the need to do a gas safety check, a letter was sent advising her that a warrant would be authorised if payment was not received (no rent paid since March 2016). MSCB Child K1 SCR Page 13 of 27 5.3.30 On the 20/06/2016 nursery contacted Child K1’s grandmother as Child K1 was unwell. They had provided medication for Child K1’s asthma in line with K1's healthcare plan but K1 was not responding, was clammy and continuing to cough. Child K1’s grandmother attended nursery and took Child K1 home. She is recorded as saying this was a sign that Child K1 was unwell. Child K1’s grandmother said at the meeting with the Review author that Child K1 was better in the evening. Child K1’s grandmother cancelled a planned visit with Families First as she reported being unwell. 5.3.31 On the morning of the 21/06/2016 Child K1 was unwell, coughing and not responding to their nebulisers. Child K1’s grandmother called an ambulance and Child K1 was taken by ambulance to North Manchester General Hospital. Child K1 was cyanosed and unresponsive. On arrival at hospital, despite intensive medical intervention, Child K1 was unable to be resuscitated. Child K1 was pronounced dead at 11.06 am. The Coroner and police were informed in line with sudden unexpected death in childhood procedures. No suspicious circumstances were identified at the hospital. The police and paediatrician carried out a home visit, recording that the house was cluttered, dirty, and smelt of smoke. All professionals working with the family were informed, as was Child K1’s mother. 5.3.3 A rapid response meeting was held on the 23/06/2016 to share information and manage bereavement support. MSCB Child K1 SCR Page 14 of 27 6.0 ANALYSIS OF PRACTICE 6.1 Child K1’s admission to NMGH in January 2016 was the fifth admission in respiratory arrest. K1's hospital care was appropriate resulting in a quick recovery and discharge home. Pre-discharge training though should have included Child K1’s father. This ignoring of the fact that Child K1’s father had parental responsibility was a factor throughout Child K1’s life; and whilst Child K1’s grandmother acted as a parent she did not have parental responsibility. There is no evidence at this, or any other admission, that Child K1’s grandmother was referred to the GP for smoking cessation, although discharge letters did identify the need for Child K1’s grandmother to stop smoking. There is no evidence that father’s smoking was taken into account at any time. This was poor practice as it showed little thought of the impact of care being provided to Child K1 on their asthma. Both the failure to identify the need for Child K1’s father to stop smoking and the fact that the GP records were scanned but not linked to other family members meant that the GP was unlikely to pick this up as an action requiring attention. Had Child K1’s records been coded as a child with complex needs or a child of concern this may have occurred. 6.2 The follow up visit by the asthma nurse and health visitor was good practice and in line with national guidance. Smoking cessation was discussed in relation to Child K1’s grandmother and her partner but not in relation to Child K1’s father. This appears to be an issue ongoing in Child K1’s care. Neither smoking nor the environment were considered in the context of child protection (neglect), despite the significant risks of ETS, particularly when co-sleeping, and the impact of a dusty and dirty environment being explained to Child K1’s grandmother on numerous occasions. A referral was made to Early Help instead. The referral requested financial help for Child K1’s grandmother who was in rent arears, and emotional support in caring for Child K1. It also noted that Child K1’s father needed support following the breakup of his relationship. The referral to Early Help was in line with local protocol16 but did not take into account the input already received by the family and the impact of the smoking and environment on Child K1’s health. Nor did it take into account the complexity of the neglect and the need to identify the root cause rather than deal only with the practicalities. This is a common failing when analysing cases of neglect and identified in many SCRs. 6.3 On the 02/02/2016 the Early Help (EH) worker attempted a visit. The EH worker was not allowed access but was concerned regarding Child K1’s presentation and the state of the house and referred the case back to Children’s Social Care (CSC). The referral back to CSC was good practice, as was the visit carried out by the social worker the next day. The house appeared a little cleaner, but still smelt and no access was allowed to the upstairs area. Child K1’s grandmother refused to make an appointment for a further visit, citing health appointments as the reason. Whilst there may have been a number of health appointments for Child K1, their grandmother’s refusal to make an appointment showed an element of non-compliance with professionals, only allowing the contact she wanted with an agency to occur. Alcohol bottles at the property were reported to be Child K1’s father, however this was not checked with him (In April 2016 Child K1’s father informed his GP that he did not drink). A more assertive approach to Child K1’s grandmother and meeting with Child K1’s father to discuss the situation, including how best to manage the health appointments as well as the risks to Child K1 would have been appropriate. When the social worker followed up on the 16 Draft Neglect Strategy for Children, Young People and Families 2016-2017 MSCB MSCB Child K1 SCR Page 15 of 27 10/02/2016 they were advised by Child K1’s grandmother’s that her mother, (Child K1’s great grandmother) had died and she didn’t want a visit at this time. This was understandable but a date should have been agreed for a future visit. 6.4 On the 11/02/2016 an ambulance was called and Child K1 taken to hospital (NMGH) with an asthma attack. The ambulance crew were concerned because Child K1 had not been given prescribed antibiotics by Child K1’s grandmother, Child K1 was in a filthy state, as was the house. Their referral to CSC was good practice, as was the referral following admission by ward staff when they became concerned about both Child K1’s grandmother and Child K1’s father’s attitude and behaviour on the ward. The social worker agreed a safety plan with the ward, which was good practice. This included Child K1 not being discharged from hospital until a home assessment had been carried out and discharge planning meeting held. 6.5 Following transfer to CMHT the cubicle Child K1 was being nursed in was recorded by the consultant to be dirty and smelling of smoke. The consultant noted that RMCH, NMGH and the asthma nurse were all concerned about Child K1’s grandmother’s compliance with Child K1’s care. The consultant requested a discharge planning or strategy meeting prior to Child K1 going home. This was good practice, however no action was taken when this did not happen and following Child K1’s grandmother insistence that she wanted to take Child K1 home, K1 was discharged home on the 19/02/2016 with follow up by the Children’s Community Nursing Team over the weekend. This followed a conversation between the ward and social worker and took no account of the concerns identified, or that a follow up home visit had not taken place by the social worker. Hospital staff did not discuss their concerns with the named nurse or doctor or escalate them in any way. This was poor practice, as was the social worker’s agreement for Child K1 to go home without a follow up visit. 6.6 Sending Child K1 home without a discharge planning meeting or a strategy meeting was a missed opportunity to assess and analyse the risk to Child K1 with input from all the professionals working with the family. The handling of the situation gave Child K1’s grandmother mixed messages as to the level of concern identified by professionals and their expectation around her actions in relation to Child K1. This remained an issue throughout the case, with no effective action taken in relation to Child K1’s grandmothers non -compliance with Child K1’s care. Having a discharge planning meeting would also have been an opportunity to identify a lead health professional to have an overview of the case and identify what Child K1’s feelings were at this time. 6.7 Evidence provided by the ambulance service, the ward and the home visit suggested a level of neglect that should have led to a strategy meeting regardless of Child K1’s asthma and should have been held before discharge. This was poor practice and a missed opportunity to properly analyse the risks to Child K1. 6.8 Child K1 was not taken for an asthma follow up with the GP in line with the asthma pathway. There is no evidence that this was ever highlighted to other professionals working with Child K1 and was poor practice. Where children are not taken to health appointments there should always be consideration as to whether this is part of a bigger picture in relation to neglect. The asthma nurse was not allowed access to the home on the 23/02/16, a planned visit; concerns were raised at nursery about Child K1’s father’s supervision of Child K1 on the 24/02/2016; and the social worker MSCB Child K1 SCR Page 16 of 27 was unable to access the house until the 02/03/2016 (partly due to Child K1’s grandmother’s mother’s funeral on the 25/02/2016). Taking this all of this into account it still showed evidence of avoidance of professionals, non-compliance with treatment, and an increase in risk to Child K1, and following the concerns raised in hospital was further evidence of the need for a strategy meeting. Not initiating one was poor practice and resulted in considerable drift by children’s social care. 6.9 The hospital discharge letter to the GP in February 2016 did not truly reflect the level of concerns identified, and resulted in not all health professionals being fully aware of those concerns. During the time covered by this Review, there is also little evidence of any face to face liaison between the asthma nurse and health visitor with the GP; although updated copies of Child K1’s asthma plan were sent to the surgery. This case would have benefited from discussion and sharing of information in relation to Child K1’s care. At the time the asthma nurse had a caseload of 500 patients, including other children with a CP plan; and the service was replacing home visits by clinic visits or phone review due to demand on the service. This had an impact on the asthma nurse’s ability to carry out home visits and liaise effectively with all the other professionals involved. This would have affected the asthma nurse's contact with the GP, although there was liaison with the HV. Health visiting contracts included having a link health visitor and the need to liaise between GP and the named health visitor for a family when there are safeguarding concerns17. It would be good practice, particularly in situations of possible neglect relating to compliance to health needs, to liaise with the GP on a regular basis. This lack of liaison reflects the findings in the Child H review carried out by Bury in 201318 and would suggest the actions have not been fully embedded in practice. 6.10 The social worker made a planned visit on the 02/03/2016. The house was cleaner and uncluttered. However, Child K1 was still sleeping with grandmother and there was no evidence that grandmother had reduced her cigarette consumption. Good interaction was noted between Child K1 and grandmother, but there is no evidence recorded to say that the social worker saw Child K1 alone to find out their view on their care, or how much K1 was missing great- grandmother. It is not clear whether the social worker understood the implications of lack of progress in relation to Child K1 sleeping in a separate bed and Child K1’s grandmother stopping smoking and keeping the house clean; however it showed further evidence of that Child K1’s grandmother was unable to respond to Child K1’s needs and should have been acted upon more pro-actively and the situation not allowed to drift. This needs to be taken in the context of a time when this Manchester social work team was under considerable pressure, with higher caseloads than elsewhere in the city and higher levels of child protection and neglect. The Locality involved has a higher level of deprivation and need, evidenced through Multiple Deprivation scores and other indicators. For example a breakdown of deprivation by income illustrates all but two wards in this area of Manchester have a higher percentage of income-deprived children than is average for the City. Four of the five wards with the highest percentage of income deprived children in the City reside in this part of Manchester. The social work teams in this area receive a higher rate of referrals and, at the point of involvement with Child K1, had average caseloads on the assessment teams of 27.8 (May and June data, 2016) and on the 17 A Model of Good Practice GP-HV Communication Guidelines; HV Taskforce 3rdDec. 2012 18 The same NHS provider organisations were involved in that case MSCB Child K1 SCR Page 17 of 27 court and locality teams of 23.2. In the subsequent year there has been recognition of this demand and additional resource recruited to in this area of the city. Three social work teams now serve the community, leading to a reduction in caseloads with current figures being an average caseload of 21.8 on assessment teams and 18 on court teams in March 2017, marking a significant decrease. There is still further recruitment taking place into this area and there is a clear undertaking to ensure an average caseload across the area of 18. Due to the changes that have occurred and continue to occur there is no finding in relation to drift. 6.11 Following discussion on the telephone on the 04/04/2016 when Child K1’s grandmother refused a visit, she identified that she needed help with arranging Child K1’s school placement. The social worker visited the next day (05/04/2016). The SW had followed up on Child K1’s school placement which was good practice. However the SW had not explored with grandmother why she had not applied for a school place in time; or considered this within the context of how able Child K1’s grandmother was to meet Child K1's needs. The condition of the house had deteriorated and Child K1’s grandmother was feeling unwell. She had a GP appointment that day for herself. The social worker advised that there would be a social work visit the next day and the house would need to be cleaned. It is not clear whether smoking cessation and co-sleeping were addressed. Nor was the impact of grandmother’s health on her ability to adequately care for Child K1. 6.12 The social worker advised Child K1’s grandmother that they may need to proceed to a child protection conference. The decision to consider proceeding to conference was good practice; however an opportunity to speak to the GP and get a clear picture of grandmother’s health and the impact it was having on Child K1’s health and development was missed. The visit by both father and grandmother to the GP should also have led the GP to considering the impact that their smoking and anxiety/depression were having on Child K1 and identified these concerns to the social worker. Throughout the period under review grandmother’s self -reporting in relation to her smoking was inconsistent and varied dependant on who she was talking to, although she was consistent in saying that she did not smoke within the house. Whilst her level of smoking may have increased at times of stress, particularly following her mother’s death, if health workers had liaised better it would have been clear as to how inconsistent her self–reporting was and the level of effort she was making to stop smoking. 6.13 On the 07/04/2016 a strategy meeting was held with the police and social worker. This was two months after the initial referral by the ambulance service and hospital had been made and reflected the ongoing drift in the case. No health or education professionals were invited. This failure to comply with Working Together Safeguard Children 2015 was reported by the review team to be common occurrence. In this case it was essential that health should have been at the strategy meeting as Child K1 had such significant health needs. This should have as a minimum included one of Child K1’s consultants and the GP who had significant information relating to Child K1’s father and Child K1’s grandmother. Had they been there the risk to Child K1 could then been more adequately assessed. The failure to invite them was poor practice. It is not however included in the findings as this has already been identified as a concern by MSCB and is being addressed. Child K1’s mother was advised of the concerns and the plan for a child protection conference. This was good practice, however there is no evidence that she was informed of the outcome. Not keeping Child MSCB Child K1 SCR Page 18 of 27 K1’s mother aware of the situation was poor practice as she had parental responsibility and had the situation deteriorated could potentially been considered as an alternative carer. 6.14 On the 19/04/2016 the consultant at NMGH contacted the social worker and various health professionals working with the family to arrange a professionals meeting. This included the safeguarding lead and was good practice. The consultant was advised on the 20/04/2016 that an ICPC was to be held the day before and therefore cancelled the professionals meeting letting those invited know of the conference. This information did not reach the consultant at RMCH and they were not invited by CSC. The consultant was unable to attend but wrote a comprehensive report for the conference. Had a professionals meeting taken place a much clearer understanding of the risks to Child K1 may have emerged, and whilst it was appropriate to cancel it did mean that neither consultant attended the ICPC and professionals did not have the opportunity to share information and agree a clear healthcare plan, which could have been incorporated into the Child Protection Plan. 6.15 On the 24/04/2016 the social worker made a planned visit to the family home. The Child Protection assessment was shared with Child K1’s grandmother but does not appear to have been shared with Child K1’s father. Whilst it was good practice to share the report with Child K1’s grandmother, the failure to involve Child K1’s father is a consistent theme running through this case and is replicated by all professionals working with the family at this time. 6.16 The Initial Child Protection Conference was held on the 03/05/2016 more than 15 days after the strategy meeting. This was not in line with Working Together 2015. Whilst it was quorate some key people were not invited or asked for reports. They included housing and the RMCH hospital consultant involved with Child K1. The GP report dealt with Child K1 but did not include relevant information in relation to Child K1’s grandmother or father which would have provided information which would have given a different perspective of the risks to Child K1, as would the housing report had it been requested. Housing were aware of a pattern in relation to rent areas and non-engagement by grandmother and could have supported CSC in their effort towards ensuring that the house was kept in an appropriate standard of cleanliness. This failure to access all the information available resulted in a lack of insight into the wider picture. In addition the child protection plan produced had a list of tasks but did not clearly identify the outcomes required, or what would happen if there were no improvements. This was not in line with good practice. “Signs of Safety” has now been introduced in Manchester and the author was assured that Child Protection Plans are now more outcome focused, this is not therefore included within the findings. Following the conference a new social worker was appointed in line with good practice guidance. 6.17 The joint visit on the 13/05/2016 by the old and new social worker was good practice. Child K1’s grandmother was unhappy with the health workers input at the conference, denying that home conditions had an impact on Child K1’s asthma as K1 was not allergic to mites, dogs, or cats (Child K1 had been tested for allergens). This assertion by Child K1’s grandmother showed that she either did not understand, or was failing to acknowledge the risks to Child K1 from smoking and a dusty environment, in that Child K1 did not have to be allergic to them for them to exacerbate their asthma. This had been an area of concern regularly raised with grandmother by the health professionals caring for Child K1. It would however have been good practice to clarify which was the case and re-iterate the risks. When discussed with Child K1’s grandmother as part of this review MSCB Child K1 SCR Page 19 of 27 she reported that she never smoked indoors and did not appear to understand the risks of ETS. The new social worker included Child K1’s father in the visit and told him of the intention to include him in the assessments. This was an action identified in the Child Protection Plan. This was the only time that there is any evidence Child K1’s father was being considered/assessed as a carer for Child K1. This was not however sustained as when the Family First worker attended the house on the 19/06/2016 and agreed a care plan with Child K1’s grandmother included within it were actions relating to Child K1’s father which were not agreed with him. 6.18 Following the child protection referral from nursery on the 03/06/2016 the proposed child protection medical should have taken place. A scratch can be an inflicted injury and this failure to believe Child K1, after speaking to their grandmother, is similar to the findings in an ongoing SCR in Manchester (Child G1) “where there was too great a focus on the individual injury rather than consideration of what the medical might or might not be able to contribute more widely to an understanding of the child’s experience”. This failure to go ahead with the CP medical was poor practice. 6.19 Although Child K1 was only three years old at the time of death, children of that age are able to communicate any concerns they may have with the adults working with them. There is little evidence that Child K1 was asked about daily life experience, or an understanding of asthma, and how Child K1 felt about not having contact with mother and great grandmother’s death. All of which must have been quite frightening and bewildering at times. A finding in relation to this is not included as both the Review team and the practitioners felt that this issue was being addressed through training and the introduction of signs of safety. 6.20 Following Child K1’s death there was no delay in initiating the Sudden Unexpected Death in Childhood procedure19 and professionals involved in Child K1’s death were informed in a timely way. Child K1’s mother was also informed promptly. This was good practice 19 Working Together to Safeguard Children 2015 p85 DfE MSCB Child K1 SCR Page 20 of 27 7.0 FINDINGS 7.1 An overview of the questions asked within the scoping document have been identified and covered within Section 3 of this report. This identifies what asthma is and the impact of EST and dirty home conditions can have on a child’s health. The findings listed below therefore deal with how this impacted on the management of Child K1‘s care. The headline findings are listed within the table and expanded on later in this section. 7.2 Professionals provided care in line with nationally agreed guidance, however this did not adequately take into account the safeguarding concerns (i.e. the impact of smoking and poor home environment) and the need to further escalate the case. 7.3 Health professionals have a lead role to play in ensuring that professionals working with a specific family have a better understanding around the concept of when care is/is not good enough for a child who has a chronic illness or disability and how this should inform case planning. 7.4 Neglect is a recognised category of abuse, however in this case the professional understanding was not sufficiently sophisticated as to the kind of behaviours that constitute neglect and their impact on children with chronic health conditions. Additional Learning 8.1 Role of fathers – Child K’s father’s role in caring for Child K1 was not seriously considered or supported resulting in professionals being unclear of his ability to care for his child or receiving the support he may have required. 8.2 Information sharing between and within agencies was not always in line with good practice. This resulted in professionals not having all the information available when assessing the risk to Child K1. 7.2 Finding 1: Professionals provided care in line with nationally agreed guidance20, however this did not adequately take into account the safeguarding concerns (i.e. the impact of smoking and poor home environment) and the need to further escalate the case. 7.2.1 Child K1 would have had a predisposition to asthma in that both parents suffered from either asthma or eczema. Research identifies that this is more likely than to occur when children are subjected to ETS and stress (in this case domestic abuse between their parents) Child K1 was exposed to both from birth. It is not surprising therefore that K1 developed asthma at such an early age, or that it became problematic to manage. Whilst this information is widely known neither NICE guidelines21 nor the 2014 report by the Royal College of Physicians,22 consider these from a safeguarding perspective referring only to the need for educating parents. The guidance comes 20 Asthma: Quality standard Published: 21 February 2013 nice.org.uk/guidance/qs25 21 Ibid 22 Why asthma still kills The National Review of Asthma Deaths (NRAD) Royal College of Physicians. Confidential Enquiry report May 2014 MSCB Child K1 SCR Page 21 of 27 from a medical rather than a social model of care. Social policy on the other hand is now recognising the impact of smoking and there is now clear guidance in relation to foster carers with “smokers” not being approved for the care of children under five years of age, and having to smoke outside of the house for older children23. Since October 2015 it has also been illegal to smoke in the same care as a child24 and there is at least one published paper, albeit American, which clearly considers ETS in a child with asthma to be child protection in the same way as substance misuse and domestic violence25. In Child K1’s case social care failure to act effectively, and health professionals not effectively escalating their concerns to safeguarding leads within their individual organisations meant that there was a lack of clarity of the true risks involved and what could be done to alleviate them. Professionals therefore need to be clear when smoking and a poor home environment puts a child at significant risk, have an agreed plan which includes both the impact of smoking and environment on the child as well as any other options available when no improvement in the child’s care occurs. This could include working with the City Council’s Environmental Team in relation to tenure compliance and enforcement in relation to social and privately rented housing. Since the review Public Health have had discussion with MSCB to ensure that the risk of tobacco smoke on Children’s Health is included within the “Safeguarding and Substance Misuse” Courses. This should ensure professionals are more aware and more able to effectively assess risk. Public Health have also agreed to collate information for non-health staff who work with families in relation to the risks of tobacco smoke to babies children and especially those who have asthma which would support that training. 7.3 Finding 2: Health professionals have a lead role to play in ensuring that professionals working with a specific family have a better understanding around the concept of when care is/is not good enough for a child who has a chronic illness26 or disability and how this should inform case planning. 7.3.1 The Munro review of child protection identified that managing cases of neglect can be problematic and difficult to manage27. It identified that the ‘safeguarding system’ and to some extent professional practice was geared to recognising emergency incidents rather than more enduring patterns of harm or risk and that there needed to be a continued shift in culture and practice to achieve earlier recognition of patterns of risk and harm, and earlier intervention to protect and safeguard the long-term needs of the child. 7.3.2 A chronic health problem, such as Child K1 had, adds an additional complexity and it becomes even more pertinent for a clear analysis and expert advice to be provided by health professionals. This should clearly identify the impact of the neglect on the child’s health and development, enabling children’s social care and other professionals to understand the impact of the neglect on the child’s life. Child K1’s care was shared between two Hospital Trusts and whilst it transpired that the consultant paediatrician from NMGH felt that they were the lead professional this was not 23 http://ukfostering.org.uk/becoming-foster-parent/your-circumstances/#sthash.WshvkpPL.dpuf viewed 20/03/2017 24 Children and Families Act 2014 25 Is Exposure to Second-hand Smoke Child Abuse? Yes Adam O. Goldstein published 2013, accessed on line February 2017 26 A Long Term Physical Health Condition (also known as a Chronic Condition) is a health problem that requires ongoing management over a period of years or decades. A Long Term Physical Health Condition is one that cannot currently be cured but can be controlled with the use of medication and/or other therapies. http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/l/long_term_physical_health; accessed June 2017 27 The Munro Review of Child Protection: Final Report: A child-centred system May 2011 DfE MSCB Child K1 SCR Page 22 of 27 however made explicit to all professionals working with Child K1. Concerns therefore did not get the attention they warranted. This meant that whilst there was good input from the majority of health professionals involved there was no one clearly identified person to taking the lead in co-ordinating health information and explaining on an ongoing basis specifically when the care provided to Child K1 was not good enough and why. This was reflected in the discussion with Child K1’s grandmother she reported that she received advice that was sometimes conflicting and that recent events were not always known by all practitioners. 7.3.3 Medical professionals are best placed to identify how a child’s health or development, particularly one with chronic health needs, is being affected by the care provided. They are often unaware however of the significance of their input into multi-agency decisions about their care28 and because of the short notice for ICPC are rarely attend as was the case in Child K1’s case. This can mean their input can be diluted or misinterpreted with CSC getting mixed messages regarding the significance of the neglect. It is therefore important that medical staff are fully involved in the care planning for children where there are clear concerns regarding compliance with health care and the impact this may have on the child. It is important that reports are robust and where appropriate provide evidence and research to support their views as well as considering the impact, both positive and negative of the family on the child’s health and development. This lack of clarity and liaison between agencies is a finding that has been identified in another Manchester SCR (Child H1) and also as a concern nationally. 7.4 Finding 3: Neglect is a recognised category of abuse, however in this case the professional understanding was not sufficiently sophisticated as to the kind of behaviours that constitute neglect and their impact on children with chronic health conditions. 7.4.1 The Manchester Safeguarding Children Board Safeguarding Standard 2015 and their Strategy for Neglect December 201629 are written within the context of the higher than national average of neglect identified within Manchester and the number of children with a Child Protection Plan or Looked After for whom neglect has been identified. Child K1 without having asthma was not considered to meet those thresholds. The Neglect Strategy is however clear that warning signs and symptoms of child neglect vary from child to child and that by understanding potential indicators, professionals can respond to problems as early as possible and provide the right support and services for the child and their family. 7.4.2 Child K1’s diagnosis of brittle asthma, meant that when considering their care and whether that “was good enough” professionals needed to consider whether K1's carers were able to comply with their health care and keep them free of triggers such as EST, stress and a dirty home environment. Unless however this is explicitly identified by health professionals, then other agencies working with the family are unlikely to realise the significance or risk. This is an area often identified in SCR’s of children and young people who have additional needs30 but is even more difficult to manage when the concerns relate to such areas as smoking and obesity. Although the clear impact of both is fully documented, there is no clear guidance as to how to manage the 28 Pathways to Harm, Pathways to protection :a triennial analysis of serious case reviews 2011-2014 Peter Sidebotham et al DfE May 2016 29 Manchester Neglect Strategy for Children, Young People and Families 2016-2019 p. 11 December 2016 MSCB 30 Pathways to Harm, Pathways to protection :a triennial analysis of serious case reviews 2011-2014 Peter Sidebotham et al DfE May 2016 MSCB Child K1 SCR Page 23 of 27 safeguarding issues successfully, the emphasis being on professionals’ focusing on health promotion and encouraging changes to adult behaviour. 7.4.3 This can disempower professionals when considering best how to manage those families where children are subjected to EST and where health promotion and support to the family have not worked. MCSB’s current strategy identifies the need for professionals to consider a broader set of circumstances which can only be pieced together through the accumulation of evidence until the legal threshold for care proceedings is met. The NSPCC screening tool is now included within that strategy31. The use of such a tool in Manchester at this time was not in place, had it been it could possibly have helped professionals identify the ongoing concerns and lack of change in Child K1’s care. 8.0 ADDITIONAL LEARNING 8.1 Finding 4: Child K1’s father’s role in caring for Child K1 was not seriously considered or supported, resulting in professionals being unclear of his ability to care for his child or receiving the support he may have required. 8.1.1 The Healthy Child Programme states that: “The contribution that fathers make to their children’s development, health and wellbeing is important, but services do not do enough to recognise or support them. Research shows that a father’s behaviour, beliefs and aspirations can profoundly influence the health and wellbeing of both mother and child in positive and negative ways.’ Maternity and child health services are used to working mainly with mothers, and this has an impact on their ability to engage with fathers. Fathers should be routinely invited to participate in child health reviews, and should have their needs assessed.’ 8.1.2.Whilst the Healthy Child Programme and government policy both encourage the active involvement of fathers this has not always transferred into practice either in Manchester or elsewhere in the country apart from specific services available for teenage fathers (not available in Manchester). In this case it was apparent that Child K1’s father was initially involved in the care of his child. There is no evidence however that he was encouraged to continue his input and become fully involved with the professionals working with Child K1. His mother provided care to Child K1 from when K1 was a few weeks old. She attended hospital appointments and took responsibility for Child K1’s asthma plan. Grandmother informed professionals that she had Parental Responsibility (PR) and made excuses for Child K1’s father when he was not available or involved in Child K1’s care. In discussion with her as part of this review a Residence Order was never applied for and she was told it was unnecessary as Child K1’s father had parental responsibility. Professional's difficulty in engaging with Child K1’s father at times meant that there was little discussion with him in relation to his responsibility as a parent; and no clear insight into what he could positively or negatively contribute to Child K1’s care, no knowledge of his understanding in relation to Child K1’s asthma; or his thoughts in relation to smoking cessation. 31NSPCC research has identified that the use of a screening tool over a period of time can enable professionals to better identify the level of neglect and changes that have occurred between one episode of screening and the next. National Evaluation of the Graded Care Profile Robyn Johnson and Richard Cotmore NSPCC Evaluation department 2015 MSCB Child K1 SCR Page 24 of 27 8.2 Finding 5: Information sharing between and within agencies was not always in line with good practice. This resulted in professionals not having all the information available when assessing the risk to Child K1. 8.2.1 Health Professionals - Whilst most health professionals communicated well, there was a lack of communication with the GP by the HV and asthma nurse; and between the paediatricians involved and acute and community services. The paediatrician at RMCH for instance being unaware of the home conditions and the social concerns until asked to attend the practitioner event. This combined with the lack of a known lead professional reduced the opportunity for an informed united front to be shown to grandmother in the management of Child K1’s care. Apart from the medical aspect of Child K1’s care the social concerns were not clearly identified on an ongoing basis between those health professionals caring for Child K1. This resulted in no clear plan in relation to smoking cessation for grandmother and father, and no way of identifying those times Child K1 was not seen for a scheduled appointment in either the hospital or community. A professionals’ meeting and supervision of complex cases would have been of benefit in this case. Currently there is little opportunity for this to occur, particularly in the acute setting. Professionals' meetings are not often held in Manchester, due to the wish to work fully with parents; this is a pattern found elsewhere in the country as well. However used effectively they can be of great benefit in clarifying and agreeing plans of action and providing a united front. 8.2.2. Another area where communication and information sharing was identified as difficult by practitioners related to the differing policies in place and systems of patient recording resulting in not all information being known to all practitioners. This is a national problem and in particular hinders communication between professionals working in different organisations, however it is also a recommendation of good practice identified in the London Asthma Standards32 and has been addressed elsewhere by the provision of honorary contracts and clear information sharing protocols being in place. 8.2.3 The housing provider involved with the family, were not invited to any CP/CiN meetings and there does not appear to have been any communication with them despite agencies being aware of the rent arrears and the condition of the house. This lack of involvement of housing with CSC in particular is a national problem and is not made easier by the outsourcing of local authority housing stock. 8.2.4 General Practitioners The RCGP’s guidance33 is very clear in relation to the role of GPs when working with CSC. The guidance states that: “GP’s have key roles in appropriate information sharing with children’s social care when enquiries are being made about children. GP’s and practice staff should make available to child protection conferences relevant information about a child and family, whether or not they are able to attend”. In this case GP records did not link the family by address, resulting in the significance of parental attendance at the surgery not being considered in relation to Child K1 and their needs. This was 32 London Children and Young People Strategic Clinical Network. London Asthma Standards for Children and Young People NHS England June 2015 33 Safeguarding Children & Young People A Toolkit for General Practice 2011 RCGP MSCB Child K1 SCR Page 25 of 27 compounded by Child K1’s records not being EMIS coded in relation to their health and social needs and K1's multiple missed appointments not being highlighted. This resulted in the report to the Initial Child Protection Conference not including all the relevant information relating to Child K1‘s father and grandmother. 9.0 WERE THERE ANY AREAS OF GOOD PRACTICE? 9.1 Areas of good practice were identified within the analysis of practice; however of particular note is the prompt and very appropriate response by the ambulance service to Child K1’s home conditions on the 11/02/2016. 10.0 RECOMMENDATIONS THE BOARD MAY WANT TO CONSIDER 10.1 The MSCB ensure all agencies are aware of, and compliant with the current MSCB Neglect Strategy. 10.2 MSCB and Public Health prioritise staff training thus increasing knowledge around the management of smoking cessation, including how to reduce the impact of ETS on vulnerable children and adults. 10.3 Commissioners of Services ensure current education and advice in relation to asthma management be updated to comply with current NICE Guidance. 10.4 NICE be contacted and asked to consider whether the impact of ETS could be more explicitly recognised and linked to safeguarding within their Asthma Guidance. 10.5 Lead health professionals be identified for all children who have a chronic health problem or a disability in line with current good practice34, with clear and robust communication systems in place to ensure effective sharing of information. 10.6 Medical staff be reminded of the need to clearly identify the risks and impact on children when liaising with CSC; the need to provide clear evidence based reports which include parental strengths and weaknesses; and when unable to attend child protection meetings, ensure that their report and concerns are represented by another health professional. 10.7 The MSCB include as part of their audit programme a review of professionals’ engagement with all those with parental responsibility, with a particular focus on fathers’ and whether they are always appropriately included and involved in decision making relating to their child/children. 10.8 The MSCB to be assured that effective processes are in place to share and receive information from housing providers when any family assessments are being carried out. 10.9 The MSCB to seek assurance that a robust pathway is in place to support practitioners in primary care to participate in the child protection process and that this audited to assess improvement. 34 National Service Framework for Children and Young People Standard 8: for Disabled Children and those with Complex Health Needs MSCB Child K1 SCR Page 26 of 27 11.0 CONCLUSION 11.1The incidence of childhood asthma in Manchester is the highest in the country, an unsurprising statistic when one considers the social and economic deprivation and the high incidence of smoking. It is therefore important to consider the impact of this on both families and the services providing support when caring for children with asthma and concerns in relation to possible neglect. 11.2 Child K1 was a well-loved little child who developed asthma at an early age, becoming severely unwell very quickly on a number of occasions. Child K1's grandmother acted appropriately to those acute occasions, calling 999 and initiating CPR. Child K1’s home environment however was not conducive to good asthma management, and whilst Child K1’s grandmother was provided with the support to enable change to happen, professional attempts to promote that change were largely unsuccessful. 11.3 Neglect is particularly difficult to manage, as it occurs over time and care can improve and then deteriorate. It is even more so when a child has a chronic illness or disability. In this case one aspect of neglect came from smoking. A habit that whilst socially unacceptable is not treated in the same way in the UK as many other harmful and addictive substances, the emphasis being on enabling smoking cessation. The assessment of the risk of neglect in such cases needs to be clear and explicit between both professionals and the carers and between professionals themselves, taking into account the risk of smoking triggering or exacerbating asthma on a child by child basis. In Child K1’s case unless there had been a period when they had not been exposed to ETS in particular it is impossible to identify the impact this had on their asthma. MSCB Child K1 SCR Page 27 of 27 12.0 APPENDICES 12.1 Appendix 1 Review Team Members Role Organisation Designated Doctor for Safeguarding Children Manchester CCG Education Case Worker Manchester City Council Named Nurse Safeguarding Children Central Manchester University Hospitals NHS Trust Detective Inspector Public Protection Division Greater Manchester Police Service Manager Social Work Team Manchester Council Assistant Director of Nursing Pennine Acute NHS Trust Locality Manager Integration and Prevention Manchester City Council Youth Justice Manager Manchester City Council Director of Revenues New Charter Housing Acting Designated Nurse for Safeguarding Children Manchester CCG 12.2 Appendix 2 NICE QUALITY STANDARDS FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA Statement 1 People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance. Statement 2 Adults with new onset asthma are assessed for occupational causes. Statement 3 People with asthma receive a written personalised action plan. Statement 4 People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment. Statement 5 People with asthma receive a structured review at least annually. Statement 6 People with asthma who present with respiratory symptoms receive an assessment of their asthma control. Statement 7 People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation. Statement 8 People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation. Statement 9 People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge. Statement 10 People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2working days of treatment. Statement 11 People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service. In addition, quality standards that should also be considered when commissioning and providing a high-quality asthma service are listed in related NICE quality standards. |
NC51186 | Life-threatening injuries to a 3-year-old child in March 2016. The child was found lifeless by an older sibling, hanging from a soft toy trapped on the top rail of a bunk bed. Ambulance services were called three times before enough information enabled paramedics to attend and take the child to hospital, where they recovered. Concerns recorded by Police related to home environment, particularly lack of food and toiletries, and poor cleanliness. History of substance abuse, child supervision concerns, and domestic abuse in the family home. Children were subject to child protection plans for emotional abuse and neglect. Reports to Police from neighbours and Mother relating to anti-social behaviour and domestic incidents prior to the incident. Learning includes: children's behaviour can be a means of communication and lively and unpredictable conduct could be indicative of exposure to domestic violence; clearer case management with specific advice regarding interventions may have prevented more incidents occurring and triggered further child protection enquiries; provide training for frontline staff in relation to recognising and implementing strategies for disguised compliance at an early stage. Ethnicity and nationality not stated. Recommendations include: consider alternative approaches to capturing the child's voice forms part of any 'direct work with children' training and part of the mentoring process for social workers in their first year of practice; consider if letters or other more suitable forms of communication depending on their particular needs, advising families of the decision to conduct a Child Practice Review are delivered by the most appropriate person.
| 1 Child Practice Review Report Cardiff and Vale of Glamorgan Regional Safeguarding Children Board Extended Child Practice Review Re: C&VRSCB 02/2016 Brief outline of circumstances resulting in the Review To include here: - Legal context from guidance in relation to which review is being undertaken Circumstances resulting in the review Time period reviewed and why Summary timeline of significant events to be added as an annex Legal Context An Extended Child Practice Review was commissioned by Cardiff and Vale of Glamorgan Regional Safeguarding Children Board (CVRSCB) on the recommendation of the Child Practice Review Sub-group in accordance with Social Services and Well-Being Wales Act 2014 Part 7, Volume 2 Child Practice Reviews guidance. The criteria for this Review were met under section 3.12 of the above guidance namely: A Board must undertake an extended child practice review in any of the following cases where, within the area of the Board, abuse or neglect of a child is known or suspected and the child has: died; or sustained potentially life threatening injury; or sustained serious and permanent impairment of health or development; and, the child was on the child protection register and/or was a looked after child (including a care leaver under the age of 18) on any date during the 6 months preceding the date of the event referred to above; or the date on which a local authority or relevant partner identifies that a child has sustained serious and permanent impairment of health and development. The terms of Reference for this review are at Appendix 1. 2 Incident Leading to Referral March 2016 – The child who is subject of this review was aged three when discovered hanging at the home address by an older sibling. The child was unconscious and described as pale and lifeless having become trapped in a soft toy that was hanging off the top rail of a bunk bed. The child was at home with mother and siblings at the time of the incident. The child’s sibling was asked to call an ambulance but the phone was not working. Mother went outside and a second call for an ambulance was made, but only the location was confirmed before Mother left the scene with the child and one of the child’s siblings. A third call was then received five minutes later from an address belonging to the child’s grandfather. This third call with more precise information enabled the paramedics to attend promptly and provide immediate medical attention before conveying the child to hospital. The child made a full recovery. When police officers attended this incident there were significant concerns about the home conditions, namely little food, a multitude of dead flies in the kitchen, no toilet paper or tooth brushes and a make do kitchen prep area in one of the bedrooms. Police considered using Emergency Powers of Protection to safeguard the children. However, Children’s Services had arranged for the children to stay with their grandmother for the night. There were concerns historically around domestic abuse within the family home. File recordings show a social worker had visited the home address in mid-March 2016. The social worker’s recording of this planned home visit describes difficulty entering the house due to ‘a wardrobe being on its side in the passage area’. Apart from the front room, the social worker did not access other rooms in the house during this visit. Whilst professionals in attendance at the strategy meeting called in response to this incident expressed their concerns over the domestic violence, mother’s lack of engagement with services and her showing ‘…little willingness to make changes’, they agreed there was ‘no evidence to suggest this (the incident) was anything other than accidental’. The minutes to the strategy meeting conclude ‘This near fatal incident cannot be attributed to mother directly although professionals feel it is symptomatic of her poor boundaries, lack of supervision and inability to meet her children’s needs safely’. Hence, it was agreed that the child had sustained a potentially life threatening injury and it was recommended that a referral be made with regard to a Child Practice Review. Significant Events Prior to the Period Under Review Cardiff Children’s Services had been aware of this family since 2007 following police reports concerning a lack of appropriate supervision of the children. Upon investigation, the child’s mother denied the allegations made – resulting in no further action by Children’s Services. A further referral received in 2007 reported similar concerns around the children’s supervision in addition to allegations around the mother’s substance abuse. Children’s Services carried out an initial assessment in response the second referral – the outcome of which was no further action and the case closed. In December 2012, Children’s Services received a referral following a domestic incident between the child’s parents. The initial assessment completed following this referral highlighted a number of 3 other worries in respect of the child’s developmental needs, parenting capacity and environmental factors. Due to the number of concerns identified, the case progressed and in February 2013, the children became subject to child protection plans following registration on the Child Protection Register (CPR) under the categories of Emotional Abuse and Neglect. To help the family establish routines in the home and offer advice on parenting, Children’s Services provided a Family Support Worker (FISS) – who visited on a regular basis. A Tenant Support worker was in place to help with the family’s housing issues, the mother was encouraged to seek support from her GP for her health needs and the father was signposted to services for support with substance misuse. As a means of safeguarding the children from the risks associated with substance misuse, the father’s contact was managed and supported by family members. All parties signing a Written Agreement to that effect. During the time that the child protection plans were in place, home conditions fluctuated, parental engagement with support services was sporadic and Children’s Services received 17 police reports all in relation to domestic abuse between the parents and other family members. The children were present during all of the domestic incidents. Around this time, Children’s Services file notes show that the FISS worker was raising concerns with regards poor home conditions and the mother ‘not being vigilant in her supervision’ of the children. Furthermore, a number of anonymous referrals from persons within the community were received highlighting concerns in relation to arguments at the home address, shouting and use of foul language by both parents towards the children. By March 2014, a Written Agreement was in place to safeguard the children from further altercations. Child protection planning continued and in April 2014, the Public Law Outline (PLO) commenced. By October 2014, the mother admitted breaching the Written Agreement and Children’s Services file notes made at the time show the mother gave inconsistent stories regarding the contravention. Although file notes show the social worker discussed this breach with the mother during a child protection visit, the notes do not show the actions taken as a result. In complying with his licence conditions for a previous offence (Possession of Class A drugs), by July 2014 professionals in attendance at the Review Child Protection Conference agreed the father could assist the mother with the children in the home ‘for a 4 week period of observation’. Probation supported this decision by agreeing to vary the father’s licence conditions to allow him daily access to the family home. The PLO process ended in August 2014 due to the ‘improvements’ (good school attendance, better home conditions and positive observations of mother’s interactions with the children). The father continued to comply with his licence conditions until it ended in October 2014. The children’s names remained on the CPR until the latter part of April 2015. Significant Events During the Period Under Review April 2015 – Abandoned 999 call to the police and tracked to the family’s home address. Father was intoxicated and had sustained injuries during an earlier pub fight. The 999 call stemmed from an altercation involving the father and mother’s sibling. The father was arrested for being ‘drunk and disorderly’ and later charged with this offence. The police shared the incident information with social services’ Emergency Duty Team and both parties agreed that the mother had acted appropriately to safeguard the children. No further action taken. 4 April 2015 – Mother makes two 999 calls to the police during the course of the day reporting the father to be outside the family home and causing a disturbance. Mother alleges the father was subject to bail conditions that stipulate he is not to be near the location. Mother refuses to provide a statement and the police take no further action. April 2015 – Multi-Agency Review Child Protection Conference (RCPC). Father attended, mother did not. Independent Reviewing Officer’s (IRO) report states the parents had made positive changes. For example, the home conditions had improved to a ‘satisfactory’ standard; there were ‘huge improvements in school attendance…both parents have engaged with services and appointments and professionals have noted improvements in all areas’. Unanimous decision to remove the children’s names from the CPR with ongoing case management on a ‘child in need’ basis. April 2015 – Children’s Services Supervision recording. File notes show some discussion around the improvements made by parents over the previous 6 months, leading to child’s name coming off the CPR. This decision reflected the improvements noted by agencies who had attended the RCPC. Guidance offered as follows: ‘A short period of child in need monitoring is required to ensure the changes are continued, then professionals to take over the monitoring and case to be closed’. May 2015 - Initial Child in Need meeting. Attended by social worker, health visitor and teaching professionals. Parents did not attend. It is usual practice to arrange the date of the Initial child in need planning meeting at the RCPC. It is therefore assumed the child’s father was aware of this meeting date given he attended the RCPC. There is no evidence on file to show how – or whether - the child’s mother was informed of the date. Professionals in attendance at this ‘attempted’ meeting shared concerns regarding a decline in school attendance, the children’s presentation and the emotional wellbeing of the older sibling. Social worker advises of need for further meeting given parents’ non-attendance. File notes show meeting re-arranged for July 2015 so professionals in attendance presumably took note of the rearranged date. File notes do not show how or who informed the parents – although some dialogue must have been had with the mother as she did show up at the rearranged meeting. During the intervening period further Public Protection Notifications (PPNs) were submitted by police following incidents of domestic abuse. In addition, agencies received further anonymous referrals reporting similar concerns in respect of substance misuse and anti-social behaviour. May 2015 – Complaint from neighbour. Further report of Anti-Social Behaviour (ASB), arguments and substance misuse taking place at home address, shared by housing. Social worker advised caller to phone police and update them of a result of a home visit. June 2015 – Domestic abuse incident reported by a member of the public to police. Children sighted as safe and well by police officers. A PPN was completed and mother assessed as ‘Medium’ risk in terms of further domestic violence incidents occurring. The form was shared with Cardiff Women’s Centre (CWC), NHS and Intake & Assessment. The PPN was also tasked to South Wales Police Child Abuse Investigation Unit. An officer from the South Wales Police Child Abuse Investigation Unit (CAIU), contacted social 5 worker to make her aware. Upon receipt of the PPN – social worker has recorded –“It is a concern that mother is in touch with father and this needs to be discussed with mother by the social worker.” July 2015 – Mother made two calls to police reporting domestic incidents involving father attending her address and ‘smashing it up’. It transpired that father was trying to retrieve property. PPN’s completed and shared. Mother also contacted Children’s Services stating that father’s behaviour had become erratic over the previous weeks. Referred to police and Cardiff Women’s Aid. July 2015 - Rescheduled ‘Initial’ Child in Need meeting. Attended by social worker and a teaching professional. The child’s mother arrived late (towards the end of the meeting) and stated that she has been having issues with the child’s father and had been advised to contact Women’s Aid/Women’s Safety Unit. The child’s father did not attend this meeting. File notes show meeting re-arranged for September 2015. As with the previous meeting, the teaching professional in attendance presumably knew of the rescheduled date but notes do not specify how the parents and other professionals were informed. August 2015 – Children’s Services supervision recording meeting - Mother does not want any support services but school are not happy for the case to be closed due to the children being tired and older sibling’s behaviour in school being challenging. A child in need planning meeting has been arranged for early September and case to be closed if no significant concerns arranged. This was the second recorded formal supervision session in over 3 months (the first supervision having taken place in April 2015). September 2015 – Further re-scheduled ‘Initial’ Child in Need meeting. Children’s Services file notes from this date only state ‘No one attended’. As stated above, as there is no evidence on file to show how parents and professionals were invited, it is unclear as to whether people knew of this meeting. This was the 3rd ‘failed’ meeting in terms of full attendance and ongoing ‘child in need’ planning. Subsequent Children’s Services file recordings in respect of a timely follow up to this failed meeting are lacking in detail. However, in a recorded ‘child in need’ visit undertaken in October 2015, mother is noted to have stated she did not ‘turn up at the last meeting due to childcare’ and when offered a follow up meeting it is stated that the mother declined. There are no file recordings to show any communication with the child’s father at this time. December 2015 – Children’s Services close the case. The closure report provides the following reasons behind the decision: ‘Children’s Services had not received an incident report since July 2015. During the ‘child in need’ period (father) has not been observed under the influence of drugs during visits to the family home’. The children were described as ‘happy and calmer than previously seen’ and ‘well-presented and appropriately dressed’. The Mother informed social worker she does not want support from social services. The mother declined further support and the report concludes ‘There is no current role for the social worker and it is apparent that mother is able to meet the needs of the children without Children’s Services involvement at this time’. Whilst the remarks within the closure report regarding the children’s emotional wellbeing and general presentation can be verified from the home visit recordings around the time, the timeline clearly shows the comment regarding ‘no incident reports’ being received is incorrect. In October 2015, Children’s Services received a call from a neighbour reporting the child was playing unsupervised in her garden with a dog and raised concerns regarding a potential injury. 6 There was no follow up to this report. On consecutive days in December 2015, Children’s Services received communication from the Anti-Social Behaviour team regarding multiple complaints from neighbours. There is no evidence on file to show the student social worker (allocated to work with the family at the time) brought this to the attention of her practice assessor and due to the lack of recording, it appears the information prompted no further action at this time. In December 2015, Children’s Services received an anonymous call regarding the mother’s sibling, reporting concerns over the individual’s ‘aggressive and volatile’ behaviour and alcohol misuse. The neighbour reported hearing doors slamming, ‘shouting and screaming’ whilst the children were present. The unannounced ‘child in need’ visit recording from the same day shows these concerns and those of the Anti-Social Behavioural team were discussed with the mother. The mother denied the allegations against her sibling and told the student social worker she ‘did not care’ about the reports of anti-social behaviour potentially leading to her eviction. Later that month, which was the day before the case closed, Children’s Services received a further call regarding the mother’s sibling alleging the individual a threat to kill him approximately 5-6 months ago. The caller stated he had not reported the matter to the police because he feared the mother’s sibling. January 2016 – A new report of domestic abuse received by police following a 999 call from mother. Father arrested by police but as the mother refused to provide a statement of complaint a prosecution could not proceed. As such, police released the father with no further action. The incident prompted further involvement from Children’s Services and child protection enquiries commenced. February 2016 – Initial Child Protection Case Conference (ICPCC) held in respect of all the children. Those in attendance unanimously agreed the children were at risk and their names subsequently placed on the CPR under the categories of Neglect and Emotional Abuse. Practice and organisational learning Identify each individual learning point arising in this case (including highlighting effective practice) accompanied by a brief outline of the relevant circumstances Practice and Organisational Learning As part of this Child Practice Review a Learning Event was held engaging practitioners involved with this child. The reviewers would like to thank all those who attended the learning event and their contribution to the learning from this review. Incidents where a child could have potentially died or come to significant harm can be distressing and we are grateful to all the practitioners for their attendance, candour and willingness to share viewpoints and learning. However, it was clear to the reviewers at the start of the learning event that certain staff members had not received appropriate preparation to attend and were anxious expecting it to be ‘about blame’. This anxiety was further exacerbated by the fact that some attendees mistakenly believed that the child subject of this review had died. Some practitioners had not seen their timeline prior to attendance and it is worth noting 7 that those who had earlier access were able to bring additional information to the event and thereby enhance the learning experience. The presence of a Local Authority legal representative would have potentially added additional value to the event and provided context to some of the threshold decision making in this particular case. Legal representation should be a consideration when planning future learning events. Recommendation 1: Panel members representing Agencies at Child Practice Reviews should consider requesting a timeline from its Legal team in cases where legal involvement formed part of the case management. Much of the practice and organisational learning considered below was raised at the learning event. The Voice of the Child Previous reviews have emphasised ‘…the importance of seeing, hearing and observing the child’. (Ofsted, 2011:6) and highlighted the need for children to meet on their own with practitioners, away from parents and carers in an environment where they feel safe so that the children can speak about their concerns. In this case, during the first period of child protection planning between February 2013 and April 2015, the social worker demonstrated good practice and saw the child at home during planned and unannounced visits completed at various times of the day. However, although the child was seen during each visit, a parent was always present and there is no reference in social worker recordings of the child having been spoken to alone. As such, the child’s ‘voice’ was difficult to find. It is acknowledged that throughout the period identified in the timeline the child was of a young age (2-3 years old) and known to have some speech and language delay - making it difficult for the child to express feelings in words. Yet, there is little evidence of practitioners using alternative approaches such as direct work using playful activities to obtain the child’s views. Other reviews involving young children have stressed the importance of practitioners listening to what older children in the home had to say with findings concluding the failure to speak to all children in the home resulted in ‘vital components’ being missed in assessments (Ofsted, 2011:7). Here, other than general conversations with the child’s siblings around school, hobbies and favourite items of clothing it is unclear as to whether any of the children’s worries, wishes and feelings were fully explored until January 2016. Attention to the reporting and recording of observations made by the social worker during home visits throughout 2015 is evident. For example, practitioner notes described the child’s behaviour as ‘boisterous’ and ‘erratic’ with incidents of head-butting the sofa, hitting out at siblings, attempts to pull down curtains and playing dead on the floor being observed frequently. Practitioners need to recognise that children’s behaviour can be a means of communication (Wilson et al, 2008) with research (Stanley, 2011) suggesting that a child’s lively and unpredictable conduct could be indicative of exposure to domestic violence. Given the practitioner’s observations of the child’s rowdy behaviour, this arguably presents as a missed opportunity to have talked to the child about personal feelings. 8 Cardiff Council has since introduced the Signs of Safety model of working across Children’s Services. One of the key aims of the Signs of Safety model is to ensure the voice of the child is clear, and the tools the approach adopts underpins this requirement. Recommendation 2: All agencies to consider training to ensure alternative approaches to capturing the child’s voice forms part of any ‘direct work with children’ training and the concept forms part of the mentoring process for social workers in their first year of practice. Recommendation 3: Cardiff and Vale Regional Safeguarding Board via the Child Practice Review/Adult Practice Review (CPR/APR) Sub Group need to be satisfied that Social Workers are actively offering an advocate to children in receipt of Local Authority care and support. Family involvement with the review process The parents of the child were informed in writing of the decision to undertake this Child Practice Review. However, both parents claimed to have not received/seen the letters when contacted by the reviewers. Recommendation 4: CPR Panels to consider if letters or other more suitable forms of communication depending on their particular needs, advising families of the decision to conduct a Child Practice Review are delivered by the most appropriate person. During the telephone call to the child’s mother in September 2017, she explained that since receiving a mental health diagnosis, she opens no mail and possesses no mobile phone as she finds ‘communication and messages stressful and upsetting’. She was critical of Children’s Services involvement reporting more could have been done to keep the child’s father away from her, suggesting Children’s Services representatives could have taken ‘…the kids to school every day’. That said, Children’s Services file recordings made in July 2014 clearly show both parents (and professionals involved) agreeing with the plan of the father providing help with the children in the home. The child’s parents have now separated and are no longer in contact with each other. In an attempt to include their views in this review, both parents had the opportunity to meet independently with the reviewers on two occasions. Regrettably, despite the parents choosing the dates, times and venues of the meetings, each failed to attend and neither attempted to re-establish contact with the reviewers thereafter. It is unfortunate, that other than the mother’s comments noted above, the family’s views are missing from this report. Debatably, the experience the reviewers had in their attempts to engage the parents in the review process mirrors that observed throughout the timeline with the concept of ‘disguised compliance’ (Brandon et al, 2008:106) being noted by the panel and identified by practitioners at the Learning Event - the risk factors and learning of which is discussed later in this report. 9 Interagency Communication and Information Sharing Research and findings from previous child practice reviews has well established that effective practice in safeguarding stems from efficient and effective information sharing between multi-agency partners (Munro, 2010). It is clear from the timeline that agencies involved in this family were receiving a great deal of intelligence regarding the family’s activities and the review identified a number of instances that evidenced good practice of information sharing. For example, the incident of domestic violence between the child’s parents during January 2016 prompted swift action from Children’s Services upon receiving the report from the Police. However, the timeline also demonstrates instances where information sharing did not occur. For instance, the complaints received by Cardiff Housing during April, November and December 2015 from the family’s neighbours over domestic violence, cannabis use, drug dealing, use of foul language in the street and shouting at the children was not shared with the Police. Likewise, there is no record of the social worker talking to the police in response to the reports of drug use. Further missed opportunities were highlighted at the learning event with practitioners drawing attention to times where information was passed to some partner agencies that either resulted in no action or a delayed response. For example, the information from the complaint received during April 2015 passed from the Anti-Social Behaviour team to Children’s Services within 3 days. However, the extent of the telephone call appears limited to whether the case was ‘open’ or not and there is no record of Children’s Services requesting or receiving a Multi-Agency Referral Form (MARF) in response to this information – perhaps highlighting a lack of understanding around the referral process. Equally, although the Anti-Social Behaviour team did pass on the information in the telephone call to Children’s Services, this bypassed the established route for sharing information via its single point of contact – the Social Inclusion Unit (SIU). In response, the review has since learned that Cardiff Housing is currently assessing its process to ensure it is more robust and its staff are to receive refresher training. Recommendation 5: Practitioners at the learning event identified that the Housing teams are a particularly useful source of information with extensive case recordings highlighted as an example of good practice. Cardiff Local Authority senior management teams to develop effective mechanism for ensuring appropriate Housing representation (including Tenancy support workers) at multi-agency meetings to promote the sharing of information and the operation of the Multi-Agency Safeguarding Hub (MASH). The learning event highlighted a further missed opportunity for agencies to intervene sooner when discussing the 999 call made by the child’s mother to the Police in early July 2015. Here, Children’s Services received the police report because the attending officer was concerned over the ‘…state of the house and that children live there’. This was the second reported incident to Children’s Services in a week and the receiving team manager subsequently identified the need to assess the status of the parents’ relationship and the home conditions. The review identified that clearer case management advice giving specific timescales and instructions regarding intervention, may have prevented more incidents occurring and triggered further child protection enquiries and the need for legal advice – particularly given the children were no longer subject to child protection plans as their names had been removed from the CPR 10 weeks previous. 10 As part of the Signs of Safety model of working, the project ‘Steering Group’ is producing a new online referral form that will include an additional question relating to whether agencies have made previous referrals – thus providing an additional prompt to the individual responsible for determining subsequent actions from the referral. Feedback from the learning event further identified the inconsistent approach to requesting and use of police welfare checks. The term ‘welfare check’ has become widely established across many agencies and used when an external agency requests that police visit someone who is believed to be vulnerable, or at risk for a wide variety of reasons. The learning event heard that in the majority of cases the responsibility for these checks, or the management of the specific risk or vulnerability, should not fall to police. A typical ‘welfare check’ occurs where police officers are requested to attend an address and speak to a named occupier to check they are alive and well, that is, to determine the ‘existence of life’ and report back to the requesting agency. This type of request is entirely appropriate and in line with core policing duty and skills. However, a wide range of other requests are now being made of police including: - Checks on individuals who have failed to attend routine medical appointments. - Checks on individuals who are not reported or classed as ‘missing’ but apparently absent from a place they should be or are expected to be. - Checks to establish if an individual has taken their medication. Police are unlikely to have a role in the above scenarios – unless the requesting agency is able to explain and evidence an immediate risk to life. Practitioners at the learning event also highlighted that the mere presence of police can have a negative impact for those who are living with mental health issues or recovering from crisis – particularly when there is no reason for police involvement. Practitioners from Housing and Independent Domestic Violence Advocacy (IDVA) services highlighted the positive support their departments had received from police when requests for welfare checks had been made and where good evidence of immediate risk that something serious was about to or already occurred had been presented. The procedures were less clear regarding ‘non-emergency’ welfare checks with practitioners from Children’s Services voicing problems in having such requests accepted by the police – a matter that typically causes tension amongst agencies. Arguably, the friction is exacerbated given the Emergency Duty Team do not undertake such checks due to its resources and the team’s remit in covering Cardiff and the Vale for matters regarding children and adults. Recommendation 6: Cardiff & Vale Regional Safeguarding Board’s Policies, Procedures & Protocols Sub Group to develop a local policy relating to welfare checks and produce guidance around requesting such checks for partner agencies to follow. The panel meetings and learning event held in respect of this review highlighted the need to ensure that when managing a case on a multi-agency basis there needs to be an opportunity to share information, discuss it, reflect, challenge and agree actions together. This generated much discussion around partner agency attendance at Children’s Services meetings. The reviewers recognise that there is no statutory requirement for police to 11 attend all meetings – RCPCs providing an example. Yet, given the amount of police involvement during the 26-month period of registration, consideration should had been given to police attending the RCPC in respect of this family in April 2015 - particularly as the child’s father had allegedly breached his bail conditions around the same time by attending the family home in an intoxicated state. The RCPC report produced by the Independent Reviewing Officer (IRO) at the time shows some discussion of the incident took place with those in attendance. Unlike the child’s mother, the father attended the RCPC yet his response when asked about the incident was ‘I had gone to the football with friends and been drinking. At home-time, I automatically went to the house but (the mother) said I had no chance of being allowed in if I’d been drinking. I didn’t go there to cause trouble and police just moved me on’ appears to have gone unchallenged. Furthermore, there is no indication of attendees at the RCPC having full knowledge of the father’s bail conditions. Hence, the view of practitioners at the learning event was the police would have been in a position to contribute substantially to the RCPC and the decision to remove the children’s names from the Child Protection Register may had been disputed. That said, the learning event highlighted the issue of invitations to some Children’s Services meetings either not reaching the recipient or arriving too close to the event or indeed after the meeting had occurred. Recommendation 7: South Wales Police representatives to review procedures and policy around police officer attendance at RCPCs. The reasons behind the mother’s absence from the RCPC held towards the end of April 2015 is somewhat unclear – although the calls she made to emergency services on the days leading up to the conference probably offers some explanation. There is no evidence in the form of documentation to show the risks associated with the domestic abuse history between the parents was considered and a ‘split’ conference proposed as a means of reducing potential danger. Furthermore, file recordings show no reference to a follow-up meeting with the child’s mother to discuss the outcome of the RCPC and decisions made thereafter. In contrast, the social worker allocated at the time of the child’s second period of child protection registration (February 2016) demonstrates good practice in terms of documentation and risk management. The timeline shows the risks associated with the parents’ domestically violent past was considered (in the context of them both being invited and needing to attend the child protection conference). It is unfortunate therefore, that despite the mother expressing a reluctance to attend the same conference as the father the request for a ‘split’ conference, was declined by the IRO. A file recording made in February 2016 outlines the discussion between the social worker and the IRO whose view was that unless a specific Order stipulating the parents were not to have contact was in place, then the ‘split’ conference would not be agreed. The IRO did agree to speak to both parents prior to the RCPC but there is no recording on file to show this discussion occurred. For clarity, a different IRO chaired the RCPC. Recommendation 8: Cardiff and Vale Regional Safeguarding Board to review current practice and procedures for addressing the needs of vulnerable persons and victims who are required to attend Child Protection Conferences. Consideration to be given as to whether the use of facilities that would enhance the ability to be more effective 12 participants through the implementation of ‘special measures’ such as the use of Live-link technology and screens. Disguised Compliance The practitioner discussions stemming from their reflection of the timeline demonstrated a clear consensus over the family’s disguised compliance with perhaps the most notable example of this being the parents’ almost immediate disengagement when the children’s names came off the Child Protection Register with each failing to attend the Initial Child in Need Planning meeting in early May 2015. By this time, the Health Visitor was already raising concerns over the family’s need to re-register with a GP and Education professionals were worried over the decline in school attendance by the child’s siblings. Recommendation 9: Once GP’s are aware that a family is off-listed from their practice due to lack of engagement, the Primary Care Team, Cardiff and Vale University Health Board must be notified immediately. The Primary Care Team will notify Children’s Services within 1 month of the de-registration to ensure that any children’s needs within the family are not compromised. Moreover, the timeline shows a series of further complaints made from neighbours in respect of anti-social and alleged criminal behaviour at the home – which to the credit of the Anti-social Behaviour Officer, was brought to the attention of Children’s Services. It is apparent the mother maintained a level of cooperation with the Housing teams, for example, making herself available for a home visits and returning calls to Tenancy Management. This is perhaps an indication of the good relationship the child’s mother had with Housing and as indicated in research, an attempt to deflect attention from her lack of engagement with other services and avoid raising suspicions (NSPCC, 2014). Here, a seemingly over optimistic view of the parents’ progress and their ability to manipulate or deceive services into believing they were sustaining positive change caused delays with case management. The rescheduled dates of the Initial Child in Need planning meetings perhaps providing evidence of the drift. Previous reviews have highlighted situations where professionals have delayed or avoided interventions owing to parental disguised compliance. This review is consistent with previous findings and emphasises the need for agencies to ensure adequate training is provided to frontline staff in relation to recognising and implementing strategies around the issue of non or disguised compliance at an early stage. Recommendation 10: Cardiff and Vale Regional Safeguarding Board to consider circulation of the Multi-Agency Protocol on Working with Families who are not Cooperating with Safeguarding Issues amongst Children’s Services staff and its partner agencies on an annual basis. 13 Recommendation 11: Cardiff and Vale Regional Safeguarding Board’s Training Sub-Group to consider making ‘Disguised compliance/Dealing with Difficult, Dangerous and Evasive Parents’ training mandatory for all practitioners. Alternatively, consideration that the said training forms part of the first 3 years in practice programme for newly qualified social workers. Thresholds and Decision Making The multi-agency decision to continue working the case on a ‘child in need’ basis – despite the concerns of some agencies and the parents’ non-engagement - prompted much debate at the learning event around thresholds and decision making in terms of case management, worker allocation and legal input. In this case, practitioners from some partner agencies expressed confusion over the legal processes associated with pre and care proceedings with others questioning why child protection procedures were not initiated again when the child’s parents - and indeed some of the professionals involved - failed to attend the third rescheduled Child in Need meeting in early September 2015. In October 2015, the time the student social worker took on the case, the Child in Need planning meeting was still outstanding and as discussed earlier in this report, agencies and members of the community were still raising concerns for the child’s welfare. Practitioners at the learning event heard that as a final year social work student, this case is typical of the type that would be allocated – particularly given the student was soon to qualify. Furthermore, the social work student’s practice assessor was the previously allocated social worker – thereby providing consistency in terms of case management and knowledge. That said, there is clear evidence of oversight in terms of Children’s Services file recordings showing no formal handover of the case. Despite the continued referrals from members of the public, towards the end of December 2015 the case closed to Children’s Services. As with the initial case allocation to the student social worker, there is no recording to show a formal supervision discussion took place regarding case closure. Practitioners attending the learning event heard the decision to close was taken by Children’s Services management and not the student – a decision made despite the Child in Need meeting never taking place. This review demonstrates the crucial involvement members of the community play in safeguarding children. Throughout the period under review, there are clear examples where members of the public have contacted agencies - including Children’s Services – to express significant concerns regarding the children and the behaviour and fitness of the parents. Yet, it was not always clear what action (if any) was taken and the decision to close implies that referrals made by members of the public are not taken seriously - the fact that a further incident of domestic violence took place four weeks after the case closed perhaps substantiates this point. It is recognised that as a ‘child in need’ case, the parents had the right to choose not to engage or accept services. Yet, this review arguably demonstrates the importance of compiling a chronology of significant events. Chronologies can greatly assist multi-agency assessment of a child’s circumstances and provide evidence of past parenting experience, including possible former instances of disguised compliance. There is no evidence that an up-to-date chronology was produced or maintained by Children’s Services staff allocated 14 to work with this family. The absence of a chronology may be a systemic issue linked to the limitations of the electronic records systems and/or a wider training issue more linked to professional practice. Recommendation 12: The Cardiff & Vale Regional Safeguarding Board should consider introducing a consistent standardised multi-agency timeline template that becomes the responsibility of each agency to complete when attending the initial child protection conference. The agency timeline should be maintained and updated at each core group meeting by individual agencies and presented as part of the report to the review child protection conference. Recommendation 13: All agencies to ensure a standardised approach for gathering, risk assessing and disseminating information from all sources – including members of the community is in place. If this information is considered within a triage or assessment model, organisations would be better placed to manage associated risk, make prioritised and defendable resourcing decisions as well as formulate tactical plans to coordinate further activity. Key examples of effective practice In compiling this report, the reviewers have noted a number of examples of good professional practice. Child protection plans evidence the identification of appropriate interventions linked to domestic abuse, substance misuse and mental health for the child’s parents. A focus on these areas was seen as a route to retrieving and building the parenting skills of the mother and father and the initial separation of the parents was pivotal in ending the children’s exposure to domestic violence in the short term. Although not noted in the main body of this report, the effectiveness of the Cardiff Multi-Agency Risk Assessment Conference (MARAC) meeting was identified as a further example of good practice by practitioners at the learning event. In this case, the up-to-date, risk focussed information enabled a richer picture to be formed – aiding safeguarding decisions and relevant interventions. It was recognised that since the introduction of the Cardiff Multi-Agency Safeguarding Hub (MASH), such information is now routinely shared at a far earlier stage – demonstrating one of the key aims of implementation. Practitioners attending the learning event were also keen to commend colleagues from the Welsh Ambulance Service on their lifesaving work. Responding promptly from the time of the initial call, the ambulance crew reacted to a rapidly changing scenario having to gather information en route to trace the mother and child who had moved from the scene of the original incident. 15 REFERENCES: Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., Black, J. (2008) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003-2005. London. Department of Education and Skills. p.106. Munro, E. (2010) The Munro Review of Child Protection Interim Report. The Child’s Journey. Available at: www.gov.uk/government/collections/munro-review [Accessed: Jan 2018] NSPCC. (2014) Disguised compliance: learning from case reviews. Summary of risk factors and learning for improved practice around families and disguised compliance. Available at: www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/discuised-compliance [Accessed: Dec.2017] Ofsted (2011) The voice of the child: learning lessons from serious case reviews. p6. Available at: www.ofsted.gov.uk/publications/100224. [Accessed: Jan. 2018] Stanley, N. (2011) Children Experiencing Domestic Violence. A Research Review. Dartington. Research in practice. Wilson, K., Ruch, G., Lymbery, M., Cooper, A. (2008) Social work: An introduction to contemporary practice. Cambridge. Pearson. Improving Systems and Practice In order to promote the learning from this case the review identified the following actions for the SCB and its member agencies and anticipated improvement outcomes:- (What needs to be done differently in the future and how this will improve future practice and systems to support practice) 1. Panel members representing Agencies at Child Practice Reviews should consider requesting a timeline from its Legal team in cases where legal involvement formed part of the case management. 2. All agencies to consider training to ensure alternative approaches to capturing the child’s voice forms part of any ‘direct work with children’ training and the concept forms part of the mentoring process for social workers in their first year of practice. 16 3. Cardiff and Vale Regional Safeguarding Board via the CPR/APR Sub Group need to be satisfied that the Social Workers are actively offering an advocate to children in receipt of Local Authority care and support. 4. CPR Panels to consider if letters or other more suitable forms of communication depending on their particular needs, advising families of the decision to conduct a Child Practice Review are delivered by the most appropriate person. 5. Practitioners at the learning event identified that the Housing teams are a particularly useful source of information with the extensive case recordings highlighted as an example of good practice. Cardiff Local Authority senior management teams to develop effective mechanism for ensuring appropriate Housing representation (including Tenancy support workers) at multi-agency meetings to promote the sharing of information and the operation of Multi-Agency Safeguarding Hub (MASH). 6. Cardiff & Vale Regional Safeguarding Board’s Policies, Procedures & Protocols Sub Group to develop a local policy relating to welfare checks and produce guidance around requesting such checks for partner agencies to follow. 7. South Wales Police representatives to review procedures and policy around police officer attendance at RCPCs. 8. Cardiff and Vale Regional Safeguarding Board to review current practice and procedures for addressing the needs of vulnerable persons and victims who are required to attend Child Protection Conferences. Consideration to be given as to whether the use of facilities that would enhance the ability to be more effective participants through the implementation of ‘special measures’ such as the use of Live-link technology and screens. 9. Once GP’s are aware that a family is off-listed from their practice due to lack of engagement, the Primary Care Team, Cardiff and Vale University Health Board must be notified immediately. The Primary Care Team will notify Children’s Services within 1 month of the de-registration to ensure that any children’s needs within the family are not compromised. 10. Cardiff & Vale Regional Safeguarding Board to ensure circulation of the Multi-Agency Protocol on Working with Families who are not Cooperating with Safeguarding Issues amongst Children’s Services staff and its partner agencies on an annual basis. 11. Cardiff & Vale Regional Safeguarding Board’s Training Sub-Group to consider making ‘Disguised compliance/Dealing with Difficult, Dangerous and Evasive Parents’ training mandatory for all practitioners. Alternatively, consideration that the said training forms part of the first 3 years in practice programme for newly qualified social workers. 17 12. The Cardiff & Vale Regional Safeguarding Board should consider introducing a consistent standardised multi-agency timeline template that becomes the responsibility of each agency to complete when attending the initial child protection conference. The agency timeline should be maintained and updated at each core group meeting by individual agencies and presented as part of the report to the review child protection conference. 13. All agencies to ensure a standardised approach to gathering, risk assessing and disseminating information from all sources - including members of the community is in place. If this information is considered within a triage or assessment model, organisations would be better placed to manage associated risk, make prioritised and defendable resourcing decisions as well as formulate tactical plans to coordinate further activity. Statement by Reviewer(s) REVIEWER 1 Karen Haslett Principal Social Worker, Child Health & Disability Team, Cardiff Children’s Services REVIEWER 2 (as appropriate) Dinlle Francis Detective Chief Inspector, Professional Standards Department, South Wales Police Statement of independence from the case Quality Assurance statement of qualification Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review The review was conducted appropriately and was rigorous in its I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review 18 analysis and evaluation of the issues as set out in the Terms of Reference The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference Reviewer 1 (Signature) Reviewer 2 (Signature) Name (Print) Karen Haslett Name (Print) Dinlle Francis Date 13.08.18 Date 09.08.18 Chair of Review Panel (Signature) Name (Print) Linda Davies Date August 2018 19 Appendix 1: Terms of reference Child Practice Review process To include here in brief: The process followed by the SCB and the services represented on the Review Panel A learning event was held and the services that attended Family members had been informed, their views sought and represented throughout the learning event and feedback had been provided to them. The Cardiff and Vale Regional Safeguarding Children Board (CVRSCB) Chair notified Welsh Government in 2016 that it was commissioning a Child Practice Review in respect of Case CPR 2/2016. The services represented on the panel consisted of: South Wales Police Cardiff Children’s Services Cardiff and Vale University Health Board Cardiff Council Housing Cardiff Council Education Community Rehabilitation Company (Wales) Welsh Ambulance Services NHS Trust (WAST) C&V RSCB Business Unit A learning event was held on 19th October 2017 and was attended by representatives from the following agencies: Cardiff Children’s Services FISS Cardiff and Vale University Health Board South Wales Police Cardiff Council Housing Community Rehabilitation Company (Wales) Welsh Ambulance Services NHS Trust (WAST) The parents of the child were informed in writing of the decision to undertake a CPR. Both parents had the opportunity to meet independently with the reviewers on two occasions in order for their views to be sought and represented. However, despite the parents choosing the dates, times and venues of the meetings, each failed to attend and neither attempted to re-establish contact with the reviewers thereafter. It is unfortunate that other than the mother’s initial comments noted within the report, the family’s views are missing from this report. The reviewers and Chair will attempt to share the learning from the report with the parents prior to publication. x Family declined involvement 20 For Welsh Government use only Date information received ……………………….. Date acknowledgment letter sent to SCB Chair ………………………… Date circulated to relevant inspectorates/Policy Leads …………………………. Agencies Yes No Reason CSSIW Estyn HIW HMI Constabulary HMI Probation 21 Appendix 1 – Terms of Reference C&V RSCB Child Practice Review 02/2016 Extended Review Terms of Reference Background On 22nd March 2016 the child was discovered at their home address by their sister and had been found hanging, after becoming trapped in a monkey toy which was hanging off the top bunk of a bunk bed. The child was unconscious described as being pale and lifeless. The child was ice cold to touch. The child was at home with his mother at the time and siblings. A sibling was asked to call an ambulance but the phone was not working. The mother went outside and asked to use someone’s phone. The mother deemed the ambulance to be taking too long so drove to her mother’s address around the corner and paramedics attended sometime later. The child was taken to hospital where he escaped with no lasting injuries. The child and sibling’s names at the time of this incident, were placed on the child protection register under the categories of emotional abuse and neglect. There are concerns historically around domestic abuse within the family home and when officers attended this incident there were significant concerns about the home conditions. A strategy meeting took place on 24/03/16 and there were significant concerns raised by all professionals that this incident was accidental in nature but linked to a lack of supervision. The paediatrician described the incident as a near miss and that the strangulation was a near fatality but concerned about the lack of care/supervision. The home conditions were a concern for children on the child protection register. The lack of engagement from mum historically was concerning and exposed safeguarding risks. The outcome could have been detrimental and professionals believed that the information shared at the strategy meeting reached the criteria for CPR. Timeframe for Review: 22nd March 2015 – 22nd March 2016 Criteria for an extended review The criteria for extended reviews are laid down in the Social Services and Well-being (Wales) Act 2014; Working Together to Safeguard People Vol. 2 – Child Practice Reviews are: 22 3.12 A Board must undertake an extended child practice review in any of the following cases where, within the area of the Board, abuse or neglect of a child is known or suspected and the child has: died; or sustained potentially life threatening injury; or sustained serious and permanent impairment of health or development; and the child was on the child protection register and/or a looked after child (including a person who has turned 18 but was a looked after child) on any date during the 6 months preceding – the date of the event referred to above; or the date which a local authority or relevant partner identifies that a child has sustained serious and permanent impairment of health and development Core tasks Determine whether decisions and actions in the case comply with the policy and procedures of named services and Board. Examine inter-agency working and service provision for the child and family. Determine the extent to which decisions and actions were individual focused. Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress. Take account of any parallel investigations or proceedings related to the case. Hold a learning event for practitioners and identify required resources. In addition to the review process, to have particular regard to the following: Whether previous relevant information or history about the child and/or family members was known and taken into account in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances. How did that knowledge contribute to the outcome for the child? Whether the child protection plan (and/or the looked after child plan or pathway plan) was robust, and appropriate for that child, the family and their circumstances. 23 Whether the plan was effectively implemented, monitored and reviewed. Did all agencies contribute appropriately to the development and delivery of the multi-agency plan? What aspects of the plan worked well, what did not work well and why? The degree to which agencies challenged each other regarding the effectiveness of the plan, including progress against agreed outcomes for the child. Whether the protocol for professional disagreement was invoked. Whether the respective statutory duties of agencies working with the child and family were fulfilled. Whether there were obstacles or difficulties in this case that prevented agencies from fulfilling their duties (this should include consideration of both organisational issues and other contextual issues). Specific tasks of the Review Panel Identify and commission a reviewer/s to work with the review panel in accordance with guidance for extended reviews. Agree the time frame. Identify agencies, relevant services and professionals to contribute to the review, produce a timeline and an initial case summary and identify any immediate action already taken. Produce a merged timeline, initial analysis and hypotheses. Plan with the reviewer/s a learning event for practitioners, to include identifying attendees and arrangements for preparing and supporting them pre and post event, and arrangements for feedback. Plan with the reviewer/s contact arrangements with the individual and family members prior to the event. Receive and consider the draft child practice review report to ensure that the terms of reference have been met, the initial hypotheses addressed and any additional learning is identified and included in the final report. Agree conclusions from the review and an outline action plan, and make arrangements for presentation to the Board for consideration and agreement. Plan arrangements to give feedback to family members and share the contents of the report following the conclusion of the review and before publication. 24 Tasks of the Safeguarding Children Board Consider and agree any Board learning points to be incorporated into the final report or the action plan. Review Panel complete the report and action plan. Board sends to relevant agencies for final comment before sign-off and submission to Welsh Government. Confirm arrangements for the management of the multi-agency action plan by the Review Sub-Group, including how anticipated service improvements will be identified, monitored and reviewed. Plan publication on Board website. Agree dissemination to agencies, relevant services and professionals. The Chair of the Board will be responsible for making all public comment and responses to media interest concerning the review until the process is completed. |
NC043639 | Death of two siblings in 2012 at their family home in Wiltshire. Cause of death is still to be determined but it is believed that father drugged then suffocated Child R and Child S before hanging himself. Family were well known to services and the children had been looked after by the local authority for a period of 7 months, which ended when they were returned to father's care, 6 months prior to their deaths. History of: parental substance misuse; acrimonious separation and conflict in regards to custody and contact; domestic abuse; paternal convictions for violent offences and possession of illegal substances; and concerns regarding emotional abuse related to mother's abusive relationship and alcohol use. Issues identified include: destructive nature of the parents' relationship; insufficient multi-agency assessment and planning; failure to revise professional judgments and evidence of 'rigid' thinking; and a lack of clarity and confidence among professionals in the use of legal processes to protect the children. Recommendations include: review of management and supervision processes across agencies, to ensure that fixed thinking by professionals is identified and challenged; evaluation of frontline professionals' communication with children to ensure a balance between responding to children's wishes and ensuring that their needs are met; and ensuring frontline professionals have a working knowledge of each other's legal frameworks to protect children.
| Title: Overview report on the serious case review relating to Child S and Child R LSCB: Hampshire Safeguarding Children Board Author: Ron Lock Date of publication: October 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hampshire Overview Report – Child S and Child R published 1 October 2013 1 Overview Report on The SERIOUS CASE REVIEW relating to Child S and Child R Hampshire Overview Report – Child S and Child R published 1 October 2013 2 Hampshire Overview Report – Child S and Child R published 1 October 2013 3 Contents 1. INTRODUCTION P4 2. THE FACTS P9 3. VIEWS OF FAMILY MEMBERS P18 4. KEY THEMES IDENTIFIED BY THE REVIEW PROCESS P19 5. ANALYSIS P25 6. ASSESSMENT OF INDIVIDUAL MANAGEMENT REVIEWS AND THE SERIOUS CASE REVIEW PROCESS P31 7. LESSONS LEARNED FROM THE REVIEW P37 8. CONCLUSIONS P39 9. RECOMMENDATIONS P40 10. GLOSSARY OF TERMS P41 Hampshire Overview Report – Child S and Child R published 1 October 2013 4 1 INTRODUCTION 1.1 Background to the review 1.1.1 In 2012 two children, along with their father, were found deceased at their home in Wiltshire. It is thought that the children had been drugged prior to being suffocated and that the father hung himself. The exact cause of the deaths is still to be determined by the Wiltshire Coroner however the police are not looking for anyone else in connection with them. Prior to the incident there had been involvement with this family from agencies across Hampshire and Wiltshire but there had been no evidence to suggest that father had ever acted violently towards the children prior to this event. The children had been in the care of Hampshire County Council, on a voluntary basis, for seven months. They had been living with their father for the six months immediately prior to their deaths. 1.1.2 The matter was discussed by the Hampshire Safeguarding Children Board (HSCB) Serious Case Review Sub-Committee on 28th September 2012 which considered the criteria for a serious case review (SCR) to have been met on the grounds that ‘The Local Safeguarding Children Board (LSCB) should always undertake a SCR when a child dies, and abuse is known or suspected to be a factor in the child’s death’ and it was recommended that a serious case review should be held. That recommendation was confirmed by the Chair of the LSCB the same day. 1.2 The Terms of Reference 1.2.1 The purpose of a SCR as set out in 8.5 of Working Together (WT) to Safeguard Children 2010 is to: establish what lessons are to be learned from the case about the way in which local professionals and organisations worked individually and together to safeguard and promote the welfare of children; identify clearly what those lessons were both within and between agencies, how and within what timescales they would be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. 1.2.2 Each Individual Management Review (IMR) author was particularly asked to address the following issues: - Identify and evaluate decisions, assessments, plans and services offered by the agency in relation to members of the household and family, with particular regards to: o domestic abuse/adult violent behaviour o parental substance misuse and mental health o the competencies and limitations of the parents in their parenting task o the extent to which the children’s needs, views and wishes were taken into account. Identify and evaluate decisions, assessments and plans and/or recommendations made by the agency in relation to the residence and contact arrangements for the children. To what extent were the children’s needs, views and wishes taken into account. Hampshire Overview Report – Child S and Child R published 1 October 2013 5 Identify and analyse key events/opportunities for assessments and decision making in the 3 months leading up to the children’s deaths. Were any child care or safeguarding concerns recognised and responded to appropriately. Examine and analyse the level and effectiveness of exchange of information and communication between agencies and across areas. Identify any gaps which may have impacted upon assessment, service provision or outcomes. Were there any organisational difficulties being experienced within or between agencies? Were these due to lack of capacity within the agency? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? Highlight ways in which practice can be improved and make recommendations as appropriate. 1.2.3 Additionally it was agreed that authors of IMRs, SCR panel members and the author of the overview report should give consideration to the areas identified in W.T. 2010 page 245 in their analysis of involvement that were not covered by the above specific issues and should bring to the attention of the SCR panel chair any other matters identified which appeared to fall within the scope of the review if they thought that there were lessons to be learnt either for an individual agency or for the HSCB. Working Together 2013 was produced during the period of this review and this final report was produced in accordance with the requirements for full publication. 1.2.4 It was also expected that authors of IMRs who identified other significant issues not falling within the scope of the review should bring them to the attention of a senior manager within the agency. Finally it was expected that consideration would also be given to the findings of recent SCRs both locally and nationally. 1.2.5 The time frame of the review was from 1st September 2010 until 3rd September 2012 and agencies were asked to provide a detailed chronology for that period. All agencies were also requested to provide a summary of any significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis. 1.3 SCR Process 1.3.1 IMRs were received from the following sources: Hampshire Children’s Services Department Hampshire Education – Primary School Hampshire Police Hampshire Probation Southern Health NHS Foundation Trust – Hampshire Health Visiting & School Nursing Hampshire Early Years Borough Council Housing Provider Solent NHS Trust – Homer Substance Misuse Service Southern Health NHS Foundation Trust - Mental Health Hampshire Adult Services Primary Care (Health) - GP Services CAFCASS Hampshire Overview Report – Child S and Child R published 1 October 2013 6 Wiltshire Children’s Services Department Wiltshire Police Wiltshire Probation Great Western Hospitals NHS foundation trust – Wiltshire Health Visiting South Central Ambulance Service 1.3.2 IMR authors were provided with a briefing session and authors were also asked to attend the SCR panel in order that feedback could be provided on the reports and the panel could ask questions in order to clarify any issues. 1.3.3 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: Hampshire Hospitals NHS Foundation Trust HMP Winchester University Hospital Southampton NHS Foundation Trust Wiltshire Early Years 1.3.4 A health overview report was also produced by the Designated Nurse to enable NHS Hampshire, as commissioners, to review and evaluate the practice of all involved health professionals (including GPs and providers) commissioned within the PCT area. 1.3.5 IMRs and the health overview report were drawn up by officers who had had no previous involvement in the case. 1.4 Family Input into the SCR 1.4.1 Consideration was given to involving the family in the review process and the independent overview author met with the mother, the father’s brother and the maternal grandparents. The paternal grandparents lived a great distance away, and had less contact with the children, so the overview author had a telephone conversation with them. The panel is conscious of the distress experienced by family members and is grateful for their significant contribution to this review. 1.5 The SCR Panel 1.5.1 The review group membership was as follows: - Ron Lock Independent Chair Hampshire Police Hampshire Probation Hampshire Children’s Services (Education and Inclusion) Hampshire District and Borough Councils Hampshire Children’s Services (Children and Families) Designated Nurse, NHS Hampshire Designated Doctor, NHS Southampton Southern Health, Mental Health Acting Board Manager Wiltshire LSCB Hampshire Overview Report – Child S and Child R published 1 October 2013 7 CAFCASS Additionally Fiona Johnson, the independent overview writer attended SCR Panel Meetings. 1.5.2 The panel met on eight occasions; four meetings to review individual management reports and four meetings to agree the independent overview report. Dates of review Panel meetings were as follows: - 7th January 2013 11th January 2013 16th January 2013 28th January 2013 13th February 2013 25th February 2013 6th March 2013 21st May 2013 1.5.3 The chair of the panel is Ron Lock and he has had no direct involvement with any of the professionals’ work being reviewed. He is a qualified social worker who has spent his entire career in the field of child protection, for most of that time with the NSPCC, finishing in their employment in 2001 as a Regional Head of Child Protection Services. Since then Ron has been an independent consultant in safeguarding children, is the chair of the Bournemouth and Poole LSCB, and has specialised in SCRs, to date being involved in more than 70, either as independent chair or overview author. Much of this work has occurred for a number of LSCBs across the Midlands and South of England, and has on one previous occasion been the author of a SCR in Hampshire. Ron has not had any professional connection with any of the agencies who provided services to the family who were subject of this SCR. 1.5.4 The independent overview writer is Fiona Johnson, an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997 contributing to the development of strategy and operational services with a particular focus on safeguarding and child protection. She is HCPC registered and has previously written overview reports for East Sussex, Brighton & Hove, Portsmouth, Southampton, Kent, West Sussex, Wandsworth, Surrey, Slough, Kingston and Bracknell Forest LSCBs. 1.5.5 As part of the SCR process the overview author, the independent chair and some members of the SCR panel met with front-line professionals and their managers to discuss the early findings from the review process. 1.5.6 Child deaths and their consequences are distressing for staff who have been directly involved with the child and their family. This review has been greatly assisted by the co-operation and commitment of staff from all contributing agencies. 1.5.7 The overview report was completed based on information provided in the IMRs and the additional reports supported by the discussions with the family members and Hampshire Overview Report – Child S and Child R published 1 October 2013 8 front-line professionals and their managers. The overview author was also provided with executive summaries from previous serious case reviews held in Hampshire that were considered to be relevant. 1.5.8 The SCR panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. Full publication of the findings of the review will follow on from the completion of the serious case review process. 1.6 Parallel Processes 1.6.1 The children’s deaths have also been considered by the Wiltshire Coroner to establish the causes. The Wiltshire LSCB representative on the SCR Panel acted as the link between this review and coronial investigations. The coronial process had not been completed at the time of the conclusion of the serious case review process. Hampshire Overview Report – Child S and Child R published 1 October 2013 9 2 THE FACTS 2.1 The Family Background 2.1.1 The children were siblings and until 2010 lived with their mother and father who were not married. After their parents separated the children lived with their mother until they moved to foster carers. After seven months in foster care they moved to live with their father and remained there until they died. Their maternal grandparents and maternal aunt and uncle lived locally as did a paternal uncle. The paternal grandparents lived some distance away. 2.1.2 Both parents are white British and English is their first language. 2.1.3 Maternal Grandparents had regular and close contact with the children until they were placed in foster-care. Once the children moved to live with father their contact was when the children were staying with mother. Mother worked part-time until she was made redundant following a long period of sickness. Mother had worked at this job for thirteen years, returning to work after the birth of both children. 2.1.4 Father was one of four children. Paternal grandmother and her husband saw the children once or twice a year because of the geographical distance, but had regular ‘phone contact’. It is reported that father moved south because of debts and problems associated with drug-use. Father worked full-time until he was sent to prison. Mother and father had significant debts. This meant that they became insolvent and were the subject of an Individual Voluntary Arrangement to pay off the debts. 2.1.5 Mother and father met when she was 17 and he was 23 years old, and their first child was born within a year. A history of domestic abuse and violence has been reported by mother that is said to have started when she was pregnant with her first child. The aggression was not continuous and mother described it as being exacerbated by father’s use of alcohol and drugs. Mother did not tell professionals about the abuse and when she needed medical treatment for injuries she described them as being accidental. Mother did confide in colleagues at work about the domestic abuse, and her younger sister was also aware; however, she did not share the information with her parents. The police were occasionally involved in domestic disputes prior to 2010 however there was limited involvement from any other agencies apart from universal services such as GP, school and health visitor. 2.1.6 The older child attended school and the younger child was cared for by a child-minder whilst mother worked. Both children suffered from a genetic condition but otherwise they were generally fit and healthy. The older child was doing well academically at school and had appropriate friendship networks. There was no evidence available to any agency that the children suffered significant harm as a result of the alleged domestic violence. 2.2 Agencies’ Involvement with the family 2.2.1 There were three main periods of agency involvement; ten months when the children were primarily in the care of their mother; seven months when the children were in foster-care and six months when they lived with their father. Hampshire Overview Report – Child S and Child R published 1 October 2013 10 2.3 First Period - Children living with mother 2.3.1 The parents separated after a ten year relationship and father left the family home. Over the next ten months both parents were known by professionals to abuse alcohol and possibly drugs. They both reported mental health problems and were seen by mental health professionals. Each parent was assessed regarding possible suicide risks and in neither case was the risk considered to be high. Support was offered to both parents by mental health services; but father refused it on the basis that his problems were resolved, and mother failed to attend appointments. 2.3.2 Despite living apart the parents continued to be involved in each other’s lives and their relationship continued to be conflictual. There was significant police involvement with the parents. Both raised concerns about each other’s parenting and both were given advice about seeking legal support in resolving custody and contact difficulties. At this stage only mother had parental responsibility for the children and this was known to all agencies. 2.3.3 Mother made a number of allegations about domestic abuse to a range of agencies and on occasions was seen with injuries. She did not co-operate with police investigations about the domestic abuse allegations and was often observed by the police to have been drinking although she was never considered by police officers to be incapable of caring for the children because of her alcohol intake. 2.3.4 During this period mother was discussed at three multi-agency risk assessment conferences (MARAC). These are meetings where information is shared on the high risk domestic abuse cases between representatives of local agencies. After sharing all relevant information they have about a victim, the representatives discuss options for increasing the safety of the victim and turn these into a co-ordinated action plan. The main focus of the MARAC is on managing the risk to the adult victim but in doing this it will also consider other family members including any children involved and managing the behaviour of the perpetrator. At one of these meetings professionals discussed the risk to the children but as by that time they were in foster care it was agreed there was no need for further intervention to provide additional safeguarding. These meetings discussed the risks to mother and considered that she was placing herself at risk by some of her actions which made it difficult to provide her with sufficient support. Father was also described by a Probation Officer at one of the meetings as having a ‘significant drug problem’ and being a ‘loose cannon’. 2.3.5 Children’s Social Care (CSC) undertook two initial and one core assessment regarding the children because of concerns regarding possible emotional abuse resulting from alleged domestic abuse and mother’s possible alcohol abuse. These assessments involved consultation with the health visitor and school and mental health agencies but did not include communication with the GP. There was also very limited assessment of father who was seen once during this period at the CSC office. There was evidence of social workers talking with the older child who expressed unhappiness at mother’s ‘drinking’ and said that father provided good care. 2.3.6 There were concerns about the safety of the children when in mother’s care at the family home and it was therefore arranged that she should look after them at the maternal grandparents’ home. During this time father was arrested for four offences, two involving violence to other adults, one concerned with violence towards mother and one for possession of cocaine. Mother returned to the family home, against the Hampshire Overview Report – Child S and Child R published 1 October 2013 11 advice of CSC and her parents, and the police took the children into police protection and they were then placed in foster care. At this point the Local Authority considered it necessary to initiate the Public Law Outline (PLO) process which is a pre-curser to applying to the courts to remove the children from their parents’ care. At this point a Public Law Outline (PLO) letter was sent to both parents that set out the expectations on both of them if they wished to avoid the Local Authority applying to the courts for care orders and explained to the parents how they could apply for legal aid. This was followed soon after by the social worker meeting with both parents together to explain the PLO process. Soon after, father was sentenced to three months imprisonment. This sentence related to four offences, three for violence and one for possession of cocaine. The probation recommendation for sentencing was a Community Order with a condition to attend the Integrated Domestic Abuse Programme (IDAP). However, this was not accepted by the court which felt that imprisonment was more appropriate. 2.4 Second period - Children in Foster Care 2.4.1 Soon after the children moved into foster care there was a change in the lead social worker because there was a need for a worker from the long-term team to become involved. The process of handover was managed well and there was a clear case summary produced which identified future work which included mother changing her lifestyle to prioritise her children’s needs and father addressing the issues of his drug-use while in prison. 2.4.2 During the period that the children were in care there were two main planning processes in operation. The first was the ‘Looked After Children’ (LAC) review arrangements and the second was a series of legal strategy meetings which began as a result of the initiation of the PLO process. 2.4.3 There were three LAC reviews held during the seven months that the children were in foster care. At the first review, held within a month of the children moving to foster care, neither school nor health visitor were present. The school attended the next two reviews but the health visitor was not present at any and it is unclear if she was invited. The first two review meeting were attended by mother but she was not at the final LAC review however father was at that meeting. All reviews were attended by social worker and foster carer and the children also attended all reviews with the eldest child contributing fully to the discussions. Much of the focus of the LAC reviews was on immediate planning for the children including health and education issues. The meetings did however give a clear direction about the need for permanence planning and that this should be achieved speedily. 2.4.4 The legal strategy meetings were attended by the social worker, his manager and a representative from Legal Services. The focus of these meetings was to ensure that there was planning in place to ensure that the children were returned safely to either parent’s care and if that was not possible to ensure that appropriate plans were made for the children to move to alternative permanent carers. Soon after the children were placed in foster care there was a meeting that involved the paternal grandmother and paternal aunt to discuss possible longer-term care arrangements for the children. It was agreed at this meeting that if it were not possible for the children to return to mother or father’s care then placement with the extended family would be the preferred option. Neither mother nor maternal grandparents were at this meeting although it is thought they were invited. Hampshire Overview Report – Child S and Child R published 1 October 2013 12 2.4.5 Initially there were plans to return the children to their mother’s care. However, there were on-going concerns about her abuse of alcohol and her choice of partners. Mother was unreliable during contact visits and failed to co-operate with the social worker. It was clear from social work contact with the children that the elder child did not like mother’s current partner and there were significant professional concerns about him which included his domestic abuse of previous partners and drug misuse. During this three month period mother disengaged from the planning process involving the children and it is unclear how well she understood what was happening. 2.4.6 It is known that during this period father had contact with mother by telephone and she reported to the police that he was threatening her saying that he would ‘make her life hell’ when he left prison. An investigation was undertaken which resulted in father being ‘gate-arrested’ on his discharge from prison and charged with harassment. Soon after this mother told the social worker that she was considering allowing father to have custody of the children as she was concerned that he would ‘hound’ her otherwise. 2.4.7 After the children had been in foster care for four months father was released from prison and immediately indicated that he wished to care for the children. Regular contact was arranged between father and the children supported by the paternal aunt and uncle with whom he was staying. The contact between father and the children was observed to be good and the older child was clearly happy seeing father on a regular basis. It was arranged that the children would spend Christmas with their father and with the support of the social worker he took them to stay with his sister and then paternal grandparents. 2.4.8 At this point mother was failing to co-operate with the social worker who wrote to her advising her that he intended to assess father as a carer for the children. There is no evidence that he told her that he was agreeing to the children being in their father’s care over Christmas or that they would be spending Christmas away from Hampshire. At this point father did not have parental responsibility for either child as he was not named on the younger child’s birth certificate and although named on the older child’s this pre-dated the legislative change that presumed parental responsibility where the father is named. Although the first social worker had been fully aware of the legal position of the children and it had been discussed between agencies prior to the children moving to foster care, there was confusion at a later legal strategy meeting about the children’s legal status however it is clear that the social worker was aware that father did not have parental responsibility prior to the children spending Christmas with him. 2.4.9 The social worker undertook assessments of both mother and father however these assessments were not written up until three months after the children had left foster care and so much of the planning decisions were being made on the basis of verbal reports from the social worker to his line manager and to the legal strategy meeting. The recording on the general case records by the social worker was also very limited which meant that there is minimal evidence as to which agencies were consulted during the assessment work. The assessments were therefore dependent on the social worker’s direct observations of both parents and their interaction with the children. There is no evidence of formal consultation with the police, probation, mental health or substance misuse services about their perspective on his previous Hampshire Overview Report – Child S and Child R published 1 October 2013 13 violence and drug misuse and what its implications were for his parenting. There was also no evidence of contact with the prison service to identify whether he had received any support regarding substance misuse whilst in prison. It is also noteworthy that within two weeks of father’s discharge from prison the social worker spoke to the housing department, and confirmed that the children were in local authority care, that he did not have parental responsibility for them but that if father had suitable accommodation, he had been assessed as suitable to care for them. 2.4.10 Maternal grandfather raised concerns about the assessment of father with the social worker saying that the CSC treatment of mother and father in assessing their parenting abilities had, in his view, been unequal. Maternal grandfather then followed this up in writing, a week later, raising concerns that he felt that father was emotionally unstable, was involved in drug abuse and had tendencies to violence and excessive alcohol use. There is no evidence that these allegations were investigated. 2.4.11 Soon after Christmas father approached a solicitor regarding applying for custody of the children and with the assistance of the Housing Department Rent Guarantee Scheme obtained private rented accommodation in Wiltshire. At the same time the foster carer told the social worker that the older child was increasingly distressed by contact, and wanted to move in with father. The social worker then agreed a plan with the foster carer that the children would move to live with father within three weeks. The children immediately started to have overnight stays with father and at a LAC review three weeks later it was agreed that the children would move permanently to his care. 2.4.12 The LAC review date was brought forward because the overnight contact between the children and father was going very well and the older child was asking to move to live with father. Mother was not present at the LAC review and there is no evidence that she was formally consulted about the decision to place the children with father. The meeting agreed a change in the care plan; that the children should reside with their father with close monitoring in place for three months. The children moved to live with their father from this date and effectively left the care of the local authority and from this point forward there were no formal multi-agency processes to monitor the children. It is relevant that at this point, the only person with parental responsibility was mother, who could have at any time, legally, removed the children from father’s care. 2.4.13 At this time mother was having limited contact with the children as she had been disruptive in the meetings and had spoken inappropriately to the children. She was also not co-operating with the social worker who was undertaking a separate assessment of her capacity to care as she was pregnant and there were significant concerns about her capacity to care for a child appropriately. Mother sought legal advice for the first time at this point and appeared to understand her legal rights that she could remove the children from foster care and therefore from fathers care. The police had also been involved in a dispute between mother and father about custody arrangements. The day before the LAC review father appeared in court on the charge of malicious communication with mother whilst he was in prison. He pleaded guilty to the charge and the court requested a pre-sentence report. He was bailed to return to court on condition that he had no contact with mother. There were delays in Hampshire Overview Report – Child S and Child R published 1 October 2013 14 the pre-sentence report being completed by Wiltshire Probation, due to work pressures, and this report was not completed until 3rd April 2012. 2.5 Third period – Children living with Father 2.5.1 For the first month father seemed to cope well with looking after the children. The only problem reported to agencies by father, at this time, was regarding transport to school as he was living some distance away and was dependent on public transport. The school monitored the older child who seemed happy and well. The younger child was seen during this period by medical staff when father took him for an ophthalmology appointment; and by the health visitor, who undertook an initial assessment and recorded that he was well within age appropriate speech and physical development. 2.5.2 During this period mother’s life style was very chaotic and there was police involvement because of domestic abuse incidents between her and her new partner which resulted in him being remanded to prison. A review legal strategy meeting was held which noted that the children were placed with father and that there were no concerns. The major issues discussed were mother, and her relationship with her ex-partner. It was agreed that there would need to be an Initial Child Protection Conference held later in the pregnancy. The only risk associated with the children was the dysfunctional relationship between the parents. It was agreed that the social worker should complete a Section 7 report for the court recommending supervised contact for mother and continued monitoring of father’s care of the children. 2.5.3 There was however evidence that mother and father were resuming contact. Within the first six weeks the social worker made an unannounced visit to father and was told by him that the children were at mother’s house, and would be having an overnight stay that night. Father explained that he had made this arrangement because he was due in court the following day. There was no evidence that the social worker advised that the children should not stay overnight despite the legal strategy meeting having recommended that mother’s contact should be supervised and father’s bail conditions precluding contact between father and mother. Four days later during a telephone conversation with the social worker, father admitted that the previous week mother had stayed overnight, and that she was now threatening to inform Probation that he was in breach of his bail conditions. The social worker expressed concern about this, but there is no evidence that he took any other action. 2.5.4 At this time a MARAC meeting was held that discussed the incidents the previous month concerning mother and mother’s ex-partner. At that meeting mother’s pregnancy was noted and health professionals and CSC identified that pre-birth assessments would be undertaken. The meeting noted that the children were in the care of father and the police informed the meeting that they had intelligence that father and mother had reconciled and that mother was staying with father in Wiltshire. The source of this intelligence was not disclosed; and, it is unclear if the social care representative on the MARAC shared this information with the social worker. 2.5.5 Later that month Wiltshire police were contacted by mother alleging that father had tried to strangle her and that this had been witnessed by the younger child. Mother phoned from outside a local police station and when the police arrived could not be Hampshire Overview Report – Child S and Child R published 1 October 2013 15 found. Wiltshire police contacted Hampshire Emergency Duty Service (EDS) who confirmed that father had care of the children and provided background information. Wiltshire police also spoke with the foster carer, who confirmed that the older child was staying overnight with them, because of a football engagement. The police visited father, who denied the assault, but said that mother had been with him all day, and had been drinking, and as she had become argumentative he asked her to leave. There was no sign of an altercation at the address and the child was seen asleep in bed. Mother was contacted again by the police, but refused to co-operate, so the matter was closed without any further action. Wiltshire police informed Wiltshire CSC about this event who failed to identify that there was a social worker in Hampshire working with the family, and therefore did not pass on any information. In reality, however, the social worker knew about the incident because of the contact with Hampshire EDS. 2.5.6 Soon after this incident father mentioned it to his probation officer, and also told him that mother had cared for the children the previous night, and that he was concerned she might not return them to his care. The probation officer asked father what he would do if this happened, and he said that he intended to discuss his options with his social worker, and asked to leave his unpaid work early to allow him to contact him. This was facilitated by the probation officer who also tried to contact the social worker, to advise him of father’s contact with mother, and the possibility of friction if she did not return the children. The social worker was not available, but the probation officer left a detailed message with the duty social worker. There is no record of any follow-up by the social worker, either with the probation officer, or by contacting father and seeing the children. 2.5.7 During this period father’s application for parental responsibility and residence orders on the children were considered by the courts. As Hampshire CSC were already working with the family CAFCASS had very limited input and the court decisions were made based on information provided by the social worker. He recommended that the father be given residence orders and that their contact with mother should be at his discretion, and should include overnight contact. The court accepted these recommendations. No defined contact order was made, but the court determined that contact should take place up to three days a week, and should include overnight stays. The court also required a further review of the arrangements after three months. 2.5.8 From this point onwards the children’s contact with mother was at the discretion of father. It is unclear what direct contact the social worker had with the children from this date onwards as there are few records. A month after the court hearing there was a final legal strategy meeting. The purpose of this meeting was to determine further CSC involvement. It was noted that father continued to co-operate with the social worker. Furthermore the court had granted father parental responsibility and a residence order had been made in his favour, with contact between the children and mother at his discretion. The social worker reported one domestic incident in April that was caused by the parents becoming too close, but said that father had learned from this experience, and that there had been no further incidents. The meeting agreed to end the PLO process, and that social work involvement would cease or transfer to Wiltshire CSC, following the review in court. Hampshire Overview Report – Child S and Child R published 1 October 2013 16 2.5.9 In the three months prior to the children’s death there was limited contact by any agency with father and the children, although the older child continued to attend school, and was doing well. Both children, when seen by professionals, seemed happy and there were no identified concerns regarding health or development. Father was seen regularly by his probation officer for supervision, and also attended unpaid work. Father did miss some supervision sessions and unpaid work which was ascribed to child care problems. The probation officer offered that the Probation Service would pay for a child minder, and father appeared to make arrangements for this, however it is unclear if the child ever attended; and father continued to attend supervision sessions with the child, inhibiting full discussions. On these occasions father blamed mother for failing to keep to arrangements for her contact with the children. When father met with the probation officer he presented as sober and discussed, rationally, the arrangements he was making for the children’s contact with mother. Father also said that he was not drinking, and that he had no debts. When the younger child was seen at supervision sessions, there were no concerns noted. The probation officer also checked regularly with Wiltshire police for any evidence of further domestic disputes. 2.5.10 The relevant district council housing department in Hampshire had some involvement with father during this period. The first matter concerned the rent deposit loan which he was due to pay back monthly. There were delays in this payment being started and he was in arrears resulting in a letter threatening legal action being sent to him. Following receipt of this letter, father started monthly payments which were received regularly up until his death. Father was also nominated for a housing association property close to mother’s address. Father visited this property, with mother and the younger child. They presented as a couple, and mother was put down on the application forms as next of kin and a key-holder. She was also heard by the housing official to say that the timing of the possible allocation was good as it would enable her to move in when she was evicted. The child was observed to be content and related well to both parents. In the event father’s nomination to this property was refused by the housing association on the grounds of his anti-social behaviour and offences in the last three years. The property was also considered to be too near to mother’s house. The social worker was advised that father was refused the property but it is unclear whether he was told of mother’s presence at the visit. 2.5.11 Mother’s tenancy was in jeopardy because of her anti-social behaviour and significant rent arrears. She was served with an eviction notice and contacted the housing department saying that the older child was living with her and asked for advice to avoid the eviction and made an application for housing benefit claiming that the child was living with her. The benefits officers observed father with the younger child waiting outside for mother whilst she made the application. At this time the police advised the social worker that they had been told that mother and father had resumed their relationship. The social worker telephoned father who denied that this was the case and said that he was aware that mother was about to be evicted and was sad that this would prevent the children having overnight stays with her. Father was adamant that despite mother’s potential homelessness he would not resume their relationship. The social worker updated the police following this conversation. Later that month mother went to court and made an application to stay the eviction order, due the next day. This was unsuccessful, so she made a homeless application for herself and the older child, providing a letter awarding her child benefit as proof Hampshire Overview Report – Child S and Child R published 1 October 2013 17 that the child was living with her. The housing officer contacted the social worker and advised him about mother’s homeless application and the letter showing that she was in receipt of child benefit. The social worker unexpectedly saw father and the two children the next day in town. He asked father about the claims made by the housing department and father explained that he had allowed mother to make the claim for child benefit in order to stop her being evicted. He also assured the social worker that the children were in his full-time care and that he regretted allowing mother to make the claim. The social worker saw both children and observed that they looked well-presented and appeared happy and content. The older child said that living with father was all right but that the area they lived in ‘was a bit boring’. 2.5.12 A month later father was arrested by Hampshire police because he was seen by a CCTV camera operator snorting a white substance. He was arrested on suspicion of being in possession of a ‘Class A’ drug, he had also been drinking. On interview father reported that the substance was a legal high known as ‘poke’. This investigation was open at the time of father’s death and the white substance has since been identified as methiopropamine (MPA) which is not a controlled drug under the Misuse of Drugs Act 1971. Information about this matter was not passed to other agencies as the children were not present at the time of the arrest. Later in the month Wiltshire CSC received a telephone call from the manager for the flat saying that the rent on the flat had not been paid since the beginning of the year and that the tenant was due to be evicted. This message was taken by an administrative worker and a record made on the case file but it is not clear if it was seen by the social worker or his manager. 2.5.13 A week later father saw his GP because he was having difficulty sleeping. He said that he was experiencing stress regarding the court case for custody of the children and was prescribed medication to assist with sleep, for a limited period. There is no evidence that the GP considered whether this was a suitable prescription for a man having sole care of two children, nor evidence that he investigated father’s home circumstances any further. Father failed to attend his appointment with the probation officer at the end of the month which was thought to be because it was the school holidays and he had not been sent a reminder about the meeting. 2.5.14 Three days later, as father was due to be evicted; the lettings agent visited the flat, with a potential new tenant, and found the bodies of father and the children. Wiltshire police then undertook a full investigation for the coroner which has yet to be completed. 2.5.15 The cause of the deaths has yet to be determined. There are indications that the children did not die on the same day. Mother and maternal grandparents have also told the author of this report, that around the probable time of the children’s death, father suggested that mother should visit him at his accommodation to collect the children for contact, she refused to do this as she could not afford the travel costs. Hampshire Overview Report – Child S and Child R published 1 October 2013 18 3. VIEWS OF FAMILY MEMBERS 3.1 The overview author met with the maternal grandparents, the paternal uncle and his partner, with mother and also had a telephone conversation with paternal grandmother. Detailed reports were made of these conversations which were agreed with them. The key issues from these reports are included below. 3.2 All people interviewed were clear that they did not expect father to hurt the children and that they had not seen or reported to professionals any concerns that he would physically harm the children. 3.3 The paternal grandmother and paternal uncle felt that father was given insufficient support after he had moved to live in Wiltshire and felt that he found it challenging caring for two children alone. They felt that he should have been monitored more closely with more practical and emotional support provided, in particular, they identified assistance with money management and access to other people in a similar circumstance, as they feel he was very lonely as a single parent caring for a young child. The paternal uncle, who cleared the house after the children had died, said it was in a poor state and was surprised that this had not been monitored more closely. 3.4 The maternal grandparents and mother considered that the assessment of father prior to the children moving to his care was inadequate and did not fully address the issues of substance misuse and violence. They also felt that there was insufficient monitoring of the children once they were in the care of father. In particular they were concerned that he had been able to have rent arrears and be facing eviction without any action being taken by CSC. 3.5 Maternal grandparents, paternal grandparents and mother all considered that the arrangements for the children to spend Christmas with their father were arranged hastily and were influenced by a desire to have the children away from Hampshire over the Christmas period. 3.6 Paternal grandparents and paternal uncle considered that the second social worker could be difficult to contact and that assumptions were made by him about the level of support that they as family members would give. Maternal grandparents described him as disorganised and considered that he had a poor relationship with mother. Mother disliked the second social worker and said that she found it hard to work with him. All agreed that the social worker was keen to present the views of the children and was anxious for the children to move from foster care back to live with a parent. 3.7 Maternal grandparents and paternal uncle were both clear that the relationship between mother and father was conflictual and enmeshed and was not in the children’s interests. They were both unhappy that the contact arrangements recommended by the social worker and confirmed by the court meant that there had to be on-going contact between the two parents. Hampshire Overview Report – Child S and Child R published 1 October 2013 19 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS 4.1 The parents’ relationship 4.1.1 There is clear evidence that the parents’ relationship was enmeshed and that even after they separated there was significant contact which was destructive to both of them and potentially was emotionally damaging for the children. This was most apparent in the period prior to the children being placed in foster care, however, there is significant evidence that after the children moved to live with father there were close links which went beyond that needed for contact arrangements. 4.1.2 The continued contact between mother and father made it impossible for professionals to assist her in protecting herself from further domestic violence and resulted in some professionals doubting the validity of her claims about domestic abuse. Mother also often presented under the influence of alcohol. This affected how some professionals perceived her and contributed to the discrepancies between different agencies’ assessments of risk. Mother’s behaviour contributed to professionals’ lack of confidence in her ability to work with them positively and in the children’s best interests. 4.1.3 It is apparent that mother had a problematic relationship with the second social worker and she found it difficult to work in partnership with him. There were some aspects of his interventions which were difficult for her to accommodate as a victim of domestic abuse. His approach was initially to treat both parents equally and to work with them through contracts of agreement signed by both of them. This approach whilst suitable for work with couples experiencing marital difficulties could be experienced negatively by a woman who had experienced domestic abuse. It is clear that mother felt pressurised by father even when in prison and therefore was unlikely to feel that she was an equal partner in these processes. After father’s discharge from prison he worked co-operatively with the social worker and increasingly became a partner in planning processes around the children from which mother was increasingly isolated. 4.1.4 Mother was sometimes not involved in making key decisions about the children’s future, partly because she would not co-operate with the social worker. After the children were placed with father, he had almost total control over when and how mother saw the children. This situation is not uncommon and research has shown that men with a history of domestic abuse may use custody and contact with the children as a mechanism to control their ex-partner after the relationship has ended. ‘In a study of abusive men referred to a parenting group, the use of custody proceedings to control or harass a former partner was a strategy commonly identified by the men themselves’ (Francis, Scott, Crooks, &Kelly, 2002). Indeed, threats to obtain custody are often used by abusers as a weapon against the abuse victim to enhance power and control post-separation. Furthermore, research has shown that batterers are more likely to apply for custody and equally likely to be granted it in comparison to non-violent fathers ( Liss &Stahly, 1993; Zorza, 1995)’.1 1 Understanding Women's Experiences Parenting in the Context of Domestic Violence - Implications for Community and Court-Related Service Providers Peter G. Jaffe, Ph.D. Claire V. Crooks, Ph.D. Hampshire Overview Report – Child S and Child R published 1 October 2013 20 4.1.5 Whilst mother’s reasons for remaining involved with the father may be explained by her desire to maintain contact with her children; father’s motivations for continuing the relationship are less clear. The paternal uncle was very clear that he considered that the adults were mutually destructive, and that father understood this; which was why, when he was living with them, there was no contact. This position ceased almost immediately after father’s move to independent accommodation. It is probable that father understood this was not in the children’s best interests as he repeatedly denied to the social worker that he was seeing mother despite evidence to the contrary even when that contact was prohibited by bail conditions. It is also clear that, throughout the period of time that father looked after the children, he was aware of mother’s personal circumstances including knowing about her possible eviction. It is obvious that father had not disengaged from an involvement in mother’s life as evidenced by him assisting her in obtaining proof of child benefit for the older child as a means of being re-housed. 4.1.6 There was understanding within the wider professional system that on-going contact between the parents was unhelpful and not in the children’s interests. On occasions contact between the adults was prohibited such as when father was subject to bail conditions. After the children moved to live with father the assumption by the social worker was that the couple would be able to manage contact arrangements, without the involvement of any other person or agency, and in the best interests of the children. There was however also an expectation that the couple would not resume their relationship as that would not be good for the children. It is unclear if this was ever formalised in a written contract or shared with other agencies. There was however evidence of agencies alerting the social worker to the indications that the couple had resumed their relationship which would suggest that professionals understood the risk of possible emotional abuse that this posed to the children. 4.1.7 The nature of the parents’ relationship may be relevant with regard to father’s final actions. Research about filicide, (the act of the murder of a child by a parent), has classified six different sets of characteristics of child murder2. Of these characteristics, one could potentially apply to the acts by this father; “Spouse Revenge Filicide - where the parent kills the child as a means of exacting revenge upon the spouse, perhaps secondary to infidelity or abandonment”3. Mother has certainly suggested that this was father’s motivation for the children’s deaths and there is some suggestion from her and the maternal grandparents that he might have wished to kill her as well. Research about filicide where the perpetrators then commit a self-destructive act identifies ‘a subgroup of men who react poorly to conjugal separation and commit killing in a context of reprisal. In some situations, the children seem to be perceived by the man as an extension of the woman and their death seems to be a way of hurting her…’4 4.1.8 There was however no evidence available to professionals that would indicate that father presented a risk to the children and filicides are often difficult to predict and therefore prevent. More apparent would be the potential for on-going parental disharmony or domestic abuse. While the parents continued to have a close relationship there was the potential for incidents of domestic violence that could be 2 Resnick, PJ, “Child Murder by Parents: a psychiatric review of Filicide. American Journal of Psychiatry (1969) 3 Sara G West, “An Overview of Filicide”. Psychiatry MMC, (February 2007) 4 Suzanne Léveillée & Jacques D. Marleau & Myriam Dubé, Filicide: A Comparison by Sex and Presence or Absence of Self-destructive Behavior. Journal of Family Violence (2007) Hampshire Overview Report – Child S and Child R published 1 October 2013 21 witnessed by the children. Such an incident occurred within the first months of the children living with father although the emotional impact on the children was limited as the older child was staying with the foster carer and the younger child was said to be asleep. 4.2 Multi-agency Working 4.2.1 A significant feature identified in this review was the limited nature of the structured multi-agency working regarding the children once they were placed in foster care. Most of the assessments undertaken largely consisted of professionals in isolation assessing the parents in accordance with their own assessment processes and tools. Thus the probation officer, mental health and substance misuse services all assessed mother and father as adults requiring their services. Some of those assessment processes involved communication to gather information from other agencies but there was no multi-agency assessment. Most of these assessments included an expectation of judging parenting as a part of the assessment but this was always undertaken by the professional alone. 4.2.2 This was apparent in the context of the social work assessment of each parent. The main source of information used by the social worker for these assessments was his own observation of the interaction between the children and the parents and the information he gathered from interviews with them. There is no evidence that he used any specific professional tools such as ‘motivational interview’. There is little evidence of the social worker collecting information and evidence in the ‘context of an ecological framework based on clearly understood developmental and psychosocial theories.’5 A good assessment of the father should have included an understanding of his own relationship and history; an assessment of his state of mind and reflective functioning; a perception of the caregiving environment generated by the carer; and, a knowledge of how the children’s behaviours matched the environment provided. Using these factors the social worker could have assessed his likely responses to potential stresses, both social and environmental. Whilst there was some evidence that he evaluated the last two areas, there was little recorded about his relationships, childhood or his state of mind and functioning, despite a recent history of violence and substance misuse. An example of this being that there is no evidence that the social worker was aware that father had a complex childhood with different father figures. 4.2.3 The social worker did gather some information from other professionals, mainly school and health visitor, but this was largely focussed on how the children were presenting or whether parents were accessing services. He did not directly involve other professionals in gathering information about the parenting skills. This was particularly important in the context of understanding how their parenting was being affected by their alcohol and drug-misuse. Both parents were said to be abusing alcohol and drugs but there was never any systematic attempt to assess this or to clarify the extent of it and to judge the effect on parenting. There was widespread use of the term ‘in drink’ by professionals however there was no clarity as to what that meant and professionals understood the term to have different meanings. For the police it meant that adults had consumed alcohol but were not drunk. There was however little testing of the adults by any professional to gauge levels of alcohol 5 P 67 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 Brandon et al DCSF 2008 Hampshire Overview Report – Child S and Child R published 1 October 2013 22 usage or frequency. Much information about the parents’ alcohol and drug-use was self-reported which is notoriously unreliable. Mother’s erratic behaviour was clear evidence of her ‘binge-drinking’ but reports of father’s alcohol and drug-use were rarely investigated despite evidence from his conviction of substance misuse and no knowledge of any treatment having been accessed. A recommendation was made by the legal strategy meeting that both parents should undertake drug and alcohol testing prior to contact however there is no record of this testing and it is likely that this did not happen. 4.2.4 There was significant reliance by the social worker in his assessment on the children’s wishes and feelings. It is positive to see that the children were listened to and did provide substantial input to planning and reviews. This should also be seen in the light of the generally positive feedback with regards to the children’s progress and development whilst in his care. It was unfortunate however that there did not seem to be any acknowledgement that the child’s views might be influenced by parental pressure or that the children might prefer ‘risky’ care with a parent to remaining in foster-care or being passed to the care of the other parent. It is essential that children are consulted and that their wishes and feelings are taken into account however this must be balanced by considered and energetic risk assessment which understands that children’s views are partial and influenced by a range of factors. 4.2.5 One effect of the absence of multi-agency assessment was that there was no creation of a multi-agency package of support for father once the children were placed with him. Thus problem areas such as transport to school or child care were addressed separately by individual professionals. The school attempted to resolve the travel arrangements and both the health visitor and probation officer provided assistance with child care. A more co-ordinated approach would have been more effective and might have highlighted better some of the difficulties he may have been experiencing. Visits to the family home after the children were placed were limited and there is no evidence that any professional visited the house after the first three months. 4.3 Failure to revise judgements and plans 4.3.1 A significant feature of all the professionals involved with this family was a tendency to make judgements about the parents that were partial and did not appear to understand that even when one parent seemed more effective than the other there were still risks that needed to be assessed. Thus father was seen either, as a ‘bad person’ abusing his partner and involved in drug-use, or, a ‘good man’ who was working hard to care for his children. In reality, he was both, and the risks associated with his former actions needed to be fully assessed. 4.3.2 This is not an uncommon phenomena and recent analysis of serious case reviews found ‘a tendency for professionals to adopt what they term ‘rigid’ or ‘fixed’ thinking. Fathers were labelled as either ‘all good’ or ‘all bad’, leading to attributions as to their reliability and trustworthiness’. 6 The researchers go on to describe how these fathers can be labelled as ‘reformed good dad’.7 After father came out of prison he appears to have quickly established himself in the minds of professionals as a reformed 6 P52 Understanding serious case reviews and their impact: A Biennial Analysis of Serious Case Reviews 2005-7, DCSF 2009 7 P53 Understanding serious case reviews and their impact: A Biennial Analysis of Serious Case Reviews 2005-7, DCSF 2009 Hampshire Overview Report – Child S and Child R published 1 October 2013 23 character and the professional memory of his previous behaviour as witnessed by his criminal record was not given sufficient weight, despite some significant attempts by the maternal grandparents to redress the balance. Mother was similarly defined as ‘bad mum’ because of her alcohol abuse and erratic behaviour and as such became marginalised from involvement in the care of her children. 4.3.3 The reasons for this approach by an individual professional, has previously been identified, as a human cognition issue. One of the most persistent and important, problematic tendencies in human cognition is a slowness in revising a view of a situation or problem. Once people have formed a view on what is going on, there is a surprising tendency to fail to notice, or to dismiss, evidence that challenges that picture. As Eileen Munro has described it, ‘Becoming fixated on one assessment despite an emerging picture that conflicts with it becomes a significant source of cognitive error.’ 8 This is further described as a ‘Garden path’ problem where professionals find it hard to revise their initial view because ‘early cues strongly suggest [plausible but] incorrect answers, and later, usually weaker cues suggest answers that are correct’. 9 In this case the strong and positive relationship between the children and their father appears to have outweighed the information provided by mother and maternal grandparents who were seen as unreliable and biased. Later reports, by other agencies, of father and mother having increased contact, and their collusion to obtain accommodation, continues to be given insufficient weight because father is able to provide believable explanations and the children continue to present as being happy and well. 4.4 Use of legal process to protect children 4.4.1 Another common theme in this work was a lack of clarity and confidence regarding the use of legal process to protect children. This was first evident when the children became the subject of police protection and were placed in foster care. Police protection can last for up to 72 hours however the police officer making the decision has to consider how long such protection is needed and it should only be in operation for as long as is necessary to ensure that the child is safe. In this case the police protection was put in place on Friday afternoon but it appears that mother’s consent to the children being accommodated was not gained until Monday morning. The delay in obtaining mother’s consent was because she was inebriated and needed time to become sober before she could meaningfully give consent. Police and social work staff did not discuss the timescales for police protection and it is thought that social workers assumed that it would be for 72 hours. Police officers are required to end police protection as soon as a child is in a place of safety unless there are specific concerns that warrant it remaining in place longer. In this case the children needed to remain the subject of police protection until mother had given her consent for their accommodation but this required agreement between police and CSC. In this case this issue did not adversely affect outcomes for the children however it nevertheless is an important lesson for future practice. 4.4.2 There was also confusion as to whether father had parental responsibility for either child; which was of greatest significance for CSC as they needed to be working in partnership with whoever had parental responsibility, and needed to make key decisions about their welfare, only after consultation. The social worker undertaking 8 P 53 A review of safety management literature. Eileen Munro, London School of Economics. SCIE 2008 9 P 53 A review of safety management literature. Eileen Munro, London School of Economics. SCIE 2008 Hampshire Overview Report – Child S and Child R published 1 October 2013 24 the initial assessment clearly recorded that father did not have parental responsibility; however, at the legal strategy meeting, the second social worker assumed that he did have it for the older child. In reality father did not have parental responsibility for either child until after they moved in with him. It is evident that the social worker knew before Christmas that father did not have parental responsibility so it would seem that he chose to place the children with father without any legal framework with the risk that mother could legally remove them from his care. 4.4.3 One explanation for this could be that mother was choosing not to have contact with the social worker and thus forcing him to act without her consent. In this context the most appropriate action by the social worker would have been; either, to facilitate the father obtaining parental responsibility more quickly; or, to consider whether (in the absence of a person with parental responsibility) the Local Authority should apply to the court for an interim care order to enable the parental responsibility to be shared with mother. The local authority had already started this process by issuing the PLO and had previously been confident that the grounds were met for an order. Clearly the circumstances had changed since then; and, it is possible the court would not have supported the application, however such an action would have meant that father could still have been considered as an alternative carer but within a more structured legal framework. 4.4.4 One advantage of this approach would have been to ensure that both parents were legally represented and CAFCASS would have been involved which may have resulted in a greater focus on the children. As was identified in the CSC IMR, it was clear that mother had no real insight into why the children were in foster care and did not understand the seriousness of the PLO process. It was reported by the CSC representative to the review panel that it was very unusual for a parent involved in the PLO process not to have legal representation. It was apparent on a number of occasions that mother was unclear of her rights and did not fully understand the PLO process. If there had been an application made to the court by CSC this might have proved a spur to mother to get legal advice, also her entitlement to legal aid may have been different if the matter had been reviewed under a public law framework. There would also have been separate representation for the children and this might ultimately have been better for them. It must be acknowledged however that the PLO was a legitimate process to be used in these circumstances and there was significant efforts made by CSC to ensure that mother had sufficient information with which to understand her legal rights and responsibilities. 4.4.5 An additional effect of the absence of any formal legal order with regard to the children was that the decision to place them with their father, (and subsequent monitoring of their care) was the sole responsibility of CSC, and the social worker. Once the children were placed with father, there were no inter-agency frameworks in place to review their care. If the children had been the subject of a care order, they could only be returned to father’s care via ‘placement with parent’ processes which require formal consultation with other agencies, including the police. They would also have remained the subject of LAC planning reviews until the order was discharged. Hampshire Overview Report – Child S and Child R published 1 October 2013 25 ANALYSIS 5.1 What was the quality of decisions, assessments, plans and services offered by agencies with particular regards to: domestic abuse/adult violent behaviour? 5.1.1 There were positive aspects of the work undertaken by agencies with regard to domestic abuse. There was regular notification of events by police to all agencies including school and health visitor. There was also evidence that police regularly considered children’s needs and on occasions spoke to children when appropriate. There was also positive engagement by most agencies in the MARAC process and significant information sharing between agencies. 5.1.2 There were some limitations to the MARAC process in that the absence of clear records produced by one agency meant that each agency recorded what they thought relevant which could lead to inconsistency. The requirement to store records centrally also meant that individual case records did not always include the full detail of discussions. The MARAC process, where central representatives discuss a number of clients, meant that the discussions and decisions reached at MARAC lacked personal knowledge of the families. Also as the MARAC meetings only occur monthly there was sometimes a tendency for events to have overtaken these meetings. There was one MARAC immediately prior to the children being placed in foster care when the MARAC discussion was very focussed on the safety of the children and it is possible that it could have been more appropriate for there to have been a child protection conference which would have allowed those professionals directly working with the children to have contributed. It is probable however that the concerns being discussed would not have met the threshold for calling a child protection conference. This was discussed fully at the professionals consultation event and raised questions about the need for a more formal child in need planning process where there are concerns that do not warrant calling a child protection conference. 5.1.3 Most of the assessments undertaken by CSC whilst addressing the effect on mother of the domestic abuse did not include sufficient contact with father to assess his response to the allegations. Thus they relied on mother’s interpretations as to what had happened which did not provide a good gauge of the risk that father posed as often mother minimised or exaggerated the abuse or was too inebriated to judge the effects. 5.1.4 There were two opportunities for father to receive assistance regarding being a perpetrator of domestic abuse. The first was when Hampshire Probation recommended attendance at an IDAP programme but the court gave a custodial sentence. The second was when Wiltshire Probation recommended that father should receive a sentence of ‘supervision with unpaid work’ in response to his action of making malicious threats from prison. This assessment should have considered recommending attendance at an IDAP programme given the nature of the threats and the fact that they were made when father was in prison. 5.2 What was the quality of decisions, assessments, plans and services offered by agencies with particular regards to parental substance misuse and mental health? 5.2.1 It was unfortunate that neither father nor mother fully engaged with either mental health or substance misuse services. Significant effort was made to engage mother in both but she was in such emotional chaos that she was unable to maintain regular Hampshire Overview Report – Child S and Child R published 1 October 2013 26 contact with any professional. It is clear that mother did have mental health difficulties but the extent to which these were clinical or were a learned response to her domestic abuse is open to debate. There is one perspective that describes much behaviour by abused women to be a legitimate response to trauma. 5.2.2 Father was only seen by the mental health services once despite some evidence that when under extreme stress he did have some aspects of suicidal ideation. There are two references to father considering taking his own life; once when the couple had first separated and the second after he has been arrested for assault and possession of cocaine. When he was seen by mental health services he presented very rationally and denied any need for help. In such circumstances it is hard for agencies to intervene further. 5.2.3 It is also unfortunate that there was not a multi-agency approach to the parenting assessments on both mother and father. It was clear that alcohol and drugs played a significant part in the couple’s problems and was identified by them both as being a source of the domestic violence. A more co-ordinated approach to the parenting assessment that involved joint working between mental health, substance misuse and social work professionals might have identified more clearly the risks and the actions that needed to be taken to better promote the welfare of the children. It is noteworthy that mother and maternal grandparents were not happy about the assessment of father by the social worker and they raised concerns that the children may have been at risk of harm through neglect because of his alleged alcohol and substance misuse. 5.2.4 There was also very little evidence from most agencies of a knowledge or use of the Hampshire Joint Working Protocol10. Health partners whilst they communicated to some degree did not recognise the necessity to share information between health services working with the adults and those working with the children, sharing information in silos. The community mental health services and health visiting services did not communicate directly with each other, as guided by the Joint Working Protocol. This protocol was developed following a previous serious case review that identified issues about how risks were managed in a family where there were significant mental health and substance misuse issues. The expectation is that where agencies are working with adults who are parents and there are such issues that there should be immediate communication with key agencies such as the health visitor to ensure that the parenting risks are addressed. The development of the protocol was an acknowledgement of the difficulties in transferring information between agencies however this review has not identified significant improvement in this area. 5.3 What was the quality of decisions, assessments, plans and services offered by agencies with particular regards to the competencies and limitations of the parents in their parenting task? 5.3.1 As has been clearly stated previously the major limitation in the assessment of the parents to the parenting task was with regard to the possible effects of alcohol or drug abuse on their parenting. The assessment of father undertaken by the social 10 Hampshire Joint Working Protocol http://4lscb.proceduresonline.com/pdfs/joint_working_pr_parents_have_problems.pdf#search="Joint Hampshire Overview Report – Child S and Child R published 1 October 2013 27 worker was dependent on his direct observation of the children and information provided directly by father. There is no evidence that he gathered information from other sources apart from the school and family centre. An omission was that he did not ask the paternal grandmother how father had cared for the children over the Christmas period despite this being the first long period during which they were in his care. With hindsight the paternal grandmother considers that father found caring for the two children together too much. 5.3.2 There is some evidence that the social worker made judgements very early in the assessment process. Thus two weeks after father had left prison the social worker advised the Housing department that if he had accommodation he would be deemed suitable to care for the children. Mother, maternal and paternal grandparents all reported that the social worker seemed extremely keen that the children should not be in foster care over the Christmas period. The rationale for this is not known and it is clearly an emotive time of year when significant efforts are made for children to be with their families. This should not be a driving force, however, and in this case it seemed to lead to actions that were not technically lawful and caused distress within the wider family. There may also have been some pressure for the children to be discharged from care because of the need for planning for the older child’s school place in September and this was mentioned at a LAC review. Whilst it is clearly important that social workers are thinking ahead about children’s education this should not preclude proper assessment of risk. 5.4 What was the quality of decisions, assessments, plans and services offered by agencies with particular regards to the extent to which the children’s needs, views and wishes were taken into account? 5.4.1 There was clear evidence throughout the work that all professionals worked hard to ensure that the children’s views and wishes were taken into account. Many professionals spoke directly to the older child who was articulate and expressed his wishes. Examples of this prior to children being moved to foster care include the social worker seeing the older child alone during a visit when the child said that it was ‘fun with father playing on the PlayStation’ and that ‘it did not feel safe with mother because she drank vodka, beer and wine starting at 5pm’. 5.4.2 There were also examples of the older child contributing fully to the LAC reviews particularly early in the placement when the child clearly stated a desire to remain in the foster placement rather than move to one closer to home and school. There is also evidence that when the older child felt that the move to live with father was not progressing in a sufficiently speedy manner the child made this clear to both the school and the foster carer who informed the social worker. 5.4.3 There is however sometimes a requirement for social workers to be able to differentiate between children’s expressed ‘wishes and feelings’ and their ‘needs’. In this case the ‘wishes and feelings’ were clearly heard by the adults but this may have overwhelmed their judgement about how those ‘needs’ would be best met. In the author’s opinion and based on case recording there is a sense that on some occasions the social worker found it hard to accept the pain that the child was experiencing as a result of the separation from the father and that this had too great an influence on his practice. Hampshire Overview Report – Child S and Child R published 1 October 2013 28 5.4.4 There was also sometimes a lack of judgement about ‘when’ and ‘how’ the children should be included and involved in decision-making. An example of this was when the social worker spoke with the older child, and advised the child that, in his view, the assessment of mother was not favourable and that he had begun an assessment of father. At this stage, father had been released from prison for seven days, and the only person with parental responsibility was mother. It is not clear if mother had been advised by the social worker that he was assessing father as a carer, or that he considered her to be unsuitable to care for the children. 5.5 What was the quality of decisions, assessments and plans and/or recommendations made by the agencies in relation to the residence and contact arrangements for the children? To what extent were the children’s needs, views and wishes taken into account? 5.5.1 As previously stated the decision to place the children with father when he did not have parental responsibility or a residence order depended on mother co-operating with the arrangement. Similarly the recommendation to the court that father should manage the contact with the children was problematic. At best this arrangement meant there was on-going direct contact between two individuals who repeatedly showed that they had difficulty maintaining appropriate boundaries. At worst it was enabling father who had previously abused his partner for thirteen years to have significant power over her. However, it should be acknowledged that the court made this order having considered all of the facts at that time. 5.5.2 It is clear that the social worker was acting in accordance with the children’s wishes in enabling their move to live with father. It is also clear that the older child particularly was disillusioned by mother’s actions and felt that she was unreliable. In this context it was important to ensure that on-going contact was a positive and enabling experience. It is unclear how this was expected to be achieved given the attitude and behaviour of both parents. The social worker repeatedly asked the parents to work together in a mature way to ensure that the children’s needs were being met but there was significant evidence that mother was unable to do this, and some evidence that father also was failing to do so. In these circumstances it may have been appropriate to recommend the involvement of a third party in the handover arrangements which could also have served to monitor the progress of the relations between mother and father. 5.6 What was the quality of assessments and decision making in the 3 months leading up to the children’s deaths? Were any child care or safeguarding concerns recognised and responded to appropriately? 5.6.1 There were two significant events that might have prompted agency action in the three months prior to the children’s deaths. The first was father’s arrest for being in possession of a white substance. This event was being investigated at the time of the deaths and because the children were not present, in line with police policy, it was not reported to the police Child Protection Team. When interviewed father advised that the children were in the care of their mother. The second event was the notice of eviction of father for non-payment of rent. It is clear that this suggested a lack of stability by father in providing accommodation for the children and warranted further examination. 5.6.2 During the three months immediately prior to the children’s deaths, there was limited contact by any agency with them. The older child attended school for half the period Hampshire Overview Report – Child S and Child R published 1 October 2013 29 and did not show any distress or report anything unusual. Father attended probation appointments regularly but nothing unusual was noted. The housing department and police reported to CSC that mother was having significant contact with father. The social worker did discuss this with him, when he met the family in the street, and on that occasion, he saw both children who seemed happy and well. 5.6.3 During the three months leading up to the children’s deaths it is evident that there was some drift in the planning by CSC. There was no decision made regarding closure or transfer but there was equally no active input recorded by the social worker. The supervision record at this time indicates that either transfer to Wiltshire or closure would be appropriate but did not make a decision about which was the most appropriate course of action. It is unclear what the rationale was for the case remaining open to Hampshire CSC at this time. Transfer of case responsibility to Wiltshire CSC may have been appropriate but would have depended on their willingness to accept case responsibility. It is concerning that there was no consideration of consulting with other agencies about this decision or evidence that they would have been informed about the case being closed. 5.7 What was the quality the level and effectiveness of exchange of information and communication between agencies and across areas? Were there any gaps which may have impacted upon assessment, service provision or outcomes? 5.7.1 There was some evidence of good communication between agencies and there were significant levels of information sharing. There was however a tendency for most of the service provision to be undertaken in silos and until the children were accommodated there was no clear multi-agency planning process with regard to them. Even whilst they were looked after the assessment and decision-making was largely undertaken by the social worker with limited involvement of other agencies. Whilst there was regular contact with the school there was limited involvement of the health visitor and minimal contact with the GP. Once the children moved to live with father there was no multi-agency planning and professionals reverted to passing information to the social worker. 5.7.2 There was limited evidence that professionals were aware of and using the Hampshire Joint Working Protocol (JWP) despite both parents having ‘complex problems that might impact on their ability to care for children’11. Communication between all adult services and CSC was minimal and few agencies linked appropriately with the GP despite that professional being a central hub for information sharing, particularly about the adults. The MARAC process was multi-agency and was well attended by professionals. The effectiveness of the process was however questionable given the recurrence of domestic abuse incidents and earlier in the report are details of reasons why this could be the case. 5.7.3 Another factor that impacted on information sharing was that father moved into accommodation outside the Hampshire boundaries which meant a significant change in the professionals from all key agencies. As the children were not looked after there was no obligation on Hampshire CSC to advise Wiltshire CSC that the children had moved into their area but this clearly could have facilitated communication. It would 11 Hampshire Joint Working Protocol http://4lscb.proceduresonline.com/pdfs/joint_working_pr_parents_have_problems.pdf#search="Joint Hampshire Overview Report – Child S and Child R published 1 October 2013 30 also have been good practice for the social worker to discuss with Wiltshire CSC whether they would accept case responsibility to provide support for the family particularly given that the possibility of transfer was raised in the LSM. 5.7.4 There were also communication difficulties between Wiltshire police and Hampshire police when Wiltshire failed to contact Hampshire to get more detailed local information. At the front-line professionals group there was a strong view from Hampshire police officers that the move weakened the focus on the family as the Hampshire police force knew both parents well. The issue was that mother reported a domestic violence incident in Wiltshire whilst she was resident in Hampshire. If Wiltshire police had passed the details of this incident to the Hampshire police Domestic Violence Team they would have had a complete picture of the risks from domestic violence to a Hampshire resident and then could have referred her to a Hampshire MARAC if appropriate. It is also noteworthy that information sharing about domestic abuse incidents varied across the two counties so the school was not advised of the domestic abuse incident that occurred in Wiltshire. 5.8 Were there any organisational difficulties being experienced within or between agencies? Were these due to lack of capacity within the agency? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? 5.8.1 The Wiltshire CSC IMR clearly identified that workload pressures and vacancies resulted in the delays in responding to the police referral about the domestic abuse incident in April 2012. It is clear however that this delay did not have a significant impact as the Hampshire social worker was aware of the incident although Hampshire police were not. 5.8.2 The main social worker in Hampshire was an agency worker, brought in to cover vacancies in the team. The team was therefore not fully staffed; however caseload data, and feedback from staff, indicate that workload pressures were not greater than in comparable teams. There were also changes in management arrangements but the IMR author did not consider that these affected practice and the social worker when interviewed did not consider that it affected his supervision. 5.8.2 There were workload pressures because of vacancies in the health visiting teams in Wiltshire and this was seen as one explanation for the lack of closer monitoring of the younger child by the health visitor. It is not clear that this would have made a significant difference to the children’s safety as the child was seen by a range of health professionals when in his father’s care and seemed happy and well. 5.8.3 A resource issue, identified by the school, was regarding support for father with transport in getting the older child to school. The panel agreed with the professionals that continuing the school placement for the older child in his last year of primary school was important, and that the very long journey on public transport would have placed some stress on father, which may have been alleviated, if transport could have been provided. This was also an issue raised by the paternal uncle and his wife, who felt that the daily journey both led to greater contact between mother and father, and, also was a financial pressure. Hampshire Overview Report – Child S and Child R published 1 October 2013 31 6. ASSESSMENT OF IMRs and the SCR process The review ran smoothly, with good participation from most agencies. The quality of management reviews was generally good and agencies kept to timescales. Family members contributed to the review process and frontline staff and managers were also involved. The multi-agency meeting had a significant personal impact on some individual staff. The panel noted the importance of all staff involved with child deaths to be given sufficient support in contributing to serious case review processes which can be very challenging for them. It was also agreed that the methods by which front-line staff can contribute to the review process would be further evaluated. 6.1 Hampshire Children’s Services Department 6.1.1 This was a very full report that detailed all of the involvement of CSC staff with the family. It described the three periods of involvement firstly whilst the children were living with their mother, then whilst they were in foster care and then the later period when living with father. The report is robust in its critique of social work intervention and identifies a number of areas for improvement including improved social work record keeping, better recording of MARAC decisions and police checks. It also identifies ways in which the public law outline procedures could be strengthened and rightly identifies that the legal strategy meetings that are a part of the process should be as robust as the child protection planning systems. In the bulk of the report there are other areas of weakness identified that the author either considers to be specific to that worker or are areas where compensatory action has already been taken by the local authority, for example changes in the file audit processes that will present greater challenge to individual practitioners. The panel considered that the report was less robust with regard to the weaknesses of the social work assessment of father, particularly the absence of significant consultation with other agencies, and the limited supervision of the children after their return to his care. It also did not fully address whether the management and supervision provided to the social worker was sufficiently strong. 6.1.2 The original report was scrutinised by the panel who asked for additional information regarding the role and involvement of the fostering service and the foster carer. Otherwise there were minimal changes required and the panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.2 Hampshire Education - school 6.2.1 This report provided an overview of the involvement of the school attended by the older child for the period of the review. Generally the school had provided him a supportive environment when family life was difficult. The school had provided ‘a close watch’ over the older child for the duration of the review which meant that the class teacher, class teaching assistant and special needs co-ordinator observed the child closely in class and outside of lessons in order to identify any signs of deterioration in behaviour or progress. Most of the school’s report focussed on information received from outside agencies as the child’s progress within school was uneventful and the child was a popular and successful pupil. The report did evidence good information sharing across agencies. The only real difficulty identified was with regard to the distance travelled by the older child when living with father and the one Hampshire Overview Report – Child S and Child R published 1 October 2013 32 recommendation relates to provision of support to children travelling to school from outside the area. 6.2.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report. There was no action plan as the issue of transport was incorporated into a CSC recommendation 6.3 Hampshire Police 6.3.1 This report was a very detailed synopsis of the significant involvement that Hampshire police had with the family. It identifies strengths in the police response to domestic abuse but also highlights areas for improvement. It reports on the changes in the police Public Protection Department and the development of the Central Referral Unit as central point of receipt for all notifications of children at risk. The report also identifies the potential for children to be at risk when police are involved in making informal short term care arrangements and identifies checks that need to be made to militate against these risks. 6.3.2 The original report was scrutinised by the panel who asked for additional information regarding the MARAC. Otherwise there were minimal changes required and the panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.4 Hampshire Probation 6.4.1 This report reviews the limited involvement of Hampshire Probation which was concerning the production of a pre-sentence report. The recommendation that father should attend IDAP was not adopted by the court but their decision to impose a custodial sentence was seen as understandable in the context of his escalating violence. There are no recommendations. 6.4.2 This IMR was reviewed by the panel and as the terms of reference had not been formally addressed some minor amendments were suggested. The panel considered that the authorship was sufficiently independent. 6.5 Southern Health NHS Foundation Trust - Health Visiting 6.5.1 This report details the involvement of the health visiting service in Hampshire prior to the children being accommodated. It identified that both children suffered from a medical condition and evidenced the involvement of the service in the MARAC process. Recommendations made relate to operating procedures and recording systems for MARAC. 6.5.2 This IMR was reviewed by the panel and the first draft was felt to need some changes as it was insufficiently critical and did not address the terms of reference. Even after amendment there was a need for additional recommendations which was addressed via the Health Overview report. The panel considered that the second draft was acceptable; the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. Hampshire Overview Report – Child S and Child R published 1 October 2013 33 6.6 Hampshire Early Years 6.6.1 This IMR provided an analysis of the involvement of the family centre in providing supervision for contact and the work of the child-minders who care for the younger child at different times. It identified the difficult task child-minders have in maintaining relationships with parents whilst maintaining appropriate professional boundaries and ensuring that children are safeguarded. The report also identified difficulties in commissioning the IMR because of the specific nature of the relationship between the Local authority and commissioned services such as child-minding. Recommendations made relate to the need for improved training and support for child-minders and improved protocols regarding the undertaking of serious case reviews 6.6.2 This IMR was reviewed by the panel who felt that significant changes were needed as the report did not address the terms of reference and needed substantial additional information regarding the role of the local authority as commissioner of services and the actual times that the child attended the child-minder. The panel considered that the second draft was acceptable; the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.7 Borough Council 6.7.1 This report is concerned with the housing and revenue and benefit services provided to the family. There was significant involvement over the period as both mother and father were in receipt of housing benefit and father required re-housing during the period of the review. The lessons learned from the review are mainly concerned with improving the confidence and knowledge of staff to, where necessary, challenge the judgements of colleagues in CSC. The recommendations are therefore relating to how to improve joint working between the two agencies. 6.7.2 This IMR was reviewed by the panel and as the terms of reference had not been formally addressed some minor amendments were suggested. The panel considered that the second draft was acceptable; the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.8 Housing Provider 6.8.1 This report related to the involvement the housing provider had with mother who was their tenant and also a decision made by the agency to refuse to provide accommodation to father who was nominated for a house near to mother after he had custody of the children. The recommendations mainly relate to improving awareness of safeguarding across staff. 6.8.2 This report was reviewed by the panel and additional information was required about involvement with mother. Additionally the report needed to be re-written to address the terms of reference. The panel considered that the second draft was acceptable; the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. Hampshire Overview Report – Child S and Child R published 1 October 2013 34 6.9 Solent NHS Trust – Homer Substance Misuse Service 6.9.1 This report provides an overview of the limited involvement the service had with mother when they tried to engage her in addressing her substance misuse problems. The review highlighted good attempts to engage mother and that domestic abuse and child safety were considered in the work. The review also identifies that the recording system did not allow for full records to be made of all the interventions particularly with regard to domestic abuse and safeguarding. The recommendations are directed to addressing this deficiency. 6.9.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.10 Southern Health NHS Foundation Trust - Mental Health 6.10.1 This IMR GAVE an overview of the services provided to mother and father. It identified that the services provided to mother were appropriate and that clinicians involved with her identified the vulnerabilities of the children resulting from her behaviour. It noted that mother failed to engage with on-going therapeutic services despite significant encouragement to access them. It identified that services to father were also appropriate but that a more detailed assessment of him might have elicited information about potential risks and in particular his parenting responsibilities. The recommendations relate to the importance of improving understanding of domestic abuse, better recording and multi-agency liaison. 6.10.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.11 Hampshire Adult Services 6.11.1 This report reported on the very limited involvement the service had in screening referrals and passing them on to the Community Mental Health team. The recommendations relate to improving safeguarding training for staff involved in screening. 6.11.1 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.12 Primary Care (Health) - GP Services 6.12.1 This report reviewed the involvement of GP services with the family. There were three practices involved and primary care practitioners were closely involved in assessing both parents around mental health and substance misuse issues. Primary care practitioners were also aware of domestic abuse problems. The major finding of the review was that there was insufficient focus on parenting capacity when primary care practitioners undertook the assessments and that there were several opportunities where potential risks to the children could have been assessed. The Hampshire Overview Report – Child S and Child R published 1 October 2013 35 recommendations relate to increasing awareness of domestic violence, improving assessment of parenting capacity and ensuring that this is recorded appropriately. 6.12.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.13 CAFCASS 6.13.1 This report relates to the limited involvement of Cafcass following father applying for parental responsibility for both children. The report concludes that the actions were appropriate and in line with procedures. The report also identifies the need for improved operational guidance regarding Standard Operating Principles to define and support the standards of practice required in its Work to First Hearing. 6.13.2 This IMR was reviewed by the panel who considered that it was acceptable and that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.14 Wiltshire Children’s Services Department 6.14.1 This report provided a very detailed overview of the single period of involvement by Wiltshire CSC. This related to the domestic abuse incident investigated by Wiltshire police. CSC failed to identify that a Hampshire social worker was working with the family and passed the case for assessment. Unfortunately due to pressure of work this was not undertaken and at a later date the case was closed with no action being taken. Recommendations relate to the development of new domestic abuse notifications and the associated changes in procedures and training systems. 6.14.2 This IMR was reviewed by the panel and was felt to need some changes as it was too long and included unnecessary detail. The panel considered that the second draft was acceptable; the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.15 Wiltshire Police 6.15.1 This report related to the one incident of domestic abuse that was investigated by the Wiltshire police. The findings identify some areas for improvement regarding the sharing of information about domestic abuse with other agencies. The recommendations also relate to changes in these systems. 6.15.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.16 Wiltshire Probation 6.16.1 This report details the involvement of Wiltshire probation in preparing the pre-sentence report and then supervising father. The report is critical of the recommendation as attendance at an IDAP programme would have been more Hampshire Overview Report – Child S and Child R published 1 October 2013 36 appropriate and the evaluation of the supervision is that it was insufficiently robust. The professional practice was not considered to be representative of general practice but was associated with individuals’ practice that was being responded to via competency human resource processes. Recommendations relate to improving consistency of practice across all parts of the service. 6.16.2 This IMR was reviewed by the panel who considered that it was acceptable and that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.17 Wiltshire Health – Health Visiting 6.17.1 This review relates to the period when Wiltshire Health was responsible for monitoring the health and well-being of the younger child. The health visitor saw the child on two occasions, including one home visit. The review concluded that there should have been closer monitoring of the child when full consideration was taken into account of father’s history. The recommendations therefore relate to changes in the recording of risk assessment and more training for staff on risk assessment. 6.17.2 This IMR was reviewed by the panel and some minor amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.18 South Central Ambulance Service 6.18.1 This IMR reports on six contacts with the family during the period of the review and identifies weaknesses with regards to ambulance staff safeguarding responses. The original IMR was not felt to be sufficiently robust and did not fully address the terms of reference so amendments were requested. After significant interventions these amendments were achieved. 6.18.2 This IMR was reviewed by the panel and amendments were recommended. These were implemented and an action plan was received. 6.19 Health Overview Report 6.19.1 This very comprehensive and detailed report appropriately reviewed the key themes from the health IMRs and identified any relevant matters of concern for commissioners. They also evaluated the health IMRs and where necessary made additional recommendations. These were the lack of GP involvement with the children once they were looked after; concerns as to whether safeguarding alerts placed on GP records were seen by clinicians; the lack of risk assessments by the health visitor where there was parental substance misuse, domestic abuse and mental health issues; and the limitations in the ambulance service regarding notification of previous safeguarding concerns when involved in repeat call-outs to the same address. There were six additional recommendations addressing these issues. 6.18.2 The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. Hampshire Overview Report – Child S and Child R published 1 October 2013 37 7 LESSONS LEARNED FROM THE REVIEW 7.1 The review highlighted the need for integrated multi-agency assessment of families where children may be in need but which do not meet the threshold for child protection; particularly if there is evidence of the toxic trio of mental health, substance misuse and domestic abuse. Best practice demonstrates the need to move beyond information sharing, towards a more collective approach to making decisions regarding the care of children. Furthermore, the assessment needs to ensure that there is realistic understanding of parents whole life experience; and, it is important that issues of past substance misuse and domestic abuse are fully evaluated, when making decisions about the future care of children. This was particularly relevant with regard to the assessment of father which did not involve other agencies sufficiently. 7.2 A significant finding from the review is the danger of ‘fixed thinking’ and the need for challenging management and supervision processes that ensure that professionals involved in safeguarding children have sufficient professional curiosity so as to enable reflective case work even in a context where there is no evidence of direct physical harm to children. This was relevant with regard to the assessments by many agencies of mother where insufficient attention was paid to the impact of prolonged domestic abuse on her mental health. It was also significant with regard to father and it is important that managers should ensure that, where assessments depend on the work of a single person, the evidence base for their decision is robust enough and is appraised via critical analysis. The question that needs to be answered is what would have assisted the professional involved in being able to analyse and identify the effect that their interaction with the client was having on their practice. Clearly a significant factor has to be the nature and type of supervision being provided. This review has shown the importance of the ‘critical review’ aspect of supervision; there are certain types of erroneous thinking and decision making that will simply not be picked up by the individuals concerned themselves. The systemic issue for the LSCB is the extent to which agencies know how well their supervision provides sufficient ‘critical review’. 7.3 The review also showed the importance of ensuring that whilst communicating and consulting with children there are still appropriate adult/child boundaries. Adults need to make the adult decisions, albeit having first obtained children’s views, noting that in this case the local authority did not at any stage have parental responsibility for the children and the fact that the court granted residence orders to father. 7.4 A specific aspect of learning was the need for professionals from all agencies to have a greater mutual understanding of the legal framework within which they operate. Where possible, professionals need to enable these legal processes to include consultation and communication with professionals from other agencies. This clearly links to the learning in 7.1 around greater multi-agency involvement in assessment processes. It is important that all professionals feel confident in calling for multi-professional planning meetings to discuss safeguarding concerns. In this case it was apparent that there was no obvious point at which a child protection conference should have been held; but, all the front-line professionals consulted were clear that in the absence of such a need a multi-agency meeting of another kind would have enabled a better understanding of the family’s problems. Hampshire Overview Report – Child S and Child R published 1 October 2013 38 7.5 The review also showed that the MARAC process, while well established, needs to ensure that it is better integrated with individual agency processes and systems. In particular it is important that any records of discussions about individual children are included in the individual client records and that each agency is confident that systems are in place which ensure that information is passed speedily from the MARAC representative to the individual key worker and it is clear what action is expected. Furthermore the review identified a need for clarity about when it is appropriate for a discussion within a MARAC to trigger a child protection conference, and how this should be initiated. 7.6 The review also identified the difficulties of working across boundaries and how important it is for all agencies to ensure that, when a family moves out of the area, sufficient relevant information is shared with professionals in the new area to enable them to fully understand any safeguarding risks. Hampshire Overview Report – Child S and Child R published 1 October 2013 39 8 CONCLUSIONS 8.1 Even with the benefit of hindsight it is clear that the events that resulted in the children’s deaths could not have been predicted. Whilst father’s violence towards mother had been identified the risks to the children were less tangible. None of the professionals involved with the family anticipated his actions. There is no evidence of physical abuse by father against the children prior to their deaths. No-one, including members of the family, anticipated his actions nor is there any substantive information to suggest that anybody could or should have anticipated the tragic outcome. 8.2 This review has highlighted, however, areas where practice could be improved and has shown that there could have been a better multi-agency assessment of father, before he assumed care of the children. It has also identified that after the children were returned to his care by the court there could have been closer monitoring of their well-being and better information sharing between agencies. 8.3 It is possible that if a more rounded assessment of father had been undertaken that this would have identified further information, but it is equally possible that this would not have provided any additional knowledge. It is therefore not obvious how these deaths could have been prevented. Hampshire Overview Report – Child S and Child R published 1 October 2013 40 9 RECOMMENDATIONS 9.1 Hampshire Safeguarding Children Board (HSCB) 9.1.1 That HSCB requires that Hampshire Children’s Services Department review their planning processes for looked after children returning to their parents’ care, where there have been concerns about neglect or abuse, to ensure that there is a robust multi-agency assessment and rehabilitation plan. 9.1.2 That HSCB requires that Hampshire Children’s Services Department review their ‘Child in Need’ procedures to ensure that there are clear and timely decisions regarding closure or referral to a new authority area (if the family has moved) and that relevant information is shared in a timely manner with involved professionals and where relevant, professionals in the new authority area. 9.1.3 That HSCB requires Hampshire police to review the MARAC process to ensure that all meetings are suitably recorded and that all agencies have systems in place to enable records from MARAC meetings to be actioned and placed on individual case records. This review should include consideration of how the MARAC process interfaces with the child protection conference system. 9.1.4 That HSCB requires all agencies to ensure that their management and supervision processes are sufficiently robust as to ensure that fixed thinking by professionals is identified and challenged. 9.1.5 That HSCB should, via its Learning and Improvement Framework, evaluate the quality of frontline professionals’ communication with children; reviewing whether they are sufficiently clear about the balance between responding to children’s expressed ‘wishes and feelings’ and ensuring that their ‘needs’ are met. 9.1.6 That HSCB should, via its Learning and Improvement Framework, ensure that front-line professionals have a working knowledge of each other’s legal frameworks to protect children. 9.1.7 That HSCB re-launches the Joint Working Protocol to ensure that it is understood and utilised across all partnership agencies. Fiona Johnson June 2013 Hampshire Overview Report – Child S and Child R published 1 October 2013 41 Glossary of terms SCR Serious Case Review CSC Children’s Social Care NSPCC National Society for the Prevention of Cruelty to Children MARAC Multi-agency Risk Assessment Conferences CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Service GP General Practitioner CP Child Protection PSW Parent Support Worker HSCB Hampshire Safeguarding Children Board IMR Individual Management Review PLO Public Law Outline IDAP Integrated Domestic Abuse Programme LAC Looked After Child EDS Emergency Duty Service CAFCASS Children and Family Court Advisory and Support Service JWP Joint Working Protocol LSM Legal Strategy Meeting |
NC042880 | Executive summary of a review into the death of a 10 month old baby who was the subject of a child in need plan, from a non-accidental head injury. The mother's boyfriend was convicted of manslaughter. The mother was 16 and living in a hostel. Considers issues around supporting young mothers and assessing the needs of the mother and the baby; disguised compliance, neglect; parenting capacity; assessing unknown men in the family; optimistic thinking; failure to take up support services offered; adolescent behaviour; substance misuse; capacity to challenge families and professional colleagues. Makes interagency and various single agency recommendations covering children's social care, housing, early childhood services; GPs and NHS Trusts and the police.
| Title: Executive summary of the serious case review relating to Child G LSCB: West Sussex Local Safeguarding Children Board Author: Fiona Johnson Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 West Sussex Local Safeguarding Children Board Executive Summary of The SERIOUS CASE REVIEW relating to Child G 2 1 INTRODUCTION 1.1 Background to the review The review was held because, whilst in the sole care of her mother’s partner, Child G sustained a catastrophic head injury caused by the use of significant force. Police investigation of the events resulted in mother’s partner being arrested and charged with murder; he was convicted of manslaughter for which he was sentenced to 8 years in prison. 1.2 The specific Terms of Reference for the case were • The key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Specifically: o Were the decisions made at the CP Conference reasonable o In light of the Conference recommendation was the full extent of the role and responsibilities of mother’s partner in Child G’s life, and his ability to care for the child assessed appropriately? o Were there any indications of potential risk at any point during the period of review, and if so were they shared or acted upon appropriately and in a timely manner? • The actions taken following assessments and decisions and whether appropriate services were offered/provided or relevant enquiries made, in the light of assessments? Specifically: o Did the Children in Need plans and services provided effectively meet the child’s needs? • The degree to which the child’s needs were taken into account when making decisions about the provision of children’s services, and whether this was accurately recorded? • The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and family, and whether this was explored and recorded? • Was there sufficient management accountability for decision making and the involvement of managers at key points in the case? • The adequacy of training and supervision of staff to carry out their role? • The consistency of work with each organisation’s and the Local Safeguarding Children Board’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? • Any organisational difficulties being experienced within or between agencies and whether there was a lack of capacity or resources in one or more organisations? • Any examples of good practice or lessons to be learned about single and multi-agency working? • Any recommendations you would make to the West Sussex Local Safeguarding Children Board regarding training, practice or procedures? 3 Later information was provided by the police that became available via their criminal investigation. This information indicated that Child G was exposed to drugs over a period of time. As a result all agencies were asked to provide an addendum report indicating to what extent did they consider substance misuse by any adults involved with Child G to be a factor. 1.3 The serious case review panel membership was as follows: • Jane Browne, Surrey and Sussex Probation Trust: Chair • Designated Nurse • Manager, Early Childhood West Sussex County Council • LSCB Business Manager • Sussex Police • Managers, Children Social Care West Sussex County Council Additionally Fiona Johnson, the Independent Overview Writer attended review Panel Meetings. 1.4 Reports were received from the following sources: • West Sussex County Council Children Social Care (including the Child Protection Unit), • West Sussex County Council Early Childhood (Children and Family Centre and outreach) • Sussex Police, • A Residential Hostel, • Sussex Community NHS Trust (Health Visiting), • NHS Sussex Cluster (West Sussex) (GP) • Western Sussex Hospitals Trust (A&E, Midwifery and Child Development Centre) • Health Overview Report 1.5 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: - • A London Hospital • South East Coast Ambulance NHS Trust • Borough Council Housing Department • A domestic violence victims advisory service Checks were also undertaken with Connexions and the Youth Service with regard to any involvement that they may have had. 1.6 Consideration was given to involving the parents in the review process however this was not immediately possible because of on-going criminal investigations. When the criminal trial was completed contact was made with mother and maternal grandmother and maternal grandfather. The independent overview author met with 4 mother and maternal grandmother and their views are included later in the report. Numerous unsuccessful attempts were made to arrange a meeting with maternal grandfather however this was not achieved. The father was offered to see a copy of the report prior to full publication. 2 THE FACTS 2.1 The Family background Name1 Relationship Age Ethnicity Child G Subject baby White British Carly G Mother 17 years White British Russell S Father 19 years White British Chris B Mother’s Partner 26 years Dual heritage white British/black Caribbean Maureen G Maternal Grandmother Unknown White British Mark G Maternal Grandfather Unknown White British Pam B Chris B’s mother 44 years White British 2.1.1 Child G’s parents are white British and their first language is English; religious affiliations are unknown. Chris B is dual heritage, white British/black Caribbean, his first language is English and his religious affiliation is unknown. Child G was the first child of Carly and Russell and their relationship ended soon after Child G’s birth. Carly started her relationship with Chris B when Child G was very young. Child G and Carly were living in a hostel as a result of Carly becoming homeless during her pregnancy, following a disagreement with her mother. Prior to being pregnant Carly worked as a hairdresser; however, for the period of the review she was in receipt of benefits. Chris B had a criminal record for minor drugs offences. Russell S was known to the police and he had been involved in incidents of domestic abuse but had no criminal convictions. Carly had some support from her father and was also supported by Chris B’s mother. 2.2 Agency Involvement with family 2.2.1 The first significant agency involvement with Carly was when she booked for her confinement early in her pregnancy. She was identified as a potentially vulnerable mother by virtue of her youth and received an enhanced service from the midwife with whom she developed a positive relationship. At this stage Carly was in a relationship with Child G’s father although they were not living together. 2.2.2 Early in the pregnancy Carly had to leave her mother’s home and was provided accommodation in a hostel for vulnerable young mothers. The hostel offered Carly 1 Grace, Carly, Chris B etc are the names given by West Sussex LSCB to provide anonymity 5 a range of services aimed at improving practical skills such as cookery and money management. Child G was born after a difficult labour where Carly experienced an eclamptic fit; but was a healthy baby of normal weight. 2.2.3 Soon after Child G’s birth there was an incident of domestic abuse between Carly and Child G’s father which resulted in their relationship ending. Carly received support at this time from all agencies via a Multi-agency Risk Assessment Conference (MARAC2) domestic violence support plan. At this point Carly was being supported mainly via the health visitor but an assistant care manager (ACM) from Children’s Social Care was also involved. Carly started a relationship with Chris B two months later. 2.2.4 Carly’s care of Child G was initially supervised by the midwife and then health visitor and during the first three months the care was deemed ‘good enough’ although there were some concerns that Child G was left unsupervised in the room in the hostel. Soon after Carly started her relationship with Chris B the health visitor received a referral from a person who reported that Carly was not coping, was feeling low and had no milk for Child G. The health visitor found Carly with ‘made-up’ feeds that were not refrigerated and no further formula; she also said she had few clothes for Child G that fitted. Carly seemed low but said that she had more formula at her boyfriend’s flat which she visited regularly. Child G was seen and seemed well and had gained a little weight. The health visitor was concerned about the poor management of money and the lack appropriate care regarding Child G’s formula and reported these concerns to the ACM. 2.2.5 The ACM discussed these concerns with her manager and following this a visit was undertaken by the ACM and a Senior Practitioner. This visit took place at Chris B’s flat as Carly was staying there. This visit raised further concerns regarding the care being provided to Child G as the conditions within the shared house were poor. There was evidence of cannabis use in the bedroom and it became apparent that Child G had spent the night in a bouncy chair as there was no travel cot despite Carly having previously told the ACM that this was where Child G slept when they stayed over at the house. 2.2.6 Following further discussion with the manager and a strategy discussion with the police it was agreed that an appropriate way forward was to convene a child protection conference. At this stage the police considered that there was no need for a joint section 47 investigation. The evidence of need for a child protection conference was limited being based on the two visits by the health visitor and ACM; the concerns that were raised were that Child G was at risk of chronic neglect, Carly failing to prioritise Child G’s needs and Carly associating with people involved in drug-use. 2.2.7 The decision of the conference was that there would not be a child protection plan but that Carly and Child G would be supported via a child in need plan. The 2 Multi-Agency Risk Assessment Conferences (MARACs) are meetings where information on high risk domestic abuse victims is shared between local public agencies. By bringing all agencies together to share information, a coordinated safety plan can be put together to support the victim. Around 250 MARACs operate across England, Wales and Northern Ireland. http://www.caada.org.uk/marac/MARAC.htm 6 recommendations from the conference included that the core assessment should be updated and an assessment of Chris B undertaken; that Carly should attend all appointments and engage in support offered by the Children and Family Centre including a parenting course and independent life skills course; that Carly should be supported regarding housing difficulties and any recurring difficulties regarding domestic abuse from Russell; that a family group conference be considered; and finally that a contract of expectations should be drawn up which would specify the need to have a further child protection conference if Carly did not co-operate with services provided. The child protection conference was not attended by the hostel who sent a report or by the GP who was not invited. 2.2.8 Soon after the conference; and following a review of the police file by a supervising officer, Sussex Police determined that there should be an unannounced visit to Chris B’s accommodation to check regarding possible substance misuse. Sussex Police made contact with the student social worker to arrange a joint unannounced visit. This was delayed for over four weeks as Chris B had moved address and there were difficulties in getting the new address from Carly. Eventually there was a joint visit but it was not unannounced due to miscommunication between the police officers and the student social worker. When the visit was undertaken the flat was seen to be clean and tidy and was newly decorated, there was no evidence of drug-use and the officer visiting considered that Chris B appeared to be making an effort to provide a suitable home environment for Carly and Child G. 2.2.9 Immediately after the conference all agencies found it hard to make contact with Carly who was also spending significant periods away from the hostel. She continued this behaviour for the next six to eight weeks having an increasingly contentious relationship with staff at the hostel as she was unhappy that other residents were rehoused before she was. During this time Carly spent significant periods away from the hostel and was also in rent arrears. 2.2.10 At this time the student social worker was attempting to work in partnership with Carly and had drawn up a contract of expectations and had an outline child in need plan. Neither of these documents were shared with other agencies; and although there were planning meetings held, these were disorganised, and minutes of the meetings were rarely circulated. Carly was unwilling to attend the children and family centre but did undertake some direct work with the student social worker. 2.2.11 After the student social worker had been working with Carly for approximately four months she appeared to become more co-operative and started to spend greater time at the hostel. At this time she also paid off her rent arrears possibly with assistance from her father. As a result of the progress the hostel indicated that Carly would be able to move into permanent accommodation in the near future and the student social worker thought that sufficient progress had been made for the child in need plan to be downgraded to a CAF plan co-ordinated by the children and family centre staff or health visitor. 2.2.12 The day before Child G sustained the life threatening injury, the child was seen by the health visitor and student social worker who both visited, separately, but on the same day. The student social worker visited in the morning and considered that all was well with Carly and Child G. Carly told the social worker that Child G had fallen 7 onto the headboard of the bed the previous week and mentioned a bruise to the head. The student social worker could not see any sign of an injury. The health visitor called later in the afternoon and was not told by Carly of the fall. The health visitor examined the child who was seen to be ‘babbling, smiling, sitting, crawling, weight-bearing and exploring [the] environment’; ... height and weight were normal and no problems were identified’. 2.2.13 Later that day Carly took Child G to stay overnight with Chris B; she left Child G in Chris B’s care and returned alone to the hostel. It had been agreed that he would care for Child G to enable Carly to sleep as she was very tired. At some point that night Child G experienced a life-threatening injury that eventually lead to the child’s death. 3 VIEWS OF FAMILY MEMBERS 3.1 Carly was clear that in her view there was nothing that could have been done to prevent Child G dying, as no-one knew that Chris B would harm Child G; and, since the death nothing further had been identified that would have indicated that he posed a threat to the child’s safety. 3.2 Carly was also very clear that she had never seen Chris B taking drugs apart from occasionally smoking cannabis which he always did outside, away from Child G. Carly said that she never took any drugs, even cannabis, and would not have remained with Chris B if she knew that he was taking other drugs. 3.3 Carly was asked about the support that was provided to her, before and after Child G’s birth. She indicated that prior to the birth she was assisted by the midwife, although she was surprised that the input was an enhanced service. After the birth she felt everything was acceptable until a person contacted the health visitor and made untrue allegations about her care of Child G. Carly said that the child protection conference held after this was a difficult meeting; and did not enable her to express her point of view, or to tell people the truth. Particular inaccuracies were that Child G had not slept overnight in a bouncy chair, but in a carry-seat that was part of the push-chair and was meant to be used as a travel cot for babies. Also there were plenty of toys and clothes available. 3.4 Carly agreed that after the conference she was not very co-operative with professionals as she was angry that they had not listened to her. She was also unhappy that other girls had been re-housed from the hostel ahead of her. Carly said that she did not like it at the hostel as there were mouse droppings in her room and on her bed. Carly said that this was the reason that she did not pay her rent rather than because she did not have money. Although she also said that Chris B was often short of money and that she used to feed him. Carly paid off her rent arrears independently without any assistance from her father and said that the staff at the hostel did not offer any support in enabling her to learn to manage her money. 3.5 Carly confirmed that she were unaware that there was a child in need plan and had not signed any written agreement and felt that while the social worker was visiting she received very little support but had to go to a lot of meetings which was sometimes unhelpful. 8 3.6 The maternal grandmother was able to offer little in addition to Carly’s views. She said that she had never met Chris B and had no contact with Carly for the period of the review. Maternal grandmother’s major concerns were about the effect that publication of the case review would have upon Carly who was emotionally vulnerable. 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS 4.1 Skills in engaging families 4.1.1 A significant issue identified in this review was the extent to which any professional was able to engage and build a positive working relationship with Carly. With the possible exception of the midwife it does not appear that any professional found it easy to engage Carly and there is some evidence that she avoided contact and could be deceptive in her responses. 4.1.2 This ambivalence and unwillingness to engage was however not clearly understood by the agency system as Carly was also very adept at diverting professional attention by being critical of other professionals. This is most overt in her relations with staff at the hostel but could also be seen in some of her responses to the student social worker and health visitor. For instance there were a number of occasions when the student social worker contacted the health visitor on Carly’s behalf rather than encouraging her to take responsibility for resolving matters with the health visitor directly. Carly was also very adept at appearing to be positive about future involvement in support services which she then failed to attend. This behaviour was apparent with regard to attendance at the parenting groups and involvement with the sessions offered by the hostel. 4.1.3 Adolescents are often difficult to engage and a pattern of partial co-operation is not unusual from teenager mothers. There were aspects however of Carly’s behaviour, particularly after she became involved with Chris B, that were more representative of a pattern of behaviour observed in other serious case reviews where families show disguised compliance. This is described in research as being ‘where parents defused professionals’ attempts to take a more authoritative stance by making pre-emptive shows of cooperation… The family’s compliance was only temporary but it was sufficient to persuade workers of their apparent willingness to be more open and therefore kept them at bay.’ 3 Ostensibly the family seemed to co-operate with the professionals but in fact this was illusory and the pattern of engagement included ‘deliberate deception, disguised compliance and “telling workers what they want to hear”, selective engagement and sporadic, passive or desultory compliance.’4 4.1.4 Whilst there was significant involvement by agencies with Carly and Child G and much time was invested in helping her improve their circumstances; it was clear from the IMRs that very little was known about their day-to-day life. In particular it was very unclear to what degree Chris B was involved in direct care for Child G and whether it was intended that when Carly moved into independent living that Chris B would be living with her. 3 Reder et al (1993), 4 P 76 Understanding Serious Case Reviews and their Impact – Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren and Black, DCSF 2009 9 4.1.5 As a result of meeting with Carly and receiving her contribution to the review process the overview author considered that Carly’s lack of compliance was mainly a product of her youth. It was clear that no professional was able to engage her however this was not because she was deliberately manipulative but was a feature of her inexperience. It is possible that a greater understanding of her adolescent ambivalence by professionals might have enabled better partnership working. 4.2 Quality of supervision 4.2.1 It is clear that all staff were receiving regular supervision; however, there is some concern as to the quality of the supervision provided; in particular whether it sufficiently challenged professionals in their attitudinal perspectives. Reder and Duncan argue that front-line staff need to develop ‘a dialectic mind-set’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. 5 Similarly in ‘Working together to safeguard children’ it is suggested that professionals ask themselves: • Would I react differently if these reports had come from a different source? • What were my assumptions about this family and what, if any, is the hard evidence supporting them?6 4.2.2 The absence of clear analysis of the major risk factors in the core assessment initially undertaken by the ACM would argue that the supervision and oversight provided to her work did not provide her with sufficient challenge and scrutiny. Similarly the supervision provided to the student social worker was practically oriented and there was little evidence that it questioned the developing optimism about the apparent change that was being achieved. The role of the supervisor should be to provide independent and objective challenge and if that had been available it seems unlikely that the drift in child care planning and failure to effectively engage with Carly would have remained hidden. Despite discussion in supervision about agreeing a contract of expectations there was apparently no consideration of actions that should be taken if the contract was breached. 4.2.3 There was some evidence of challenge provided in the police oversight however the delay in arranging the follow-up visit and the move to a pre-arranged appointment would indicate that this was not sufficiently robust. 4.2.4 The health visitor was clearly receiving regular supervision and there was a child centred approach as indicated by the decision to maintain health visitor continuity when the GP changed. The supervision seemed however to be led by the health visitor and there was no evidence that the supervisor queried whether there was sufficient improvement or enabled the health visitor to challenge the student social worker perspective about the effectiveness of the child in need plan. 4.2.5 Overall the extent to which the supervision provided to professionals provided the opportunity for critical reflection is dubious given the failure 5 Reder & Duncan Lost Innocents 1999, p98 6 Department of Health, Home Office, Department for Education and Employment, 2006: p113 10 by any agency to critically analyse the purpose and functioning of the child in need planning process. The exception to this would be the police supervision of the initial section 47 investigation; unfortunately the follow-up to this intervention was less effective and the delay in action influenced the outcome. 4.3 Significance of substance misuse 4.3.1 Substance misuse was never identified as a key issue in the assessment of this family despite there being some evidence that Chris B used drugs and at one time lived in a house where it was suspected that there was drug-dealing. The significance of this issue was not recognised at the initial strategy discussion as it should have resulted in a joint section 47 investigation. This error was however identified during supervising police officer review of the work and rectified. 4.3.2 It is clear that the state of Chris B’s first flat was a significant factor in the ACM’s perspective that an initial child protection conference should be held. This issue however then became absorbed into a general concern about Carly’s neglect of Child G rather than focussing on what could have been the reason for the neglect. No professional linked the neglectful parenting with possible substance misuse. 4.3.3 One reason for this may well have been that there was very little evidence that Carly was involved in drug-use. She was never seen to be intoxicated by professionals and there was only one referral alleging alcohol abuse which was received after Child G’s death. The evidence of drug use may have been hidden as professionals had very limited access to Chris B’s accommodation and it is probable that he was the source of any drugs. 4.3.4 Since Child G’s death there have been two allegations by family members that the child was given alcohol by adults however there is no other evidence to support these assertions. Neither of these alleged incidents were known about by professionals prior to Child G’s death. 5 LESSONS LEARNED FROM THE REVIEW 5.1 The importance of effective engagement of families and the need for assertive and inquiring interventions that include all adults, particularly men in the assessment process. Alongside this the review identified the difficulty of working with teenager mothers; and the problems of distinguishing between ‘usual’ adolescent behaviour, and more problematic, ‘passive resistance’. A key factor for professionals working with families is their capacity to challenge and confront when outcomes are not achieved; regardless of the underlying causes. 5.2 The need for challenging and empowering supervision that enables professionals to review their work effectively. This needs to engender sceptical review and the capacity to re-evaluate existing presumptions. The challenge for supervisors is to be sufficiently aware of progress in work with families whilst still maintaining a degree of independence and scrutiny. It is crucial that supervisors do not solely rely on the supervisee to raise issues. 5.3 The need for improved child in need planning processes. These systems need to have multi-agency involvement and ownership and must ensure that there is 11 sufficient capacity and capability to review the effectiveness of the child in need plan. This evaluation needs to include an on-going consideration of the assessment process which allows for re-assessment as time progresses and enables an evidence–based approach to casework planning. 5.4 The importance of greater awareness and consideration of substance misuse and the ways in which it may influence and affect parents and carers’ abilities to provide safe and consistent care for children particularly the more vulnerable babies. This understanding requires that professionals move beyond outward signs such as direct use of drugs and alcohol and consider other factors such as money management and availability as other indicators of possible substance misuse. 5.5 The importance of ensuring that all appropriate persons are invited to conferences and receive minutes within reasonable time frames. 6 CONCLUSIONS 6.1 Even with the benefit of hindsight there has been no evidence identified that Chris B presented a risk of physical harm to Child G. It must be acknowledged however that very little was known about him or about the level and nature of care that he was providing to Child G. If the work undertaken with agencies had been significantly different there would be no guarantee that Child G’s death could have been avoided. The reality is that there was limited information held by any agency to indicate that Chris B posed a risk to Child G and the review has not been able to identify any information that could have been accessed that would have shown that he was unsuitable to be caring for the child. 6.2 With hindsight it is clear that Child G was exposed to drugs. The issue of substance misuse was not fully addressed in any professional assessment of Child G and the mother. It is possible that if there had been a more thorough investigation of this issue when it was first raised then the risks to Child G might have been identified. 6.3 It is possible that if an effective assessment had been undertaken investigating the concerns regarding substance misuse that this would have identified further information about Chris B but it is equally possible that this would not have provided any additional knowledge. It is therefore not clear how this death could have been prevented. 7 RECOMMENDATIONS LSCB 7.1 That the West Sussex LSCB ensures that the learning is shared with all relevant staff. 7.2 That the West Sussex LSCB ensures that the recommendations in all of the completed IMRs are implemented by regular review of individual action plans. 7.3 That the LSCB ensures that all relevant member agencies are engaged with and fully understand the child in need planning processes including the use of ‘contracts of expectation’. 12 7.4 That all relevant agencies should satisfy the West Sussex LSCB that assessment processes include due consideration of the involvement of fathers and/or partners in the child's life. Where possible this should include their effective involvement in the process. 7.5 That the LSCB request all agencies examine their supervision of professionals who work with children in need. Agencies to report on whether supervision arrangements are sufficiently robust and capable of challenging and sceptical review. 7.6 That the LSCB undertake a review of multi-agency working with families where substance misuse is considered; following the launch of the ‘Think Family’ protocols 7.7 That the LSCB requests the Children’s Safeguarding Unit to review the processes regarding invitations to and distribution of minutes from child protection conferences. WSCC CHILDREN’S SOCIAL CARE 7.8 To ensure agency checks are completed and recorded on Framework I within all Section 47 enquiries (7.5.9) 7.9 A review of the quality of Child in Need Plans arising from an Initial Child Protection Conference (7.5.4) 7.10 Improve the quality of assessment in relation to the following; • children alleged to be suffering from neglect. (7.2), • parenting capacity of teenage parents (7.1) • the role and impact of new partners in relation to the child (7.5.2) • ensure all CIN plans include a contract of expectations (7.5.4). 7.11 Improve the quality of student supervision in relation to casework practice, analysis and planning, allocation of cases and understanding of working in a multi-professional context. 7.12 Raise awareness of the value of Family Group Conferences or family meetings in Children in Need plans. (7.5.7) SUSSEX POLICE 7.13 That any changes to the existing Police processes for the way information is shared and recorded are subject of post implementation audit and review. WSCC EARLY CHILDHOOD 7.14 Establish a single strategic oversight for Safeguarding and Family Support activities within ECS - (reference paragraph 10.1 in Section 10 ‘Learning Points’.) 7.15 The implementation of a case file structure for Family Outreach Worker Service – to ensure consistent practice across the service - (reference paragraph 10.2 in Section 10 ‘Learning Points’). 7.16 Ensure consistent practice for casework supervision with related record keeping – (reference paragraph 10.3 in Section 10 ‘Learning Points’.) 13 7.17 Family Outreach Service to have clear and consistent care planning requirements which ensure focus on children’s needs and related improved outcomes - reference paragraph 10.4, 10.5 and 10.6 in Section 10 ‘Learning Points’. 7.18 To ensure that diversity issues are routinely considered in all contacts with children and their families – (reference paragraph 10.7 in Section 10 ‘Learning Points’.) HOSTEL, 7.19 Improve record keeping. 7.20 Align Hostel ISP and CIN Plan reviews and Safeguarding processes. 7.21 Review Visitor Time procedures to ensure robust risk assessment of visitors to vulnerable tenants. 7.22 Revise Hostel Safeguarding policy and procedures to make more comprehensive. 7.23 Revise Confidentiality and Data Protection policies. 7.24 Develop Trustees understanding of Safeguarding. 7.25 Improve management and sharing of key information. 7.26 Increase manager involvement in Safeguarding cases. 7.27 Review all Safeguarding cases. SUSSEX COMMUNITY NHS TRUST (HEALTH VISITING), 7.28 Sussex community Trust to ensure that HV assessments meet the required Core Service Standard. 7.29 Sussex Community Trust to ensure that practitioners who attend child protection conferences are fully conversant with the process. 7.30 Sussex Community NHS Trust Child Protection and Safeguarding Children Procedures to include clear guidance on the roles and responsibilities of health professionals within integrated working on a CIN plan. WESTERN SUSSEX HOSPITALS TRUST 7.31 Where there are vulnerabilities recognized at clinic consultations, letters should be copied to relevant parties such as the health visitor, with the consent of the individual 7.32 Although the A & E visit of 1st September 2010 appears to imply a minor illness, it is unclear that there was any regard taken of her social situation. This should be reviewed using the new paediatric A&E flow chart to trigger the assessment of vulnerabilities. 14 7.33 Although safeguarding training and the hospital procedures provide clarity on how the safeguarding team can be accessed to support staff and help with progressing safeguarding concerns, this should be strengthened. 7.34 There are not any copies of the PICU retrieval documentation in the notes; this should be remedied by the provision of an HDU/PICU retrieval pathway, or copies of PICU documentation should be added to the medical notes. NHS SUSSEX CLUSTER (WEST SUSSEX) (GP) 7.35 That NHS Sussex Cluster (West Sussex) advise all GPs in West Sussex that when the GP hears of a child protection conference being scheduled, they ensure that they have been invited and if they are unable to attend they send a report and also advise GPs that the GP contacts the social worker if they do not receive a report after the conference. 7.36 That the NHS Sussex Cluster (West Sussex) advises GP surgeries in West Sussex to ensure that their practice nurses document which adult attends with a child for vaccinations and whether they have parental responsibility and they document why a vaccination has been given later than advised if this has happened. 7.37 NHS Sussex Cluster (West Sussex) requests that the Acute Trusts that are commissioned by them ensure that their Accident and Emergency Discharge Summaries are legible so that GPs and Health Visitors and others are able to identify any concerns from the records. 7.38 NHS Sussex Cluster (West Sussex) commission future midwifery services to include a requirement for midwives to document antenatal and postnatal consultations within the GP medical notes. 7.39 Recommendation that NHS Sussex Cluster (West Sussex) carry out an audit of all West Sussex GP Surgeries to discover which GP surgeries hold a regular multi-disciplinary child safeguarding meeting (to include GPs, practice staff, health visitors (HV), school nurses (SN) etc) and to encourage those surgeries that do not hold such meetings to introduce them. SUSSEX COMMUNITY NHS TRUST & WESTERN SUSSEX HOSPITALS NHS TRUST 7.40 Sussex Community NHS Trust and Western Sussex Hospitals NHS Trust to review the system for receiving and processing Child Protection Conference invites and documentation, to ensure there is a clear audit trail of receipt of information and that non receipt of expected documentation is followed up appropriately. Fiona Johnson January 2013 |
NC52176 | Severe knife injuries of an infant boy in June 2018. Father subsequently pleaded guilty to the attempted murder of Child R and his mother. Child R's mother and her family had moved several times and were known to 20 organisations across four local authorities. During her separation from her first husband, against whom she had made allegations of domestic abuse, Mother became pregnant with Child R. Following low level concerns about Mother's mental health, there were referrals to social care and a social worker was allocated. Child R's Father assaulted Mother in August 2017 and threatened to kill Child R in December that year. In March 2018, Child R's father again assaulted Mother and a children's social care assessment concluded that there was no risk to the children. After being convicted for the assault, Child R's father stabbed Child R and Mother. Family is Muslim and from a Pakistani background. Learning points include: focus on children's daily lives and the emotional impact of domestic abuse; recognise the importance of previous episodes in assessment; and recognising the importance of families that move frequently. Makes recommendations including: ensure that all agencies promote a culture and competence to enable staff to evaluate the risks of domestic abuse in full; ensure that staff take full account of race, religion and other characteristics that may shape domestic abuse and its impact; highlight the importance of compiling and sharing information when a family leaves or arrives in an area.
| Title: Serious case review for Family K. LSCB: Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership Author: Fergus Smith and Keith Ibbetson Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership Serious Case Review for Family K Independent Reviewer – Fergus Smith Overview Report – Keith Ibbetson Published on 25th September 2020 Contents Page 1. Background and reasons for conducting the review 1 2. Brief narrative of family background and events 1 3. Learning and recommendations 3 • Learning point A 3 o Recommendation 1 3 • Learning point B 4 o Recommendation 2 4 o Recommendation 3 4 • Learning point C 4 o Recommendation 4 4 • Learning point D 4 o Recommendation 5 5 • Learning point E 5 o Recommendation 6 5 Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership 1 | P a g e 1. Background and reasons for conducting the review 1.1 In June 2018 an infant (referred to below as Child R) suffered severe knife injuries when his father attacked him and his mother. Child R’s father subsequently pleaded guilty to the attempted murder of both Child R and the mother. At the time Child R’s mother was living in Hounslow with her four children. Child R’s father was awaiting sentence for a domestic assault on the mother committed in March 2018 at the address in Hounslow. This had never been his home address and at the time of the attack on Child R, his bail conditions barred him from contacting the mother or going to the family home. 1.2 The mother and her children had moved back to Hounslow in early 2018, having lived over the previous two years at a number of locations in London and the South-East. Child R’s mother, the children, Child R’s father and the father of the three older children in the family had been known to at least twenty organisations in four local authority areas including the police, Children’s Social Care, schools, voluntary sector domestic abuse services, hospitals and community-based health services, as well as the National Probation Service and the Child and Family Court Advisory and Support Service (CAFCASS). 1.3 All members of this family are from Pakistani heritage; identifying as Muslim or practising Islam. The mother had moved to the UK from Europe and had the right to reside permanently here. She travelled regularly to see her family throughout the period under review. Child R now lives with his mother’s extended family in Europe. The father of the three older children is a UK national and he now has responsibility for their care. The father of Child R was born in Pakistan and had a limited right of residence in the UK. 1.4 In July 2018 Hannah Miller, the Independent Chair of Hounslow’s Safeguarding Children Board (now Partnership) decided that the criteria for undertaking a Serious Case Review (SCR) were met, taking account of the very serious injuries to Child R and his mother, the number of services that had been involved with the family and some initial concerns about the way in which agencies had worked together. It was clear that in hindsight that the level of risk to the children and their mother had been underestimated. 1.5 Although work on the review began immediately and its scope and approach were set in a proportionate way, delays to the review were caused by the large number of agencies and local partnerships involved and the difficulty in obtaining and verifying potentially relevant information. This mirrored the difficulties experienced by professionals working with the family before Child R was injured. 1.6 This summary report sets out the learning and recommendations of the review and has been prepared for publication in order to comply with the statutory guidance and transitional arrangements for safeguarding children boards and partnerships.1 2. Brief narrative of family background and events 2.1 The children’s mother had an arranged marriage to a Pakistani man living in the UK. They had three children over a period of four years who are all now of secondary school age. Agency records give no indication of concerns about their care until 2016, when their mother made allegations of domestic abuse, including a very serious sexual allegation, against the father. These allegations 1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/722306/Working_Together-transitional_guidance.pdf Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership 2 | P a g e were subsequently retracted, and the mother later expressed her confidence in his ability to care for the children. Initially the family court granted the mother care of the children and an order enabling her to live in the family home. 2.2 The mother also said that she felt threatened by members of her own family, alleging that they might try to remove her children. This was recorded by the police as being possible ‘honour-based violence’, though no specific details were noted and there was no investigation. Despite her reported fears, the mother subsequently had numerous contacts with her family, travelling several times to see them with her children, causing no apparent difficulties for her. The alert in police records led officers to track her when she made travel arrangements to leave the UK, and on a number of occasions welfare checks were made (sometimes on her return to London). 2.3 During the period of separation, mother moved home on a number of occasions. Although initially the court ordered that the children should live with their mother, the arrangements for the children appear to have been fluid and not always in line with the intentions of the court. The reasons for this are not clear but no urgent concerns were ever raised about their care. Court welfare officers expressed concern about the veracity and inconsistency of the mother’s accounts, which were never tested in court through a fact finding (which is a requirement of the relevant family court guidance).2 2.4 At around the time of her separation the mother from her first husband, she met the father of Child R and became pregnant. They married under Sharia law (Islamically), a status not recognised under UK law. She booked antenatal care at more than one hospital and during her pregnancy presented to a number of health trusts and women’s organisations (in Hounslow, East London and elsewhere). She usually repeated the allegations of domestic abuse (by the father of the older children) and agencies suspected low level concerns about her mental health. The latter were not specific or serious and therefore were not judged to require further assessment or treatment. No agency obtained a comprehensive account or chronology of the children’s history. Mother persistently denied any allegations of abuse from her new partner until much later in the review period. 2.5 Sharing of these concerns led to referrals to social care from a number of agencies, a pre-discharge planning meeting after the birth of Child R and the allocation of a social worker from the Local Authority in East London where the family (mother, the three older children, Child R and his father) planned to live. A single assessment was started though social work involvement was limited. 2.6 The older children attended primary school, who were alert to the children’s needs and in liaison with the mother, facilitated contact with their father, which was positive for the children and was not deemed to have caused any difficulties. 2.7 In August 2017, the father of Child R assaulted the mother during a dispute about the contact that was taking place between the older children and their father. She had informed her family about this, who told her to stay in her Islamic marriage due to the shame of being divorced twice. There is no evidence that she told any professional about the assault until March 2018, when she reported that the abuse had continued from that point and had become worse 2.8 In December 2017, the mother told Child R’s father that she was ending the relationship because she had found sexual videos of him with another woman. In response, she reported that he had threatened to kill Child R and attempted to persuade her to send him to be brought up in Pakistan. The police investigation highlighted inconsistencies in the mother’s account and prosecution was 2 ‘Practice Direction 12J - Child Arrangements & Contact Orders: Domestic Abuse and Harm’. https://www.justice.gov.uk/courts/procedure-rules/family/practice_directions/pd_part_12j#21a Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership 3 | P a g e not pursued. Mother continued to seek separation from Child R’s father, though when offered a refuge place she did not accept it because it was located outside London. It is not clear whether the couple remained in the same household after this point. 2.9 For this period, there is no record of action by the responsible Local Authority, Children Social Care service and the reasons for this could not be determined by the review. Information about the family was maintained and shared in the professional network through the actions of an Asian women’s voluntary organisation who worked closely with the mother. The local Multi-Agency Risk Assessment Conference panel (MARAC) was notified of the most recent incident. 2.10 In early 2018 the mother found accommodation for the family and moved back to Hounslow. The previous Local Authority did not share information about the family moving, however the domestic abuse organisation working with the mother did and the Hounslow MARAC obtained information from its counterpart. Mother was given support to live in Hounslow by voluntary sector domestic violence services, stating her intention that she would not tell the father of Child R where she was living or have contact with him. Professionals accepted her view that this was adequate protection against further attacks by Child R’s father. 2.11 In March 2018 he assaulted the mother after she gave him the address of where she and her children were living. She reported to professionals that this was on the pretext that he needed to collect his possessions, and that he ‘snuck in’ and she was too frightened to make him leave letting him stay overnight. At this point the police pursued a prosecution against him. Children’s Social Care and a domestic abuse organisation both undertook an assessment and practical protective measures were put in place. The Hounslow MARAC panel noted that the Local Authority was undertaking a risk assessment and took no further action. 2.12 The Children’s Social Care’s assessment concluded that there was no risk to the children from Child R’s father. After being convicted for the assault, but before sentencing, he stabbed the baby and his mother. This is understood to have been linked to the mother’s refusal to undergo a paternity test, which the father had pressed for. 3. Learning and recommendations Learning Point A - The need to focus on the children’s daily lives and the emotional impact of domestic abuse The focus of investigations and assessments was on the possibility of there being immediate risk of physical harm to the children, though in two instances, after the children had returned to live in Hounslow in 2018, that risk was not identified. Most agencies paid insufficient attention to the day to day experience of the children and the potential for emotional harm resulting from the instability caused by exposure to incidents of violence, repeatedly moving home and uncertainty caused by changing family composition. Recommendation 1 The safeguarding partnership will recommend to member agencies that assessments of children’s needs should always take account of the emotional impact of domestic abuse. Learning Point B - Recognising the importance of families that move frequently The frequent household moves over a relatively brief period of time caused difficulties for professionals. The mother approached different agencies (for example antenatal services) without always informing them that other services had already been involved. Although there were Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership 4 | P a g e exceptions, agencies rarely sought information from their counterparts in other areas, as a result of which the risk assessment could only be based on information provided by the mother and the current presentation. At several important points, information was not shared by agencies when they knew that a family had moved. Recommendation 2 The safeguarding partnership should highlight the importance of compiling and sharing information that is crucial to the safe transfer of cases; case summaries and reviews, case closure documents, and chronologies setting out key events. Agencies must ensure that when a family leaves or arrives in an area their staff take all relevant steps to transfer and request information. Recommendation 3 The safeguarding partnership should ensure through Learning and Development, that all agencies have arrangements in place to consider within assessment and supporting multi-agency procedures the child’s experience and emotional impact, as well as the child’s voice. Learning Point C - Recognising the importance of previous episodes in assessment Recommendation 4 The safeguarding partnership should ask member agencies and partnerships (including those who are the commissioners of services) to ensure that whenever possible, professional assessments of risk in relation to domestic abuse consider relevant history. For example, past accounts of abuse, including those with other partners, pervious services provided and their impact and the impact of abuse on the victim and children. Learning Point D - The need for professionals to evaluate the veracity of accounts of abuse The review highlighted the difficulty faced by professionals in deciding how to evaluate the allegations made by the mother. The records show that professional understanding of risks had been based exclusively on the accounts given by her, with no corroborative or supportive evidence until the final episode of abuse. In hindsight, it is clear that some allegations of abuse were retracted or not shared with professionals by the mother. There was little evidence that she followed up offers of support, often changing her opinion about the ability of the father to look after the three older children safely. At the time, professionals were either not aware of these inconsistencies or did not choose to understand them better within the context of the family function. It is not the responsibility of the Serious Case Review to retrospectively judge whether the allegations made were true or not. However, the lack of a careful evaluation at the time may have contributed to professional views which underestimated the very serious risk posed by the father of Child R. Professionals need to recognise that victims of domestic abuse may not always give full, truthful or consistent accounts of what has happened and are most likely to understate its severity or impact. The reasons for this should not be hard to understand. Many victims find it difficult to trust professionals and wish to keep as much control as possible; they may take a particular view as to the best way to protect themselves and their children, which they may not feel that professionals understand or agree with. It is also the case that victims who fear losing their children may understate the impact of the abuse on them. It is the responsibility of agencies to take all of these factors into account in evaluating allegations made, starting with a recognition that all allegations should be taken seriously and responded to respectfully. The police are legally charged with investigating allegations with an open mind. Social Care professionals must place a particular onus on understanding potential risks to children, which Hounslow Safeguarding Children Partnership and Newham Safeguarding Children Partnership 5 | P a g e should always include making an evaluation of how reliable and protective the alleged victim and those who are supporting her can be. Sometimes it will be right to advocate or take immediate measures to protect a woman making allegations, returning later to a more careful evaluation of the circumstances. Recommendation 5 The safeguarding partnership should ensure that all agencies promote a culture and competence that enables staff to evaluate risks from domestic abuse in full, always taking them seriously and treating alleged victims with respect but in appropriate circumstances exploring how complete allegations are and whether they are valid. Learning Point E - Assessments must take account of race, religion and other individual and family characteristics that shape its impact on victims Assessment and management of risk, where there are allegations of domestic abuse need, to take account of specific factors of race, religion and family background – recognising that this will be a unique assessment because every family and individual has a different interpretation of these factors and individual needs. For example, in this case insufficient attention was paid to the characteristics and circumstances of Child R’s father. As a (reported) overstayer, whose Islamic marriage had not secured his right to remain in the UK, his need to remain involved with his child, control his partner’s behaviour by remaining in contact and establish his paternity were all of considerable significance, but were not properly recognised or assessed. Similarly, the status of the mother as a potential victim of ‘honour-based violence’ were noted as an alert on her police record but never explored to enable the reality of any risk to be determined. Some other agencies were aware of this but there is no evidence of any professional asking either the police or the mother what it signified in practice. The subsequent decision to place the injured infant with this branch of the family, suggests that there was never a serious, current risk of honour-based violence, but in other instances this might be very significant. Recommendation 6 All services dealing with domestic abuse allegations and assessments of risk to children must ensure that staff take full account of race, religion and other individual and family characteristics that may shape its impact. |
NC50540 | Sexual assault of a 14-year-old male, by a 20-year-old male care leaver (YPA) in June 2016. The assault took place whilst the two males were being housed in temporary accommodation by the local District Council who were unaware of YPA's harmful sexual behaviour. Child Z had been placed in temporary accommodation with his mother and sister in January 2016 after eviction from previous rented accommodation in November 2015. YPA had been taken into care after a difficult and unsettling early childhood. He developed inappropriate sexualised behaviour in early adolescence and in 2011, aged 14, was placed in residential care. In December 2015 he was arrested for assault of an 11-year-old boy and bailed with conditions that he should not be alone with a person under 16. Lessons learned include: Children's Services should ensure its leaving care service is fit for purpose; the need to put in place effective early intervention services for young people, including care leavers, who exhibit HSB; unaccompanied children under 16 years of age must not be placed in temporary accommodation; Police child sexual exploitation perpetrators' risk assessments must result in effective and timely multi-agency planning of suspected individuals. Recommendations: that HSB procedures are fit for purpose and up to date; to disseminate and embed HSB policies and procedures; to widely disseminate and implement findings and learning from this SCR; for the Sexual Abuse Referral Centre (SARC) to report to the LSCB on the feasibility of expanding the service remit to include children and young people who have suffered non-penetrative sexual abuse.
| Title: Overview report-final: Child Z serious case review. LSCB: Norfolk Safeguarding Children Board Author: Paul Sharkey Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Norfolk Safeguarding Children Board Overview Report-Final July 2018 Child Z Serious Case Review Lead Reviewer and Author: Paul Sharkey (MPA) Confidential 2 Contents Page 1. Part 1 - Introduction 3 2. Part 2 - Aims and Terms of Reference 5 3. Part 3 - Analysis 5 3.1 – ToR1 5 3.2 – ToR2 13 3.3 – ToR3 14 3.4 – ToR4 22 4. Part 4 - Child Z Mother’s Experience 24 5. Part 5 - YPA’s Experience 25 6. Part 6 - Key Findings and Learning Points 27 6.1 – ToR1 27 6.2 – ToR2 29 6.3 – ToR3 30 6.4 – ToR4 33 6.5 – Key Learning for NSCB to consider 34 6.6 - Six Overarching Lessons 36 7. Part 7 - Recommendations 37 Glossary of Terms 39 References 40 Appendix 1 41 Appendix 2 43 Appendix 3 47 3 Part 1 Introduction 1.1. Background to the SCR and Overview of Significant Events1 1.1.1. This Serious Case Review (SCR) is concerned with the sexual assault of Child Z, a 14-year-old male, by a 20-year-old male care leaver (YPA) in June 2016. The assault took place whilst the two males were being housed in temporary accommodation by a local District Council who was unaware of YPA’s harmful sexual behaviour. 1.1.2. Child Z had been placed at the accommodation along with his mother and sister in January 2016 having been evicted from their previous rented accommodation by their landlord in November 2015. They were waiting to be rehoused in June 2016 and were eventually found suitable long-term accommodation in July of that year. There had been two referrals to the Norfolk MASH (Multi-Agency Safeguarding Hub) in 2014 but these had not needed any intervention by Norfolk Children’s Social Care (NCSC). 1.1.3. YPA and his younger sister had experienced unsettling and difficult early childhoods which had resulted in both of them being taken into the care of Norfolk County Council when young. They were brought up together as Looked After children in a long term foster placement until YPA reached the age of fourteen. By all accounts, the placement met the children’s long term needs for security, emotional attachment and stability. Unfortunately, it then broke down for YPA who experienced the move to another placement as a traumatic life event, seemingly impacting quite significantly on his sense of security and vulnerability. Whilst having good general health he had developed Attention Deficit Hyperactivity Disorder (ADHD) for which he received appropriate medication. 1.1.4. YPA developed inappropriate sexualised behaviour in early adolescence and in 2011, aged 14, was placed in a residential setting run by a private provider. He started to show signs of Harmful Sexual Behaviour (HSB) towards younger boys and in 2014 received psychological intervention to address the behaviour that included a risk assessment. The Norfolk Police and Norfolk Children’s Services (NCS) were involved with YPA on several occasions in 2014-15 regarding HSB incidents. 1.1.5. YPA was subject to regular Looked After Child (LAC) Reviews up to his 18th birthday in January 2015, when he became a Care Leaver. As part of his pathway plan YPA moved into supported accommodation (a two-bedroomed flat) overseen by the residential home. He left the home on his own volition in the Spring of 2015 with no suitable accommodation and spent the rest of the year ‘sofa surfing’ with friends in the local area. 1.1.6. Regarding health matters, there is currently no dedicated health service commissioned for Norfolk’s care leavers, who receive their last health assessment as they approach their eighteenth birthday. Given YPA’s diagnosis of ADHD, ongoing health input beyond 1 See Appendix 1 for Timeline of Significant Events 4 the age of eighteen would have been beneficial to support his pathway planning. In this case, the health services played a small part in the lives of both boys, both before and after the sexual assault incident. Health services were not aware of the sexual abuse incident in relation to either of the boys and were not included in any multi-agency decision making forums, such as the strategy discussions (see below). 1.1.7. YPA was arrested in December 2015 for the sexual assault of an 11-year-old boy (Child B) and bailed with conditions that he should not have any contact with the victim and not be alone with any person under 16. The Police informed his Personal Adviser (PA1) of the bail conditions. 1.1.8. YPA and PA1 attended an interview with a young person’s accommodation agency (AA1) in February 2016. His application for accommodation was refused due to the risks he presented to young people. 1.1.9. YPA informed his personal adviser (PA1) in early May that he was homeless and needed somewhere to live. He duly registered in mid-May with the local District Council (DC)/Housing Options as homeless who made enquiries with NCS about his housing status. They were not informed of his bail conditions and placed him at the temporary accommodation on 24.05.2016 where there were several vulnerable children and young people resident with their families, including Child Z and his family. 1.1.10. YPA had been subject to a Child Sexual Exploitation (CSE) Perpetrator’s Risk Assessment by Norfolk Police on 12 April 2016 and graded as Medium risk. On 10 June, the Police became aware that YPA was living in temporary accommodation and spoke to NCS about their concerns regarding the potential abuse of children living there. NCS agreed to contact the District Council/Housing Options service and obtain the name of the staff member who had dealt with YPA’s homeless application and provide this to the Police. 1.1.11. Unfortunately, due to a set of mistaken assumptions by both the Police and NCS, each agency thought that the other was taking primary responsibility with the housing service for moving YPA. This resulted in a delay in moving him which eventually happened on 24 June 2016. Unfortunately, this was not in time to prevent the sexual abuse of Child Z sometime between 16 -19 June. The District Council Housing Options service only became aware of YPA’s bail conditions and the ongoing Police enquiry from Children’s Services (Leaving Care Team) on 24 June 2016, which prompted the move out of temporary accommodation. 1.1.12. YPA was moved by the District Council from temporary accommodation on 24 June. On the same day, Child Z’s mother became aware of her son’s abuse and made a complaint to the Police who arrested YPA that night. He was subsequently charged with the sexual assaults of an 11-year-old boy ( December 2015 arrest) and Child Z in late June and early July respectively. YPA pleaded guilty to the charges and was given a custodial sentence in May 2017. 5 1.1.13. Child Z was risk assessed for Child Sexual Exploitation by the Multi-Agency Safeguarding Hub (MASH) on 27 June and graded as ‘Standard Risk’ and referred to Early Help. Subsequently, no support was offered. The family moved into new accommodation in July 2016. 1.1.14. A Serious Case Review was commissioned by Norfolk Safeguarding Children Board in November 2016 and work started in January 2017 Part 2 Aims, Terms of Reference and SCR Process Issues The aims, Terms of Reference and information about the SCR Process are included as Appendix 2. Part 3 Analysis This report will now focus on addressing the four terms of reference. The analysis has, in part, been informed by the learning from the Practitioners’ Event held in June 2017. Key findings, conclusions and learning points are set out in the next section. ToR 1: Critically examine the effectiveness, or otherwise, of the care leaver planning for Young Person A (YPA). How well did the plan meet his needs for transition to independent living and address issues of risk assessment and management of his sexually harmful behaviour? The Pre-Care Leaver Period-2014 3.1.1 The evidence indicates that YPA’s needs as a looked after child, up to his eighteenth birthday, were largely well met by the staff during his time at the residential placement. His harmful sexual behavior had been recognised by the staff who had commissioned a psychologist (Psy1) in 2013 to risk assess and work with YPA. 3.1.2 A needs assessment before YPA’s eighteenth birthday was required to inform an effective Care Leaver’s Pathway Plan; one that would: • contain an analysis (amongst other things) of his independent living skills • access to suitable accommodation • arrangements for future support and care planning; and very significantly, 6 • his potential risk around Harmful Sexual Behavior (HSB).2 3.1.3 An effective and very prescient needs assessment was completed by YPA’s social worker (SW1) in October 2014. This identified two critical issues for his future, post care; namely, continuing therapeutic input from Psy1 (see above) to address his HSB and a transition to a semi-supported/moving on placement, as a ‘bridge’ to eventual independent living; overseen by the staff at the residential placement who had become very significant figures in YPA’s life. This move would be dependent on YPA continuing and completing his NVQ apprenticeship which he was later to give up. Of note, the pathway plan needs assessment documented YPA’s view that: ‘He is very frightened of becoming independent and leaving [the residential home]’. 3.1.4 The needs assessment correctly identified that without these supports YPA’s risks posed to younger children would significantly increase. 3.1.5 However, despite the LAC reviews of 2014 recognising the risk presented by YPA’s HSB, there was no evidence of a risk management plan. In this regard, there was no reference made to the Norfolk Safeguarding Children Board procedures on, ‘Abuse by Children and Young People who Display Sexually Harmful Behaviour’, which had been issued in March 2014. It is not known why these were not followed although it may be that they were not well known by practitioners at the time. In addition, despite his work with YPA, Psy1 was not involved in any of the LAC reviews. Clearly, he would have had a very important role to play in informing the future risk assessment and management arrangements regarding YPA’s HSB as a care leaver. YPA-Post Eighteen; As a Care Leaver 3.1.6 On reaching eighteen years of age in January 2015 YPA became a care leaver3 attaining the legal status of a, ‘Former relevant young person’4, making him eligible for supportive services from the local authority. 3.1.7 This meant (according to the Norfolk Children’s Services, Care Leavers, ‘Leaving Care and Transition’ procedures and Norfolk County Council, ‘Looked After Children and Care Leavers’ Strategy’, 2016-2019) that, regarding YPA, the local authority was statutorily5 required to: • Stay in touch with him. 2 HSB, is defined as, ‘Sexual behaviours expressed by children and young people under the age of 18 years old that are developmentally inappropriate, may be harmful towards self or others, or be abusive towards another child, young person or adult’. (Harmful Sexual Behaviour, NSPCC, Research in Practice, Durham University, 2016, p12) 3 Defined as a, ‘Young adult who has been in the care of the local authority’. (Norfolk County Council, Looked After Children and Care Leavers Strategy 2016-2019, page 4) 4 They are aged 18 to 21 (or up to 24 if in full-time or further education) and have left care having been previously either, ‘Eligible’, ‘Relevant’, or both. (Norfolk Children’s Services, proceduresonline, ‘Leaving Care and Transition’ 5 Provided for under Regulations 4 to 9 of the Care Leavers (England) Regulations 2010. 7 • Keep the Pathway Plan6 under review. • Continue with the appointment of the personal adviser. • Provide financial assistance to enable YPA to pursue education or training. 3.1.8 YPA was allocated a personal adviser (PA1) in March 2015 whose role was to, ‘Act as the young person’s principal source of contact in any matter relating to the pathway plan and is accountable for the effective implementation of the Plan’. (Leaving Care and Transition procedures). The role also involved the co-ordination of other agencies and individuals identified in the pathway plan and to act as the ‘focal’ point in ensuring that YPA had access to appropriate services. PA1 was required to keep in touch with YPA, keep informed as to his progress and maintain a written record of all contacts. When the care leaver moved to new accommodation the personal adviser must have seen them at that accommodation within seven days. On each visit the PA was required to consider whether the accommodation continued to be suitable for the care leaver. PA1 also had the responsibility of initiating the review of the pathway plan and recording its outcomes. His manager at this time was TM1. 3.1.9 The Review learnt that PA1 had no previous experience in this role, albeit several years prior work with adolescents up to sixteen years old. At that time, there was a joint LAC/Care leaver service which had been judged by recent Ofsted inspections (2013/15) as being, ‘Inadequate’. The Review heard that although the team manager (TM1) was, ‘Good and knowledgeable’, PA1 received no structured induction to what was a potentially complex and challenging job. The training received appeared minimal and did not cover the key aspects of roles and responsibilities. So, for example, PA1 was never given training on undertaking pathway needs assessment and planning. He also had no experience of, or instruction, in undertaking risk assessments of HSB. 3.1.10 PA1’s first Pathway Plan Review/Progress report of 5 June 2015 noted that YPA had, in accordance with the previous needs assessment, moved out of the residential home at the beginning of March and into supported accommodation - a two bedroom flat- provided by the same agency. This arrangement seemed to be meeting his needs for a transition to eventual independent living. He was also noted to have had a good working relationship with PA1. 3.1.11 However, a critical episode in this case was the breakdown in YPA’s training placement at the end of May 2015, which he terminated before its completion. This triggered the agency giving YPA notice on the supported accommodation as it was conditional on him completing the apprenticeship. The result was that YPA left the security of the agency and opted to make his own housing arrangements when it was acknowledged that the independence work was not completed. Concerns were noted by PA1 and the agency about YPA’s direction in life regarding his attitude towards his apprenticeship, the uncertain outlook regarding his future and whether he was ready for independent living in his own accommodation. He was recorded as being in a same sex relationship with a 6 This sets out the, ‘Ambitions and route to the future for young people leaving care and will state how their needs will be met in their path to independence. The plan will continue to be implemented and reviewed after they leave care at least until they are 21; and up to 24 if in education’ (Norfolk Children’s Services, procedures online, Leaving Care and Transition) 8 young man of similar age and indicated that they intended to get married in the midterm future. 3.1.12 YPA had now entered a very uncertain and fluid time in his life where the previous key supports of the residential placement, the training scheme and the sessions with Psy1 were no longer there. In addition, he was feeling unsettled about his sexuality and had no family support to fall back on. These crucial elements had been ‘key protective and resilience factor(s) in maintaining his self-esteem and social integration. Were (he) to lose (them) it increases the likelihood of boredom, social isolation and the prospect of offending’, as noted in his Pathway Plan Needs Assessment of October 2014. 3.1.13 In short, by the time of the Care Leavers Review (June 2015) the security of his previous long standing social and support networks were no longer in place. Moreover, the social controls and (limited) monitoring mechanisms overseeing his HSB from the previous pathway plan had been considerably diluted to the point where there had ceased to be any real sense of a concrete risk management plan. Although noting that YPA had finished his sessions with Psy1 and had not since displayed any sexually harmful behaviour, PA1’s pathway plan review did not include a robust risk management plan or updated assessment7 of YPA’s potential for the likelihood of future HSB. 3.1.14 Indeed, YPA’s HSB was not seen as an issue as he was thought to be in ‘an age appropriate relationship’. PA1’s focus was to ensure that YPA paid his rent and follow up the pathway into Employment, Education and Training (EET). Given PA1’s lack of any training or understanding of HSB the absence of a risk management plan was unsurprising. Compounding this omission was that Psy1 was not invited to the review. 3.1.15 In summary, by June 2015, YPA had left the relative security and supportive environment afforded by his previous care leaver plan and was intent on setting out on a path of independent living, despite PA1 and the agency’s concerns. In doing so he was now without the key supports of his former pathway plan and remained at an unknown, but not insignificant risk of sexually abusing younger children. Despite his LAC social worker having recognised YPA’s risk in October 2014 and the previous assessment of Psy1, there was no risk management plan as part of the overall pathway plan. Indeed, PA1 had not seen the previous review minutes. Moreover, there seemed to have been little thought given to developing a contingency plan following the breakdown of the pathway plan. 3.1.16 Following a critical Ofsted inspection in July 2015 which continued to find the LAC and Leaving Care (Corporate Parenting) services inadequate, a re-structuring took place in September of that year, involving the creation of two separate services, namely the LAC and Care Leavers respectively8. PA1 was located into the newly set up Care Leavers team which was led by a new team manager (TM2). There was little evidence to show that the new team had received any meaningful induction or training on roles, remits, responsibilities and the development of risk management knowledge and skills in HSB 7 For example, an AIMS2 risk assessment. 8 Both services are located in each of the six local authority districts and overseen by a district head of social work operations. 9 and other hazards. The Review received information that the new manager (TM2) had not come from a LAC/Care Leaver background and had (reportedly) not attended the service launch and locality training. In short, the evidence available to the Review seemed to suggest a less than adequate preparation for the new service. 3.1.17 By the next pathway review in November 2015, PA1 noted that YPA had experienced numerous changes. This included moving to another part of Norfolk where he was sharing a house with a friend, albeit that the arrangement had come to an end in November due to the two falling out with each other.9YPA had also enrolled on a local college course in the September but had been excluded because of poor attendance, in addition to writing off a car in a crash. He was working on a part-time, unpaid basis in a restaurant, organized through the Department of Work and Pensions (DWP). These episodes reflected a significant degree of turmoil in YPA’s life in negotiating the challenges of independent living. 3.1.18 PA1 expressed his concerns at the November review that due to the ‘huge changes’ in YPA’s life he had struggled with the transition from leaving the relative security of his supported placement, overseen by the care agency; and prematurely moving onto independent living. He had a headstrong attitude and a tendency not to listen to advice, choosing his own path instead. YPA seemed to be going from one crisis to another, not considering the consequences of his actions with his life appearing to be, ‘Out of control’ at that time. The review concluded that progress with YPA’s pathway plan was ineffective and that a ‘new plan will have to be drawn up with YPA and this will need to be specific and realistic’. There was no evidence that this was done. 3.1.19 Despite YPA’s relatively chaotic and out of control existence, known risk factors that could increase the tendency for sexual abuse and aggression, the review concluded that ‘YPA no longer requires therapeutic input, including both himself and others are no longer at risk………YPA does not pose as a risk to younger males and does not associate with them. YPA is currently in a relationship with a male slightly older……. who is proving on many levels to be a positive influence on YPA’. This was YPA’s male partner who was noted in November as self-harming and depressed. 3.1.20 This SCR is unclear as to what the evidential grounds were for concluding that, by the time of this Leaving Care review in November 2015, YPA no longer posed a risk of future sexual abuse to younger males. Especially so, given that PA1 and his manager (TM2) had received no training in HSB risk management and planning, nor had they accessed any specialist services to inform their views and decisions. How did PA1 know that YPA was not associating with younger males and what direct evidence, apart from YPA’s self-reporting, did PA1 have about the, ‘positive influence’, or otherwise, of YPA’s partner? 3.1.21 Was PA1 aware of the partner’s self-harming and depression and the potential impact of these on YPA and their relationship? How aware were PA1 and his manager about the previous history of YPA’s HSB? They had not read the key LAC report of October 9 Possibly due to a suspicion in the household that he had sexually abused his flatmate’s younger brother, Child B. 10 2014 and its prescient comments about YPA’s risks around HSB, nor the earlier CSC risk assessment of July 2013. Apparently, PA1 had received no training on how to access ‘Care First’, (Norfolk’s Children’s Services electronic care recording system) which, in any event, was not easily accessible. 3.1.22 PA1 had seen Psy1’s assessment reports of 2014 which had identified the degree of risk presented by YPA. However, PA1 and his manager were not familiar with YPA’s early history of difficulties in childhood. In short, there was no formal risk assessment undertaken of the range of both static and dynamic risk factors appertaining to YPA’s situation, nor involvement from Psy1, in the assertion that YPA no longer posed a risk of sexual harm to younger males. 3.1.23 In addition to the lack of a structured and formal risk assessment and management plan for YPA this episode raises questions around HSB recognition by Leaving Care staff, including managers, the extent to which YPA was visited by PA1,10 especially after moving into the shared house, so as to gain an understanding of his situation, the frequency and quality of supervision; and very significantly, the degree of management oversight of the case. 3.1.24 How informed were the team managers regarding both YPA’s pathway plan and the risks he posed of HSB? The CSC procedures for Leaving Care and Transition make it very clear that the designated manager for the Leaving Care team is required to approve and sign the pathway plan. There was no documentary evidence to indicate that this had been signed, by any of the parties, including the team manager and PA1. In relation to pathway reviews, the procedures state that the team manager or his/her nominee will chair these and that the team manager of the Leaving Care Service will retain a monitoring role, at six monthly intervals, to check the progress of the pathway plan. In principle, therefore the team manager should have been cognisant of YPA’s case. Unfortunately, the lead reviewer was unable to speak to TM2 as she left the service of the local authority in late 2016. 3.1.25 Finally, it may be of some significance that the deterioration in YPA’s situation in the latter part of 2015 and 2016, coincided with critical changes to PA1’s working environment. Arguably, the re-structuring and re-purposing of the Corporate Parenting team into separate LAC and Care Leavers teams, the advent of a new manager (TM2) who appeared to be out of her depth and unsupported by higher management; and the demands for service improvement, would likely have created challenging conditions for PA1, and other staff to operate within. Arrest of YPA in December 2015 3.1.26 YPA’s arrest regarding the allegations of the sexual abuse of Child B11, followed the strategy discussion about YPA’s sister and friend, between the Police and NCS on the 8 December 2015. The manager of the Leaving Care Team (TM2) was present so it is 10 A key task of the PA was to make an assessment of the suitability of any accommodation used by the care leaver, especially in the event of moves into unsupervised or unsupported premises. 11 The allegation came about because of information from Child B’s school. 11 presumed that she would have been aware of the circumstances of the incident. Consequent to YPA’s arrest, PA1 was informed by the investigating Police Officer (PO1) of the bail conditions, namely for YPA to have no contact with Child B and not to be alone with a child under 16 years old. Therefore, it can be established that both PA1 and his manager knew of YPA’s arrest and bail conditions. Indeed, the alleged offence and bail conditions were entered on Care First in January 2016. 3.1.27 It is of concern that there was no recording of the strategy discussion regarding the two girls as required by the procedures. Nor was there any sign of a strategy discussion in relation to Child B which should have been convened by NCS, albeit that it was open to the Police to have suggested one and, if necessary, escalated in the event of a disagreement. 12The evidence indicates that there was no liaison between the investigating police officer and NCS (PA1 and his manager, TM2; the MASH) around, firstly, addressing the safeguarding needs of Child B and secondly, managing the potential risk of YPA. In compliance with the Norfolk Safeguarding Children Board (NSCB) inter-agency safeguarding policy and procedures, there should have been a strategy discussion and consideration of a S.47 enquiry regarding the sexual abuse of Child B.13 3.1.28 In the event, as well as a police enquiry, a separate social work assessment was completed with Child B and his family who were offered a Child in Need support package under S.17 of the Children Act 1989. 3.1.29 Regard should also have been given to the NSCB policy and procedures in respect to, ‘Abuse by Children and Young People Who Display Sexually Harmful Behaviour’, (see 5.1 of the NSCB safeguarding procedures) which had been in place since March 2014. The issue had been frequently and regularly disseminated on fifteen occasions through the NSCB partnership learning and development programme, between February 2013 to June 2015.14 3.1.30 The policy is underpinned by three key principles involving, firstly, a coordinated multi-agency approach, secondly, consideration of the needs of the alleged perpetrator separate from those of the alleged victim and, thirdly, the carrying out of an assessment of the alleged perpetrator. 3.1.31 Anyone having concerns that a child or young person might have abused another child was expected to refer these to the MASH, ‘In accordance with the NSCB and Referrals Procedure’ (see paragraph 4.1, Referral and Assessment of section 5.3, NSCB safeguarding procedures). Albeit that YPA was by this time an adult, he was still a care leaver and the responsibility of the NCS care leavers team. 3.1.32 Following procedures (see section 5.1.5), a strategy discussion should have been held. This should have led to the convening by NCS of a multi-agency meeting (see sections 5.1.6 and 5.1.7) chaired by the appropriate NCS team manager (TM2) and involving the 12 See NSCB Safeguarding procedures (online) at section 5.1, especially paragraphs 4.5 and part 5 (strategy discussion). 13 See Section 3.4 of the NSCB Safeguarding Procedures, ‘Strategy discussions’. 14 Information received from NCSB Workforce development officer, e-mail, 07.08.17. 12 social worker (in this case PA1), the Police (PO1, the investigating officer), any other appropriate agency and YPA, to consider the issues of risk assessment and management of his HSB and bail conditions. There should have been a written risk management plan (see 5.1.7.2) covering the identification of any child at potential risk from YPA, educational and accommodation arrangements, any future assessment if required, how the plan was to be coordinated, identification of a lead professional and a review process with clear timescales. 3.1.33 Why was there not a referral to the MASH, a strategy discussion and a multi-agency risk management plan as per the safeguarding procedures? Unfortunately, it was not possible for the lead reviewer to have spoken to TM2 as she had left the employment of the local authority some time previously. PA1 suggested to the lead reviewer that the induction and training given to him when he first joined the leaving care team in early 2015 was very poor. He was unsure of his role and remit as a Personal Adviser to care leavers, had experienced a team restructuring which was confusing and experienced a change of team manager which was unsettling. He had not received any formal training in, developing and writing care leaver Pathway Plans, HSB or assessment and management of risk. He reported having received only three or four supervision sessions between September 2015 to May 2016 (when he went off on sick leave), none of which were written up. He reported to have not felt well supported by his manager. He said that management oversight of casework was not good and that the team had had no Tier 4 locality manager for some time. 3.1.34 PA1 said that he did have a supervision discussion with his manager following YPA’s arrest but the focus was on housing and EET (employment, education and training), not on the implications of the criminal investigation which was viewed as a police matter. It is against this difficult team backdrop that PA1, although knowing of YPA’s arrest and bail conditions and on-going police enquiry (as did TM2) expected his manager to follow up with a multi-agency risk management meeting to address risk. It is not clear to the Review why she did not. 3.1.35 Regarding the Police, the evidence suggests that there was no discussion with PA1 on how to manage YPA’s future risk, other than policing his bail conditions which were deemed to be sufficient controls in the circumstances. However, as discussed below, pre-charge police bail offered only limited control over YPA’s behavior and actions; and since April 2017, arguably, even less so. 3.1.36 The omission by NCS to follow agreed multi-agency safeguarding procedures by holding a strategy discussion with the Police and other relevant agencies, consequent to YPA’s arrest for sexual assault on Child B, was a missed opportunity to assess and manage his future risk of HSB and bail arrangements. Although there was a degree of information sharing, the lack of any follow up action was a breach of NSCB safeguarding policies and procedures and was not child focused. It is not understood why the procedures were not followed. The evidence indicates that the NCS and Police professionals involved in this episode were not cogniscent of safeguarding procedures around holding strategy discussions and taking appropriate actions in respect to HSB. 13 3.1.37 In addition, there should have been a re-convened pathway plan review held in December 2015 to consider the implications of YPA’s arrest, undertake a refreshed needs and risk assessment and plan for appropriate accommodation, in light of the bail conditions. This would have been consistent with existing procedures, given that there had been, ‘A significant change in the young person’s circumstances’. (NCSC, Leaving Care and Transition, p6). 3.1.38 By early 2016, PA1 was helping YPA to look for suitable accommodation and making efforts to find him a suitable employment/training placement. PA1 was clearly aware of the bail conditions and risk of YPA’s HSB as evidenced by a Housing Agency’s refusal in February to house YPA on these grounds. Likewise, his manager was aware. 3.2 ToR 2: How well were the needs, vulnerabilities and risks to Child Z and his family assessed and managed by agencies during the time they were homeless and in temporary accommodation? 3.2.1 Norfolk Children’s Services and Norfolk Constabulary had not been involved with Child Z and his family prior to the sexual abuse incident in mid-June 2016. The local District Council/ Housing Options responded to the family’s notice to quit from their landlord in November 2015 and discharged its duty under the Homeless Act 2002. The ensuing assessment identified that the family had presented solely based on the loss of their long-term accommodation and were in priority need of re-housing. The District Council considered that the risks associated with the family being homeless were far greater than those associated with them being placed in temporary accommodation. There were no other identified needs or significant vulnerabilities that required additional support or intervention from the District Council or other agencies. 3.2.2 As there was no suitable accommodation available at the end of 2015, Child Z and his family were offered temporary accommodation which they accepted and duly moved to in late January 2016. The accommodation was a privately-run Home with Multiple Occupation (HMO)15 used by the District Council for temporary accommodation. Being private, the District Council did not run or manage it and did not have control over who resided at the property. The establishment accepted individuals from other agencies and local authorities which the District Council had no control over or knowledge of. The family were allocated a self-contained room and did not need to share any facilities which was in line with general practice around housing families in temporary accommodation by the Housing Options team. 3.2.3 The proprietors of the accommodation, in whom the District Council had confidence, were proactive in providing support to the residents and worked closely with Housing Officers to ensure that any issues with individual residents were quickly identified and addressed. 15 Now no longer a HMO but unrelated to this case. 14 3.2.4 In conversation between the lead reviewer and Child Z’s mother (MZ), the latter said that the owners were ‘lovely’. MZ felt very welcome and she and the children settled in quickly. MZ was aware that she was sharing her living space with strangers and would take precautions, such as locking the door. However, overall she did not feel scared or intimidated by the other residents, including YPA. 3.3 ToR 3: Critically evaluate the efficacy, or otherwise, of inter-agency working, decision making and information sharing regarding the safeguarding of Child Z whilst in temporary accommodation. How child focused were multi-agency safeguarding actions (including Police bail management) and did they comply with existing local inter-agency safeguarding policies and procedures? 3.3.1 As previously mentioned, Child Z and his family had moved into their temporary accommodation in late January 2016 and were awaiting rehousing. Meanwhile, in mid-2016 YPA was ‘drifting’, with no tangible plans for pursuing his education and training, no suitable accommodation and subject to bail conditions for the alleged sexual assault of Child B and the ongoing police investigation. His contact with PA1 was sporadic. 3.3.2 YPA had previously been refused accommodation in February 2016 by a specialist housing agency because of the ongoing police enquiry regarding Child B and the accompanying bail conditions. He attended an interview for the accommodation with PA1, who disclosed the bail conditions when asked, with YPA’s permission. Therefore, the risks he presented to children and young people were known to PA1 and his manager when he told the NCS Leaving Care team on the 6 May of his imminent state of homelessness. 3.3.3 By mid-May the following agencies were involved with YPA, namely: • Norfolk Children’s Services Leaving Care Team • Norfolk Constabulary • The voluntary sector Youth Training Agency • The District Council Housing Options Service 3.3.4 There were several opportunities, between mid-April up to the time of Child Z’s allegations of sexual assault in late June, for there to have been effective multi-agency responses to the YPA’s HSB. Police Child Sexual Exploitation Perpetrators Scheme 3.3.5 The first of these was the Police CSE Perpetrators’ scheme which was part of the Multi-Agency Sexual Exploitation (MASE) team that, in turn, was part of the MASH (Multi-Agency Safeguarding Hub). It was introduced by the Police in February 2016 to allow them to focus on CSE perpetrators, and potential perpetrators, who were not the subject of other enforcement methods or restrictions. It offered several potential avenues for disruption, one of these being a referral to a multi-agency operations group meeting, which, at the time was held to discuss emerging victims, offenders and locations. The 15 scheme was in its early stages as a pilot, when YPA was subjected to it in April 2016. A key operational element was the risk assessment tool, the purpose of which was to: ‘Assess the risk posed by the perpetrator and in turn enable police to identify the correct response and application of tactics to: • Reduce the risk the subject poses of CSE. • Disrupt the pattern of behaviour they are engaging in. • Gather intelligence or evidence to bring them to justice for any offences identified. • Protect the community in which they are living or operating in,’ (Norfolk CSE Perpetrator Risk Assessment, Appendix V1, 29.01.16, page 1) 3.3.6 As previously noted (1.1.10), YPA was assessed as being a ‘medium’ risk. The assessment included a mandatory check of several Police and other agency information platforms, including the NCSCCare First data base, which should have shown YPA to be a Care Leaver. This should have alerted the Police to an NCSC connection and identification of PA1 as YPA’s worker. In any event, the assessment resulted in several actions aimed at mitigating YPA’s risk and seeking to achieve the aforementioned four outcomes. Two of these actions concerned, firstly, alerting the local policing team to YPA’s profile and secondly, making a referral to the CSE operational group for multi-agency tasking. At that time the group, which was at an early stage of development and in a, ‘Pilot phase’, was attended by a number of countywide agencies but predominantly by Police and Norfolk Children’s Services. 3.3.7 The local policing team was alerted and did indeed take proactive, albeit somewhat delayed action, on 10 June, to investigate the circumstances of YPA’s presence at the temporary accommodation. Although the scheme was at an early stage where systems and processes had not been fully embedded, there was no evidence to show that a referral had been made to the CSE operational group, or that it had considered a multi-agency approach to devising a risk management plan. Had this happened in May it is possible that YPA’s whereabouts and actions could have been more effectively monitored and controlled and his bail conditions safely managed. Had these multi-agency risk plan arrangements been in place, YPA would not have been placed at the location where Child Z resided and would not have had the opportunity to sexually assault him. 3.3.8 The evidence thus suggests that on this occasion there was a lack of information sharing and no inter-agency working between the Police, the NCS and other agencies such as the local authority housing service and the specialist youth training scheme. The lead reviewer was unclear why there was no risk management plan developed by the CSE multi-agency operations tasking group and why this was not followed though in a timely way by the MASE team. The ‘Pilot’ nature of the scheme and its early development may have been factors militating against the above outcomes. 3.3.9 The CSE Perpetrator Review undertaken by the MASH on the 14 June did not make reference to the lack of a risk management plan. Moreover, there was no evidence of 16 any consideration given to the ongoing intervention by both, the local police team and the MASH, regarding moving YPA out of the temporary accommodation where Child Z was staying. 3.3.10 The learning from this practice episode highlights three key issues. Firstly, the crucial importance of ensuring that agreed actions resulting from CSE risk assessments, particularly those relating to risk management plans, are implemented in a timely and effective manner. Secondly, that they are followed up by line management. Thirdly, that effective interrogation is made of appropriate Police and other agency data bases to ensure that links are made with other on-going activities, such as local policing operations. The Current Situation 3.3.11 Norfolk Constabulary state that the CSE Perpetrator Scheme has (as of August 2017) been in operation for around 18 months and that appropriate systems and processes are now in place. Over that time it has been developed and refined and is currently running 54 active perpetrators. The Police report that the scheme has become more efficient in highlighting individuals who pose risks and seeking to reduce those risks, albeit that there has, to date, been no formal external evaluation of its effectiveness. 3.3.12 Regarding the multi-agency operations group, this has seen intermittent attendees from various agencies and partners, including the Youth Offending Service (YOS), care homes and some local housing offices. However, in the last few months the operations group has evolved into the multi-agency risk panel, concentrating predominately on high risk issues (although with the ability to consider emerging issues) and is now run by Norfolk Children’s Services. The Perpetrators’ scheme remains single agency (i.e. Police) although several developments have been introduced to widen participation. 16 Police Bail 3.3.13 It should be noted that there are two types of police bail, namely pre-charge and post charge. YPA was on pre-charge police bail from his arrest on the 11 December 2015 to being charged for the sexual assault on Child B on the 28 June 2016. Pre-charge police bail has little power in law to make it effective; so for example, if an individual is in breach of their pre-charge bail, they can be arrested but have to be released unless the enquiries for the original offence are such that a charge can be brought against the individual. The individual would be told at the time of being bailed that he/she could be subject to arrest in the event of a breach. YPA’s bail conditions would have been recorded on the Police National Computer (PNC), so that, if stopped, or any police officer were to carry out a check, they would be visible to the person doing the check. Local officers would also be informed through daily briefings of anyone with bail conditions. 16 See appendix 3 for details of developments 17 3.3.14 Moreover, pre-charge bail could be renewed without senior police officer or magistrates’ oversight, sometimes for long periods pending the conclusion of police enquiries. 3.3.15 Thus, pre-charge police bail, in essence, acts as a deterrent. 3.3.16 Post-charge bail conditions have more legal powers attached in so far as an individual in breach of bail can be arrested, kept in custody and brought before the next available Court. 3.3.17 However, the Police and Crime Act 2017 introduced a provision in April 2017, placing a 28 day limit on pre-charge police bail, including any conditions. Since then, a one-off extension of up to three months can be sought but requires authorisation by a senior police officer, at superintendent level or above. In exceptional circumstances, where the police think it necessary to keep an individual on bail for longer, an application to a magistrate will be needed. An important principle underpinning pre-charge (police) bail is that it will be used when it is necessary and proportionate. Where it is not, the presumption will be that people will be released without bail. 3.3.18 Regarding the arrest of YPA in December 2015 and his pre-charge bail conditions, the actions taken by the Police and NCS have been analysed above in ToR1. The Current Situation 3.3.19 Were a similar thing to happen now it is understood that the imposition of bail conditions on YPA (i.e. not to be alone with a child under 16) would be unlikely given the 28 day limit and the lengthy nature of sexual assault enquiries. Depending upon the seriousness of any allegations and notwithstanding the provisions for extending bail as set out above, it is the Police’s view that YPA would now be released ‘under investigation’ with no restrictions at all. He would be free to stay where he wanted until such time as there was the evidence to charge him, which can often be some months later. At the point of charging he could then be subject to suitable post-charge bail conditions enabling risk management. 3.3.20 The new 28 day bail arrangements therefore suggest that in cases like that of YPA, the Police would have limited powers to risk manage such individuals. Therefore, in situations involving care leavers it is imperative that there is timely liaison between the Police, the NCSC/care leaver’s service and other relevant agencies. Clearly, at the point of arrest the Police would not necessarily know that the individual was a care leaver. As per existing procedures, a referral would normally be made to the MASH resulting in a strategy discussion focused on safeguarding the child victim. The alleged perpetrator would be identified as a care leaver at the point of the strategy discussion and ensuing section 47 enquiry, following routine interrogation of agency databases. Contacts between the Youth Training Agency and NCSC - May 2016 18 3.3.21 NCS was informed by the Youth Training Agency in May of YPA’s homeless situation but there was no record of who at NCS received this. PA1, had been on sick leave since early May. No call backs were made by NCS to the requests from the Youth Training Agency for help in managing YPA’s situation. 3.3.22 Given PA1’s sickness absence it should have been incumbent upon his manager to have taken case responsibility for YPA’s homelessness and wider needs as a care leaver. Indeed, he was due a care leaver pathway plan review in May. It is not known whether the information from the Youth Training Agency was received by the team manager of the Leaving Care Team (TM2) as there were no records. The evidence thus suggests that there was poor communication between the Youth Training Agency and TM2 regarding YPA’s situation. Contacts between TM2 and the Housing Options Team 3.3.23 Because this Review has not been able to speak to TM2 it is unclear precisely why she did not make reference to YPA’s bail conditions and the ongoing Police enquiry in the e-mail sent to the Housing Officer on the 20 May 2016. The evidence from Children’s services suggests that this was because TM2 did not want to breach YPA’s confidentiality without first seeking his consent. Her rationale was that the Police were still gathering evidence on the alleged sexual abuse of Child B and that YPA had not been charged with any offence. A possible further reason may have been the expressed need to get YPA accommodated given that he was homeless and had been ‘sofa surfing’ for some time. 3.3.24 It was not evident that TM2 had considered the balance of risk between YPA’s limited rights to confidentiality on the one hand and the imperative around the protection of vulnerable children and young people on the other; made explicit in this case by the Police bail conditions. Moreover, there was no indication that she had consulted with her line manager about the matter. Her apparent lack of understanding around inter-agency information sharing was a barrier to the safeguarding of children and young people. Had she been familiar about the guidance on information sharing and informed the housing agency of YPA’s bail conditions it is highly likely that the housing team would not have allocated YPA a place where there were children under sixteen years old. . Inter-agency practice between 9 - 24 June 2016. 3.3.25 There were several key factors accounting for the mis-communication between the Police, Children’s Services (Leaving Care Team) and the MASH and the resultant lack of timely joint action, along with the Housing Options Service, to remove YPA from his temporary accommodation. 3.3.26 The first of these was PA1’s sick leave absence from early May until August. This was a critical factor as there was no responsible personal adviser with knowledge about YPA’s situation, in situ, until PA2’s allocation on the 20 June. PA1, prior to his sickness absence, had been the leaving care team’s single point of contact (SPOC) at the front 19 line, who along with his manager (TM2), knew about the ongoing Police enquiry into the assault by YPA on Child B and the accompanying bail conditions. 3.3.27 The lack of a personal adviser with case knowledge in a fast moving and fluid situation meant that there was no-one at the front line to liaise with other agencies and help co-ordinate an effective multi-agency response to YPA’s homelessness and address the wider risk management issues.TM2’s leave absence in early June compounded the problem. 3.3.28 PA2’s involvement in mid-June came at a relatively late stage in the process. His role as an effective SPOC was handicapped by minimal management briefing, and a lack of a transfer summary, resulting in insufficient knowledge of YPA’s background, current concerns and situation. 3.3.29 The second factor was a lack of effective management oversight, direction and intervention by the leaving care team manager (TM2) who was the primary case decision maker within Children’s Services. She should have had the overview of YPA’s situation and knowledge of his bail conditions and the ongoing police involvement. PA1 was given minimal supervision and direction by TM2 in his work with YPA prior to going on sick leave in early May. There was no evidence to indicate that any appropriate decision making or action had been taken by TM2 in concert with the Police, the District Council Housing Option Service and the youth training agency to assess and manage YPA’s risk and bail conditions. This included, most importantly, not sharing information about his bail conditions with the housing agency when he became homeless and not taking timely action to move him from the temporary accommodation on TM2’s return to work on the 13 June. 3.3.30 On the available evidence, TM2 appeared and poorly prepared for her role as the manager of the leaving care team. She, and the personal advisers, seemed to have limited understanding of general safeguarding practice and were confused about the limits of data protection and confidentiality. TM2 had managed a Child in Need team prior to being tasked with managing the newly formed leaving care team in September 2015, consequent to the Ofsted inspection of July 2015 and the restructuring of the former Corporate parenting team (see below). She did not attend the initial team orientation sessionsand indicated that there was little time for staff induction as work started to transfer relatively swiftly. Questions were raised by the Review as to how well she was supported and guided in her role by her line management? 3.3.31 The wider context for the leaving care service was of‘nadequate Ofsted inspection judgements of services for care leavers and looked after children in 2013-2015.17 This resulted in the Local Authority’s overall children’s services also being deemed ‘inadequate’ and subject to Improvement Board oversight and the expectation of a timely improvement in service outcomes for care leavers. Ofsted had identified that the authority had lost contact with 25% of its care leavers, that there were poor quality 17 The most recent Ofsted inspection of November 2017 rated the Care Leaving Service as, ‘ Requires Improvement’. 20 pathway plans, with health, educational and employment needs not always adequately addressed. Moreover, service transformation had taken place within the context of several changes of senior management within Norfolk Children’s Services during the period, which had created a sense of discontinuity for staff. The care leaving team operated within this wider organizational backdrop. 3.3.32 A third factor was the delay in re-allocating a new personal adviser (PA2) to YPA. Reasons for this were staff shortages and sickness, as there were reportedly only two PAs and the team manager working at the time, out of a full staffing complement of six PAs, one social worker and the manager. 3.3.33 Fourthly, as noted above, PA2, had not been adequately briefed by his manager or given a case transfer summary on being allocated YPA on 20 June. He knew from earlier conversations with the Police about the ongoing criminal enquiry and the need to re-locate YPA, although, reportedly, was not aware of his bail conditions. 3.3.34 Fifthly, the poor understanding by TM2 and the two personal advisers of the limits of data protection and YPA’s rights to confidentiality and the need to override them in the interests of safeguarding children, was a major barrier to information sharing between the leaving care service and the District Council Housing Option Service. Compounding this was a belief within the care leaving team that YPA was a low risk to children and young people in relation to his HSB, despite his bail conditions. 3.3.35 Sixthly, given PA2’s limited knowledge of the YPA situation, there were mistaken assumptions and understandings made on both his part and that of the MASH Police that the other party was taking active and timely steps to move YPA, via the housing options team, when in reality this was not the case. PA2’s understanding was that he had been asked by the MASH police on 14 June to provide the name of the housing officer dealing with YPA’s case. His understanding was that it was the housing team’s job to find YPA alternative accommodation and that, in liaison with the Police, this would be done in due course. He did not see it as the leaving care team’s role to relocate YPA. 3.3.36 PA2 said he was unaware of YPA’s bail conditions when he passed on the required information to the MASH business support officer on 21 June, a few days after the sexual assault on Child Z. YPA’s care leaver review of 21 June clearly indicates that there was a (mistaken) belief on the part of Children’s Services that the Police were ‘looking for a new address for YPA via the district housing team’. This belief may have been reinforced by the assumption that YPA had been seen by a police officer over the weekend of 11/12 June as suggested by the MASH police officer in his telephone conversation with the Children’s service manager on 10 June (see above). In fact, there was no evidence that this had happened. 3.3.37 Another factor was the role of the Police in the episode. The case had been picked up in December 2015 and investigated by PO1, a CID officer, and the de facto SPOC in the 21 case. PO1 was not a child protection specialist and may not have been entirely familiar with safeguarding practice and procedures. The episode involved several police staff, ranging from the PO1, responsible for the Child B investigation and bail; the local team covering the area where YPA was residing; and the MASH officers, thus making for a degree of complexity regarding the Police response. Lines of communication between the three elements led to mistaken Police perceptions and assumptions that the care leavers’ service was taking action in concert with the district housing service to re-locate YPA away from his temporary accommodation, when this was not the case. It would also seem that PA2 was unsure as to whom he should have been liaising with in the Police in the task of relocating YPA. Moreover, there was no timely police follow up with Children’s Services to confirm that YPA had been moved. 3.3.38 In the event, contact was made by PA2 from the leaving care service on the afternoon of the 24 June requesting that the District Council move YPA. This was the first occasion that the housing team had been made aware of YPA’s bail conditions and the need to move him, by which time Child Z had been sexually assaulted. 3.3.39 In short, each agency mistakenly assumed that the other was liaising with the District Council to move YPA, when neither had. 3.3.40 The practitioners’ Learning Event identified that there should have been a multi-agency meeting jointly convened by leaving care management (TM2) and the Police on or shortly after 13 June following the MASH/ leaving care team discussion and agreement as to the unsuitability of YPA’s placement at the temporary accommodation. In the opinion of the lead reviewer this was a further lost opportunity for multi-agency intervention to have moved YPA and thus prevented the sexual assault of Child Z. 3.3.41 Arguably, a strategy discussion could have been considered under the Norfolk Safeguarding Children Board safeguarding procedures (Section 5.1.5 ‘Abuse by Children and Young People who Display Sexually Harmful Behaviour’). Although a care leaver, YPA was legally an adult in June 2016. However, by virtue of his legal status he was still subject to the local authority’s oversight as a ‘Former relevant young person’,18 and arguably covered by the HSB procedures cited above. 3.3.42 These procedures under section 5 provide for ‘ A co-ordinated approach between the agencies in Norfolk’, and the convening of a strategy discussion jointly by Children’s Social Care and the Police ’ In relation to the alleged abusing child and the child victim where there is reasonable cause to suspect that the child concerned is suffering or likely to suffer Significant Harm..’ The strategy discussion could have also involved the housing options team and the training agency leading to a multi-agency, co-ordinated approach to relocating YPA. 18 See notes 3-6 above. 22 3.3.43 For the avoidance of any doubt or confusion the lead reviewer would suggest that all care leavers (i.e. including those over eighteen years old) should be incorporated into the current NSCB HSB procedures. 3.4 ToR 4: Why did Child Z and his family not receive the appropriate multi-agency support services and Early Help offer, following the sexual abuse? 3.4.1 MZ reported the sexual abuse of her son to the local Police station at around 7 p.m. on Friday 24 June 2016. Coincidentally, YPA had been moved out of the temporary accommodation by the housing team and PA2 sometime after 4 p.m. on the same day and placed in alternate short-term accommodation. By this point the housing team had become aware from the housing officer with the Leaving Care Team of YPA’s bail conditions. At the point YPA was moved neither the Leaving CareTeam nor the District Council were aware that an offence had taken place as Child Z’s allegations against YPA were not made until later that day. 3.4.2 The Police, having established YPA’s location, arrested him at 10.45 p.m. on Friday 24 June, on suspicion of having sexually assaulted Child Z. He was placed in custody. A child protection investigation (CPI) referral and CSE Perpetrator Risk Assessment notification was entered in the Police ‘Night book’ and for the MASH (Police) the next day. Because the notification was madeout of hours, (i.e. after 7pm) the referral was actioned overnight of 24/25 June (Saturday) by the uniformed sergeant who had located YPA. The local authority Emergency Duty Team (EDT) was contacted and informed by the MASH detective sergeant of YPA’s arrest and custody. A charging decision would be made by the CPS regarding YPA and EDT would be told in due course. 3.4.3 EDT was given details of the alleged victim (Child Z) who was not known on the local authority recording system; in fact, he was known, but not as an active case. Of concern, it was noted that there were no EDT recordings of the information exchanges with the Police. At that point, the EDT worker should have raised a contact and referral (to the MASH) with the information shared by the Police. There were sufficient grounds for a strategy discussion in that Child Z had suffered significant harm. There needed to be a discussion regarding the plan for next steps and who was responsible for them. This did not happen and the incident proceeded as a single agency Police enquiry, when accepted practice would have mandated a joint enquiry. Why this did not happen is not known. It may have been that an assumption was made that the EDT would not have the capacity to assist. 3.4.4 The Police proceeded with the enquiry over the weekend. Child Z was ABE19 interviewed on Saturday 25 June 2016. YPA was charged the same day and remanded to appear in the magistrate’s court on the following Monday, 27 June. 19 Achieving Best Evidence 23 3.4.5 The police Night Book was shared with other partners in the MASH at the 9.00 a.m. Monday morning meeting. A decision was taken by the assistant team manager (MASH, NCSC) not to proceed to a strategy discussion, possibly because the moment had passed, Child Z had been interviewed, YPA charged and remanded, and there was a high volume of work. A CSE risk assessment on Child Z was done by the MASH which resulted in a Standard Risk outcome and a referral to the Early Help and Family Focus service. 3.4.6 Reflecting on this Key Practice Episode at the Learning Event, MASH personnel agreed that there should have been a strategy discussion as per the agreed safeguarding procedures, either on the weekend (involving the EDT) or the Monday morning with the MASH/ Children’s Services. This would, probably, have led to a Children and Family (social work) assessment and a Child in Need plan (under S.17 of the Children Act,1989) which, amongst other things, would have provided some post abuse therapy for Child Z and emotional and practical support for MZ and her daughter. 3.4.7 In addition to involving the Police about the ongoing criminal enquiry, a strategy discussion would have been an opportunity to have liaised with Child Z’s school (it was only told of the incident by MZ and not Children’s Services, see below), the Housing service and the Youth Agency Training provision (who were at the time working with YPA and were left in the dark about what was happening), to have provided a holistic and co-ordinated support package to Child Z and his family. 3.4.8 Albeit that the existing remit of the Sexual Assault Referral Centre (SARC) covers penetrative offences only and that the offence only came to light sometime after the incident, thus making problematic the recovery of any forensic evidence, the Panel took the view that consideration could have been given to referring Child Z to the SARC following the sexual assault. This could have provided a holistic assessment, including a forensic examination if required and screening for sexually transmitted diseases, as well as care of the victim to minimise risk of subsequent physical and mental health difficulties and promote recovery. 3.4.9 The Panel learnt that despite the current SARC remit, the SARC manager does consider the acceptance of other cases, dependent on the situation and the resourcing and capacity levels at the time. However, a referral for a non-penetrative sexual offence would be dependent on the police officer/staff member having the understanding and awareness that a particular case would benefit from such a referral. The Panel and lead reviewer thought that it would be reasonable to suggest that the SARC Board undertake a review of the SARC’s remit and referral criteria. The Early Help Offer 3.4.10 Regarding the Early Help referral; following the standard risk outcome of the CSE assessment made at the MASH on 27 June 2016, an Early Help referral (locally known as a CARF) was started the same day. This was finished on 5 July 2016 and put on DOREIS (Children’s Services Early Help electronic system) on 14 July with an 24 expectation of offering support to the family following a Multi-Agency Sexual Exploitation (MASE) meeting and decision making. There was a delay, possibly due to there being a backlog for processing standard risk cases, until 22 July when the Early Help and Family Focus service (EHFF) attempted to contact MZ on her mobile phone. A further call was made on 26 July. On both occasions, MZ’s phone was uncontactable. By this time Child Z and his family had been found suitable accommodation and had moved out of temporary accommodation. 3.4.11 A decision was made by EHFF management not to send a letter to MZ due to the temporary address, the time elapsing since the incident (over one month) and the unsuccessful attempts at contacting MZ. It was rationalised that the Police were still involved and a service was therefore not offered. Child Z and his family thus did not receive, or have the opportunity to consider, a timely support and therapeutic service. 3.4.12 Reflection on this episode by Children’s Service for doing things differently suggests that the temporary accommodation could have been contacted to establish whether the family were still resident. A recorded delivery letter could have been sent to MZ rather than a standard post. Discussion could have been had with the MASH to see if a service might have been offered through the Police who had maintained contact with MZ and the family. Additionally, the case could have been passed to the Local Early Help team to continue attempts to contact the family. As there is nothing in the current processes to cover this situation there needs to be a review and change of procedures to reflect the learning from this SCR. Part 4 Child Z Mother’s Experience 4.1 In a conversation with MZ, the lead reviewer was told that life was stressful after the incident and that she had received no support from Norfolk Children’s Services in the period after the disclosure. She would have welcomed some support for Child Z and herself, as she did not know what to say to him or how to manage the situation. She said that the Police, ‘Were great while they were there but she had to do a lot of chasing. As time went on and Child Z moved on, she chased less.’ The Police could have provided better updates regarding progress on the enquiry and what was happening to the alleged perpetrator; was he locked away as she and her children were anxious that they might bump into YPA. She would have liked direction if he had turned up. 4.2 MZ informed Child Z’s school in late June of the incident and she reported that the school generally handled things well, for example, by arranging for him to have some counselling. However, she was unhappy about the way that instances of Child Z being bullied were handled. The District Council Housing Options Service did as much as they could for the family, helped also by her local MP. She and the children are happy with their allocated accommodation. 25 4.3 The family eventually received support from EHFF after being advised by a local police officer to contact them. She did so in April 2017 and was allocated a family support worker (FSW1) who was helpful in assisting a school transfer for Child Z to the area where he is now living. FSW1 has seen Child Z on several occasions which MZ reported as good for her son. Child Z was reported by his mother to be happy in his new school and has made some new friends locally. Part 5 YPA’s Experience 5.1 YPA was interviewed by the lead reviewer and panel chair whilst in custody. The purpose was to hear from him directly about his experience as a care leaver and see if there was any useful learning to be gained for the SCR. 5.2 YPA was taken into care as a young child and, along with his sister, lived with foster carers until early adolescence. By all accounts the placement meet his needs for security and attachment and he was happy there. For various reasons the placement came to an end after eight years. He was very upset at having to move and said that, “The pinnacle of my downward spiral was when I moved out of (there)”. He spent two short periods with a new foster carer and then in a residential unit before moving to a permanent residential establishment where he remained until leaving care on his eighteenth birthday. He said that this placement was a ‘safe haven’, somewhere he could ‘plant roots’, and became emotionally attached to the adults who ran the home. 5.3 YPA said that the therapy he had with Psy1 was difficult for him as he had spent many years building barriers and mental blocks to cope with difficult earlier experiences as a young child. He said that he would be taking part in therapeutic work in prison. 5.4 Regarding his care leaving experiences YPA couldn’t remember many of the social workers he had but did recall PA1 whom he thought was a social worker rather than a Personal Adviser with the Care Leaver service. He was not clear of PA1’s role and thought that the system was not explained clearly enough to him. He thought that the LAC Reviews were poor in quality and that, ‘I was spoken about in the third person and mostly ignored’. He was not a child anymore and wanted more involvement. He was given a chance in 75% of the LAC reviews to speak to his social worker beforehand and thought that one of his Independent Reviewing Officers (IRO) became his social worker for a period of time. 5.5 He said that he gained seven GCSE’s and through connections with the Home he started an apprenticeship but gave it up shortly before completion due to differences with the staff. YPA claimed that the decision to leave the apprenticeship led the local authority to stop funding the semi-independent flat provided by the Home which in turn resulted in him moving to stay with friends. He had no job and ran into money problems. He saw his PA who was trustful and reliable but seemed to be off sick or on holiday a lot and was not always available. It was up to YPA to contact PA1’s manager to find out 26 whether PA1 was at work or ill. It was at this time (in mid to late 2015) that he wanted better access to employment from the Care Leaving Team and hardly ever saw his PA. That said, he did receive a lot of help from the Leaving Care Head of Apprenticeships in PA1’s absence who, whilst sorting out his bursary also gave him some emotional support. 5.6 YPA thought the Leaving Care service, was not poor and was not good, but average. He felt that he had lost his ‘safety bubble’, namely the Home (where he had been for several years), the flat and the two senior care workers who had meant a lot to him, on having to leave the placement in March 2015.” I was literally chucked out into the big wide world when I was nowhere near ready”. On reflection, he would have liked to have stayed in care until he was 21. 5.7 On being arrested in December 2015, he was bailed which PA1 knew about. The Police were good as they, “Explained things clearly what I needed to do not to end up in trouble again”, and he said that he managed his bail conditions well for some time. Things went downhill after this, he lost his accommodation and spent the next few months until May ‘sofa surfing’, with friends. He had no money and “was up the creek without a paddle”. He did not want to contact the senior care workers at his old placement as he felt he had let them down and felt ashamed. He was unable to find any suitable supportive accommodation, for example with the specialist housing agency, because of the risk he presented from his bail conditions. This led in May 2016 to him lying to the youth training agency and the local authority housing agency about his bail conditions. He wanted “somewhere safe where he could put his head down”. 5.8 Soon after arriving at the temporary accommodation in May 2016, he met Child Z’s family and attached to them. He was also visited by the Leaving Care Apprenticeship worker who was not aware of his bail conditions. He was eventually reminded of his bail conditions by a local authority housing officer on the 24 June when he was moved and later arrested by the Police for the assault on Child Z. 5.9 YPA accepted that he had harmed Child Z because of his behaviour and was not in denial. He said that he had the mentality to change. He thought that it was important that children and young people who showed harmful sexual behaviour needed help in addressing it. 5.10 Regarding three key improvements to the Leaving Care service he suggested: • Ensuring a continuous service by having a backup/contingency staff for service users. • Clearly explain the care leaving system and provide contact numbers so that care leavers can access support. • Provide support for care leavers when they leave prison and ensure that offender managers communicate with Children’s Services/ Care Leavers’ social workers so that they are supported while they are serving their sentences. 27 Part 6 Key Findings and Learning Points 6.1 ToR 1 YPA’s pre-care leaver experience 6.1.1 Firstly, YPA’s placement up to his eighteenth birthday met his overall needs very effectively. The proposed care leaver plan appeared, save for considerations about HSB, to have been a well thought out and informed by a sound needs assessment. YPA’s proposed transition to young adulthood and independent living through the provision of supported accommodation, overseen by the care staff, and the continuation of his apprenticeship, were key elements in the pathway plan. 6.1.2 Secondly, whilst accurately assessing YPA’s risk of HSB, there was no involvement in the LAC reviewing and care leaver planning processes by Psy1 whose contribution would have been helpful in addressing considerations of risk management. 6.1.3 Thirdly, the plan did not address how YPA’s HSB risk was to be managed over the medium to longer term and was not compliant with existing NSCB policy and procedure. It did not follow through with a multi-agency HSB risk management plan. This is a recurring theme of the SCR. YPA’s care leaver experience 6.1.4 The implementation of YPA’s pathway plan was sub-standard, did not meet his needs for the transition to young adulthood and independent living and failed to address the risks presented by his HSB. Reasons for this included the following factors. 6.1.5 Firstly, the preparation, induction, learning and development of the personal advisers in the leaving care team, before and after re-structuring in September 2015, were inadequate. The PAs were not clear about their role, remit and responsibilities towards YPA and had not received training in basic tasks such as developing robust pathway plans. 6.1.6 Neither PA1 (and PA2 as seen later) or his manager (TM2) received training in the assessment and management of HSB. As a result, there was no concrete risk assessment and management plan incorporated into YPA’s wider pathway plan from leaving care in January 2015 to committing the sexual offences in July 2015 and in June 2016. 6.1.7 Management oversight, direction and supervision of PA1 was inadequate. There was no evidence to indicate that the team manager (TM2) had any meaningful involvement in the case by way of decision making or offering PA1 any constructive challenge. 28 6.1.8 There was no evidence of any contingency planning following the breakdown of YPA’s pathway plan in mid-2015. 6.1.9 There seemed to be difficulties encountered by the PA in accessing Care First and attaining competency in its use. The importance of recording visits and contacts was not always recognised. 6.1.10 YPA reported that there was a need for care leavers to receive continuous service with a contingency back up for when PAs are not available through sickness or leave. It was important to ensure that care leavers were clear about the roles and responsibilities of PAs, their managers; and what support they were entitled to. There was a need to provide early intervention to address the needs and risks of young people exhibiting HSB. It was also important to provide support to those care leavers after their release from prison and ensure effective liaison with offender managers whilst serving custody. The Care Leaver’s Service: Ofsted and Recent Developments 6.1.11 The Service moved out of, ‘Inadequate’, to ‘Requires Improvement’, i.e. moving towards good, following the recent Ofsted inspection of November 2017. 20 This SCR notes that, “ Young people who leave care are well supported by their social workers and personal advisers, who work hard to stay in touch and help them live independently and to follow their career or further education choices”. ( Ofsted: January 2018:8) 6.1.12 Ofsted reported that the service is making steady progress since the last inspection and that social workers and personal advisers prioritise care leaver’s safety. However, not all areas of practice are yet good. In most cases, young people are well prepared for independence, although inspectors saw examples where young people were transferred too rapidly to the leaving care team, without adequate preparation. The restructure of the service resulted in a large volume of transfers in a short period. Pressures in staffing capacity in the receiving team meant that key actions, such as visits to young people, assessments and pathway plans, were not timely. 6.1.13 In response to a request from the lead reviewer to Children’s Services to provide evidence of actions taken to improve the care leaver’s service, the following comments were made, “Children social care no longer considers acceptable to place looked after young people or care leavers, who are aged 16 and 17, in hotel accommodation. The introduction of the Locality Children’s Resource Panel provides an additional scrutiny as commissioning of resources requires Panel discussion and approval. Learning and Development Programme for Personal Advisers specifically has been set up. Assessment of risks has been a theme that underpins many training sessions.When this Serious Case Review is published, specific learning sessions for the Leaving Care 20 See Ofsted Report published 19 January 2018. 29 Teams across Norfolk County Council will have been rolled out. The Strategic Lead for Corporate Parenting chairs the Looked after Children and Leaving Care Service Development Group, where all designated team managers attend. This forum is used to embed learning and improve practice in risks assessment and management.” 6.1.14 The SCR Panel and lead reviewer were encouraged to learn from the Ofsted report of the steady progress being made with the leaving care service and are keen to see this continue to the point where it will be rated ‘Good’, by Ofsted when next inspected due to consistently high quality outcomes for care leavers. YPA’s arrest in December 2015 6.1.15 Both PA1 and his manager, TM2, had been informed by the Police of the arrest of YPA and the accompanying bail condition. A strategy discussion between NCS (Leaving Care team), the area team in which Child B lived (assuming they were from Norfolk), health and the Police should have been held regarding the alleged sexual assault of Child B. The strategy discussion on the two young women should have been recorded in compliance with procedures. 6.1.16 There appeared to be a significant degree of unfamiliarity on the part of the Care Leavers staff and Police regarding the HSB procedures which were not referred to by either agency following YPA’s arrest. 6.1.17 Overall, there seemed to have been a lack of knowledge and use of basic safeguarding and child protection practice as evidenced by not holding a strategy discussion on Child B. 6.1.18 Had the procedures been followed there could have been a multi-agency risk management meeting convened on YPA to monitor and, as far as possible, control his behavior, pending the conclusion of the police enquiry and the decision on charging. This episode was a missed opportunity to have done so. 6.1.19 There was a further missed opportunity to have convened a multi-agency risk meeting on YPA by not holding an early pathway planning meeting as set out in procedures. Key Learning 6.1.20 For NCS-Care Leavers’ Service to consider. Ensure that the Care Leaver Service continues making progress to the point where it has achieved a, ‘Good’, Ofsted rating and achieves high quality outcomes for care leavers. Ensure that the Care Leaver Service management is competent in providing effective oversight, direction, supervision and challenge to PAs. Ensure that attention has been given to the effective preparation, induction, learning and development of care leaver team PAs and managers, including competencies in needs assessment and pathway planning, risk assessment and management, basic awareness around the safeguarding of children, when to convene strategy 30 meetings, use of ‘ Care First’, involvement in multi-agency planning meetings, recording and awareness of HSB issues. The need for involvement of HSB specialists, when appropriate, in risk assessment and management planning of Care Leavers and other young people, through LAC Reviews, Pathway Planning Reviews and multi-agency risk management meetings. The need for early intervention with assessment, treatment and risk planning of young people, including care leavers, who exhibit HSB. The need for care leavers to be offered continuous support from the service, especially when the PA is not available through sickness or annual leave. The need for care leavers clear to be clear about the roles and responsibilities of their PAs and team managers and what support they are entitled to. The need for effective liaison between the service and offender managers when a care leaver receives a custodial sentence; ensuring that support is offered on release from prison. Ensure that the Care Leavers’ Service understands the NSCB Information Sharing Policy and knows the circumstances under which an individuals’ rights to confidentiality can be overridden in the interests of safeguarding children and young people. The need for leaving care team managers to be reminded that they act as the Single Point of Contact (SPOC) when PAs are on leave, on sick leave or otherwise unavailable so they can receive, respond and act on communications and requests from other agencies regarding care leavers. 6.2 ToR 2 6.2.1 Child Z and his family’s needs were mainly focussed on being re-housed. There were no identified additional needs or vulnerabilities. 6.2.2 The placement in temporary accommodation whilst awaiting re-housing was appropriate. 6.2.3 Being a privately run HMO made it difficult and impractical for the District Council to carry out any assessments in relation to potential risks from other residents to MZ and her children. Through experience, the District Council had trust and confidence in the owners of the accommodation to ensure, as far as possible, the health and safety of its residents. 6.2.4 In this instance, the District Council was not informed about the ongoing Police investigation and the accompanying bail conditions regarding YPA until he was moved on the 24 June 2016 at the behest of PA2, a few days after the sexual assault incident on Child Z. 6.2.5 The District Housing team’s internal review has agreed that ‘In the future, should a client (such as YPA) present with similar circumstances, [i.e. police bail conditions] then they would only be placed in accommodation that didn’t have children under 16 and that this was approved by the probation officer or equal person supporting the client’. 31 6.2.6 Moreover, all customers are now asked if they have any bail conditions or restrictions that present a risk to others. Key Learning 6.2.7 For Housing Options to consider. Avoid placing children under 16 in temporary accommodation with shared communal facilities. Ensure that adequate safeguarding controls are secured throughout the procurement of temporary accommodation. Ensure that temporary accommodation providers are aware of safeguarding risks from individuals that is compliant with data protection and confidentiality guidance. Ensure effective multi-agency information sharing between all agencies so that children are not placed in temporary accommodation with people who present a risk to their safety. Ensure that clients are asked if they are subject to any bail conditions, ongoing police enquiries or other restrictions that would present a risk to others. If possible, to arrange for a client who is subject to bail conditions, ongoing police enquiries or other restrictions regarding allegations of assault against a child or vulnerable person, not to be placed in accommodation that has children under 16; and that this is approved by the probation officer or equal person supporting the client. 6.3 Tor 3 CSE Perpetrator Scheme 6.3.1 Albeit in its early stage of development, the Police CSE Perpetrator Scheme having graded YPA as a medium risk in April 2016, did not refer onto the CSE operational group for multi-agency tasking. This was a missed opportunity to have developed a multi-agency risk management plan for YPA prior to him going to the temporary accommodation. 6.3.2 The CSE review on the 14 June 2016 appeared not have cross reference with Police intelligence concerning the ongoing MASH and local police interventions seeking to move YPA out of the temporary accommodation. 6.3.3 There was a lack of information sharing, minimal inter-agency working and a lack of effective decision making, which was not child centred (on potential victims) or seemingly, in compliance with agency policy and procedures of the time. 6.3.4 The ineffectiveness of the scheme in April 2016 should be seen in the context of it being at an early stage of development. Norfolk Police currently report that effective systems 32 and processes are now in place resulting in the scheme being more efficient in risk assessing and managing individuals who behave in a harmfully sexual manner.21 Police Bail 6.3.5 Following the changes to Police pre-charge bail in April 2017, arising from the provisions in the Police and Crime Act 2017, it is unlikely that YPA would now be subject to any bail conditions. The Police view is that in all probability he would now be released under investigation, with no restrictions. The current bail arrangements therefore suggest that in cases like that of YPA, the Police would have limited powers to risk manage such individuals. 6.3.6 Therefore, in situations involving care leavers it is imperative that there is timely liaison between the Police, the NCSC/care leaver’s service and other relevant agencies. Clearly, at the point of arrest the Police would not necessarily know that the individual was a care leaver. As per existing procedures, a referral would normally be made to the MASH resulting in a strategy discussion focused on safeguarding the child victim. The alleged perpetrator could be identified as a care leaver at the point of the strategy discussion and ensuing section 47 enquiry, following routine interrogation of agency databases. 6.3.7 Likewise, any decision not to hold a strategy discussion should be recorded, including the rationale. Inter-agency information sharing 6.3.8 The communication between the Youth Training Agency and the Leaving Care team was poor with messages left by the former not being responded to by the latter. 6.3.9 Because of the non-availability of TM2 the review was not able to understand precisely why critical information about YPA’s arrest, bail conditions and the ongoing police enquiry were not passed on to the District Housing Agency on the 20 May 2016. A likely reason was that TM2 may have had a poor understanding of the parameters of information sharing regarding YPA’s conditional rights to confidentiality. Had information about YPA’s bail conditions and the ongoing Police enquiry been shared with the Housing Agency, as it could have been, it is probable that YPA would not have been placed at the temporary accommodation where Child Z and his family were resident. Inter-agency risk management; 9-24 June 6.3.10 The actions of the Police and NCS/Care Leavers’ team to have the District Housing agency move YPA were ineffective due to a combination of the following factors: 21 See sections 4.3.11-4.3.12 above and Appendix 2 33 • No personal adviser in place during May to mid-June to act as a co-ordinating single point of contact (SPOC) in the care leavers’ team. • Ineffective care leavers’ team management oversight and involvement in the episode. • A delay in allocating a new personal adviser (PA2) to the case. • Inadequate briefing, direction and support given to PA2 on becoming the allocated personal adviser on the 20 June. PA2 was unaware of YPA’s bail conditions. • Deficient preparation, induction, learning and development given to the Leaving Care Team • Poor safeguarding knowledge by the leaving care team. • Staff shortages • Misplaced understandings by the leaving care team around the parameters of inter-agency information sharing regarding YPA’s bail conditions. • Mistaken assumptions and misunderstandings by the Police and the Leaving Care team that the other was liaising with the District Housing team to move YPA, when this was not the case. 6.3.11 A timely strategy discussion and multi-agency risk management meeting could have been convened by the leaving care team when it had become evident on the 10 June that YPA was in breach of his bail conditions. Arguably, this could have been done under the NSCB HSB procedures, albeit that YPA was an adult but still a responsibility of the local authority. Key Learning; See above at 6.1.15 For Norfolk Police/ Norfolk Children’s Services regarding the CSE Perpetrator scheme For risk assessments to be translated by the multi-agency risk panel into effective risk management plans on suspected perpetrators Much of the learning from the above findings has been incorporated into the current operation of the CSE perpetrator scheme22. Of critical importance is the need to ensure that, when appropriate, risk assessments are passed on to the multi-agency risk panel for actioning. For Norfolk Police regarding arrest and Police Bail See sections 6.3.5-6.3.7 above 22 See previous note 22, ibid. 34 6.4 ToR 4 6.4.1 There was an appropriate and timely Police enquiry that led to the speedy arrest and subsequent charging of YPA. 6.4.2 As to why Child Z and his family did not receive an appropriate and timely Child in Need support service the following factors are relevant. Firstly, as identified at the Learning Event, there should have been a strategy discussion and joint S.47 Police/EDT/CSC enquiry in compliance with NSCB safeguarding procedures. This did not happen because, in the opinion of the lead reviewer, there was an overemphasis on processing the criminal enquiry. This was aggravated by it taking place at the weekend with a reduced service, when there was no MASH (NCS) service23; and insufficient focus on Child Z’s medium/longer term well-being from the Police and Norfolk (MASH) CSC on the Monday morning. 6.4.3 Secondly, there are pressures on ‘High volume, rapid throughput’ services, such as MASHs to process demand (referrals) quickly, sometimes at the expense of keeping a focus on (in this case), the child. 6.4.4 Thirdly, there may have been some conflation between Child Sexual Abuse and Child Sexual Exploitation resulting in the outcome of a CSE risk assessment rather than understanding Child Z’s experience as sexual abuse needing a strategy discussion, a S.47 joint enquiry and social work assessment of need by NCSC. 6.4.5 Fourthly, the EDT should have convened a strategy discussion, recorded it and let the MASH know of the outcome. This raises questions as to whether the Out of Hours/Weekend EDT/Police Countywide VPU interface presents as a potential weak point in the safeguarding process. Where a strategy discussion has been held at the weekend a second strategy discussion should be called for Monday mornings as standard practice to ensure health and other agency involvement, as appropriate. The Current Situation: Changes to the MASH service 6.4.6 Since the incident, there have been several changes made to the operation of the MASH service which NCS report will make a difference to practice. Firstly, since the 17 May 2017 it is now standard practice for the Children Services MASH manager to review the Police Night Book before the 9am meeting thus enabling research to be undertaken on NCS’s electronic systems. This should result in greater consideration being given to what action is needed to ensure the child’s safety and welfare, rather, than in Child Z’s case, just hearing the information shared at the 9am meeting. 6.4.7 Arguably, this highlights the importance of the imperative to keep a focus on both the safety and welfare of the child and to be aware of an over focus on technical 23 Albeit, there was a Police MASH service. 35 processing. This is a good example of how interaction at the human/technical interface can result in a ‘Tickbox’, approach when human action is subsumed to the technology. 6.4.8 Secondly, work is in progress to improve the handover between EDT and the Children’s Service element of the MASH, including, when appropriate, the requirement by EDT to convene and record strategy discussions and not to re-assign to the MASH or the allocated locality team to deal with later. 6.4.9 Thirdly, the links with the Early Help and Family Focus (EHFF) service within the MASH have been improved (see below). When a threshold decision is made that a social work assessment is not required the EHFF manager is asked to contact the referrer and family to see if an Early Help offer is appropriate. Key Learning to consider For the MASH and EDT: Ensure that in cases of extra-familial sexual abuse strategy discussions are appropriately convened and joint S.47 Police/EDT/CSC enquiries undertaken in compliance with NSCB safeguarding procedures. The need to maintain a focus on the child when processing a criminal enquiry. Ensure that there is a focus on the child’s medium/longer term well-being from the Police and Norfolk (MASH) CSC on the Monday morning meetings. To bear in mind the pressures on ‘High volume, rapid throughput’ services, such as MASHs to process demand (referrals) quickly, sometimes at the expense of keeping a focus on the child. The need for awareness around possible conflation between Child Sexual Abuse and Child Sexual Exploitation resulting in the outcome of a CSE risk assessment rather than understanding the subject child’s experience as sexual abuse needing a strategy discussion, a S.47 joint enquiry and social work assessment of need by NCS. Ensure EDT compliance with NSCB safeguarding procedures, including, when appropriate, the holding and recording of a strategy discussion with the Police (and/or other agencies) and passing it onto the MASH in a timely manner. Ensure that there is not a potential ‘Weak spot’ in the safeguarding process at the Out of Hours/weekend EDT/ Police interface. For the SARC Board: Consider whether the remit of the SARC can be changed to include children and young people who have suffered non-penetrative sexual abuse. 6.5 Key Learning for the NSCB to consider That the HSB procedures are fit for purpose and up to date. That there is a robust strategy to disseminate and embed the HSB policies and procedures, including the need for early risk assessments and management plans 36 for children and young people identified as presenting HSB, across the safeguarding partnership that includes the Care Leaving Service, the MASH, and relevant sections of the Police service. That the findings and learning from this SCR will be widely disseminated and implemented across the NSCB partnership so as to make an evidenced and demonstrable improvement to the safeguarding outcomes for children and young people. 6.6 Six Overarching Lessons Finally, many learning points have been identified by this SCR, all of which are commended to the NSCB and its partners. However, here are six overarching lessons: 1. Norfolk Children’s Services should retain a focus on improvement to ensure its leaving care service is consistently fit for purpose. 2. The need for the NSCB and agencies to put in place effective early intervention services for the assessment, treatment and risk planning of young people, including care leavers, who exhibit harmful sexual behavior. 3. (a) Norfolk Children’s services shall not, at any time, place unaccompanied children under 16 years of age in temporary accommodation. (b) Local housing authorities and their agents should not place ‘households’ with children under 16 years of age in non-self-contained (i.e. shared toilets/bathrooms/kitchens) temporary accommodation nor ‘households’ with children under 16 years of age in self-contained temporary accommodation with shared communal facilities (e.g. rest room/bar) unless there is no alternative solution available. (c) Local housing authorities shall demonstrate their adherence to this policy by retaining relevant statistics on TA and reporting to District Council Safeguarding Group as required. 4. Arrangements to be in place so that Police CSE Perpetrators’ risk assessments result in effective and timely multi-agency planning of suspected individuals. 5. On the arrest of individuals for alleged extra-familial sexual offences against children, the Police should make a referral to Children’s Services who will consider ongoing safeguarding risks to children and will arrange for a strategy discussion to be held, if appropriate. This will allow for consideration of a S.47 enquiry, safeguarding of the relevant children and, if applicable, the identification of the suspect as a care leaver. 6. The need for the care leavers’ service to be familiar with the NSCB Information Sharing protocol, the limits of data protection and when it is necessary to override confidentiality in the interests of safeguarding vulnerable individuals. 37 Part 7 Recommendations 7.1 Norfolk Children’s Services 7.1.1 The Director of Children’s Services should within six months of the approval of this SCR take steps to assure the NSCB that the Leaving Care service continues to make progress to the point where it is rated as, ‘Good’, by Ofsted and achieves high quality outcomes for care leavers, by reference to the learning in Part 6.1.20 Key Learning above at page 27. 7.1.2 The Director of Children’s Services should within six months of the approval of this SCR, take steps to assure the NSCB that a service is in place for early intervention regarding the assessment, treatment and risk planning of young people, including care leavers, who exhibit HSB. 7.2 Norfolk Housing Options 7.2.1 The Director of Housing Options, or their local District Council equivalent, should within six months of the approval of this SCR take steps to assure the NSCB that children under 16 who are in need of temporary accommodation are found placements which maximise their safety and well-being by reference to the learning points in Part 6.2.7 Key Learning above at page 28 and Overarching Lesson 3 (a) (b) (c) at page 35. 7.3 Norfolk Constabulary 7.3.1 The Chief Constable of Norfolk Constabulary should within six months of the approval of this SCR, take steps to assure the NSCB that, (a) the CSE Perpetrators’ Scheme is operating effectively, (b) that a safeguarding referral is made to the Children’s Services on arrest of an individual suspected of being a perpetrator in extra-familial sexual abuse of a child. 7.4 Jointly for Norfolk Children’s Services and Norfolk Constabulary 7.4.1 The Director of Children’s Services and the Chief Constable should within six months of the approval of this SCR, take steps to assure the NSCB that, in cases of extra- familial child sexual abuse, arrangements (when appropriate) are made by the Children’s Services to convene strategy meetings and initiate joint S.47 CSC/Police/EDT enquiries, in compliance with NSCB safeguarding procedures, by reference to the learning points in 6.4.9 Key Learning above. 38 7.5 For the SARC Board 7.5.1 The SARC Governance Board should report to the NSCB on the feasibility of expanding the service remit to include children and young people who have suffered non-penetrative sexual abuse. 7.5.2 For the Health and Voluntary sector to advise the NSCB on any services outside of the SARC that can provide support to children and young people who have been sexually abused so that the Board can promote these services and address any commissioning gaps. 7.6 Norfolk Safeguarding Children Board 7.6.1 That the NSCB Chair should within six months of the approval of this SCR, take action to ensure that: The HSB procedures are fit for purpose and up to date. That there is a robust strategy to disseminate and embed the HSB policies and procedures, including the need for early risk assessments and management plans for children and young people identified as presenting HSB, across the safeguarding partnership that includes the Care Leaving Service, the MASH, and relevant sections of the Police service. That the findings and learning from this SCR will be widely disseminated and implemented across the NSCB partnership so as to make an evidenced and demonstrable improvement to the safeguarding outcomes for children and young people. 39 Glossary of Terms ABE Achieving Best Evidence ADHD Attention Deficit Hyperactivity Disorder AIM2 Adolescent Integrated Assessment Model CARF Child Assessment Referral Form CSE Child Sexual Exploitation CSW Children Services Worker CPS Crown Prosecution Service DfE Department for Education EDT Emergency Duty Team EET Education, Employment and Training HMO Home with Multiple Occupation HSB Harmful Sexual Behavior IRO Independent Reviewing Officer KLOE Key Line of Enquiry LAC Looked after Child MASE Multi-Agency Sexual Exploitation team MASH Multi-Agency Safeguarding Hub NCS Norfolk Children’s Services (Local Authority) NCSC Norfolk Children’s Social Care (Local Authority) NEHFF Norfolk Early Help and Family Focus NSPCC National Society for the Prevention of Cruelty to Children NSCB Norfolk Safeguarding Children Board NVQ National Vocational Qualification Ofsted Office for Standards in Education SW Social worker PA Personal adviser (Care leavers’ service) PO Police Officer Psy1 Psychologist 1 SARC Sexual Assault Referral Centre SCR Serious Case Review TM Team Manager ToR Terms of Reference 40 References 1. Harmful Sexual Behavior; NSPCC, Research in Practice, Durham University, 2016 2. Norfolk Child Sexual Exploitation Perpetrators Risk Assessment, V1, 29.01.16, Norfolk Constabulary 3. Norfolk Safeguarding Children Board, Safeguarding Procedures online 4. Norfolk Children’s Services, Looked after Children and Care Leavers’ Strategy, 2016-19. 5. Working Together, 2015, H.M. Government 6. Ofsted Report on Inspection of Norfolk Children’s Services, November 2017, published 19 January 2018. 41 Appendix 1 Timeline of Significant Events Month Year Event November 2011 YPA moves to Residential Home January 2013 YPA reaches his 16th birthday July 2013 Risk assessment of YPA completed by Children’s Services September 2013 Psychological risk assessment of YPA’s HSB completed September 2013 YPA starts course at College April 2014 Investigation by Children’s Services on YPA June 2014 MASH referral on Child X August 2014 Meeting convened by Residential Home agency and psychologist on YPA’s HSB August 2014 MASH referral on Child Z January March 2015 YPA now 18: care leaver YPA moves into semi-independent flat provided by Residential Home agency May 2015 YPA moves out of the semi-independent flat provided by the Residential Home agency into shared accommodation November 2015 Child Z’s family homeless December 2015 Strategy discussion held on YPA’s sister and friend and risks posed by YPA December 2015 YPA arrested and bailed for sexual assault on Child B. Children’s Services informed January 2016 YPA family move to temporary accommodation Feb – April April 2016 YPA ‘sofa surfing’ and looking for accommodation Police assess YPA as a ‘ Medium Risk’ of CSE Early May 2016 YPA contacts social work team – homeless, needs somewhere to live Mid May 2016 YPA presents at local DC office. Housing Options make contact with leaving care team re YPA’s homelessness 24 May 2016 YPA moves into temporary accommodation 42 10 June 2016 Police and Children’s Services discussion re moving YPA from temporary accommodation due to bail conditions 14 June 10-24 June 2016 Police conduct CSE perpetrator review Leaving Care team and Police botched attempt to move YPA 16 – 19 June 2016 Child Z sexually assaulted by YPA 24 June 2016 District Housing informed by leaving care team of YPA’s bail conditions and decision made to move him. Incident reported to police by Child Z’s mother YPA arrested 26 June 2016 Local DC state they were not aware of YPA’s previous bail conditions 27 June 2016 CSE screening on Child Z. Given standard risk. Referred to Early Help 28 June – 2 July 2016 YPA charged with sexual offences against Child Z and Child B [Dec 2015] 43 Appendix 2 Part 2 Aims and Terms of Reference of the SCR 2.1 Aims The overall purpose of this Review is set out in Government Guidance24, namely to undertake a rigorous, objective analysis that will: “Look at what happened in this case, and why, and what action needs to be taken to learn from the Review findings. Action results in the lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm. There is transparency about the issues arising from this case and actions which the organisations are taking in response to them. Including sharing the overview report with the public” (Working Together: 2015, 72) 2.2 Terms of Reference (ToR) The SCR and overview report have been undertaken in relation to the following Terms of Reference, namely: (A) Critically examine the effectiveness, or otherwise, of the care leaver planning for Young Person A (YPA). How well did the plan meet his needs for transition to independent living and address issues of risk assessment and management of his sexually harmful behaviour? (B) How well were the needs, vulnerabilities and risks to Child Z and his family assessed and managed by agencies during the time they were homeless and in temporary accommodation? (C) Critically evaluate the efficacy, or otherwise, of inter-agency working, decision making and information sharing regarding the safeguarding of Child Z whilst in temporary accommodation. How child focused were multi-agency safeguarding actions (including Police bail management) and did they comply with existing local inter-agency safeguarding policies and procedures? (D) Why did Child Z and his family not receive the appropriate multi-agency support services and Early Help offer, following the sexual abuse? 24 Working Together to Safeguard Children (2015): HM Government/Department for Education 44 2.3 Scope of the Review The SCR examined in depth the decisions and actions taken by agencies and the significant events occurring between January 2013, when YPA turned 16 and November 2016, the commission date of this review. 2.4 Methodology The SCR was undertaken by; Reference to the four ToRs. Collating a composite chronology within the above time-frame of the five agencies’ involvement with Child Z, his family and YPA. Receiving reports from the five agencies25 informed by the ToRs and the KLOEs. Sight of all relevant documents. Reflective conversations between the lead reviewer and key front-line professionals. A conversation with the mother of Child Z A conversation with YPA Conversations with professionals involved with the case. Discussion and analysis of the case at five overview Panel meetings The holding of a Practitioners’ Learning Event on the 13 June 2017, facilitated by the lead reviewer and SCR Chair and underpinned by five Key Practice Episodes. The adoption of a broadly, ‘Systemic’, approach to the understanding and analysis of how and why YPA was able to sexually assault Child Z within an organisational context of professionals’ actions and decision making at the time. A focus on learning and not second guessing with the benefit of hindsight. 2.5 The Overview Panel The Overview Panel consisted of the following senior agency representatives: Detective Inspector Norfolk Constabulary Designated Nurse for LAC Great Yarmouth & Waveney CCG Designated Nurse, Safeguarding Children Great Yarmouth & Waveney CCG Education Adviser for Schools Norfolk County Council-Education Head of Environmental Health Housing Options Local District County Council Family Intervention Team Manager Norfolk Children’s Services 25 Norfolk Constabulary, Norfolk Children’s Social Care, Local District Council/Housing Options, Norfolk Community Health and Care, Norfolk Education 45 Deputy Named Nurse, Safeguarding Norfolk Community Health & Care Chair Norfolk Children Safeguarding Board Business Manager 2.6 Lead Reviewer Mr Paul Sharkey (MPA)26 was the lead reviewer. He had no previous connection with either the NSCB or any of the partner agencies, including those involved in the SCR. He has written and/or chaired more than fifteen SCR reports since 2002 and has attended several DfE/NSPCC courses on improving the quality of SCRs over the last few years. 2.7 Confidentiality In compliance with Government guidance this SCR has respected the right to anonymity of Child Z and his family, YPA and the professionals involved in the case. 2.8 Family Involvement The views of Child Z mother (MZ) were noted in a conversation with the lead reviewer and the Chair. Child Z choose not to talk to the lead reviewer. 2.9 Race, religion, language and culture Child Z and his family are of White British heritage whose language is English. The family’s religion, if any, is not known. 2.10 Parallel Enquiries There are no other outstanding enquiries. The criminal proceedings regarding YPA were concluded in May 2017 when he was convicted of various sexual offences against Child Z and another child and given a custodial sentence. 2.11 Dissemination of Learning The NSCB will disseminate the learning from this SCR by: Ratifying the report at Board Publishing the report on the NSCB website alongside a summary Power Point of key learning for dissemination within agencies and teams 26 Master in Public Administration (2007) from Warwick University Business School; Certificate in Strategic Management; Kennedy School of Government, Harvard University. 46 Incorporating the learning in the implementation plan for the NSCB Strategy on Preventing, Identifying and Tackling Child Sexual Abuse Incorporating the findings, recommendations and actions in the NSCB’s Composite Action Plan and the Thematic Learning Framework Ensuring that all the Board’s subgroups, including the sector specific Advisory Groups, the Local Safeguarding Children’s Groups and the Workforce Development Group, are aware of learning and single/multi-agency actions required to take learning forward Undertaking a series of multi-agency roadshows to disseminate learning from this and other SCRs The above will also be followed up in the Section 11 safeguarding self-assessment challenge days. 47 Appendix 3 Norfolk Police CSE Perpetrators’ Scheme 1. If a young person aged under 18 who is living in Norfolk is deemed as a CSE perpetrator and a Police investigation has not resulted in conviction, but there are ongoing concerns around harmful sexual behaviour the Police will request a consultation with The Harmful Sexual Behaviour Team. This consultation service will provide advice on identifying areas of concern around harmful sexual behaviour, developing an understanding of the young person’s needs, safety planning and identifying resources/interventions to use with the young person. 2. During the CSE perpetrator risk assessment process research will be conducted on the Children’s Services Carefirst system to identify if they are open to Children's Services or gain details of any previous engagement. Further to this, the Police will assess their home life as part of any overt visit conducted to the CSE Perpetrator; a visit is not always conducted to a CSE perpetrator, when, for example, they are already under investigation for the offence for which they have been referred to the CSE Perpetrator Scheme. 3. The CSE Perpetrator SPOC (single point of contact) has attempted to liaise with YOT in order to integrate their involvement at an early stage, in particular during risk assessment and to establish a two-way intelligence stream between both organisations as the perpetrator work progresses. 4. The CSE Perpetrator Scheme liaises with the NPS (Norfolk Police Service) in order to employ disruption tactics and safeguarding measures with those offenders open to the NPS who have an ongoing concerning association with a young person. For example, the MASE Team will request regular visits to the offender and if offences are identified, will look to pursue recalls or breaches of supervision licences in order to disrupt the relationship. Further to this, the MASE Team will request CSE focused exclusion and non-association conditions to release licences once offenders are released again following the recall. |
NC52641 | This review considers three young people, two of whom were fatally injured with the third suffering serious injuries, following two separate knife crime incidents. The incidents took place in July 2020 and November 2020. Learning includes: the importance of earlier multi-agency intervention; the importance of understanding the impact of earlier life experiences, trauma and loss; the importance of sharing accurate information and ensuring prompt multi-agency responses, utilising critical moments more effectively and completing assessments and convening planning meetings in a more timely fashion; accurate and timely information sharing within and between schools; and holistic and creative planning to ensure that young people remain in education. Recommendations include: promote the use of the National Referral Mechanism and review its effectiveness for vulnerable children in relation to safeguarding from criminal exploitation; the partnership should be assured by school leaders that arrangements regarding fixed term and permanent exclusions consider issues of vulnerability or risk of harm; and be assured that effective quality assurance systems are in place which ensure that records accurately reflect the correct spellings of names, dates of birth, addresses and family details.
| Title: Thematic local child safeguarding practice review – Child N, YK and B. LSCB: Manchester Safeguarding Partnership and Trafford Strategic Safeguarding Partnership Author: Manchester Safeguarding Partnership and Trafford Strategic Safeguarding Partnership Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. THEMATIC LOCAL CHILD SAFEGUARDING PRACTICE REVIEW - CHILD N, YK AND B FEBRUARY 2023 Contents 1. INTRODUCTION, SCOPE OF REVIEW AND METHODOLOGY ............................................. 2 2. BACKGROUND .................................................................................................................. 4 3. THEMATIC ANALYSIS ........................................................................................................ 6 3.1 The Importance of Early Help .................................................................................... 6 3.2 The Importance of Trauma Informed Practice ........................................................... 9 3.3 The Timeliness of Intervention ................................................................................ 11 3.4 The Quality of Multi Agency Assessment and Planning ........................................... 14 3.5 The Critical Nature of Education and the Impact of Exclusions ................................ 16 3.6 The Factors that Increase and Reduce Vulnerability ................................................ 19 4. SUMMARY ...................................................................................................................... 24 5. RECOMMENDATIONS ..................................................................................................... 26 APPENDIX 1 – CHILD S .............................................................................................................. 27 APPENDIX 2 .............................................................................................................................. 27 Manchester and Trafford Child Safeguarding Practice Review 1. Introduction, Scope of Review and Methodology 1.1 This review considers three young people, two of whom were fatally injured with the third suffering serious injuries, following two separate knife crime incidents. Manchester Safeguarding Partnership subsequently commissioned a separate learning review following the death of another young person due to serious youth violence and the additional learning from that review is included at Appendix 1. 1.2 The review explores the young people’s journey through services, how their needs were identified and responded to and how effective the interventions were. It considers whether young people in need of protection from knife crime receive appropriate and effective interventions in a timely manner and whether services were sufficient and in line with both individual and multi agency practice standards. 1.3 A literature review has also been provided at Appendix 2, which considers national and local reviews, current research and which provide a benchmark against which to assess both strategic priorities and the quality of practice. 1.4 The review considers the adequacy of service provision for all three young people with particular reference to the key themes of early help, the timeliness of intervention, education, school exclusions and the availability of additional support. Consideration is also given to the impact of the Covid-19 pandemic on the quality of the interventions with the young people. 1.5 The review also draws on individual reports provided by service leads and the contributions of practitioners, managers, officers, teachers, health professionals, school nurses, senior leaders and case workers who attended a Practice Event on the 15/7/21. Consideration is given to already existing initiatives in Greater Manchester focussing on good practice and how effective this has been. 1.6 Family members and the surviving young person have been interviewed and have shared in detail their views and perspectives. This has provided a rich source of information regarding their sons and brothers and what may have made a difference. All have expressed a wish that this review improves the quality of services for young people. It is a contribution that I am deeply appreciative of. 1.7 N was a young male of 16 years of Somalian heritage who received fatal knife wound injuries in July 2020. 1.8 YK is a young male aged 17 years and of dual heritage who received significant injuries on the same date. The circumstances involving N and YK was a single related event, however the two young people involved resided in separate Greater Manchester Local Authority Areas. 1.9 B was a young male of Portuguese and Nigerian heritage who received a fatal knife wound in November 2020. He was 16 years old at the time. The incident involving B was unrelated to N and YK although B resided in Greater Manchester at the time of his death. 2. Background 2.1 Child N was a young male of Somalian heritage of 16 years and was described by his sister as a bright, charismatic and engaging young man who had been a loved and valued member of his family. He had high aspirations at school and had a sharp sense of humour, often being described as funny and playful. He had a wide circle of friends and enjoyed video games. Child N resided in Manchester, part of the Greater Manchester area. 2.2 Child B was a young male of dual heritage of 16 years who came to live in the United Kingdom with his family when he was 7 years old. He was described as talented lyricist who loved music. He had high aspirations at school being described as bright and engaging and had expressed a desire for a career in medicine. Child B also resided in Manchester 2.3 Child YK is a young male aged 17 years of dual heritage. His family described him as outgoing and engaging, loved by his family and like many teenagers was at times more influenced by his peers than his family. He loves music and has had an interest in cars and mechanics. Child YK resided in Trafford, also part of the Greater Manchester area. 2.4 It was important for the review to understand the background and experiences of these children in order to consider if there were similarities that could inform the learning for agencies and that could improve safeguarding responses. 2.5 It was critical that the specific experience of young black males was recognised as being of particular importance. This is the lens that has been applied throughout this review as agency responses have been analysed and has informed the recommendations made. It would be a disservice to the families not to recognise that ethnicity and identity play a crucial role in how children experience the world, how they are perceived and how they receive services which are designed to help and protect them. 2.6 It has also been helpful to identify a number of other factors that they share, that have informed the analysis in the report. Some of these are not surprising and reflect the national understanding that should act as triggers for agencies in considering the risks of exploitation and violence that a child may be facing and inform their plan to safeguard them. For these children these are identified as • Experience of domestic violence and abuse. • Difficulties within secondary school, sometimes as result of known factors such as speech and language difficulties, exclusions, a sense of being ‘let down’ and consequently declining attendance and commitment. • Associations with others involved in criminality, including drugs, the use of knives and the risk of exploitation. • Episodes of being missing from home 2.7 It is also important to recognise that all these children were loved and supported by their families; were known to statutory agencies and had lived through the difficulties and limitations that the covid-19 pandemic presented to teenagers, impacting on their lives and relationships. 3. Thematic analysis In examining the narratives, chronologies and background histories of all three young people there were a number of interrelated thematic areas which were agreed as areas for further analysis. These were key themes explored at the Practice Event on the 15/7/21, namely; • The importance of early help • The importance of ‘trauma informed’ practice • The timeliness of intervention • The quality of multi-agency assessment and planning • The critical nature of education and the impact of exclusions • The factors that increase and reduce vulnerability 3.1 The Importance of Early Help 3.1.1 For all three young people there were issues that related to early help and support. For N there were seven presentations at Accident and Emergency between 2004 and 2019 with three occasions being due to injuries. Whilst there was not information to suggest either compromised or neglectful parenting, there was certainly one instance in 2019 when N attended hospital with an injury to the jaw. Whilst he did not wait to be seen, this may have provided an opportunity to explore whether the injury was related to an assault and whether further support could have been provided. 3.1.2 B had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) before he reached 7 years of age when the family were living in Germany. As referenced earlier a referral to CAMHS was made in April 2016 and the family were offered an appointment in June of the same year However, B was not brought to the appointment and was subsequently discharged from the service. 3.1.3 This suggested a level of vulnerability related to B’s mental health and emotional well being particularly as his behaviours in school then escalated during 2019-20. This included making violent threats, intimidation and on one occasion, a class was dismissed to ensure their safety. It was also noted that B would often ‘lose his temper’ during sports competitions and display aggressive behaviour towards staff and opposing teams. Information from school as early as 2016 referenced physical assaults against his peers and threatening behaviour towards staff, which were described as ‘reckless and dangerous’. Conversely, B had received awards for positive behaviour and was described by staff members as ‘mature and sensitive, having a lovely side to him’. 3.1.4 Missed appointments are a feature for all three young people during their earlier years which suggested the need for greater ‘professional curiosity’ and a more tenacious approach to the issue of ‘non engagement’. Expected practice, now in line with both local authorities’ Missed Appointments Policy, would be to review the impact on the child’s health and well-being of non-attendance at appointments. 3.1.5 Regarding concerns that B had been involved in anti-social and gang related activity whilst at school, it is recognised that both schools which B attended did provide pastoral support for him, although this could have included wider and earlier multi-agency intervention with partner agencies, particularly given the significant issues with challenging behaviours, aggression and possible gang affiliation. 3.1.6 YK had been diagnosed with a ‘stammer’/speech dysfluency during childhood, which had deteriorated since he was 8 yrs old. There is also a lack of evidence in the Child Health Record regarding the School Nursing Service liaising with either the GP or the school to understand the impact that speech dysfluency was having on his learning or experience which would have evidenced more robust joint working. It was noted that YK had also missed his 2 year developmental assessment, which may have been an opportunity to intervene earlier regarding speech and language issues. YK was not referred to the service until the age of 8 years, suggesting that the issue had been identified far later than necessary. 3.1.7 The repeated missed appointments also suggested some level of family vulnerability, which may have been related to compromised parenting, however this was not explored. YK’s mother reported that his ‘stammer’ had significantly affected his confidence, particularly during year 7, but that ‘he just learned to deal with it’. YK was also noted as having moderate learning difficulties at primary school. However, this was not recorded at secondary school with the matter remaining unaddressed. 3.1.8 These are critical issues as the literature has identified that the prevalence of Learning Disability and Learning Difficulty in the offending population is 23-32%, compared to a general population prevalence of 2-4% and that 60-90% of young people who offend have speech, language and communication needs. Research also suggests that negative social consequences can begin early for children who stammer, including being perceived negatively by their non-stammering peers. They may be more susceptible to bullying and may have more difficulty in establishing friendships. Communication anxieties are significantly higher in children who stammer and this often increases with age. Many individuals with either a moderate or severe stammer also perceive it as a barrier to effective communication and therefore as a negative life event, which increases a sense of powerlessness 3.1.9 In addition, during April 2008, when YK was 5 years old, he witnessed a domestic abuse incident at the family home. It is recorded that YK’s estranged father attempted to assault his mother with a phone and was verbally abusive towards her. Records also indicate that between 2006 and 2008 YK was identified as a child linked to 4 domestic abuse incidents between his parents, although it is unclear as to what interventions or services were offered at the time. This may well have been a factor which impacted on YK’s language and communication skills, creating further anxiety and possibly contributing towards a poor self-concept and a greater sense of powerlessness and emotional distress. Similarly, there is information which suggests that B may have been exposed to violence in the home and research literature points to the links between exposure to violence growing up and the risks of violent behaviour as an older child or adult. 3.1.10 YK’s father had historical criminality recorded against them. YK’s mother was a victim of Domestic Abuse. YK along with his mother and siblings were residing with YK’s maternal grandmother for a period of time. These factors were areas of vulnerability which may have warranted an Early Help Plan. As the research acknowledged, ongoing parental acrimony can have a corrosive effect on self worth, identity and efficacy and exposure to criminal activity can profoundly influence behaviour and choices in later life. 3.1.11 Whilst joint initiatives between Police and CSC was a positive example of partnership working, with young people who had been in receipt of threats to life receiving joint home visits by Police and Children’s Services, there was less of a cohesive strategy for these young people who were seen as peripheral or nominal. This links to the importance of earlier multi-agency intervention which could be informed by the involvement of Police School Engagement Officers (PSEOs) in respect of information sharing with schools, so as not to miss earlier opportunities to intervene 3.1.12 However, current initiatives include a community led programme where six of the most ‘in need’ communities have been identified and are now receiving support from the wider GM partnership to develop the building of stronger community links with the Police in order to reduce violence. 3.1.13 Manchester Local Authority also continues to commission Elklan training for school staff from speech and language therapy services. This ensures that there is at least one member of staff in each school who is trained and skilled at identifying and meeting the communication needs of pupils. Encouragingly, most schools in Manchester now have trained members of staff and termly communication networks assist professionals in maintaining skills, sharing best practice and new resources. In the recent SEND joint area inspection, inspectors found: ‘SENCo’s have received training that has improved their ability to identify and support children’s emerging speech, language and communication needs. Referrals to therapy services are then triaged and, where accepted, either signposted for urgent attention or placed on the general waiting list for assessment. This makes it easier for families and professionals to get the support they need.’ 3.2 The Importance of Trauma Informed Practice 3.2.1 Research into Adverse Childhood Experiences (ACEs) suggests people who experience four or more ACEs are around seven times more likely to perpetrate violence as an adult. The Early Intervention Foundation suggests that 10% of the population have experienced 4 or more ACEs. In the past 5 years, Barnardos frontline staff have reported increasing cases of children with complex vulnerabilities, including experiences of early trauma, neglect, criminal exploitation and gang violence (Overcoming Poverty of Hope: Barnardos (2019)). 3.2.2 For all three young people there were issues that related to traumatic earlier life events and these have been described above. It is therefore critical that practitioners are able to emotionally connect with young people and family members using relational and attachment based interviewing techniques which facilitate change, create possibility and raise aspiration. The absence of trusted relationships characterised by consistency and integrity is a critical factor for practice and is repeatedly referenced by young people in both local and national research. This is a key theme consistently cited in reviews of failures around child exploitation and abuse (Early Intervention Foundation, 2018). 3.2.3 The conversation between practitioner and young person is at the core of practice and the essential tool for the formation of a relationship within which change can take place. The healing power of such relationships is also recognised in research which notes; ‘through just one relationship with an understanding other, trauma can be transformed and its effects neutralised’ (Fosha 2003). It is critical for practitioners to lay emphasis on the centrality of relationship skills in promoting social change, problem solving and facilitating empowerment which enhances well being. In that sense ‘relationship competence’ is an integral component of a trauma informed response, with practitioners being able to develop emotionally intelligent styles of interviewing and empathic responses to the key elements of attachment and loss. This therefore demands that organisations create the capacity and space to develop these complex skill sets for key practitioners. 3.2.4 Brandon’s (2000) study of over 100 children who had suffered significant harm found that there was a clear link between the quality of the worker’s relationship and the comprehensiveness of assessment information. In particular, information about material such as trauma, loss or substance misuse is significantly influenced by the degree to which the assessor is empathic and non-judgmental. Insensitive assessment practices can result in a failure to elicit crucial aspects of the details and meaning of the young person’s story, leading to inadequate plans, reduced user commitment and ineffective services. Motivational or attachment based interviewing can therefore be crucial tools in the practitioner’s repertoire. It is also encouraging to note that research is currently being undertaken by Manchester Metropolitan University, examining the links between Adverse Experiences in Childhood and serious youth violence. 3.2.5 In that sense the importance of listening to children, identifying who has the trusted relationship and utilising ‘the critical moment’ are critical considerations. The analysis identified ‘critical moments’ as times when a ‘decisive response can make a difference to a child’s long-term outcome’. Critical moments allow all professionals, particularly Police Officers, at the point of first contact, to make a positive contribution to the life of a young person, ‘perhaps by getting them support, being a listening and empathetic ear, understanding more about what is happening for them and making them safer’ (Child Safeguarding Practice Review Panel: March 2020). 3.2.6 The importance of understanding the impact of earlier life experiences, trauma and loss cannot be underestimated. Both N and B spent a year abroad in Somalia and Nigeria and very little is known regarding their experiences when there. It would have been important to understand the impact that this had on family and peer relationships, attachment, loss and re-integration back into home and school life in the UK. N’s sister described him as ‘not fitting in’ when he was in Somalia and that he had attended a number of private schools whilst there. Very little was known regarding N’s father and YK’s mother described his father as ‘struggling with his mental health’, with both YK and his father finding it difficult to communicate with each other. YK had also spent time with his maternal grandmother and there were concerns that his father parents had been involved in criminal behaviour. However, it is not clear what this related to, or how it had impacted on YK when he was younger. Similarly, very little is known about B’s father, B’s relationship with him or how the dynamics in the family home were impacting on his behaviour. Again, Brandon et al (2000) argue that; ‘insufficient attention has been paid to the many dimensions of biography and that such an understanding could lead to differential patterns of intervention’. This has some resonance with Bernard and Harris’ (2019) research which analysed 14 reviews involving Black children and found that even when children were old enough to contribute, their stories and voices were often overlooked. 3.2.7 Positively, a Mentoring Schemes in both Greater Manchester authorities, which addresses the issue of cultural congruence during interventions, has had a positive and significant impact with over forty young people having been referred to the scheme 3.2.8 GMP has also commenced a programme of education to provide all front line officers with the skills to recognise the effects of trauma caused by Adverse Childhood Experiences. The Making a Difference App also provides Police officers with access to a directory of local services to support victims and offenders. 3.3 The Timeliness of Intervention 3.3.1 As referenced earlier, the literature points to the importance of listening to children, identifying who has the trusted relationship and providing trauma informed empathic interventions. However, this must be in the context of timely responses. These are the ‘critical moments’ noted above and organisations must be agile and flexible enough to respond immediately to the critical moment, when the child is more likely to be open to change. This is referred to in the literature (The Child Safeguarding Practice Review Panel, 2020, 8.6). 3.3.2 For N, there were a number of junctures which may have provided greater opportunities for engagement. These included being taken home in March 2019 following concerns that he was associating with older males who were carrying knives, a ‘safe and well’ check undertaken in April 2019 and an incident on the 3 September 2019, following an anonymous referral when N was ‘attached’ to the care plan for an arrested male and when no further enquiries were made. Following an assault on the Police Officer in June 2019, which resulted in a comprehensive referral being made to Children’s Social Care, N was not visited until over nine weeks later and even then was not seen. The Child and Family Assessment was not completed until October 2019 and a multi-agency Child in Need (CIN) Meeting did not take place until November. The period of time between the date of the incident and the first multi-agency meeting was therefore over 5 months. 3.3.3 Agency requirements also specify that a young person must be seen within 5 days of initial allocation. There were 16 weeks from initial allocation to the completion of the first Child and Family Assessment despite agency standards prescribing a timescale of no more than 35 working days. It was then a further 8 weeks until the first CIN Meeting despite an agency requirement that the first CIN Meeting be held within 20 working days of a referral. 3.3.4 N’s arrest for possession with intent to supply (PWITS) in January 2020 may also have been an opportunity to refer him to the National Referral Mechanism (NRM) due to concerns in relation to exploitation which was linked to the holding and selling of drugs on behalf of another. 3.3.5 For B, there was information regarding challenging behaviour at school from as early as 2016, including concerns in respect of gang related activity, violent threats and at least one instance when a class had to be dismissed for their safety. This resulted in ‘trigger point’ meetings and a decline in his attendance during 2019/20. Following the incident in February 2020 when B was arrested following a male receiving a stab wound, a timely and comprehensive assessment was completed which was in line with agency standards. However, following B being arrested in August 2020 following a report by an adult female that a group of males had confronted her and threatened to murder her son, the information was not shared with partner agencies until the 25/9/20. In addition and within this time period, on the 25/8/20, Police were called to a disturbance at the family home which resulted in B being placed in handcuffs and detained, although this incident was not shared with partner agencies until the delayed strategy meeting. 3.3.6 For YK, there were a number of critical junctures. These included being linked to a robbery in December 2018 and being stopped in Manchester City Centre during May 2019 in the company of a male in possession of a knife. Of particular concern however was the incident in February 2020, when YK was arrested for possession of drugs and an offensive weapon. Whilst both Youth Justice and the Emergency Duty Team were informed, no interventions were provided due to YK’s information being merged with another young person’s records with similar identifying details. This was a critical missed opportunity which was only identified after the incident when YK was injured in July 2020. 3.3.7 Systemic theory literature provides the concept of the ‘critical moment which changes social worlds’. It is when the words used at a particular critical moment can have a powerful influence on the direction taken after the conversation has ended. It is the idea of the ‘teachable moment’. ‘As agencies, we need to find ways of being flexible and responsive enough to be ready to engage in those moments in real time. Days after the event might be too late. Services have to be constructed to be nimble enough to respond in the right moment, in the crisis’ (The Child Safeguarding Practice Review Panel, 2020, 8.6) 3.3.8 These issues have been recognised within Greater Manchester. Arrangements such as the GM Hospital Navigator programme. This has been commissioned by the Greater Manchester Violence Reduction Unit (GMVRU) and seeks to intervene at the critical or ‘teachable’ moment. The project, within four GM hospitals, focuses on areas which have seen some of the highest levels of youth violence and has so far provided support to 125 young people, more than a quarter of whom had suffered knife wounds. 3.3.9 Again, this draws on the principles embedded in initiatives such as the ‘Engage’ Project in Camden which offers a child-centred and child-friendly service at the point at which a child has been arrested. As a child often remains in custody for 10 to 12 hours, a worker is available to meet with the child, complete an assessment and use it to develop a working relationship with the family, often via a Family Group Conference. Nearly all the children involved in Engage agreed to early help or another intervention and over a third of the families engaged in a family plan of intervention (The Child Safeguarding Practice Review Panel: 2020). 3.3.10 Other national initiatives continue to be developed in Greater Manchester and to influence practice although there is a need to consider initiatives such as the ‘golden hour’ approach when a child enters custody. Officers immediately make contact with the relevant Local Authority or Multi-Agency Safeguarding Hub (MASH) that the child resides in, within the hour. The contact with the Local Authority within the first hour enables ‘real time’ information sharing and enables both Police and Social Care to have all relevant information at hand to help inform decisions and next steps. Information received from social care can also support with safeguarding the child in custody and also helps better inform ‘pre-release’ risk assessments (Vulnerability, Knowledge and Practice Programme (VKPP): July 2020). 3.3.11 GMP has also instigated the Prosecution, Prevention, Intervention, Education, and Diversion (PPIED) processes which is being implemented across the county. This involves a multi-agency response to all young people who come to police attention with the aim of providing bespoke support to the young people and their families to prevent an escalation of violence. 3.3.12 For practitioners the issue is one of timeliness and the importance of sharing accurate information and ensuring prompt multi-agency responses, utilising critical moments more effectively and completing assessments and convening planning meetings in a more timely fashion. 3.4 The Quality of Multi Agency Assessment and Planning 3.4.1 The section in respect of Early Help references a number of issues related to more effective multi agency planning particularly with respect to schools. This was a particular feature for one of the two Manchester children. In terms of the quality of assessment and planning there are a number of elements which merit further consideration and which related to the interface between the Complex Safeguarding Hub (CSH) and the Court and Locality (Central) Team (CLT) in Manchester. It must be noted that interventions with N and B were provided by Manchester Children’s Services. 3.4.2 During the period of Children’s Services involvement from Manchester, N had two Social Workers, the first from the Duty and Assessment Service between June 2019 and December 2019. N was then transferred to a Social Worker within the CLT who retained case responsibility from December 2019 until April 2020 when the case was closed. In addition, a practitioner from the CSH had involvement from July 2019 to April 2020, when the matter was closed to the CSH. However, it was noted that the CLT had an underdeveloped understanding of family dynamics as the CSH worker had greater face to face contact with N than the CLT Social Worker and there was lack of connectivity between the CSH Plan and the CLT Plan. This was compounded by separate supervision sessions which reinforced silo working, a narrow perspective and a less holistic overview. 3.4.3 The CSH was also viewed as the key professional element, which contributed to a ‘stepping back’ by the CLT. This is reflected in the visiting patterns of the Social Workers. In the ten months that N was open to Children’s Services he was seen by a CLT Social Worker on just five occasions. The quality of the visits is variable and the impact of any interventions is not evident. As referenced earlier, investment in relationship building, using attachment based or motivational interviewing to build trust and collaborative interventions is critical. There was also no analysis of family dynamics to understand the lived experience of N in the context of his family or community, nor was a Family Group Conference considered, which may have identified further support from extended family or the wider Somali community. 3.4.4 Whilst it was reported that N was difficult to engage with, particularly from a Social Work perspective, this did not result in further endeavours or a more tenacious approach to relationship building. The belief that N was unreceptive to interventions combined with a low level of professional curiosity resulted in a superficial understanding of his lived experiences, his family and community context, his anxieties about his circumstances or his beliefs about himself. In that sense it is of critical importance that professional tenacity and curiosity drives and informs effective planning with clarity of role for relevant agencies and measurable outcomes. This element can also have a cultural dynamic, as in for instance Somali culture, where a service needs to be offered a number of times before it is accepted as genuine and authentic. 3.4.5 It must also be recognised that staffing issues within the service in Manchester were at the time particularly challenging. In the Duty and Assessment Teams, vacancy rates contributed to cases remaining in this part of the service for longer periods, which then impacted on work load management. Staffing issues were also an issue for the CLTs and out of 48 full time social work posts, there were only 29 at the time, equating to 60% capacity. This therefore impacted on the ability of the CLT to work collaboratively with other parts of the service, such as the CSH. 3.4.6 Whilst the CSH undertook two complex safeguarding assessments which were detailed and comprehensive, this information did not translate into the Child and Family Assessments undertaken by the CLT or N’s Child in Need (CIN) Plan. This consisted of actions which were both vague and non specific, including that N was to just ‘work with’ the CSH worker and the Youth Justice worker. As these elements did not change throughout the period of CIN planning, this questions the effectiveness of the mechanism for review, evaluation and risk assessment and therefore the overall quality of the CIN Meetings and planning. Whilst CIN Meetings were eventually held on a monthly basis, this did not result in a more developed and effective plan. Neither the Police nor the CSH Social Worker were invited to attend monthly meetings and the Growth Company, where N was pursuing a vocational course, reported that they were unaware of the support plan for him. This inhibited a wider understanding of N’s circumstances and resulted in an incomplete overview of his needs and a fragmented perspective regarding risk. Importantly, N was considered primarily as a perpetrator of suspected criminal activity rather than a child who was being groomed. The language used is one of ‘choices’ rather than an analysis of power due to the coercive relationships that N was enmeshed in. 3.4.7 Whilst these issues indicate a lack of coherence and focus within and between agencies, it must be recognised that positive work has been ongoing in Manchester regarding more effective coherence between the CSH, the CLTs and Youth Justice. 3.4.8 However, for YK, the missed opportunity for assessment and intervention by Trafford Children’s Services, due to wholly inaccurate records, was a critical omission. This has however been addressed by positive developments in Trafford which have brought together the Complex Safeguarding Team (SHINE), Missing from Home (MFH) Services and Youth Justice as part of a significant service redesign reporting to a single Head of Service. This has improved information sharing, organisational agility and ensured more effective responsiveness. For B and as referenced earlier the quality of multi-agency response, assessment and planning, following the incident in February 2020 was timely, of good quality, in line with agency practice standards and included the young person’s views. However, information was not shared with the relevant sixth form college in September 2020, which was a significant omission given the seriousness of the incident in February. In this respect the transition of safeguarding records between schools are critical to ensure appropriate support, informed intervention and more effective oversight. 3.5 The Critical Nature of Education and the Impact of Exclusions 3.5.1 There is a lack of information regarding the year that N spent in Somalia, what experiences or trauma he may have been exposed to and a lack of clarity regarding precisely why N had travelled there, particularly as a concern had been expressed that this was either for ‘punishment or correction’. Academic ‘catch up’ may well have been an issue for N and it is unclear what pastoral support was considered on his return. N (like B) was out of education from the spring of his final year and this lack of visibility was compounded by the Covid 19 restrictions that came into play from March 2020. Whilst N was supported in his education placement at the Growth Company, particularly by his Youth Justice Worker, he struggled to maintain consistent attendance and there was some decline in motivation, particularly after March 2020. The early impact of the pandemic and the period of lockdown when the placement was closed also had a detrimental effect on N’s connectedness with the course. Whilst attempts were made to secure alternative provision, this will have increased his sense of disconnect and isolation. The impact of ‘lockdown’ has been referenced by a number of schools, particularly in respect of reduced pupil visibility, lack of connectedness, greater isolation and alienation, the availability of support services and the ability to implement behaviour management strategies, such as ‘managed moves’. 3.5.2 Following his year in Somalia, N returned to an academy for Year 10 but this did not take place until November 2017, due to an admissions related delay. During Year 11, N was educated off site for 105 days out of 190 and received 20 days of fixed term exclusions due to behavioural issues. Whilst the academy ensured that N progressed to post-16 study with the Growth Company, it is recorded that he stopped attending and was removed from the course shortly before his death in July 2020. 3.5.3 N’s sister believed that his exclusions were for relatively low-level behaviours, recalling that he had ‘sworn at a teacher, slammed doors, and thrown ‘something’ on the floor’. This was 5-6 months before his GCSEs and he was consequently placed in alternative provision. As his sister reported, ‘this had no structure or consistency…it was at this point that his aspirations dipped. He had ‘nothing to look forward to… All of us have achieved educationally and we are not a typical criminal family. It then became harder for mum to control him, mum would give him ‘such a telling off’… we were all on his back’, when at school he would stay in, when in the alternative provision he would go out... 3 days in school, 4 days doing nothing… whilst all his old friends were working towards their GCSEs’ 3.5.4 Similarly, during the school year 2017/18, B attended a college in Nigeria and on his return enrolled at an academy in Manchester. However, records indicate that transition information was not requested from his primary school. B reported to his Social Worker that he was angry and felt let down by the school, particularly as he had missed his mock examinations and that his involvement with the Police was based solely on ‘word of mouth’. He expressed his frustrations trying to keep up to date with his school work, which was on-line due to his bail conditions. B also reported that he was anxious about his future opportunities and had been refused entry to one college due to an ongoing criminal investigation. 3.5.5 As referenced earlier, the research literature extends the idea of the ‘critical moment’ to include the point at which young people are injured or excluded from school and notes that exclusion from mainstream school is a significant trigger point for risk of serious harm. N’s sister spoke of her brother’s feelings of rejection, the severing of friendships and a greater sense of isolation, expressing concerns regarding the loss of peers who might have had a positive influence. There was also a concern that attendance at a Pupil Referral Unit would lead to negative behaviours being reinforced. The National Child Safeguarding Practice Review (2020) notes; ‘we cannot emphasise strongly enough the learning from this review about the impact on children of exclusion from mainstream school. Leaders of local safeguarding agencies and head teachers must work together to ensure an immediate response in providing suitable full-time education each week. This is vital in preventing the escalation of risk of harm’. 3.5.6 There are a number of examples of pro-active and positive practice involving schools in both Manchester and Trafford. These include collaborative work with Greater Manchester Police to support a greater awareness of knife crime, including the No More Knives initiative, the Knife Crime Protocol, stronger multi-agency collaboration, including visiting schools and colleges and an emphasis on stronger pastoral support for all the schools referenced in this review. Curriculum time is also provided, which is dedicated to supporting young people with knife crime education. Whilst the No More Knives Initiative is relatively recent, the Community Safety Partnership has commissioned awareness sessions, facilitated by the Manchester Safeguarding in Education Team, which has been in place for 5 years. The Complex Safeguarding Hub (CSH) has also supported targeted schools and colleges via mapping activity and training to address issues relating to exploitation and knife crime. Whilst the GMVRU has commissioned activity regarding knife education at a small number of selected settings the impact of this has yet to be evaluated. 3.5.7 GMP has also deployed 20 new Schools Engagement Officers (SEOs) across the region as a targeted resource to support schools in challenging circumstances. The aim of the SEO is to build positive relationships and trust with students and to influence students towards more a positive community orientation. Manchester has 4 officers out of the 20. 3.5.8 The Manchester Inclusion Strategy also emphasises a holistic cross partnership approach to prevent exclusion and to support children and young people to thrive. Manchester City Council, in collaboration with partners, including schools and colleges has produced guidance in respect of managing concerns for young people who carry knives and weapons which identify risk factors and the support which is available. This was developed in response to the GMVRU knife protocol and provides a rich evidence based resource for educational establishments. 3.5.9 The Team around the School is a positive example of a multi-agency strategic approach which has been effective in supporting schools with complex safeguarding issues. Manchester’s Thrive in Education offer for children and young people, regarding well-being and mental health and introduced in September 2020 for all schools and colleges, provides a source of early help and support. 3.5.10 The effectiveness of these initiatives is currently being evaluated by Manchester Metropolitan University and the evaluations will be available during 2022. This is part of a wider strategic endeavour which aims to build a longer term public health approach to youth violence and knife crime in accordance with national policy and research. 3.5.11 In Trafford, schools have also adopted the ‘Knife Crime Protocol’ leading to a reduction in exclusions and a package of multi-agency support for young people found in possession of a knife in school. In addition the Serious Youth Violence Fund has sponsored 3 full time mentors working with over 50 young people, since March 2020, who were at risk of involvement in knife crime. The mentoring has seen no offending or a reduction in offending for the majority of young people on the programme. However, it must be noted that YK was not identified as a Trafford Young Person otherwise it is likely that a referral would have been made. The Serious Youth Violence Fund has also supported detached Youth Work, targeted at areas where there are a disproportionate number of young people not in employment, education or training (NEET) and based on community and police intelligence. This has been delivered by the Councils Street Talk Team and a number of partners working together. The extended role of the Virtual Hub has also provided enhanced scrutiny regarding exclusions. 3.5.12 However, further work needs to take place to ensure the timely transition of safeguarding records and the sharing of information between educational establishments so risks can be identified and mitigated against, and support can be provided in a timely manner. This includes concerns from siblings who may attend other schools and is crucial in ensuring effective and informed ‘managed moves’. Designated Safeguarding Lead (DSL) networks are continuing to address these issues, including sessions in respect of ‘whole family’ approaches, transitions and information sharing. Transition guidance, critical incident management and risk assessment guidance has been refreshed with best practice and the GMVRU Knife Protocol Guidance has been shared with schools and colleges to ensure alignment with local priorities. However, concerns remain from a number of schools in Manchester that knife crime is increasing, that school staff cannot be available for young people when incidents occur out of school time and that, for at least one school, an incident involving knives was not taken seriously enough by Children’s Services. For another school collaborative support has been inconsistent and a request for more enhanced support regarding complex safeguarding has not been recognised. 3.5.13 The impact of Covid 19 on commissioned services, intelligence gathering and information sharing regarding schools, families and young people cannot be underestimated. It has been referenced by all the schools in this review and was a factor in implementing effective interventions for B in his final year at school. This has profoundly impacted on visibility, face to face contact with services and schools, the agility of organisational responsiveness, teaching and learning time, anxiety and stress levels for young people, their families and communities, economic stability and multi agency working. The elements of increased isolation, reduced social contact, greater alienation and a more acute sense of dis-connectedness, which have characterised government imposed ‘lockdowns’ have also exacerbated already existing structural and environmental issues which contribute to knife tolerance and violence (Damilola Taylor Trust, 2021). 3.5.14 For practitioners and schools, successful outcomes will often depend on early recognition of concerns, accurate and timely information sharing within and between schools, holistic and creative planning to ensure that young people remain in education and robust oversight and review, either via early help, or CIN processes. 3.6 The Factors that Increase and Reduce Vulnerability 3.6.1 In understanding the factors which increase vulnerability there are number of key elements to consider. Firstly, the extent to which ‘hyper’ or ‘aggressive’ masculinity contributes to increased risk is well documented in the research literature. Carrying weapons are part of a wider dynamic which causes young people to feel unsafe, reflecting the importance of understanding knife crime in a wider structural and cultural context (Bateman 2019). In addition, the issue surrounding aggressive masculinity, image and the need for respect is referred to by young people and is supported by national and international research such as The Future Men (2018) Survey which identified that 2 out of 3 18-24-year-old men believe they are pressured to display ‘hyper-masculine behaviour’. As referenced earlier, the need for physical defence, the need for respect, limited trust in authorities and limited control over status were found to be inter-correlated and predictive of aggressive masculinity, which was then predictive of knife tolerance (Palasinski, M. 2019). 3.6.2 Not only did YK report that he had carried a knife for protection, but when asked if he would have done anything differently reported that he ‘would not be as showy’. His decision to carry a knife that day influenced his behaviour and whilst his actions were not pre-meditated, they were reactive. If he had been unarmed it is far more likely that he would have run away, as others did. 3.6.3 YK described the incident when N was killed and how YK and his associates inadvertently met another group of young people who then targeted one of YK’s group. ‘It all happened so quickly, the other group ran away to get weapons - I couldn’t run away because I would be ‘violated’ on social media’. The exchanges were therefore fuelled by the threat of social media postings which YK perceived as potentially impacting on his identity and self concept and which will have been exacerbated by the speed and volume of the communications. In this respect ‘bravado’, not being seen to ‘lose face’ and the importance of reputation and respect in peer groups was perceived as key and therefore predictive of behaviour, particularly knife tolerance. As his Youth Justice Officer reported, ‘an aggressive response is celebrated; a young person who flees is mocked’. 3.6.4 In a similar manner, B’s behaviour at school was at times both adversarial and challenging but little is known regarding what the drivers may have been, or how B perceived himself in the wider contexts of family or community. 3.6.5 Secondly, and as referenced earlier, the literature references the confiscation or loss of items such as drugs as a factor which then increase a young person’s vulnerability to violence. Following the incident in January 2020, N was found to be in possession of a large sum of money and a significant amount of a Class A drug, which was then retained and sent for forensic examination. Importantly it was noted that ‘danger statements’ were not updated and the risk to N of having the drugs taken from him was not considered. Following this incident his sister described N as ‘staying in more’, and whilst this was reinforced by the Covid-19 restrictions which commenced in March 2020, his sister had noticed this as being ‘a relief to him’. 3.6.6 Thirdly, the level at which all professionals have an in-depth knowledge relating to child exploitation in its various and diverse forms is also a key element in the reduction of risk to young people. The ability of professionals to be able to recognise and identify young people who are at risk of child criminal exploitation, not to rely on assumptions and to therefore effectively assess risk is critical in effective responses (The Child Safeguarding Practice Review Panel: March 2020). For N the focus of concern was in respect of suspected criminal activity not the risks associated with exploitation. Consequently no concerns were shared with partner agencies such as health colleagues or the GP. N’s sister, when describing his involvement in ‘drug dealing’ reported that, ‘he didn’t need money, mum would give him money’ suggesting that it was not an economic imperative that was driving his behaviour, but deeper issues related to identity, belonging and vulnerability. 3.6.7 As referenced earlier, the national CCE report identified that children who are at risk of criminal exploitation require strengths-based, relationship-driven approaches. This was a recurrent theme in all the research literature which repeatedly emphasised the importance of trusting, consistent relationships in effective work with young people. For practitioners there needs to be sufficient emphasis on relationship-based work, developing professional curiosity and the building of capacity to allow this. In addition, known risk factors often associated with vulnerability, such as ‘being in care’ or being ‘known to Social Services’, are not necessarily predictive of exploitation or greater risk. The corollary of this is that the absence of these factors does not suggest an absence of risk or lower levels of vulnerability. It is important for practitioners and responding officers to be aware of misplaced assumptions regarding background and therefore proclivity to knife crime. 3.6.8 As N’s sister reported, ‘we are not a typical criminal family…it became harder for mum to control him, mum would give him ‘such a telling off’… we were all on his back’. His sister also reported higher levels of aspiration when N returned from Somalia describing him as wanting to do well and be successful. YK’s mother actively supported him and challenged her son regarding as to why he was carrying a knife and B reported aspirations for a career in medicine. As the literature identifies, most of the children considered in national research were characterised by practitioners as bright, respectful and polite. In that sense there are no conclusive findings about deprivation or poverty and there was no common pattern, with young people from families with working and non-working parents and from a range of areas, not only those with high levels of disadvantage (The Child Safeguarding Practice Review Panel: 2020). 3.6.9 Fourthly, the literature has cited how ethnicity, age and gender are integral features in how young people are perceived and engaged with by professionals. Thus is reinforced by Goff et al, (2014) who provide the category of ‘Adultification’, meaning the concept of childhood may not be applied equally to all Black children. They may be excluded from being perceived as vulnerable and may experience punitive and neglectful responses, therefore being more likely to be treated as ‘adult-like’. N’ sister described her brother as ‘very charismatic, very noticeable, tall, he walked upright, he was big boned and looked like an adult, ‘all eyes were on him’ when he was out… he stood out from the crowd, he was a ‘young boy in a big man’s body…he looked older than me and yet he was my baby brother’. Misplaced perceptions regarding conceptions of ‘adulthood’, particularly in respect of Black children, can inhibit an ability to recognise child vulnerability, potentially increasing or compounding risk. 3.6.10 Fifthly, the literature has identified as problematic an overemphasis on ‘gangs’, which can result in the perpetuation of highly racialised stereotypes, particularly as gang-specific interventions have mixed evidence of success. There is also increasing evidence that the designation of ‘gang-member’ is applied in ambiguous and opaque ways which then results in a range of discriminatory consequences. The Serious Crime Act 2009 definition of a gang is now defined as; ‘having one or more characteristics which enable its members to be identified as a group by others’ (Section 34(5). This can include a common name, emblem or colour, an association with a particular area, a leadership structure and involvement with unlawful activity. However, care must be taken not to assume alliances or a predisposition to organised violent behaviour which may not be entirely accurate. Excessive focus on ‘gangs’ as a primary driver of violence can therefore detract attention from the deeper structural drivers of violence, racism and identity. 3.6.11 YK reported that he had images on his phone relating to a ‘red bandana’ and this was used to create a group image. However, it did not infer anything further than ‘purely wearing red’ to identify with a particular area of Manchester. This had previously been referenced as a link to the Active Only (AO) gang which had one time been more prevalent in the Manchester area 3.6.12 Whilst this must not detract from the seriousness of the offence which resulted in N’s death, it is critical that racialised stereotypes, regarding gangs as a primary driver of violence, are subjected to more rigorous analysis. Encouragingly, the GMVRU is currently piloting a community led approach to Policing over six areas in Greater Manchester which seek to address issues regarding risk and vulnerability at the point of arrest or intervention. 3.6.13 There are also ongoing and recent concerns regarding the potentially racist nature of Joint Enterprise convictions, which hold all participants in a violent incident, however minor individual actions, equally guilty if they have found to have intentionally encouraged and assisted anybody who has committed the most serious violence (Guardian, 6/6/21). Amnesty International has argued that young black men are classed as gang members and criminalised ‘based on weak indicators’ including ‘reasons as trivial as the music they listen to or the videos they watch on line’. In a similar vein it has been argued that collective prosecutions have led to ‘black youths serving hundreds of years inside for crimes they did not commit’. 3.6.14 The issue here is for practitioners to rigorously examine any assumptions regarding gang involvement as primary drivers of violence and to have a greater degree of professional curiosity and inquisitiveness with regards young people’s experiences, life histories, aspirations and how these elements shape identity. This will inform a more considered response and influence any support service provision. 3.6.15 Sixthly, parental and wider family engagement is a key factor in risk reduction. The literature noted that parents are often recorded as ‘refusing to engage’ or having ‘poor relationships’ with statutory services, which can influence relationship building. All three children had family members who cared deeply about them and have provided a rich source of information and insight for this review. There is also the issue of precision and clarity regarding names, dates of birth and address details for families and young people. The issue regarding YK’s details being merged with another young person’s information has already been referenced and contributed to a missed opportunity to provide an intervention for him, therefore increasing vulnerability. Police systems had three different names for N, including mis-spellings and during the Court process an attendee noted that N had been referred to by five different names. N’s sister also reported that ‘the day after he died, 2 officers turned up at the house for the tag, laughing and joking, they didn’t know… ‘how could they not know he was dead… and they got his name wrong in Court… a Barrister referred to him by five different names…’ . It must be noted that the visit to the family address was made by representatives of the Electronic Monitoring Service (EMS) who were responsible for the oversight of tagging. This visit took place at 10pm on the evening after N’s death and whilst a number of other agencies had been informed of the incident, this had not been communicated to the EMS Company. This resulted in further and avoidable distress for the family. This issue has been shared with all Youth Justice Managers to ensure that appropriate and timely communication following significant events takes place. 3.6.16 The research also questioned the applicability of the Child Protection framework in certain circumstances and whilst acknowledging its strengths when responding to intra-familial risk of harm expressed concerns regarding it’s applicability for young people involved in criminal behaviour or serious violence. The review noted that ‘whilst parents clearly retain some responsibility for their children’s safety, where most of the risk is extra-familial their experiences of Child Protection Conferences can sometimes feel blaming and unsupportive. If the conference is not chaired well, it can lead to deterioration in the relationship between practitioners and parents’ (11.3). 3.6.17 In Trafford this issue is already being addressed, incorporating the key themes and findings contained in ‘Adolescent Safeguarding Principles (DfE) and the ‘Achieving Change Together’ (ACT) Programme. 3.6.18 The response to children who are at risk of significant harm and exploitation from within their communities must be therefore formulated in the light of that wider context. The current narrative and requirements in Working Together are not clear enough about how the guidance should be applied to children who are subject to risks from outside the home. This may well have been the rationale for interventions for N and B having been delivered on a CIN basis, however, this carries the possibility that elements of risk are not considered as thoroughly as possible 4. Summary 4.1 This review has considered the experience of three children, N, B and YK. The young people’s journey through services and how needs were identified and responded to have been described in detail. The key questions throughout the review have been: • How effective the interventions were And • Whether young people in need of protection from knife crime receive appropriate and effective interventions in a timely manner. The review has considered these two questions in the context of six interrelated themes; • The importance of early help • The importance of ‘trauma informed’ practice • The timeliness of intervention • The quality of multi-agency assessment and planning • The critical nature of education and the impact of exclusions • The factors that increase and reduce vulnerability 4.2 Consideration has also been given to the impact of the Covid 19 pandemic on the strength of engagement and the quality of the interventions with the young people. 4.3 These factors have been examined in the context of the individual experiences of the young people and have been located within a review of literature and current research regarding knife crime. This has provided a ‘benchmark’ against which to assess both strategic priorities and the quality of service responses and interventions. 4.4 It has been recognised that whilst there was considerable evidence of some good practice, innovative initiatives and in places, strong relationships with the young people and their families, there were areas of engagement which did fall short of agency practice standards. For both authorities this related to the themes of earlier recognition and response regarding issues related to learning disability, domestic abuse and accurate communication both within and between agencies. However, for Child YK it is recognised that there was very limited involvement with services in Trafford although the issue regarding ‘merged’ details, which appeared to be related to human error, is key. 4.5 For Manchester the timeliness of referral and responses and wider family engagement were critical features and there were a number of critical junctures where services and support could have been provided in a timelier manner and where the quality of plans could have been improved. The review has also considered the wider themes related to racism and ‘hyper’ masculinity which increase risk and vulnerability. The importance of locating the experiences of young people in a criminal exploitation context is also referenced, as is a wider treatment of whether an emphasis on ‘gangs’, as a primary driver of violence, can divert attention from more fundamental issues. 4.6 However, the review could not identify any specific deficits which suggested that the tragic events which befell Child N, Child B or Child YK were preventable. The review also acknowledged that much work has been undertaken by safeguarding partners to address these issues and that an effective response to the issues of knife crime will continue to require a wider organisational and cross partnership approach. 5. Recommendations 5.1 The following recommendations are grouped into four broad areas namely; The Importance of Critical Moments, Education and Exclusions, Safeguarding Processes and Early Help and Trauma Informed Practice 5.2 A more comprehensive set of considerations, referencing wider strategic priorities drawn from national research and regional policy planning is included with the literature review at Appendix 2. This addresses wider issues in respect of organisational coherence and connectivity, wider strategic planning and the critical importance of understanding serious youth violence, particularly knife crime, as a public health issue. The Importance of Critical Moments 5.3 Manchester: For the Safeguarding Partnership to be assured that risk assessments consider Child Criminal Exploitation where appropriate, including factors such as the impact of retaining drugs or money which may increase vulnerability. 5.4 Manchester: To continue to promote the use of the National Referral Mechanism (NRM) and to review its effectiveness for vulnerable children in relation to safeguarding from criminal exploitation. 5.5 Manchester and Trafford. For the Safeguarding Partnerships in both areas to receive assurances that risk assessments for children and young people at risk of violence or exploitation routinely involves parents, particularly fathers and wider family members. Education and Exclusions 5.6 Manchester: For the Safeguarding Partnership to be assured by School Leaders that arrangements regarding fixed term and permanent exclusions consider issues of vulnerability or risk of harm and that alternative education arrangements are both appropriate and safe 5.7 Manchester: For the Safeguarding Partnership to receive assurances that arrangements regarding transitions and information sharing between schools, particularly when there are cross border issues, are both effective and timely. Safeguarding Processes 5.8 Trafford and Manchester. For the Safeguarding Partnerships in both areas to be assured that effective quality assurance systems are in place which ensure that records accurately reflect the correct spellings of names, dates of birth, addresses and family details 5.9 Manchester: For the Safeguarding Partnership to be assured that the Children’s Social Care interventions of referral, assessment, planning and review to be in accordance with agreed practice standards and appropriately link with other services such as Youth Justice or the Complex Safeguarding Hub. Early Help and Trauma Informed Practice 5.10 Manchester and Trafford. For the Safeguarding Partnerships in both areas to receive assurances that arrangements for the Early Identification of need are effective, so that families receive support in a timely manner, particularly where this relates to domestic abuse complex needs and learning disability. 5.11 Manchester and Trafford. For the learning from this review to inform training and professional development regarding trauma informed practice, professional curiosity, child criminal exploitation, ‘Adultification’ of Black children, working with hard to reach families and relational and attachment based practice. Appendix 1 – Child S Child Practice Reviews – resources for practitioners : Manchester Safeguarding Boards (manchestersafeguardingpartnership.co.uk)' Appendix 2 Literature Review for Thematic Review |
NC047207 | Non-accidental injury to 14-week-old baby in October 2013 who was admitted to hospital with a fractured femur. Both parents were charged with grievous bodily harm but no convictions resulted. Both children were subsequently permanently removed from their care. Child C and Sibling were subject to child protection plans under emotional abuse. Sibling had previously been a Child in Need. Family were known to agencies due to issues of violence and domestic abuse; alcohol and drug misuse by parents and maternal grandmother; mental health; and unstable housing arrangements leading to frequent moves. Issues discussed include: family history and its impact on parenting; parental alcohol misuse; the involvement of fathers and the extended family in assessments; and the role of staff supervision across agencies. Highlights the importance of multi-agency working in cases involving domestic abuse, mental health issues and substance misuse and the need to avoid over-reliance on the opinions of health professionals or children's social care alone. Uses the Significant Incident Learning Process (SILP) methodology. Recommendations to the Safeguarding Children Board include to: review the sharing of domestic abuse notifications between the police and partner agencies; promote the "Think family" approach; ensure that multi-agency training covers the impact of domestic abuse, mental health and substance misuse on parenting; review how partner agencies provide supervision to ensure reflective challenge; and highlight the potential for non-accidental injuries to be missed by the national 111 medical helpline triage system. Highlights examples of good practice, such as the relationship developed between C's mother and the Family Nurse Partnership, and outlines developments including the establishment of police protecting vulnerable people referral centres.
| Title: Serious case review: Child C (born 2013) and Child C (sibling, born 2010): Overview report. LSCB: Bracknell Forest Safeguarding Children Board Author: Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. STATEMENT OF THE INDEPENDENT CHAIR- SCR C The Bracknell Forest Safeguarding Children Board (BFLSCB) is publishing the Overview Report of a Serious Case Review (SCR) undertaken during 2013 and 2014. The review concerned a 2 month old baby, born to young parents, who was seriously harmed as a result of abuse. Publication of the report has been significantly delayed by the criminal proceedings involving both parents and further attempts to undertake discussions with the family. The incident, which led to the SCR occurred over two years ago. BFLSCB received and agreed the SCR report in June 2014 .It was written prior to the publication of statutory guidance Working Together 2015 and has been amended to reflect the outcomes of the proceedings in both the criminal and civil court jurisdictions. All partner agencies involved in this case engaged positively in developing the Action Plan in response to the recommendations in the SCR Overview Report and those of the individual organisations. There was clearly learning for all partner organisations. These Action Plans have been subject to regular monitoring and challenge and the key areas of learning have been disseminated through partner agencies, discussed in a series of workshops for front line practitioners and fully integrated into the LSCB training programme. Overall, it was felt that a key issue in this review was the opportunity to raise awareness and ensure understanding of the risk to non independently mobile babies. The evidence is clear that babies are unlikely to be bruised before they are mobile and everyone should therefore be alert to this and to ensure appropriate action is taken. The LSCB has developed a document to explain this to parents/carers, reviewed procedures and supported training to all practitioners to continue to raise awareness. In addition this review has highlighted the need to ensure all agencies “think family” and that information held around adults is shared and considered pro-actively. The LSCB has reinforced this through its training programme and has been reassured by the improved operational arrangements between children’s and adults services where there is now regular liaison and discussion. The Overview Report highlighted a number of areas of good single agency and interagency practice and also identified issues for partner organisations where it was felt that practice could be improved and made 10 overarching recommendations for the LSCB. Each organisation has made good progress to address the recommendations and examples of progress include: Acute Hospital - reviewed training and undertook learning events resulting in increased numbers of appropriate referrals and the hospital now receives information on all children subject to child protection plans. Schools - significant effort has been made to raise awareness of safeguarding, and through the revision of existing procedures increased support and improvements have been made to professional communication and the recording of concerns. Primary Care - undertook focused training and devised a new procedure/template to record information and strengthened arrangements to enable receipt of domestic abuse notifications. Children’s Social Care - provided significant professional development opportunities in relation to the importance of family history and involvement of fathers. They reviewed case transfer and decision making processes, and improved arrangements for Children’s Social Care and adult services to discuss cases and regular case file audits are undertaken to monitor progress. Bracknell Forest LSCB has ensured the key learning from this Serious Case Review has been addressed and encourage ongoing discussion and challenge between partner organisations and the use of audit activity to continually monitor progress against areas for improvement. Alex Walters LSCB Independent Chair February 2016 BRACKNELL FOREST SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW USING THE SIGNIFICANT INCIDENT LEARNING PROCESS CHILD C (Born 2013) CHILD C Sibling (Born 2110) CONTENTS 1. INTRODUCTION 1.1. Genogram 1.2. Introduction to Child C 1.3. Summary of Circumstances Leading to the Review 2. PROCESS OF THE REVIEW 2.1 Introduction to SILP 2.2 Process 2.3 Independence 2.4 Voice of the Family 3. THE FACTS – Summary of Agency Involvement 4. Key Practice Episodes 5. ANALYSIS OF PRACTICE AND LESSONS LEARNED 5.1 Inter-Agency Notifications 5.2 Following Safeguarding Procedures 5.3 The Quality of Assessments 5.4 The Response 5.5 Inter-Agency Working 6. VOICE OF CHILD C 7. GOOD PRACTICE 8. DEVELOPMENTS SINCE THE SCOPING PERIOD 9. CONCLUSIONS AND SUMMARY OF WHAT HAS BEEN LEARNED 10. RECOMMENDATIONS FOR LSCB 11. APPENDICES – Appendix A Terms of Reference Appendix B Single Agency Recommendations 1 1. Introduction 1.1. Genogram 1.2. Introduction to the Children Child C 1.2.1. Child C is now 2 ½ Years. Following proceedings held in the family court an adoption order was granted in September 2015. It is understood that he settled in well with his adoptive parents. Although initially observed to be slightly small for his age he developed well and was described as having a very happy disposition and as being a cheerful and playful young child. 1.2.2. The review was informed that C was meeting his developmental milestones and even exceeding them in some areas. 1.2.3. C was reported to be an active little boy who swims regularly and this appeared to aid his gross motor development. As a baby C was fascinated by lights and mirrors although this had lessened and as he became more interested in toy cars and balls. 1.2.4. It was reported that C had developed a secure attachment following his placement and was able to demonstrate his cheerful and happy personality. 1.2.5. Regular contact had been supported with his sibling, supervised by Children’s Social Care. He demonstrates neither enjoyment nor aversion in this relationship; instead showing a mixture of passive and happy behaviours during this contact. Child C Father Child C Mother Child C Sibling Father Child C’s Sibling Living with Father Child C Maternal Grand mother Child C Maternal Grand father Child C Maternal Aunt Child C Paternal Grand mother’s Partner Child C Paternal Grand mother Child C Living with foster carers 2 Child C’s Sibling 1.2.6. Child C’s sibling is now 5 ½ years old. As a result of the further investigations following C’s injuries his sibling was cared for by his father and has remained living with him on a permanent basis. He was reported to have settled well and was described as generally being a happy and cheerful child, who can be shy and withdrawn around people he is less familiar with. C’s sibling is beginning to form friendships at school. 1.2.7. However when first placed with his father C’s sibling speech was said to have been significantly delayed and that he had a very limited vocabulary and was reluctant to communicate. C’s sibling’s father expressed concern about his son’s speech and has been active in pursuing speech therapy. Following the support offered by speech and language therapists he was said to have been slowly making progress. 1.2.8. C’s sibling has almost completely gained control over his bladder, an area he had also been slightly delayed in. However, overall C’s sibling’s development is in line with his other developmental milestones, having good command over his gross motor skills and enjoying play, particularly enjoying water play and making craft pictures. 1.3 Summary of Circumstances Leading to the Review 1.3.1 C was a child who had been known to services, including Children’s Social Care, and he and his sibling were made subject to Child Protection Plans when C was around 8 weeks old. 1.3.2 C’s sibling is 3 years older than C and was born to a different father. At the time of C’s sibling’s birth his mother was engaging with the Family Nurse Partnership (FNP) as she was a young mother who was expecting her first baby. The FNP worker conducted an assessment of C’s mother and discovered she had witnessed multiple domestic abuse incidents between her parents as a child and that she was an elective mute until the age of 12. C’s sibling’s father was seen as supportive, although was not living with C’s sibling and his mother at all times during their relationship. 1.3.3 The police hold records of 11 domestic incidents leading to them being called out during C’s sibling’s early years and prior to C’s birth. C’s sibling was present and witnessed some of these. This led to various assessments and investigations being undertaken by Children’s Social Care as well as a period of working with the family under a Child in Need plan. 1.3.4 C lived in a home in which domestic disputes were a frequent feature and this, alongside the substance abuse and mental health issues experienced by those who cared for the children, were the issues around which agency assessments and intervention were based. 3 1.3.5 Agencies involved included the Family Nurse Partnership, with whom C’s mother participated in an intensive parenting course; Children’s Social Care, who had been aware of the family since October 2010; the police who responded to numerous callouts and engaged in multi-agency discussion; health visitors and general practitioners; domestic abuse workers; housing staff and education professionals. 1.3.6 C was admitted to hospital on 19 October 2013 with a displaced fractured right femur which was considered to be a non-accidental injury. 1.3.7 Although both parents were initially arrested for grievous bodily harm and lengthy criminal proceeding followed, no convictions have been made. 2.1 Introduction to SILP 2.1.1 Working Together 2013 states that SCRs and other case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings. 2.1.2 This review has been undertaken in a way that ensures these principles have been followed. For this review the SILP model was used. 2.1.3 The key principle of a SILP is the engagement of frontline practitioners and first line managers, giving a much greater degree of ownership and a much greater commitment to learning and dissemination of lessons. SILP uses systems methodology, looking at how the actions of professionals are influenced by the organisations and systems in which they are working. 2.2 Process 2.2.1. After discussion in the LSCB Serious Case Review Sub-group on 19th November 2013, a recommendation was made to the Independent Chair of Bracknell Forest Safeguarding Children Board that the circumstances did meet the threshold for a serious case review. On the same day the Independent Chair accepted this recommendation. The Independent Chair undertook a peer challenge discussion with another experienced LSCB chair on 22nd November 2013 who agreed the criteria for a serious case review were met. The Independent Chair confirmed agreement to undertake a serious case review on 25th November 2013. 4 2.2.2. From a scoping meeting comprising representatives of the agencies (the same membership as the Reference Group) on 12th December 2013 agencies were commissioned to provide written reports and were issued with a template requiring factual reporting and analysis. Learning points and recommendations were also addressed in the document and all agencies followed the same format. 2.2.3. It was decided that C and his sibling would be within scope and the time period was set from 1st January 2010 to 25th October 2013. An opportunity was provided for authors to report on any significant information outside this scope. Case-specific terms of reference were issued covering 13 broad domains and requiring authors to provide details of the case in relation to 4 additional areas of focus for some authors to address. 2.2.4. A Learning Event was convened for 13th March 2014 and was largely well attended by representatives from: Children’s Social Care Mental Health Midwifery Health Visitor Police Domestic Abuse Perpetrator Service Housing GP Education Early Years These representatives were at practitioner, manager and Safeguarding Lead levels. The attendees also included members of the Serious Case Review Subgroup. 2.2.5 A first draft of this report was circulated to all attendees prior to the Recall Day on 7th May 2014. 2.2.6 On the basis of that discussion a second draft was sent out for the Reference Group to consider. A third draft was further consulted upon with the Reference Group and accommodated suggestions which have been incorporated into this final draft which was presented to the Board on 19th June 2014. 2.2.7 The process has been efficiently administered by the Democratic Services Officer, to whom I would extend my thanks. 5 2.3 Independence 2.3.1 To ensure transparency, and to enhance public and family confidence in the process, the Local Safeguarding Children Board (LSCB) appointed an independent person to lead the process. 2.3.2 The Lead Reviewer who has acted as Chair and Overview Report Author for this review is Donna Ohdedar, an independent safeguarding consultant with no links to Bracknell Forest Safeguarding Children Board (BFSCB) or any of its partner agencies. 2.3.3 The Independent Chair of Bracknell Forest Safeguarding Children Board was appointed to chair the Reference Group. This group was made up of members of relevant agencies who had not had contact with the case. It became apparent at the first meeting of the Reference Group that one of the members present had provided an additional view of the decision not to take the case to conference in May 2012, alongside the Assistant Team Manager and Child Protection Conference Chair. It was decided that within a small authority with only 3 Heads of Service such minor contact is inevitable. This decision has been considered by this review at the practitioner events and was debated at the Reference Group. It was discussed in some of the agency reports, including that commissioned by Children’s Social Care from an independent consultant. It is dealt with in the overview report in section 5.2. 2.4 Voice of the Family 2.4.1 At the outset of the process a commitment was agreed to providing the opportunity for the family to participate as fully as possible. It was agreed that Child C’s mother, the fathers of both siblings and the maternal grandparents should be approached. 2.4.2 The independent lead reviewer wrote to the mother, the fathers of both siblings and the maternal grandmother on 12th January 2014 offering a meeting to explain the process and making it clear that they would be welcome to contribute. C’s mother indicated over the telephone that she did not wish to be involved in the review. The door was left open for further contact should she change her mind. C’s sibling’s father indicated he would think about the review and he would initiate contact with the Lead Reviewer if he decided he wanted to contribute. This never happened. The Lead Reviewer also contacted C’s father who said he preferred not to get involved. 2.4.3 After explaining the process by letter, on 10th April 2014 the lead reviewer telephoned the maternal grandfather. He wanted to express his view that he felt he had not been involved by Children’s Social Care during the time he had spent with C’s mother and C’s sibling living with him during the early part of the scoping period. He stated that C’s mother does not always open up but that he knew what was going on ‘behind the scenes’. He wanted to say he was conscious he should have got involved sooner but he has only got involved now the children have been taken away. 2.4.4 Child C and his sibling were considered to be too young to contribute to the case review. 6 2.4.5 The LSCB Chair wrote again to mother and both fathers at the conclusion of the criminal proceedings offering a further opportunity to meet to share the report and discuss the learning for agencies, but unfortunately there was no response. 3. THE FACTS - Summary of Agency Involvement 3.1 This section is designed to summarise the key relevant information that was known to the agencies and professionals involved about the parents, and the circumstances of the children. 3.2 Child C’s family has been known to a number of agencies for a number of years; certainly in the last two generations. Children’s Social Care was involved with Child C’s mother as she was growing up. Her parents were in a violent relationship and she and her sister spent time moving between the two parents during their teenage years. She has convictions for offences of violence, disorderly conduct, possession of a class A drug and driving with excess alcohol. 3.3 Child C’s maternal grandmother has a history of severe mental health problems and serious drug and alcohol addictions. Child C’s maternal grandfather has a history of depression and one conviction for a serious offence committed when he was a young man. 3.4 Children’s Social Care first had contact with Child C’s sibling and his family in October 2010 when the maternal grandmother alleged Child C’s mother had assaulted her. 3.5 Domestic disputes were then reported throughout 2011 and 2012; the police have records of 8 such disputes during this period. They occurred between Child C’s mother and her partner, her sister and her mother. On some occasions Child C’s sibling was present and on some he was not. It was a regular feature at this time for the mother to move between homes, e.g. moving from the home of maternal grandmother to maternal grandfather following a dispute or sometimes moving to her partner’s home with Child C’s sibling. 3.6 A significant point in the 2011/12 period was in October 2011 when the police were called to the home of the maternal grandmother. They found her caring for Child C’s sibling whilst under the influence of drugs and alcohol. Child C’s sibling was then aged 14 months and had been left there all day by his mother. He was unsuitably dressed, unfed and his nappy had not been changed. The police called his mother who was out with his father. She failed to return for over an hour and asked the police officers to feed him and put him to bed. This incident prompted a section 47 investigation as part of a core assessment. A monitoring period followed during which Child C’s mother engaged with services and signed a letter of agreement acknowledging the importance of not leaving the child with her mother or other unreliable baby sitters. The case was closed in December 2011. 3.7 Also of note during this period was an incident in May 2012 when Child C’s mother was alleged to have hit her sister twice in the face and swung a vodka bottle at her. The child was present during the altercation. He was 21 months old. The response to this incident was a telephone strategy discussion which led to a single agency investigation by Children’s Social Care. The outcome was that Child C’s sibling was to be treated as a Child in Need rather than deciding to take the case to a child protection conference. 7 3.8 2013 saw not only the birth of Child C, but also 9 incidents which led to the police being called out to the family home. 6 of these incidents were treated as domestic incidents and were appropriately shared with Children’s Social Care. The 5th incident of the 9 was not recognised as a domestic incident by the police officers and was therefore not shared with Children’s Social Care. The 6th incident of the 9 did not warrant a referral in the opinion of police. The 9th incident was the alleged grievous bodily harm to Child C which was appropriately shared. The 3rd and 4th incident resulted in the case being taken to a Child Protection Conference on 17th September 2013. Child C and his sibling were made subject to a child protection plan under the category of emotional abuse. 3.9 Two days after the conference, the Deputy Head of the school attached to the nursery which Child C’s sibling was due to start attending called to ask about the outcome of the conference. The school and nursery had not been invited to the conference as the child had changed setting but Children’s Social Care had not been notified. She reported that bruising had been seen on Child C’s cheek a week before on 12th September when she had seen Child C’s sibling and his mother at the school for an introductory visit. The Duty Social Worker had visited the family home on 16th September and had not seen any bruising on Child C. It was decided there would be no benefit from a medical examination. 3.10 In October 2013 agencies were alerted on 3 occasions leading up to the incident which triggered the children being taken into care. The situations giving rise to these alerts were a domestic violence incident between C’s parents; the health visitor voicing concerns that C’s mother had friends in her flat who she thought were drinking alcohol early in the morning; and a further domestic dispute involving the police being called to verbal disputes. 3.11 On 19th October Child C’s mother called 111, the out of hours number for medical advice and signposting. C was 14 weeks old. The mother reported his right leg had gone floppy. Advice was given to seek advice from a GP or other local service within 12 hours. Child C was admitted to hospital four and a half hours later. He had a displaced fractured right femur and was reported to be in considerable distress. The mechanism of his injury raised safeguarding concerns to the staff very quickly and through questioning of parents the involvement of Children’s Social Care was identified. 3.12 C was admitted to the paediatric ward for treatment and assessment of his injury which was considered to be non-accidental injury (NAI). Police arrested C’s mother and father the next day for grievous bodily harm with intent. Child C was made the subject of police protection and arrangements were made for C’s sibling to remain with his father. 4. Key Practice Episodes 4.1 This review will now focus on the key practice issues during the period in question. There were 4 key practice episodes, and these are : • Domestic Incidents January 2010 to October 2011; • Child C’s Sibling found in the care of Maternal Grandmother (October 2011); 8 • Domestic Incident of 9th May 2012 through to closure of case on 22nd October 2012 • Escalation of risk May to October 2013 4.2 Domestic Incidents January 2010 to October 2011 4.2.1 Police have records of 6 domestic incidents during this period, although Children’s Social Care have records of only 4. There is one incident regarding which police have records of a referral but Children’s Social Care do not have records of this being received. The incident that was not referred was not recognised as a domestic incident. Whilst incidents are referred automatically where a child is present on the scene, they are not automatically referred in other cases e.g. there is a child in the family who is not present at the time of the incident. 4.2.2 The first contact recorded with the police came just after the birth of C’s sibling on 2nd October 2010. C’s mother dialled 999 but abandoned the call before the call was picked up. When officers called back an unknown male answered and when the operator asked to speak to C’s mother he said ‘Yeah if you’re going to come and arrest her’. Checks revealed the mother did not wish to be seen and she later could not recall phoning the police as she had been drunk. The agency report author was unable to establish whether Child C’s sibling was present when his mother called the police. 4.2.3 The first recorded contact with Children’s Social Care was on 16th October 2010. It arose when the maternal grandmother alleged Child C’s mother had assaulted her. The grandmother was known to have a history of severe mental illness, alcohol and substance misuse, and her daughter and grandson were living with her at the time. When it was confirmed that Child C’s mother and sibling were moving to the home of Child C’s maternal grandfather the decision was made to close the case. 4.2.4 Police have a record of a call from C’s mother on 5th February 2011, who reported her boyfriend had tried to strangle her and she was now locked in the bathroom. C’s sibling’s father also called the police alleging C’s mother had attacked him in his sleep. Police responded by arresting C’s sibling’s father and interviewing him. However, neither of the adults wished to pursue a prosecution against the other. Whilst C’s sibling was not present, the police record shows Children’s Social Care were notified. Children’s Social Care has no record of this incident. 4.2.5 Police have records of domestic disputes in March 2011, both of which were referred to Children’s Social Care. The father of C’s sibling had returned to live with his family following the couple separating and C’s mother was living with the sibling as a single parent. Both incidents involved alleged harassment and threats by telephone in which C’s mother was the aggressor. A referral was made for Children’s Centre Outreach and when it was confirmed that the Family Nurse Partnership (FNP) was continuing to support C’s mother, the case was closed. 9 4.3 Child C’s Sibling found in the fare of Maternal Grandmother (October 2011) 4.3.1 On 30th October 2011 the police were called to the home of the maternal grandmother, who was saying she had not slept for 3 days and was very irritated. They found her caring for Child C’s sibling whilst under the influence of drugs and alcohol. Child C’s sibling was then aged 14 months and had been left there all day by his mother. He was unsuitably dressed, unfed and his nappy had not been changed. The police called his mother who was out with his father. Initially she told the officer she had no idea where she was and requested for her child to be fed and put to bed prior to her coming home. The officer explained the seriousness of the matter to C’s mother and after a number of phone calls and approximately 1 or 2 hours later, she said she was on her way home. 4.3.2 Upon returning home at 8.20 pm C’s mother told officers she had left her son with her mother the previous evening and on her return home the child was still up and her mother was intoxicated. Despite this, C’s mother left C’s sibling in the care of his grandmother again the following day. 4.3.2 This incident led to a strategy discussion between Children’s Social Care and the police. The decision was made to conduct a section 47 investigation as part of a core assessment. A monitoring period followed during which Child C’s mother engaged with services and C’s sibling was observed to be healthy and confident with both parents. C’s mother was still receiving support from the Family Nurse Partnership and it was concluded that the decision to leave C’s sibling with the maternal grandmother was a lapse of judgement by his parents. C’s mother signed a letter of agreement acknowledging the importance of not leaving the child with her mother or other unreliable baby sitters. The case was closed on 13th December 2011 after a two month monitoring period during which no further concerns had been identified from the assessment. A referral was made of C’s mother to Talking Therapies. 4.4 Domestic Incident of 11th May 2012 through to closure of case in October 2012 4.4.1 This incident led to C’s mother being arrested for violence towards her sister whilst under the influence of alcohol. The maternal aunt alleged C’s mother had attacked her with a vodka bottle which had hit her on the hand. C’s sibling was present during the altercation. He was 21 months old. He and his mother were living at maternal grandfather’s home but moving between the two grandparents. C’s mother was interviewed in custody and was released without charge the same day, due to lack of evidence. An appropriate referral was made to Children’s Social Care of this incident. 4.4.2 On 24th May 2012 a telephone strategy discussion was held with the police and a single agency investigation by Children’s Social Care was agreed. The 10 day delay occurred because an initial assessment had begun but as more information emerged this was escalated to a strategy discussion. 10 4.4.3 The Family Nurse Partnership shared information regarding the family’s situation. C’s sibling’s parents were separated and his mother had a new boyfriend (C’s father). She was struggling to find her own accommodation as her housing application had been put under review. The reason for this was it was unclear where she was living as she had specified she was living with the maternal grandfather but spending ‘occasional overnight stays’ with the maternal grandmother to provide support. Information shared by the Family Nurse Partnership with Housing Services suggested C’s mother was splitting her time between the two homes, taking the opportunity to stay at her mother’s home whilst she was in hospital. 4.4.4 The FNP worker described C’s mother as ‘a lovely mum’ who does ‘all that is expected of her’. A concern was flagged regarding C’s sibling’s delayed speech development and the FNP worker was encouraging attendance at the Speech and Language Clinic for him. C’s mother signed a written agreement regarding engaging with the Children’s Centre and the voluntary agency support worker, a self-referral to the Community Mental Health Team and no inappropriate carers for C’s sibling. 4.4.5 The assessment identified no immediate risks and described the mother as providing a very good standard of care. Child C’s sibling’s father was not seen but was spoken to by telephone. C’s father and his family were seen as a positive influence. 4.4.6 The case was transferred to the Under 11s Team as a Child in Need case and a family group conference was recommended due to the impact of other family members on outcomes for C’s sibling. This did not take place as C’s mother felt it was inappropriate for her mother to take part, she said she didn’t like her sister and she had not had much help from her father. The decision that the case was under ‘Child in Need’ rather than proceeding to conference was arrived at following a 4-way discussion between the managers of the social worker who had conducted the risk assessment and a Child Protection Conference Chair. The Chair agreed with the plan once she had heard all the relevant factors had been taken into consideration. The case was allocated to a Family Support Worker; a Child in Need Plan had been drawn up by the social worker who conducted the risk assessment. 4.4.7 The period from June to September 2012 was characterised by regular visits from Family Support Workers and the Family Nurse Partnership. However, the FNP Programme had been completed in September 2012 and the handover to a health visitor took place. This took the form of a joint visit with the FNP worker and health visitor in September 2012. 4.4.8 The Child in Need plan was reviewed on 19th October 2012 within Children’s Social Care without any other agency present. The health visitor, upon calling, was told the review meeting had been cancelled and the case was now closed. The health visitor attempted a visit with the family the following day but did not gain access. No further visits were made by the health visitor until July 2013. The review of the Child in Need plan recorded that direct work had been carried out with C’s mother in her home, she no longer lived with her sister and there had been no reported incidents. 11 4.4.9 Neither of the children’s fathers were included in the work done. It was noted elsewhere on the record that not all agreed actions had been completed by C’s mother. In addition to this, Children’s Social Care had been notified of a police callout on 8th September 2012 during which C’s mother alleged her mother and her partner were high on drugs and he was threatening to beat her up. C’s sibling was present. C’s mother and sibling were moved to C’s Sibling’s father’s and planned to move in with the maternal grandfather thereafter. The Family Support Worker discussed this with her supervisor on 19th September 2012 when it was recorded that ‘anger is not seen as a significant issue’. 4.5 Escalation of risk May to October 2013 4.5.1 On 21st May 2013 police referred a domestic violence incident to Children’s Social Care. C’s mother, who was 7 months pregnant, alleged C’s father, who was drunk, was smashing glass in the living room. C’s sibling was at that time 2 years old, was not present during the altercation. The couple were living with C’s sibling in their own rented property. 4.5.2 This was the first notification to Children’s Social Care that C’s mother was pregnant. The GP had been aware of the pregnancy since January, but had not referred the pregnancy. The midwives were aware there had been previous social work involvement and thus would have been expected to refer the pregnancy. However, the midwife who was involved in C’s case is no longer in post and it has not been possible to contact her to explain why this did not happen. 4.5.3 Duty social workers tried to make contact with C’s mother, who was resistant to any support or intervention. Calls were made by the social worker to the health visitor and midwife regarding a domestic violence incident when C’s mother was 7 months pregnant. As midwifery were continuing to support the family and health visiting services were going to initiate support and the mother refused support from Children’s Social Care the case was closed on 13th June 2013. Child C was born just over a month later. 4.5.4 The police report records four incidents in the month of August 2013. Three of these incidents were treated as domestic incidents which were all appropriately shared with Children’s Social Care. One was not treated as a domestic incident, although it should have been. Thus Health visitor recording and that held in Children’s Social Care only reflect three domestic violence incidents in this period. 4.5.5 Two of the incidents of domestic violence in August took place within a 6- day period between C’s mother and father. The first of these involved C’s mother returning home after having been out drinking. C’s father had locked her out and her 9 day old son was with him. C was found to be asleep in his Moses basket. C’s father was requested to leave. 4.5.6 During the second of the two incidents C’s mother alleged she was being attacked by C’s father. Police recording suggests he had kicked her 5 times whilst she was on the floor and had tried to strangle her in front of her baby. However, the police report received by Children’s Social Care relates that there was no sign of struggle and no injury. 12 4.5.7 A Child in Need assessment was under way when the second incident was reported. A strategy discussion was held between Children’s Social Care and the Police on 13th August 2013. It was agreed that Children’s Social Care would carry out a section 47 investigation as a single agency assessment. A third incident occurred in that month when C’s mother returned home late after being at a festival which triggered a further dispute. 4.5.8 The assessment recognised an emerging pattern of acrimony and domestic violence. Whilst both parents denied physical violence, they did accept the verbal altercations had a negative impact on the children’s emotional well-being. The assessment identified the changes needed and the evidence required to confirm those changes had been effected. 4.5.9 The assessment noted C’s mother was receiving treatment from her GP for depression at the time. C’s father called the duty social worker on 2nd September to report that he was worried that C’s mother would ‘do something stupid’ if she did not get the help she needed. The social worker contacted the GP that day and C’s mother and arranged an urgent GP visit for her. The GP records, however, do not reflect this. There is recording of a call from the social worker when C was 3 weeks old when information sharing took place (but the details of this are not recorded). They also record a consultation with C’s mother about low mood, angry outburst and alcohol abuse when C was 5 weeks old. It is recorded that C’s mother started antidepressants and contacted Talking Therapies but there is no mention of a threat of suicide. There is no record of the GP contacting Children’s Social Care or the health visitor about this situation. 4.5.10 C’s sibling’s father had not been included in this assessment. He was made aware that a Child Protection Conference was taking place at a late stage in the investigation. C’s parents did not want him to be invited to the conference but their wishes were overruled and he did attend, as did they. 4.5.11 The conference took place on 17th September 2013, about a month after the two August domestic violence incidents. Apologies were received from the GP, the Health Visitor and the manager of the nursery recently attended by C’s sibling. Representatives from the nursery C’s sibling was due to attend were not invited due to him having moved settings over the school holidays and Children’s Social Care not having been notified. The invitation was sent to the previous setting. The invitation to the core group was sent to the wrong setting, with confusion surrounding the fact that two nurseries are located on one site. Reports were received from C’s mother’s GP, the health visitor and Children’s Social Care. The decision of the conference was that C and C’s sibling should be made subject to a child protection plan under the category of Emotional Abuse. A newly qualified social worker in the Long Term Team was allocated to jointly work the case with an Assistant Team Manager. 13 4.5.12 On 19th September the Deputy Head of the nursery C’s sibling was due to start attending called to ask about the conference and to report an incident that had taken place a week earlier. On 12th September C’s mother had been for an introductory visit at the school to view the nursery facilities with an application for a place in mind for C’s sibling. Both Child C and his paternal grandmother were present for the visit. C’s sibling was not present. No record was made of this information and it was not passed on to Children’s Social Care. However, the school was not aware C and his sibling were open cases to Children’s Social Care since Children’s Social Care did not know the child had moved setting. 4.5.13 On 19th September 2013 the pre-school contacted the Head teacher of the school to report she had been receiving messages regarding C’s sibling, but that he was not known to that setting. When the Head teacher shared this information with the Deputy Head, the Deputy Head disclosed that she had seen 3 small bruises on the left side of C’s face. No record had been made of this observation, it had not been addressed with C’s mother at the time and the information had not been passed to Children’s Social Care. The Deputy Head was unaware of the bruising protocol which required such sightings to be reported in non-mobile babies. She considered at the time that the facial bruising may have been caused by a feeding tube, which was something she had seen before. Whilst she had received child protection training, this training had been delivered prior to the bruising protocol having been established. 4.5.14 The social worker from the Long Term Team spoke to the Duty Social Worker who had visited the home on 16th September 2013. The Duty Social Worker had not seen any bruising on C. The Team Manager from the Long Term team decided it was too late to pursue a medical examination of C and that instead the matter should be taken up with the parent and with the school in relation to late reporting and non-compliance with the Bruising Protocol relating to a non-mobile child. 4.5.15 Issues in the parental relationship were once again evident to agencies in the weeks which followed as C’s mother told the social worker during a visit on 25th September that she and C’s father had separated. Then two domestic incidents were reported to the police within a period of 8 days at the beginning of October, both of which occurred with the children present. The two incidents were interspersed with the health visitor reporting concerning information about the situation in the family home. 4.5.16 On 2nd October C’s mother called the police to report C’s father had pulled a chunk out of her hair and had smacked her head against the floor. She said her two children were with her, one of whom was her 3 year old son who had seen what had happened and tried to pull them apart. C’s father received a caution. He admitted he had assaulted C’s mother when she returned late from a night out. The police referred this incident to Children’s Social Care, but Children’s Social Care records suggest that this was not done until 4th October. The Ambulance Service did not raise a safeguarding alert. 14 4.5.17 The health visitor called the social worker on 7th October to report she had visited the family home that morning and had observed C’s mother to be under the influence of substances or alcohol. She had asked C’s mother directly and she denied it. She also observed young people present in the flat who were drinking from cans. The observation had been made at 10.30am and Children’s Social Care were notified at 4.30pm. The social worker made an unannounced visit the following morning. A visit that afternoon was not considered as the smell had been detected early that morning and it was considered unlikely any smells would be detected by the late afternoon. The social worker found C’s mother was up and ready and had taken C’s sibling to school. There was no evidence of alcohol and C’s mother stated the cans seen by the health visitor the previous day contained Red Bull. 4.5.18 On 10th October C’s father called the police to report C’s mother had thrown his belongings off the balcony. Both parents said the two children were present but were asleep in bed. The call had been made at 7.33pm. 4.5.19 Children’s Social Care was notified of a domestic incident on 4th October. They responded by speaking to C’s sibling’s nursery and the domestic abuse project which was being attended by father and by visiting the family the next day. Talking Therapies were approached, who were willing to consider joint work to include C’s father. The social worker discussed the case during supervision on 17th October and the notes reflect increasing concern about the use of alcohol and arguments and assaults between the parents. A joint visit was discussed, whose purpose would have been to lay down boundaries by way of a written agreement with a view to seeking legal advice if concerns increased. This plan was not recorded. The practitioners at the Recall Day explained the rationale for this approach was that previous written agreements had been short term whereas this one would have a longer term remit and would be used to assemble evidence to support a discussion with legal advisers. The two previous written agreements had been largely adhered to and thus at the time this appeared to be an appropriate plan. A joint visit between the health visitor and social worker was agreed the same day, but no agreed date was recorded. 4.5.20 On 19th October C’s mother dialled 111, the out of hours number for medical advice. C was 14 weeks old and C’s mother was reporting his right leg had gone floppy. C’s mother was advised to see a GP within 12 hours. C’s mother attended the Accident and Emergency department and C was admitted to hospital four and a half hours later. Whilst the hospital had no record of Children’s Social Care involvement with the family, they had established this via questioning with the family who had been open and honest about this. 4.5.21 The hospital informed the Emergency Duty Service (EDS) that day that C was in hospital with a broken femur. A strategy meeting was held on 20th October with police and hospital representatives including the consultant paediatrician as well as an emergency duty social worker. The decision of the meeting was that the police would arrest both parents and that C would be made subject to police protection. The basis for C’s sibling not being included was that C’s sibling was to remain with his father. C’s sibling was not visited to check these arrangements, but the account of the adults was relied upon. 15 4.5.22 On 21st October the parents agreed to C being accommodated and C’s sibling remaining with his father. C’s parents were to have supervised contact with C’s sibling. 5. Themed Analysis The analysis section of this review will consider the information above, which was gained from the agency reports and from the practitioner events, thematically. These themes, which link to the terms of reference agreed at the start of the process, are: • Inter-Agency Notifications • Following Safeguarding Procedures • The Quality of Assessment • The Response • Inter-Agency Working 5.1 Inter-Agency Notifications (a) Police 5.1.1 Police were called out by C’s family on 18 occasions during the scoping period and on a 19th occasion when C was admitted to hospital. They were called upon to respond in a variety of ways, including agreeing the arrangements for who should remain at which address following a dispute; to remaining at the property to ensure the safety of the children until parents returned home; to considering what criminal action should be taken in response to a situation. Importantly for this review, however, the police had a role in grading risk, recording information and sharing it appropriately with other agencies with responsibilities for safeguarding children. The police can hold important information about children who may be suffering, or likely to suffer, significant harm, as well as those who cause such harm. They should always share this information with other organisations where this is necessary to protect children. (Working Together to Safeguard Children 2013) 5.1.2 The information they held about the 19 calls they had received helped to paint a picture for other agencies about what was going on in the home. However, the police are required to filter this information in line with what they believe at the time is relevant to safeguarding children. They are required to include in reports of every domestic incident details of a child living at the address or with whom the suspect(s) have contact and this includes unborn children. 16 5.1.3 Some callouts were made prior to the police establishing their 3 referral centres in October 2011 which has streamlined the notification process. For these callouts, officers were required to automatically notify Children’s Social Care where a dispute occurs with children present. In other situations, such as where there is a child in the family who is not present, this notification would not be automatic i.e. some such calls would result in a notification and others would not. In the period since October 2011, the referral centres receive all internal and external referrals regarding child protection and domestic abuse and their child protection referral managers make the appropriate risk assessments and share information. 5.1.4 Since October 2011 the referral centres receive all internal and external referrals regarding child protection and domestic abuse. The Risk Assessments of the domestic incidents are managed by the risk assessors as opposed to the Child Protection Referral Managers. The child protection referral managers review child protection referrals and liaise with Children’s Social Care to agree an appropriate course of action and also notify child protection reports to the local authority which have been created by officers. Currently high risk domestic incidents are graded as such where: (1) children are subject to a child protection plan (2) unborn baby (3) children listed These are referred by the child protection manager on the day of the report. Alll other domestic reports where children are listed are referred by a ‘crystal’ report. Occasionally, domestic reports are referred which do not fit this criteria but which did reveal a child protection concern. These are also reviewed by the child protection referral manager and referred to Children’s Social Care. 5.1.5 The police report states 13 of the 18 callouts resulted in Children’s Social Care being notified although Children’s Social Care have recording of only 12 being notified. Of the 5 that were not notified, this happened for a range of reasons. Two were not recognised as a domestic incident, although they should have been. Three were not domestic incidents and did not need to be notified. 17 Comment Irrespective of whether the referrals were before or after the establishment of the referral centre, the system is solely reliant upon the attending officer relaying their concerns. With hindsight it is possible to see that it would have been helpful for agencies to have had access to information about some of the unreported incidents as they helped with building a picture of how life was in the family home. However, this information could have been requested as part of the information-gathering process for the assessment. Similarly, some of the softer information regarding these incidents that appears in the police record was not available within the police referral. Equally this information could have been requested or could have been shared during multi-agency discussions. Recommendation 1 (b) Health Organisations 5.1.6 Information was held by some health organisations which was not known by all agencies who needed to be made aware. When C’s mother first became pregnant the trainee GP consulted her trainer and appropriately made a referral to the health visitor by letter. However, when C’s mother became pregnant with C, no such referral was sent by either the GP or the midwife. It was known to the GP and midwife in January 2013. However, the GP notes suggested the previous pregnancy had gone well and contained nothing about alcohol consumption between pregnancies. In terms of the midwife’s perspective, the booking was not made in the GP surgery and thus the midwife did not have access to the GP notes. Also, the mother reported she consumed zero units of alcohol; the midwife perceived that no referral was necessary. The midwife therefore made a routine referral to the health visiting service but no referral for a targeted antenatal visit was received from either the midwife of the GP. Comment This was a crucial time in terms of the support the family was receiving. The support of the Family Nurse programme came to an end and there was a 9 month interval during which the health visitor did not undertake any visits. The relationship C’s mother had made with the Family Nurse was considered to be a strong and trusting one and the intensive, focussed visiting was key in supporting C’s mother to cope with parenting despite the many difficulties she was experiencing. These included lack of wider family support, relationship problems, being a carer for her mother and not having stable housing. Whilst the health visitor was notified of her pregnancy, no referral for a targeted antenatal visit was received. It is hoped that this would also have resulted in the health visitor notifying Children’s Social Care, who had reviewed C’s sibling’s Child In Need plan 7 weeks earlier. The maternal grandmother’s mental health history was well known to the practice and C’s sibling was being left in her care. There is now an expectation that midwives review GP records and health visitors review all booking paperwork. The separation of information technology systems exacerbated problems between these health organisations. Communication between GP, midwife and health visitor was recognised as a theme in the Child B Serious Case Review undertaken in September 2011. 18 5.1.7 When the ambulance service was called to the family home on 2nd October 2013 C’s mother alleged she had been assaulted by her partner with her children present. However, no safeguarding alert was raised by the crew. The police were already present at the address, but there was a need to alert Children’s Social Care. Comment This particular ambulance crew did not undertake safeguarding training until early 2014. The police notification did not reach Children’s Social Care until 4th October. 5.2 Following Safeguarding Procedures 5.2(i) Strategy Discussion Whenever there is a reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority children’s social care, the police, health and other bodies such as the referring agency. (Working Together to Safeguard Children 2013) 5.2.1 The first strategy discussion which took place during the scoping period was held on 31st October 2011. This followed the two incidents during which C’s mother left C’s sibling in the maternal grandmother’s care despite having found him up late at night in the care of his grandmother who was under the influence of alcohol on the first occasion. The agency with whom the family had had most contact at this stage was the Family Nurse Partnership, but also CMHT had been involved. Comment Whilst it may not always be possible to secure the attendance of health professionals at short notice, there was no reason why an invitation to this strategy discussion could not have been sent. The assessment which was decided upon during the discussion focussed on the support that was needed for C’s mother, particularly in view of her depression, and the need for monitoring. This was a discussion within which health professionals had a key role to play. 5.2.2 The same comment applies to the second strategy discussion which was held in response to the incident on 14th May 2012. This was the incident witnessed by C’s sibling at the age of 21 months. C’s mother was alleged to have hit her sister twice in the face and swung a vodka bottle at her. An initial assessment had begun but as more information emerged this was escalated to a telephone strategy discussion between the police and Children’s Social Care on 24th May. Comment There was a sense at this time from the agency report that the FNP worker was working in isolation with this family and taking a lot of responsibility for the case. 19 The FNP worker does not feel this was the case. However, when a crisis occurred, this worker failed to liaise across agencies or make referrals. This factor adds further weight to the need for health organisations to have been invited to strategy discussions. A subsequent individual call to the FNP worker, as was undertaken in this case, is no substitute for full inter-agency working in the spirit of the statutory guidance. 5.2.3 On 2nd October 2013 C’s mother dialled 999 and alleged C’s father had beaten her up. She said he had pulled a chunk out of her hair and had smacked her head against the floor. She said she had her two children with her, one of whom was her three year old son who had attempted to pull them apart. This was a serious incident during which C’s sibling could have been injured. Police, Children’s Social Care and health visitors were aware of the incident, yet there is no evidence that the emotional impact of C’s sibling witnessing domestic abuse was considered. It did not give rise to a strategy meeting to consider the immediate safety of the children. The rationale was that a tight written agreement should be drawn up with a view to legal planning. Comment The fact that the discussion itself was not triggered is raised as an issue by some of the agency report authors. It should be recognised that the function of the strategy discussion within the child protection system is to strengthen the inter-agency response and allow for objective consideration and professional debate. However, there is no evidence that the other agencies involved at the time were minded to challenge the lack of action. There is no evidence of escalation or advice being taken from named professionals at this point. Certainly this was available for health visitors at the time, yet not taken up. 5.2 (ii) Child in Need Plan and Review 5.2.4 What followed from the strategy discussion in May 2012 was a Child in Need Plan. The outcome of the section 47 investigation was that the concern had been substantiated, but that C’s sibling was not considered to be at immediate risk of harm due to the measures that had been implemented. Comment This decision has been called into question during the process of this review, taking into account what was known at the time about C’s sibling having witnessed the vodka bottle incident. However, recording suggests the decision was taken following a discussion between a senior practitioner, an Assistant Team Manager, a Team Manager and a Child Protection Chair who agreed upon hearing ‘all the relevant factors had been taken into consideration’. The rationale in part was that there had been two section 47 investigations in the first two years of C’s sibling’s life, yet Child in Need services had not yet been offered to this family. The decision was taken in good faith after some deliberation. The process of decision making is offered as an example of good practice by the agency report author for Children’s Social Care. 20 5.2.5 Also worthy of scrutiny was the decision which followed to allocate the case to a family support worker. The basis for the decision was the worker’s extensive experience of working with domestic violence situations and was supervised by an Assistant Team Manager whose role was to take a full overview of the case. Comment The statutory guidance in Working Together to Safeguard Children 2010 required a qualified social worker to lead the completion of a core assessment (and undertake the necessary enquiries to satisfy the duties set out within section 47 Children Act 1989).However, the guidance was vague in respect of the required experience/qualification for staff undertaking the assessment/enquiry. The interpretation of ‘leading’ the case was debated at the Recall Day. In spite of the ambiguity in the guidance it is important that following core assessments/section 47 enquiries complex cases are allocated to suitably qualified and experienced staff. The proposal from Children’s Social Care to risk assess such cases, taking account of how cases can change, is welcomed. 5.2.6 When the time came to review the Child in Need plan in October that year, the FNP worker had completed her final visit with the family and had handed over the case to the health visitor. When the health visitor contacted Children’s Social Care regarding the meeting scheduled for 19th October she was told that it had been cancelled and the case was now closed. Thus the Child in Need Plan review, like the discussions above, was not truly multi-agency and once again did not include health representatives, including CMHT who held relevant information. Comment The decision of the meeting was to step the case down at a time when the supportive relationship between C’s mother and the Family Nurse had just ceased. The family did not receive a visit from the health visitor for a further 9 months, during which time C’s mother had once again fallen pregnant. 5.2 (iii) Child Protection Conference 5.2.7 The conference took place on 17th September 2013, following domestic violence incidents in August of that year. The section 47 investigation revealed that the children’s basic care needs were being met but that the altercations were having a negative impact on the children’s emotional well-being. Following section 47 enquiries, an initial child protection conference brings together family members (and the child where appropriate) with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development. (Working Together to Safeguard Children 2013) 21 5.2.8 Once again, key agencies were not present for this conference. The GP, the health visitor and the nursery which C’s sibling had recently attended sent apologies. This was considered to be an exceptional departure by this particular health visitor given the priority health visitors were giving to conferences at this time. However, for GPs it is more common that they do not attend. A number of reasons have been cited for this, including the notice they receive when they have fully booked clinics and the length of meetings. Whilst the GP and the health visitor did produce reports, this is no substitute for attendance. The nursery C’s mother was considering for C’s sibling was not invited due to him having moved setting and Children’s Social Care not having been notified. Mental Health Services were not invited despite the impact of the mental health issues of both the maternal grandparents and C’s mother being of significance to the case. 5.2.9 A significant development had arisen during the course of an introductory visit on 12th September to the nursery she was considering for C’s sibling. Bruising had been noticed by the Deputy Head on C’s cheek. This should have been reported earlier, which would hopefully have resulted in staff from this setting being invited which would have brought this development to the multi-agency arena sooner. Comment Some invitations were sent appropriately in this instance, other than the omission of the nursery C was due to attend. This was due to it not being known C’s sibling had moved setting. Once again Mental Health Services were omitted on the basis that their involvement was with grandparents and with C’s mother historically. 5.2.10 The conference made both children subject to a child protection plan under the category of Emotional Abuse. Whilst the category fitted well at the time, it has been considered that the learning from this case would be that in cases such as these the category of physical abuse should be favoured. The case was allocated to a newly qualified social worker, although the intention was for the case to be jointly worked by an Assistant Team Manager. Comment For the first week of the work the Assistant Team Manager in question had not yet arrived in post. ‘Joint working’ did not include joint visits, but the social worker was able to receive support when needed. Whilst the manager was clear she was directing the social worker’s actions this arrangement is more akin to supervision than joint working. Furthermore, it is once again a departure from the local requirement for child protection cases to be worked by a social worker who is 3 months qualified and taken part in child protection training . At this point they would only be allocated a child protection case where it would be on a joint basis for a period of time. The decision was taken to allocate the case to this particular worker on the basis of his extensive experience as a mental health worker and knew the family history. 22 5.2 (iv) Referral to Emergency Duty Service 5.2.11 A referral was made by the hospital to the Emergency Duty Service when Child C was admitted to hospital on 20th October 2013. At that point it is required under local procedure to contact the on-call manager, undertake a records check and make a joint visit with the police to speak to C’s parents and hospital professionals. The recording of the referral in C’s case was very poor and contained little or no information. Some details were contradictory regarding decision making and the details of the consultant. The social worker did not enquire as to whether there were other children living in the family home. Comment When interviewed this social worker agreed that these actions should have been undertaken. These are required under the Berkshire Emergency Duty Service Local Safeguarding Boards Child Protection Procedures. However, due to excessive workload the social worker passed the case onto the overnight social worker to liaise with management and take forward the referral. Due to a social worker calling in at short notice the on-call manager who was notified of the case was acting up as a child care social worker. The Head of Service was contacted who instructed the social worker to undertake a joint visit with police and to contact C’s sibling’s father to ensure C’s sibling’s safety. This was not done and the social worker, when interviewed, explained this was due to the shift being extremely busy and explained that in her opinion Child C was safe. The third social worker who had contact with the case was described as thorough in her enquiries, she attended the strategy meeting and arrest. However, she did not visit C’s sibling but did contact his father to check he would care for C’s sibling and ensured he understood contact with C’s mother and father should not be permitted. This was a busy weekend for this service, which received 259 phone calls and dealt with over 146 referrals. Extra staff were asked to work due to demand on the service and the complexity of some of the cases. 5.3 The Quality of Assessments 5.3 (i) Understanding of Family History 5.3.1 The family history was a significant factor in this case. This was not only because of the impact of this history on C’s mother, but also because C’s maternal grandmother was involved in the care of children. C’s maternal grandmother has been known to Community Mental Health Services (CMHT) since 2003. 5.3.2 The FNP worker demonstrated good practice in terms of making a clear assessment of the history and the impact this would be likely to have on C’s mother’s ability to parent her child. A plan was formulated which took account of this combined with C’s mother’s current difficulties, including lack of wider family support, relationship problems, being a carer to her mother who was experiencing mental health issues and not having stable housing. The plan, discussed during management supervision, for the antenatal period included work around risk taking behaviours and on building self-esteem. 23 Comment This was a robust plan. 5.3.4 This experience of pregnancy and babyhood for C’s sibling was not mirrored during the second pregnancy. This became known to services in May 2013, during which time an opportunity was missed to provide targeted support during the antenatal period, assess risk in light of the family history and plan for the extra stress of a new baby within the family. Comment The family history and the recent history of domestic dispute was vital in assessing risk once the health visitor began work with the family. It did form part of the handover from FNP worker. The report from Berkshire Healthcare NHS Foundation Trust states that the records following this visit were very brief and the new birth assessment paperwork was not completed. It is not possible to ascertain from the record how long the visit took. The completion of the paperwork may have prompted the health visitor to have asked C’s mother about domestic abuse when her partner was not present. This gap in knowledge was further exacerbated by the health visitor not attending the child protection conference or the first core group. Significantly, the failure to ask the question about domestic violence featured in the Child B serious case review in 2011. 5.3.5 Within Children’s Social Care, the family history was well understood, with C’s mother’s own experience of childhood being considered in the context of her parenting within the Duty and Referral Team. However, this was not always evident in the Long Term Team as evidenced by their response to escalating concern and the way in which the Child in Need plan was implemented. Comment This raises questions as to whether the fullest information was adequately passed on by the transferring team and understood in the receiving team. It also raises questions about the decision to allocate the case to a family support worker in 2012 and a newly qualified social worker in 2013. 5.3.6 Police records relating to C’s mother date back to 2003 and go back further in relation to the maternal grandmother. Police made risk assessments on each occasion based on previous risk assessments, and ensured officers were fully appraised of the history each time a domestic incident was recorded via access to live records. The hospital and education setting were not aware of the history. There was an exception to this in terms of one particular worker at the setting who knew some of the history due to a previous role she had worked in. She would have been required to bring this knowledge to the fore had child safeguarding issues been evident to her. 24 5.3.7 GP records contained notes regarding the family history of depression, drug and alcohol abuse as well as C’s mother’s history of elective mutism in her youth and being under CAMHS as a child. Thus there is no reason to believe this did not form part of assessments made within the GP practices. However, whilst the history prompted a referral of her first pregnancy, this was not the case for the second pregnancy. Comment In the Child B serious case review, a recommendation was made that GPs, health visitors and midwives should be encouraged to consider initiating the CAF (Common Assessment Framework) for pregnant women who present in pregnancy with complex social factors. 5.3 (ii) The Toxic Trio 5.3.8 When assessing risk for the children, how well understood was the impact of alcohol and substance misuse, domestic abuse and mental health issues for their carers? The health visiting records show no evidence of these factors being considered. There were 5 incidents of domestic abuse in the first 12 weeks of C’s life, but the health visitor did not challenge the progress of the case or the lack of a strategy meeting. Many professionals involved in the case, unsurprisingly, were influenced by the Family’s Nurse’s views as she had been involved in a close and supportive relationship with C’s mother. This may or may not have been a factor in the lack of challenge. Comment The Children’s Centre did not feel minded to challenge on the basis of the good parenting they observed. However, they felt they may have taken a different view had they known the family history. The health visitor agency report author would have expected the health visitor to have challenged in these circumstances. 5.3.9 Whilst the FNP worker was clearly considering risk factors from the historical context to enable her to support C’s mother, it is less clear the same approach was taken to considering the impact of these factors on C’s sibling. Comment When discussions took place between the FNP worker and the social worker following domestic abuse notifications, the FNP worker felt she had no concerns about C’s mother’s ability to parent C’s sibling. Following the fight between C’s mother and his maternal aunt the underlying family problem of domestic abuse was not explored with C’s mother and a referral to domestic abuse services or the freedom programme was not explored. When the FNP worker was consulted by C’s mother due to her feeling low in mood, there is no evidence that she spoke to the GP to discuss C’s mother’s wellbeing or the likely impact of her low mood on C’s sibling. Recommendation 3, Recommendation 7 25 5.3.10 In Children’s Social Care, the impact of these factors did not seem to be taken into account at all stages. We did receive reassurance at the Learning Event from the agencies involved in the strategy discussion of October 2011 that the meeting took account of how difficult the combination of these three factors make it to work with families. In the summer of 2012, three sessions of direct work were offered to C’s mother around issues of concern, including her anger. However, these sessions seemed to focus on C’s mother’s relationship with her sister and they ceased in October 2012 after a Child in Need meeting decided all necessary work had been done. Whilst a referral to Talking Therapies was made as early as 2011, there was no service offered to mother as a perpetrator of domestic violence. She was encouraged to contact the drug and alcohol service, although this was not taken up and it was not escalated. It was recognised that this service was reliant on self-reporting and would close the service for clients who did not attend for two appointments or more. 5.3.11 It is important to recognise that the worker identified to work with the family was seen as a match for this case due to his extensive experience as a mental health worker. However, the child protection plan was not implemented in such a way which reflected such an understanding. This may have been due to the joint working arrangement being more akin to supervision or it may have been due to inadequate transfer arrangements. Comment Whatever the cause, effective multi-agency safeguarding arrangements are needed to ensure cases involving these three issues receive the priority they deserve. The recommendations made by Children’s Social Care are welcomed, see also Recommendation 3. 5.3.12 When a domestic incident was notified by the police in May 2013 Children’s Social Care became aware of C’s mother’s second pregnancy and appropriately made enquiries of midwifery and health visiting services. This was an example of good inter-agency communication. The two agencies expressed ‘no concerns’ and this led to closure of the case. In the case of the health visiting service, it was not working with the family at the time, and this resulted in none being identified. This was an opportunity for any of the 3 agencies involved in this dialogue to consider: • This case involved a child under 3 where there had been two section 47 investigations. • The latest notification involved a new relationship provoking violence. • Whether a pattern was emerging which may increase risks to the safety of C’s sibling and unborn C. • What significance should be attached to the violence occurring when C’s mother was 7 months pregnant i.e. this not acting as a deterrent for either partner 26 Comment The case was closed following this consultation. Children’s Social Care felt at the time they were balancing risk factors against what they saw as reassuring information from the police about C’s sibling’s presentation. The decision to close the case and rely on other agencies to provide support suggests too much reliance was placed on these agencies. Overall, the response to the impact of the three issues coming into play at this time was lacking. 5.3.13 GPs were not aware of domestic dispute as an issue until October 2013. However, it was apparent from records that C’s mother had been tagged for a criminal offence. Leaving this aspect aside, the combination of the alcohol and substance misuse issues presenting for this mother led to a referral to the health visitor in her first pregnancy but not her second. In the case of her second pregnancy a referral to Children’s Social Care would have been appropriate. Comment Issues around alcohol generally were given insufficient prevalence. Alcohol was known to be an issue for C’s mother from adolescence and was ongoing. Both fathers used alcohol but more latterly it seemed C’s father was frequently using alcohol. What role was this or any other substance playing in the domestic disputes and what impact was it having on parenting the two children? Greater efforts could have been made to require the parents to engage with local drug and alcohol services. The health visitor discussed making a referral to drug and alcohol services with the perinatal health lead in September 2013 but this was not taken up. The recommendation for refresher training made by Children’s Social Care is acknowledged here. 5.3 (iii) Involvement of Fathers and Extended Family ‘Every assessment should be informed by the views of the child as well as the family’ (Working Together to Safeguard Children 2013) 5.3.14 The voice of the children is considered below, but the extent to which both fathers and both sets of grandparents were involved in assessments is relevant to this review. 5.3.15 The assessment in Children’s Social Care which followed included both parents, as did the work undertaken thereafter. However, C’s sibling’s father was not seen during the second investigation. The assessments of August 2013 involved both C’s father and his family but not C’s sibling’s father, who continued to play an active role with C’s sibling. The social workers stated they did want to involve C’s sibling’s father earlier but that C’s mother refused to provide contact details. There is a sense overall that workers got to know C’s father better than C’s siblings father. 27 Comment The varying levels of involvement of the children’s fathers in assessments led to significant information being held about the mother’s history and family background with relatively little being known about that of the fathers. For instance, both fathers work full time but it was not known what their occupations were. Work had an overall focus of work on C‘s mother as main care giver. However, both fathers remained involved in their children’s lives, even when separated from the mother and were part of the relationships based on domestic abuse which had been ongoing throughout the children’s early childhood. A similar theme was highlighted in the Child B serious case review in 2011, with limited assessment of the roles of males and others living within the household. 5.3.16 The grandparents were also key figures for the purposes of assessments of this family. A pattern was emerging which suggested many of the incidents triggered a move with C’s mother and children to either the home of the maternal grandmother or the maternal grandfather. The maternal aunt was also living at the maternal grandfather’s address but they were not successfully engaged. 5.3.17 The maternal grandparents were included in the first section 47 investigation. However, by the end of 2011 the maternal grandmother was clearly viewed as an unsuitable baby sitter. That view appears to have been formed following the incident when C’s sibling was found in her care when she was under the influence of alcohol on 31st October of that year, rather than resulting from an assessment of her. Comment There is no evidence that C’s mother’s role as a young carer emerged and this may have been clearer had the maternal grandmother been involved in assessments and the impact of their complex relationship on the family dynamics been considered. Recommendation 2. In the Child B case of 2011 assessments were identified as having failed to address the broader social context and including the nature of the relationships between those caring for Child B. 5.3.18 There was an instance in response to the domestic incident in May 2012 when a suggestion of a Think Family approach emerged. The team manager who oversaw the work recommended a family group conference because of the impact of other family members on outcomes for C’s sibling. However, this was not implemented as C’s mother was not happy with family members participating. Comment Greater efforts could have been made to make this conference happen. Work has been undertaken to increase the number of Family Group Conferences with a 48% increase since 2012. 28 5.3.19 Latterly it is recorded that the paternal grandmother visited the pre-school with C and his mother and we heard at the Learning Event that she was seen as a supportive influence. However, it appears that it was not until the incidents in August 2013 that their involvement in assessments began and it is not known what their views were of what was happening for the family. Comment The reason given for the paternal grandparents not being consulted was that the case was not open to Children’s Social Care when the relationship with C’s father began. The case was opened in July. 5.3 (iii) Consideration of Mother’s Circumstances 5.3.20 There were factors prevailing for the mother which were relevant to assessments during the scoping period. Her unstable housing situation was a factor which was taken up by the Long Term Team on mother’s behalf. Housing Services were unaware until February 2012 that she was moving between homes. Her circumstances were investigated, which was very distressing to her. Comment These factors were well understood by social workers and the family nurse, including the impact on C’s mother of the maternal grandmother refusing to have her in her home. In the Partnership Learning review undertaken in September 2013 a key message which emerged was that housing issues increase vulnerability. 5.3.21 Other factors have only been taken into account since the scoping period e.g. mother’s acceptance of her dual heritage is only recently been the subject of direct work. Once again, the treatment of these factors was criticised in the 2011 serious case review. 5.4 The Response 5.4 (i) Children’s Social Care 5.4.1 Working Together to Safeguard Children 2013 sets out a clear process for how social workers as lead professionals are required to respond to a referral. Within one working day a decision must be made regarding which category of response is warranted, which services are required and whether further specialist assessments are needed. 5.4.2 In C’s case some concerns came to the attention of Children’s Social Care in the form of a referral. For instance, most of the police callouts to domestic incidents resulted in a referral to Children’s Social Care. Other issues arose from assessments. For instance, issues arose during the process of the Child in Need plan in 2012. C’s sibling was subject to disruption, instability and domestic aggravation as a result of the moves between C’s mother’s parents and then to the home of her new boyfriend’s mother. A change of home was often triggered by a dispute, some of which he had witnessed. This was added to the change he was experiencing as a result of his mother’s new relationship. 29 Comment The Child in Need plan did not address these issues and the case was closed in October of that year with some actions identified in the plan outstanding. Contingencies were not expressed with identified consequences and this affected the response during this part of the scoping period. 5.4.3 Professionals spent time interacting with the adults in order to effect a positive change in parenting capacity. However, this resulted in this case in a loss of focus on C’s sibling. There is no evidence that professionals could see what life was like for C’s sibling. Comment The evidence was beginning to emerge at this stage, with police reports describing C’s sibling as presenting as withdrawn and anxious and his speech had become significantly delayed. 5.4.4 The role of supervision is highly relevant in understanding why the response was not what it should have been. It was suggested by Lord Laming that supervision is the cornerstone of good social work practice, an opinion that was reiterated in the second Munro Review (May 2012). This section is concerned with supervision and management oversight across agencies, not purely that of social workers. 5.4.5 It was essential to step back from the case and reflect on the increasing pattern of police notifications and the escalation of domestic dispute, especially in the period before C’s injury. 5.4.6 In Children’s Social Care, whilst supervision was regular and recorded appropriately, it missed an opportunity to reflect on the patterns. Responding with written agreements had not been accompanied by monitoring and known consequences for default. A change of approach was needed. 5.4.7 Children’s Social Care was notified of a police callout on 8th September 2012 involving alleged threats of violence from the maternal grandparents to C’s mother during which the child was present. This was appropriately discussed between the family support worker and her supervisor during supervision a week later. The recording shows ‘anger is not seen as a significant issue’, but it transpires that this comment related to C’s mother’s anger. The decision was made during that session to close the case. Comment The rationale for case closure was that the identified work had been completed. However, this latest incident highlighted a key issue for mother and child, namely that of housing. Whilst the alleged threats were being made to beat C’s mother up during this altercation she had locked herself and her boyfriend upstairs, leaving her son asleep in the next room. She had then left that address, moved to her boyfriend’s accommodation for a short period before moving in with her father. This instability around housing was a key feature in the case and was by no means resolved at the time the case was closed. 30 5.4.8 A further example of supervision taking place yet not producing a robust plan is the session which took place on 17th October 2013. Two domestic incidents were discussed during one of which both children were present and these had been interspersed with a health visitor referral regarding alleged drinking of alcohol early in the morning. Whilst it is acknowledged as good practice that a joint visit was planned in October 2013 this was not recorded and no date was agreed for it. Comment This visit did not take place soon enough before C became injured. The reason for this was the number of cases being overseen by the Assistant Team Manager at the time as a result of staff having left with replacements not yet taking up post. Some supervision was being offered by new managers who had not yet gained the fullest awareness of their supervisees’ caseloads. A positive development has arisen in the form of an opportunity to reflect in a multi-agency context arising at CMHT and the SMART Drug Treatment Agency also offers this. Social workers have attended both of these. Recommendation 5. 5.4 (ii) 111 Service 5.4.9 C’s mother called the 111 service on 19th October 2013 to report that C’s leg left leg was floppy. In these circumstances it would be expected that an investigation into how the injury had been caused would have been documented and likewise the rationale for ruling out non-accidental injury. Comment The call taker followed the national pathways triage system for the identification of potential non-accidental injury. However, there is a potential for a non-accidental injury to be missed which is inherent in the process. Recommendation 8 5.4 (iii) Inter-agency Challenge 5.4.10 Children’s Social Care was not the only agency who knew of the situation this family was in. Police officers and health visitors were receiving supervision during the scoping period, but there is no evidence they were discussing the possibility of challenging plans and/or responses. Upon de-brief the health visitor did not see why she would have challenged the decision making about the family at the time. Certainly at the time of closure of the Child in Need plan the situation may well have looked less concerning from the perspective of this service as the FNP programme had been working well. Points at which challenge may have been considered were when: (a) the Child in Need plan was closed when all actions had not been completed and this largely relates to C’s mother’s housing; 31 (b) the case was closed in June 2013 following a domestic incident when C’s mother was heavily pregnant. The basis for case closure was the support being provided by midwifery and health visiting services. Whilst the decision was taken on balancing all factors there was an over-reliance on the other agencies at this stage; (c) the response to the domestic violence incident in October 2013 in which C’s sibling attempted to separate his parents was not to consider immediate risk in the context of a strategy discussion but to undertake further work and establish a tight written agreement; (d) the school reported they had noticed bruising on C’s cheek in September 2013 but the decision was taken not to proceed to a medical examination on the basis that the social worker had also seen the child yet had not noticed bruising; Comment The role that could have been played by specialist services cannot be underestimated in the context of the response. Whilst it is recognised that the family was not readily engaging, plans and agreements with contingencies which were followed through may have improved this. This included the drug and alcohol and domestic violence perpetrator services previously mentioned. Importantly, when these were refused or not taken up the contingency plan should have kicked in and led to an appropriate response to safeguard the children. Greater follow up with children’s centre and Talking Therapies regarding the level of the family’s engagement would have helped to evidence how little input these entrenched issues were actually receiving. 5.4 (iii) Other agencies 5.4.11 Other agencies’ responses to the family were lacking during the scoping period. Despite being told a 14 week old baby’s right leg had gone floppy the response of the 111 out of hours service was not to go to the Accident and Emergency department. Instead they offered to call back within 12 hours, and did not involve a clinician to make a full assessment of the situation. 5.4.12 When the health visitor was concerned during a home visit in October 2013 about C’s mother and possibly her friends drinking alcohol she did not investigate precisely what was in the cans whilst she was present and her referral to Children’s Social Care came six hours later. She simply did not realise the significance of sharing this information earlier. This presented a major barrier to evidence gathering. 32 5.4.13 When the school saw bruising on C’s cheek they did not refer this to Children’s Social Care until later when they made the link between C and the family who had been to the Child Protection Conference. They did not follow the bruising protocol as it had not been cascaded. This protocol was introduced in the 2011 serious case review and which also featured in the 2013 partnership learning review, which resulted in reminders being issued. The Bracknell Forest Safeguarding Children Board should take this opportunity to consider carefully the way in which its messages are being disseminated and how it will disseminate the messages from this serious case review. 5.5 Interagency Working 5.5.1 It is very pleasing to report some examples of timely and effective inter-agency communication : • The trainee GP referred C’s mother’s first pregnancy to the health visitor. This would have been improved by also informing Children’s Social Care given C’s mother’s past history of drug and alcohol abuse. • There is evidence of calls from Children’s Social Care to the GP surgery in the early part of the scoping period. Unfortunately the calls were not recorded fully enough to enable the information shared to be used appropriately at further consultations with primary care. • The housing service was proactive in making timely referrals of domestic disputes to Children’s Social Care. • Attending police officers were vigilant in grading risk and returning paperwork. Information regarding how the children presented during callouts was apparent in the recording made by attending officers. For instance, on 30th October 2011 officers’ concerns regarding C’s sibling not being fed, watered or changed were thoroughly recorded. 5.5.2 However, there is fundamental learning from this case for Bracknell Forest from examples of inter-agency and intra-agency working which were less than effective: • The GP did not refer C’s mother’s second pregnancy to Children’s Social Care. The hospital sent a routine notification to the health visiting service, but no request for a targeted antenatal visit. The GP did not later refer C’s mother when she was presenting with low mood. • The Family Nurse and CMHT were not invited to strategy meetings. • The child protection conference did not take place until one month after the incident when C’s mother alleged she had been attacked by her partner in August 2013. It received a report from the GP, but the GP did not attend. If the GP had attended, primary care would have been alerted to the domestic violence issues. The children’s fathers’ GPs were not invited to the conference and did not produce reports. 33 • The health visitor did not attend either the conference or the first core group meeting. An opportunity was missed here for the health visitor to understand the concerns and commence intervention earlier. • The transition between family nurse and health visitor was not effected, resulting in a 9 month gap in which the family did not receive support. • In May 2013 hospital midwives did not refer the police callout to Children’s Social Care. • The ambulance service did not raise a safeguarding alert when they were called out to a domestic violence incident on 2nd October 2013 during which children had been present. • When C was admitted to hospital in October 2013 they were alerted to Children’s Social Care involvement with the family as a result of questioning of the parents, who were very honest. This hospital had not received a list of children subject to a plan as they had not requested one. 5.5.3 These omissions resulted in pockets of information being held in certain agencies which were not clear to others until revealed during the process of this review. Examples would be that the GP knew C’s mother had been an elective mute, but Children’s Social Care did not know. However, the GP was not aware of domestic violence issues. • Children’s Social Care incorrectly identified the nursery setting, although confusion arose due to two settings being co-located on the same site. However, Children’s Social care was informed of its mistake on two occasions yet failed to rectify its mistake. • The lack of a strategy meeting in response to the incident on 2nd October resulted in agencies other than Children’s Social Care not being able to contribute to the decision making at this crucial time. • The Deputy Head did not inform Children’s Social Care when she first saw the bruising on C’s cheek. This affected the options open to Children’s Social Care when they were informed. • Information was not shared with the Children’s Centre by PACT, the health visitor, the family nurse or Children’s Social Care. 34 5.5.4 An integral part of effective inter-agency working is ensuring information shared is accurately recorded. Recording was deficient in this sense in GP practices and education settings linked with C’s case. Similarly, recording made by the ambulance service did not show how non-accidental injury had been ruled out, either at the time of the 111 call or when the ambulance attended at the family home. An example of what resulted in the education context was that when C’s sibling moved settings in haste this was a risk factor in the light of his circumstances. Social workers were heavily involved in his life, yet no alert was raised with them. Similarly, recording in the Emergency Duty Service was poor, leaving staff taking up the case on subsequent shifts with a very unclear picture of the situation the two children found themselves in following C’s admission to hospital. 6. Voice of the Children 6.1 C and his sibling were very young during the scoping period and largely unable to speak. C was an infant and, other than the distress he would have displayed following his injury, any non-verbal signs of abuse he may have shown at other times would have been difficult to observe. However, C’s sibling was clearly communicating his wishes and feelings through gestures and expression. 6.2 Police officers who did not know him recognised he had not been fed, watered or changed back in October 2011. Then in May 2012 he was observed to be upset when officers arrived and very quiet. He was a child who initially had been exceeding milestones and then was later seen to be anxious and delayed in his speech. 6.3 Professional curiosity may have led to questions being asked such as how the number of house moves were impacting on C’s sibling. These moves tended to come immediately after an incident. Another relevant question was around how well he was managing the adjustment to changes such as his mother’s new relationship and the birth of his sibling or his change of nursery. 6.4 C’s sibling’s daily lived experience did not come through in assessment and he was not seen holistically, with little direct observation of him. He was not observed with all his care givers and decision making was incident focussed rather than child focussed. Even in the earlier days when the case was being worked under Child in Need, there seemed to be a focus on C’s mother’s anger rather than C’s sibling. These issues arose in the serious case review of 2011. In the partnership learning review of 2013, the good physical care provided to the child masked the underlying issue of domestic violence. It is relevant to question the extent to which this factor repeated itself in Child C’s case. 7. Good Practice A SILP review seeks to learn from good practice as much as from shortcomings. The following areas of good practice are identified: 7.1 The role of the family nurse worked well; this is an example of early intervention. The FNP worker engaged C’s mother to begin with and went on to develop a close relationship with her. There was a skill in sustaining this relationship and this was achieved until the programme ended. 35 7.2 In Children’s Social Care the duty social worker and senior social work practitioner demonstrated skill and persistence in engaging with C’s mother. On one occasion it was necessary for them to sit for a long period of time in silence until she would speak to them. 7.3 The Duty and Assessment team researched the complex family history and made good use of it in assessments to understand how patterns can repeat themselves in later generations. This team shared concerns about the impact of the maternal grandmother’s mental health on mother and child with mental health services. 7.4 There were positive interventions with C’s father. The Domestic Abuse Perpetrator Service was viewed as a positive intervention by agencies involved and undertook valuable work. Evening visits were made by social workers in an effort to engage with C’s father, who worked full time. 7.5 The duty social worker obtained C’s mother’s permission to share the Children’s Social Care Assessment with the Housing Service to reinforce the urgency of the housing situation. 7.6 When Child C was in hospital a local agency was engaged to facilitate and supervise contact with the parents. Only two agency staff were used to promote consistency. The arrangement ensured that parents’ wishes around contact were accommodated. 7.7 There is evidence that supervision was provided on a regular basis across agencies including Children’s Social Care, health visiting service and the police. There is evidence of the health visitor discussing the case with the perinatal health lead. 7.8 Police officers were often called out to emergencies to find C’s mother had disappeared. They were proactive in finding her and assessing her situation on these occasions, and would stay or come back during the night to check on her. 7.9 The Children’s Centre went to visit C’s mother, even after they recognised it was clear she would not engage. They provided information and informed her of courses she may wish to take up, leaving the door open if she changed her mind. 8. Developments Since the Scoping Period 8.1 The police now have 3-county based Protecting Vulnerable People Referral Centres. When an officer identifies a child protection concern they should create a record on the database (CEDAR). The child protection referral managers in the centre then conduct research, make risk assessments and share information as appropriate. 8.2 A new domestic abuse (DOM 5) form has been developed, referred to as ‘Incident DASH’. It is shorter, sharper and more focussed on the officer attending, resulting in an improvement of the quality of information obtained following an incident. It includes an information sheet which can be detached and left with the victim. This contains information about support organisations and charities. 8.3 The police have introduced new measures to ensure low level domestic abuse is fully scrutinised, such as: 36 • If 3 domestic abuse incidents occur which are graded as ‘standard’ during a 6 month period a review is triggered by the domestic abuse risk assessor. • If the grading was raised to medium or high the case would receive a risk assessment by the DAIU. • If the grading was high risk a referral to the Multi Agency Risk Assessment Conference (MARAC). • Single Incident Reviews are being conducted to better understand ‘standard’ domestic incidents where children are present. 8.4 The police have undertaken an audit to check the quality of completion of 100 domestic abuse incident forms. 8.5 The Domestic Abuse Service Coordination Project was started by the council and the police in April 2011. It is aimed to address a gap in service to standard and medium risk victims and perpetrators. One strand is a visit to the victim, often with a Women’s Aid worker, after the initial police response 8.6 Health visitors now operate a colour coding system to enable families to be targeted for support. When a family transfers from the FNP to health visiting support they are coded pink as a vulnerable family and targeted to receive monthly visits for a minimum of 6 months. Targeted families are reviewed monthly by the health visitor manager. 8.7 Mental Health workers must now contact the health visitor if the patient is the parent or carer of a child under 5 to discuss the case and the possible impact on the mental health of the child. 8.8 Health visitor training now includes a safeguarding scenario which includes grandparents within risk training. Level 2 internal training is mandatory which covers considering risk from grandparents. 8.9 Since 2013 family nurses receive specific child protection supervision 3 times per year with a named professional for child protection in addition to the supervision they receive from their supervisor. 8.10 Health visitors involved when a domestic abuse incident occurs where a child is directly involved must seek advice from a named professional where they have concerns about actions taken following the incident. 8.11 The health visitors’ children’s safeguarding team screen police domestic violence reports and check actions taken in cases where a child is directly involved. This team has also provided mandatory seminars for all universal services staff about risk analysis and the importance of maintaining child focus. 8.12 The hospital has provided training and resource packs to deal with issues emerging at the outset of this review. 37 8.13 In Children’s Social Care child in need cases are no longer closed without multi–agency consultation and, wherever possible, a review meeting. 8.14 Communication to schools regarding safeguarding has been improved to include a termly newsletter, head teachers briefings and a termly meeting with child protection leads. 9. Conclusions & Summary of What Has Been Learned 9.1 Information sharing and multi-agency decision making were key to C’s case. Cases involving the toxic trio of domestic abuse, mental health issues and substance misuse cannot be worked effectively by any single agency. 9.2 The police held a great deal of information about what was going on in the family home, as did the family nurse partnership. The community midwifery team, primary care providers and the nursery also had information to contribute to the multi-agency arena. Not all of this information reached Children’s Social Care and if it did this was not always in a timely way. This had a considerable impact on assessments, planning and the response. 9.3 However, when the case did reach points at which multi-agency discussions were required under statutory guidance, the appropriate agencies were not present to contribute to those discussions. On some occasions this is because the appropriate professionals were not invited, on others it was because they failed to attend. This review is able to see the full picture, including what was known by all agencies at the time. Practitioners did not, and made the decisions that made sense to them based on the facts that they knew. When the Emergency Duty Service was required to undertake a joint visit with police after C was admitted this did not take place. This was due to demands on the service during a busy weekend. 9.4 Nevertheless, some decisions were questionable even when based on the facts that were known. Examples are the decision to step the case down in October 2012; the decision not to conduct a child protection medical in September 2013 and the decision not to hold a strategy discussion in response to the incident on 2 October 2013. 9.5 Multi-agency notifications of C’s mother’s second pregnancy were not made, resulting in no targeted health visiting support being offered and children’s social care not being aware of the pregnancy until a domestic dispute notification was received from the police. This meant that the child in need plan ended at the same time as the intensive support of the family nurse. What was needed during the antenatal period was targeted health visiting support, a fresh assessment of risk and a plan to take account of the extra stress of the new baby. Instead the new birth visit conducted by the health visitor on day 14 was very brief, with paperwork not completed and the issue of domestic abuse not being raised. There is insufficient evidence to suggest that the impact of the toxic trio was given sufficient weight in the risk assessment for the children. Even though the three factors did not have this label at the time, there was an awareness and this was a missed opportunity. 38 9.6 C’s sibling’s vulnerability was highlighted in early assessments which were rooted in the family history. These assessments showed that on the whole key agencies understood this history. However, an appreciation of the risk presenting as a result of the toxic trio was less evident at times. It may be that in Children’s Social Care some of this was lost in the transition between teams. 9.7 Some of those involved in the care of the children appear as shadowy figures, with little recorded about them. There is fundamental learning from this case regarding involving family members in assessments. 9.8 Some assessments undertaken failed to see C’s sibling holistically. They did not adopt a ‘Think Family’ approach, he was not seen with all care givers and they were not fully assessed. Whilst some positive opinions were clearly held of both C’s sibling’s father and latterly C’s father and his extended family, their basis is unclear. 9.9 Whilst supervision was taking place, it did not always seem to fulfil its purpose in enabling practitioners to gain a perspective on the bigger picture and make a robust plan of action. Thus the response was sometimes lacking and opportunities to take action were missed. This lack of overview, combined with the incident focussed approach taken, leads to a question regarding who was taking a step back, looking at the chronology and taking overall responsibility for the case. 9.10 There were various factors which made it harder for professionals to work with this family. C’s mother was difficult to engage and refused to participate in many of the programmes and services on offer. However, it is important to acknowledge that some professionals were able to engage her. The family nurse and some social workers made enormous efforts and did build a relationship with her. The family moved between homes on a regular basis and this acted as a barrier to them becoming known well, for instance by a single GP at the surgery. 9.11 Despite these barriers, enough was known by Children’s Social Care to enable them to have responded in a more timely and decisive way. Opportunities to do so came in response to domestic incidents, but some of these were missed. There seemed to be an over reliance on the opinions of health professionals that all was well. Alternatives or additional strategies to the written agreement were not evident, with inter-agency debate being under-utilised as a tool to identify the best strategy. Parents were not challenged sufficiently and failure to engage was not always followed through with appropriate consequences. 9.12 C and his sibling were largely too young to communicate verbally, but C’s sibling was able to give powerful indications as to how he was feeling, particularly in his responses to domestic incidents and his subsequent delayed speech development. The response to these indicators of risk was lacking. 9.13 There was a lack of professional curiosity about what day to day life was like in the family home and around some of the accounts they were being given by mother and her partner. The analysis of risk was not undertaken appropriately in a multi-agency setting, resulting in key areas of risk being missed. 39 9.14 There are some examples of highly effective inter-agency working, particularly around agencies making timely referrals to Children’s Social Care, and these are highlighted in 5.5 above. Other notable examples of good practice have emerged, with some practitioners having gone the extra mile to engage C’s mother and being successful in developing a good relationship with her. The learning from these patterns of good practice is equally beneficial as learning from shortcomings. 9.15 There is no evidence that agencies involved in this case were discussing challenging the plans that were being made to protect the children. A number of opportunities were missed to take the opportunity to approach a senior colleague or safeguarding lead to discuss challenging the plans being made by Children’s Social Care. 9.16 C’s case has generated a great deal of learning which has already translated in some significant and notable developments. These are summarised in section 8 above. There are further recommendations which result from this review and these appear in section 10 and in section 11 Appendix B. 9.17 Overwhelmingly, this case makes clear that over-reliance on the opinion of health organisations or on children’s social care alone is to be avoided and all agencies must bring their own expertise to these difficult decisions. 9.18 One of the most striking features of this review is the commonality across the features of the serious case review of 2011 and, in some ways, the learning activity undertaken in 2013. This case represents a fresh opportunity for the Bracknell Safeguarding Children Board to tackle the Think Family issues, look at how some agencies can strengthen their links, improve assessments and reconsider how its messages are being disseminated by all partner agencies. A key opportunity will be for the Board to disseminate the learning from this review to as wide an audience as possible. 40 10. Recommendations for LSCB Recommendation 1 The Bracknell Forest Safeguarding Children Board should lead a review of the process of sharing Domestic Abuse notifications from Thames Valley Police with partner agencies which specifically addresses: (a) Whether incidents should be shared if children are not present; (b) Whether fuller information should be shared; (c) Which agencies should receive the notifications and what support is required to help their response. Recommendation 2 Bracknell Forest Safeguarding Children Board should continue to reinforce and promote the need to ensure all partner agencies ‘Think Family’ i.e. consider all members of the family who may have an impact on children by listening to the Child’s voice and understanding the impact on the child of the wider family circumstances on their day to day lived experiences. This would be achieved through: (a) Its current initiatives e.g. Family CAF and Team Around the Child; (b) Inclusion in the LSCB training programme; (c) Increased promotion and use of Family Group Conferences (d) Dissemination of the learning from this serious case review to adult service providers of substance misuse and mental health. Recommendation 3 Bracknell Forest Safeguarding Children Board should assure itself that its current multi-agency training strategy incorporates improving understanding of binge drinking and the impact of the toxic trio of mental health, domestic abuse and substance misuse on the parenting of children. Recommendation 4 The Bracknell Forest Safeguarding Children Board should undertake an audit of the approach being taken by all partner agencies to disseminate key safeguarding messages, policies and procedures and consider any barriers and action needed to address gaps. 41 Recommendation 5 The Bracknell Forest Safeguarding Children Board should undertake a review of how key partner agencies provide ‘supervision’ to ensure sufficient opportunity for reflective challenge and develop standards/expectations. Recommendation 6 The Bracknell Forest Safeguarding Children Board should review current arrangements for strategy meetings and make proposals for change to ensure clarity on when they are undertaken and how agencies are involved. Recommendation 7 The Bracknell Forest Safeguarding Children Board should request the Clinical Commissioning Group to request a review of health partners in order to understand how information sharing between GP, health visitor and family nurse partnership & all other relevant organisations could be improved. This review should consider how the role of the link health visitor may be strengthened. Recommendation 8 The Independent Chair of the Bracknell Forest Safeguarding Children Board should write to the national ambulance safeguarding group and the national pathways group to highlight the potential for a non-accidental injury to be missed in the national 111 pathways triage system. The issue which arose in this case should be highlighted to reinforce the actions anticipated by the South Central Ambulance NHS Foundation Trust pursuant to its own recommendation. Recommendation 9 The Bracknell Forest Safeguarding Children Board should conduct an audit of assessments to ascertain whether professionals are listening to the child’s ‘voice’ and understanding the impact on the child of the wider family. Recommendation 10 The Bracknell Forest Safeguarding Children Board should take account of the learning points within this review and ensure that they are incorporated into multi-agency training and/or dissemination events and single-agency training to engage as wide a range as possible of appropriate professionals across agencies. The learning points include: - The capacity to undertake reflective learning exercises and to share that learning. - The importance of including as much soft information as possible in their referrals to Children’s Social Care when notifying them of incidents. - Highlight for all agencies local and national guidance on information sharing and safeguarding children, including the need to share information as fully and comprehensively as possible. 42 - The importance of using named professionals and safeguarding leads for advice and guidance in cases involving complex issues such as mental health, domestic abuse and substance misuse. - Reminder of the importance of referral to children’s social care and the police and re-referral of any changes of circumstances. - For all agencies to Think Family, seeing the child holistically within the family, including seeing the child with all care givers in order that a collective understanding is achieved of families’ vulnerability - Listening to the child’s ‘voice’ and understanding the child’s day to day lived experiences. - Highlighting the need for the practitioner to check back regarding what they have been told or have discussed and the actions and timescales agreed. - The importance of valuing the views of extended family members where they have extensive knowledge and experience that might assist with the assessment process. 43 11. Appendices Appendix A – Terms of Reference Generic Terms of Reference 1. Was any information known by any agency about parental mental health issues and/or substance abuse? If so was appropriate consideration given to how this impacted on parenting capacity? 2. Was any information known by any agency about domestic abuse or parental antisocial behaviours? I so was appropriate consideration given to how this impacted on parenting capacity and were appropriate referrals made? 3. Was the level and extent of agency engagement and intervention with the family appropriate? 4. Did agencies communicate effectively and work together to safeguard and promote the children’s welfare? 5. Were appropriate assessments undertaken in a timely manner? Was the quality adequate and did they include all historical information? 6. Were fathers and extended family members included in assessments? 7. Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed? 8. Were any safeguarding issues in respect of Child C and sibling SC identified and acted on appropriately and in a timely way by all agencies? 9. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of young non-verbal children being fully considered? 10. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised? 11. Were there any organisational or resource factors which may have impacted on practice in this case? 12. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case? 13. How did the multi-agency system enhance or impede effective practice and outcomes for this family? 44 Additional areas of focus 1. The implementation of the bruising protocol following a previous Bracknell Forest SCR in 2011: was this guidance considered by the professionals involved? 2. The Child protection conference process and core group arrangements: how effective were these arrangements in engaging the right professionals and protecting the children? 3. Following the children becoming the subject of child protection plans: did professionals follow local guidance and statutory procedures? 4. To what extent was the family history understood within agencies and incorporated into assessments? |
NC52476 | Death of a 13-year-old boy from a suspected drug overdose in August 2021. Child M was groomed into criminal exploitation from early 2020. Learning includes: need to build upon flexible approaches to working with young people to understand their worlds; family-focused service responses need to be embedded across children's social care, education and the police when working with extra familial harms; manage risk via multi-agency assessments, plans and contingency; safeguarding systems should consider the context of schools in terms of safety and risk to children; parents/ carers need more information and guidance about the process of exclusions and re-integration; family cultural and language barriers to be checked and responded to by the local authority and education providers. Recommendations include: operational multi-agency groups and CSP should align strategic and operational work to disrupt criminal exploitation activities and map children at risk; partners including police, the council, and education should consider community events, to ensure work is rooted in 'lived experience'; the child exploitation screening tool should be completed at all levels of intervention when exploitation is the main risk; consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, when due to substance misuse and/or criminal exploitation; consider how parents/carers can co-produce policies and protocols with the local education system.
| Title: In memory of Child M: a multi-agency thematic summary: extra familial harm. LSCB: Pan-Dorset Safeguarding Children Partnership Author: Sarah Holtom Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Pan-Dorset Safeguarding Children Partnership – BCP Area In Memory of Child M A Multi-Agency Thematic Summary: Extra Familial Harm Published June 2022 Report Author Sarah Holtom MSc BA(Hons) DipSW CONTENTS PAGE 1. Introduction 2 2. How the Review was undertaken 3 3. Key Learning 4 3.1 How Systems Respond to Criminal Exploitation 4 3.2 Working Together with families 8 3.3 The role of education and community provisions in keeping children 11 safe 4. Recommendations 12 5. Conclusion 13 6. Family comment on report 14 2 In Honour of Child M Child M was a much-loved son, brother, and member of his Turkish community in Bournemouth. His family have shared many memories of him, and he was undoubtedly cherished as the youngest member of their family. It is impossible to put into words the loss and heartbreak they feel. Child M’s family have been left devastated. Professionals who knew Child M describe him as a friendly and kind-hearted boy, who would always be available to those who needed him. Child M would talk openly of his love for his family and how important they were to him. Child M was beginning to develop his own sense of identity and style as he began to progress through his adolescent years. It is said that he liked “to look cool” and was thinking of different hair styles and his image as a young Turkish male living in the Bournemouth. In navigating these teenage times, professionals saw Child M’s need to build his confidence along with the vulnerabilities that may arise as young people find a way through times of peer pressure and influence, often experienced in school settings and the local community. Child M’s early years were spent in London. His family re-located to Bournemouth, and the family have a retail business in the local area. Child M attended the local primary school, two secondary schools and an alternative education provision. The multi-agency chronology shows Child M groomed into a world of criminal exploitation from early 2020 and reports centred upon him selling drugs at school and to adults in the local community, often via social media. Child M said he felt frightened for his own safety, and his range of behaviours indicated this. At times he shared he would need to carry a knife to feel safe. Towards the end of this life, Child M was openly sorry about how he had been pulled into this world. This shows a naïve understanding of how he had been coerced and controlled by those who chose to exploit him and how vulnerable he had been. Child M aspired for his future and had many dreams. Child M was 13 years old when he died of a suspected overdose of the drug Ecstasy. His untimely death has sent shock waves through his family, local community, friends, and the professionals that knew him. Our thoughts have been with them all throughout this Review process. The intention has been to sit alongside to hear their reflections and give them a voice into Child M’s life. The analysis and recommendations in this report are in honour of Child M and a commitment has been given to affect safeguarding practice and system development, where needed, to support those multi-agency professionals who work tirelessly each day with children who may be at risk of similar experiences of criminal exploitation. 1. Introduction This Learning Review is concerned with the harms to children in those contexts beyond the home through the lens of a family, community, and single and multi-agency perspective. Extra familial harm is described as harm that occurs to children outside of their family system, often during the adolescent years because at this age their social networks widen1. These extra-familiar contexts can pose a new set of complex issues for systems to respond to and the focus of this Report is criminal exploitation. Other forms of this harm include child sexual exploitation, peer-on-peer abuse, gang affiliation, serious youth violence, trafficking and modern-day slavery, anti-social behaviours by and affecting peers, radicalisation, and violent extremism. 1 Extra Familial Risks and Harm, The Innovate Project 3 The Report is the culmination of multi-agency work commissioned by BCP Community Safety Partnership (BCP CSP) and BCP Area Safeguarding Children Committee (the Partnership). It was agreed by the BCP Area Child Safeguarding Practice Review Group on 8th September 2021 that a thematic local Learning Review consider practice and system learning, which includes good practice, along with recommendations for change where required. This approach was notified to the National Child Safeguarding Practice Review Panel2. The Learning Review pays particular attention to the Turkish community. Bournemouth, Christchurch, and Poole have a combined population of 396,989; 17.2% are aged 0-15 years and 11.6% of the population identify as black or minority ethnic, with 6.1% with a main language not English.3 Child M’s family members are part of the local Alevi Community of around 600 families who attend the Centre. This culture and identity are important to their family, and they describe themselves as not practising in the religion. Given the traumatic nature of what happened, the specific details of Child M’s story are not reported in detail in this written report. This information is held in various formats by the BCP CSP and the Partnership and forms the basis for this analysis, with key learning and recommendations. The Review does not address the question directly of whether Child M’s death could have been predicted or prevented. It focuses on how agencies might respond differently or try different approaches when working with extra familial harms to reduce the risk of this happening to other children in the future. In reaching the thematic summary with recommendations for change the Review worked with Child M’s family, the local community, including schools and a range of professionals from across agencies. The BCP CSP and the Partnership would like to sincerely thank Child M’s family, local community and professionals involved for sharing their thoughts so openly and honestly at a very difficult time. Their reflections have proven invaluable to practice and system learning. This report has been translated into Turkish for the benefit of Child M’s family and community members. 2. How the Review was undertaken The period under review started from May 2017, when aged 9 Child M made comment at primary school about the Manchester Bombing4, and concludes with Child M’s very sad death in August 2021. 2 The National Panel refers to the Child Safeguarding Practice Review Panel which works with the Department for Education. It is an independent panel commissioning reviews of serious child safeguarding cases. 3 Area profile for Bournemouth, Christchurch, and Poole, maping.dorsetcouncil.gov.uk 2020 4 On 22/5/2017 an Islamist extremist suicide bomber detonated a homemade bomb as people were leaving the Manchester Arena. 23 people died, including the attacker, and 1,017 were injured, some of them children Manchester 4 The Reviews lines of enquiry were: The methodology for the Review was split into three workstreams, with a lead appointed to work with the Review Group and Independent Reviewer and author of the Report. The approach was collaborative and ensured participation of Child M’s family, the local community, schools, and multi-agency professionals. The voice of those who knew Child M was actively listened to via various communication means, such as individual and group discussions in the community and on-line surveys. The workstreams included Child M’s family and the Alevi Turkish community; Child M’s peers, including schools and multi-agency professionals who worked with Child M. The content of this report is a joint production of all professionals, individuals and agencies involved with Child M and his family, drawn together by an Independent Author from outside the local area. 3. Key Learning Points This section considers three thematic areas with key learning points when working with extra familial harms to children in the places and spaces they occupy. The key learning is drawn from the three workstreams. Set out below is a summary of this work. 3.1 How Systems Respond to Criminal Exploitation Largely driven through the work of Professor Carlene Firmin5, there is growing recognition that individualised and family-focused approaches to working with the range of extra-familial risks of county lines6, sexual exploitation and peer on peer violence faced by many children and young people in the UK are, in isolation, not sufficient. As the contextual safeguarding approach helpfully considers, risk should be addressed at two levels. A contextual “lens” adopted by practitioners when working with adolescent children which focuses upon understanding who the child ‘hangs out with’ and the spaces and places they spend time in within the community is required. Attention is directed towards helping them find safer ways of engaging in relationships and inhabiting their growing social worlds. There are examples of this approach being adopted with Child M at a ‘child in need’ level of intervention, albeit unknowingly, by the social worker who went regularly to the places which Child M frequented to understand how he 5 Professor Carlene Firmin MBE is a British social researcher specialising in extra familial harm. She is Professor of sociology at Durham University 6 County lines is a form of criminal activity in which drug dealers in major cities establish networks for the supply and sale of drugs to users in towns and rural areas, using other people (often children) to carry, store and sell the drugs • Understanding the extra-familial1 risks and harms experienced by Child M and other young people in the local community • When risk of harm is beyond the family, how this is identified, assessed, and responded to by individual agencies and when working together with families • The role that education and community safety provisions play in keep children safe and how risk is understood and managed in the context of this setting Key Learning: Safer Communities work is needed at a Strategic and Operational Level 5 presented in the local community and to determine what work was needed in response to his identified vulnerabilities. When at a ’child protection’ level of intervention, Child M was not supported by the Complex Safeguarding Service, as he was not assessed at the level of highest risk or involvement in exploitation. There were two management supervision directions on his record to refer his case to the Complex Safeguarding Service, but this did not happen. This was a practice oversight and, in hindsight, engagement with this Service might have mapped out through a contextual approach, the community risks more clearly in the spaces and places he frequented. The second level focuses upon the safety of communities for all those children (and adults) who use the spaces such as local parks, shopping centres, local shops, and schools. Rather than just centring on changing or strengthening the behaviour of an individual child, or adopting parenting strategies to support the family, this community safety approach would attempt to ensure safer contexts where young people spend their time and, means they can remain in their local areas as opposed to being relocated. As well as a policing role the Police and Crime Commissioner (PCC) is also responsible for tackling crime and the causes of it to ensure safer communities. Effective partnership working at a strategic level is essential and, one of the ways this is undertaken is through district Community Safety Partnerships (CSPs). CSPs consist of five “responsible authorities” (police, local authority, fire and rescue authority, probation, and clinical commissioning groups) and by working together they have a duty to assess local community safety issues and draw up a partnership plan setting out strategic priorities. In the BCP area CSP there are Exploitation themed multi-agency groups at Strategic, Tactical and Network Partner level which are described as moderately effective, but they are slow in pace with often a “start again” focus to the strategic work. Some key roles in these groups have been recently vacant/subject to change, and this is likely impacting on the drive to move systems work forward. At the time there appears to have been a limited coordinated, operational and strategic approach to the management of risk and harm to children when outside of the home, despite a strategy and toolkit being in place https://pdscp.co.uk/working-with-children/child-exploitation/bcp-child-exploitation-toolkit/ Effective strategies and progress of work are required to ensure safer communities which keep a relentless focus on disrupting perpetrators and networks. This Review finds the wider community responses via the BCP CSP to ensuring safer areas were not joined up in the approach needed i.e., in Child M’s community, with a significant gap in understanding and mapping local area hotspots, with adults causing harm and individual or groups of children being exploited. This resulted in children at risk of criminal exploitation being responded to in a fragmented way by services as data was not known about local areas and action plans effectively put in place by the BCP CSP. The impact of drug use and experimentation by adolescent children had a heart-breaking outcome for Child M and his family and other children in the local area. There has been reporting by the regional and local media of this and similar cases: https://www.devonlive.com/news/devon-news/luke-campbell-tapson-died-after-1839845 https://www.bournemouthecho.co.uk/news/19843088.police-update-lauren-hawkins-inquest/ At the time of Child M’s death, the local community came together to raise their concerns: 6 https://www.bournemouthecho.co.uk/news/19535202.mums-emotional-tribute-13-year-old-son-Child M-altun/ https://www.bournemouthecho.co.uk/news/19544559.hundreds-bournemouth-protest-death-Child M-altun/ A community safety partnership strategic response to drug supply and demand needs to be considered in the local area. The Review methodology focused upon asking parents, carers, and community groups from three local schools their views via an on-line survey and a community event. This approach yielded a high percentage completion rate in a short timescale. It indicates groups and individuals wish to be involved and is a good example of working together to ensure a community-based approach and is highlighted as good practice by the BCP CSP and the Partnership. The summary from the 267 Parents/Carers who completed the on-line survey shows: Community knowledge amongst parents/carers was in its infancy at the time of the survey about the risks to their neighbourhoods of criminal exploitation and county lines activity and it is clear more information is needed and wanted. Following the reduction of youth clubs, services, and workers due to austerity, the need to create safe spaces within communities for children was highlighted. Key Learning: Ensure there are continued community-based opportunities and approaches to work together with the local area and ensure safer places to live 65% were aware of county lines related issues 19% were not aware 8% were not sure 8% need more information 7 Parents, carers, and community leads suggested the numerous improvements: Most popular improvement suggestions: 1. Enhanced police and community officers’ presence, particularly in specific areas, parks, and open space areas 2. More information, advice, and guidance for children/young people via schools, outside of school and specific workshops/information for parents/carers at an early help level on spotting the signs of criminal exploitation and how to seek help 3. Increase in youth workers, youth centres, activities to engage young people. Provide more mentoring and advice from those who have been involved and managed to get out Young People Responses: 1. How worried are you about each of the following? Travelling to and from school 68% Being approached to sell drugs 54% Being pressurised to join gangs 56% Crime against other people 48% Being bullied 46% 2. Top 3 worries selected: Becoming a victim of crime 107 responses Being bullied 72 responses Local gangs in your area 69 responses Crime against other people 66 responses 3. Choose 3 things to make you feel safer – options chosen More CCTV 116 responses More police officers in uniform 108 responses Fewer drug dealers 91 More things for young people to do together 81 (youth centres/workers 70 responses) 4. How concerned are you about drug-dealing in the area you live? Never notice 97 responses Rarely notice drug dealing 34 responses Some drug dealing 45 responses Open drug dealing 18 responses 5. Where do you feel most safe? 63% of responders feel very safe/safe during the day in home area 38% of responders feel very safe/safe during the evening in home area 91% of responders feel safest at home, 2% at a friend’s home 6. 55% of responders know how to report non-urgent crime or anti-social behaviour 8 Young people in Years 9/10 were offered the opportunity to share their views via an on-line survey available at the three local secondary schools. There were 210 responses, and a summary of their voices is in the box at the bottom of page 7. The safety themes identified by the young people including travelling to and from school, bullying, gang affiliation and county lines activity will need to be aligned and addressed via a joint approach to action planning from the BCP CSP Strategic Group and Partner Agency Operational Groups. This will undoubtedly also benefit from further opportunities for young people to share their lived experiences as work progresses to understand whether it is feeling any safer for young people because of this joined up approach. 3.2 Working Together with Children & Families Those professionals working with children and young people were unanimous in their views that child criminal exploitation necessitated new ways of working with families as current national safeguarding practice frameworks are mainly focused on intra familial harm to children. Child M’s parents called for system change. This included the adoption of a rights-based approach so that their and their children’s voices are heard, increased training for teachers and other professionals, access to youth workers, and flexible, whole family support. The emotional and psychological impact of exploitation requires specialised support for children and parents/carers. Where this support is aimed at children, consideration is needed regarding what help and support children feel comfortable accessing. The building of social connections and relationships with peers is a key part of development during adolescence and Child M was beginning to explore who he was as a young person. He was described by his family as a very kind and gentle boy and at times they wanted him to remain as the “baby” of their family. Considerable efforts were made by Child M’s social worker towards the end of his life to understand his world; the family see this as ‘good work’ with their son. Many examples of direct work approaches were seen by Child M’s social worker to broker family relationships when supported at a child in need7 stage. This was seen as good practice by the Review Panel and helpful by Child M’s parents as it enabled Child M to have a voice, whilst supporting his parents to enable him to progress through his adolescent development. Child M’s vulnerabilities were known by Children’s Social Care services and work was identified at the end of his life to address his susceptibility to be drawn into situations and to explore his over-friendly nature. At times the culture against ‘snitching’, debt bondage and fear of violent repercussions to themselves and their families renders children reluctant to engage with services. However, this was not true for Child M as a good relationship was built with him by his last social worker. Persistent work with Child M by his social worker and his family support led to the case 7 A Child in Need is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled, Working Together 2018, HMO: Gov: UK Key Learning: Build upon the development of flexible approaches to working with young people to understand their worlds 9 stepping down to Child in Need and ultimately Early Help levels. Solutions when engagement is less forthcoming need to be even more creative and persistent. There was a flexible social work approach, which was responsive and relationship-based with Child M and his family. This often-meant spending time with him in local parks and visiting patterns which were very regular and often out of hours, with text messaging in between. Open conversations about county lines risks were regularly held and at the end of Child M’s life it is likely that risk had significantly reduced, and his situation was being stepped down to early help levels. The main issues identified were of Child M’s confidence levels when in the community and future school plans. Child M was of course still developing as a young person, where experimentation is likely. Drug use was not raised as a known risk through many open and honest conversations. This has been reflected upon in terms of ensuring critical thinking and a professionally curious stance to practice. There is an ongoing police investigation to ascertain the circumstances that led to Child M’s death and any link to exploitation. Professionals who are supported to adopt flexible approaches in building relationships to include children and focus upon understanding their worlds, keep practice rooted in the reality of their lives. The need for more local detached, out of hours working with young people at risk of criminal exploitation is highlighted by this good practice as it is not the norm, and the worker went above and beyond contracted hours. The benefits of a guardianship approach which is built upon trust, mutual respect, hope for change and collaboration can be seen and needs further development within adolescent integrated systems, when delivering new ways of working with young people. This Review highlights the need to work collaboratively with parents and siblings to ensure the right support to help families and manage the risks together. Child M’s older sister and parents have been at the forefront of this Review and wish to continue to offer their insights in further systems thinking, to other families and via community planned events. It is important to have effective systems in place to respond, help or protect children who are being criminally exploited, alongside effective support systems in place to guide families who are grappling with the complexities of criminal exploitation and the push and pull factors that may exist for their children. The work of SPACE8 and the National Parents as Partners (NPIES) forums are helpful to consider when developing more effective systems, strategies and solutions when working with families in tackling criminal exploitation. 8 SPACE is a specialist self-funded organisation founded in 2018 in response to the prevalence of County Lines driven child criminal exploitation. It works to improve the response to children and their families by campaigning, raising awareness and providing training to statutory responders and communities Key Learning: Family-focused service responses need to be embedded across children’s social care, education and the police when working with extra familial harms 10 Good practice was seen from the Child Protection Conference Team in the use of formal escalation at a child protection level when social work practice fell short of expected standards. There is learning for children’s social care in ensuring: • The BCP child exploitation screening tool is completed in a timely manner for all children who are assessed at risk of extra-familial harms. • Social work teams ensure assessments are completed in a timely manner, shared with parents and professionals five working days prior to a child protection conference. • Management oversight and supervision ensures compliance of practice standards. • Interpreters are considered with family consultation and booked in advance of attendance at meetings. • Receiving social work teams attend Initial Child Protection Conferences to ensure a good handover of work • Multi-agency practitioners need to ensure that Child Protection Plans link to identified risk with actions, with a referral to the specialist Complex Safeguarding Team being considered when criminal exploitation is identified. • Risk was identified and responded to at the appropriate levels of need and stepped back down when risk was seen to be reduced9. The warning indicators to Child M’s safety and well-being were shared between the statutory agencies, risk assessed by individual agencies and a child protection plan was established within assessment and plan frameworks when at a level of significant harm10. However, care is needed to ensure children at risk of criminal exploitation are referred to specialist teams by all professionals, working together so to further understand and respond to the risk factors and predictability of extra familial harms. This was not considered at the Initial Child Protection Conference or Review Conference. Professionals’ comments made about high thresholds for referral into this specialist service need careful thought by Children’s Social Care. • Work at a statutory level needs to have a robust link with and common approach to multi-disciplinary services providing Early Help intervention This Review has found some evidence to suggest that the assessments undertaken, and plans put in place focused predominantly on Child M’s behaviours, were single agency and silo-ed in approach and did not look beyond this to the contextual risks with sufficient multi-agency coordination. The reason for the lack of a coordinated approach is likely to rest in the Council not having a systems approach to responding to criminal exploitation. A coordinated and systems wide response to criminal exploitation, backed up by clear policy and procedures would clearly have helped professionals map out risk to Child M and his peers when at school and in the local community and ensure targeted disruption activities. Care needs to be taken to understand the context of extra-familial harms and consider unconscious bias towards marginalised sectors in a community when assessing risk of radicalisation with young people and their families. Understanding the significance of a child’s identity within their community networks when assessing levels of risk is important to check for unconscious bias. Child M’s parents hold the view that the Manchester tragedies and Child M’s comments about these when 9 https://pdscp.co.uk/wp-content/uploads/2021/07/Pan-Dorset-Continuum-of-Need-Guidance-Sept-2020-V2.pdf 10 Working Together 2018, assets. publishing.service.gov.uk, HMO: London Key Learning: Manage risk via multi-agency assessments, plans and contingency in a timely manner 11 aged 9 years old, were blown out of proportion. The Review concurs with this view and has been curious regarding the weight this was given when assessing risk and forming a professional view when extra-familial risk and harms were considered some years later. Professional curiosity and brave conversations are required to challenge assumptions and unconscious bias openly regarding all cultures and identities to ensure incorrect hypotheses are not drawn concerning risks. 3.3 The role of the education system Given his adolescent age and likely due to the fear of the world he was being pulled in to, Child M showed a range of behaviours which were at times challenging, especially when in and around school settings. The typical responses seen to Child M’s higher-level behaviours were to exclude him or manage a move to a different provision and this is a typical response seen in many behavioural policies in schools across the UK as it was likely deemed, they could not keep him or other children safe. Child M had attended three secondary school providers by the age of 13 which would indicate that a behavioural approach was governing his access to learning. Safeguarding and support in Child M’s schools where children’s behaviours were often seen within a lens of perpetrator as opposed to being an exploited child may have resulted in a lack of considering alternative ways to support him within a school setting. It does require a more nuanced approach from education systems in the definition of child as a victim and perpetrator, and a change in mindset where parents often or other professionals supporting the family may be best placed to identify when a child is being groomed and exploited. The education system plays a vital role in keeping children safe. Educational establishments are a source of safety and may also include spaces and places in and outside the school grounds where there are likely and actual risks. The survey results from young people regarding how safe they feel supports this view. Child M’s family also have many questions about how and why he became drawn into a world of drug dealing and anti-social activities, often when or around school. Professionals shared views on the need for focused work to understand the context of some school settings in terms of risk to individual and groups of children who may be easily influenced and groomed into a world of extra-familial harms. This would be helpful alongside considering alternative strategies to managed moves or exclusions to support children with challenging behaviours to remain within their own school setting. Education responses and action plans are required to minimise the risks and to keep future children safe. The relationship between a Council’s admissions processes and Academy Schools is complicated. Since 2014 Academies are their own admissions authority except where variations have been Key Learning: Safeguarding systems should not focus solely on a child’s behaviour in school. The context of school spaces and places need to be considered in terms of safety and likely/actual risk to children. Key Learning: Parents/Carers need more information and guidance about the process of managed moves, exclusions, and re-integration. Family cultural and language barriers need to be checked and responded to by the local authority and education providers 12 written into their funding agreement to support fair access11. If an Academy School refuses to accept a child, the Council are not able to direct them to do so. The matter can be referred to the ESFA12 and the Secretary of State can make direction. Managed moves are agreed between individual schools. In BCP area headteachers have not been able to agree a single process that they are all willing to adopt. There is local authority guidance, but there is no obligation for schools to adhere to this. When children are excluded, statutory process applies13. The statutory processes and procedures as referenced (13) sit alongside the local provisions available when children’s behaviours are seen as difficult to those tasked with educating them. (There is currently a local consultation and review of the In Year Fair Access Panel in BCP Council). The length of time taken for the transfer between mainstream and specialist educational establishments following exclusion or re-integration was considered. Child M’s parents feel very strongly about the length of time that Child M was out of education and think their voice or choice about provision of suitable educational settings for their son were not heard. They said they felt “compelled” to send Child M to a school they did not feel was the right place for him. Child M also talked openly about feeling scared at this alternative provision and how the other children’s behaviours made him feel unsafe. In summary this Review finds educations provisions: • focused too heavily on Child M’s behaviours as opposed to understanding what was happening to him to likely cause the behaviours. Strategies to support and manage behaviours were limited. • did not give enough weight to checking Child M’s parents understood education processes and ensuring their voice was heard about alternative school options. • too variable in keeping Child M safe and minimising risks. 4. Recommendations This Review highlights a need for a range of effective approaches and interventions when working with children who are or likely to be criminally exploited. There are recommendations based upon the three areas of key learning. Criminal Exploitation 1. The BCP CSP Chair should work to ensure that the draft written action plan is in place and includes actions to strategically address criminal exploitation / serious youth violence and drug use in the local areas. This plan should detail specific measurable outcomes to know whether communities are safer. The action plan should detail work with the planned violence reduction unit longer-term and the BCP Youth Strategy. 2. The BCP Community Safety Partnership, in collaboration with the wider range of local agencies, should enhance current quarterly data collection/intelligence processes to gather information about community hot spots, including local schools / serious youth violence / 11 The Fair Access Protocols ensure that all schools in an area take a fair and balanced approach when admitting vulnerable children, including those whose behaviour is seen as challenging 12 The ESFA is the Education Skills Funding Agency and is a single Government agency accountable for funding education and skills for children, young people, and adults. 13https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/921405/20170831_Exclusion_Stat_guidance_Web_version.pdf 13 county lines activity in and around the surrounding areas. This should be shared with a senior operational multi-agency group (children’s social care, health, police, and education). This data would inform the BCP CSP Strategic Action Plan (Action 1). The operational multi-agency group and BCP CSP should join up their approaches to align strategic and operational work to disrupt criminal exploitation activities and map individual or groups of children at risk 3. BCP partners (Police, BCP, Education etc.) should consider facilitating further community events in the next six months to listen to the local community, (families and young people) to ensure work is rooted in reality and ‘lived experience' and check whether communities feel safer. Working Together 4. The Child Exploitation (CE) Screening Tool should be completed at all levels of intervention from early help and statutory levels of assessment when exploitation is the main risk and should form the basis of multi-agency decision-making with the family on whether a referral to the Complex Safeguarding Service is needed. A multi-agency audit of 20-40 children at risk of CE should be completed, led by the Partnership’s QA Group to check individual children are accessing the right service at the right time according to need and achieving the desired outcome. The scoping of the audit should consider any barriers to completing the CE Screening tool. 5. The CSP and the Partnership should facilitate a revised training/learning offer on criminal exploitation to be provided, which should include the key learning from this thematic review and ensures the voices of the community and families are represented along with the effective use of the CE Screening Tool. Education Systems 6. The Director of Education in BCP should consider the education issues outlined in this report and provide an update by June 2022 to the actions already detailed in the WSOA (link). These actions should address the issues around the fair access protocol and how children transition from one school to another. This work should also consider how all parents are informed and supported to understand their choices. 7. The Director of Education should consider the development of a multi-disciplinary programme to proactively support pupils at risk of exclusion, particularly where due to substance misuse and/or criminal exploitation. An update should be provided by June 2022. It should also be considered how parents/carers can co-produce policies and protocols going forward. 5. Conclusion It is highly complex work to ensure systems and practices are based upon the values of being rights-based with children whilst also ensuring their safety, as undoubtedly tension exists between the two. This thematic summary of Child M’s last years of life shows how there is a need for a range of approaches and interventions across services when working with children vulnerable to criminal exploitation. This includes preventative, educational work at the child and family level, system change to help and support children and families exploited or at risk of exploitation and 14 community measures aimed at the provision of safe places and spaces both in local areas and school settings. At the heart of all these approaches sits the need to listen to and involve children and their families and to work in a way which is respectful, strengths based, and hopeful, whilst also being rooted in reality. At the child level, consideration is needed regarding school inclusion and exclusion practices and how to hold children when their range of behaviours are seen as difficult or risky. At the family level, the challenges of parenting adolescents and the impact of exploitation on parents and siblings should be supported. At the system level, there needs to be change so that child and family and community voices continue to be heard and included in decision making. This requires an adapted, flexible system able to work with extra familial risk and harms to adolescents. In addition, consideration is needed about the creation and maintenance of safe spaces and places for children in the wider community via a commitment to joined-up work from the BCP Community Safety Partnership. More attention is needed nationally regarding the way the county lines models present and adapt within local contexts and especially in the context of COVID-19, so that this data and information can be used to develop appropriate prevention and safeguarding strategies. The Review has started this journey of much needed improvements in the join up of local systems and there is much community and professional appetite for the work to continue. In honour of Child M and in listening and involving his family and local community, the Partnership and BCP area CSP are now committed to drive forward the recommendations outlined in this Report. By doing so the aim is for young people in the local area to enjoy a safe community, where their hopes and dreams for the future can be achieved. This is the legacy and promise to Child M and his family. 6. Family Comment Child M’s mother met with interim Director of Safeguarding Children and Early Help at the BCP Civic Centre on behalf of the Review panel to provide feedback on the Report which had been finalised and translated into Turkish for the family. As would be expected this was an emotional meeting. M’s mother wanted to pass on the thanks from his family for the Review and the Summary document which the family felt to be considerate and caring, a celebration of their much-loved son’s life, with a strong child focus. The family felt that the Review had completely achieved what it had set out to do and what the family had expected. M’s family fully agree with the contents of the report, accept the findings of the Review, and welcome the recommendations made in the Learning Summary. The family particularly wanted to thank the Alevi community who attended the focus group meeting with agency representatives in December 2021 and the young people in local schools (and their parents/carers) for their feedback on safeguarding risks within their community and many suggestions for addressing these. M’s sister also wants to carry forward the legacy of her brother’s life by working closely with the youth branch of their local Alevi community group to share her experiences and the learning from her brother’s tragic death with other young people from the community to make a difference to their lives. The family accepts and understands why the Report does not refer to the detail of the incident, as the case continues to be a live police investigation. The family support publication of an anonymised Thematic Review Report and summary referred to as Child M. |
NC047753 | Death of a 3½-year-old African boy in November 2015. There were indications that there might have been some degree of force feeding, causing ingestion of food into the lungs. The father was found guilty of manslaughter and child cruelty. Family was known to children's services and children had previously been subject to child protection plans for neglect, physical and emotional abuse and children in need plans. Family history of: missed health, optician and speech therapy appointments and repeated attendance at accident and emergency departments due to children's injuries. Maternal history of: low level neglect; domestic violence; disguised compliance; health problems due to AIDS and missed medication. Paternal history of: physical abuse; domestic violence; refusal to attend parenting education; irregular attendance at the home as he rented another property where he stayed four nights a week. Child G's teenage step-sister had joined the family from Africa and was providing care for her step-mother and step-siblings. Identifies findings including: lack of recognition of the impact of the mother's ill health on her parenting capacity; insufficient awareness of father's lifestyle and the reliance placed on Child G's step-sister to provide family care; parental inhibition of their children's voices; problems in information sharing following the family relocation; and professionals overlooking the needs of the children. Sets out key findings and opportunities for learning. Recommendations include: amending the Neglect Toolkit to include feeding issues and dental health; practice tool to be used by the Health Visiting Service to ensure systematic and robust information capture for new families.
| Serious Case Review No: 2016/C6264 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. ‘BOROUGH 2’ SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD G FERGUS SMITH 29.11.16 Contents 1 INTRODUCTION 1 1.1 Background & event triggering a serious case review 1 1.2 Purpose & conduct of the serious case review 2 2 FAMILY HISTORY & CHILD G’S EXPERIENCES 5 2.1 Introduction 5 2.2 Family’s move to current borough 7 2.3 Assumption of responsibility by borough 2’s Children’s Social Care 12 2.4 First review child protection conference (RCPC) in borough 2: protection plans retained 16 2.5 Second review child protection conference in borough 2: step down to ‘child in need’ status20 2.6 Case closure by Children’s Social Care 23 2.7 Renewal of child in need plan in response to domestic abuse 24 2.8 Initial child protection conference: protection plans formulated 26 2.9 Further review child protection conference: step down to ‘child in need’ status 36 2.10 Case closure by Children’s Social Care 39 3 RESPONSES TO TERMS OF REFERENCE 41 3.1 Introduction 41 3.2 Quality of assessments 41 3.3 Thresholds 44 3.4 Culture, religion & language 45 3.5 Voice of the child 46 3.6 Information sharing 48 3.7 Supervision & management 50 3.8 Resourcing & organisational change 51 4 FINDINGS & CONCLUSIONS 52 4.1 Findings 52 4.2 Opportunities for learning 53 5 RECOMMENDATIONS 55 5.1 Introduction 55 6 BIBLIOGRAPHY 57 7 FINAL TERMS OF REFERENCE 58 CAE 1 1 INTRODUCTION 1.1 BACKGROUND & EVENT TRIGGERING A SERIOUS CASE REVIEW 1.1.1 On 27.11.15 at 17:20 child G’s father made a 999 call and asked for an ambulance to be dispatched to one of his children (a 3.5 year old male of African ethnicity referred to in this report as ‘child G’). Father explained to Ambulance Control that he had just fed child G, gone upstairs to obtain a nappy and returned to find his son limp and unresponsive. Father was advised to initiate cardio-pulmonary resuscitation while awaiting an ambulance though there remains doubt about whether he did so. 1.1.2 In spite of the ambulance crew arriving only six minutes later, efforts to resuscitate child G were unsuccessful. He was transported to the local ‘hospital 1’ arriving at 18.05. At 18:32 life was pronounced extinct. Mother who had not, it is understood, been present at the time of her husband calling an ambulance, returned home in time to accompany her son to hospital. 1.1.3 Following provision of inconsistent explanations of the lead-up to the 999 call, both parents were arrested. There were indications that child G might have suffered some degree of force feeding, causing ingestion of food into the lungs. A criminal investigation was initiated, and child G’s three other siblings were placed with a foster carer. 1.1.4 Prior to child G’s death, his family had been in receipt of a significant level of services from Children’s Social Care in a neighbouring ‘borough 1’ and when the family moved there in December 2012, from Children’s Social Care in ‘borough 2’ where he died. RAPID RESPONSE & CONSIDERATION OF A SERIOUS CASE REVIEW 1.1.5 In accordance with the Local Safeguarding Children Board Regulations 2006 and local agreed procedures, child G’s death was reviewed at ‘rapid response meetings’ on 01.12.15, 07.12.15 and 17.12.15. It was concluded that the primary criterion for initiating a ‘serious case review’ (SCR) which are reproduced in paragraph 1.2.1 below, was satisfied and a recommendation made to the independent chairperson of the borough’s Safeguarding Children Board that a serious case review be commissioned. The chairperson ratified that recommendation and the Department for Education’s regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE) were immediately informed. 1.1.6 This serious case review was undertaken between January and July 2016. Parallel criminal inquiries led to a decision by the Crown Prosecution Service that father would be charged with manslaughter and child cruelty (he was subsequently found guilty and has been imprisoned). Mother faced no criminal charges. A Coroner’s Inquest has been initiated and is currently adjourned awaiting further evidence. CAE 2 1.2 PURPOSE & CONDUCT OF THE SERIOUS CASE REVIEW 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died [this case satisfied that criterion] or been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. A serious case review is not concerned with attribution of culpability (a matter for a criminal court) or cause of death (the role of the Coroner). The period for review was from the date of the family’s move to the area in December 2012 to the day of child G’s death. An independent report was commissioned from www.caeuk.org and it was agreed that upon receipt of relevant material the lead reviewer Fergus Smith would: Collate and evaluate it Conduct any required supplementary enquiries Develop for consideration by the review group a narrative of agencies’ involvement, an evaluation of its quality, conclusions and recommendations for action by the local Safeguarding Children Board and member agencies 1.2.3 The review group consisted of the: Independent Chairperson of the LSCB A Lay Member / Deputy Chairperson of the LSCB Independent Lead Reviewer Locum Designated Doctor Associate director of Quality, Safeguarding & Safety (NHS Foundation Trust) Head of Service (Quality Assurance & Service Improvement Children’s Social Care) Designated Nurse (Borough 2 Clinical Commissioning Group) Review Officer (Police) Interim Head of Safeguarding & Quality Assurance (Children’s Social Care) Divisional Director Education Services Principal Lawyer for Borough 2 The LSCB Business Manager & a Support Officer 1.2.4 A copy of this report is being sent to the government-appointed national panel of independent experts (NPIE) and to the Department for Education (DfE). CAE 3 INVOLVEMENT OF FAMILY MEMBERS 1.2.5 To avoid the risk of contaminating trial evidence, father’s involvement was deferred. A translated invitation to contribute was sent by the LSCB to child G’s mother and a further invitation issued later by the lead reviewer. Mother has not responded. The advice of the allocated social worker and Children and Family Courts Advisory and Support Service (Cafcass) officer was that sib.3, though old enough, is too emotionally disturbed to contribute without risking further distress and damage (in consequence of some of her observed conduct, a psychiatric opinion has been sought). The younger children were regarded as having insufficient understanding to evaluate services delivered. 1.2.6 The report has been anonymised to minimise the risk of identifying family members or involved professionals and is being published on the national repository of completed serious case review reports. TIMETABLE FOR COMPLETION OF SERIOUS CASE REVIEW Event Date Decision to initiate serious case review & formal notifications 18.12.15. Completion of merged chronology 18.03.16 Panel meeting 1 03.03.16 Consultation / briefing of professionals 09.03.16 Panel meeting 2: analysis of submitted agency reports 14.04.16 Panel meeting 3: analysis of revised and delayed reports 12.05.16 Panel meeting 4: panel debate about all remaining incoming material 27.05.16 Panel meeting 6: debate about revised and delayed reports 08.06.16 Panel meeting 7: discussion of preliminary overview of 15.06.16 20.06.16 Revised draft submitted 29.06.16 Practitioners’ event November 2016 Involvement of family members Father - deferred during criminal proceedings; mother: 2 offers made; sib. 3 too vulnerable Presentation of final draft to Safeguarding Children Board 08.12.16 Submission of report to national panel of independent experts (NPIE), Department for Education (DfE) & NSPCC repository December 2016 CAE 4 STRUCTURE OF CHILD G’S FAMILY Father Age 31 Mother Age 34 Unknown Step-sister Sib.3 Age 17 Sib.2 Age 8 Sib.1 Age 9 Child G Age 3.5 CAE 5 2 FAMILY HISTORY & CHILD G’S EXPERIENCES 2.1 INTRODUCTION 2.1.1 The period for review was December 2012 when the family moved from adjoining ‘borough 1’ to the current ‘borough 2’ through to November 2015 when child G died. The following summary of the family’s history prior to its move, helps to evaluate better the events that occurred after it. Italicised comment on professional practice is provided at relevant places and issues arising from such observations are further analysed in section 3. PARENTAL ORIGINS, RELATIONSHIP & INITIAL CONCERNS 2.1.2 Information provided by borough 1 indicates that both parents were born in the same central African country, came to the UK over a decade ago, met in their local church and were married in 2004. 2.1.3 Records confirm that Children’s Social Care in borough 1 was aware of mother’s chronic blood-borne infection1. Borough 1’s Children’s Social Care first became aware of the family when medical staff at ‘hospital 1’ initiated a referral rooted in a concern that mother was not taking her own prescribed medicine nor administering necessary anti-viral medication to her then new-born child sib. 1. FIRST SUSPICIOUS INJURY: SIBLING 1 2.1.4 In November 2006 sib.1 (aged 9 months) was taken to hospital 1 by both parents with what was diagnosed as a broken left clavicle. Examination also revealed three old rib fractures. Parental explanations were inconsistent with the medical observations and after an initial child protection conference, the child was made subject of a child protection plan. Care Proceedings were initiated and in a fact-finding hearing in February 2007 the Judge concluded the rib fractures were non-accidental and could have been caused by either parent. 2.1.5 Whilst legal proceedings were continuing, mother gave birth to sib. 2 in July 2007 and the new baby, mother and father, moved to a residential assessment centre where they were later joined by sib.1. The outcome of the residential assessment was positive and the family was discharged in December 2007. Both children were made subject of a child protection plan later in December (in consequence of physical abuse) and an extensive support package put in place. 2.1.6 A final hearing in May 2008 resulted in a 1 year Supervision Order and a joint Residence Order (the latter intended to assist father’s immigration application). By August 2008 the children ceased to be subject of protection plans. 1 Mother had been HIV+ for some years and her condition deteriorated to the extent that during the period under review, she was living with AIDS. CAE 6 FURTHER SUSPICIOUS INJURY SIBLING 1 & BROADER INDICATIONS OF NEGLECT 2.1.7 An injury to sib.1’s face observed by a health visitor in October 2008 was investigated under s.47 Children Act 1989 and the explanation provided by his father found to be credible. A month later the health visitor re-referred with concerns about a parental failure to protect their children e.g. not seeking medical advice in the event of illness / accident, insufficient stimulation of both children (sib.1 spent long periods of time in a high chair and had few toys) and developmental delay. The health visitor also relayed a parental claim that both children (aged 3 and 2 respectively) slept from 4pm until 8am or 9am next day. 2.1.8 The 1 year Supervision Order with respect to sib.1 expired in May 2009 and marked a further decline in parental co-operation. 2.1.9 On a date in late August 2009 both parents brought their then 3.5 year old son sib.1 by bus to hospital 2 where he was treated for a fractured left femur. A number of suspicious features were recognised and further medical examinations arranged. The parents denied any involvement of Children’s Social Care. Legal proceedings were commenced though the children remained in the care of their parents during that time. 2.1.10 The expert opinions of an orthopaedic paediatric and a paediatric radiology consultant were that the parental explanation was plausible. The injuries were concluded to have been accidental and in October 2009, proceedings were by agreement, terminated. The case remained open with minimal involvement until it was closed in August 2010. INITIAL & REVIEW CHILD PROTECTION CONFERENCES 2.1.11 Both parents were involved in crimes of dishonesty in 2010. Of greater relevance was a growing concern during 2011/12 about ‘low level neglect’ and in May 2012 sib.1 reported at his school, physical abuse by his father. This prompted an initial child protection conference in July 2012, the result of which was that all three children were once again made subject of child protection plans under category of ‘physical abuse’. 2.1.12 Sib.1 revealed at this time that he had been told by his parents to deny being hit by his parents and there were occasions on which the children had been left alone emerged. The school was aware that the children were wary of their parents to the point where staff had become reluctant to raise any concerns with them about the children’s conduct (aggression and violence toward peers) lest it result in them being physically chastised. CAE 7 2.1.13 At a review child protection conference in October 2012 concerns remained about the impact on child G of witnessing parental use of physical punishment of his siblings, as well as mother’s ability to function as a result of her chronic medical condition. Plans were re-formulated under the category of ‘emotional abuse’. The level of parental co-operation increased during this period, in particular with the last of several social workers allocated to the case. 2.2 FAMILY’S MOVE TO CURRENT BOROUGH TRANSFER OF INFORMATION 2.2.1 It is understood that the family moved into its ‘address 1’ in early December 2012. An electronic transfer of school health records was completed two days in advance of that move and a phone briefing provided by an unidentified health professional to borough 2’s HV1. HV1 in turn sought to contact the then allocated social worker in borough 1 (SW3) by phone and was told she was on annual leave until January 2013. Comment: although a few days after the actual move, the briefing of the family’s health visitor about this vulnerable family was good practice; the social worker’s leave was unusually extended and it is unclear whether the arrangements for covering her caseload were made known to callers. 2.2.2 Paper records were received only on the day of the home visit described below and arrived in Community Health via a third borough’s Safeguarding Children Office implying that borough 1 might have transferred the relevant material to the wrong borough. Comment: though transfer of records is now completed electronically, the risk of human error in defining the intended destination will always remain. INITIAL CONTACTS WITH FAMILY 2.2.3 HV1 managed after further efforts to make contact with borough 1’s SW4 whom it appears had by then replaced SW3. He was told of HV1’s planned home visit three days later. At HV1’s home visit she met mother and all three children. Child G was observed to be developing normally and to be up-to-date with his immunisations. Dental care, diet and nutrition were discussed and HV1 recorded no concerns. A follow-up visit in two weeks (it later transpired this was to become a phone contact) was planned and no specific needs or risks were noted. Comment: the records do not refer to the mother-child or child-child interactions nor to the observed affect of each family member, which, given the existence of child protection plans, were relevant. CAE 8 PLANNING FOR A TRANSFER-IN CONFERENCE 2.2.4 On 09.01.13 and 16.01.13 borough 1’s SW4 asked for a ‘transfer-in conference’ to be arranged and supplied minutes of the review conference of October 2012. Borough 2’s records of the calls suggests that no chronology of involvement was supplied at this time nor before the conference when finally held some five months later. Evidence was found during the course of this review confirming the provision of a partially legible though nonetheless usable ‘system-generated’ chronology. The papers supplied to borough 2 indicated that there had been no recent repetition of inappropriate physical punishments. Comment: ‘transfer-in’ conferences should, in accordance with the Child Protection Procedures be convened within 15 working days of a family’s arrival; earlier if the move is known in advance. All available material should be supplied. Support & monitoring from health professionals in borough 2 2.2.5 Having spoken with mother by phone on 31.12.12 and the day before to confirm availability, HV1 called on 22.01.13 and again met mother and all three children. Her records indicate child G was alert and well and had been registered with a GP. There was a routine discussion and a reminder about immunisation. Mother reported (accurately) that borough 1’s social worker had visited twice since HV1’s last visit. Comment: HV1’s actions suggest a careful attention to detail. Authorisation of ‘transfer-in conference’ 2.2.6 Borough 2’s Children’s Social Care records confirm that by 17.01.13 the deputy in that agency’s Multi-agency Safeguarding Hub (MASH) had authorised a transfer-in conference and that by 02.02.13 the existing child protection plan, conference report and core group minutes, though not what was perceived to be a missing chronology had been received. Comment: the absence of an anticipated chronology (unjustifiably) delayed the convening of the required transfer-in conference. At his supervision on 23.01.13 SW4 had assured his supervisor that all relevant documents had been sent to borough 2. A recommendation is included in section 5. 2.2.7 HV1 sought from borough 1’s SW4 the date of the next ‘core group’ and commented upon the absence to date of liaison. Records transferred in December had referred to a core group having already been scheduled for 10.01.13, though there is no evidence to confirm that it was held. Records do not confirm that SW4 returned HV1’s call. On 29.01.13 borough 1’s School Nursing Service made phone contact with its equivalent in borough 2 and provided a briefing. School nurse SN1 initiated liaison with school 1, a clinic and Children’s Social Care. The latter agency informed her that the case had yet to be allocated and was awaiting a ‘transfer-in conference’. Comment: the actions of the school nurse represented good practice. CAE 9 2.2.8 Child G’s mother had some contact as an out-patient and (briefly) as an in-patient at hospital 2 at this time. Some doubts about her compliance with medication were noted. There was no indication of involvement of any social worker and it is uncertain whether a ‘flag’ in mother’s GP medical notes was an accurate or historical reference to her children being subject of child protection plans. There was anyway no code in the children’s records at this time. Comment: the potential value of a ‘flag’ to alert a GP to safeguarding issues is lost if the record does not appear in child/ren’s record and/or is incorrect. 2.2.9 An unremarkable new patient screening for sib.1 was completed on 14.02.13. On the same day School Health received paper records from borough 1 and arranged for their collection. Comment: the physical collection by SN1 minimised the risk of loss and was an example of standard good practice. Formal initiation by borough 2 of transfer-in conference 2.2.10 On 18.02.13 the Child in Need (CIN) deputy team manager recognised that what had been merely noted in mid-January as a ‘contact’ requiring no significant response, needed to be re-designated to trigger action. She initiated a request for a transfer-in conference by 11.03.13. The delay was ascribed to a failure to provide borough 1 with records. Borough 2’s SW5 became the allocated social worker and made efforts via email to acquire the documents required from the previous borough. Comment: the arrangements for a transfer-in conference should have been more robust than it was in this instance. In accordance with child protection procedures, case accountability remained with borough 1 pending re-allocation at a formal conference. 2.2.11 HV1 made a planned visit on 20.02.13 to find curtains drawn and no response to phone calls. Later that day borough 1’s SW4 indicated that the overdue conference was scheduled for 06.03.13 (Police records indicate instead an intended date of 13.03.13, later postponed to 27.03.13). Borough 1’s SW4 reassured HV1 that he had been visiting regularly and had no concerns. HV1 expressed concern about the absence of core groups and lack of communication from SW4. Comment: The report supplied by borough 1 confirmed visits by SW4 on four occasions to the end of February; no conference was held on 06.03.13 and no explanation has been found for the reported statement that it would be (though borough 1’s SW4 did meet mother and children on that date). 2.2.12 HV1 made a further two unsuccessful attempts in February to complete planned home visits as well as a third unplanned visit in March when she was denied entry. She was unable to get confirmation from Children’s Social Care of the conference she thought was scheduled for 27.03.13 and it remains unclear whether a report she prepared was actually submitted. Comment: HV1 would have been justified in escalating her concerns. CAE 10 Support & monitoring from education & health professionals in borough 2 2.2.13 Borough 2’s SW5 helpfully tried to agree a joint visit with his counterpart SW4 but the latter reported that he was unable to do so in advance of what was still anticipated to be a transfer-in child protection conference. An initial visit by SW5 alone on 07.03.13 indicated that he found that ‘the home circumstances seemed on the surface good’. A second visit a fortnight later also revealed nothing of concern and his record included an observation of a smiling child G. Comment: the date of the potential conference remained uncertain; further confusion arose when SW4 and SW5 discussed a potential step-down to child in need status and in consequence convening the meeting in borough 1. 2.2.14 On 18.03.13 child G’s elder brother ‘sib.1’ (aged 7) transferred from school 1 to school 2 and entered Year 3. A week later its head teacher HT1 received a call from borough 1’s SW4 who had been alerted to a report of mother hitting her daughter sib.2. SW4 was at this point still anticipating a conference two days later. There was no confirmation of these contacts in the report provided to this review by borough 1 and it appears likely that this incident was not shared with SW5. 2.2.15 HV1 tried again on 22.03.13 to obtain confirmation about the conference she understood to be scheduled for 27.03.13 (three and a half months after the family had moved into the area).Nobody in the office was able to help. A borough 2 Children’s Services supervision record dated 22.03.13 referred to a borough 1 decision to convene the conference there because it now planned to step-down to child in need status. Comment: the response to the health visitor was unacceptable and she should have escalated her concern about this muddle; appropriate multi-agency debate and decision-making that a conference offers should not be pre-empted. Postponement of the scheduled transfer-in conference 2.2.16 The actual decision to postpone or indeed cancel the anticipated conference was a result of a disagreement between respective independent chairperson 1 (borough 1) and 2 (borough 2). The exchange occurred only after borough 2’s SW5 had actually travelled to borough 1 on 27.03.13 in anticipation of the meeting. Borough 1’s SW4 completed his sixth home visit to the borough 2 address on this date. Comment: the needs of the children were overlooked in this relatively academic exchange. A debate focused on the needs of the children should have taken place at the by now long overdue transfer-in conference. 2.2.17 The organisational tension implied by the exchanges between independent chairpersons risked exacerbation when borough 2’s manager decided on 12.04.13 to close the case and re-open it when a conference was convened. A senior manager in borough 2 then appropriately directed the conference to be held in his area within 15 working days. CAE 11 2.2.18 In response to an enquiry from Police at this time, borough 1’s SW4 reported that the planned conference (he is quoted as saying “on 20.03.13”) had been postponed and that ‘senior managers’ in both boroughs were ‘having meetings about next steps’. 2.2.19 HV1 made a further unsuccessful attempt to access the family on 17.04.13 when she visited unannounced. Next day the lunch-time supervisor at school 2 reported child G’s older brother sib.1 (then aged 7) was wearing a nappy / pull-up. When staff from the medical room spoke to him, he indicated that mother had told him not to tell anyone. 2.2.20 When contacted, mother denied that her son was wearing a nappy. Next day, sib.1 clarified that he wore a ‘pull-up’ to bed and had forgotten to take it off in the morning. Comment: whatever the reason for or frequency of sib.1’s use of nappies, the episode suggests a lack of transparency on the part of mother. 2.2.21 What would have been an advisable joint visit by HV1 and borough 1’s SW4 was cancelled by the latter and not re-arranged. An opportunity to gain an insight into domestic childcare arrangements was also lost when at a pre-operation assessment of mother at the local hospital 1 on 02.05.13, relevant sections of the form were left blank. 2.2.22 There was further confusion in early May when the borough 1’s independent chairperson confirmed that all required material had been provided to borough 2 but the newly allocated SW6 from the latter area indicated that no chronology has arrived (a conference report, protection plan and core group meeting notes had done so). Comment: in the view of those who have seen the systems-generated chronology, it was poorly presented but nonetheless of use. 2.2.23 HV1 succeeded in gaining entry when she made a further unannounced home visit on 09.05.13. Her records indicate that she addressed mother’s lack of compliance and was given an apology as well as a current mobile number. HV1’s observations of child G (then 14 months old) indicated that he was alert, well, active and developmentally within normal limits (though not yet walking unaided). 2.2.24 Nutrition and food was discussed and mother reported that her son had a good appetite, enjoyed home cooked meals and that his diet was being supplemented with multi-vitamins. HV1 noted that child G’s lower lip was slightly swollen with a ‘little pale old white mark line’. Presumably because mother could not explain the cause of the mark, HV1 assumed that child G had hit his lip against something. She then discussed home safety and accident prevention. Comment: the minor injury noted by HV1 could have been connected to the manner in which the child was fed; she should have been more curious though in the absence of other indicators it is unsurprising that such a rare cause was not considered; the contribution of child G’s father to his children’s care is not apparent from records. CAE 12 Ongoing monitoring by borough 1’s Children’s Social Care & allocation of borough 2’s social workers 2.2.25 There were it seems, no core groups arranged by borough 1 and limited contact by its allocated social worker during the six months in which the transfer-in conference was awaited. Although borough 2’s SW5 had been allocated on 18.02.13 involvement had been limited to two home visits. On 02.05.13 borough 2’s SW6 became case-accountable and a record indicates that she reminded borough 1’s SW4 to bring the still-awaited chronology to the conference on 21.05.13. Comment: case management of a family living in another area is intrinsically more demanding and is why the agreed regional procedures require a prompt 15 working day transfer of responsibility. 2.3 ASSUMPTION OF RESPONSIBILITY BY BOROUGH 2’S CHILDREN’S SOCIAL CARE TRANSFER-IN CONFERENCE 2.3.1 The transfer-in conference was finally held on 21.05.13. Borough 1’s SW4 and his senior were the only representatives from that area. In spite of the lengthy delay in it being convened, the head teacher of school 2 HT1 was apparently given insufficient notice to enable her attendance (a recurring problem). Police were represented though it remains unclear which agencies were subsequently sent minutes. 2.3.2 The report from HV1 was generally positive with respect to mother’s level of co-operation, receptivity to advice and observations of how she related to her children. HV1 reported no examples of risk since her first involvement some six months earlier. The conference noted but did not explore a reference to sib.1 (aged 7) having a lock on his bedroom door and it is uncertain whether allegations of hitting and/or the nappy incident were debated. The outputs of the conference included the following: Borough 1 to provide a chronology of contacts (this had been sought for over six months, though as indicated elsewhere borough 2 did actually possess sufficient to use or challenge) A family group conference (FGC) was to be arranged (a task first identified whilst the family was in borough 1) A core assessment which would include the impact of mother’s chronic illness, father’s role in the family and the support from extended family Comment: HV1’s report is at odds with her four ‘no access’ visits of which three were planned; recent apparent engagement may have been unduly influential. 2.3.3 The decision was made that all three children would remain subject of a child protection plan for ‘physical abuse’ (a reflection of the previous physical punishment of sib.1 and sib.2). CAE 13 2.3.4 HV1’s child protection supervision immediately preceding her conference attendance had been essentially task-focused and had not included discussion of the risk of physical punishment of child G. Although an identified ‘strength’ was mother’s reported seeking-out of services that would offer her toddler more stimulation, which services she had actually considered was unrecorded. 2.3.5 HV1 had covered for SN1 who was unable to attend the conference. She later prompted SN1 to write to the parents urging them to ask their GP for a referral to the enuresis clinic for sib.1. Though un-represented at the conference, specialist hospital 2 was sent a copy of the protection plan of 21.05.13. It received no further reports. Comment: it is uncertain why neither HV1 or SN1 initiated direct contact with the GP Practice. IMPLEMENTATION OF INITIAL CHILD PROTECTION PLANS 2.3.6 Borough 2’s SW6 made her first home visit on 29.05.13. Her records indicate that child G was again sleeping strapped in his buggy and this was ‘to be discussed at her next visit’. Father refused to contemplate attending a parenting course though this had been agreed previously in the course of borough 1’s involvement. 2.3.7 On 04.06.13 mother consulted a locum GP1, not about sib.1’s enuresis but about stammering which she reported began at the age of 5. A referral for speech and language therapy was initiated two days later. Sib.1 was not present. Medical presentation 1: child G / respiratory condition 2.3.8 About a fortnight after the conference decision that all three children still required protection plans, child G was brought (by which parent was un-recorded) to hospital 2’s Urgent Care Clinic and was reported to have experienced diarrhoea and vomiting for some days. A ‘respiratory infection’ was diagnosed and the allocated social worker was informed by the unit’s liaison health visitor on the same day. Medical advice to the serious case review has indicated that unless such infections become frequent, further exploration should not be expected. Comment: the clinic IT system had helpfully enabled the doctor to be aware of child G being subject of a protection plan. Upon notification, the event was also promptly up-loaded onto borough 2’s health visiting database. Core group 1 2.3.9 HT1 was (for the second time) given insufficient notice of a multi-agency event and was unable to attend the first core group in borough 2 on 07.06.13. Present were borough 2’s SW6, HV1 and a school 2 special educational needs co-ordinator (SENCO). Neither parent attended and in spite of an unannounced home visit later that morning by HV1, it did not prove possible to make contact with either parent. Comment: it was to be over two months before the record was inputted of that core group, leaving it invisible to colleagues until then. CAE 14 2.3.10 On 13.06.13 mother consulted GP2 about sib.1’s nocturnal enuresis. An analysis of a urine sample (a routine step in formulating a referral to an Enuresis Clinic) showed no infection. Comment: sib.1 (aged over 7) was reported never to have been dry at night – an unusual phenomenon justifying exploration e.g. there is evidence bedwetting children are more likely to have behaviour problems (Joinson 2007) and that consequential stress within families can be considerable with an increased risk of child punishment including abuse (Sapi 2009): http://www.eric.org.uk/Professionals/info_bedwetting_wetting_professionals#sthash.1Dqn3prS.dpuf. 2.3.11 On 14.06.13 (possibly prompted by a concern about mother’s non-compliance with medication) a specialist nurse from hospital 2 initiated contact with borough 2’s SW6 who undertook to send a child protection report to the nurse. 2.3.12 At a further home visit on 26.06.13 SW6 was told about father’s other daughter and his plans to bring her to the UK. SW6 was also given addresses for mother’s own mother, brother and sister. The former lived in the same region. In SW6’s supervision several days later, it was agreed borough 1 should again be chased for a chronology of its involvement. Comment: the potential value of case history was clearly recognised; what was overlooked is the utility of what was already possessed by borough 2’s staff. Further contact by health professionals & referral to Children’s Social Care 2.3.13 Sib.1 (aged 7.5) was seen at his school by school nurse 1 on 01.07.13. Her observations (shared at the second core group later that month) were that the child looked well-presented though had a hole in one of his shoes. Sib.1 said he liked school and his friends and reported he had been to an optician but not to a dentist. Relative weight and height were comparable at the 97th centile i.e. sib.1 was much taller and heavier than most of his peers. An examination of sib 2 by SN1 on the next day identified no concerns. Comment: an absence of dental care was a recurring concern. 2.3.14 Just three days after his consultation with the school nurse, school 2 made a referral to Children’s Social Care because sib.1 (aged 7) had soiled his trousers prior to attending school and while changing had exposed himself to another child. His stammer and a perceived need for speech and language support were was also included in the referral. 2.3.15 Borough 2’s SW6 liaised with a SW10 from her Adult Social Care department on 08.07.13 and was told she would be contacted upon completion of an assessment of mother’s social needs. CAE 15 2.3.16 HV1 was again unable to make contact because of ‘inactive’ mobile numbers. She made an opportunistic home visit on 11.07.13 and for the first time met the children’s father whom she noted was receptive and accepting of the visit. Child G (16 months old) was in his buggy and at HV1’s suggestion taken out. He demonstrated that he could crawl and pull to stand against his mother and furniture, though was not yet able to walk unaided (most achieve this at 14-18 months). HV1 was satisfied with his diet, nutrition and development and reminded the parents of the core group. Comment: the note of child G sitting in a buggy mid-afternoon raises the question of how often and for how long his movements were constrained in that manner. Linguistic development was not captured on this occasion. 2.3.17 Borough 2’s SW6 met father with child G at a home visit on 15.07.13 and became aware that he also had an alternative address thus (possibly) enabling an unjustified Benefits claim. Nothing of significance was noted in terms of conditions or care of child G. Comment: other members of the network were also aware of and did not challenge or report to housing colleagues the suspicious arrangement. A recommendation is included in section 5. Core group 2 2.3.18 Both parents (and SN1, SW6 and unknown others) attended the core group on 17.07.13 held at school 1 at which sib.2 remained a pupil. It was confirmed that sib.1 was due to see an optician and had been taken for an enuresis appointment. His soiling at school was discussed and the school raised concern about his aggression toward peers. The group recorded that child G was typically in his buggy on each occasion that a professional called which was likely to constrain his walking skills. Comment: next day, mother told GP2 that she no longer wanted further investigation of sib.1’s bed wetting – arguably one of a number examples of apparent or disguised compliance.2 2.3.19 The parents were encouraged to minimise child G’s time in his buggy so as to offer him more opportunity for development of ‘large motor’ skills. SW6 who said that she had been making announced and unannounced visits, agreed to explore the possibility of some nursery time for child G. HV1’s report identified no other concerns and reported she thought there had been an improvement in family functioning in the months she had known it. SW6 agreed to explore the use of a ‘systemic practitioner’ or a referral to some form of parenting programme. Comment: it is unclear what precise parental needs had been identified nor why it was thought they might be motivated or able to use such services. 2 Disguised compliance’ involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention - the term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book ‘Beyond Blame: Child Abuse Tragedies Revisited’. CAE 16 2.3.20 The notes of the core group were received in Community Health after a two month delay and then took a further month to be uploaded to electronic records (thus significantly reducing their potential value). The fact sib.1 was subject of a child protection plan was uploaded for the first time at GP Practice A only on the day of the core group and an invitation to the review conference received five days in advance of it. Comment: All of these apparently straightforward administrative tasks when completed efficiently can assist in briefing professionals such as GPs of relevant facts in a timely manner and thus reduce the risk of un-informed responses. Second referral from school to Children’s Social Care & a disclosure by sib.1 2.3.21 On the same day as the core group met, sib.2 (rising 6) was referred to Children’s Social Care. She had been ‘unkind’ to another pupil, then kissed her/him and exposed her bottom. She reported that this was how her older brother behaved and that she had kissed his bottom. Enquiries confirmed with sib.1 the accuracy of his sister’s account. 2.3.22 Borough 2’s SW6 appears to have taken no further action in response to sib.1 telling her on 18.07.13 that his parents had instructed the children not to report that they were physically punished because they might be taken away (the children were at this time subject of a protection plan under the category of ‘physical abuse’). Comment: sib. 1 had made similar claims whilst in the previous area (see para. 2.1.12) and the lack of response implies an insufficiency of interest in the children’s daily experiences; the instruction attributed to the children’s parents also challenges the idea of their engagement with the efforts of local agencies. 2.4 FIRST REVIEW CHILD PROTECTION CONFERENCE (RCPC) IN BOROUGH 2: PROTECTION PLANS RETAINED 2.4.1 The notice given of the review conference on 23.07.13 was very limited e.g. the invitation to HT1 was received only 5 days before the conference, itself convened on the last day of term. In consequence, HT1 was unable to attend though she did submit a report. Comment: given the inadequate notice, the inability of the GP Practice to be represented is unsurprising as is, to a lesser extent the fact that it did not provide a report (the serious case review group was informed that this is not unusual). 2.4.2 Father was present at the conference and the professionals in attendance were borough 2’s independent chairperson and SW6, HV1, SN1, senior practitioner SP1 and the SENCO. CAE 17 2.4.3 Father expressed resentment at the ongoing social work involvement. He reported that he took on the bulk of the household chores. The possibility of a nursery place for child G was blocked because father was unwilling to present wage slips. The following tasks for professionals reportedly remained unachieved: Receipt of a chronology from borough 1 (senior practitioner SP1 undertook to follow this up with the conference chairperson willing, if necessary, to escalate the issue) A family group conference (though father indicated that, amongst the extended family, only his mother-in-law was aware of Children’s Social Care involvement – this option was anyway later rejected by the parents) 2.4.4 Borough 2’s SW6 confirmed the lock on sib.1’s door had been removed. The aetiology of the observed aggression of sib.1 and sib.2 was not explored. Mother’s assertion that she had resolved sib.1’s enuresis by waking him at night and would arrange dental examinations was accepted. Father admitted renting a second property. Records lack detail so that it is unclear whether the lawfulness of the arrangement was addressed nor its consequences for his family (subsequent comments by him suggest staying up to four nights a week at his second home). Father’s plan to bring his eldest daughter to the UK was noted. Comment: the lawfulness and time spent at the other property were relevant to the issue of honesty, openness as well as his availability to care for the children. 2.4.5 The decision was made by the chairperson that child protection plans were still required. The category used to justify the child protection plan was ‘physical abuse’ though there were also significant indicators of neglect of the children’s basic needs as well. ‘ALERT’ TO THE IMPACT OF MOTHER’S HEALTH ON PARENTING 2.4.6 The day after the conference, CNS1 wrote to borough 2’s Housing Department (Children’s Social Care also possessed a copy) and provided a very clear and detailed account of the impact of mother’s serious and chronic illness on her ability to adequately parent her children e.g. she referred to the need for child G to remain in his buggy if his mother needed to go up to the first floor. Comment: the proportion of the week that father actually spent in the home had been and remained of critical importance in terms of support or risk. Father was entitled to a ‘carer’s assessment’ and the extent of mother’s reduced ability had not been reflected to the extent here described at the review conference. It does not appear that an earlier proposed core assessment adequately captured the extent of mother’s disability and its consequences for her children. 2.4.7 On 06.08.13 a helpful three monthly summary was completed by SW6 in order to inform her successor SW7. Aside from the recurring concern about how much mobility child G was experiencing, the question of whether father was actually cohabiting with the family and a failure to sort out Benefits were (relatively recent) concerns that were spelled out. CAE 18 2.4.8 The GP surgery received confirmation from speech and language therapist SLT1 of an initial consultation. Sib.1 reported that English and a (named) central African language were spoken at home, though he preferred English. The child did not stammer during his appointment. His school had reported that he was above average in terms of literacy but that he hit and pushed others when angry or frustrated. Observed concerns at home visits by Children’s Social Care 2.4.9 At a home visit by borough 2’s SW6 on 09.08.13 an account was provided of how an argument between sib.1 and sib.2 had resulted in the former being stabbed with a pencil. SW6 was not wholly convinced by the children’s description of events. She also remained concerned that child G was still not getting enough stimulation or opportunity to practice walking. 2.4.10 SP1 undertook a visit on 28.08.13 and noted that father was not pleased to see him. Child G was asleep in his high chair. No further detail of that visit has been provided, so presumably does not exist. Comment: if the frequent observations that child G was spending unhelpful periods of time in a buggy or highchair had been more effectively aggregated and addressed, the consequences for his development and for mother’s need for more support would have been better understood. Core group 3 & ongoing support 2.4.11 A third core group was convened at school 2 on 04.09.13. Both schools, SW6 and mother were present. The group heard that sib.2 (aged 7) had stabbed her elder brother with a pencil and it was agreed that behavioural support would continue to be offered by her school. No notes of the meeting or of what the ‘behavioural support’ actually entailed have been located. Mother reported the imminent arrival (from Africa) of her partner’s daughter (sib.3 aged 16) from a previous relationship and said she had made arrangements for her to enrol at a local college. 2.4.12 Borough 2’s SW6 made her final home visit on 06.09.13 and reported no concerns. She informed mother and the children (father was not present) that the case was to be taken over by a SW7. 2.4.13 Mother underwent a routine operation on 13.09.13 rendered more complex because of her chronic medical difficulties. A number of administrative issues have been identified by those evaluating the records of this health-related episode e.g. ambiguity of personal and professionals’ contact details, next of kin, and who was caring for the children etc. 2.4.14 HV1 completed a further planned home visit on 16.09.13 and met child G together with his mother. Her notes indicate he was alert, happy and playful, beginning to use some clear expressive language appropriate to his age. Diet and nutrition were again discussed. Child G was almost walking. HV1 noted ‘nil apparent concern’. CAE 19 Child protection supervision of HV1 2.4.15 At her supervision next day HV1 raised the issue of mother disengaging from professionals and ceasing to take reliably her prescribed medicine, thus reducing her ability to care adequately for the children. Both parents were noted to be actively stimulating their children. As in the previous supervision session, family support and church members were described as strengths and protective factors. Comment: without the FGC that had been planned, it is unclear what level of support was actually being afforded the family from friends, relatives or fellow church-goers; the query about the frequency of father’s presence as in SW6’s summary was not addressed, nor was the school’s continuing concern about the behaviours of sib.1 and sib.2, which could have placed child G at risk and anyway suggested a level of family-related stress. 2.4.16 Though the immediate outputs of the conference were uploaded within a week, minutes of the July core group meeting were received by Community Health only on 10.09.13 (a 2 month delay) and their uploading was further delayed and completed on 11.10.13. Minutes of the conference of 23.07.13 were not received until October. Thus the supervision of HV1 on 17.09.13 depended upon her individual perspective. Comment: the fact of substantive delays in circulation and inputting of minutes on both occasions, coupled with the absence of complaint or challenge suggests that this is a systemic weakness. 2.4.17 On 17.09.13 SW7 took on the case from SW6. An apparent attempt at arranging a nursery place for child G was thwarted by father’s reluctance to supply details of income. It seems as though the issue of child G spending excessive in his buggy was not discussed. Comment: father’s suspicious reluctance to divulge details of income that would allow an assessment denied his son required additional stimulation but does not seem to have been articulated in that manner within records of professional involvement. 2.4.18 When SLT2 contact sib.1’s school on 03.10.13 she was unaware of the child being subject of a protection plan and referred to mother’s lack of interest in the speech therapy, describing it as ‘boring’ – though she had agreed to attend an intensive course at half-term. 2.4.19 An exchange between CNS1 and the clinic treating mother indicated that the former had discussed with SW7 mother’s mental capacity / function (which presumably might have been impacted upon by her medical condition). Comment: the issue of the mother’s mental as opposed to physical condition is not apparent from records provided. CAE 20 2.4.20 HV1 completed a further planned home visit on 15.10.13 and met mother and child G. Father was said to be at work and the other children at school. Child G was well, alert and happy. A reference to him ‘feeding himself with family food’ is ambiguous and might refer to an observation or an assertion by his mother. HV1 left health promotional information on dental care, home safety, accident prevention and immunisations. 2.4.21 Later that day, SN1 met with sib.1 whom she noted was well-presented though with worn out shoes, torn trousers and a holey sock. His history of bed wetting was not raised. 2.5 SECOND REVIEW CHILD PROTECTION CONFERENCE IN BOROUGH 2: STEP DOWN TO ‘CHILD IN NEED’ STATUS 2.5.1 The second review conference was convened on 16.10.13. Father but not mother was present. Professionals present included the independent chairperson, SW7, SP1, HV1, HT1, and SN1. The GP service was unrepresented and no report was submitted from it. A check of GP records has confirmed that a flag indicating child protection status existed in child G’s but not in his sibling’s medical records. Comment: the absence of GP contribution represents a significant systemic weakness though it is unclear in this instance whether the Practice was sent an invitation; it is also unclear whether mother’s earlier reluctance to make use of speech and language therapy was addressed. 2.5.2 Sib.1 was reported to be scheduled to attend speech and language treatment for his stammering. His mother had reported that bed-wetting has ceased and in-school support for aggressive conduct was ongoing. Professionals no longer felt concerned about parental physical abuse. 2.5.3 With respect to the ongoing perceived absence of a chronology from borough 1, the chairperson suggested that a worker might have to organise to go and read that borough’s records. Comment: it had been agreed on many previous occasions that the chronology was required and would be chased. The chairperson should have escalated the issue of the (apparent) failure to provide it. 2.5.4 The decision made by the chairperson of the review conference (and supported unanimously by those present) was that the children no longer required protection plans (recorded as having been for ‘neglect’) and would instead be supported by means of ‘child in need’ plans. 2.5.5 In October 2013 GP Practice A’s records erroneously noted child G as having ‘CP status’ (he had by then been stepped down to child in need status). Comment: this apparent misinformation raises doubts about the efficiency / effectiveness of the system by which GPs are notified of the attribution or amendment of such a status. CAE 21 2.5.6 The minutes of the review conference were received in Community Health some four weeks later but the ‘child in need’ plan was not received until 15.01.14 and its inputting delayed a further month until 19.02.14. Pending receipt of those documents, health professionals were obliged to depend upon the chairperson’s ‘action plan’. 2.5.7 At a further health review completed by SN1 on 02.12.13 sib.1 (aged 8) was noted to be above 97th centile for weight and height i.e. very tall and heavy in relation to peers. SN1 noted the child’s worn trousers and shoes but considered him ‘well-presented’ and did not initiate any liaison with Children’s Social Care. Attempts by HT1 a week later to return a call from newly allocated SW8 failed in spite of 4 recorded attempts, suggesting an absence of ‘voicemail’ facility. Comment: colleagues should always have the means and be aware of how to leave a message or alert a manager. 2.5.8 Though the information was shared by sib.2 rather than a parent (father was noted to be ‘disappointed’ that the news had been shared), SW7 became aware at her visit on 17.12.13 of the arrival four days earlier of father’s eldest daughter (sib.3 then aged 14 from a Central African country). 2.5.9 Sib. 3 engaged with the local health services during December 2013, initially by means of GP registration and later for specialist hospital treatment where her need for a French-speaking interpreter was recognised (no interpreter was used for an appointment early the next year possibly because her step-mother interpreted for her). Sib.3 initially complied but later proved unreliable in take-up of prescribed hospital treatment and was supported by community paediatric nurses. No record of such contact exists in GP medical records suggesting that the Practice was denied the advantage of having a complete picture of medical needs. 2.5.10 Child G was again seen at home by HV1, for a planned appointment this time in the care of his mother (father was at work). No concerns were noted and development was recorded on his ‘red book’ (the standard parent-held document) as being within normal parameters. It was agreed a nursery would be sought for a February 2014 start. Nearly two months elapsed before the record of this visit was uploaded. FIRST CHILD IN NEED REVIEW MEETING 2.5.11 At the first of the multi-agency reviews of the child in need plan held on 16.01.14 at school 2, no new incidents were reported. The arrival in the UK of sib.3 before Xmas was noted. It was understood that her mother had died (though when appeared unclear). Sib.1’s need for speech therapy had still not been taken up by the parents. The additional possibility of learning mentor input was noted to depend upon a parent meeting the class teacher to discuss this. Comment: to this date, there was limited evidence of actual, as distinct from promised, parental co-operation with services offered. CAE 22 2.5.12 HV1 planned a further home visit in February. Material shared with the serious case review group has not clarified what actions were agreed by other professionals in attendance. A further CIN meeting was planned for late April. The completion of tests in this period prompted the prescription of routine medication for all family members. 2.5.13 During February the family moved to ‘address 2’ (local authority accommodation awarded on the basis of mother’s medical needs). Further monitoring by health professionals 2.5.14 On two occasions during a week in March 2014 mother presented herself at a hospital A&E department and her chronic medical condition was noted. On the second occasion she did not wait to be seen. Sib. 1 was again seen by school nurse SN1 on 18.03.14. Observations were essentially unchanged as was sib.1’s relative height and weight. SN1 did not share her findings with other professionals. 2.5.15 On 27.03.14 HV1 completed her planned visit and saw child G (by then 2 years old). Records indicate he was appropriately dressed and toddling happily around the house. He was noted to be heavy and tall for his age but had anyway ‘always been a big baby’. Mother was encouraged to use a cup not a bottle to provide water and in the presence of HV1 was able to get child G to accept this overdue step. 2.5.16 Mother referred to child G’s unclear speech and a family history of such difficulties. It would appear that measures to encourage speech and language development were not discussed at this visit, though management of temper tantrums was. The arrangement agreed with mother was that she would contact HV1 if required and that HV1 would otherwise review child G’s speech development in 2 months. Comment: HV1’s reasonable hope was that interactions at nursery would serve to improve receptive and expressive language. It is unclear whether HV1 ever saw child G feed himself or was noting mother’s description of him doing so. SECOND CHILD IN NEED REVIEW MEETING 2.5.17 At the planned review of the child in need plans held on 29.04.14 and attended by mother, sib.1’s stutter was noted to have worsened and it was agreed that SW7 would re-refer to the Speech and Language Service. No other concerns were shared and a unanimous view was formed that after three more months of monitoring, the case should be closed to Children’s Social Care. Mother claimed all the children would be seen by a dentist on 07.05.14 (sib.2 had reported to SN1 perhaps inaccurately, that she had been taken to a dentist in March). Comment: a reliance on mother’s account and perspectives risked mis-calculating the impact on the family of her chronic medical conditions; with respect to the narrow issue of the children’s dental treatment, no confirmation that they received any has been located. CAE 23 Presentation of child G at hospital 2.5.18 As a result of respiratory difficulties child G was brought to hospital 2’s Urgent Care Centre and referred on to its A&E Department on 18.05.14. A ‘viral wheeze’ was diagnosed. Medical notes indicate that the parents denied current involvement of a social worker. Comment: if current involvement of Children’s Social Care had been acknowledged or known, the hospital’s safeguarding team would routinely have been alerted; this presentation was not captured in the child’s GP records. 2.5.19 Mother was hospitalised for three days in late May and required follow-up having failed to comply with the use of some of her medication. 2.6 CASE CLOSURE BY CHILDREN’S SOCIAL CARE 2.6.1 A decision was made by a manager on 28.05.14 that the case would be closed. There remained the following uncompleted actions: The required chronology had not (apparently) been provided by borough 1 nor developed by borough 2’s staff The intended FGC had not been organised No assessment of the impact of mother’s physical (and mental) health had been completed 2.6.2 The ability or willingness of the newly arrived sib.3 to provide safe and sufficient care of younger step-siblings remained untested; nor had sib.3’s own emotional, educational or practical needs been addressed. PRESENTATIONS: SIB.3 AT A&E & CHILD G AT URGENT CARE CENTRE & GP PRACTICE 2.6.3 About a month later sib.3 (approaching 16) was presented by father and step-mother to hospital 2’s Urgent Care Centre and referred on to its A&E Department. Gynaecological symptoms were explored and relevant follow-up arranged to complete investigations the young woman found too intrusive at the time. Records confirm she was spoken to alone by a consultant and that a follow-up by phone was completed with sib.3’s GP. 2.6.4 It would appear that child G’s parents again denied that there was any social work involvement (it is currently unclear whether the family had by then been told of the case closure decision). It seems probable that information available to them was insufficient for the hospital staff to make the link with the other children in child G’s family. 2.6.5 An unnamed paediatric liaison health visitor emailed sib.3’s school nurse about the above presentations. Other medical information was provided and no safeguarding concerns passed on. CAE 24 2.6.6 On 25.06.14, the parents though they did not present child G, sought medication from the same hospital’s Urgent Care Centre. The symptoms about which they were concerns are not clear. A nurse provided a letter for them to present to the GP and notification was sent by the duty health visitor and received by the Health Visiting Service on 03.07.14. 2.6.7 About a week later mother attended the Practice again without child G, and sought from the GP an inhaler for his use. Child G was subsequently seen at the Practice on 07.07.14 by a GP when antibiotics and an inhaler were prescribed. Comment: the parents had twice sought medication for child G without presenting him to a medical practitioner; the extent to which their child’s symptoms were related to the consequences of aspirating food remains unknown. 2.7 RENEWAL OF CHILD IN NEED PLAN IN RESPONSE TO DOMESTIC ABUSE 2.7.1 Police attended the family home on 18.07.14 in response to an argument between child G’s mother and sib.3 (by then aged 15). Whilst officers were present, mother and sib.3 began to fight. Mother was arrested for actual bodily harm (having allegedly bitten sib.3) and sib.3 arrested for affray. Both mother and sib.3 were brought to the local hospital 3 A&E where their medical needs were assessed and liaison with the paediatric team initiated. SN1 was notified on 22.07.14 of the incident but records do not offer any confirmation that the child protection history of sib.3’s step-sibling was acknowledged. 2.7.2 There were no prosecutions following the altercation during which it appears that father sought to contain the mutual aggression. In spite of the notification from Police of the domestic abuse incident, no strategy discussion / meeting was convened (which in all the circumstances would have been justified). Children’s Social Care did re-open the case and a re-assessment was completed by SW7. The agency response was signed off by her manager. Material supplied refers to effective case supervision by a ‘Pod manager’. 2.7.3 SW7 informed HT1 of the incident of 18.07.14 and was offered reassurance that there were no concerns about sib.1 and sib.2 who were being collected from school by the 15 year old sib.3. 2.7.4 At a home visit on 22.07.14 SW7 and manager TM1 saw an injury to the side of child G’s mouth said by his siblings to have occurred whilst they played outside. Records do not indicate whether the explanation offered was questioned or medical assessment recommended. 2.7.5 At SW7’s supervision on 13.08.14 the impact of sib.3’s arrival was discussed. It was agreed SW7 would seek advice about the justification for a further initial child protection conference (the independent chairperson later advised such a response was not justified), establish the school’s capacity to provide mentoring, explore the value of some therapeutic input and/or a referral to a parenting course. CAE 25 2.7.6 On 21.08.14 HV1 was late arriving for a pre-arranged home visit and was unable to gain access. Mother had left for another appointment and sib.3 who was caring for the three younger step-siblings explained she was not allowed to open the front door. A record of this was only made a month later. It does not seem as though a further attempt to complete a visit was made nor that the experience was shared with SW7. 2.7.7 SW7 made direct contact with sib.1 and sib. 2 on 08.09.14 and in the course of her re-assessment of the family’s needs father’s insufficiency of insight as well as resistance to agency involvement became clear. Mother was hospitalised overnight on 15.09.14 for treatment associated with her chronic medical condition. CHILD G LEFT ALONE 2.7.8 At 17.17 on Thursday 25.09.14 police officers (dealing with another issue) spotted child G (aged 2.5 years) at a window with ‘a white substance around his mouth’. They correctly discerned that he had been left alone at home and forced entry. Mother returned during the course of the actions taken by Police and claimed that her sister should have been looking after her son. 2.7.9 Child G was taken by ambulance to hospital 3 A&E for a precautionary check-up. No injuries were recorded but a diagnosis of ‘? lower respiratory tract infection’ was made. A reference to a ‘foreign body’ remains unexplained. Standard notifications were initiated electronically for community health visitors, school nurse and GPs. 2.7.10 Sib.3 remained at home with her father and step-mother and Police Powers of Protection under s.46 Children Act 1989 were exercised on the 3 younger children all of whom were then fostered with parental consent under s.20 Children Act 1989. 2.7.11 A strategy discussion was completed on 29.09.14 between Police and TM1 and a joint investigation under s.47 Children Act 1989 initiated. HV1 contacted the family and visited on 29.09.14 when she noted that mother was tearful and appeared remorseful (mother later admitted to Police that she had left child G alone and accepted a caution for the offence of neglect). Later still, it emerged that mother had been shopping and that child G had been unsupervised for over an hour. 2.7.12 HV1 later liaised with the children’s carer though a planned visit to the foster home was overtaken by their return home. The school had become aware of the incident only when sib.1 and sib.2 failed to attend. Comment: the school should have been informed by Children’s Social Care. 2.7.13 The children were returned to their parents’ care on 03.10.14 and the agreed conclusion of the s.47 investigation was that an initial child protection conference was required. Information provided by Police included the fact (not seen in previous records and possibly unknown to the local network) that there has been violence between father and a previous partner in a local authority in rural England. CAE 26 2.7.14 HV1 completed a planned home visit two days after the children’s return home. Her notes refer to the home being ‘a bit cluttered’ which the parents attributed to a planned transfer to a three bedroom house. Child G was noted to be appropriately dressed and calmer than on previous occasions but still not communicating verbally. Mother said that child G had a good appetite and disliked ‘mashy foods’ (an observation that was consistent with the comments made to HV1 by the foster carer). 2.7.15 Mother reported child G’s nursery had made a referral and HV1 liaised with the Speech & Language Therapy Service to be told that a referral had been received on 02.10.14 and an appointment was pending. It seems no attempt was made to expedite an initial appointment. 2.8 INITIAL CHILD PROTECTION CONFERENCE: PROTECTION PLANS FORMULATED 2.8.1 Mother attended the conference on 13.10.14 but her partner sent his apologies. Professionals present were the same independent chairperson as for previous conferences, SW7, HT1, the pastoral manager from school 4 at which sib.3 was a pupil, SN2, HV1, CNS1, Police and a representative of the nursery child G had begun to attend 2.8.2 Concerns that were discussed included sib.2’s ‘scruffy and a little smelly’ appearance at school, as well as about her aggression toward other children. Mother’s difficulty in relating to her step-daughter and (for health-related reasons) managing the demands of toddler child G were acknowledged. The parents had refused a suggestion that they undertake some form of parenting programme that could offer them an enhanced ability to deal with the newly arrived teenager. Comment: previous reports from teachers and school nurse had been more positive about the children’s presentation. 2.8.3 A GP was reportedly invited (though no record of that was found in medical records) but did not attend or provide a report. It does not seem as though paediatric input was sought. None of the participants were aware that Care Proceedings had been initiated whilst the family had lived in borough 1. The result of the discussion at the conference was that all four children were made subject of protection plans for neglect. The chairperson’s conference report was uploaded within a week and the minutes after two and a half months (it is unclear with whom responsibility for that lay. As well as child G continuing at nursery, the plan involved: HV1 escalating child G’s referral for speech therapy and seeing him monthly, alternating between home and clinic A school nurse completing termly health assessments Sib. 1 being provided with a block of concentrated speech and language therapy during half-term SW7 requesting a neuro-psychological report on mother and (again seeking advice from a systemic practitioner with respect to more effective ways of working with the family CAE 27 Comment: this conference (like its predecessors) was weakened by the absence of GP input - though it remains unclear whether an invitation to contribute was issued; Practice A had also failed to capture the change of status of the records for child G’s siblings; the conference focused on the narrow recent issue of child G being left alone as opposed to the overall family dysfunction. 2.8.4 SN2 initiated her first school-based assessments of the children within a week. She noted sib.1 to be very tired and wearing a dirty ill-fitting school uniform; his face was unwashed and nose dirty. Sib.1 reported the children were given biscuits or crisps with tea instead of an evening meal. He contrasted this with the proper cooked dinners (meat and pasta) whilst fostered. He was unable to recall ever attending a dentist. Records indicate an intention to discuss the findings with mother. 2.8.5 Sib.2 (at her school) reported that she shared a bedroom with her step-sister who provided comfort when she had bad dreams; sib.3 also told sib.1 off ‘when he hit child G’. Sib.2 described an inadequate diet at home. 2.8.6 SN2’s assessment of sib. 3 (aged 15) was of a sullen reluctant child with poor eyesight and evidence of tooth decay. Sib.3 claimed that nobody would take her to an optician or dentist. The child’s account of her diet at home also implied that she was inadequately fed. Though of average height, her weight was below the 3rd centile i.e. extremely few children of her height would weigh as little. Comment: lack of dental care had been identified from an early stage and the clear allegations of inadequate feeding were of real significance. Sib.1 who was known to be aggressive could have seriously hurt child G thus representing an acute risk. SN2 should have immediately shared her findings of neglect with the allocated social worker SW7. FIRST CORE GROUP MEETING 2.8.7 The first core group meeting following the October conference was held on 21.10.14. Child G was then aged 2 years and 7 months old. Present were HT1, SN2, SW7, CNS1, HV1, and the pastoral manager for the High School at which sib.3 was then a pupil. Sib.1’s increasing lack of focus at school was noted. The account provided by both children of their evening food intake differed from that of their mother. SW7 was tasked with monitoring the children’s evening meals and SN2 was to ‘possibly start food diaries’. Mother claimed that the children had optician appointments during the imminent half-term. Comment: how SW7 was to achieve her task is unclear and no evidence has been provided to confirm that she did so. The word ‘possibly’ with respect to SN2’s food diaries was too vague to be of value. Compliance with dental and optician appointments remained unchecked. CAE 28 2.8.8 There is no record of SN2 sharing with others the account of sib.1 hitting child G. There was a recognition of the possibility of sexual exploitation of sib.3 though the risk was agreed as ‘low’. 2.8.9 Later that week the GP Practice at which all the children were registered received a record of the initial conference. A flag was added to the records of child G but not his siblings and no further updates were made following the review conference in 2015. Comment: as well as a recurring absence of contribution to the multi-agency planning, this Practice had no flag within children’s records to confirm the previous and once again, current status of being subject to a child protection. 2.8.10 An intention by SW7 to spend time with the children on 27.10.14 (a trip to McDonalds) was prevented by mother who said they were all too busy preparing for their house move. A second home visit on 05.11.15 (presumably to the new address) found nobody at home. SW7 was able to meet the children on 12.11.14 but enquiries about what meals the children had recently been given were blocked by sib.2 citing father’s instruction not to share anyone outside the home any ‘family business’. Comment: sib.2’s attribution of the comments to her father seem credible; father should have been confronted and it made clear that a failure to comply with the defined child protection plan would lead to a legal planning meeting. TRANSFER TO GP PRACTICE B & FURTHER OBSERVATIONS OF CHILDREN BY HEALTH PROFESSIONALS 2.8.11 On 19.11.14 all members of the family transferred to an alternative ‘Practice B’ presumably in consequence of their move to larger accommodation in a new area. Comment: any erroneous or misleading information in records is automatically transferred to a new Practice via the ‘GP2GP’ system. 2.8.12 SW7 received supervision on 19.11.14 from TM1 and it was agreed that mother though not her husband, was engaging with the professional network. SW7 and the independent chairperson held an apparently unrecorded meeting with a systemic practitioner in an attempt to develop a more effective way of gaining acceptance by both parents of the need for professional involvement. 2.8.13 Two days later sib. 2 was brought by her mother to the Urgent Care Centre at hospital 2 and diagnosed as having an upper respiratory tract infection. Mother also presented child G at the same time and he was diagnosed as having diarrhoea and vomiting. Though the involvement of a social worker was identified, it does not appear that Children’s Social Care was informed of the presentations. CAE 29 2.8.14 HV1 completed a home visit on 24.11.14 (whether planned or not is recorded). Mother was in hospital and HV1 saw child G with his father for the first time. HV1 noted him to be alert and well and the home to be clean. Child G was having a snack of juice and a biscuit before attending nursery. Father reported his son had already eaten lunch which HV1 though was early in relation to a nursery start-time of 1pm. 2.8.15 Child G responded positively to HV1 and she thought he had a good and reciprocal relationship with his father. Records do not refer to HV1 offering advice about child G’s delayed use of speech and language, though she had noted father’s assertion that child G spoke more when siblings were home. HV1 did discuss diet and dental care. 2.8.16 HV1’s action plan was to continue her monitoring pending a transfer to a new HV2 (a consequence of the family’s move). By 28.11.14 HV1 had received confirmation from the Speech & Language Service of child G’s expressive speech delay and the advice offered his parents. No further involvement of that agency has been seen. A further visit by SW7 on 27.11.14 found nobody at home. SECOND CORE GROUP MEETING 2.8.17 A second core group meeting was convened on 03.12.14. Mother was in hospital at the time and father attended. The same professionals as had made up the first core group were present. Sib. 1 was still coming to school in dirty clothes and the issue of insufficient food was again debated. HV1 recommended that father reduce the children’s intake of juice and offer them healthy snacks. 2.8.18 The aggressive behaviour of sibs.1 and 2 continued and they were reported not to be progressing at school. Child G was doing well at his nursery. No concerns were shared about sib.3 who was immaculately presented though performing below average at college. Comment: the source of sib1 and sib 2’s aggression needed exploration as did the perhaps connected issue of food; sib.3 was old enough to self-care and her under-performance as a recently arrived non-English speaker, unsurprising. 2.8.19 Dates for the review conference and further core groups were agreed. Following a home visit about which no notes were made, SW7 and her supervisor TM1 discussed the case again on 10.12.14 and apparently retained the hope that father could be persuaded to access therapeutic service in his own right or involving the family. 2.8.20 In mid-December HV1 discussed the case in her child protection supervision. A reported level of ‘support from maternal grandmother and the church community’ was not described or evaluated. Comment: HV1 had shown a high level of commitment to the family but her view of parental engagement and parental progress was at odds with the evidence. CAE 30 INITIAL OBSERVATIONS OF NEW HEALTH VISITOR 2.8.21 On 05.01.15 an initial home visit was made by HV2. She met child G in the care of his mother. His recorded self-help skills extended to consuming juice and yogurt without help. HV2 noted also that child G’s expressive language had improved. Comment: it is unclear why HV2 thought any more input from speech & Language Therapy Service was scheduled. REVIEW CHILD PROTECTION CONFERENCE 2.8.22 On 07.01.15 the first review child protection conference was convened and was chaired by independent chairperson 2 covering for his colleague who had chaired previous conferences. A (confirmed) hospital appointment prevented attendance by mother but father was present. 2.8.23 SW7, SN2, HV2, HT1, CNS1 and representatives from schools and nursery were present. Police were unrepresented though sent a report confirming no new contacts. No GP or GP report was available and it is uncertain whether any requests had been made. 2.8.24 HV2’s account of the family was comparable to that of her predecessor i.e. the family was engaging and receptive to advice and strategies and no sources of risk had been observed. HV2 was asked to expedite what was apparently considered to be an active referral for more speech and language input. There seems to have been no debate about father’s historical record of violence toward a previous partner. Comment: though HT1 reported sib.2’s further comments about insufficiency of food at home, no written confirmation of the results of SW7’s monitoring of the children’s evening food intake has been traced. 2.8.25 The thought that there might be value in a neuro-psychological report on mother disappeared at this conference with a comment from CNS1 that neither she nor her consultant had observed changes in mother’s functioning. 2.8.26 The needs noted within the analysis section of documentation remained essentially unchanged and a manager’s comment of ‘minimal progress’ was justified and perhaps a little more positive than the facts suggest. 2.8.27 The independent chairperson decided that all four children would remain subject of a protection plan under the unchanged category of neglect. Concerns included mother having left child G alone (the trigger for action in October 2014), mother’s ability to manage teenager sib.3 and toddler child G, the emotional condition of sib.1 and sib 2 (both still bedwetting) and their appearance as well as the parental relationship. CAE 31 2.8.28 With respect to child G in particular, the chairperson’s plan may be summed up as ‘more of the same’ and the contingency position also remained as the possibility of legal planning meeting if the plan was blocked or the younger children again left without supervision. Comment: This conference focused less on the issue of sufficiency of food for the school-aged children; the extent to which child G’s mobility was being limited so as to reduce the pressure on mother was not addressed. CORE GROUP MEETINGS & ONGOING MONITORING 2.8.29 An unannounced visit to the family’s new address on 16.01.15 found nobody at home. The day before the core group meeting on 20.01.15 SN2 met with sib.1 in school. His uniform was clean and well-fitted though his face dirty. Sib.1 reported cooking a pizza for himself after school and then his mother or older step-sister cooking a meal in the evening. He described twice-weekly baths and admitted that he did not brush his teeth every day. 2.8.30 Sib.1 also described a fight with sib.2 in which she had cut her back sufficiently seriously to prompt his father to return home. His mother was said to have been ill and asleep in bed at the time of the incident. Sib.1 reported that he had still not been seen by an optician. The issue of a dental appointment was apparently not raised. SN2 also met with sib.2 who offered positive news with respect to provision of a hot meal in the evening but reported getting herself ready in the mornings. Comment: there is no record to confirm that the school shared this information with the allocated social worker (SN2’s failure to share information with relevant others has emerged on previous occasions). 2.8.31 The parents arrived late for the meeting and most of the discussion centred on the older children. It appears that the altercation between sib.1 and sib.2 was not raised by SN2. In response to the parents’ claim that sib.2 had been taken to but refused to co-operate with a local dentist, SN2 followed up with the specialist dental service and received confirmation of the offer of an appointment. Comment: it seems that no core group meeting notes from this or previous meetings were kept or if they existed, were not circulated to participants; it seems unlikely that the dental appointment was kept. 2.8.32 The day after the core group sib.3 was seen by SN2 who had no concerns about the young woman’s dress or physical appearance. On 27.01.15 SW7 completed an unannounced home visit. Neither parent was present though all four children were and sib.3 appeared distressed. She reported that mother had packed her belongings and told her that she could no longer stay there. SW7 remained with the children for over two hours before father returned. He refused to accept that sib.3 was not old enough to be left with that amount of responsibility. CAE 32 Comment: SW7’s notes suggest that this episode amounted to emotional abuse of sib.3 and that she planned to discuss with managers and the independent chairperson, it is not clear that anything more decisive emerged, perhaps because SW7 left her role in the borough soon afterwards. 2.8.33 SN2 brought this case to her safeguarding children supervision on 10.02.15 where it appears that based upon her positive account of parental co-operation, the existing approach was ratified. FURTHER CORE GROUP MEETING 2.8.34 Though SP1 remained in post, SW7 was replaced on 10.02.15 by borough 2’s SW8. It would appear that no handover visit had been achieved. At the next core group meeting on 14.02.15 SW8 who had not yet met the children heard about the aggressive behaviours of sib.1 and sib.2 as well as some reduction in school attendance rates. 2.8.35 HV2 completed a home visit on 17.02.15 (whether planned or unannounced is uncertain). She met mother, sib.1 and child G (rising 3) who was noted to look well and able to user his inhaler to good effect. SW8 made his first home visit a few days later on 24.02.15 though beyond his encouragement that parents might engage with a clinician in the recently developed ‘Pod’ 3, no other observations of the children’s quality of life was recorded. Father asked for additional alternative care for child G though whether this reflected his wife’s difficulties in coping with her chronic ill-health and all the children was not noted. Comment: with respect to the idea of deploying a therapist, this family had no capacity and little motivation to engage with any additional professionals. The priorities remained ensuring that they did not abuse their children and did meet the most basic needs for food and clean clothes. 2.8.36 SW8 made his contact with the family on 24.02.15 and noted nothing of concern. Mother was seeking subsidy for more nursery care of child G. FURTHER CORE GROUP MEETING 2.8.37 A further core group meeting was held on 04.03.15 at school 4. HT1 had sent her apologies and provided a report. SW8 and CNS1 as well as both parents attended. The latter reported that glasses for either sib.1 or sib.2 had been fixed and that an appointment had been received for sib.2 to be brought to the specialist dentist. Comment: the review group has been unable to confirm the accuracy of the claim about the specialist dentist. 2.8.38 SW8 completed a home visit on 10.03.15 and met and spoke with all the children. He was informed of an argument between the adolescent and her step-mother but concluded that it was of no significance and that ‘the family was functioning well’. 3 Along with a proportion of other Children’s Social Care Departments, borough 2 has established a number of Pods (units consisting of a team of social workers and therapist led by a manager of that team / unit) CAE 33 2.8.39 Any attempt in late March by HV2 to establish the date of the next core group meeting was thwarted when she was unable to contact parents or leave a message for SW8. Comment: liaison levels between health visitors, nurses and social workers seems to have declined during 2015. ‘POD SUPERVISION 1’ IN CHILDREN’S SOCIAL CARE 2.8.40 A process labelled ‘Pod Supervision’ took place in Children’s Social Care on 19.03.15. The case supervisor was named as someone other than TM1 and the supervisee as SW7 who had actually left her employment on 06.03.15. Comment: the purpose and recording of this event as well as those that followed it, in particular their link to other sources of case supervision, should have been clearer. 2.8.41 SW8 made a further home visit on 24.03.15 and spent time playing with child G who appeared to be well, appropriately dressed and lively. Feedback from the older children indicated some form of bedtime routines though their reports could not be verified. 2.8.42 Sib.3 attended the Urgent Care Centre on 04.04.15 complaining of abdominal pain. No treatment was required and the electronic system which flagged up the involvement of Children’s Social Care enabled SW8 to be informed of the incident. 2.8.43 SW8 was not informed of the presentation at the same Centre of sib. 2 at midnight on 08.04.15, though records confirm an awareness of his involvement. The child (7.5 years old) is thought to have had a urinary tract infection but mother did not wait for her to be seen. Comment: the significance of such a late night presentation and potential consequence of mother’s refusal to wait deserved exploration. 2.8.44 SW8 was able to complete an unannounced visit on 09.04.15 when father willingly let him in. Child G was present but no specific observations about him were recorded. SW8’s record shows that he believed that father had good insight into the needs of his children and was engaging well with the child protection process and the therapeutic worker. His view at that time was that he would recommend ‘stepping down’ to child in need status at the next review conference. Comment: whilst the parents’ love for the children was not in doubt, there was limited evidence of sustained co-operation with the child protection plan, no demonstrable improvements in the children’s lived experience and long-resisted therapeutic work had only just started. CAE 34 2.8.45 A further core group meeting was held on 15.04.15 and both parents were present. HT1 who had been very involved in all planning to this point was apparently not invited (though a conversation with SN2 a week or so later indicated that there were no new concerns about sib.1) The consensus remained that the parents were being co-operative (seemingly based upon attending two sessions with a systemic practitioner) and that the risks to the children were thought to have decreased. It seems probable that no minutes were kept. Comment: without an agreed record of the output of this or any other meeting, the obvious risk is that individuals will have differing view of allocated tasks. SCHOOL NURSE HEALTH REVIEWS & AN IN-SCHOOL INCIDENT 2.8.46 On 21.04.15 sib.1 hit 2 other class-mates and in addition to an in-school response from the learning mentor, a note was sent home to the parents. 2.8.47 Later that week at an unannounced home visit mother spoke of the incident in September 2014 when she had left child G strapped in his high chair and gone to the GP Practice (shopping at Argos was another possible explanation according to observations of attending police officers). Mother said this would not happen again. SW8’s observations of all three younger children (which have not been provided) prompted no concerns. POD SUPERVISION 2 IN CHILDREN’S SOCIAL CARE 2.8.48 There was a further ‘Pod supervision’ session on 24.04.15 which referred still to the recently departed SW7. Its record suggested that the focus of the systemic therapist’s work was the marital relationship and management of the teenage sib.3 – not the concerns about care of the younger children. Nonetheless based upon the debate at that forum, the named case supervisor proposed to consult the independent chairperson about bringing forward the date of the scheduled review conference. Comment: if such forums are able to exercise a level of influence seemingly greater than traditional individual case supervision, it is critical that this is understood and accepted by all agencies. 2.8.49 At the core group earlier in the month it had been agreed that a further health review would be completed by the school nurse prior to the scheduled review conference. SN2 completed those health reviews on sib.1 and sib.2 on 08.05.15. Sib.1 (whose presentation was ‘improved’ though the hem of his trousers were falling down) spoke of being friendless because he hurts people. He reported that home was okay and that he expected to be moving school. His relative height and weight remained above the 98th centile. At his sister’s review no health concerns were identified. Her weight and height were not recorded. Comment: it would have been best practice to capture weight and height. CAE 35 2.8.50 At a further unannounced home visit by SW8 on 08.05.15 child G was seen and briefly spoken to. Mother reported that aside from a respiratory infection, she was fine. No other detail has been provided. Four days later HV2 also visited and obtained from mother the date of the next core group meeting and, apparently a name for the new social worker. Child G (3 years and 2 months old), was on the 96th centile for weight and height. Immunisations were up to date and mother reported that use of his inhaler was limited to those times he had a cold. 2.8.51 A core group meeting was convened on 20.05.15 at school 2. In addition to both parents, the professional attending included assistant head of school 2, school 4’s ‘pastoral manager’, SW8, SN2 (and her student), CNS1 and HV2. 2.8.52 SW8 offered reassurance about the provision of food within the family (he had seen ‘plenty’). The initiation of contact with the therapeutic worker was noted though no feedback about its effectiveness was received. SW8 thought that mother’s relationship with her step-daughter had somewhat improved. Sib.3 was collecting her younger siblings from their nearby school every day. 2.8.53 Sib.1’s stutter had worsened though he had been discharged from the Speech & Language Therapy Service. The ongoing issue of a lack of dental or optical care was not debated and, because not all had been notified, the high and erratic use of the urgent care, A&E and GP services remained largely unknown. 2.8.54 A consensus was developed that the children could safely be stepped down to ‘child in need’ status at the next review conference. A home visit was completed later that day by SW8 who spent time with the three young children. No concerns were recorded. 2.8.55 On 22.05.15 SN2 undertook a further assessment of sib.2 who presented and engaged well in conversation. The chid said she had friends at school and was happy. She indicated though that she had still not been to a dentist. Sib.2 referred to her favourite food at home which was prepared by her step-sister not a parent. POD SUPERVISION 3 IN CHILDREN’S SOCIAL CARE 2.8.56 A third ‘Pod Supervision’ was completed on 22.05.16 and (aside from the recurring errors with respect to the allocated social worker and dates of proposed further sessions) merely repeated what had been rehearsed at the last core group. 2.8.57 The contents of a child protection supervision session for SN2 on 28.05.15 in which the family was discussed do not appear in her records. A home visit by SW8 on 04.06.15 noted nothing of concern in appearance or behaviours of the children. CAE 36 2.8.58 A report from the speech and language therapist SALT 1 dated 05.06.15 (though it may have been sent earlier) offers a very different account of the extent to which mother was in touch with child G’s needs and her ability or interest in engaging and improving his delayed receptive and expressive language e.g. mother presented her son significantly late on four of five sessions and prioritised examining her mobile when she should have been focusing on child G. 2.9 FURTHER REVIEW CHILD PROTECTION CONFERENCE: STEP DOWN TO ‘CHILD IN NEED’ STATUS 2.9.1 The second review conference on 10.06.15 was attended by both parents. Police who had had no new contacts with the family did not attend. Aside from the independent chairperson other professionals present were SW8, HV2 (and a student) HT1, SN2, CNS1, the speech and language therapists and the school’s pastoral manager. Child G’s nursery was not represented and SW8 was tasked with obtaining a report from staff there. 2.9.2 The parents reported that they had found the therapist very helpful and now related to one another differently. The speech therapist reported that mother had not fully engaged with the block of therapy offered to child G. In spite of mother’s ongoing reluctance to accept speech therapy for child G, a consensus was reached that the children no longer required to be subject of protection plans. HV2 would henceforth visit every other month. POD SUPERVISION 4 IN CHILDREN’S SOCIAL CARE 2.9.3 A fourth ‘Pod Supervision’ on 23.06.15 merely noted and welcomed the fact that the case had been stepped down to child in need status. It contained the same inaccuracies about allocated social worker and next scheduled session as its predecessors. 2.9.4 During June and July mother was provided with a high level of specialist treatment for her chronic medical difficulties. On 02.07.15 an offer by SW8 of a parenting programme was turned down by the parents who reminded him that the child protection plans had now ceased. Comment: the incentive implicit in a child being subject of a child protection plan had been removed and the parents’ apparent engagement diminished. 2.9.5 In mid-July a visit by HV2 was completed. She observed child G (3 years 4 months old) with mother and older sister though father returned during the course of her visit. Child G was thought to be ready to start nursery in September. He was heard to use some expressive language. A holiday play scheme was discussed but the extent to which there existed any extended family or community support was not explored. CAE 37 CHILD IN NEED (CIN) MEETINGS CIN review 1 2.9.6 On 15.07.15 the first ‘child in need’ meeting was held. Father and sib.2 were present as were SW8, HT1, the school’s pastoral manager and HV2. Apologies had been received from SN2 and the specialist nurse neither of whom passed on any current concerns. The school reported that sib.1 had responded well to anger management sessions. Sib.2’s class teacher remained concerned about that child’s ability to process information and the child was still receiving weekly counselling. 2.9.7 HV2 reported no concerns about child G who was awaiting a further block of speech therapy. She raised the possibility of funding from Children’s Social Care for holiday activities citing mother’s recent poor health. In the parents’ view they no longer required support and the professional view also appeared to anticipate stepping down within a short period from CIN status. Comment: the fact of mother’s continuing and probably permanent poor health and her acknowledged need for support over the summer was at odds with the parents’ wish to be free of the CIN plan. 2.9.8 Mother’s ill-health required further high levels of specialist intervention over the summer and into the autumn of 2015. Comment: the time mother was obliged to spend seeking and receiving treatment and its various side effects must have rendered it very difficult to be sufficiently available both physically and psychologically to her children. 2.9.9 A home visit by SW8 on 04.08.15 raised no concerns. SW8 spent time with child G and noted the family’s plans for schooling after the summer break (sib.1 and sib.2 were to transfer to an alternative school nearer to the family’s new home). Child G was about to re-start speech and language therapy. POD SUPERVISION 5 IN CHILDREN’S SOCIAL CARE 2.9.10 Senior practitioner SP1 was noted as the supervisee at a further example of ‘Pod supervision’ on 25.08.15. SW8 was not involved thus reducing the opportunity for individual reflection on facts and fears. Comment: contents of a sixth session in October cast no more light on the family’s needs; there is a need to review the purpose and conduct of these events. CIN review 2 2.9.11 Sib. 1 and sib. 2 began to attend a new school 3 in September and soon after child G began attending the nursery. On 15.09.15 staff suggested mother present child G to the GP to examine a ‘sore lip’ which mother indicated she had inflicted (how she had done so was not captured and, in the light of the circumstances of his death may have some relevance). CAE 38 2.9.12 On 16.09.15 a second review of the CIN plan (CIN review 2) was completed. Both parents attended. Professionals were SW8, HV2 and the deputy head of school 3. SN2 and mother’s specialist nurse sent apologies. Child G was reported to have settled into nursery well, and to arrive well dressed with spare clothes as requested. HV2 had last seen child G at a visit in July. 2.9.13 Mother reported 80% attendance for child G’s speech and language therapy sessions. One record seen indicates that the family would be monitored for a further two months with a view to ending the CIN status at the next review. 2.9.14 In fact, rather than that approach or a ‘step-down’ with a view to involvement with the ‘Early Intervention Service’ a unanimous decision seems to have been that Children’s Social Care would close the case. One consequence of that decision was the immediate discontinuation of visits by HV2. Comment: cessation of visits by the health visitor was not inevitable, was regrettable and presumably reflected a need to prioritise apparently needier families. PRESENTATION OF CHILD G AT GP PRACTICE 2.9.15 A phone consultation about child G (reported by mother / father to have a high temperature aggravating his asthma) was initiated with a nurse practitioner on 29.09.15. Child G was later seen by GP7 who was told child G had ‘been unwell for three days, to have a blocked nose with some wheezing and to have been off his food’. His inhaler had been exhausted. Examination indicated a viral infection with asthma exacerbation. 2.9.16 Soon after the cessation of child in need status, the parents failed to present child G to several speech and language therapy sessions and were warned that he would be discharged unless they made contact. This information was shared with HV2 but it appears to have triggered no further action by her. Comment: given how recently these children had been considered at risk or in need, the news should have triggered at the very least, contact with the parents. 2.9.17 The Practice nurse saw child G on 07.10.15 and noted that he looked better. Child G was still coughing, using Clenil and Ventolin4 and was noted to be due for his flu immunisation. 4 Clenil and Ventolin are standard medicines used to alleviate the symptoms of asthma CAE 39 ONGOING CONTACT / OVERSIGHT FROM CHILDREN’S SOCIAL CARE & SCHOOL EXPERIENCES 2.9.18 The last recorded visits by SW8 was on 14.10.15 when all the children and were seen and an explanation provided about him ceasing visits. SW8 recorded that child G had engaged with his speech and language though that is at odds with the view of the therapist herself. A parents’ evening on 20.10.15 revealed some continuing concerns about sib.2’s aggression toward some other children. 2.10 CASE CLOSURE BY CHILDREN’S SOCIAL CARE 2.10.1 SP1 formally closed the case on 02.11.15 (a decision ratified next day by his manager). The closure record offered a positive picture of progress with a brief mention of mother’s illness. The rationale for closure was that child G was in nursery three days per week and sib.3 (who had recently begun a course at a local Further Education college) now provided additional assistance to the family. 2.10.2 Tasks originally specified when the family arrived in the borough (ensuring the provision of a case chronology, and convening a FGC) remained undone. School 2 (teaching staff and SN2) were formally notified by email later that week and there was no further discussion. Next day mother agreed that sib.2 could see a play therapist at school. INJURY TO CHILD G 2.10.3 On 04.11.15 father presented child G to GP6. He reported an incident on the morning of the day before. He had not himself witnessed the event but understood that his 10 year old i.e. sib.1 had accidentally hit child G with his head. Child G had not lost consciousness and had not bled. When asked by the doctor child G said that it was his sister sib.2 who had struck him but did not divulge any other detail. He said he didn’t hurt anywhere else. 2.10.4 The medical record indicates an abrasion to the right cheek; evidence of bilateral erosion to the mouth (father reported a dentist as having attributed that to the child biting those areas); no break in the lip border, no puncture wounds and no other injuries on the boy’s trunk. 2.10.5 The doctor thought the child’s behaviour was unremarkable and that the account was consistent with the observed injury. He was fully aware of the history of child protection plans but understood there to have been no history of violence to child G. The doctor surmised that father was presenting his son because of his partner’s view that he should do so. The advice given was to monitor in case an infection developed. Comment: in the light of what later happened to child G, injuries to and around the mouths of these children may have had a significance beyond what would normally be considered but the GP’s responses were justifiable given the information available to him. CAE 40 RENEWED CONCERNS ABOUT APPEARANCE & BEHAVIOUR & DEATH OF CHILD G Renewed signs of neglect 2.10.6 On 20.11.15 HT2 at sib.1’s new school was obliged to ask mother to attend to discuss her son’s conduct toward other children, personal hygiene and his torn and dirty shirt. Sib.1 had explained to HT2 that his step-sister got him and his sister up in the mornings. 2.10.7 Mother appeared to take the concerns shared by HT2 seriously and there was a marked improvement in the boy’s appearance and cleanliness the following week. Fatal incident 2.10.8 Immediate and subsequent responses on 27.11.15 by Ambulance and Police services respectively, when father made a 999 call for an ambulance have been described in section 1 of this report. 2.10.9 The implications of risk to child G’s siblings were recognised by medical staff at Accident & Emergency and liaison with Children’s Social Care appropriately initiated. Records relating to the safeguarding work associated with sib.3 had not been passed over to the college when she began attending it and were transferred only as a consequence of the liaison that followed child G’s death. A recommendation has been included in section 5. CAE 41 3 RESPONSES TO TERMS OF REFERENCE 3.1 INTRODUCTION 3.1.1 The inclusion of a number of paragraphs of italicised comment in section 2 justifies the provision below of relatively succinct responses to the elements of the appended terms of reference. Section 4 provides some overarching findings and opportunities for learning and section 5 some resulting recommendations. 3.2 QUALITY OF ASSESSMENTS INFORMATION PROVIDED BY BOROUGH 1 & EMERGING FROM FAMILY’S INITIAL PERIOD IN BOROUGH 2 3.2.1 The electronic transfer of school health records, a phone briefing and (belatedly) the arrival of paper records offered HV1 relevant information that informed her initial visit. 3.2.2 For the period of nearly six months prior to borough 2 assuming responsibility, no core groups were convened and the un-coordinated monitoring of the family depended upon the 7 contacts by borough 1’s SW4, as well as the persistent efforts of HV1 described in section 2 of this report. 3.2.3 Records indicate that HV1 worked hard to engage the family and an initially unresponsive Children’s Social Care. There was scope within her accounts of the family to better capture the parent / children relationships and dynamics and the role of father. The more substantive areas for learning though, centre around: An acceptance (rather than a challenge via the escalation procedure) of the ‘transfer-in’ muddle The distinction between her real-time records of the substantive challenges presented by child G’s family (disguised compliance was evident) and her more optimistic reports at core groups and to conferences 3.2.4 Consultation events with staff suggested that there may be (possibly because the need for its use is infrequent) insufficient appreciation across the network of the existence or appropriate use of ‘escalation processes’. The recommendation in section 5 that this case is used to inform LSCB training addresses that implied need. RECOGNITION OF THE IMPACT OF MOTHER’S ILL-HEALTH 3.2.5 There was very limited liaison between hospital 2 from which mother’s specialist treatment was organised and her GP. This fact coupled with the absence of GP advice at any multi-agency forum meant that the network was almost entirely dependent upon information and advice from the very committed clinical nurse specialist CNS1. CAE 42 3.2.6 The letter sent by CNS1 to the Housing Department in July 2013 was very clear and made explicit the name and nature of mother’s health condition. Discussions amongst the professional network were more circumspect and seemed (in the view of the serious case review panel members) to have been unnecessarily coy about a condition that no longer evokes the same level of fear and prejudice it did a generation ago. Meetings with staff served to confirm that professionals felt constrained by an uncertainty about who knew what about mother’s medical condition. There existed insufficient clarity about the extent of mother’s consent to share (amongst involved professionals) the fact and impact of her medical condition (though mother’s involvement with the ‘specialist nurse’ offered an indication). 3.2.7 In the view of CNS1 the network did not appear to sufficiently appreciate mother’s ongoing and varying physical vulnerability and its consequences for capacity to parent i.e. that the excessive proportion of child G’s waking and sleeping time spent unstimulated in his buggy may have been primarily a result of mother’s health-related lethargy. 3.2.8 On a more practical note, CNS1 was not invited to all relevant meetings and the absence of her expertise and ability to advise on mother’s current health and functioning would have represented a loss to those co-ordinating protective or supportive plans. FATHER’S PRESENCE & SIGNIFICANCE, & WIDER SUPPORT NETWORK 3.2.9 In general terms regarded as a positive and supportive presence, the significance of father’s attitude and behaviours and indeed the proportion of time spent with his family should have been challenged and more fully explored. 3.2.10 In this instance, in addition to the often-observed marginalisation of fathers (without sufficient evidence of positive or negative potential) a further factor was at play. The network knew and chose to set aside the knowledge that father was maintaining a second tenancy (about which little was or is known). 3.2.11 The well-intended but unacceptable consequence was that what was probably an unlawful arrangement served to confuse understanding of, and diminish the level and nature of support to meet the needs of his wife and growing family. 3.2.12 A failure amongst professionals to challenge parental reluctance and check the actual quantity and nature of support from the extended family and church may also have been linked to a fear of identifying mother’s health condition. CAE 43 NEED / RISK ASSESSED AT INITIAL & REVIEW CONFERENCES 3.2.13 After borough 2 had assumed responsibility, core groups and conferences were held in a timely manner. There was though room for improvement in terms of the information and/or assessments provided for use by the network: There was a complete absence of input from GPs even when advice or reports had been sought The issue of dental health, though often raised, was never pursued to a definite conclusion At times when the children’s food intake was in doubt, it appears as though an opportunity to set one of the parents a simple challenge i.e. to list each evening meal for a week was missed Consistent weight and height checks by the School Nursing Service were desirable 3.2.14 It would appear that the professional network at its review conference of July 2013 had recognised the possibility of father being a registered carer and of the value of a nursery place for child G which would have reduced the levels of physical and emotional demands on his mother. 3.2.15 The brief report provided by Adult Services SW10 added little additional understanding beyond confirming that mother did not want any additional help. SW10 did though usefully add the family to a waiting list for a more suitable property. 3.2.16 The fact of mother declining further help from Adult Services together with a refusal by child G’s father to provide requested wage slips appears to have diverted attention from the originating rationale for their consideration i.e. that mother’s medical condition at times reduced her capacity to provide her young child with constant care and stimulation. A more child or parent-centred approach might usefully have challenged father’s reluctance and/or argued for the use of s.17 funding to cover the costs. DISGUISED COMPLIANCE 3.2.17 A retrospective analysis of records reinforces the possibility of disguised compliance (see footnote 3 on page 14) e.g.: After several unconvincing excuses offered, HV1 finally gaining entry at her at unplanned visit on 09.05.13 - a few days before the transfer-in conference The parents, having agreed to it effectively undermined attempts to provide speech and language therapy for sib.1 Mother declined initially accepted treatment, of sib.1’s nocturnal enuresis, offering an unconvincing explanation later about how she had resolved the problem CAE 44 3.3 THRESHOLDS 3.3.1 The muddle that ensued at the point of case responsibility transferring between the boroughs has been described elsewhere. It and the resultant delay before completion of transfer would have justified a challenge via the escalation policy by either Health or Education colleagues, but the threshold for taking such action was not recognised. 3.3.2 Debate between borough 1’s SW4 and borough 2’s SW5 risked adding to the confusion when they anticipated an immediate step-down from the child protection plans that had been introduced in borough 1. 3.3.3 The decision made at the first review conference in borough 2 (July 2013) that the children should remain subject of child protection plans was wholly justified. The decision at the second review conference (October 2013) to step-down to child in need status was, on the basis of the known facts and then current experiences, not unreasonable. Had the full history been better appreciated, the confidence felt by all those who contributed to that decision might have differed. 3.3.4 As well as threshold decisions with respect to child in need / in need of protection, there were other examples of insufficient recognition that the threshold for taking individual action had been reached: SN2’s observations of the children in October 2014 reached the threshold for immediate reporting to SW7 CNS1 could usefully have alerted the school nurse to the anticipated arrival in the UK in late 2013 of sib.3 HV2 when told in October 2015 of the parents’ failure to present child G to his speech and language therapy did not make contact with the family or any other professional 3.3.5 The justification for the conclusions of core groups of April and May 2015 that a step-down to ‘child in need’ status was justified is not obvious. The parents attended both meetings and their assertions may have unduly influenced the debate. 3.3.6 The view of the parents’ co-operation appears to have been based upon attending two sessions with a therapist (they were not continued). The focus of concern had by then shifted toward the adults’ relationship and the tension between mother and her step-daughter sib.3. 3.3.7 Underlying anxieties about parental performance remained and there existed unfulfilled objectives e.g. dental care for sib.2 and perhaps his brothers and sisters and a worsening of sib.1’s stammering had been observed. Nonetheless the conference chairperson at the review in June 2015 supported the widespread view that the children no longer required protection plans. Unsurprisingly without the incentive those plans had represented, the parents declined an offer by SW8 of places at a parenting programme and reminded him that engagement was now wholly voluntary. The parents also failed to make use of the speech and language therapy planned for child G (though later denied that). CAE 45 3.3.8 At the second CIN review in mid-September 2015, what was to have been a planned further step-down at the next review (leaving the possibility of ongoing involvement with the Early Intervention Service) became instead, an agreement that Children’s Social Care should close the case. The formal decision to do so followed soon thereafter and (with a contemporaneous cessation of health visitor contact) left the family with no targeted service intervention. Renewed concerns from his school about sib.1’s appearance and behaviours weeks later suggests that the case closure was premature. 3.4 CULTURE, RELIGION & LANGUAGE 3.4.1 Although the fact that both parents had originated in a central African country was known and captured by most agencies, the implications of that for parental knowledge about or commitment to operate within, the parameters of acceptable / good enough parenting in the UK remained un-explored. For example, the country in question has suffered prolonged wars, massacres of civilians and widespread abuses of human rights. The extent to which mother, father or sib.3 had been directly or indirectly impacted upon by such experiences remained unknown. 3.4.2 It may be that in the course of challenging the parents’ use of physical chastisement (assumed to be a euphemism for beating) that borough 1’s staff debated the differences between what may have been accepted practice in the parents’ country of origin and what is lawful in the UK. If so, such detail was not forwarded and/or accessed by professionals in borough 2. 3.4.3 For practical day to day purposes, whilst it was known that mother’s first language was linked to her country of origin and that she could also speak French, her command of English was considered quite sufficient for everyday and health / social care-related purposes. In the course of this serious case review no new evidence has emerged to contradict that presumption. 3.4.4 The parents’ reluctance to facilitate contact with extended family was rationalised in terms of most of them being unaware of mother’s diagnosis and accepted by professionals for that reason. It may be that any thought of approaching their church for additional support (no record of that has been seen) was met with a similar response. 3.4.5 Whilst it is a fact that an HIV diagnosis can have pejorative associations and that these may be more prevalent in some African countries than in contemporary Britain, mother was quite open about her diagnosis when she had bitten her step-daughter in the presence of police officer and when her specialist nurse composed (with her agreement) a letter to the Housing Service seeking more suitable accommodation. CAE 46 3.4.6 With respect to the issue of feeding traditions, the academic with expertise about various African cultures (who had assisted in the other published case of death by force-feeding) confirms the importance attached by parents in a number of cultures across the continent of Africa (and indeed in Asia) of taking steps to avoid their child being ‘too thin’. What might be considered fat or obese by current Western standards may instead reflect and indicate family wealth or a child who will be regarded as attractive to the opposite sex as they grow up. 3.4.7 The charity AFRUCA set up following a number of high profile deaths of African children in the early years of this century offers some useful guidance on the cultural differences that are of relevance to child protection professionals working with African families who may still follow traditional practices that are unlawful in the UK5. 3.4.8 A more accessible example of a potential clash of cultures was that of sib.3 joining child G’s family. Very little indeed was known about this young woman’s childhood experiences in her war-torn country of origin and whether traumatic experiences (including the reported death of her birth mother) had or would impact on her adjustment to life in the UK. 3.4.9 There was a passing recognition of a risk of sexual exploitation but little exploration of the more mundane possibility of being used or at worst exploited, as a young carer for her step-mother and step-siblings. 3.5 VOICE OF THE CHILD PARENTAL INHIBITION OF THEIR CHILDREN’S VOICES 3.5.1 For the reasons explained elsewhere, the professional network in borough 2 was aware of only a proportion of the family history in the UK. As far back as the summer of 2012, sib. 1 had revealed that he had been instructed by his parents not to tell professionals that he was being hit at home. School staff had also been sufficiently worried about the parental reactions as to withhold from them, concerns about the child’s behaviour at school. 3.5.2 Moving ahead to the period under review, if there existed any awareness that the children might have been coached by parents to offer false reassurances about their well-being, few records confirm it. Where they do, as described below, they led to no decisive action. 5 Africans Unite Against Child Abuse - Promoting the Rights and Welfare of African Children -WHAT IS PHYSICAL ABUSE? -Safeguarding African Children in the UK Series 6 CAE 47 OPPORTUNITIES MISSED 3.5.3 Apparently accepted as merely examples of low level neglect, at times, one or other child had been sufficiently confident to refer to, or present an appearance that implied sub-standard parenting: There is no documentary evidence about how parental use of the lock on sib.1’s bedroom (noted at the transfer-in conference in summer 2013) was explored or challenged Sib. 1 in July 2013 (aged 7.5) revealed to a school nurse that he had never been to a dentist and it remains probable that this important example of responsible parenting was not followed through properly for him or his siblings In Autumn 2014 sib.1 and sib.2 told the then school nurse of their inadequate diet at home, the former contrasting it with the ‘proper cooked dinners’ they had received whilst being fostered Later in 2014 sib.2 told her social worker who had enquired about food, that her father had prohibited her from speaking to anyone outside the family about ‘family business’ 3.5.4 From the children’s perspectives, little changed regardless of what they reported. Though less directly available than their various statements, the needs of the children could also have been usefully explored if the reasons underpinning the aggressive attitudes of both sib.1 and sib. 2 observed at school had been explored in their own right. 3.5.5 Very few records capture the lived or day-to-day experiences of any of the children and only a report by a Contact Centre supervisor (provided at the time of the children’s temporary removal and of no direct relevance to this serious case review) provided a comprehensive account of the children’s appearance, behaviours and affect. WISHES & FEELINGS OF SIB.3 3.5.6 Whilst the impact of sib.3’s presence on the parental relationship was recognised and addressed, the needs of a then 14 year-old, non-English-speaking female entering the UK and joining a mainstream school were insufficiently considered. It is unclear from records to what extent this young woman was provided with any opportunities to discuss her childhood experiences, hopes and fears and whether she was content with the domestic and educational life that had been planned for her by father and step-mother. 3.5.7 Staff events revealed that there had been more effort made to engage with and seek to better understand the needs of sib.3 than was apparent from formal records of meetings i.e. the records of such exchanges was limited to ‘case records’. CAE 48 3.6 INFORMATION SHARING 3.6.1 Given the complexity of an increasingly fragmented network of commissioners and service providers, it is and will remain a substantial challenge to ensure that all relevant information (and no more) is shared in a timely and efficient manner with professional colleagues. MAJOR CONSTRAINTS 3.6.2 In this case, there seems to have been two major factors and several less strategic ones limiting the extent to which all those in the professional network knew what they might usefully have known. 3.6.3 The main and more tangible constraint amongst local professionals was the muddle associated with the family’s move to the borough which denied them an appreciation of the family’s full and worrying history whilst in borough 1 (injuries, proportion of time sib.1 had spent restrained in a buggy/ highchair, parental dishonesty etc). 3.6.4 A less tangible but nonetheless significant constraint appears to have been insufficient appreciation amongst those (other than the specialist nurse CNS1) of just how debilitating mother’s chronic condition was. Clearly, a balance has to be struck between maximising patient confidentiality and the legitimate needs of dependent children. 3.6.5 The reluctance of CNS1 to identify mother’s condition was more than an individual professional judgement. The reticence is also reflected in her employing Trust’s current insistence that such details are not available in the database employed elsewhere in its organisation. The unintended impact in this case was that school staff and to a less certain extent, social work staff underestimated the level of mother’s disability and hence the increased dependence on her partner and/or consequential pressure on her children. 3.6.6 The wider systemic risk is that until the Trust resolve how to capture such information and include it (suitably ‘masked’) in more general patient records the unacceptable practice of an individual nurse having to carry around highly sensitive paper records which cannot be linked to other community service records will continue. Other Trusts have developed suitable electronic systems and the Healthcare Trust must also do so. CAE 49 OTHER CONSTRAINTS TO EFFECTIVE INFORMATION SHARING 3.6.7 Other examples of systemic or individual weaknesses with respect to information sharing may be summarised as follows: The fact that the children had been subject of protection plans whilst in borough 1 was not apparent in the medical records transferred to GP Practice A Though in February 2013 there was a so called ‘Read code’ in mother’s notes at GP Practice A referring to protection plans for the children, there were no such ‘Read code’ in the children’s records When all the children were again made subject of a protection plan in October 2014, a ‘Read code’ was added to child G’s medical record but not to those of his siblings There were unhelpfully long delays in the circulation of notes of core groups and conferences by borough 2’s Children’s Social Care with the consequent risks compounded by delayed inputting of records by Community Health There was very limited liaison with other agencies initiated by staff at hospital 2 e.g. CNS1 was not copied in to correspondence sent to mother’s GP 3.6.8 Further examples of weakness in information management or sharing that appear to be more individual than systemic are offered by the following examples: HT1’s determined yet unsuccessful attempts to contact SW8 in late 2013 suggests a lack of responsivity in that individual’s team The results of the school nurse’s assessment of sib.3 in Autumn 2014 and her contact with sib.1 in January should have been shared promptly with the allocated social worker In September 2014 the school was not informed that the children had been removed and temporarily fostered No evidence has been found of GP – health visitor liaison with respect to child G In GP Practice B, minutes of child protection conferences are kept in paper format and not scanned into the database Following the allocation of SW8, the very significant professional CNS1 received no further invitations to multi-agency meetings CAE 50 3.6.9 In spite of the organisational and individual weaknesses identified above, there were many examples of basic or commendable best practice e.g. a clinician from hospital 2 in March 2011 phoning Practice A and a very prompt provision by that same Practice of medical information when in September 2014 the children were temporarily accommodated. 3.6.10 In those cases where an identified failure implies a need for systemic action, a recommendation is included in section 5. 3.7 SUPERVISION & MANAGEMENT 3.7.1 Records offer clear and welcome evidence of the individual supervision of involved social workers and health visitors and of the appropriate involvement of managers at relevant stages in the case planning processes. However, the Trust providing health visiting services and Children’s Social Care respectively should address the issues below. TASK-FOCUSED / SELF-REPORTING IN SUPERVISION 3.7.2 HV1 had sought and been provided with safeguarding supervision immediately prior to the ‘transfer-in’ conference of May 2013. It was essentially a task-focused event and did not for example enable a reflective discussion about what other and associated risks there might be to the youngest child. 3.7.3 In spite of the insufficient level of co-operation that followed HV1 managed to form a working relationship with mother and later father of child G. Her perception and hence her reporting (late 2014) of the case at her supervision appeared at times to be unduly positive. 3.7.4 If supervision is based wholly on what is self-reported and/or causing the supervisee concern, there is a significant possibility that sources of risk may be overlooked or understated. There is therefore potential value is some cases being selected by a supervisor. ACCOUNTABILITY IN SUPERVISION 3.7.5 Within Children’s Social Care there appears to be at least from a consideration of records, some overlap and therefore risk of confusion between traditional individual case supervision, that provided by senior staff in ‘Pods’ and the formal decision-making for which responsibility rests with independent chairpersons of child protection conferences. 3.7.6 Aside from the mis-attribution of names for the supervisees (referred to in the narrative of section 2), the authority of the so-called ‘Pod Supervision’ (the first of which was provided in March 2015) is unclear. A second such supervision was provided a month later when the supervisor was minded to consult the independent chairperson about bringing forward the date of the scheduled review conference. A third such session a month later added no new information. CAE 51 3.7.7 It is unclear to the author whether the social worker was also in receipt of one to one supervision at this time, nor how the independent chairperson might balance a proposal to bring forward a conference against the value of a multi-agency perspective expected to be developed at this forum. The fourth Pod supervision merely noted the decision made at the review conference in June 2015 and the fifth such session in August the allocated social worker was not present with the case represented by SP1 (thus preventing reflective challenge). 3.8 RESOURCING & ORGANISATIONAL CHANGE 3.8.1 It is not possible without further research to conclude whether the following systemic weaknesses are a function of inadequate funding and/or sub-optimal organisation. 3.8.2 In each case the relevant agency needs to consider how it can best tackle the problem implied by this case of current policy, procedure or practice. GP PRACTICES 3.8.3 GPs are of critical importance in safeguarding children and their contributions must be facilitated. In GP Practice A, it was acknowledged that invitations to attend or offer a report to child protection conferences do not always elicit a response. In Practice B, such written invitations are kept in the paper format in which they arrive and so do not become integral to the otherwise electronic patient record. 3.8.4 The capture and re-presentation of child protection status on patient information systems needs to be ensured in a more timely and accurate fashion than appears to have been achieved in this case at Practice A. CHILDREN’S SOCIAL CARE 3.8.5 An apparently common insufficiency of notice provided by Children’s Social Care of child protection conferences has been referred to elsewhere. 3.8.6 A further difficulty that may reflect staffing levels and/or efficiency is the delayed circulation of records of completed core groups and conferences. In the absence of such agreed records there is a substantial risk of mis-informed actions by involved agencies. 3.8.7 At a more general level there was during the period of review significant structural change e.g. group supervision and the use of the ‘Strengthening Families’ model. It is possible that, pending development of sufficient familiarity, these may have had a significant impact on clarity and consistency of case planning. HEALTHCARE TRUST 3.8.8 The need referred to elsewhere for the Trust to develop a database which is compliant with data protection principles and communicates across all its functions is sufficiently significant and urgent so justify a recommendation in section 5. CAE 52 4 FINDINGS & CONCLUSIONS 4.1 FINDINGS 4.1.1 No evidence has been located to suggest that child G’s death could have been predicted and very little that it might have been prevented. There were examples of effective systems and good professional practice as well as scope for learning about the issues outlined below. 4.1.2 The transfer of responsibility between the boroughs was very poorly managed & borough 2’s service delivery consequently insufficiently informed by available case history, serving to reinforce the risk of the well-known ‘Start Again Syndrome6. 4.1.3 There were numerous indications of varying and ongoing low-level (dirty clothing, lack of personal hygiene) and intermittingly more explicit (failure to ensure sufficient food or medical treatment) neglect. There was clear evidence of disguised compliance in terms of parental use of speech and language therapy or parenting courses offered. 4.1.4 There was insufficient appreciation or analysis of the impact of mother’s medical condition on her ability / motivation to cope and child G’s time spent restrained in his buggy or highchair / time attending medical appointments – possibly compounded by a misplaced sense of sympathy / hyper-sensitivity to the need for confidentiality because of mother’s specific medical condition (living with AIDS). 4.1.5 The reportedly supportive role played by the extended family and or church should not have been accepted at face value. The quite proper reason these sources had first been identified as relevant was that the parents had demonstrated an inability to sustain ‘good enough’ parenting without external input. Their rejection of such help (mobilised via the planned Family Group Conference) needed to be challenged. 4.1.6 There was also insufficient awareness and exploration of father’s lifestyle / overall impact on the family leaving no certainty that a ‘safe parent’ existed. His second address should not have been tacitly accepted and left unchallenged. 4.1.7 The children’s voices were not sufficiently sought / evaluated / explored when they actually revealed being silenced by their parents; their lived experiences were not apparent in the records maintained and there was scope for more challenge of apparent co-operation and compliance with agreed service delivery e.g. SALT, enuresis clinic etc. 6 Brandon et al 2008 pointed out that family histories tended to be complex, confusing and overwhelming for professionals who often found it difficult to decide when ‘enough is enough’ in cases of neglect ; worker can feel helpless and at times fearful of families, which leads to avoidance and drift in decision-making; the authors identified the ‘start-again syndrome’ as one way practitioners managed these dynamics i.e. little consideration is given to the parents’ past histories and the focus is on present circumstances, leading to a lack of systematic analysis of parental capacity and the children’s experience of harm CAE 53 4.1.8 Some evidence of professional optimism exists in terms of direct contacts by professionals and decision of managers based upon those contacts. Given the rarity of the phenomenon though, it is understandable that neither medical nor other professionals considered the possibility of prolonged force-feeding. 4.2 OPPORTUNITIES FOR LEARNING FORCE FEEDING 4.2.1 Amongst the many involved doctors, teachers, social workers, police officers and others, none had knowledge or experience of the phenomenon of force-feeding which is thought to be rare in the UK7 but more widespread in some African countries and elsewhere. MIND-SETS / ATTITUDINAL OBSTACLES TO BEST PRACTICE 4.2.2 Amongst the professional network the quality of assessment of need / risk and subsequent information sharing was constrained by: Well-intentioned but nonetheless misplaced sensitivity about mother’s medical diagnosis which served to mask the extent of her loss of functionality as a parent Equally well-intentioned but unjustified collusion about father’s maintenance of two properties which it was tacitly accepted may have served to increase income via Benefits and reduce the proportion of time committed to care of his children or partner RELEVANCE OF PAST TO FUTURE BEHAVIOURS 4.2.3 The ability to discern behaviour patterns and predict risk can be constrained by: Incomplete information transfer between local authorities or between agencies Extent to which personal history is incorporated into assessments ACCURACY & RIGOUR OF ASSESSMENT / REPORTS 4.2.4 There were occasions when the recorded experience of professionals e.g. compliance / co-operation of the parents did not match the rather more optimistic reports shared at multi-agency forums. 4.2.5 In the complexity of multi-agency service provision compounded by turnover of social workers, some important indicators of neglect were overlooked e.g. dental care. The extent to which the children’s (limited) accounts of their daily experiences was factored into evaluations of need and risk was insufficient. 7 The author co-authored a serious case review in 2011 for Waltham Forest LSCB which is thought to be the first (and until this one only) known example in the UK of manslaughter of a child by means of force-feeding. CAE 54 ORGANISATIONAL NEED FOR MORE EFFICIENT SYSTEMS 4.2.6 Though there was ample evidence of a willingness to share information and plan family support / child protection, the review has highlighted a number of systemic weakness that require urgent strategic management action: Any insufficiency of notice provided by Children’s Social Care of initial and review child protection conferences limits the extent to which other willing professionals from school, or health agencies are able to participate and/or offer reports An apparently common failure to ensure that GPs are invited in a timely manner and do contribute (presence and/or submission of a report) to child protection conferences denies the network key information and perspectives Toward the end of the period under review, there was a repeated failure by Children’s Social Care to invite relevant key professionals (CNS1, HT1) to multi-agency forums The wholly unintended result of the current patient information systems in the Healthcare Trust whereby records in the Acute and Community Specialist Services are electronic and paper-based respectively and an individual such as CNS1 is obliged to carry around highly sensitive material [in the panel’s view a problem of sufficient magnitude to attract the interest of the Information Commissioner’s Office] Delays in circulation and inputting of records (seen in both Children’s Social Care and Health Visiting Service) inevitably diminish their potential value to colleagues There needs to be clearer clinical pathways between the specialist services of the hospital 2 and relevant GPs and specialist nurses such as CNS1 CAE 55 5 RECOMMENDATIONS 5.1 INTRODUCTION 5.1.1 Several contributors have identified ways in which individual practice within respective agencies may be improved. So as to facilitate local learning and the Board’s monitoring of improvements introduced, the most strategic required changes are provided below. BOROUGH 2’S SAFEGUARDING CHILDREN BOARD 5.1.2 In the context of increasingly diverse communities, training introduced or evaluated by the Board should include the existence and significance of cultural practices that pose a risk to children e.g. force-feeding. 5.1.3 The Board should establish the extent to which the insufficiency of GP involvement in children’s safeguarding seen in this case is typical, and if justified by its findings, liaise with relevant member agencies or (to the extent that the issue is about performance or contractual requirements of GPs the local NHS England) so as to initiate appropriate responses. 5.1.4 The Board should seek confirmation from member agencies that potentially unlawful / improper arrangements relating to housing relevant to a child’s welfare which may be discerned by one agency will be shared with relevant other agencies (and if feedback suggests it to be necessary, develop guidance for local application). 5.1.5 The learning from this case should be used to inform local training and staff development opportunities (where possible making use of some individual professionals who have some direct experience of force-feeding practices in some cultures). CHILDREN’S SOCIAL CARE 5.1.6 A date for a ‘transfer-in’ conference should be agreed as soon as it becomes known that a child is becoming resident in the borough and any delays or difficulties in obtaining all relevant records, escalated. 5.1.7 ‘Transfer-in’ records should be quality-assured as compliant with Child Protection Procedures and if necessary, challenged by receiving manager / independent chairperson. 5.1.8 All case recording should include a chronology of significant events / professional responses. 5.1.9 The purpose and relationship with other established processes such as individual supervision of ‘Pod Supervision’ should be reviewed. 5.1.10 The extent to which the insufficiency of notice of conferences (schools and GPs) or omission of relevant professionals (specialist nurse) seen in this case is typical, should be audited and any required corrective actions taken. CAE 56 5.1.11 The current ‘Neglect Toolkit’ should be amended to include specific references to: Feeding issues Dental health e.g. s.17 or s.47 Children Act 1989 assessments should consider any feedback on dental health and any child in need or child protection plan subsequently agreed should note and take remedial action if appropriate dental development is of concern BOROUGH 2’S SCHOOLS / COLLEGES 5.1.12 The Education Service should confirm that arrangements exist and work effectively to ensure that any child protection records are transferred from an early years setting to the school and if relevant, college to which the child / young person may transfer. HEALTHCARE TRUST 5.1.13 The Trust should enable effective electronic linkages so as to offer practitioners in Acute and Community Services access to all relevant information and an alternative to the current unacceptable arrangements which clearly breach data protection requirements. 5.1.14 A practice tool such as the ‘SBAR’ (situation, background, assessment, risk) tool should be rolled out across the Heath Visiting Service in an attempt to ensure systematic and robust information capture when responsibility is allocated to a health visitor for a new family. 5.1.15 A qualitative audit programme should be completed of a sample of health visitor reports compiled for child protection conferences. 5.1.16 All professionals who work with families must receive safeguarding supervision and training at a level appropriate to their role. CAE 57 6 BIBLIOGRAPHY Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008 Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 Published December 2008 The Child’s World Jan Horwarth Jessica Kingsley 2008 What can we learn from a decade of reviews of child fatality and serious harm from maltreatment from the 4 UK nations? Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE Healthy Child Programme DH 2009 A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009 Getting it right for children and young people – Overcoming the cultural barriers in the NHS so as to meet their needs -Sir Ian Kennedy September 2010 Personal Communication: Dr Kwadwo Osei-Nyame, Jnr (D.Phil/PhD Oxford) Lecturer in African Literature, Cultural and Diaspora Studies Africa Department School of Oriental and African Studies (SOAS) University of London 2011 [related to previous case of proven force feeding in Waltham Forest] Working Together to Safeguard Children, HM Government 2010, 2013 & 2015 Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Munro Review of Child Protection: A Child-Centred System TSO www.tsoshop.co.uk Professor Munro 2011 Learning together to safeguard children: a systems model for case reviews SCIE January 2012 New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012 Improving the Quality of Children’s Serious Case Reviews Through Support & Training@ NSPCC, Sequili, Action for Children; DfE 2013 (revised Feb. 2014) AFRUCA: Africans Unite Against Child Abuse - Promoting the Rights and Welfare of African Children -WHAT IS PHYSICAL ABUSE? -Safeguarding African Children in the UK Series 6 CAE 58 7 FINAL TERMS OF REFERENCE 1. SCOPE OF THE REVIEW The Review will focus on the period from when the family moved from borough 1 to borough 2 in December 2012 to the day that Child G died in November 2015. 2. KEY LINES OF ENQUIRY a) FAMILY HISTORY AND CASE TRANSFER (i) Borough 1 LSCB will be asked to provide the family history prior to moving to borough 2 and an outline of agency involvement. Borough 1 will be asked for a more detailed account and an analysis of the case transfer arrangements when the family moved (ii) Agencies in borough 2 will be asked to provide details of their involvement in or following the family’s transfer into the borough and analysis of how this was managed. b) QUALITY OF ASSESSMENTS (i) To include an analysis of how well agencies took into account the family history and the impact of current health or cognitive issues – at the point of transfer and in on-going assessments: (ii) To consider the influence of any optimism on assessments (iii) To identify any development of hypotheses and whether these were revised over time c) THRESHOLDS (i) To include an analysis of the response to changing levels of risk and need (Step up – Step down responses) d) CULTURE, RELIGION & LANGUAGE (I) To examine the actual or potential impact of the family’s culture on parenting style and ability to work cooperatively with agencies in this country – alongside practitioners curiosity in seeking this information to inform assessments and interventions (II) To examine whether sufficient consideration and response was given to any communication needs of the family e) VOICE OF THE CHILD (i) To examine how well the views and experiences of the child and siblings were sought and how these informed intervention, including whether the children were seen / interviewed on their own (ii) To examine how well observations of the child and sibling’s appearance and interactions were obtained and how these informed intervention f) INFORMATION SHARING (i) To examine the effectiveness of information within and between agencies (ii) To examine how well child protection alert systems, including electronic systems worked CAE 59 g) SUPERVISION AND MANAGEMENT OVERSIGHT (i) To examine the formal arrangements in place for management oversight and supervision – and the effectiveness of their application in this case (ii) To examine the ad hoc arrangements for supervision when required – and the effectiveness of their application in this case h) RESOURCING AND ORGANISATIONAL CHANGE (I) To examine the impact of any resourcing, capacity or organisational change on the practice and management of this case 3. REVIEW MODEL (i) The Review will be overseen by a Panel of senior managers representing the agencies involved as well as professionals providing particular expertise (ii) The Review Panel will be chaired by the Independent Chair of the LSCB (iii) The Panel will be supported by an Independent Overview Author who will produce the final SCR Report (iv) Involved agencies will provide chronologies and single agency reports which analyse their agency’s involvement with regard to the identified lines of enquiry. The reports will be based on evidence from agency records and interviews with relevant staff. (v) Two practitioner events will be held for staff involved in the case. The first will explain why the review is taking place, its process and will also provide an opportunity for the initial Terms of Reference to be tested against the views and experiences of front-line staff. The second practitioner event will be held following the production of the Overview Author’s initial findings, in order to test these findings against the views and experiences of front-line staff. (vi) Subject to criminal proceedings and the advice of the Police and CPS, the views of the family will be sought to inform this review where possible. (vii) Agencies to be involved include local authority Children’s Social Care; Police, relevant schools and college, GP Practices, community health Trust, relevant hospitals, and borough 2’s Children’s Social Care. 4. TIMELINE The Chair of the LSCB notified the DfE, Ofsted and the National Panel of Independent Experts that a Serious Case Review would be undertaken on the 18th of December 2015. The objective of the SCR Panel is to complete the review within a six month time scale, subject to any on-going dual processes e.g. criminal proceedings. 5. PUBLICATION The final Overview Report will, following endorsement by the LSCB, be available from the NSPCC repository. The report will be anonymised with respect to family members and the professionals involved . |
NC046497 | Death of a 2-year-old girl in November 2013 as the result of non-accidental injuries, including a lacerated liver. Post mortem identified older injuries including a broken wrist. Mother's 19-year-old boyfriend was caring for Child H alone at the time of the incident. Mother's boyfriend was convicted of Child H's murder and sentenced to life imprisonment. Mother was acquitted of causing or allowing Child H's death but admitted two charges of neglect in relation to Child H's older siblings. Mother's boyfriend had a troubled childhood, which included: child in need involvement with children's social care; homelessness; offending; conduct problems; serious childhood illness; and significant involvement with child and adolescent mental health services (CAMHS), for which he was prescribed medication until his discharge from CAMHS at the age of 17. Family became known to children's social care following a referral made by Sibling 1's school, identifying a number of concerns linked to mother's boyfriend's involvement with the family, including: the deterioration of Sibling 1's presentation, her hygiene and hunger. Identifies issues from key practice episodes, including: timeliness and responsiveness of early help arrangements; use of 'what if' consultations to discuss whether concerns meet the threshold for a referral to children's social care and the need to clarify where there is an apparent misunderstanding about agreed actions following consultation; working with families under S17 of the Children Act (1989) and the effectiveness of verbal action plans; and the role of Cafcass in private law cases. Identifies themes in the case, including: professionals seeing family members as individuals and not recognising the potential impact of concerns on the family network as a whole; insufficient consideration of the role of men in the children's lives; and the over-representation of children from minority ethnic backgrounds in serious case reviews. Makes recommendations covering: interagency working, Cafcass, children's social care and schools.
| Title: Serious case review into the death of Child H: overview report. LSCB: Cambridgeshire Local Safeguarding Children Board Author: Jane Scannell Date of publication: [2015] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW INTO THE DEATH OF CHILD H OVERVIEW REPORT Author: Jane Scannell November 2014 2 Contents Page 1. Summary of findings 3 2. Introduction to SCR 3 3. Introduction to case 4 4. Family structure 4 5. Terms of Reference 4 6. Process 5 7. Background 6 8. Analysis of key practice events 7 9. Issues identified by key practice episodes 13 10. Analysis of themes 18 11. Conclusions and lessons learned 21 12. Recommendations 22 13. References 24 Appendices 5. Genogram of family 25 6. Terms of Reference 26 7. Template for Agency Reports 36 3 SERIOUS CASE REVIEW INTO THE DEATH OF H 1. SUMMARY OF FINDINGS 1.1 The conclusion of this review is that there is no evidence that the death of H could have been predicted and that the professionals who came into contact with her and her family could not have anticipated, and therefore prevented, the tragic outcome. There was nothing in Mother's Boyfriend's antecedents or known behaviours that indicated that he would perpetrate the level of violence that killed H. He had had a troubled childhood and adolescence but it was not exceptional. Many other young people have similar backgrounds but do not commit such violent acts. Professionals were alert to the changes in the family once he became involved with them and were in the process of acquiring a fuller understanding of his role in the family and its impact on the children's lives when H died. There was nothing to indicate to those professionals that the usual time scales for assessment needed to be accelerated. 1.2 However the window onto the system this review has allowed has identified some learning for the professionals involved, on both an individual and organisational level. While it is recognised that professionals' behaviour and actions which generated this learning did not contribute to H's death nevertheless it is pertinent to reflect on these aspects so that the learning can inform actions taken to ensure the continuous improvement of the multi-agency response to vulnerable children and their families in Cambridgeshire. 2. INTRODUCTION TO THE REVIEW 2.1 Working Together (2013) states that where abuse or neglect of a child is known or suspected and the child has died, then the Local Safeguarding Children Board (LSCB) must initiate a Serious Case Review (SCR). The purpose of a SCR is to enable the professionals and organisations involved with the child and their family to reflect on both their own practice and that of others and to identify improvements that are needed and to consolidate good practice. 2.2 Working Together (2013) also says that SCRs should be conducted in a way that � recognises the complex circumstances in which professionals work together to safeguard children � what are the underlying reasons that led individuals and organisations to act as they did; � seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; � is transparent about the way data is collected and analysed; and � makes use of relevant research and case evidence to inform the findings. This serious case review has been undertaken in a way that ensures these principles have been adhered to. 4 3. INTRODUCTION TO CASE 3.1 The child who is the subject of the review is referred to in this report as H. Her parents are called Mother and Father. Other family members are referred to by their relationship to H e.g. maternal grandmother. Mother's Boyfriend is referred to in this way as this was the way in which the relationship was described by the children. Agencies were given differing understandings of the relationship between the two adults with them referring to each other at various times as neighbours and partners. A genogram is attached at appendix 1. 3.2 H was 2 years and one month old when she died in November 2013. At about 8.50 am on a day in November 2013, an ambulance was called to the home address where Mother's Boyfriend had been caring for H while Mother took her older sibling to school. Mother's Boyfriend alleged she had sustained a head injury falling off the toilet. H was taken to the City Hospital where she died of her injuries which included a lacerated liver. The post mortem identified that she had other, older injuries, including a broken wrist. 3.3 Mother's Boyfriend was subsequently convicted of her murder and sentenced to life imprisonment and was told he must serve at least 17 years of his sentence. Mother was acquitted of causing or allowing H's death but admitted two charges of neglect in relation to the older children. She was given a suspended sentence. 3.4 H's two older siblings were accommodated by the Local Authority in November 2013. 4. FAMILY STRUCTURE 4.1 Mother married the Father of Sibling 1 in 2004 (when she was 19) and Sibling 1 was born in 2006. Father of Sibling 1 and Mother separated in late 2006 and Father of Sibling 1 was deported in 2007. In March 2009 Mother met Father of Sibling2, and Sibling 2 was born in March 2010. The current whereabouts of Father of Sibling 2 is not known. 4.2 Mother and Father met in in latter part of 2010 and H was born the following October. They separated in September 2012. Mother was 26 years old when H was born and Father was 23. 4.3 All three fathers are of different ethnicity. Mother's ethnicity is white British. No information was made available to the review about the religious affiliation of any of the adults except for Father who is an active Christian. 4.4 Mother's parents are separated. Maternal Grandmother lived comparatively near the family with Mother's half brother who is now aged 18. Maternal grandfather lives in another part of the country. 4.5 Mother's Boyfriend's 19th birthday was the month before he and Mother met, following the family's move to the house next door to where the father of Mother's Boyfriend lived. 5. TERMS OF REFERENCE 5.1 In order to ensure the process was proportionate to agencies' involvement, agency authors were asked to provide either full reports or background reports detailing historical involvement prior to August 2013. Those that had peripheral involvement were asked to provide a statement of involvement only. The Terms of Reference are attached at appendix 2 5 and detail which type of report each agency was asked to provide. The TOR also articulate the particular issues for consideration the report authors were asked to consider. The format for agency reports that the authors were given is attached at appendix 3. 5.2 The period of review was originally set as from August 2013, when the family moved to the property where H died. However, the first drafts of agency reports, considered at the Authors' Meeting, confirmed that there was relevant information from the month before the move, July 2013, and so the period under review was extended back to commence in July 2013. 6. PROCESS 6.1 The LSCB's SCR sub-group was informed of H's death on 26th November, and the review was initiated on 17th December 2013. Draft Terms of Reference were then further scoped at the SCR sub-group meeting on 28th January which the Reviewer also attended. A meeting for authors of individual agency reports was held on 4th March 2014 where the review process and expectations of the agency reports were discussed. 6.2 The LSCB liaised with the Crown Prosecution Service to discuss how staff who had been involved with the family could participate in a learning event without compromising the criminal trial. Original time scales were amended when the dates for the criminal trials of Mother's Boyfriend and Mother were announced so that a Practitioners' Event could take place after the trial had concluded. 6.3 On 20th May the agency report authors met with members of the SCR sub-committee and the overview report writer to review the reports, to discuss emerging themes and to identify further information needed to produce a final version of their reports. All participants had view of all the reports prior to the meeting to ensure everyone attending was able to fully understand the multi-agency context of the review. 6.4 A full day's Practitioners' Event took place on 3rd July. All the agencies who had submitted full reports were represented as well as some of those who had done only background reports. Front-line staff and line managers who had been involved with the family during the reviewed period were invited as were the agency report authors. The Event was very well attended and enabled a “window on the system” and the discussions and reflections that emerged informed this report. A further Practitioner Event to share the final report and to further discuss the learning is planned. 6.5 The draft Overview Report was considered at meetings of the LSCB Serious Case Review Sub-group on 9th September and 21st October. 6.6 The Overview Report Writer and a representative from LSCB met with Father on 27th August to give him the opportunity to share his views and, where these contribute to learning, they have been integrated in to this report. Once completed the LSCB Business Manager has subsequently shared the findings of the review with the Father, and the Overview Report writer and LSCB Business Manager have met with the mother to share the findings, however the mother had not felt able to contribute to the Review at an earlier point. 6 6.7 The Overview Report writer is an independent child protection social work manager and consultant and has no previous connection with Cambridgeshire Local Safeguarding Children Board and its partner agencies. 7. BACKGROUND PRIOR TO THE SCOPED PERIOD 7.1 Mother moved back to Cambridgeshire area from where she had been living with her father very soon after the birth of Sibling 1 in Aug 2006. By the time Sibling 2 was born in March 2010, Sibling 1 had been diagnosed with a learning disability and the family were receiving support from a local Children's Centre and a Family Worker was briefly involved. Mother was perceived by those professionals working with her at the time as a single mother with a child with special needs who needed extra help but “nothing exceptional”. Her single parent status alluded to the fact that professionals recognised that neither of the two children's fathers had remained involved although there is no evidence that there was curiosity about the how she had formed these relationships and any consequent implications for her and the children. Sibling 1 started school in September 2011, a year later than her contemporaries, her admission having been deferred because of her special educational needs. 7.2 During 2010 Mother and Father started a relationship and he was part of the household from late 2010 until September 2012 when Mother made an allegation of assault against him. She also cited previous incidents of domestic abuse which were said to have been witnessed by the children. Father was charged in relation to three incidents although these charges were eventually dismissed in court. During this time Mother obtained Prohibited Steps and Residence Orders in relation to H as she reported that Father had threatened to abduct H and take her abroad. Prior to charges being dismissed Mother reported Father for breaching his bail conditions by making indirect contact with her on several occasions. 7.3 Because Mother had made an application for the above orders, and because Father subsequently made an application for a Contact Order, the Children and Family Court Advisory and Support Service (Cafcass) became involved. Pending a Fact Finding hearing, Cafcass recommended that contact between Father and H should be not be allowed until all the data from safeguarding checks had been received and considered. The court subsequently made six findings that Father had physically assaulted Mother and had sought to intimidate her. It also made a finding that they had both argued in front of the children. Cafcass undertook an assessment (which involved telephone only contact with Father) and recommended that, in light of his denial of abuse and “lack of understanding of the need for him to make changes to his behaviour” he should have indirect, letter box, contact four times a year until he showed “some acceptance of his violent behaviour and (of) taking some steps to deal with this”. The court ordered Cafcass to identify a Domestic Abuse Perpetrator Programme (DVPP) to assess Father for his suitability to attend and that in the meantime he was to have indirect contact at six-weekly intervals. Father subsequently attended a DVPP which reported on his regular attendance and progress in its interim report. In October 2013, Cafcass requested an adjournment of the next hearing to enable the final report to be received. This meant that Father's application for contact with H was still being considered at the time of her death and he had had no direct contact with her since he had left the family home in September 2012. 7 7.4 There was no information to suggest that Mother's Boyfriend knew Mother prior to the family moving in to the house next door to his father's home at the beginning of August 2013. However, by the end of August he was living at his father's address (although his father had imposed the condition that he was not to be in the house on his own) and the relationship between him and Mother started shortly afterwards. At the time Mother was 28 and he was 19 years old. 7.5 Mother's Boyfriend had had a troubled childhood and adolescence. At 4 years old he had a serious illness, his parents then separated acrimoniously and he moved between them at various times when his behaviours became too much for one or the other to cope with. He was diagnosed as having hyperactivity and conduct problems and was involved with Child and Adolescent Mental Health Services (CAMHS) for 9 years until he was discharged when he was too old for the service. While he was under the supervision of CAMHS Mother's Boyfriend was prescribed medication for Attention Deficit Hyperactivity Disorder (ADHD). He had some “planned breaks” from the medication and reported that he preferred being on medication as he felt more impulsive and more likely to get into trouble when not taking it. At the time there was no formalised specialist adult ADHD service and when, at the age of 17 he was discharged to his GP from CAMHS, he did not continue to be prescribed medication. (Even though there is now a service for adults with ADHD within Cambridgeshire mental heath services, there is no pathway for young people to transfer from CAMHS to this service and young people continue to be discharged back to their GP. They have to be referred back to the service for adults, placing a barrier in the way of obtaining continuity of treatment for this group of young adults). 7.6 Children's Social Care services (CSC) had intermittent child in need involvement (under s171 of the Children Act 1989) with Mother's Boyfriend during his childhood. Their last involvement was in 2012 - just before his 18th birthday - when they were informed that he was homeless. He also acquired a Police record and the Youth Offending Service had been involved with him. The offences for which he was found guilty of were burglary and theft (in 2008 and 2009), a charge of destroying /damaging property in 2009, and of possessing an offensive weapon (a knife) in a public place in 2011. No further action was taken on four other offences spanning 2007-2011 and he was found not guilty of Battery in 2012 (this last incident relating to an incident between Mother's Boyfriend and his step father when there was a confrontation over money). 8. ANALYSIS OF KEY PRACTICE EPISODES Key practice episodes are episodes that are judged to be significant to understanding the way that the case developed and was handled. The term ‘key’ emphasises that they do not form a complete history of the case but are a selection of the activity that occurred and include key information to inform the review. 1 S 17 Children Act 1989 states the duty of Local Authorities to safeguard and promote the welfare of children who are in need. 8 Key Practice Episode 1 - July and August 2013 8.1 The first key practice episode started in July 2013. During this time the family were preparing, and then moving, to their new home. Staff from the agency that had had the longest involvement with the family – the Health Visiting Service – reflected that this move was seen as a positive development for the family and was “seen to be the answer” to most of the family's presenting problems at that time. These problems included mother's depression – her GP had prescribed antidepressants on 15th July, Sibling 2's “erratic, destructive and disruptive” behaviours reported by mother, the poor condition and unsuitability of the flat they were living in and “issues” with neighbours. 8.2 However, prior to the actual move, on 21st July, a neighbour contacted the Emergency Duty Team (EDT) to make a referral to CSC. The neighbour said she regularly looked after the children for mother and made allegations about the mother’s behaviour whilst looking after the children. This referral was responded to by an (agency) social worker from the Integrated Access Team (IAT) completing a threshold assessment. The purpose of a threshold assessment is to avoid “undue escalation to statutory assessment” (IAT Manual) by gathering further information, which can include seeing the family, to inform decision-making. There was some uncertainty about whether the family had already moved to their new address or not and the efforts to clarify this caused some delay in undertaking the threshold assessment which was eventually completed on 2nd August. 8.3 The social worker who completed the threshold assessment undertook a home visit and also spoke with the Nursery Nurse who was involved with the family at this time. The Nursery Nurse, who is a member of the Health Visiting team, had been asked by the allocated HV to complete a CAF (Common Assessment Framework) assessment. This was because a GP had requested Health Visiting input in regard to Sibling 2 (who was then aged nearly 2½) for sleep and behaviour advice. The Nursery Nurse's assessment noted that Sibling 2's behaviours were reported by mother to include “throwing herself off her bed and cutting herself, eating tissue paper and not sleeping well”. 8.4 The social worker's threshold assessment concluded that no further action was needed as “no safeguarding concerns were identified” and that the family were receiving “relevant support from the children centre”. This was not the case at the time. The children's centre was referred to by name in the assessment and staff at the Practitioner Event pointed out that this children's centre was not in the local area and therefore would have been very unlikely to have been involved. The fact that the social worker was an agency worker and perhaps not familiar with the locality may have contributed to this error, though this does not explain whether the social worker simply made an assumption about the children's centre involvement or was given misinformation when he did the home visit - or why the person signing off the assessment did not recognise that the family were unlikely to be receiving support from a children's centre some 25 miles away. 8.5 The CAF was considered at the August Locality Allocation and Review Meeting (LARM). LARMs are professional meetings used to identify appropriate resources and actions to help children and families who have more complex additional needs but who do not require social work involvement. The chair of the LARM was aware of the referral and threshold 9 assessment and concluded that the family's needs “might be higher than suggested by the original CAF” and asked the Locality Social Worker (LSW) to clarify whether CSC were going to transfer the case for a social work assessment. This request is in keeping with the responsibilities of the LSW (who is a senior social worker) which include “supporting the interface of service provision ...between Locality and Social Care”. The LSW confirmed that the referral to IAT had been assessed as not reaching the threshold for children’s social care involvement and confirmed that the children centre team should allocate a Family Worker and proceed with a Team Around the Child (TAC) meeting. As a result a Family Worker from the Children's Centre was allocated on 30th August 2013. 8.6 This is a key episode because Sibling 2's behaviour was noted to be of concern, a first referral was made to CSC and the first LARM was held, offering professionals opportunities to explore what the children's lives were like. It is also the period during which the family moved to their new home. It evidences that some concerns already existed prior to the house move and Mother's Boyfriend becoming involved. Key Practice Episode 2 – Start of school term (4.9.13) - school referral to CSC (17.10.13) 8.7 Very soon after the start of term school staff started a “diary of concerns” about Sibling 1 as they noted that she was “sad and clingy and not her usual happy self”. Despite the family's move Sibling 1 had been able to continue at the same school she had been attending and at the Practitioners' Event her Teaching Assistant spoke eloquently about the changes she observed, both in Sibling 1 and in Mother, not only as the term progressed but in contrast to her previous experience of them both. Frequent concerns were noted in the diary about Sibling 1’s appearance: “her teeth are dirty and breath smelly” “same dirty clothes on as all week” as well as an observation of Sibling 1 trying to take food off another child. This was a stark contrast with the school's previous experience of Sibling 1 when “she always had everything she needed; she was not hungry and was pristine”. 8.8 The school also formally recorded some concerns in the school's child protection file. A child protection file had been started in 2012 when the school had been informed of two domestic violence incidents. During this key practice episode two incidents were recorded on the child protection file - the fact Sibling 1 had a red mark on her face along with mother's explanation (that it may have been caused by a coat zip) and a further incident, seen outside school, when Sibling 1 was told off by Mother's Partner and was threatened with no food. Then, on 26th September, after Sibling 1 had spoken of her sister “being bad at bedtime” and that Mother's Boyfriend had “shut the bedroom door hard and the door had hit (Sibling 2) making her nose bleed”, the school had a “What If” conversation with CSC. “What If” conversations are an opportunity for a professional to discuss a concern with a social worker to clarify appropriate action to take. 8.9 The school recorded the outcome of this conversation as being told to monitor. However, CSC had recorded their advice as to make a referral. As is IAT's routine practice, they sent a letter to the school confirming their advice to make a referral. This letter was sent by IAT on the day following the “What If” conversation (27th September). It was received by the school on 30th September and was reported in the agency report to have been “annotated.. . to say they were advised to monitor”. The School did not contact IAT to clarify the difference in their 10 understanding of the outcome of the “What If” conversation. When the school did eventually make a referral to CSC on 17th October, it was in relation to further concerns about Sibling 1 being hungry and not in response to the letter of 27th September from IAT. It has been difficult to understand how such a diametrically different understanding of a conversation can have happened and the use of “What If” conversations gave rise to discussion at the Practitioner Event and is considered further in the analysis section. 8.10 On 30th September a member of staff from Sibling 2's Pre-school observed an incident in the community involving Sibling 2 being roughly handled by a man - assumed to be Mother's Boyfriend. The member of staff was concerned enough to telephone her manager to report what she had seen and subsequently completed a “log of concern”. However this information was not shared with any other professionals working with the family nor was a referral made to CSC. The Agency Report recognised that the Designated Person2 at the Pre-School was “acting up” as Manager. She continued to cover her substantive post's responsibilities while she was Acting Manager and, although she had completed the Child Protection Designated Person training she had not previously taken an active role as the previous Manager had taken responsibility for safeguarding issues at the Pre-School. This meant that both her capacity and experience was limited. 8.11 The Nursery Nurse's CAF regarding Sibling 2 was again considered at LARMs in September and October 2013. The Family Worker who had been allocated at the end of August (once clarity had been obtained about that CSC were not currently involved) had been asked to arrange a Team Around the Child (TAC) meeting but had not done so as she was about to leave the service. At the September LARM the case was reallocated to another Family Worker who first met the family on 8th October. During this visit the Family Worker met Mother's Boyfriend and was concerned about what she considered his “controlling behaviour” towards Mother. Because she had access to the CSC recording system she was able to establish the fact that the School had had the “What If” conversation and this caused her to take advice from her line manager and to then contact the School. The resultant meeting between the Family Worker and the Special Educational Needs Coordinator (SENCO) took place on the same day as the School made the referral to CSC. 8.12 The only other incident of significance that occurred during this practice episode was contained in the report from the Ambulance Service who noted that on 11th October there was a 999 call from the family home at 00.51am because of a “3 year old feeling faint and dizzy” and suffering from vomiting and diarrhoea. Paramedics attended and gave advice but were not concerned about either the child's health, the carers' (reported to be a man and a woman) behaviour or the home conditions. There is currently no reliable system for notifying other agencies – including GPs – of ambulance call outs that do not result in taking the patient to hospital and so this incident was not known to the professional network around the family. It is not possible to form a view on the significance of this incident but had it been known to the professional network it may have prompted additional curiosity. 8.13 This is a key practice episode because the significant change in Sibling 1's presentation and 2 The role of designated professional lead is “to support other professionals in their agencies to recognise the needs of children, including rescue from possible abuse or neglect” (Working Together 2013) 11 behaviour was noted by the professional network then working with the family and linked to Mother's Partner's involvement. There was an emerging pattern of concerns for two of the three children in the family but there was delay within the professional network involved at the time, in linking and responding to these concerns and considering the impact on H about whom no specific concerns were being raised. Key Practice Episode 3 – Start of CSC involvement (17.10.13) – CSC complete initial assessment (31.10.13) 8.14 The referral from the School listed their concerns about the deterioration in Sibling 1's presentation, her hunger and linking them to Mother's Boyfriend's involvement with the family was received by CSC on 17th October and passed from the IAT to a Social Work Unit for assessment. There was a conversation between the Family Worker (who had been copied in to the referral by the School) and the Consultant Social Worker (CSW) and they agreed that the Family Worker's visit, planned for that day, would go ahead as “ no social worker would be available to visit in the next couple of days or so”. It was also agreed that the planned TAC, arranged at the October LARM for 24th October would be held as a Child in Need (CiN) meeting instead of a Team Around the Child (TAC) meeting thus enabling “handover” from the lead professional to the social worker. 8.15 However, after this discussion the CSW decided to allocate the case to a different, more experienced, social worker in recognition that the referral had been categorised as at MOSI level 43 , implying that the details contained in the referral gave rise to greater concern than other child in need referrals. The new social worker undertook an unannounced visit to the family on the same day (17th October). At the Practitioner Event the social worker described that, as he was on duty and in the area that afternoon, he “would be pro-active” and call on the family, and, because the concerns from school were “regarding food”, by calling without warning he could clarify “the reality of the situation”. At the Practitioner Event it also became clear that the school had not informed Mother that they had made a referral to CSC (but had tried to contact her by phone), therefore the social worker's visit would have been a total surprise to Mother. The impact of this is considered further in the analysis section. 8.16 When the Family Worker undertook her planned visit - shortly after the social worker had left - she found the family “very upset” and at the Practitioners' Event the school recalled how Mother had been “very cross” (with them) the next day. The social worker did another home visit the following day – the primary function of which was to check that food had been obtained as there had been very little in the house the previous day. He took a food parcel with him but there was food in the home and evidence of a food delivery having been arranged. At this visit the social worker gained Mother's Boyfriend's permission for Police National Computer (PNC) checks to be done. 8.17 At the conclusion of this second home visit the social worker agreed a verbal “action plan” with the family. It is clear from the social worker's recording and contribution at the Practice 3 Cambridgeshire's Model of Staged Intervention (MOSI) provides a framework for developing a common understanding of children’s needs, a shared understanding of the roles and responsibilities of services and aids practitioners in understanding the thresholds of different services. Cases meet MOSI Level 4 if needs are complex and enduring and cross many domains.. 12 Event, from mother's subsequent actions and from information recalled as being shared at the TAC meeting that took place on 24th October that it was agreed that Mother would take responsibility for taking the children to and from school. The CSC agency report states that it was also agreed that “Mother's Boyfriend would not be left alone with the children, that Mother's Boyfriend would not be involved in the parenting of the children”. 8.18 Between this period of professional activity starting on 17th October and the TAC meeting on 24th October the only incident of note was that H was taken to the GP by Mother with a “bony swelling” on her forearm. H was able to move her wrist and arm without pain and Mother said there was no history of trauma. The GP referred H for an X ray at hospital and asked Mother to call the surgery to discuss the results. H was not taken for the X ray but the GP was not made aware and did not follow this up. The GP Agency Report Author subsequently clarified that the X-ray Department's policy is to only notify GPs of non-attendance after six weeks has lapsed, sadly H died before this. The GP's surgery were unaware of CSC's involvement at this time. 8.19 On 24th October the TAC meeting that had been arranged at the October LARM was held at the family home. It was attended by the Family Worker and the Locality SW, the Special Educational Needs Coordinator (SENCO) from the School and the Health Visitor as well as Mother, Mother's Partner and Maternal Grandmother. Crucially, despite the Family Worker having been advised by CSC on 17th October that the arranged TAC should go ahead and become a CiN meeting in order to hand over case responsibility (in line with “step up” process), no one from the Social Work Unit attended. The absence of CSC was caused by the allocated worker taking unavoidable leave and no one else being available to attend. 8.20 The content of the meeting as recorded by the Family Worker was that the SENCO explained the reasons why the school had concerns about Sibling 1 and that Mother “was able to see the concern and agreed that she needs support” and that “we discussed openly the concerns that we all have for Mother and the girls regarding her new partner”. It is clear from Agency Reports that there was uncertainty in the professional network about what limitations of Mother's Boyfriend's involvement with the children had been agreed with CSC . In fact it was reported that Mother's Boyfriend himself that told them that he was not to be left alone with the children. 8.21 On 31st October, the social worker completed writing his initial assessment within the prescribed time-scales4 which concluded that a CiN meeting should be convened and a core assessment be completed “to further understand the family and the children's world”, recognising that only a limited understanding had been obtained so far. The initial assessment identified that, other than details provided by Mother and her Boyfriend, it was informed by input from the School and the Family Worker. No contact was made with Health Visiting Services or the GP, the assessment simply recording that there were no health concerns, based on the family's information. 8.22 This is a key practice episode because during this time CSC became involved and instituted a 4 At this time Cambridgeshire were working to the requirements of Working Together 2010 which required initial assessments to be completed within 10 working days from the referral to CSC and core assessments within 35 working days. 13 verbal agreement that included that Mother was to take the children to and from school and take “full care” of the children. Key Practice Episode 4 – November 2013 8.23 On 6.11.13 the social worker met with Mother, Mother's Boyfriend and the children and discussed the information obtained from the PNC check (received by CSC on 25th October). The social worker thought the information it contained to “be concerning.... partially due to the number of entries which (he) felt were significant for a young person”. However, the Reviewer's opinion is that it is not an unusual record for a troubled young man to have and does not contain information that would give immediate safeguarding concerns. 8.24 At this meeting the social worker discussed with Mother's Boyfriend why the information gave rise to concern and re-iterated to both Mother and Mother's Boyfriend the need to continue to abide by the verbal action plan, described as a “brief holding plan leading up to the CiN meeting” (CSC Agency Report). By the time of this meeting Mother had been expected to abide by it for 4 weeks. 8.25 On the same day, November 6th, Mother took Sibling1 to the GP having had a telephone conversation with a doctor from the surgery earlier in the day. She told the doctor that the school and the social worker were concerned about Sibling 1's weight and height and had commented that she “smells”. Mother told the GP about CSC 's involvement and this prompted the GP to both review Sibling 1 a week later (when positive progress in her presentation and weight were noted) and also to contact the school. The doctor did not check Sibling1's other siblings' records and so did not ascertain that H had not had her X-ray. 8.26 On 14th November, within the locally prescribed time-scales, the first CiN meeting was held at the School. Apart from the family members the only other person there who had been at the TAC was the SENCO. The Health Visitor who came to this meeting was covering for the family's Health Visitor who was not available to attend. No formal notes of this meeting had been circulated before H's death, however, all attendees noted down agreements and expectations of their agency. Mother was contacted by her allocated Health Visitor the next day and was reported to “be a little overwhelmed by what is expected of her” . 8.27 On the afternoon of 20th November the Teaching Assistant noticed that Mother did not have the other children with her when she collected Sibling 1 from school. She recorded this in the school's child protection concern log the next morning but had not passed this information on to CSC before the school were contacted following H being taken to hospital. 8.28 This is a key practice episode as it had been concluded by the initial assessment that there were concerns that needed further assessment and so the children were assessed as being in need of support, the primary focus of which was the verbal agreement to limit Mother Partner's involvement with the children. H sustained an injury for which she was taken to the GP and which the post mortem has confirmed was non-accidental. Because of limitations within systems, the GP practice were not alerted to the non-attendance and so did not pursue when she was not taken for an X-ray. 14 9.0 ISSUES IDENTIFIED BY THE KEY PRACTICE EPISODES 9.1 A number of issues were identified in the key practice episodes which warrant further consideration. These are � the Early Help5 arrangements (including the CAF, LARM and the role of the locality social worker), � the use of “What If” conversations and referrals to CSC � the initial assessment and the verbal agreement with the family. In addition, as one of the functions of the review to use it as a window on the system, the impact of Cafcass involvement is also considered although it started outside the period of the review. Early Help arrangements 9.2 The CAF completed on Sibling 2 was initially considered at the August LARM and reviewed at two subsequent LARMs. Although Cambridgeshire CAF arrangements now include the possibility of using an e-form CAF, which can include a number of children's needs on one form, this facility was in the process of being rolled out across Cambridgeshire in July 2013 and was not utilised in this case. Adding this to the fact that LARMs are age-banded and the CAF completed by the Nursery Nurse was presented to a LARM convened to address the needs of 0-5 year olds caused the reviewer to consider whether these arrangements preclude/hinder a holistic approach to families with children of different ages. 9.3 This risk is recognised in the 0-5 LARM Guidance which states that “consideration needs to be given to which LARM a family sits within .... (the) decision should be based on either the complexity of need of the youngest child or the level of need of other siblings, whichever is greater”. The August LARM took place before concerns for Sibling 1 started to develop and, although the CAF initiator, the Nursery Nurse, attended, little information about H seems to have been presented (this “invisibility” of H is considered later in this analysis). Systems in place informed the LARM of CSC's recent involvement which enabled a “joining up” of this information. The conclusion is that there is no evidence that it was the age-banding of the LARM that prevented a joined up approach and the current development of a paper and electronic Family CAF will support a Think Family approach by Early Help practitioners. 9.4 The CAF (which had been initiated in July) was considered for three consecutive monthly LARM meetings with the Family Worker only making a first home visit to meet with the family the day before the third LARM in October. This is not a timely process although it is recognised that there are several factors contributing to this including the holiday period, staff who had been allocated leaving, the time taken to clarify CSC's involvement and some difficulty the eventually allocated Family Worker had in arranging a home visit. Nevertheless early help services need to be arranged so that they are responsive and support is provided in a timely way to stop situations deteriorating. However, although there was delay, this did not materially alter the course of events. 5 Early Help refers to services provided by a number of agencies which provide a ‘bridge’ between specialist services such as Social Care and universal services such as schools and the NHS. 15 9.5 The LARM was unsure whether the Threshold Assessment by the IAT was robust, as one of the rationales for recommending that no CSC involvement was needed was that the family were receiving relevant support from a Children's Centre and they had identified that this was not the case. The Locality Social Worker simply reviewed the CSC electronic case record and confirmed that the case had not met the threshold for social care and therefore advised the children centre that the team should allocate a Family Worker and proceed with the TAC meeting. There was no communication with IAT about the anomaly concerning the Children's Centre and whether this had any bearing on the assessment's conclusion that the case did not meet CSC threshold. Cambridgeshire is currently undertaking a Consultation on the Re-commissioning of Early Help Services where the question of what the best arrangements to secure social care input to Locality Teams to support risk management and advice on casework is being considered and this case should be used to inform the decisions made. “What If” conversations and referrals to CSC 9.6 These types of consultations are provided by CSC duty desks to professionals who want to discuss whether a concern meets the threshold for a referral to CSC or for advice on what further action or information they need to obtain before making a decision about referring. In Cambridgeshire this facility is provided by an IAT duty social worker with calls being put through to them from the Contact Centre. At the Practitioner Event it was clear that the professional network found this opportunity for discussion supportive “(it makes you) feel you are not alone. (You can) share the concern”. 9.7 However, it also emerged at the Practitioner Event that referrers found the system clumsy because if the “What If” discussion concluded that a referral was needed the referrer had to repeat the information they had just shared with the IAT duty worker to someone else in the Contact Centre who would record it as a referral. Referring agencies found this especially frustrating as the IAT workers do also make a record of the “What If” conversations and it does appear to be duplication of effort. 9.8 The IAT's practice of sending a letter stating the agreed actions following a “What If” conversation provides a system for confirming the outcome of the discussion. However the efficacy of this system is reliant on the recipient both reading the letter and, if it then appears that there is a discrepancy in the in the understanding of what the agreement was, making contact with CSC to clarify. In this case the School did recognise that there was a difference in understanding between themselves and IAT about the outcome of the “What If” conversation of 26th September but they did not contact IAT to obtain clarification which would have been expected practice. 9.9 IAT processes now include routine monitoring of actions agreed in “What If” discussions to ensure that they have been actioned. Working with families under s17 (Children Act 1989) 9.10 The decision made by IAT once they received the referral from School was that the threshold 16 for s47 enquiries6 was not met. The IAT summarised the referral as “worries about mother's new partner, the impact that this has upon the children, and mother's ability to be protective. Sibling 1's appearance has deteriorated, she is hungry and people had witnessed that new partner now collects her and she is shouted at on the way home”. The Agency Report author consulted with a wide range of staff about this decision and there was unanimous agreement that the presenting information warranted a response under s17 rather than a s47 child protection investigation. From the information available this would appear to be an appropriate decision. 9.11 The School had not discussed the fact that they were making a referral to CSC with Mother and at the Practitioner Event confirmed that not to do so was their usual practice. This is not consistent with the Cambridgeshire LSCB procedures which state that, that unless to do so would place a child at increased risk of significant harm, “concerns should be discussed with the child (as appropriate to their age and understanding), and with their parents, and their agreement sought to a referral being made”. Although CSC have an expectation that staff taking the referral will confirm that it has been discussed with the family, this was not done in this case. Mother therefore had no reason to anticipate contact from a social worker. 9.12 Working with families under s17of the Children Act (1989) is a voluntary arrangement and the family has a choice whether to accept the intervention and support being offered. The initial interaction with the social worker can have a critical impact on any family's perception of them as a supportive and approachable individual and influence the quality of the relationship and the family's willingness to accept their advice and support. Given that the social worker's initial home visit was unexpected - both because the School had not told Mother of their referral as well as because the social worker had called without first making contact, it is unsurprising that the family were “very upset”. Cambridgeshire LSCB procedures state that “Where the referral is Section 17, the allocated worker must contact the family at the point of allocation of the referral. When the case is allocated for Assessment a letter should be sent”. 9.13 At the Practitioner Event it was explained that, as School's referral had included concerns about Sibling 1 being hungry, an unannounced visit afforded the opportunity to “check the reality of the situation” to see if there was sufficient food in the house. However, even if there had been a well stocked larder, the concerns about Sibling1's hungry presentation would not have been resolved as other causes, such as the deliberate withholding of food would have needed to be explored. It should also be noted that at about this time there was a lot of national attention on the case of Daniel Pelka and issues about food and the agency report author hypothesised that this may have influenced the approach. In fact, there was very little food in the home and the social worker acted practically by returning with a food parcel the next day. 9.14 It is recognised that the home visit was very timely, being undertaken on the same day as the Unit received the referral. The Unit were “on duty” that week and therefore had responsibility for undertaking assessments on all incoming work and so there would be 6 Under section 47 (Children Act 1989) an enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. 17 pressure to “pull in” visits if a worker was in the right area. However, the fact that the visit was unannounced had the potential for setting a tone about how social workers engage with families. 9.15 The verbal action plan agreed following the social worker's second visit was described in interview with agency report author as a “brief holding plan leading up to the CiN meeting”. At the Practitioner Event the social worker spoke articulately about the rationale for suggesting it, explaining that the intended purpose of the agreement was to put some element of distance between Mother's Boyfriend and the children to “eliminate potential risks” while he continued to assess and offer support. However verbal agreements are not an effective way of confirming expectations with families as their status (and content) is ambiguous and open to misinterpretation. 9.16 Although the action plan was stated to be a “brief holding” plan, the CiN meeting on 14th November confirmed that Mother was still being expected to adhere to it some four weeks later. The proportionality - and reasonableness - of the action plan is debatable. There could be a logic in suggesting it (under s17 it could not be a formal requirement) as a very temporary measure to “protect” not only the children but also Mother's Boyfriend (from allegations) but to continue it for so long and to reinforce its importance by asking School to monitor implies that there was a belief that the risk of harm to the children was more significant than the initial assessment implies. Although it is acknowledged that that the initial assessment concluded that a core assessment was needed in order to gain a fuller understanding of what was happening in the children's lives there was no suggestion that consideration had been given to whether the initial assessment identified that threshold for s47 enquiries was met, which could reasonably be expected, given the conditions of the plan. 9.17 Mother was described as being “a little overwhelmed” by the expectations of her after the CiN meeting. She had three young children (then aged 7, 3 and 2 years old) to cope with and there is no evidence of consideration of the practical implications of the action plan, such as how much support Maternal Grandmother would be able to provide. CiN plans need to be explicit about what it is that needs to change and what help the family are going to get to implement those changes. Children and Family Court Advisory and Support Service's role 9.18 Cafcass is asked by a court to become involved in private law cases (where arrangements need to be made for children when parents separate) to provide judges with advice, information and recommendations so that they can make a safe decision about children’s future. In this case Cafcass's role was to complete a s7 (Children Act 1989) welfare report into father's request for contact with H. Cafcass's initial advice that, because of the allegation made by Mother that Father had threatened to take H abroad, there should be no direct contact until further assessment of risks was completed was appropriate. However the continued recommendation that contact should be indirect – and the suggested level and type, (four times a year post box contact) raises questions about how this could be meaningful for a child of H's age (she was under a year old when Father left the family home). 18 9.19 The Cafcass worker who completed the s7 report did not meet father, relying on a telephone discussion and referring in their report to a Police record that the children had appeared “very withdrawn” when they had attended an incident and to Mother's and Maternal Grandmother's assertion that the children were “scared” of Father. There is no evidence of efforts made to contextualise these statements. The worker recognised that supervised contact in a Cafcass centre may have been relatively safe for H in terms of any physical risks she might face. His rationale for not recommending this was that “ it would serve little purpose at this stage as it could not move on to unsupervised contact in the community, whilst Father is unable to show any insight into his behaviour”. 9.20 The balancing of the need to ensure that children are not exposed to any additional harm following parental separation that has involved domestic abuse with the need to enable the child to maintain a meaningful relationship with the non-resident parent is complex and requires thoughtful assessment. The Cafcass representative felt that participation in a Domestic Violence Perpetrator Programme was necessary to demonstrate Father's acceptance of the need to address his behaviours that had been established by the fact finding hearing. However he did not consider that her age meant that indirect contact, via cards and letters would not be meaningful nor whether H could have contact with her father before he completed the program. No plans were made as to how Father's progress on the DVPP was to be monitored and how he was going to assess H's readiness for progression of contact and how this might be introduced. 10. ANALYSIS BY THEME 10.1 There are several themes which pervade the key practice events and which are also reflected in the above analysis. Viewed from a systemic perspective it is apparent how these themes influenced and impacted on each other. The themes are � professionals seeing the family as individuals � working with the children and the “invisibility” of H � working with men � recording and information sharing These themes are inextricably linked and they are considered in turn below and the links explored. Seeing the family as individuals 10.2 There was a pervasive theme, especially in the work prior to the referral to CSC, of professionals seeing the family members as individuals and not recognising the potential impact of the information agencies held, or of their actions, on other members of the family (and other professionals in the family's network). There were some examples of very insightful observations made about Sibling 1 but little of consideration of whether similar concerns might apply to her siblings. Similarly the Pre-school's record of the incident witnessed by a member of staff involving Sibling 2 was not shared either with CSC, as a potential referral, or with other professionals working with the family and therefore was not available to contribute to an holistic picture of growing concerns. The Practitioner Event 19 identified that the school’s information system does not collect information on siblings and was a contributory factor in why there was not communication with the Pre-school setting attended by Sibling 2. The agency author explored with the nursery nurse who had initiated the CAF the rationale for the CAF not including information about the other two children (Siblings 1 and H) and established that it was because “no concerns were raised for...(them)...at that time and so a family CAF was not indicated”. The report also noted the limited amount of information that can be recorded on the paper version of the CAF. The e-CAF now available enables a family CAF to be completed and is more supportive of a systemic way of working with families. 10.3 A later example of not joining up concerns occurred when Sibling 1 was taken to the GP. The GP was sufficiently worried by mother's description about School's and CSC's concerns to arrange to review Sibling 1's progress and also to contact the School but did not review the other children's records in light of this. If he had done so he would have seen that H had been sent for an X-ray but no results had been returned and he could have followed this up with Mother. The GP practice's electronic case record system is not linked to the one the Health Visiting Service uses and this adds additional barriers to the GPs being aware of concerns that may surround a family although the system of quarterly meetings has been instituted as a result of this case may ameliorate this. 10.4 Maternal Grandmother's involvement in the family was peripherally noted throughout the agency reports. She is recorded as being present at most of the professional meetings with the family that took place in their home during the review period. It was assumed that she would support the verbal action plan by assisting mother with child care/school run following the agreement that Mother's Boyfriend would not be involved. The practical implications of this, of her understanding of the concerns and of her role in the family were not explored. She was not at the CiN meeting (held at the School) and so the actual contribution she was able and willing to make was not specified. The invisibility of H 10.5 What was striking about the reports and the time lines of significant events that the main agencies involved with the family submitted to the review was the infrequency of H's name being mentioned. To some extent this is unsurprising given that she did not yet attend any educational setting so reducing her exposure to professional attention but this also had the effect of increasing her vulnerability. This was compounded by professionals who had concerns about one or other of her siblings not explicitly considering how these concerns might also apply to or impact on H. 10.6 H's age and stage of development meant that obtaining her views and feelings relied heavily on means other than verbal communication. These would include observation of her behaviours and reactions and would be limited by the fact that professionals had been peripheral to her life and so would not have the opportunity to observe the differences that may have been evident once Mother's Boyfriend became involved with the family. The CSC agency report author identified that the social worker had seen the children a total of five times during the five weeks the case was open to him, which would have allowed him the opportunity to start to become a more familiar figure to H but it remains a challenge for any 20 worker to gain meaningful impression of a young child's views and feelings early in their relationship with them. The Cafcass officer had even fewer opportunities to gain an understanding of H's wishes and feelings having only met her on one occasion. 10.7 As it was, H's elder sibling, Sibling 1, was the child who may have been able to provide information about what was going on in the children's lives. The social worker spoke with her alone on at least four occasions and, recognising that he may have needed support with communicating with a child with a diagnosis of autism, also arranged to speak with her in the presence of her Teaching Assistant. This was a very appropriate action but the Teaching Assistant's subsequent report that she had not been sure that Sibling 1 had understood the questions she was being asked emphasises the responsibilities on professionals to both plan and debrief effectively after such sessions. A 2011 report of Ofsted’s evaluation of serious case reviews identified that “even when practitioners did listen to children and others who represented the voice of the child .. (there were).. difficulties and sometimes (the) shortcomings in interpreting what was seen and heard”. Working with men 10.8 In the same way that H's name was not very obvious in the reports and the time lines of significant events submitted to the review, there is also little mention of the men in the children's lives with the notable exception of Mother's Boyfriend. All three children had different fathers, who also all had different ethnic backgrounds. The fathers of Sibling 1 and Sibling 2 were not part of the children's lives. This did not prompt much professional curiosity about any vulnerabilities Mother may have had that could impact on the children's well being. Studies of serious case reviews (Brandon et al 2008,2009) have emphasised the need to understand the role that men play in individual children's lives and, although in this case, professional attention was quickly alert to Mother's Boyfriend's involvement, there was very little consideration of the role of other men, who besides the fathers also included maternal grandfather and uncle, in the children's lives. 10.9 Cambridgeshire CSC has adopted systemic practice as the under-pinning methodological approach and social work is delivered through Social Work Units. The family were discussed at three Unit meetings where the issues to be explored further were discussed. However there is no evidence that basic systemic tools such as genograms and family history chronologies were utilised by any of the practitioners involved with the family. The use of such tools with families enable discussion to take place about relationships and events which reveal not only underlying patterns of behaviour but also where there are gaps in professional knowledge of the family and where more inquisitiveness is needed. 10.10 The fact that the children's fathers all had black ethnicity reflects a pattern in the SCRs (and other reviews) completed by the LSCB over the past five years. A high percentage of the subjects of these reviews were children from minority ethnic backgrounds. Studies (Brandon et al 2012) have shown that there is a tendency for children of black/black British ethnicity to be over-represented in serious case reviews but the numbers in Cambridgeshire are noticeably disproportionate to both the general population and to the numbers of children identified as vulnerable (because they are Looked After or are on child protection plans). The reasons for this are not clear and warrant further investigation. 21 Recording and information sharing 10.11 Most of the full agency reports identified issues where recording could be improved and made recommendations to achieve this. Of particular relevance would be ensuring that agencies do not have (internal) parallel systems for recording concerns. For example the School had a child concerns diary and child protection log and the Pre-School had injury forms and child protection chronologies. This does not facilitate a comprehensive understanding of a child's situation and risks information being missed and patterns not identified. This parallel recording has developed because some recording is done by (more junior) front line staff and the other (the formal child protection record) by more senior members of staff. 10.12 This division was also reflected in this case by the CiN meeting which was attended by professionals representing their agencies who did not know the children on the intimate level some people did. To be meaningful, the people at the CiN meeting needed to have sufficient level of “hands on” knowledge and understanding of family so that an accurate picture of the situation was gained. However it is recognised that there needs to be balance between this requirement and the need for the representatives to be of sufficient seniority to be able to commit their agency to undertake certain actions. It is also acknowledged that there are potential difficulties in providing cover to free up front line staff to attend although there was no evidence that this was the reason the Nursery Nurse (the CAF initiator and someone who had longer term knowledge of the family) or the Teaching Assistant (who knew a lot about Sibling 1's everyday life) did not attend the CiN meeting. vi 10.13 Staff at the Practitioner Event staff reflected on the need for professional confidence in both approaching families to ask for permission to gather information as well as in supplying it. The fact that the School did not tell Mother that they had made a referral to CSC – and confirmed at the Practitioner Event that this was their usual practice – reflects this lack of confidence. The recent judgement against Haringey Council (where the local authority was found to have acted unlawfully in its data gathering) was cited by one practitioner as a reason for not seeking permission to talk to the family's GP. This illustrates how practitioners' practice and confidence can be influenced by media reporting. 10.14 The dissemination of Police notifications of domestic abuse incidents was reasonably effective with the key agencies having been notified of the incidents involving Father and responding by starting formal child protection files. The exception was the GP's surgery. The surgery have taken subsequent action and set up a system whereby the Health Visiting Team notify them of “families causing concern” which is recorded on children's and parents’ records. 11. CONCLUSIONS 11.1 This review sought to establish whether those involved with the family were aware of the risks that the children were exposed to and to identify any factors that either promoted or inhibited agencies and individuals to act to ensure the children's safety. It concludes that there is no evidence that the death of H could have been predicted or prevented because 22 there was nothing in Mother's Boyfriend's antecedents or known behaviours that indicated that he would perpetrate the level of violence that killed H. He had a troubled childhood and adolescence but it was not exceptional. Many other young people have similar backgrounds but do not commit such violent acts. Professionals were alert to the changes in the family once he became involved with them and were in the process of acquiring a fuller understanding of his role in the family and its impact on the children's lives when H died. There was nothing to indicate to those professionals that the usual time scales for assessment needed to be accelerated. However the process of undertaking the review has allowed a window on the system through which learning can be generated which can contribute to the continuous improvement in the safeguarding of children. 11.2 The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour” (Woods et al 2010). Although there were instances were practitioners could have more effective in sharing information, others where more professional curiosity was called for and examples of not considering the whole family system or intervention not being timely, the review has concluded that there was no evidence that the tragic outcome could have been anticipated. Busy child care professionals work with many families where there are concerns about the risk posed by a new partner entering the family system and it is very difficult to identify the case were the unexpected will occur. Low probability events do occur. Good practice 11.3 There were examples of strong practice by individuals and by agencies. Of particular note was the work of the school with Sibling 1 and their understanding of her needs arising from her autism. The Nursery Nurse's consistent involvement with the family was an organisational effort to ameliorate the effect of changes in the actual Health Visitor allocated. CSC's system of following up “What If” conversations with a letter confirming the outcome of the discussion is good practice. The subsequent development of monitoring to confirm that actions agreed in “What If” conversations have been implemented further strengthens the system. The social worker's involvement was very timely with all expected time scales adhered to. 11.4 There was also evidence that a number of staff did show some professional curiosity when they felt intuitively that something was not right – gut feelings - although they did not always pursue the questions raised to conclusion. Lessons learnt 11.4 Some actions, such as CSC amending their recording guidelines and the GP practice instituting multi-disciplinary team meeting to discuss families “at risk”, have already been taken by agencies as a result of the lessons learned from this case. The Practitioner Event identified other lessons learnt from undertaking the review and which assumed significance from the inter-agency feedback the event allowed, for example, how the ripple effect of agencies concentrating on individuals contributed to the “invisibility” of H. This reflects the concept that some of the “best learning from serious case reviews may come from the process of carrying out the review” (Brandon et al 2012). 11.5 The importance of all professionals considering the whole family system - and to “Think 23 Sibling” - in their work is a key lesson from this case. Where there are concerns for one child in a family, practitioners need to think about whether they give rise to concerns for the other children, in particular for pre-school children who have the potential to be less visible to the professional network. Recording systems can mitigate against seeing the family holistically and this can be further impacted on if there are parallel systems within a single agency. 11.6 Unless by doing so, children will be put at further risk of significant harm, agencies need to share their concerns with parents and tell them if a referral to CSC is to be made. CSC need to ensure that their system ensures confirmation with the referrer that the family are aware that the referral is being made and that they behave in a respectful way and communicate their intention to visit the family at home. 11.7 The review has identified the need to clarify when there is an apparent misunderstanding about agreed actions following “What If” conversations and in general, the need for agencies to clarify the status and agreed outcomes of conversations in the context of sharing information and concerns about children. 11.8 The use of verbal agreements and whether they serve a useful function is key learning point identified by this review. Verbal agreements are even less enforceable than written agreements and, by their very nature difficult to ensure are consistently understood by the parties and are open to misinterpretation. If they are to be used, it is important that they are proportionate to the family's identified needs; are shared with other people in the family's network; and are reviewed in a timely way and do not run the risk of unintended consequences. 12. RECOMMENDATIONS It is recognised that actions have already been made in relation to some of the individual agency's identified learning. In addition, agency reports included a number of recommendations which this review endorses. The purpose of providing additional recommendations is to ensure that all professionals in the partner agencies of the LSCB are confident that the areas identified as of concern in this review are addressed. Recommendation 1 The LSCB's expectations regarding working in partnership with families are reinforced and that agencies are compliant with the LSCB procedures when sharing information. Recommendation 2 Cafcass to consider how its work on supporting staff to distinguish between coercive and situational couple violence can include consideration of: a) the different treatment options b) how safe and beneficial contact can be achieved when the child's age means that indirect contact can not be meaningful. Recommendation 3 LSCB ensures that partners understand the mechanisms of ‘What If’ discussions and checks compliance with the actions agreed Recommendation 4 CSC consider their procedures in regard to verbal agreement and define their expectations 24 regarding good practice in their use. Recommendation 5 Education settings review their recording processes and ensure there are not parallel systems which impact on the effectiveness of seeing an holistic picture of the child and their family Recommendation 6 The LSCB considers how to ensure that the message “Think Sibling” is disseminated. 25 References A study of recommendations arising from serious case reviews 2009-2010 Marian Brandon, Peter Sidebotham ,Sue Bailey ,Pippa Belderson DfE Behind Human Error Woods D et al Farnham Ashgate (2010) quoted in Munro Final Report Common Assessment Framework(CAF) Guidance for Practitioners Cambridgeshire Children's Trust Revised November 2013 Informal Consultation on the Recommissioning of Early Help Services Cambridgeshire County Council June 2014 Judicial Review Regina (AB and CD) v Haringey London Borough Council (2013) Munro review of child protection: final report - a child-centred system DfE 2011 New learning from serious case reviews: a two year report for 2009-2011 Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson DfE 2012 The voice of the child: learning lessons from serious case reviews Ofsted DfE 2011 0-5 LARM Guidance for Practitioners Cambridgeshire Children's Trust December 2013 26 Appendix 1 Genogram HMGM FATHER Child H Aged 2 MOTHER SIBLING 1 Aged 5 SIBLING 2 Aged 3 MGF FATHER SIBLING 1 FATHER SIBLING 2 MOTHERS BOYFRIEND 27 |
NC050505 | Hospitalisation of 14-month-old boy in April 2021 who suffered significant harm caused by neglect. Learning is embedded in the recommendations. Recommendations include: training which provides triggers and recognises disguised compliance, domestic and honour-based abuse (HBA), trauma, culture and faith and how to professionally challenge and scrutinise using professional curiosity; implementing a programme of champions/specialists around certain fields such as HBA and/or complex cases; improve understanding of vulnerabilities within a whole family approach within Black and minoritized (BME) and diverse groups by taking an intersectionality approach to protect and support individuals within a family unit; increase understanding and awareness of cultural harms, HBA triggers and implement a specific multi-agency pathway/process within agencies and as part of a multi-agency framework; review decision making protocols and documents including how risks are accounted for and weighed up, and the value of professional frontline opinion where trends and patterns are emerging; review escalation procedure where police intervention is required through a multi-agency/professional meeting; implement complex case guidance; conduct equality impact assessments where appropriate and relevant; ensure procedures and policies support equality of opportunity; and review processes to include referral to specialist agencies to undertake pieces of work such as engagement with family members to better understand the lived experience.
| Title: Local child safeguarding practice review: Child Q. LSCB: Hartlepool and Stockton-on-Tees Safeguarding Children Partnership Author: Hartlepool and Stockton-on-Tees Safeguarding Children Partnership Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 February 2022 Local Child Safeguarding Practice Review Child Q Page 2 February 2022 Contents Executive Summary ................................................................................................................... 3 1. Background ..................................................................................................................... 3 2. Purpose and Scope of the Review .................................................................................. 3 3. Methodology .................................................................................................................... 4 4. Family Engagement ......................................................................................................... 4 5. Summary Key Findings ................................................................................................... 4 6. Recommendations ........................................................................................................... 5 7. Introduction ...................................................................................................................... 7 8. Abridged Summary of Family, The Timeline and Background ......................................... 8 9. Serious Incident and Rapid Review ............................................................................... 10 10. Multi-Agency Involvement ............................................................................................. 10 11. Rapid Review ................................................................................................................ 10 12. Rapid Review Key findings ............................................................................................ 10 13. Local Children’s Safeguarding Practice Review ............................................................ 11 14. Family Engagement ....................................................................................................... 13 15 Summary of Review Findings ........................................................................................ 13 16. Safeguarding children where there is non-engagement with services ........................... 15 17. The impact of cultural and religious considerations ....................................................... 16 18. Themed Recommendations .......................................................................................... 17 19. Learning and Development Recommendations ............................................................. 18 20. Process and Review Recommendations ....................................................................... 19 21. Good Practice Recommendations ................................................................................. 19 22. Practice recommendation .............................................................................................. 21 23. Practice recommendation .............................................................................................. 21 24. Practice recommendation .............................................................................................. 21 25. Practice recommendation .............................................................................................. 21 26. Practice recommendation .............................................................................................. 21 27. Monitoring and Evaluation ............................................................................................. 22 Appendices and References .................................................................................................... 23 Appendix 1, Terms of Reference Decision making .................................................................. 23 Terms of reference ............................................................................................................... 23 Practitioner involvement ....................................................................................................... 23 Scope of the Review Themes ............................................................................................... 24 Appendix 2 Summaries and Sources of other reference for the Review ................................ 25 Page 3 February 2022 Executive Summary 1. Background 1.1 A Rapid Review commenced following serious incident notification submitted by Stockton Borough Council in June 2021 in relation to Child Q who suffered serious harm caused by neglect. Child Q was admitted to A & E Department at University Hospital of North Tees in April 2021 following several concerns including appearing to be severely underweight following a welfare visit by Social Care and the Police. 1.2 The Family (Mother, Father, Child Q and siblings) have been known to Children’s Services since 2011 and came across to the UK as asylum seekers fleeing death threats and persecution in Pakistan. Child Q is a 14-month-old Asian ethnic minority child who has been on a child protection plan under the category of neglect from being an unborn baby. Child Q has older siblings who are currently subject to an Interim Care Order and another sibling on a supervision order. 1.3 Child Q is currently in foster care having faced severe malnourishment. Mother was reported to have eaten only milk and honey during the pregnancy and beyond impacting significantly on the growth and development of Child Q resulting in serious health issues. 1.4 Mother is currently under investigation by Cleveland Police for neglect and following a short stay in hospital under observation, has now been transferred to a mental health specialist Hospital under mental health assessment and care. 1.5 Parents were religiously divorced sometime in early 2017 but both were residing in the family home. 2. Purpose and Scope of the Review 2.1 The Rapid Review identified several areas where further consideration of practice learning is required. Hartlepool and Stockton Safeguarding Children Partnership Executive, in line with the views of those participating in the Rapid Review, considered that there remains a significant amount of information that remains unknown about the lived experiences of the children in this family and the effectiveness of partners to safeguard and promote the welfare of Child Q. 2.2 The Rapid Review recommended a Local Child Safeguarding Practice Review to inform professional curiosity, risk assessments and having a fuller understanding of the relationship and dynamics of the family and/or nature of abuse between parents, and the impact on the child(ren), with a focus upon two key areas: Safeguarding children where there is non-engagement with services The impact of cultural and religious considerations. Page 4 February 2022 2.3 The Local Child Safeguarding Practice review was undertaken from November 2021 to February 2022 following the HSSCP Rapid Review and meets the criteria for relevant government guidance: “A serious incident is where abuse or neglect of the child is either known or suspected and the child has died or has been seriously harmed” (16C (1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017)). 3. Methodology 3.1 A blended approach has been adopted providing a safe space for practitioners to share learning and identify good practice, strengths, and opportunities through focus group events, providing opportunities for reflective practice and problem solving. Recall and Learning workshops have enabled a broader range of views from Managers and decision makers to be captured and understood. 3.2 The Reviewers had several key questions that informed the discussion with frontline practitioners and decision makers as part of the information gathering stage to: enhance understanding, encourage professional curiosity, challenge, and adopt a solution focused approach. These included: What actually took place? What was supposed to take place? Why is there a difference - barriers, gaps, one off? What is the learning and what should be done about this? 4. Family Engagement 4.1 Engagement with the family has not taken place due to several risks that have needed to be managed regarding the health - both physical and mental, and the wellbeing of family members. Reviewers have worked with existing agencies and information regarding the welfare of family members and after careful consideration, following a risk-based approach, agreed that contact could negatively impact the mental health of family members. A number of approaches were made to the Father, as it was considered safe to do so using a number of mediums both in English and Urdu - but to date, no contact has been made by the Father. 5. Summary Key Findings 5.1 Layers of complexity and intersectionality alongside restrictions from the pandemic made it difficult for the professionals to navigate, circumvent and address concerns leading to them feeling stuck at times. 5.2 Professionals struggled to identify accumulative risk around domestic abuse, lack of engagement, honour-based abuse (HBA), disguised compliance of Father, mental and physical ill health and the lack of historical and contextual reference to trauma made it difficult for the case to be escalated at an earlier date. Page 5 February 2022 5.3 Turnover of professionals at times resulted in reduced consistency for the family and impacted upon engagement and connection with them. 5.4 Inconsistent signs of safety ratings gave mixed messages to decision makers. 5.5 Lack of awareness of abuse within BME families led to indicators around this not being picked up and referred on to specialist support. 5.6 Gender split within the household was not unpicked enough, which might have led to a deeper insight into family dynamics. 5.7 Disguised compliance of Father – he was the only lens that was on offer to see the family and therefore, the Mother and the other female members of the household’s rights, responsibilities, and entitlements were not explored enough. 5.8 Front line professionals presented as passionate, experienced, and skilled with a strong membership of the core group who shared information in and out of meetings, but at times reported feeling frustrated, not heard, and stuck. 5.9 Attempts were made to fully engage the parents via holding core group meetings in the family home, local venues, using translators and consulting with a local Iman. 5.10 Description of Mother and how she presented was not considered to be part of a trauma response to the historic disclosure of domestic and sexual violence, which was not referred on to a specialist agency. 5.11 Cultural sensitivity blocked and led to lower standards of care and safeguarding, Inter-agency communication and management oversight; failure to fully understand a family’s race, culture, ethnicity, impinged on professional’s ability to provide effective help to the parents and children. 6. Recommendations 6.1 Getting the balance right between support and challenge when working with parents can be difficult, it is a complex balance which requires skilled practitioners, reflective practice, effective supervision, and professional challenge within and between agencies. The following recommendations are key to improving future practice and case management. 6.2 Training which specifically provides triggers and recognises disguised compliance, domestic and honour-based abuse (HBA), trauma, culture and faith and how to professionally challenge and scrutinise using professional curiosity with mechanisms that test and ensure that the training is being embedded into practice. 6.3 Multi agency supervisions - when dealing with complex cases; identify through training which supports supervision encouraging professional curiosity which can assist professionals to determine key facts and base decisions on more than a risk assessment or historic judgement; a contextual and intelligence-led approach can provide justifications for tailored actions. Page 6 February 2022 6.4 Implementing a programme of champions/specialist around certain fields such as HBA and/or complex cases. 6.5 Improve understanding of vulnerabilities within a whole family approach within BME and diverse groups by taking an intersectionality approach to protect and support individuals within a family unit. 6.6 Increase understanding and awareness of cultural harms, HBA triggers and implement a specific multi-agency pathway/process within agencies and as part of a multi-agency framework. 6.7 Review decision making protocols and documents including how risks are accounted for and weighed up, and the value of professional frontline opinion where trends and patterns are emerging. 6.8 Review escalation procedure where police intervention is required through a multi-agency/professional “quick check-in” meeting. 6.9 Performance review at the end of multi-agency meetings encouraging reflective practice, professional challenge, and key learning areas to be identified. 6.10 Implement complex case guidance; this is currently being reviewed by the Tees Procedures Group. 6.11 Conduct equality impact assessments where appropriate and relevant ensure procedures and policies support equality of opportunity. 6.12 Review processes to include referral to specialist agencies to undertake pieces of work such as engagement with family members to better understand the lived experience, and to provide guidance and support to professionals. 6.13 Align practices with new domestic abuse model currently being explored by a HSSCP Task and Finish Group. 6.14 Conference Chairs to be the point of contact for professionals wanting to challenge progress and to also set up mid-way review meetings to help prevent drift. The review highlighted the challenges professionals face within a complex case with multiple barriers and risk, compounded with the multi-agency management of such a case. In doing so, one of the key barriers to engaging with the family included the role of the one communicator; namely the Father who became the provider of information. He led professionals to the risks posed by Mother, all of which were compounded by the struggle to provide a culturally sensitive setting which stifled professional challenge and curiosity with gaps in gaining a real understanding of the dynamics and BME characteristics of the family which subsequently led to the abuse of Child Q, the other children and Mother. Page 7 February 2022 7. Introduction 7.1 This independent review is commissioned by The Hartlepool and Stockton-On-Tees Safeguarding Children Partnership (HSSCP) with two of the area’s specialist charities, the reviewers, namely A Way Out and The Halo Project, selected for the combined delivery practitioner support and expertise of children’s safeguarding and violence and abuse in Black and Minoritised communities. Led in partnership by: Sarah McManus CEO of A Way Out, part of the Child Sexual Abuse Transformation Partnership, delivers targeted support to boys and girls in primary and secondary schools across Cleveland; wrap around support for families and specialist support for girls and women around sexual exploitation and abuse. Yasmin Khan CEO and Founder of HALO; Government Advisor in Wales around violence against women, domestic abuse, and sexual violence. Leads pioneering work and programmes to support victims and survivors of Forced Marriage and Honour Based Abuse in the North-East along with campaigns for system change. 7.2 This review was undertaken from November 2021 to February 2022 following HSSCP Rapid Review and meets the criteria for relevant government guidance: “A serious incident is where abuse or neglect of the child is either known or suspected and the child has died or has been seriously harmed” (16C (1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017)). • The Family have been known to Children’s Services since 2011 and although this review highlights the most recent interventions relating to Child Q it has been necessary to understand the multi-agency interventions from this earlier date; see 8. Abridged - “Summary of Timeline and Background”. • Child Q is a 14-month-old Asian ethnic minority child who has been on a child protection plan under the category of neglect from being an unborn baby. Child Q’s older siblings are currently subject to an Interim Care Order and one sibling on a supervision order. • Child Q is currently in foster care having faced severe malnourishment. Mother was reported to have eaten only milk and honey during the pregnancy and thereafter impacting significantly on the growth and development of Child Q resulting in serious health issues. • Mother is currently under investigation by Cleveland Police for Neglect and following a short stay in hospital under observation, has now been transferred to a mental health specialist Hospital under mental health assessment and care. • Parents were religiously divorced sometime in early 2017 but both were residing in the family home. Page 8 February 2022 8. Abridged Summary of Family, The Timeline and Background South Asian - Fled death threats and persecution in Pakistan. Came to UK as asylum seekers in 2011. Both parents educated professionals in Pakistan. Father Mother Religiously divorced in early 2017 but still resided together in family home. Child Q Older siblings Parents sought asylum in UK in 2010, fleeing death threats and persecution in Pakistan. The family came to the attention of Children’s Social Care in 2011 seeking their right to remain, which was granted to Father and the children only. Mother was not contacted directly, and Father stated she would not sign the paperwork. 8.1. There were no assessments carried out to explore domestic abuse, coercive control, or honour-based abuse. However, Father self-referred himself to the service in August 2019, stating he was the victim of emotional abuse and control. The Lead Practitioner contacted Father who agreed to a full assessment; however, he did not attend and subsequently asked for his case to be closed. 8.2. In 2017 the Father reported Mother to the Police for concerning behaviours towards the children in August, Early Help were involved but closed the case in October 2017 as mother was reluctant and would not engage. 8.3. Case was reopened in November 2017 following concerns in relation to mother’s mental health from the children’s school, which resulted in the children being made subject to child protection plans for the first time under the categories of emotional and physical abuse. 8.4. Mother’s mental health was questioned and reported by the Father, she was admitted to hospital in December 2017, the Consultant Psychiatrist found no evidence of psychosis or depression. Mother did however report her husband was abusive, so she stayed in one room in the home. Liaison between services and Social Care was positive as too was sharing of information and analysis of risk. No action was taken regarding domestic abuse disclosure following discharge. 8.5. In August 2018, Police attended the family home following an anonymous contact reporting that a child could be heard screaming; access was initially refused but eventually gained. This information was not shared with Children’s Social Care or the wider partnership network, no referrals were made. Child Protection Planning continued until September 2018 until the plan was removed, the case subsequently closed due to small differences being made and it was felt Father was now meeting the needs of children and therefore referred back to Early Help. Page 9 February 2022 8.6. A further anonymous contact to the Police was received in April 2019 reporting similar concerns of a child screaming. Mother refused to engage and is described as “aggressive”. This information was shared with Children’s Social Care and a Public Protection Notification was submitted. 8.7. In May 2019, Father had approached housing in relation to a sole tenancy. At this time, Father reported that he and Mother were separated and religiously divorced. Father informed Housing Provider of Mother’s immigration status, stating she did not have leave to remain. He also informed she would be returning to Pakistan and that the children would be remaining in his care. Sole tenancy was granted to Father in July 2019 - it does not appear that the Mother had been spoken to directly regarding her rights or entitlements going forward. Mother remained in the property where her condition deteriorated until she was removed and taken to hospital in late 2021. 8.8. In September 2019, a GPs home visit established Mother was pregnant and a SAFER referral was made. Perinatal Mental Health referral was made by the midwife. A home visit was undertaken, and the perinatal assessment was attempted, however Mother refused to take part. 8.9. Throughout the remainder of the pregnancy, three formal Mental Health Act assessments were requested by the Crisis Team. However, all of them reached the same conclusion - that there was no evidence to support detention under the Mental Health Act. Mother was not willing to work with mental health services, and she was also reluctant to engage with midwifery. Father reported Mother was not happy about the pregnancy. 8.10. Strategy meeting held 11 November 2019 escalating concerns relating to the unborn child and siblings and agreed S47 enquiries and recommended escalating risk to Initial Child Protection Conference (ICPC) and to hold a legal meeting. 8.11. Single assessment completed 30 November 2019. ICPC December 2019 siblings became subject to a CP plan under the category of emotional abuse and unborn child under neglect. 8.12. Legal Gateway Panel meeting in December 2019 concluded there was insufficient evidence to reach threshold to initiate court proceedings or Public Law Outline (PLO). Non-engagement continued to be a reoccurring concern as well as the condition of the home and the well-being of siblings. 8.13. A MARAC referral was submitted in February 2020 by Stockton crisis team due to Mother having historically reported (during her time at Hospital) 17 years of physical and sexual abuse. This referral was declined due to a lack of information for high risk of harm. 8.14. Child Q born in February 2020; intermittent engagement follows with continued concerns for Child Q and siblings, isolation, and voice of child unknown. Page 10 February 2022 9. Serious Incident and Rapid Review 9.1. A Rapid Review commenced following serious incident notification submitted by Stockton Borough Council in June 2021 in relation to Child Q who suffered serious harm caused by neglect. Child Q was admitted to A & E Department at University Hospital of North Tees in April 2021 following several concerns including appearing to be severely underweight following a welfare visit by Social Care and the Police. 9.2. A child protection medical found the following concerns Failure to thrive Severe Vitamin D deficiency Advanced Rickets Severe metabolic bone disease with multiple fractures Iron-deficiency anaemia Dropping from weight of 25th Centile at birth to 0.4th centile In addition, Child Q had food allergies to milk, dairy, egg, wheat, peanuts, and hazelnuts; global developmental delay; and no immunisation had been received with no registration with a GP. 10. Multi-Agency Involvement 10.1. Agency involvement with the family commenced in 2011 when the family sought asylum. Restarted engagement in 2017 where a Child Protection Plan was initiated for the older siblings and where agencies were intermittingly involved throughout this period to date. Several partner agencies involved were all consulted as part of the Rapid Review. A Chronology document was also produced summarising in detail the involvement by each agency and outlining specific actions taken. 11. Rapid Review 11.1. Recommendations from the Rapid Review summarised the following which initiated the LCSPR: “It is clear we do not know nor have explored the lived experience and lives of the children; we do not understand the family dynamics and the roles and responsibilities of parents. The family culture has not been factored into professional’s engagement in understanding expectations. In my opinion due to the history and complexities of this family, this case would benefit from further exploration in the form of a Local Child Safeguarding Practice Review.” 12. Rapid Review Key findings 12.1. The two key areas arising from the Rapid Review were: A. Safeguarding children where there is non-engagement with services B. The impact of cultural and religious considerations Page 11 February 2022 12.2. The Rapid Review requested a review into two specific areas to inform professional curiosity, risk assessments and having a fuller understanding of the relationship and dynamics of the family and/or nature of abuse between parents and the impact on the child(ren). Some of the considerations included: • Over-reliance of father to provide information and highlight concerns to professionals and how this impacted professional judgement and decision making. • Over-optimism demonstrated whenever slight improvements or engagement was made, some assumptions were made of the older children seemingly okay and professionals assuming “baby must be okay” (from a health / neglect perspective). • How professionals deal with refused consent / lack of engagement and how to escalate in complex cases. • Consideration to Culture and religious beliefs – the perception held in some religions regarding sexual abuse within marriage. Professionals’ confidence in asking direct questions and in challenging religious beliefs where there are potential risks to the health and well-being of children. • Potential missed opportunities for Information-sharing and making referrals to support agencies. • Identifying concerns in silo rather than looking holistically / considering cumulative risk and decisions made without all information available. • Acceptance / challenge – The threshold for care proceedings not being met and how professional challenges can be supported and encouraged. • Case management of complex cases; considering the guidance of such cases and/or seeking expertise from specialist providers specifically for Black and minoritised (BME) communities with multiple vulnerabilities. • Domestic Abuse awareness and risk management – asking domestic abuse questions, recognising the risks and indicators especially surrounding cultural issues and abuse within BME communities. 13. Local Children’s Safeguarding Practice Review Methodology A blended approach has been adopted providing a safe space for practitioners to share learning and identify good practice, strengths, and opportunities through focus group events highlighting learning and solutions. Recall and Learning workshops have enabled a broader range of views from Managers and decision makers to be captured and understood. 13.1 Reflective practice was encouraged following the events and workshops which enabled partner agencies to share their evaluation outside of structured meetings via emails and telephone calls. The Lead Reviewers also consulted a range of professionals directly themselves to help deepen understanding and expand opportunity for further involvement from practitioners. In total, 21 frontline practitioners took part in two focus groups with a further 17 Managers and decision makers at both the Learning and Recall events. 13.2 To gain a broader insight to lessons learnt, academic and desktop research of reviews has also been considered to explore best practice in similar cases and to ascertain themes and key areas of improvement. Page 12 February 2022 In addition, the chronology report and information provided by each agency alongside the Rapid Review Report helped to shape the context, delivery and decision making around the case. The Reviewers had several key questions that informed the discussion with frontline practitioners and decision makers as part of the information gathering stage through two focus groups, the main areas explored were: What actually took place? What was supposed to take place? Why is there a difference - barriers, gaps, one off? What is the learning and what should be done about this? 13.3 To enable a greater understanding and identify what more could be done, the latter part covered the key areas such as the reasons why specific decisions were made, how individual agencies responded to non-engagement and whether there were gaps within a multi-agency setting, systems and processes. 13.4 The focus groups and workshop provided opportunities for challenge, reflection, and analysis so that learning could be identified and safeguarding practices strengthened, thereby reducing the risk of future harm to children and families. Participants were asked to share good practice and identity what worked well, prompting balanced opportunities. 13.5 A discussion briefing paper was produced and shared with the Hartlepool and Stockton. 13.6 Safeguarding Children’s Partnership Executive ahead of the draft report to stimulate discussion, ownership, and challenge. As leaders of the charitable sector, The Lead Reviewers were keen to capture critical thinking of the members around wider system change linked to initial findings and recommendations. 13.7 Governance and scrutiny were provided through a (1) joint practitioner, (2) Manager’s accuracy event reviewing the first draft of the report and (3) Hartlepool and Stockton Safeguarding Children’s Partnership Executive. 13.8 Key to the review was the need to capture the voices and lived experience of the family members, particularly the Mother and the children. Following analysis of the case drawn from the chronology and the practitioner discussions, several tailored engagement tools and options were offered by the Reviewers, tailored to family members. Consideration was given to timescales and the emotional position of family members. The engagement methods included a therapeutic and empowering approach e.g., using reflective journals, arts and craft targeted activities to enable the voice of the child to be safely and creatively articulated and heard, enabling freedom of expression by the individual. Page 13 February 2022 14. Family Engagement 14.1 Engagement with the family has not taken place due to several risks that have needed to be managed regarding the health - both physical and mental, and the wellbeing of family members. Reviewers have worked through existing information provided by agencies for the welfare of family members and after careful consideration, it felt imperative the on-going risks to further introduce yet more professionals could have a negative impact. Some of the risks included: 14.2 Family members have agency fatigue and hold much mistrust. 14.3 Timescales to conduct the review do not support building trust to enable meaningful engagement. 14.4 Mother is currently in hospital she has been under constant 24/7 care and fed by a tube. As her physical condition has improved slightly, she has now been moved to stay at Roseberry Park, for her mental health. Professionals are keen that her physical and mental health care is not disrupted at the present time. 14.5 One sibling has just started a programme of counselling which professionals are keen to protect as further interventions could disrupt attendance and engagement with much needed support. 14.6 Family dynamics are still not fully understood by agencies although the evidence does suggest domestic and sexual abuse / coercive controlling behaviour displayed by Father. 14.7 A number of letters have been sent both in English and Urdu to the Father along with a number of telephone calls and texts introducing the Safeguarding Practice Review, its purpose and an open offer for involvement to contribute to the findings and help shape services going forward. To date no response has been received. 14.8 The offer around future engagement from Reviewers has been extended following the review so that the findings and understanding can be enriched and enhanced once family members are able to engage as part of the partnership’s commitment to continuous improvement. 15 Summary of Review Findings 15.1 The case has many different layers of complexity relating to culture and religion, mental ill health, indicators around domestic and sexual abuse, along with the long-term impact this has had on the children; potential historic trauma experienced in Pakistan which has not been documented exasperated by the lack of engagement and questions around domestic abuse around paternity of Child Q. Whilst there is recognition of challenges caused by the pandemic, there is a shared understanding and recognition by professionals that the level of complexity undoubtedly made it difficult for them to navigate, circumvent and to address some of these concerns. Page 14 February 2022 15.2 Professionals and agencies struggled to identify the accumulative risks of this complex case which could have led to an earlier escalation and/or outcome. The challenges presented throughout this case caused by non-engagement with the family led to the barriers professionals faced. The contextual and historical trauma were not reflected in the initial assessments - such information is important and should have been clearly articulated within a multi-agency safety plan. This may have provided an understanding of the family dynamics and some of the cultural attributes which were important in terms of specific trauma within BME communities. 15.3 Frontline practitioners referred to some of the difficulties around escalation as “battling to be heard, feeling stuck, not knowing what else they can do, and feeling isolated as the core group”. 15.4 Services describe “significant abuse” taking place, “hidden abuse”, “dad disguised compliance” and dad as a “ringmaster isolating services”. Children were described as more withdrawn when Father was present at meetings. The actions instigated by agencies with regards to concerns raised regarding the behaviour of the Father do not seem to reflect the belief held by professionals. 15.5 Although Indicators and a disclosure of domestic abuse was made, there was a lack of awareness of abuse within BME families which led to honour-based abuse, and specific referral pathways for taking the necessary action or making a referral to a specialist agency. In most domestic abuse including honour-based abuse, this is generally perpetrated by men against women and the Home Office provides guidance on safeguarding the children who, through being in households / relationships, are aware of or targeted as part of the violence. 15.6 There is reference to a “one chance rule” to be applied in cases of honour-based abuse whereby professionals must act on the one opportunity victims have to seek help. 15.7 Lack of clarity for how the impact of disguised compliance by dad has been accounted for, assessed, and understood in terms of risk. 15.8 Escalation procedures needed to be in place taking account of the number of times Police were involved and had to gain access to the property for Social Care. This could then have been part of the Child Protection Plan leading to legal advice possibly being sought at an earlier stage, which may have led to a different outcome. 15.9 In the four years since 2017 leading to the serious incident arising in 2021, the case has been handled by different individuals in the same agency (example of this is seen via the number of social workers involved with this case) highlighting the lack of continuity with the family, impact on relationships, engagement, and trust. New professionals have had to revisit the entire case which has led to delayed actions and a lack of understanding of the whole-systems approach required for such a complex case. 15.10 Evidence of good practice with a range of services consistently attending Core Group meetings, sharing information in and outside of the meetings, supporting one another demonstrating strong partnership working. Page 15 February 2022 15.11 Evidence demonstrated in part where strong multi-agency collaboration was present involving the midwife, health and social care sharing information to inform agreed safety planning. This led to some questioning surrounding the Father and mother regarding the pregnancy and whether it was planned. 15.12 Frontline practitioners presented as passionate, experienced and skilled at their jobs but also expressed their frustration at feeling stuck, not heard, when it came to trying to escalate the case and did not know what else they could do. 15.13 Inconsistent ratings around the Signs of Safety between professionals was raised providing mixed messages to decision makers. Some agencies consistently scored between 2-3 on the Signs of Safety but struggled to understand how this had not then met with the threshold criteria for further action. 15.14 Conference meeting membership was not consistent starting at 12 members reducing to 4 partner agencies, so current intelligence information was not always shared to enable better informed decisions to be made and actions taken. There was evidence of a Core Group meeting being cancelled at short notice and some drift between meetings between February and end of April 2020. 15.15 One Core Group meeting did question and challenge Adult Mental Health services as to their position around the Mother having capacity to consent. 15.16 Variances with supervision and management support for frontline practitioners left some professionals feeling isolated and anxious about the case However, evidence of good practice from the Conference Chair who held a reflective practice meeting with professionals enabling further exploration and challenged decisions regarding the level of progress achieved to date. 16. Safeguarding children where there is non-engagement with services 16.1 Agencies described Mother as “difficult”, “challenging”, “aggressive” which went on to inform a collective understanding as to who she was and underpinned the challenge around engaging with her. Little analysis was evident or shared around “why” she might present in this way; link to previous disclosure of domestic abuse in 2017 or how this could be a trauma response to harm she was experiencing or had experienced. 16.2 Father was “the voice” for the entire household; his opinion and lens was the one given to professionals to see the family through. Lack of the voice and lived experience of other family members affected engagement and services being able to better understand family dynamics and thus tailor delivery and interventions accordingly. It is unclear as to what challenge and professional curiosity around a single point of contact was explored linked to the rights, entitlements and equality, diversity, and inclusion around the lack of a female insight into the household. Connections have started to be made and engagement increased since two of the siblings were placed into foster care. 16.3 Where engagement was difficult and challenging, services seemed stuck as to what else they could do and other options available - hence more of the same happened with little progress being made leading to drift and delay for the children. Page 16 February 2022 Other options around using a specialist voluntary sector organisation to establish connection and engagement do not appear to have been explored. It must be noted, an area of good practice developing within the School where A attended through a key worker has started to show positive engagement and trust. There is potential for this developing and moving forward, real opportunities to better understand the family dynamics and the contextual setting of the family’s entry into the UK, highlighting any trauma and/or abuse which may have occurred. 16.4 Non engagement with services does not appear to have been unpicked asking not “what else can I do?” but rather “why does it look like this?” and making links to indicators and historic reports of domestic abuse, cultural factors, who is best placed to engage and meet the need of family members and looking at trauma. 16.5 Good practice was noted where engagement had been encouraged around attendance at Core group meetings where venues had been changed to accommodate access, such as offering to hold them in the family home, use of translators, written communication in Urdu and consulting with a local Iman. In addition, some direct work was undertaken with the children which was not mentioned in the Rapid Review. 17. The impact of cultural and religious considerations 17.1 Police response whilst it seems disproportionate (using an armed response vehicle to gain access to the family home) was to enable safe access. Obvious key domestic abuse indicators were not acted upon, despite two similar complaints being made to them about a child screaming for hours and little consideration around potential honour-based abuse and prevention. Evidenced by lack of information sharing and referrals being made. 17.2 Reports that females were in the darkened bedroom with Mother, whilst males opened the door to agencies or often the ones who engaged with professionals. No evidence of this gender balance was unpicked to explore what this meant for the females of the family. Designated Social Worker did enquire why the girls were left upstairs in the dark whilst the boys were downstairs but there does not appear any further assessment around this. 17.3 Assumed view of the family was through the father’s lens only as he engaged, the remaining family did not. It is his views that formed the views about his wife, and he informed how she was presenting and the family dynamics. Father’s compliance and engagement was sporadic at times; evidenced by him leaving the family following expressing concern about how his wife was coping and presenting. Lack of knowledge around specific cultures and religions can affect professional confidence to challenge harmful parenting practices. 17.4 A lack of awareness of cultural and religious practices and how these should be applied within the safeguarding and protection procedures and practices. Professionals wanted to respect the family’s cultural and religious practices but the desire to be culturally sensitive can result in accepting lower standards of care. This is evidenced via the malnutrition of Child Q and concerns about mother being pregnant just before she was admitted to hospital when she was unable to bear her own weight when coming out of bed and was so very frail. Page 17 February 2022 This has been highlighted in many serious case reviews (see Alexis Jay review of sexual exploitation in Rotherham) where the safeguarding of the child should be the paramount overriding concern, yet the fear around cultural sensitivity is one that professionals struggle with. 17.5 Misunderstanding between culture and religion both used and blurred together in some agency reporting. Ethnicity, culture, and faith should all be considered when looking at family relationships. 17.6 Professionals demonstrated wanting to be culturally sensitive yet lacked the confidence to challenge parents when raising culture to distract attention from a focus on the child. Culture then becomes prioritised above safeguarding practices and is driven by the fear of getting this wrong. 17.7 The case has been driven by what Father has reported, however no question of his accountability appears to have been considered, nor is he subject to Police action / prosecution given he was one of two parents residing in the home, had joint parental responsibility and was the most vocal member of the household. 18. Themed Recommendations 18.1 Decision makers should review how risks are weighted and value professional frontline opinion and intelligence, including belief, where trends and patterns are evolving to support actions which follow. The importance of robust multi-disciplinary sharing of historical information, taking account of the views of partner agencies, was essential to ensure the child’s care plan was well co-ordinated and appropriate supports identified and put in place. 18.2 A review of procedures and policies to include referrals to specialist agencies around domestic abuse, engagement, and other issues to ensure different routes and pathways are taken to help safely progress a case, strengthen safeguarding practices and understanding. Referrals could be made to a specialist for them to take on elements of that work or to provide advice and guidance to enable professionals some specialist provision to lean into, increasing awareness around the intersectionality of similar cases. 18.3 Increasing professional accountability as a multi-agency group, if progress is not being made, specifically exploring as to why a PLO has not been considered and how this is communicated to partner agencies. Key explorative questions evaluating the performance, effectiveness and progress of the group should be in place at the end of each meeting reaffirming the purpose and outcomes to achieve. This would provide an opportunity for multi-agency reflection, encourage challenge and evaluation identifying when other support/advice or guidance is needed. 18.4 Broader assessment to take account of race, religion and abuse and family characteristics. 18.5 Refresh, “Think Family Approach” to encourage a holistic consideration of the whole family when assessing need and planning care packages which will take into consideration domestic abuse, mental health, culture enabling tools and goals to be set and informed by these factors. Page 18 February 2022 18.6 Adopt and align to Complex Case Guidance already being developed across the Tees following a previous review. 18.7 Review decision making protocols to strengthen and support professional challenge 19. Learning and Development Recommendations 19.1 The combined chronology and significant events present opportunities for improvements and learning, both for individual agencies and as a collective partnership through a multi-agency evaluation of the risks. A common thread in any review is the training and learning we can embed to make the necessary changes. The HSCCP requires assurances that the risks are managed effectively, and professionals can competently protect families with complex needs. The following key areas will provide a platform to improve the gaps identified throughout this review: 19.2 Peer to peer support to instil confidence to frontline practitioners where professional challenge is necessary, structure as to how and when as well as disguised compliance, the voice of the child and engagement. 19.3 Case and management supervision to explore and encourage professional curiosity requiring intelligence, as well as information to enhance a better understanding which helps to inform core group discussions with partner agencies. 19.4 Raising awareness around culture and domestic abuse and illegal cultural harms needs to be prioritised understanding the indicators and signs and how to respond to concerns. This should be interactive, practical based, sharing tools and strategies to address as frontline practitioners and illustrated with practice examples and case studies to help inform learning and understanding. 19.5 Training around trauma and how this can manifest, impact on the brain when experienced compound trauma, along with techniques to stabilise. Trauma informed approach and responses can also help encourage engagement and thus inform and strengthen safeguarding practices. 19.6 Asset based practices encouraged looking at good practice and sharing across agencies to strengthen what is working well, adopting an appreciative enquiry approach outside of safeguarding practice reviews. 19.7 Develop multi-agency supervisions in complex cases such as this to join up work, sharing of information and strengthen collaborative working and partnership understanding. Consider external clinical supervision sessions at a multi-agency level to support a culture of challenge and professional curiosity whilst supporting practitioners and providing positive tools to do this. 19.8 Develop a programme of champions and ambassadors who will lead as specialists in certain fields such as HBA cascading learning, supporting professional challenge and curiosity to help embed understanding, creating a shift in approach. Page 19 February 2022 19.9 Link into the new approach and model being developed and reviewed by the Domestic Abuse Task and Finish group which would support an evidence base for action and provide tools and guidance around the complexities and intersectionality of domestic abuse cases. 20. Process and Review Recommendations 20.1 Review of safeguarding practices to ensure that safeguarding is prioritised above culture using toolkits to support staff to do this. 20.2 Review how information is shared to streamline this between professionals making it more timely, efficient, and effective; this could be a training need around professional responsibilities as information sharing is clear in child protection. 20.3 Signs of safety ratings to be reaffirmed, giving examples of what this looks like to illustrate and ensure that this is rolled out to all and can be consistently applied. 20.4 Review the role of the Child Protection Conference Chair as a point of reference for any professional concerned about the progress of the CP plan and the challenge that the Chair can exercise to support escalation. Look to the Chair setting midway review meetings between Core Group meetings to monitor and prevent drift. 20.5 Capture the Child’s voice and experience / whole family view / wider family linkages / family circumstances history, when appropriate, making use the voluntary sector or specialist agencies to help support and enable this, recognising that as non-statutory agencies engagement can be more readily embraced by families experiencing multiple disadvantages. 21. Good Practice Recommendations 21.1 There is a danger in such a highly charged and emotional case such as this, that with the crude application of hindsight any genuine and more honest learning will be lost. Reliance on hindsight can wrongly infer that wrong personal or professional judgments were made rather than looking at what was known at the time and analyse how and why information was being processed by all the relevant people (family and professionals) and the reasons behind this. 21.2 The review highlighted the difficulty faced by professionals in deciding how to evaluate the allegations made by the father. The records show that professional understanding of risks had been based largely on the accounts given by him, with no corroborative or supportive evidence until the most recent episodes of abuse to Child Q. The following areas for improvement are supported by the recommendations in section 6 and are intended to provide a broader, thematic approach for the safeguarding partnership, however they can also be applied to individual authorities including health trusts, police, education, children and adult social care and relevant public bodies involved with safeguarding responsibilities. Page 20 February 2022 21.3 The safeguarding partnership should ensure through learning and development, that all agencies have arrangements in place to consider within assessment and supporting multiagency procedures the child’s experience and emotional impact, as well as the child’s voice. 21.4 The safeguarding partnership should ask member agencies and partnerships (including those who are the commissioners of services) to ensure that whenever possible, professional assessments of risk in relation to domestic abuse consider relevant history. For example, past accounts of abuse, including those with other partners, pervious services provided and their impact, and the impact of abuse on the victim and children. 21.5 Assessments must take account of race, religion and other individual and family characteristics that shape its impact on victims’ assessment and management of risk, where there are allegations of domestic abuse within BME communities; need to take account of specific factors of race, religion, and family background. This will be a unique assessment because every family and individual have a different interpretation of these factors and individual needs. For example, in this case insufficient attention was paid to the characteristics and circumstances of the family. 21.6 It is recommended that training around improving professional curiosity and embedding this as part of day-to-day delivery with the mechanisms to test and ensure that this is the case needs to take place. 21.7 If there is a lack of experience within multi-disciplinary teams of abuse within BME communities, the specialism and expertise should be sourced. Similarly, their needs to be a review of the tools, interventions and pathways around Honour Based Abuse (HBA) separate to domestic abuse as referenced in Home Office guidance and associated protocols. 21.8. Training, along with toolkits to support and improve understanding and delivery around honour-based violence enabling indicators and questions to be asked to inform safeguarding practices and decision making are recommended. 21.9 This review identified the need to train and raise awareness of professionals around culture and faith and how this can practically be used when completing child, adult and family assessments. Lack of knowledge may result in professionals adopting a reactive and punitive approach when confronted with cultural or religious values. Practices which put a particular ethnic group at a disadvantage in comparison to their white counterparts fails to meet Public Services Equality Duty (Equality Act 2010), furthermore leads to institutional and systematic failures to protect Black and minoritised communities. 21.10 When working with families where a lead communicator is apparent to the level the Father became, staff need to be made aware that research and practice evidence demonstrate that the level of manipulation by one parent can be considerable, and their subsequent actions must be rigorous to a point of not automatically trusting the information provided. Analysis of the potential risks and assessments of the children and Mother involved need to be subject to additional scrutiny in such complex cases. Page 21 February 2022 22. Practice recommendation All services dealing with domestic abuse allegations and assessments of risk must ensure that staff take full account of race, religion and other individual and family characteristics that may shape its impact. A specific honour- based abuse risk assessment and multi-agency referral pathway should be developed with risks and harm training to enable professionals to understand the triggers and thereby the relevant interventions and support. 23. Practice recommendation The safeguarding partnership should providence due regard that all agencies promote a culture and competence that enables staff to evaluate risks from domestic abuse, lack of engagement, disguised compliance in full, always taking them seriously and treating alleged victims with respect but in appropriate circumstances, exploring how complete allegations are and whether they are valid. 24. Practice recommendation The safeguarding partnership should highlight the importance of compiling and sharing intelligence and information which is crucial to building a whole systems approach to supporting cases where non-engagement is experienced. Assessments for children and all the adults within the family is essential as part of any chronology setting out key risks and challenges. Agencies must ensure appropriate tools and culturally specific interventions are available such as the use of arts and craft, journals to promote an environment which is trauma-informed and explores in different ways how information can be obtained. 25. Practice recommendation Ensure that all local multi-agency pre-birth risk assessment tools and protocols and information sharing comply with child protection procedures and local guidance, and that staff are aware of, and trained, in using these. 26. Practice recommendation Protecting children from extremist behaviour during pre-natal assessments and multi-agency responses requires careful assessment and working collaboratively across agencies as, initially, concerns may be inconclusive and protecting a child or young person against a potential risk can be dependent on a wider range of factors. Sharing information effectively and keeping the child in focus should be the main aim of any interventions and services. Increased awareness of extremism behaviour and professional cultural competency can be enhanced by training, tools, and specialist roles/lead professionals. Page 22 February 2022 27. Monitoring and Evaluation 27.1 Learning and good practice recommendations should form part of an implementation plan around the LCSPR for Child Q. Milestones and review periods should be established to assess progress, impact and difference ensuring that the changes identified do take place, become embedded and shift the culture and approach, thus strengthening safeguarding practices for future families and children. Managers in all agencies should ensure staff supervision of complex cases, risk assessments are critically evaluated, and hypotheses are tested. 27.2 The partnership should agree how they will measure the impact and distance travelled and report upon this incrementally ensuring that above becomes part of everyday practice in general. 27.3 Critical thinking and challenge, reviews frequently highlight ‘over optimism’ and a lack of ‘professional curiosity’. Practitioners should be confident in using the authority of their role to promote ‘support and challenge’ relationships between themselves and children and young people. Critical thinking can provide a framework for practitioners to analyse and reassess their work with children and families. Page 23 February 2022 Appendices and References Appendix 1, Terms of Reference Decision making HSSCP Executive members took the role of a governance group for the review and dedicated governance group meetings were scheduled at regular intervals throughout the independent review period. The Executive issued terms of reference, agreed actions, and monitored progress. A governance meeting gave final sign off to the review. Terms of reference A focussed review which was to explore two key learning themes identified from the Rapid Review already undertaken; Safeguarding children where there is nonengagement with services and the impact of cultural and religious considerations. The independent reviewer(s) appointed undertook an examination of agency chronology information. Following this, two focus groups were to be undertaken with frontline practitioners; one for each of the key themes identified. A facilitated learning event was then held with wider representation from across the partnership; the aim of which was to explore how identified learning translates across the safeguarding system. A recall event was then undertaken to examine the draft report, prior to its submission to the HSSCP executive for final consideration. Practitioner involvement Frontline practitioners from the following agencies that were involved with the case were identified to be part of the two focus groups: Harrogate and District NHS Foundation Trust – 0-19 Service, Health Visiting Stockton Borough Council - Children’s Social Care Stockton Borough Council - Early Help Stockton Borough Council – IRO Service School Hartlepool and Stockton-On-Tees Children’s Hub North Tees and Hartlepool NHS Foundation Trust Tees, Esk and Wear Valley NHS Foundation Trust NHS Tees Valley Clinical Commissioning Group Cleveland Police Harbour Support Services The learning event and recall event included representation from managers / strategic leads from the focus group agencies, with the addition of: Housing (Thirteen) Hartlepool Borough Council 0-19 Service – Health Visiting Hartlepool Borough Council - Children Social Care Hartlepool Borough Council – Early Help HSSCP Engine Room Page 24 February 2022 Scope of the Review Themes Safeguarding children where there is non-engagement with services What was known /understood in relation to the father and family dynamics (in relation to DA / power and control / non-engagement)? What were the gaps in professionals’ knowledge and understanding? What were the barriers to: Engagement with services? Family engagement in conference / core group? Engaging with the siblings/undertaking direct work? ➢ Was lack of engagement questioned or accepted? What information could / should have been shared when the case was escalated (concerns re non-engagement) and legal advice sought / when referral was made to MARAC? Processes were followed but were largely ineffectual. Do we understand why The impact of cultural and religious considerations What was known / understood in relation to the father and family dynamics (in relation to culture / religion impacting upon dynamics and the lived experiences of the child(ren))? Was culture / religion a barrier? How? Was culture perceived to be a rationale for parental behaviour? Did professional understanding of / fear of culture or religion impact upon professionals’ ability to challenge? Were professionals involved aware of these barriers? How did the core group understand family dynamics / cultural beliefs and challenge? Meetings with Family/ Significant Others HSSCP required the reviewers and a representative from the HSSCP to make contact with the family to introduce themselves and explain the review process, so they were given the opportunity to input their views into the review. Page 25 February 2022 Appendix 2 Summaries and Sources of other reference for the Review Published case reviews highlight that professional sometimes lack the knowledge and confidence to work with families from different cultures and religions. A lack of understanding of the religions and cultural context of families can lead to professionals overlooking situations that may put family members at risk; whilst the desire to be culturally-sensitive can result in professionals accepting lower standards of care. The learning from these reviews highlights that professional need to take into account families’ cultural and religious context when undertaking assessments and offering support. The rights and needs of the child need to remain the focus of interventions at all times, regardless of this context. Professional misconceptions, lack of confidence and lack of knowledge. Many professionals lack knowledge about specific cultures and religions and do not feel confident in challenging harmful parenting practices. Professionals want to be respectful of families' cultural and religious practices but the desire to be culturally sensitive can result in professionals accepting lower standards of care (NSPCC Briefing 2014). Annual review of Local Child Safeguarding Practice Reviews (LCSPRs) and Rapid Reviews 2020 The Child Safeguarding Practice Review Panel commissioned the University of Birmingham and University of East Anglia to undertake a review of case reviews. The review highlights learning from the published LCSPRs as well as unpublished advice from the Panel to local child safeguarding partnerships to support local safeguarding partners and the Panel in their work to improve child protection practice. Several themes emerged from the analysis of the reviews, including: opportunities to be curious inter-agency communication and sharing knowledge and application of policies and procedures and training working with families during the coronavirus pandemic peer-on-peer abuse young people’s gender and sexual identities child trafficking Overall NSPCC review found that domestic abuse was featured in 42% of all serious incidents. Working with families where engagement is reluctant and sporadic Reviews often refer to a ‘lack of engagement’ by vulnerable families, including missed appointments, cancelled home visits and refusals of offers of support. It is important to understand the underlying issues, such as unresolved adverse childhood experiences, socio-economic pressures or difficulties engaging with large numbers of professionals, that give rise to reluctant or sporadic engagement from families. Relationship-based practice and motivational interviewing can help practitioners develop connections with families and maintain a balance between being directive, supportive and non-judgmental. (source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984770/Annual_review_of_LCSPRs_and_rapid_reviews.pdf ) |
NC52190 | Death of a 7-year-old girl in November 2017. Child D was murdered by her father in the family home. Father then rang the police and reported what he had done; Child D was resuscitated at the scene but died in hospital the following day. Father pleaded guilty to Child D's murder and was sentenced to life imprisonment. Family was known to numerous agencies. Father and Mother were experiencing a breakdown in their relationship. Father had attempted suicide on several previous occasions due to stress and depression. Mother was not a fluent English speaker and there were concerns about Father's coercive control of Mother and his continual disguised compliance and deception. Post-mortem discovered semen in Child D's vagina but investigation was unable to establish how it got there. Father denied sexual assault. Child D's father was White British and mother was from South East Asia. Learning points relate to: mental health risk assessments; multi-agency assessments; thresholds and 'step-up' and 'step-down'; the use of interpreters and cultural sensitivity in assessments where English is not the first language; considering and assessing coercive control and disguised compliance; information sharing; sexual abuse. Recommendations include: seek assurance that in mental health assessments following attempted suicide where the adult has responsibility for children, that risks to them and partners are considered, including where the dependent is seen as part of the patient's perceived 'problem' or 'protective element'; review multi-agency approaches to assessing for the possibility of sexual abuse of children.
| Title: Serious case review: Child D. LSCB: Merton Safeguarding Children Partnership Author: Malcolm Ward Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Merton Safeguarding Children Partnership Serious Case Review Child D January 2020 ��������� 1 Contents 1. Executive Summary 2 2. Reason for the Review and its Methodology 4 3. Family and Background 4 4. Summary Timeline of Agency Involvement from January 2017 5 5. The Parents’ Views 13 6. The Practitioners’ Views 15 7. Analysis and Lessons 19 8. Recommendations 28 9. Appendices 30 9a Panel membership 9b Seven Golden Rules of Information Sharing Merton Safeguarding Children Partnership Merton Civic Centre https://www.mertonscp.org.uk/ August 2019 2 1. Executive Summary 1.1 D died in November 2017. During the trial, in April 2018, her father changed his plea to guilty to her murder. He was sentenced to life imprisonment. 1.2 From January 2017 D’s family was known to statutory, charitable, independent and private services, some universal and some specialist, first as a result of D’s mother’s emotional reaction to the breakdown of the parental relationship, and later because of D’s father’s suicide attempts. 1.3 After the trial, in 2018, the Independent Chair of the Merton Safeguarding Children Board agreed that a review should be undertaken into agencies’ work with D and her family to see if any improvements to local safeguarding systems and arrangements were required. 1.4 This review used information from post-incident management analyses of the agency and multi-agency work done, information from original case records, and information from the criminal investigation. The Independent Reviewer met with D’s mother. Practitioners’ views were sought through a Learning Focus Group. 1.5 D’s mother and father jointly consulted their GP in January 2017 as she was reacting badly to the discovery of his long-standing affair. They were advised to seek relationship counselling. They later separated, temporarily. D’s father sought private therapy in the spring. Due to concern about D’s progress at school the parents arranged for her to transfer to boarding school in September. 1.6 As a result of D’s father making a suicide attempt in the summer the family came to the attention of mental health services and children’s social care services. He made a further suicide attempt a few weeks later. Mental health services and children’s social care completed assessments. It was noted that D’s father had stress-related depressive episodes. He was not diagnosed to have a mental illness and at no time was he seen to require compulsory admission under the Mental Health Act. The assessments did not find any ongoing risk to others or to D’s father himself. By late September it was agreed that there was no ongoing need for statutory mental health services or children’s services; it was understood that D’s father was accessing local independent counselling. 1.7 The review has found six main areas of learning and two lesser issues for further exploration. 1.8 In relation to the mental health assessments, following the attempted suicides, it was found that they met national and local standards and that as there was no prior evidence of violence there was no reason to predict harm. He was assessed as low risk and consequently proportionately lower priority. It is questioned, however, whether sufficient attention was given to a possible pattern of stress-induced suicide attempts (he said he had attempted suicide on a prior occasion when faced with stress); and consideration of family members, including D, being responsible for the stress. 1.9 Multi-agency working was not as good as it could have been, although there was some exchange of information. Mental health services and children’s social care worked more in parallel than jointly. Other agencies, except the GP, were not informed of the nature of the concerns. Given the assessment of low-risk agencies have suggested that joint work would have been 3 disproportionate. There was a lack of curiosity about D’s mother’s view, and her own needs, and no questioning about the state of the marriage – there was an assumption that they were a couple again, which was not so. Given D’s mother’s racial, cultural and language background there was over reliance on D’s father to speak on her behalf which allowed him to exercise control. She became disempowered, did not understand what was happening or what services may be available to her and the children. She did not fully understand what she was asked or advised in English, or why agencies may be concerned about the children. She was not asked independently about the (failed) state of the marriage, about the dynamics at home or about financial worries. 1.10 Thresholds and ‘step-down’ When it was agreed that the children did not need ongoing social work support the case was not formally ‘stepped-down’. The schools were not aware of what the issues were. Although there was a good handover from mental health services to primary care to support D’s fathers mental health there was also an erroneous assumption that he was in receipt of help from the independent sector. 1.11 Interpreters and cultural sensitivity More attention should have been given to D’s mother’s need to have an independent interpreter to help with language and understanding cross-cultural and systems issues. The Panel has queried whether this is a systemic issue going wider than this case. 1.12 Coercive control and disguised compliance D’s father controlled access to D’s mother and her access to services; she was dependent on him. He also gave misleading information to practitioners, which was taken at face-value, as he was plausible. The case shows the need to consider these two dynamics in contemporaneous work, but this is a challenging area for face to face work and only became fully clear in retrospect. Fuller conversations with D’s mother may have signposted this at the time. 1.13 Information sharing Information was shared but there were boundaries and anxieties about what could and could not be shared. Key information held by one services was not always passed on to another. A greater sharing of information and a team approach may have highlighted the discrepancies in the father’s accounts – these directed the work. 1.14 In addition to these findings the Review also noted possible systems dynamics in relation to assessing and working with families where there are different socio-economic, cultural and language factors and where a family uses private and independent sector resources which are not part of the mainstream of child welfare services. 1.15 At the time of D’s murder there was no information available to suggest that D or her family were at risk. Her death could not have been predicted. Information from the criminal investigations after her death shows that D’s father had been considering her murder throughout October; he also spoke, after the event, of also planning to kill his wife and son, and himself. 1.16 The Review has made eight recommendations from these lessons in relation to: assessments after repeated suicide attempts, joint agency working in parental mental health, use of local thresholds and ‘step-down’ processes, interpreting, practice awareness of coercive control and disguised compliance, information sharing guidance and reviewing local approaches to detecting sexual abuse. 4 2. Reason for the Review and Methodology 2.1 The Independent Chair of the Merton Safeguarding Children Board (MSCB)1 decided shortly after D’s death that, with the information available at that time, the circumstances of D’s death met the requirements for a Serious Case Review under Working Together to Safeguard Children, 2015, chapter 42. 2.2 The Review was to learn lessons about agency and multi-agency practice, using systems theory methodology, avoiding hindsight bias in making judgements, and seeking to involve D’s parents. The practitioners who had worked with D and her family in the period before her murder were involved in a Learning Focus Group. 2.3 D’s mother met with the Independent Reviewer with a personal supporter and an interpreter. D’s father declined the invitation to meet or contribute. 2.4 D and her family were known to three schools, a local GP Practice, private and independent counselling services and, as a result of D’s father’s depressive episodes and attempted suicides, to statutory mental health services, to children’s social care, and to the police. Each service was asked to provide a report of its contacts with the family and an analysis of how the work was undertaken and of any lessons learned. The review examined, in detail, the agencies’ work in the period from January 2017 to D’s death in November 2017. 2.5 The Independent Chair of the MSCB agreed the Terms of Reference and appointed a Serious Case Review Panel of senior managers who had not been directly involved in the case management. An experienced Independent Reviewer was commissioned to work with the Panel and compile the report for the Safeguarding Children Board (now Partnership). 3. Child D, D’s Family and Background prior to January 2017 3.1 D lived with her mother, father and her older brother. At the time of her death D was 7 and her brother was 9. This was her father’s third marriage. He told at least one agency that he had older children from a previous marriage, but D’s mother has told this Review that D’s father had no other children by the previous marriages. He co-owned a business. 3.2 D’s father had had a prior episode of mental health problems and had made a previous attempt to take his life. This was understood to be twenty years prior and associated with the ending of a relationship and money worries. 3.3 D’s mother was from Thailand. She was not fully fluent in English. The couple married shortly before D’s birth. 1 The MSCB was replaced by the Merton Safeguarding Children Partnership (MSCP) in April 2019 2 Working Together to Safeguard Children, 2015 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 5 3.4 From September 2013 to July 2014, D attended the nursery class of a local primary school. She was a quiet, happy, sociable child who achieved the expected level of development for her age across all areas of the curriculum. There was no concern about her welfare and there was good engagement between the nursery and D’s parents. 3.5 In September 2014, D transferred to a local independent day school. The school had no concerns about her welfare. Between November 2015 and January 2016, it was noted that D’s academic progress was slower than average. Additional lessons were arranged for her. By the end of Year One (July 2016) D’s standardised test results were within the average range. 3.6 D’s brother attended a different independent day school from September 2012. He was seen as a bright pupil, working at his potential. There were no concerns for his welfare. 3.7 In 2016 D’s mother discovered that D’s father was in a relationship, of two and a half years, with another woman. This led to tensions in the marital relationship. It is understood that, as a result of this discovery and the reconciliation that followed, D’s father bought a new family home. This later contributed to perceived financial difficulties which became a key factor in the possible causes of D’s father’s mental health difficulties in 2017. 4 Summary Timeline of Agency Involvement from January 2017 4.1 The Review Panel collated all known contacts with the family members by local agencies. Not all agencies had completed a day by day record of their contacts with the family or other agencies about D and her family members. Some agencies had summarised their work in periods. In a summary report of this type it would not be appropriate or proportionate to show the complete timeline which the Panel analysed. 2017 4.2 January Problems within D’s family first came to light to public agencies when D’s mother and father attended their GP. D’s mother had discovered that D’s father had been in a long-standing affair and as a result she was experiencing acute anxiety. The relationship was discussed, and the couple were advised to consider attending relationship counselling, to which they would have had to self-refer. They planned to remain together. There were no concerns about D’s father’s mental health at this time and there were no concerns about the children or the children’s care. 4.3 March At D’s private school, D’s father queried whether D may have special needs and whether she might be dyslexic. He talked of arranging a screening for dyslexia – the school completed a questionnaire about her for an external organisation for a special education assessment. She was described as below average in key subjects but said to be happy and to have friends. D’s school was unaware of the difficulties at home. 4.4 April - June D’s father in private counselling In late April D’s father self-referred and started private counselling in his own right to discuss his emotions and the stresses he was experiencing as a result of the discovery of the affair and the tensions in the martial relationship. These took 6 place in the premises of a local charity but were not provided by them. This arrangement later led to confusion as D’s father told several agencies that he was receiving or had received a service from the charity when in fact the service was from a private and independent practitioner who was not part of the charity. 4.5 D’s father had seven meetings with the counsellor between late April and early June when he ended the sessions. Initially he had appeared anxious and distant. He was planning to move out of the family home but was unsure if that was the best thing to do. He talked about a historic suicide attempt when he was experiencing financial difficulty during his second marriage. This had been a turning point for him, and he had not considered suicide since. In later sessions D’s father shared problems with eating and sleeping as a result of his worries but said that he did not feel suicidal. He saw his children as something to live for. He revealed a history of extra-marital affairs. He was anxious and regretful about what he had done. He was encouraged to visit his GP if his low mood and anxiety continued. 4.6 In a later session he expressed fear of being alone when he moved out of the home and agreed to see his GP. In the next session he said that he had seen the GP who had prescribed anti-depressants. D’s father felt that his mood had improved and that his anxiety had lessened. He also said that he had moved out of the family home earlier than planned as a result of the rapid deterioration in the marital relationship. In the sixth session, at the end of May, D’s father stated that he wished to end the individual counselling as he felt better, but that he would like to consider group psychotherapy. The counsellor was concerned that it may be too early to withdraw from counselling, given his circumstances. The counsellor advised him how to self-refer for group therapy. In the final session, at the beginning of June, D’s father seemed calmer and showed signs of improved mood. 4.7 May There were concerns about D’s brother’s possible bullying behaviour at school and counselling was arranged for him, for a short period. The school was unaware of the difficulties at home. 4.8 D’s father made an application for D to attend a state boarding school from September. Her independent day school provided a reference for her. They noted that there were no safeguarding concerns for D. The school thought that D had grown in confidence. They were concerned about her academic progress. 4.9 D’s father did attend the GP Practice in mid-May and requested anti-depressants. He told the GP he was leaving D’s mother. When seen two weeks later it was understood that he had moved out of the home and was seeing the children at the weekend. 4.10 June In early June D visited the proposed boarding school and, after interview, was offered a place. Both parents signed the forms and indicated that there were no safeguarding concerns. 4.11 D’s father saw the GP again, three days after the final session with the private counsellor and stated that he was living back at home with his wife. Three weeks later he reported that he was attending relationship counselling with her. D’s mother has told this Review that they did not attend relationship counselling. 7 4.12 D’s father referred himself to the local charity which provides group psychotherapy, amongst other services. He was seen initially in the third week of June for an assessment. He stated that he was not living at home (which is different to what he told the GP). No safeguarding issues were identified. 4.13 July In the middle of July D’s father cancelled a second appointment to consider group psychotherapy, a further appointment was offered for the beginning of August. 4.14 D went to Thailand with her mother and brother. D’s mother has said that D’s father had moved back into the family home when they returned. 4.15 August At the beginning of August D’s father was seen again by the group psychotherapist as part of the assessment of his suitability for group psychotherapy. He spoke of worries about finances, marital problems, isolation and loneliness. The children were only discussed briefly when D’s father mentioned that they fought occasionally. The assessment concluded that in the present circumstances group psychotherapy could not be offered to him as his personal needs would not fit with the current group dynamics and it was known that he was being treated by his GP. First Critical Incident 4.16 In the middle of August D’s father attempted to take his life. He had taken sleeping pills and tried to hang himself in a London hotel. When he was unsuccessful, he called an ambulance and was taken to the emergency department of an acute hospital in west London. D’s father told staff in the psychiatric hospital that he had changed his mind and untied the ligature rather than his attempt had failed. He stayed in the acute hospital overnight under mental health supervision. In assessment he stated that he had financial difficulties ‘because of maintenance payments to an ex-wife’ and not being able to find a job. D’s father said that he was ‘not ready to talk about’ the difficulties with regard to access to children from his first marriage. He did not see a way out of his situation and felt hopeless. 4.17 He was transferred to the local psychiatric hospital for his family home in Merton early the following morning. The acute hospital informed Merton children’s social care of the admission – however, it has transpired that there was an error in the home address used. 4.18 In the psychiatric assessment unit D’s father was re-assessed. He reported a previous attempt to hang himself 20 years before, in the context of a divorce. The current attempt was because of financial stresses. He described himself as a self-employed man who had suffered a financial crisis, but also reported that he had just made a lucrative sale. There were also family stresses and low mood. He described thinking about ending his life for some time. D’s father reported that he was currently in ‘private psychology’ sessions (this was not so). He said that his family was a protective factor. He was discharged to the family home that same day after the psycho-social and risk assessment. It was noted that D’s mother was involved in his care. His psychiatric care was transferred to the Home Treatment Team (HTT) and Children’s Social Care (CSC) was advised. The GP was also informed by letter and was told that D’s father was most worried about how he would pay D’s boarding school fees. 4.19 D’s father was seen the next day at home by the Home Treatment Team. He was seen to be evasive when questioned but was assessed as no longer being a risk to himself or to others. He 8 declined daily contact but agreed to be seen after two days but then later cancelled this saying he was going away with his family. (This was not the case). 4.20 The Children’s Social Care (CSC) received the referral from the west London acute hospital. It was noted that D and members of her family were not previously known to CSC. 4.21 There was liaison between the Home Treatment Team and the Merton Multi-Agency Safeguarding Hub (MASH) early the following week and the social worker from CSC asked for D’s mother’s telephone number. 4.22 It was noted by CSC that D’s father did not wish to have home visits from children’s services. The following week, it was agreed that a child and family assessment3 should be undertaken. From the initial information gained by CSC there was nothing to indicate that a child protection assessment was required. 4.23 D’s father was seen by a Home Treatment Team (HTT) practitioner and he described being more positive and planning to return to work the next day. He also reported that he was attending the local charity for counselling – which was not the case. The worker asked him for D’s mother’s phone number to give to CSC – but he said that he did not have it with him. D’s father did not keep the next appointment, three days later, as he ‘had a stomach upset’. The HTT kept in touch with him by phone. Two days later, on the Bank Holiday Sunday, he was reviewed by phone and provided D’s mother’s phone number. 4.24 September D’s father was seen by the HTT at the team base at the beginning of September. Risks to himself and to others were assessed as low. He was given sleeping tablets for two nights. He spoke of a session of counselling at the charity and gave the worker the impression that he was receiving therapy from them – which was not the case. 4.25 D’s father was seen by the HTT three days later, as agreed. His sleep had improved. He was given two more days sleeping tablets and agreed to see the GP for a prescription. Risk to himself and to others was assessed as low. The plan was to assess him three days later with a view to discharging him from the service. 4.26 D started at her new boarding school, the same day. The school was not aware of any of the current family issues. 4.27 D’s father saw the GP two days later and was prescribed more sleeping tablets. He stated that he was living back at home with D’s mother. Second Critical Incident 4.28 That evening D’s mother reported D’s father as missing to the police. He was found the next day in a local park by the police, D’s mother and D’s brother (age 9). He had taken an overdose of 12 of the sleeping tablets and some other similar tablets the night before. He was taken to the 3 Child and family assessment – can be undertaken under sections 17 or 47 of the Children Act 1989. This assessment was under section 17; its purpose was to see if the children were in need (or parents) and may benefit from any support. 9 local acute hospital was assessed and then admitted as a voluntary patient to a psychiatric ward. He was discharged home six days later. 4.29 While in hospital D’s father was re-assessed. He said that he had ‘just wanted to sleep. He had been ‘thinking about taking his life for some time’. Financial worries had led him to take the overdose. He felt guilt and anguish about what he had done. He was lonely and had difficulty forming relationships. Although D’s mother and D’s father’s brother visited him in hospital, they were not interviewed about him or his circumstances, on the ward. During this in-patient stay, as an informal, voluntary patient he had periods when he was allowed to go home; psychiatric staff spoke with D’s mother about those arrangements. The assessment was that D’s father had depressive symptoms as a result of psycho-social stressors and that he had taken an impulsive overdose. He was discharged back to the care of the Home Treatment Team. 4.30 CSC was informed by the acute hospital of this second suicide attempt by overdose and of the in-patient stay. The MASH / CSC social worker was, however, unaware of this second suicide attempt when they visited the family at home on the day of D’s father’s discharge from hospital. This may suggest a systems issue in relation to information received on open cases. This was the first social work visit. The delay in visiting has been noted to be because of the error in the address on the first referral, delays in gaining D’s mother’s phone number, and because the case was given lower priority, based on the initial information received. The parents were unprepared for the visit and were described as wary. They did agree to agency checks being undertaken about them but not with the schools. D’s brother was at home; the social worker spoke with him briefly. 4.31 D’s father contacted the group therapist at the local charity by email saying that he had ‘had a short holiday to France’ – this is unlikely to have been true (D’s mother has no knowledge of it); the email appears to have been sent on the day of his discharge from hospital. 4.32 A mental health HTT practitioner visited D’s father at home the following day and assessed the risk to self and others as low. D’s father planned to sell the family home to deal with the financial stresses. D’s mother’s view was not noted. He also told HTT staff of an appointment with the counselling service at the local charity the following week. It was agreed that HTT would see him every two days. 4.33 After the first follow up HTT contact the frequency was changed to every three days. The next contact three days later was by phone rather than face to face as there was a clinical emergency on another case. D’s father advised the HTT practitioner that he had seen a worker at the counselling charity and that they had suggested Cognitive Behavioural Therapy, which they were arranging. This was not so, as he had not yet seen the group therapist. He had also contacted the Improving Access to Psychological Therapies Team (IAPT) and left a message on an answerphone seeking to refer himself. As he was feeling better HTT considered discharging him from the service soon. 4.34 D’s father emailed D’s boarding school to say he was in hospital and would not be able to attend a parents’ event, scheduled for the Saturday. D’s mother attended with a friend who translated for her – but she did not speak individually to any of the school staff. 4.35 On the Sunday, during a home visit by a HTT worker, D’s father was remorseful, he said that he had decided to sell the house and that his ‘family is protective’. That same day D’s father visited 10 D at the boarding school and spoke directly with a child and their parent there since that child had allegedly bullied D. The school asked him not to speak directly to other children but to speak with them if he had concerns. He was polite and agreed to do so. 4.36 The local charity group therapist met with D’s father to assess if his circumstances had changed from the previous assessment that he was not suitable for group psychotherapy. He disclosed that he had attempted suicide and was under the care of the Community Mental Health Team / HTT. It is not clear if he disclosed both suicide attempts. The clinical assessment was that it was still not appropriate for him to be seen in group psychotherapy. It was also noted that he was still in treatment with the HTT. 4.37 D’s father was seen at home by HTT the next Saturday. He was concerned about the side-effects of his medication; he was advised to discuss it with his GP. He wished to be discharged from the HTT as he understood this would prevent him using the IAPT service. (Information from the IAPT suggests that he had not at that point self-referred; but that is not clear as he reported leaving a message on an answer phone.) He was more positive about his business picking up. However, he was worried about a visit from CSC which that was planned for the next day. His concern was that the children would be taken away. The worker planned to discuss the possibility of discharging D’s father from the HTT with the Multi-Disciplinary (HTT) Team so that D’s father could start with IAPT. 4.38 The CSC social worker visited the home the next day, the last Sunday of September as D was at home from boarding school. The social worker undertook direct work with D and tried to engage her brother, but he was reluctant to talk. Their father came into the room to encourage D’s brother to speak but he did not, except to answer, ‘I don’t know’. There was nothing observed in the children’s behaviour or conversation that indicated any anxiety or concern. It was noted that D’s brother was aware of his father’s suicide attempt, but that D was not. D’s mother reported that she was fearful of D’s father killing himself or running away if the house was not sold. The parents gave permission to contact the children’s schools. 4.39 The next day (Monday) the CSC social worker contacted both schools to seek information, advising the schools that something traumatic had happened but not giving detail. D’s brother’s school had no worries about him. They have reported that they asked the social worker for more information about what had happened but that the social worker declined to provide more information, on grounds of confidentiality. D’s school responded two days later with reports saying that there were no concerns about D but that she was behind academically. They also mentioned that D’s father had been asked not to speak directly to other children if he had concerns but to raise the matter with staff. 4.40 On the Tuesday the HTT social worker contacted D’s father and mother by telephone and spoke with both of them. During the conversation she asked D’s father and mother questions based on the Merton Wellbeing Parenting Capacity proforma. There was no concern about D’s mother’s ability with the use of English. The HTT social worker advised them both about local resources which may be able to assist financially and also the possibility of D’s mother using the local Carers Association – but D’s mother agreed with D’s father who said that she did not need support. Information from this call was shared with the CSC social worker. 11 4.41 Later the same day another HTT practitioner visited D’s father at home. D’s father described poor sleep. His medication was reviewed. He was to be discharged back to the care of the GP with a plan for him to engage in therapy with the IAPT. 4.42 The next day, the IAPT noted receipt of a self-referral by D’s father who had made a self-referral asking for help with depression. The referral was screened and there was no risk indicated. 4.43 The HTT Consultant Psychiatrist discussed the plan for discharge with the GP, in a phone call, and sent a letter noting low risk and recommending that the medication should be prescribed fortnightly. There is no information to suggest that there was direct contact by D’s father with the GP after this, to review his medication. 4.44 At the end of September, the Child and Family Assessment was completed. It concluded that the case was not one of child in need and that the schools could monitor the situation. The schools, GP and HTT do not appear to have been made aware that the social worker was withdrawing. 4.45 In the second week of October D’s father was assessed over the phone by IAPT. He revealed the recent suicide attempt (not the first one in August) and said that he had been in hospital and seen by the HTT. He disclosed the suicide attempt 20 years previously. He reported being no longer suicidal. He described his wife and children as protective factors. He did not share that the marriage had broken down. D’s father said that a CSC social worker and HTT had visited but were no longer involved and said that he was seeing his GP every two weeks, which was not the case. He was keeping himself well by walking and with YOGA; and he had returned to work. There were still financial worries but he planned to sell the family house to resolve these. He said that he had no current symptoms of anxiety. D’s father finally told the IAPT assessor, in this phone call, that he had been seeing a therapist at the charity for the past two months and that he would continue with this; and so he did not wish to follow up with IAPT – this was not, in fact, the case. 4.46 From the information gathered no professional seems to have seen D’s father, face to face in October. Assault on D and her death 4.47 At the end of October D came home for half-term from boarding school. At the beginning of November while D’s mother was taking D’s brother to school D’s father strangled D with a dressing gown cord while she was still in bed. He then rang the police and reported what he had done. She was resuscitated at the scene but died in hospital, the following day. 4.48 There was post-mortem evidence of the presence of semen in D’s vagina (probably within the last seven days). The forensic evidence was rigorously tested and there was detailed consideration by the Crown Prosecution Service but it was not possible to establish how the semen came to be present. D’s father denied sexual assault but admitted the strangulation. Information which became available in hindsight through the subsequent criminal investigation and trial 12 4.49 It is important when considering information gathered in hindsight to be careful not to judge the quality of the work with this bias. A question is, however, could this information have been reasonably gathered in the work at the time and, if so, what systems dynamics may have prevented that? 4.50 The Judge described D’s father as ‘deceitful and manipulative’ and ‘calculating and disingenuous’, concealing his plan to kill D. 4.51 D’s father told police that he had intended to kill his wife and family (and himself) as he feared bankruptcy and wished to spare them pain; but in the end he could not and could not explain why. He described D’s school fees as the ‘whole scenario of his debt’. He said that he had become ‘too tormented with his life’ and ‘could not bear going on’. 4.52 The Forensic Psychiatric Assessment provided to the trial indicated that at the time of the offence, D’s father was suffering from a moderate depressive episode. However, this would not have been such as to impair his mental ability to understand his actions, judgement or self-control at the time. He did not meet the thresholds for legal defences of insanity or diminished responsibility. It became clear that his actions were pre-meditated. 4.53 In the psycho-social history given by D’s father as part of the forensic assessment, he revealed a troubled childhood and adolescence, with social awkwardness and isolation; including being bullied, assaults on others and a period with an eating disorder. He considered self-harm and overdosing in his teens. He had a brief period as a young man as a soldier but was discharged for psychological reasons. Subsequently he established a successful business with a brother. 4.54 He married three times and on occasions had affairs with other women. Under stress, as a result of financial pressure from the purchase of a house with his second wife he was responsible for an altercation in which she was injured. As a result, he took an overdose and tried to hang himself but sought no medical assistance. 4.55 D’s father, in his account, said that there were no children from the two prior marriages. 4.56 D’s father said that he found being a father of young children, D and her brother, ‘trying’. He found it hard to spend time with them. He sought escapism from his situation by entering into an affair. He found the stress of hiding the affair and the costs incurred difficult but enjoyed the affair. 4.57 To conciliate with D’s mother when this affair was discovered he bought the family house in Merton but entered into financial difficulty as a result (repeating the response when he had bought a house to appease his second wife). 4.58 D’s father said that from May 2017, he experienced a ‘breakdown’ as a result of the stresses over the affair, the marriage, finances, and difficulties for D at school and the parental view that she should change school. These stresses led to the two suicide attempts in the Summer of 2017. 4.59 On the day of the assault, while being psychiatrically assessed in custody, D’s father reported that he had been experiencing low mood, poor concentration, poor sleep and low appetite over nine months. He had not had any psychosis or hallucinations. He reported that he had been thinking about killing both children and his wife to save them the shame of bankruptcy and loss of 13 the home. He was assessed as suffering from a depressive episode, but he did not meet the criteria for assessment for a sectioning under the Mental Health Act. 4.60 D’s father told the police that he had been planning to kill D for several weeks and had been ready to do so several times in the preceding week. He realised on the fatal day that this was his last opportunity, as she was due to return to boarding school. 4.61 D’s father told the police that he had been going bankrupt, had no control over anything and had been finding it impossible to live. He felt trapped. He felt he had neglected his children. He had been unable to discuss any of this with D’s mother, with the mental health services, or with his GP. 4.62 Evidence from the investigation showed that D’s father had sufficient funds to settle all his current debts but that there was a substantial future payment required to redeem the mortgage for his former wife’s home. 4.63 Internet use on D’s father’s computer and phone in the last month showed searches about child killing, child killers in jail, suicide, and children’s homes. 4.64 In subsequent police and psychiatric interviews, before trial, D’s father denied sexually abusing D. He feared bankruptcy. He also maintained that he had had voices telling him what to do and that D must die. He told no-one about these voices. The psychiatric view of these later statements and thoughts by D’s father about his reasons for killing D and the voices is that they are less reliable than the contemporaneous accounts given on the day of D’s death. 5. The Parents’ Views 5.1 D’s parents were informed of this Review and its purpose and were invited to take part by meeting with the Independent Reviewer or by making a submission in writing. D’s father declined the invitation. 5.2 D’s mother met the Independent Reviewer, with a supporter and an interpreter. The interpreter had worked with D’s mother during the murder investigation and trial and so was familiar with the case. D’s mother had great confidence in the interpreter. It was clear that D’s mother had a limited understanding of English and appeared to understand more that she was able to say. It was important to use the interpreter for her to be able to fully understand and fully express her views and questions. 5.3 D’s mother gave new information which had not been known to the agencies at the time. Namely that, in early 2017 D’s father moved out of the family home and went to live in a flat in another borough. At the start of the school summer holidays D’s mother took both children on holiday to Thailand. When they returned, D’s father moved back into the family home but the parents lived separately within the house. He stayed in his own room, working most of the time. There were continued arguments between them. There was no physical violence and D’s mother did not fear him. D’s mother said that she and the children did not go to France and she does not know if D’s father did. 14 5.4 D’s father’s worries about money D’s mother thought that the family had enough money but there were problems as D’s father previous wife, who still had an interest in the family business, successfully sued him as he had used money from the business to purchase the new house. The court ordered that he should pay his former wife a large sum of money, which he did not have. 5.5 Support from local services D’s father controlled which professional services D’s mother had access to. In her view, he would often ‘put her down’ to those services. Regarding his mental health treatment in hospital and the community, he would tell her that it was not her business. She did not know he had undertaken private counselling – she only learned about this later. (This would appear to have been in the period when he was not living in the house). 5.6 GP Service Early in 2017 D’s mother had been very stressed about the relationship breakdown. She did not feel that the GP Service helped her with the breakdown in the parental relationship. She would have liked counselling in her own right but was not referred. Although relationship counselling was recommended D’s parents did not take this up. (D’s mother did not know about an agency called Relate). D’s father acted as the interpreter and spoke positively about how things were. 5.7 Change of school for D Originally D’s parents had planned that D’s older brother would go to boarding school as the two children ‘fought too much’. However, it became necessary for D to change school. She was not doing well at her school and they did not think that it suited her needs. D’s brother did not want to go to boarding school. It was agreed that D would go instead, and she was happy to go. D’s parents chose the boarding school together. D did better at the boarding school. At first, she was very happy but after a while she was sad because she missed home. There was an (alleged) incident of D being racially bullied and her father intervened but was asked by the school not to speak direct to the child involved. D and her mother kept in touch by phone and text. D could have come home for more weekends but did not do so on the first two weekends as her father was unwell. D’s mother was pleased with the brother’s school and with D’s boarding school. 5.8 The awareness of their father’s mental ill health D’s mother was sure that D did not know about her father’s mental ill-health or suicide attempts. After the first attempt D was told that he was in hospital, but not why. They kept from her the second admission as she was at boarding school. D’s brother was aware of the second attempt. 5.9 Mental Health Services D’s mother did not really know what had happened to D’s father. She was told about the first suicide attempt. She did not feel that she was given much assistance by the mental health staff. She was not offered an interpreter. He was discharged home. She did not feel that she was given advice and feels, in retrospect, that she should have been given more information and that he should not have been let out of hospital. When she asked him about his treatment he said it was ‘none of her business’. She was not included when mental health staff visited D’s father at home. She understood that she was not involved in his after care as they lived separate lives in the house. Regarding the second suicide attempt, D’s mother reported him missing when they had not seen him for the day in September. She did not think that he was a risk to the children. 15 5.10 Children’s Services D’s mother said that she was not involved with Children’s Social Care (CSC). She did not know that they had been wanting to contact her and that D’s father had not given them her number. D’s father feared that CSC was going to take the children away. D’s mother could not see why that would be so as she thought that her care of the children was good and that, even if there was worry about D’s father, there was no reason to take the children from her. She did not think that the social worker involved her enough. There was no interpreter to assist communication. She thinks that when the social worker spoke to the children the social worker should have then met with her, as the mother, to tell her what the children had said. 5.11 What help would have supported D’s mother when D’s father was unwell? D’s mother thought that the workers (from all services) should have spoken directly with her. She said that she should have been given advice about D’s father’s mental health and told what was happening with him. There should have been interpreters to help her. After the children were interviewed, she should have been told directly what the children had said and, as their mother, she should have been involved more fully. She did not know what help to ask for or why some agencies were involved. 5.12 Police D’s mother said that the police were very helpful and kind. Since D’s death there has been a very good relationship with the Family Liaison Officer; and the Police have used an interpreter. 6. The Practitioners’ Views 6.1 Practitioners with direct contact with D or members of her family and the direct line-managers of those practitioners took part in a confidential focus group with the Lead Reviewer and the Designated Nurse. The purpose of the event was to give practitioners the opportunity to share their perspectives on what had happened and the work done to assess D’s father and to support him and the children and D’s mother from an agency and multi-disciplinary point of view. The group was also invited to comment on the emerging lessons suggested by the Review Panel which had been drawn from the analysis of the agency reports. Twenty practitioners attended; some were representing their whole service as not all staff who had been directly involved could attend. 6.2 The practitioners’ insights are valuable in helping to gain a picture of how D’s father, the family and the professional systems were working at the time. However, caution is required when considering the practitioners’ views since D’s death had had an impact on them and they had re-evaluated their views of the family in the light of the tragedy and of the newer information that had become available after the event but which some of them had not known at the time. Some of those present were seeing a fuller picture for the first time in this meeting. 6.3 The MSCP would like to thank the practitioners for their openness and honesty in sharing their thoughts about what happened, about the decisions they made and about the work done. They had clearly been affected by the tragedy and saw the importance of seeking to learn from it. Their feedback was grouped and summarised into themes and possible lessons. 6.4 The event preceded D’s mother’s meeting with the Lead Reviewer, thus the different information which she gave (see section 5) was not known at the time of the practitioners’ focus meeting. 16 Could the assault on D have been predicted? 6.5 For several of the practitioners and managers a key question was: could D’s father’s behaviour and the assault on D have been predicted and prevented? Such a question is not a primary reason for this Review which is seeking to learn about wider systems dynamics and patterns in agency and multi-agency working. Risk and parenting assessments were done with regard to D’s father’s mental state. Even in the light of information that has come to light subsequently there was nothing that would have shown that he was a potential risk to D, or to anyone else. An important lesson from the clinicians is that when an individual does not have a significant mental health problem, risk is likely to be assessed as low. It is not possible to know if a sane and intelligent person has a criminal intent if it is not shared in conversation or through behaviour. 6.6 It was still the view of those who saw D’s father that there was nothing in his behaviour, at the time, which showed him to be a risk. He gave the impression of being caring of D and her brother, although at times frustrated with their perceived behaviour. He expressed his anxiety about them being taken away. Until his two attempts at suicide in the summer of 2017 there were no concerns about him or his role as a parent by any agency. Practitioners’ Views on Mental Health Assessments and Parenting Assessments 6.7 The practitioners noted that at the time the priority was the possibility of D’s father being a risk to himself. He was assessed not to have a diagnosable mental illness and in the clinical observations and conversations with him there was nothing in what he said or how he behaved to suggest that he may be a risk to anyone else. 6.8 Mental health practitioners noted that adult-focussed mental health workers need to think about how to talk with patients who are parents with regard to the possible impact of their illness on children and to include the second parent in assessments, if one is available. 6.9 At the time of the assessments, in the late summer of 2017, The Joint Mental Health Protocol applied only to adult mental health workers and children’s social care staff. It has been re-issued since and now includes all services4. A lesson from this case for the practitioners was that there should have been more joint-working and even joint-visiting. The two services seemed to work in silos. The case did not show evidence of a Think Family5 approach being in place in day to day practice at the time. Psychiatric assessments must use Think Family principles to reinforce good joint working and appropriate referrals to social care colleagues. The Mental Health Trust has questioned, given the low priority of this case, whether the practitioners’ suggestion about joint working or visiting would have been proportionate. 4 Multi agency Protocol to meet the needs of children and unborn children whose Parents or Carers have Mental Health Problems, Merton Safeguarding Children Board and Merton safeguarding Adults Board, February 2018 https://www2.merton.gov.uk/joint_protocol_for_safeguarding_children_and_families_with_mh_needs-_dec_2014.pdf 5 Social Care Institute for Excellence: Think child, think parent, think family: May 2012 https://www.scie.org.uk/publications/ataglance/ataglance09.asp 17 6.10 Similarly, there was recognition among the practitioners that there had not been use of wider systems thinking in looking at the needs of this family. For mental health practitioners the focus was on D’s father. A view was shared that this may still be so in some cases. 6.11 It was also questioned by practitioners whether there is professional cultural resistance to joint visits and that this should be explored further. If this is so it would be a systems issue. The Mental Health Trust has subsequently queried whether this is also a practical matter. 6.12 CSC thought that after the second suicide attempt the mental health services should have made a further referral to children’s social care, to ensure that they were aware. It has been noted that the Mental Health Trust was aware, at the time, that the Hospital and the Police had informed CSC about the incident and so it is reasonable that the Trust would not also do this. 6.13 A question was posed, in retrospect, about how assessors consider the risk of a possible filicide when a parent is being assessed for suicidal ideation and behaviour? Practitioners noted that the significance of the children to D’s father was not known. They wondered, in retrospect, what they meant to him. (The Lead Reviewer’s comment here is that D’s father may not have been able to say what the children meant to him or his answers may have been unreliable. What was known at the time, and has been confirmed by D’s mother, is that he was frustrated by the children fighting but he was also very worried that the children were going to be taken away. The post-incident forensic assessment confirms that this was his view also.) 6.14 The family as a system and the context of the family’s culture Practitioners accepted that there was too much focus on D’s father and that not enough attention was given to the importance of D’s mother by services. D’s father was able to prevent services accessing D’s mother and this was accepted too readily. Some practitioners asked if this may have been a response to perceptions of the family status in terms of wealth and culture. Are practitioners less likely to question and challenge a family such as D’s? There was recognition, again in retrospect, in the practitioners’ group that D’s mother had been disempowered and that interpreting services should have been arranged for her. 6.15 Practitioners’ Views on professional curiosity, control/manipulation and possible disguised compliance – the need for triangulation in assessments In seeing a much fuller picture, after the event, practitioners recognised the need to consider that information should be questioned rather than taken at face value. Information from D’s father that he was using and being helped by the services of a voluntary agency was not checked out. It is important to keep an open mind about patient statements about intentions and to seek corroborating information, if necessary. A challenge for practitioners is how do you hold in mind that a patient / service user may be exercising control over information or using disguised compliance. A busy work environment may hinder professional curiosity. 6.16 A question arose about evidence of the use of professional curiosity, about what the significance was for D’s father in seeking assistance from different services – a private therapist, and independent counselling services. What was his reason for wanting group therapy rather than individual therapy – did he feel isolated? These questions were perhaps not considered at the time as the case was seen as low risk and low priority. Practitioners’ Views on Proportionality and Thresholds for Intervention 18 6.17 The case did not meet the thresholds for child in need. (This raises the question of how it was ‘stepped-down’ to the schools and to primary health care and other services, if they were unaware of what the issues were or that CSC was closing the case. It also raises a question about how the overall impact on the children and D’s mother of D’s father’s mental health was assessed – not just the risk. 6.18 D’s brother’s school were unaware of the issues at home – they had learned that there had been a ‘traumatic incident’ at home in September but when they later sought to ask D’s father about it he had composed himself and presented as a man in control and getting help. This led the school to be reassured that there was no risk to D’s brother, especially as CSC had closed the case. 6.19 There are challenges in ensuring a dynamic engagement between the MH Home Treatment Team and the Primary Care Team. Copying correspondence to the GP is probably not sufficient as a means of joint working. 6.20 Be clear about risks to others when someone harms himself – or impact on others. Practitioners’ Views on Information Sharing, confidentiality and consent 6.21 Mental health practitioners noted the need to develop skills to have authoritative conversations with patients who are parents about consent to share information with other services in a way to support and inform child in need assessments. 6.22 Information sharing needs to improve as key services, including schools, were not advised of what had happened – especially in relation to the second suicide attempt. 6.23 When information is requested from a service (e.g. by the CSC for an assessment) it is important that the service knows why the information is being requested so that they can respond proportionally and in line with the need for information in a way which meets the Data Protection Act. 6.24 Is there a challenge in mental health services sharing information with CSC? That was how CSC experienced it. 6.25 How explicit should consent be when children are involved? 6.26 Information sharing across the wider system has been better since the Multi-Agency Safeguarding Hub came into place. Practitioners’ Views on recording of rationale for decision-making by mental health practitioners 6.27 Mental health services and practitioners need to consider how they document the reasons behind the decisions that are made. 19 Practitioners’ Views on Other issues 6.28 The importance of accuracy in referrals with regard to the family address. The mistake in the address in this case caused delays for CSC. 6.29 How can schools get a fuller picture of families to support children, without compromising the admissions procedure or intruding into family privacy? 6.30 The good work by the CSC social worker in seeking to engage directly with the children and to help their father to think about the impact of his ill-health on them. 6.31 The GP Practice was unaware of D’s father’s background in terms of culture and previous marriages. 6.32 Is enough known about how to access interpreter services in primary care? 6.33 Agencies were unaware that there was a period in the late Spring of 2017 when D’s father was not living in the family home. 6.34 There was not enough systems thinking about the family and what was happening at the time? Was there a cultural issue of ‘Well to do people do not harm their children?’ There was a lack of consideration for D’s mother. 7. Analysis and Lessons The Panel members, in analysing information from the Agency Reviews and other source material, together with D’s mother’s comments and those by Practitioners, concluded that there are six priority areas of lessons. 7.1 Mental Health Risk Assessments 7.1.1 The Mental Health Trust’s internal and independent Sudden Untoward Incident (SUI) Review and this Review have concluded that the mental health assessments undertaken in the Summer of 2017 with regard to D’s father’s two suicide attempts and subsequent mental health met the local and national guidelines. 7.1.2 An important lesson from the clinicians was that, when an individual does not have a significant mental health problem, has no history of violence, and does not express anything which would raise concerns, risk is likely to be assessed as low. It is not possible to know if a sane and intelligent person has a criminal intent if it is not shared in conversation or through behaviour. There was no suggestion or evidence at the time that her father intended to harm D or any other family member. It was not predictable and there was no evidence of mental illness. 7.1.3 D’s father was plausible and there was no reason to doubt his statements, given the openness with which he seemed to share what he was thinking and what had led to the suicide attempts. 20 7.1.4 In retrospect, an issue arises about how in repeat incidents, such as the two suicide attempts within a few weeks, consideration is given to the possible building up of risk. Coupled with this is the issue, of when children are seen as a ‘protective factor’, how do practitioners consider whether if the risk of self-harm becomes greater that there may then be an increasing risk to the children? Overview research into filicide and mental health, 20136 gives some pointers to possible links but there must be caution using them as clear predictors in current assessments (as they are by their nature retrospective studies when more information has come to light through investigation). The 2013 overview suggests that mental illness, per se, is not a major feature of filicide. However, it is suggested that parents who have severe mental health problems require careful monitoring. D’s father did not have severe mental ill-health. The research literature review by McManus, Almond, Rhodes and Brian, 20157 suggests possible links between filicide and stress, such as financial stress, breakdown in relationships, and deaths in parallel with or as a result of sexual assaults. Parental mental health is a known risk factor in intra-familial deaths. However, no one of these singly or in combination can be seen as a clear predictive indicator. The literature review notes that ‘acting strangely’ in the days immediately prior to the incident may be an important factor. There are also links between suicidal thinking and filicide which may be significant. Other factors which may be significant are abusive and unstable parenting, including the breakdown of the parental relationship. However, there needs to be caution in using this information since the number of such deaths is small, and the variables and child characteristics are multiple. 7.1.5 A question for local services is how are these risks thought about in mental health assessments of parents indicating self-harm, suicide or violence? In this case D’s father had made two recent attempts to kill himself and shared with professionals that he was under stress – relationship breakdown, severe financial failure / bankruptcy (in his view), and that D was a partial cause for that (school fees). He feared that the children would be taken into care. It is easier to see possible links after the tragic event but how can we raise awareness of such possibilities for current assessments in mainstream practice rather than just forensic practice? D’s father did not seem to be a violent man and did not appear to have the other more worrying factors associated with abuse and harm. A key question for assessments: Is the partner or child in any way a focus or possible cause of the stress which may be leading to self-harm or suicidal behaviour and, if so, if there is not improvement will that lead to risk? If so, what protective factors should be put in place? There should be scepticism about children or dependents being seen as protective factors in preventing self-harm. 7.2 Multi-Agency Assessments 7.2.1 At the time of these assessments in 2017, the Merton Safeguarding Children Board Joint Protocol for Safeguarding Children and Families with Mental Health and /or Drug and 6 Filicide: mental Illness in Those Who Kill Their Children: Flynn, Shaw and Abel; April 2013, PLOS One ,Volume 8, Issue 4 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0058981 7 The Co-occurrence of Risk Factors for Intra-Familial Child Homicides and Suspicious Child Deaths in England and Wales; McManus, Almond, Rhodes and Brian; 2015, University of Central Lancashire, in Journal of Investigating Child Death, Volume 1, Issue 1, 2015 http://clok.uclan.ac.uk/11679/1/11679%20Journal%20of%20Investigating%20Child%20deaths%20V1%20Issue1.pdf 21 Alcohol Needs was in place. This was first published in 2007, reviewed in 2010, and again in 2013. This was, at that time, a bilateral protocol for Adult Mental Health Services and Children’s Services. Subsequently it has been extended to include other Partner Agencies8. The purpose of the protocol was to encourage greater understanding and co-working between adult mental health services and children’s services of the needs of children, not just of possible risk but also of more general welfare. 7.2.2 The review of this case suggests that although there was information exchange between the two services (i.e. adult mental health and children’s social care) their work was more in parallel rather than being joint. There were no joint-agency visits and complementary work. It is not clear if this was a cultural issue or a workload issue. It is possible that the children were seen to be cared for sufficiently because the mental health risk was assessed as low and there was not an ongoing need for community mental health services. The Mental Health Trust has said that they do not think it is a wider cultural issue but that it may be a workload issue or a priority or proportional issue. Practitioners stated that they thought it may be a more systemic cultural issue. In this case we found no evidence that joint-work was considered. A question for the MSCP and the Safeguarding Adults Board and the relevant agencies will be if this is common. 7.2.3 It is of note that the two services had different accounts of what information had been gathered from D’s father in the assessments, for example about whether there were children from a previous marriage, or not. If he was truthful in the forensic interviews after D’s death the answer is that D and her brother were his only children. The two Health Trusts believed that he had said that he had children from a previous relationship – but this was not shared with CSC to explore further. 7.2.4 Joint-visits and use of an interpreter many have prevented some of these confusions and the Trust staff may have been able to help D’s father and mother understand that the role of CSC is not just to take children away if they had presented a more unified and supportive front. 7.2.5 The Panel has formed a view that insufficient account was taken of D’s mother’s needs and her understanding of D’s father’s mental state, or what to look for in any changes in his health or behaviour after the withdrawal of services. 7.2.6 There seems to have been an acceptance that they were ‘a couple’ again with no in depth exploration of how they had come back together, given what had happened, and that this was what D’s mother wanted, nor how, or if, she had come to terms with her husband’s infidelity. It is not clear that her views on his proposed sale of the house where she and the children lived was explored. There should have been more professional curiosity about the reunification, about D’s mother’s willingness to ‘look after’ D’s father, and about the impact on the children of the separation and reunification as well as the impact of the father’s illness. 7.2.7 The assessment social worker made good attempts to work with D’s father and with both children on the need to help the children understand what was happening with him. D’s 8 Joint Services Protocol to meet the needs of children and unborn children whose Parents or Carers have Mental Health Problems; Merton Safeguarding Children Board (now Partnership) & Merton Safeguarding Adults Board, December 2018 https://www.mertonscp.org.uk/wp-content/uploads/2019/02/Merton-Multi-agency-Mental-Health-Protocol-Final-December-2018.pdf 22 brother, in particular, was aware of the impact of the affair on his mother and the parental relationship (including, it has been found, that D’s father sought to encourage D’s mother to go to live permanently in her country of origin with the children, which D’s brother did not want). D’s brother had become involved in the parental dispute about his father’s affair and he was also involved directly in the worry about D’s father being missing and the second suicide attempt. It was recognised that D’s brother would have been impacted by this but, as there were no apparent safeguarding concerns, it was not possible to do more than to negotiate with D’s parents to help them understand the possible impact on the children of what had been happening. The social worker prepared material to help D but was reliant on D’s father in using it with her. There was no evidence to suggest that he did do so. However, in a child and family assessment where it likely, or it is decided that the threshold for social work allocation as a child in need is not met, there is no opportunity for a social worker to seek to make a deeper relationship with children over time and to help them share their wishes and feelings and, in a case like this, perhaps their worries. This is a systems issue. 7.2.8 It is to be noted that for several months D’s mother was the children’s principal carer but on returning to the household D’s father had re-assumed control in relationships with the welfare agencies; even though they were effectively no longer living as a couple – but this was not ascertained at the time. D’s mother’s account is that, although practitioners spoke to her, she did not feel consulted, informed, advised or involved by either mental health services or children’s services. At times, discussion with her was through D’s father because of her limited ability in English; more will be said about this below. 7.3 Thresholds and ‘Step-up’ and ‘Step-down ‘ 7.3.1 The children’s schools were consulted and asked for information to assist the child and family assessment. Both schools have reported that they were not informed of the reasons why CSC was undertaking an assessment, even though they asked. The outcome of the assessment was that schools could keep a watchful eye but they did not know what they were watching for. 7.3.2 The Panel’s view is that, while it was correct that the threshold for child in need was not met, the children remained vulnerable and should have been considered for ‘step-down’ more formally under Merton’s Child and Young Person Wellbeing Model9. This would have helped the schools to be aware of the issues that the two children were facing and to offer emotional support and understanding, and to keep a watchful eye. It raises a question for the MSCP and its Partner agencies, especially schools (including independent schools and non-Merton schools), about the interface between child in need and early help. It seems the referral pathway up the threshold hierarchy is clearer than the process by which families can be offered help when they are assessed not to meet the child protection or child in need thresholds. The MSCP may wish to audit this area of ‘step-down’ to see if this is a one-off issue or more systemic. 7.3.3 If more work had been done directly with D’s mother about this, she may have understood the need for the children to have help. She could have been advised and asked to give consent 9 Merton Child and Young Person Well Being Model, (2013) updated 2017 https://www.merton.gov.uk/social-care/children-young-people-and-families/safeguarding-children/merton-child-and-young-person-wellbeing-model-2013 23 in her own right for the schools to know more if she had understanding of how what was happening at home may be impacting on the children. At the time, the predominant dynamic was D’s father’s fear that the children would be taken into care. It is not clear that D’s mother understood what her status as a parent was and what actions she could take in her own right. 7.3.4 A parallel ‘step-down’ lesson is possibly the transfer of D’s father’s support from the mental health services to primary care. There was a good handover of D’s father’s care, in that the psychiatrist spoke with the GP surgery and followed this up in writing with a recommendation that medication should be prescribed fortnightly, given the two recent overdose attempts. However, there was no active monitoring or review. There was also an erroneous belief by professionals (from D’s father himself) that he was in receipt of other community-based counselling services, which was not the case. This raises a question about what active review processes may be put in place by primary care when a patient has recently made one or more suicide (or serious self-harm) attempts. A family approach and support for D’s mother was not part of this, yet it was known, earlier in the year, that she was acutely distressed by the discovery of her husband’s longstanding affair. She does not appear to have been offered support nor was there consideration of how she was being helped to manage the aftermath of his two suicide attempts and the apparent re-unification of the relationship, which also impacted on the children. 7.4 The Use of Interpreters and cultural sensitivity in assessments where English is not the first language 7.4.1 A key dynamic in the response to D’s mother was her limited ability in English. It is not clear what active thought was given to her need for an interpreter. D’s father often spoke of her poor English and he acted as her spokesperson, yet it is not clear that he was a Thai speaker. Several practitioners spoke to her on the phone or face to face in his presence. It is not clear that she was ever offered an interview, advice or support in her own right, or asked if she would like or was even encouraged to have an interpreter. Her comments about this are noted above in section 5. After D’s death the police were clear that she needed the support of an interpreter and the Independent Reviewer who met with her for this Review is also clear that her use of English was not good enough for her to understand the processes, to be able to express her wishes, and to receive information about services. As is common, she showed some limited ability to understand simple English spoken to her but she was not able to ask questions, or express her own thoughts or views in English without the interpreter. 7.4.2 It was not only a language ability issue but a cultural matter for her to understand how systems worked and what her rights as a woman and mother were. She was not clear what was happening, and the services relied on D’s father to explain and mitigate it for her. For example, she would have liked relationship counselling, as suggested by the GP, but did not know how to arrange this and was dependent on her husband who did not follow this up. She did not understand why CSC was involved as, in her view, she was a good mother and this was not questioned. She was signposted by mental health services to the local Carers Association, but there appears to have been no assessment that she understood what this was or how to access it. 24 7.4.3 A related issue may have been her cultural beliefs about the status of women in personal relationships, and as a Thai person dealing with professionals or those in authority. These were not explored with her. 7.4.4 Panel members have noted the systems issues in arranging interpreters, the financial costs, and that there is not a clear commissioning arrangement for activity. This may be leading to reluctance by workers to consider using interpreters or telephone-interpreting services when a service user has limited English. Absence of an interpreter will not permit the depth of interviews needed, including emotional and possible domestic abuse issues for complex mental health or child and family assessments. 7.5 Considering and Assessing Coercive Control and Disguised Compliance 7.5.1 Practitioners doubted D’s father when he said that he did not have D’s mother’s phone number. This was a possible sign that he was being controlling. When she was asked questions, he appears to have answered for her or suggested how she should answer. He was able to be the filter by which D’s mother was asked for information or to give her view or was given information. D’s mother was financially dependent on him and relied on him to help her navigate her way through services. He did not follow up the relationship counselling. Coercive control is a known dynamic in abusive relationships. Disguised Compliance? 7.5.2 Hindsight has shown that D’s father told different practitioners different things and some of the things he told practitioners were not true. It is not clear how much this was deliberate deceit and whether some may have been a genuine misunderstanding on his part. The information given about older children from a previous marriage suggests deceit. An example of possible misunderstanding is that the services of the private therapist were being delivered in the same premises as the local charity services. With regard to his claim about group psychotherapy, he did meet several times with the therapist but was not in fact approved for treatment in the group. Over optimism? 7.5.3 It was suggested during the Review that there was over optimism. A question arises as to what leads agencies or practitioners and their supervisors to be over optimistic and what might have counteracted this. Mental health professionals believed that D’s father was accessing counselling resources as part of the treatment plan. The social worker believed that the children were probably impacted by their father’s suicide attempts, particularly D’s brother. The social worker prepared materials to help him support the children emotionally. 7.5.4 Practitioners have to assess what they are told with an open mind and consider whether it is true or not. D’s father was known to have been deceitful to his wife, which was an indicator that some degree of scepticism and checking may be required in assessing what he said. Yet in many ways he seemed to be truthful, open and remorseful about what had happened. Indeed, there was a degree of congruence in what he said, and his statements seemed to be borne out from other information and not denied by D’s mother. 25 7.5.5 This is a challenging area for practitioners as it is hard to recognise and then challenge at the time. As the case was not in the child protection arena and was low priority there were not grounds to triangulate all the information with other agencies to check if D’s father was actually attending therapy, etc. There is not more that could have been done at the time except to accept at face value what he said. Hindsight suggests, however, that he was manipulative. A reminder from this case is the need for practitioners and their clinical supervisors to keep an open mind and to exercise respectful scepticism about some of the behaviours and information from service users where they may be anxious about the possible outcomes of intervention by welfare and protection services. 7.6 Information Sharing 7.6.1 Linked to the point on disguised compliance and deceit above (7.5.2 & 7.5.4) is the issue of Information Sharing in assessments and ongoing work. A clearer picture may have emerged about discrepancies if there had been more comprehensive information sharing – including through joint work, or a Team Around the Family Approach. However, this was unlikely to change the final decision about whether D and her brother were children in need. Even if it had been known that D’s father was not accessing counselling or even if the schools had had a more comprehensive account of what the children had been through this would not have increased the threshold or predicted the final outcome. 7.6.2 The case does, however, raise systems issues of how practitioners and agencies share information to enable assessments. CSC practitioners believed that mental health practitioners were reluctant to share information. Mental health practitioners had taken a psycho-social history, but this was not shared with CSC, which remained unaware of some of the stated background issues. The schools were asked for information but not, in their view, given information in return about why it was needed. 7.6.3 Clearly consent and proportionality are an issue here. The Panel understand that D’s mother and father did give permission for information to be shared, but they were initially reluctant for this to be shared with schools, only agreeing to this later. 7.6.4 The schools reminded this Review that their duty in considering requests to share information with partner agencies involves a duty to assess whether the information that they share is proportionate and consistent with the need for such information. They cannot assess that duty if they are not told why the information is needed. 7.6.5 This is and was a known systems issue at the time of this case. Nationally, there was increased agency anxiety about information sharing and interventions by the Information Commissioner on breaches leading to a tightening of information sharing arrangements. The European General Data Protection Regulation arrangements were being introduced raising awareness about privacy and systems. 7.6.6 No single agency had an overview about what was happening for D and her brother. 7.6.7 In July 2018 the Department for Education recognised some of these dilemmas for practitioners in sharing information and updated both the Information Sharing section in 26 Working Together to Safeguard Children10 and the separate revised Information Sharing Guidance11. 7.6.8 Page 17 of Working Together, paragraphs 23 and 24 are clear that good information sharing is not just a safeguarding matter: 23. Effective sharing of information between practitioners and local organisations and agencies is essential for early identification of need, assessment and service provision to keep children safe. Serious case reviews have highlighted that missed opportunities to record, understand the significance of and share information in a timely manner can have severe consequences for the safety and welfare of children. 24. Practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children, whether this is when problems are first emerging, or where a child is already known to local authority children’s social care (e.g. they are being supported as a child in need or have a child protection plan). Practitioners should be alert to sharing important information about any adults with whom that child has contact, which may impact the child’s safety or welfare. 7.6.9 Consent, proportionality and security remain key issues and require skills in authoritative work with service users to help them see the need for information sharing for children’s welfare. (See: The seven golden rules of information sharing – quoted in the Appendix to this review.) In this case, the social worker was later able to help the parents see the importance of sharing information for the children’s welfare. However, the case would have benefitted from better information sharing between agencies. The practitioners’ views have suggested that there is a lack of confidence in this area, more generally. Other issues 7.7 Sexual Abuse 7.7.1 A question which has arisen from the hindsight of the post-mortem is: Was there any evidence that D was being sexually abused? If so, was there a missed opportunity to recognise this and protect her? 7.7.2 At the time of the assessments in 2017 there was no such suggestion and no evidence to suggest that D was being harmed sexually or in any other way. 10 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, HM Government, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf 11 Information sharing advice for practitioners providing safeguarding services to children, young people, parents and carers; HM Government, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721581/Information_sharing_advice_practitioners_safeguarding_services.pdf 27 7.7.3 The criminal investigation and enquiries for this Review, after D’s death, have established that there was no physical evidence of prior sexual abuse and that there was no evidence in D’s behaviour prior to her death that was suggestive of sexual abuse. 7.7.4 The Merton Safeguarding Children Partnership has recognised that the presence of semen in D’s vagina may be an indication of sexual abuse. Even though the forensic evidence was rigorously tested and there was detailed consideration by the Crown Prosecution Service it was not possible to establish how the semen came to be present. A wider learning point is that D’s experience serves as a reminder that sexual abuse is often hidden, and that children and young people do not always speak out about it at the time. National data show an under-reporting of sexual abuse12. There is a need, therefore, for systems and practitioners to hold in mind the possibility of sexual abuse and when it would be appropriate to raise with children the possibility that they may have been sexually harmed. What worked well? 7.8 The Review has noted the following areas of good practice: • There was good use by the assessing social worker of the Mental Health Adviser based in CSC. • There was good work by the assessing social worker to engage the children – in one visit - and to get the father to see the need to help the children understand what was happening, including the preparation of some materials to help them, particularly D. A challenge is what is possible in a short-term assessment to develop a trusting relationship with a child. • The local charity thoroughly assessed D’s father (on two occasions) and noted the inappropriateness of him joining group psychotherapy – following their own guidance and the then Joint Protocol for Mental Health. • Both schools were responsive to children’s general needs – but they were unaware of the marital, financial and mental health issues at home. 7.9 Additional Analysis 7.9.1 Given the information available at the time the decision that the case did not meet the criteria for child protection or child in need was correct. Systems issues 7.9.2 The Review has noted the following systems issues. 7.9.3 The family’s socio-economic status, different cultures and language may have been dynamics in affecting how they were approached and assessed. The financial issues which 12Improving understanding of the scale and nature of child sexual abuse; Measuring the scale and changing nature of child sexual abuse. Analysis of 2017/18 official and agency data; Sherrelle Parke and Kairika Karsn; Centre of expertise on child sexual abuse. July 2019 https://www.csacentre.org.uk/documents/scale-and-nature-update-2019/ 28 were stressors in the family are not familiar ones in social work assessments. There was a need to have a fuller understanding of the family cultures as a mixed culture family – D’s father was white-British and D’s mother was from SE Asia. This was not explored as fully as it might have been with regard to what it meant for daily life and relationships and significance. 7.9.4 The family’s use of private sector resources. The family used a number of private resources. Both children went to private school until D transferred to another school with boarding fees, outside Merton. D’s father used private counselling services; and sought access to, or was signposted to, charitable and voluntary services. This poses systems questions about information sharing and joint working for statutory agencies where there may not be clear expectations and protocols. Where such services are part of commissioned services through contracting this may be easier. This is an area that the MSCP and the Commissioners may wish to explore further how to ensure that such local services are aware of the local multi-agency child welfare systems. How are such services brought into the local safeguarding arrangements – protocols / guideline? Are there issues about how such services are commissioned, financially supported and quality assured, and what are their relationships to the expectations of the Safeguarding Adults Board and the MSCP? 8 Recommendations At the time of D’s murder there was no information available to suggest that D or her family were at risk. Her death could not have been predicted. Information from the criminal investigations after her death shows that D’s father had been considering her murder throughout October; he also spoke, after the event, of planning to kill his wife and son, and himself. The recommendations which follow have been developed from the lessons from this Review. This does not mean that the Panel saw any failings in the case which would have brought about a different outcome. It is unlikely that if D’s father had been asked more questions about his mental state and any possible risk that he would have answered truthfully. 8.1 The MSCP should seek assurance from the Mental Health Trust that in mental health assessments following attempted suicide, and particularly repeat attempted suicide, where the adult has responsibility for children or dependants, that risks to them and to partners or carers are fully considered, including the risk where the dependent may be seen as part of the patient’s perceived ‘problem’ or as a ‘protective element’. 8.2 The MSCP should review how the Multi-Agency Mental Health Protocol is working to ensure that information is being shared appropriately and that joint work is considered as much as possible, including with the non-statutory sector. It is recommended that an audit of recent cases is considered, including involvement of schools and the non-statutory sector. 8.3 The MSCP and SAB should update the Multi-Agency Protocol to ensure that it is compliant with the most recent national Information Sharing guidance (2018). 29 8.4 The MSCP should ask Children’s Social Care to review how cases which do not meet the criteria for child in need are formally considered for Early Help under the Merton Family Well-Being Model. It may be appropriate for this to be the subject of a future audit. 8.5 The MSCP should ask all Partners to confirm that the data from and efficacy of practice arrangements for interpreting is monitored by senior management. This should include protocols on the inadvisability and possible risk to vulnerable people when family members act as interpreters. In addition, agencies should be asked to confirm how practitioners are supported in understanding cultural dynamics in assessments and ongoing support to families. 8.6 The MSCP should ask Partner Agencies to confirm arrangements for regularly raising awareness with front line practitioners and their clinical supervisors / advisors and designated safeguarding leads of the dynamics of coercive control, disguised compliance, and possible over-optimism. The MSCP may wish to offer a seminar on this for cascading to Agencies, through its Training Programme. 8.7 The MSCP should seek assurance from all Agencies that as part of their Section 11 Children Act 2004 and Section 175 Education Act duties they have updated their local guidance on Information Sharing in line with the revised national guidance of July 2018; and that practitioners and clinical supervisors or managers are aware of this and supported in work in this area so that direct work with service users to seek consent is authoritative and not defensive. (See also recommendation 8.2) 8.8 The MSCP should review the multi-agency approaches to assessing for the possibility of sexual abuse of children, through its policies, training and practice and by examining its own data about incidence of sexual abuse. Such a review will enable the Partnership to decide if any actions should be taken in relation to the multi-agency detection of and response to sexual abuse locally. ____________________ August 2019 30 Appendices Review Panel Membership Chair: Asst Director of Children’s Social Care; From March 2019 replaced by Designated Nurse, CCG Independent Reviewer: Malcolm Ward Panel Representatives Merton CSC: Head of Service - Quality Assurance Unit (replaced by subsequent Head of Service from April 2019) & Interim Asst Director of Children’s Social Care (from April 2019) Clinical Commissioning Group: Designated Nurse (took over as Chair from March 2019) South West London & St George’s Mental Health Trust: Named Nurse Central London Community Health Services: Safeguarding Lead Metropolitan Police: Sergeant of the Child Abuse Investigation Team Merton Education Service: Education Inclusion Manager; and Head of Service, Early Years Local Charity: CEO and Senior Manager MSCB: MSCB/MSCP Policy and Development Manager MSCB/MSCP Administrator supported the Panel. The seven golden rules to sharing information 13 1. Remember that the General Data Protection Regulation (GDPR), Data Protection Act 2018 and human rights law are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately. 2. Be open and honest with the individual (and/or their family where appropriate) from the outset about why, what, how and with whom information will, or could be shared, and seek their agreement, unless it is unsafe or inappropriate to do so. 3. Seek advice from other practitioners, or your information governance lead, if you are in any doubt about sharing the information concerned, without disclosing the identity of the individual where possible. 4. Where possible, share information with consent, and where possible, respect the wishes of those who do not consent to having their information shared. Under the GDPR and Data Protection Act 2018 you may share information without consent if, in your judgement, there is a lawful basis to do so, such as where safety may be at risk. You will need to base your judgement on the facts of the case. When you are sharing or requesting personal information from someone, be clear of the basis upon which you are doing so. Where you do not have consent, be mindful that an individual might not expect information to be shared. 13 Information sharing Advice for practitioners providing safeguarding services to children, young people, parents and carers; HM Government, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721581/Information_sharing_advice_practitioners_safeguarding_services.pdf 31 5. Consider safety and well-being: base your information sharing decisions on considerations of the safety and well-being of the individual and others who may be affected by their actions. 6. Necessary, proportionate, relevant, adequate, accurate, timely, and secure: ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those individuals who need to have it, is accurate and up-to-date, is shared in a timely fashion, and is shared securely. 7. Keep a record of your decision and the reasons for it – whether it is to share information or not. If you decide to share, then record what you have shared, with whom and for what purpose. ______________ Malcolm Ward Independent Reviewer August 2019 |
NC046639 | Death of a baby girl as a result of a drowning accident in May 2014. Mother found Baby Penny under water in the bath after she left her unattended to answer the door. Mother had experienced significant mental health problems during a previous pregnancy, following which her children were subject to child protection plans until it was established that her ex-partner would take over sole responsibility for their care. During her pregnancy with Baby Penny, mother had regular contact with her GP, community psychiatric nurse, health visitor and midwife. A pre-birth core assessment concluded that Childrens Services should close the case as there were no child protection concerns. Professionals had limited information about the father as mother refused to disclose his identity until after the birth. Following Pennys death it was found he had a history of convictions for violent crime and had been involved in domestic abuse with his previous partner. Issues identified include delays in childrens services response to referrals from other agencies; lack of full consideration of the parents histories and the role of fathers; failure to escalate and challenge inaction by childrens services; and missed opportunities for early intervention. Uses a systems methodology to identify areas of significant practice and findings. Includes recommendations for the safeguarding children board, including: to ensure there is a clear contingency procedure and process in place for when it has been agreed that there should be follow up if and when additional information is identified in a case; to design and develop regular multi-agency workshops; and to review the effectiveness of early help services.
| Title: Serious case review: Baby Penny. LSCB: Sunderland Safeguarding Children Board Author: Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Baby Penny (The SSCB has used a pseudonym to protect the identity of the child and family) Publication date 26 November 2015 Conten 1. D 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 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SCB) Regulatio‘advise the Aect of a Child med and therersons have woesult of a dccidental dguarding Cht the circumSCR.1 The Iune 2014. being addrher SCRs bes of babies ue SSCB Chang and recention to g a ’systems of practitiof factors, s the methach that pror practice with the famre asked toons 2006 requuthority and is known or se is cause for corked togethedrowning aeath. hildren Boamstances sundependen The reasoressed by SSeing undertunder the air thereforecommendatthe findms methodoioners occumany of wod recommrovides a thoccurs, somily or wero join a Revuires SSCBs totheir Board psuspected: andconcern as toer to safeguar3 ccident in ard (SSCB) rrounding nt Chair of on for the SCB, but it taken was age of one e directed tion from ings and ology’, an ur through which are mended in heory and effective e working iew Team o undertake partners on d b) either – o the way in d the child.’ 4 2.4 Agencies represented on the Review Team were as follows: Amy Weir Lead Reviewer Jan Grey Chair of Serious Case Review Panel Lynne Thomas SSCB Business Manager Head of Safeguarding Sunderland CCG Lead Nurse Safeguarding STPCT NHS Foundation Trust Legal Representative Sunderland City Council Detective Inspector Northumbria Police Named Midwife for Safeguarding City Hospitals Sunderland Temporary Strategic Service Manager Sunderland People Directorate2 Lay Member SSCB 2.5 Each member of that team was asked to identify the frontline practitioners from their agency who were known to, or had worked with, the family of Baby Penny. These practitioners met to discuss their experience of the case. 2.6 The Practitioner’s Group was held February 2015. It was attended by a representative group of those who had been involved. 2.7 The Lead Reviewer was commissioned to carry out this review in October 2014. Within the first few months of the review, the SCR process, the role of the Lead Reviewer and Review Chair and the functions of the Review Team and Practitioner Group were shared and clarified. 2.8 The methodology adopted for the review and the opportunity to be an integral part of a multi‐agency review process was still new to some of the professionals involved. Whilst some reservations were apparent at the outset of the review, there was general enthusiasm about the opportunity it afforded for identifying and understanding factors that influenced the nature and quality of their work with this and other families. 2.9 In this review, there were no individual conversations with practitioners. However, two meetings were held jointly with the practitioners who had been involved. The notes from these conversations together with key documents were the key documents for consideration within the review. 2.10 Further information about the function of the SCR Review Team and the roles and responsibilities of key groups can be found in Appendix 1 and Appendix 2. Comments on the methodological limitations are attached in Appendix 3. 2.11 The formatting designed by a colleague, Linda Richardson, for previous SSCB SCRs has been customised to report this review. 2 Previously Children’s Services and remains the term used in this report. 2.12 3 3.1 3.2 3.3 4 4.1 4.2 4.3 There was being revieScope and Taking a sythan a pre‐which arisemanagers around: thcompletionhistory andThere haveThe Coroneaccidental. This reviewPenny’s Mothe bath. Child’s VoicPenny was another baAll the obsfully immureviewed. Mother prosome evidePenny’s MoReviewer wresponded services. Shfamily wereThe CPN wknown her There is a involved inshe was bohave a relasome delayewed in SunTerms of Rstems appr‐determinede to drive thor a reviewhe timelinesn, endorsemd the conside been otheer held an w looks at evother discovce and the a much waaby. Her Mervations bunised andPenny’s exovided. Altence that thother, AP hwas able toearlier. Shhe said she e also helpfwas mentiofor more thlimited am her care. Horn. She toationship any in progresderland. eference roach encoud set of quehe key issuew panel. Kess of respoment and sheration of /er parallel pinquest in vents that tvered she wFamily’s Peanted babyMother prepby professiod her Mothxperience whough, herhey argued aas been moo meet her he gave a ureceived aful. Penny woned as havhan eight yeount of infHer Motherld us when nyway; theyssing the reurages revieestions fromes to be expey lines ofonses to reharing of as/ role of fatprocesses uMarch 201took place bwas pregnaerspectivey and her Mpared well fonals of AP’her ensurewas likely tr Mother aand this maost distressand to discuseful accoll the suppowas well looving been ears. formation ar refused towe saw hey met a coview becauewers to bem terms of plored as opf inquiry foeferrals andsessments, hers. nder way d5 and her fbetween Jannt to the deMother (AP)for the bab’s care of Ped that heto have beand Father ay have hadsed by the dcuss the reount of howort she neeoked after aparticularlyabout CP, Po tell profeer about theuple of timuse of the lagin with anreference. pposed to thor this revied thresholdthe lack of uring the cfinding wasnuary 2013 eath of Pen) was very eby and imprPenny were er developmen positivedid not liv some impadeath of Baview in Octw she wasded from pnd she was ay supportiveenny’s Fathssionals whe review thames and thearge volumn open enquThis helps the preconceew quickly ds, the timf full considcourse of ths that the dand May 2nny from drexcited to ressed prof positive. Pment was e given theve togetheract on her. aby Penny. tober 2015s supportedprofessionaa very happye since Moher and hoho he was uat they did en she got 5 e of cases uiry rather the issues eptions of emerged eliness of eration of his review. death was 014, after owning in be having fessionals. Penny was regularly e care her r, there is The Lead . She had d by local ls and her y little girl. other had w he was until after not really pregnant; 4.4 4.5 5 T5.1 Backgro5.2 5.3 5.4 3Names atime of Bshe did nothe may havWe know tthat he wasPenny’s FatThe FamilyThe Family3Mother ‐ AFather ‐ CP Half‐siblingHalf‐sibling Baby Penny ound Inform Prior to 200pregnant wperiod of sadmitted toand he asschildren wchildren wMother’s caMother coCommunitydischarged GP. AP stocontent. Father, CPagency seahave a hist and some famBaby Penny’s dt tell him sve found ouhat he cares looking afther was invy as known t3 P g 1 g 2 y mation to 207, Penny’swith her secsignificant mo hospital aumed care were subjecere safe anare. ntinued to y Psychiatriby the meopped takin’s backgrourches weretory of conv mily details havdeath. he was preut earlier. ed for Pennyfter her. CP vited to meto Agencies 2007‐2012s Mother hacond child imental heaas an inpatieof their twct to Child nd they webe supportc Nurse (CPental healthng her medund and h carried ouvictions for ve been changegnant untily directly onwas writteneet with thes 36 year 51 yea16 year 7 years b. Auguad two childin 2007, shalth problement. She sepwo children. Protectionere flourishted by menPN), was prh service andication in 2istory onlyt as part ofviolent crimged to preserv two weeksn some occn to and ask Lead Reviers rs rs Lives Live ust 2013 d. dren with he became vms includinparated froChildren’s n Plans unthing and wntal health rescribed mnd she was 2012 and sy became kf the SCR scme and to hve anonymity.s before shasions becaked to contewer but hees with Birthes with BirthMay 2014 her then parvery anxioug disturbedm her partnServices wetil it was eould not bservices unedication. Dthen regulashe appeareknown afteoping procehave been i. The ages givhe had Pennause her Moribute to the did not resh‐Father h‐Father rtner. Wheus and exped thoughts.ner of fourtere involveestablished be returningntil 2012; sDuring 201arly reviewed to be ser Penny’s ess. He wasinvolved in ven are the ag6 ny though other said he review. spond. n she was erienced a . She was teen years d and the that the g to their she had a 2, AP was ed by her table and death as s found to domestic es at the 7 abuse with his ex‐partner. However, this was not identified until the end of that relationship. 5.5 It appears he became involved with AP at the end of 2012. He was registered at the same GP practice as AP though they saw different doctors there. He was known to mental health services and was prescribed anti‐depressants. AP did not tell him about the pregnancy for several months. After Penny was born, he was involved in Penny’s care, was seen by professionals and came to the house. Period under review: January 2013 to May 2014 5.6 On a visit to her GP in January 2013, AP was surprised to discover that she was pregnant. She stated that she had a partner but that they were not living together. The GP, aware of her history and that she was vulnerable, discussed with AP contacting a Psychiatrist to ensure she received the support she needed and she agreed to this. At the end of January, a CPN contacted the GP and it was agreed that, as Mother appeared to be stable and well, the Midwife should monitor her rather than mental health services becoming involved. 5.7 The Midwife saw AP in mid‐January. She completed an Antenatal Vulnerability Assessment Form and made a referral to the Vulnerable Adults’ Clinic for AP. The Midwife was concerned that AP was vulnerable given that she had previously suffered mental health problems when she was pregnant with her second child. She was also aware that AP’s Mother had died in violent circumstances when AP was only 11 years old. 5.8 At the beginning of April, AP was seen at the Vulnerable Adults’ Clinic and the Obstetrician in attendance wrote to mental health services asking for her to be seen. As a result, AP was assessed in early June by the mental health service; she was to receive CPN support and contact was made with the Health Visitor. 5.9 Although AP seemed to be doing well and to be stable, the Midwife decided to discuss with AP referring her and unborn Penny to Children’s Services. The Midwife, who had known AP from her last pregnancy, made this referral at the end of April. She suggested that an Initial Assessment was required given AP’s previous history of mental health problems. AP continued to decline to name the Father of the baby. This referral was not acknowledged and so she called Children’s Services on 20 May; she was told the case had not yet been allocated. A week later the Health Visitor also made a referral to Children’s Services saying she had a general concern given AP’s history. Having still heard nothing, the Midwife called Children’s Services again at the beginning of June when she was told that the case was still not allocated. 5.10 Finally on 13 June, the case was allocated and Mother was seen and an Initial Assessment completed on 18 June. A meeting was held the next day with the 8 professionals involved – it was described by the Social Worker as an Initial Planning Meeting; AP was present and she was said to be doing well. It was agreed that a Pre‐Birth Core Assessment should be completed. On 26 July, a Pre‐Birth Core Assessment Meeting was held. The assessment had been completed and the agreed outcome with the other professionals was that Children’s Services should close the case as there were no concerns. However, Children’s Services should be involved again, if and when, the baby’s Father’s details became known. This Core Assessment was not recorded on file at this time and so was not available to anyone looking at the case prior to Penny’s death. 5.11 AP was regularly seen by her GP, CPN, Health Visitor and Midwife. She remained calm and stable and was well prepared for the baby’s arrival. Baby Penny was born at the end of August 2013 and was well and healthy. AP was happy and cared well for the baby. The Midwifery visits and the Health Visitor’s primary visit went well and there were no concerns. AP named Penny’s Father to the Health Visitor at her first visit but following this disclosure, this information was not passed on. In October, when AP attended for her post‐natal check with her GP she said that CP was caring for the baby. The GP told AP that she would need to let Children’s Services know his name. The Social Worker rang the GP a few days later but they agreed there were no apparent concerns about CP and the case was not reopened. 5.12 During October and November, AP and the baby were regularly supported by the CPN, Health Visitor and GP. AP seemed well and she reported being well supported by her family and through daily contact with CP. In December she was a bit tearful and said she was having relationship problems with CP and feeling low as a result. It appears that CP was also experiencing depression and seeing his GP. 5.13 In mid‐January 2014, Mother spoke to the Health Visitor and said she was back in contact with Father. She also said that Penny had had three episodes of stopping breathing (apnoea), going blue and eyes rolling. AP was advised by the Health Visitor to take her to the GP that day. The Health Visitor does not appear to have followed this up directly but left it to Mother. It does not appear that Mother went to the GP till a few days later about her own backache. During this consultation she mentioned the apnoea stating that one of these episodes had occurred when the baby was being looked after by CP. The GP referred the apnoea to a Paediatrician. He informed Children’s Services about his knowledge of Father and that he knew CP was caring for the baby ‐ recalling that an alert had been set up for this in the practice. 5.14 An ECG was carried out on Penny at hospital in mid‐February. The Paediatrician could not identify any cause for the apnoea and decided to see her again in two months. AP and CP went to the hospital together and were advised to reduce the amount of milk they were feeding her as there were concerns that Penny’s recent weight gain had been excessive. 5.15 5.16 5.17 5.18 5.19 5.20 6 6.1 AP was regwell for thagreed all wGP had haFather somwere said nIn early Maarguments had been wexcessivelyof Penny stAt the end involved. MOn the Sunthat Pennythe out‐of‐under watewas switchThe ambulPolice weredelay in threported toThe cause result of negave a detawater whePenny at thfrom AP a wAreas of SigThis sectionPenny’s famquestions wwere in plaA key factoare still preselect and rgarded by te baby. In was going wad no respome weeks eanot to be avarch, AP ranwith Pennyweepy for y. AP also totill seemed tof April, theMother said nday 18 Mayy was unwe‐hours GP ter in the baed off five dance’s arrive not inforhe arrival o the Reviewof Baby Peear drowninailed accoun she wenthe time of tweek beforegnificant Prn looks backmily and exwere imporace at that tor of a systeesent and horeview a sphe Health VFebruary 2well. The CPonse from arlier; he wvailable. ng the Crisisy’s Father. Ta few weeold the CPN to be good.e CPN closeshe was feey, the day bll crying anto continueath. Penny days later. Aval was demed by theof the amw Team. nny’s deathng. There wunt of her a to answer the incidente the incideractice (ASPk at the actxplores whrtant as thetime to supems review ow these caecific case aVisitor and 2014, the CPN said thaChildren’s was told thas Team sayiThe GP preks. She said that her re. ed the case eling betterbefore Pennd with loose to observwas taken AP and CP welayed thoue Ambulanbulance wh is believewere no extactivities ththe door. It. When seent and he hP) ions and dehy these prey helped thport good pis also to coan be changand to use tCPN as conCPN spoke at she was iServices abat there wasng she wasescribed herd Father welationship wand mentar. ny fell in these stools; she her. The to hospitalwere at the gh it is noce Service as fully invd to have bternal injurat day. Shet is likely then by Polichad not seeecisions of pofessionalshe Review Tpractice or onsider wheged. The aimthis to provntinuing to to the Heantending tobout his res a new Soclow in moor anti‐deprewas unreliabwith CP wasl health sere bath, AP che was subsfollowing dl and put ohospital. t clear whyof this untvestigated been a hypoies or retinae said the bhat AP was e, CP statedn Penny forprofessionaacted as tTeam undemake poor ether any sym of using avide ‘a windbe stable aalth Visitor o close the eferral in recial Workerod becauseessants; sheble and wass turbulentrvices were called NHS 1sequently aday AP fouon life suppy this was toward inciand the reoxic brain ial haemorrbaby slippednot fully sud that he hr several daals working wthey did. Trstand whapractice mystem vulna systems mow on the s9 and caring and they case. The elation to r but they of having e said she s drinking . Her care no longer 111 saying advised by nd Penny ort which the case. dent. The esult was njury as a hages. AP d into the upervising ad parted ays. with Baby The ‘why’ at systems ore likely. erabilities model is to system’. 10 6.2 From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified five areas of significant practice. These are listed below and are explained in more detail in later sections. ASP 1: Children’s Services: Timeliness of response to referrals from other Agencies ASP 2: Managerial Oversight and Supervision, Timeliness of completion, endorsement and sharing of assessments ASP 3: Opportunities to support through early intervention or CAF missed ASP 4: Lack of full consideration of history and the consideration of / role of fathers ASP 5: Context in which professionals were working ‐ Failure to escalate and challenge effectively inaction by Children’s Services 6.3 ASP 1: Children’s Services: Lack of timely Response to Referrals According to agency records, two referrals were made to Children’s Services between April 2013 and May 2013, one from the Midwife, and one from the Health Visitor. The Midwife first referred on 30 April 2013 and she chased this referral on four occasions as she had had no response – 20 May, 28 May, 3 June and 13 June 2013. These referrals were as a result of knowing the history of the family and Mother’s vulnerability during the previous pregnancy. The GP also contacted Children’s Services in October 2013 and January 2014. 6.3.1 Mother’s GP contacted Children’s Services in October 2013 by telephone and also in January 2014 through a faxed letter with a follow up telephone call to chase a response on 25 February 2014. In October the Social Worker called the GP about a week later when it was agreed that action was not required as no concerns had been identified. In January / February 2014 he did not manage to speak to the Social Worker, being told that there was a new Social Worker who was not available to speak. These referrals related to the alert on the GP system to say that Children’s Services should be notified when the name of Penny’s Father was known. 6.3.2 There was no response to the 2013 referral for almost six weeks then an Initial Assessment was completed followed by an Interagency Initial Planning Meeting. This identified the need for a Core Assessment to be completed in compliance with the Unborn Baby Procedure; this was completed and a meeting held on 26 July 2013. However, the Core Assessment was not recorded on the system or shared with other agencies until after Penny had died. 11 6.3.3 There was considerable frustration from the health professionals about the long delay in response from Children’s Services. As Mother was pregnant and had not yet had the baby it seems that the allocation of the case was not prioritised. The lack of communication and response to the Midwife was a missed opportunity to share the history and any concerns at the earliest possible stage and to put in place an effective early response. 6.3.4 The referral from the Midwife was made following her completion of the Antenatal Vulnerability Assessment, which took into account past history and what was currently known about the family. The number of vulnerability indicators met led to the referrals to Children’s Services. 6.3.5. When eventually a Planning Meeting was held in mid‐June 2013, the health professionals attended and so did Mother. There are minutes of this meeting and these are on the case record. The GP was asked for information at very short notice but did respond. 6.3.6. Even at this early stage Mother was reticent about naming Penny’s Father. This pattern of her cooperating well and engaging with the professionals – apart from providing the name of Father – continued throughout. When she did disclose the Father’s name to the Health Visitor, this was not shared. 6.3.7. The GP contacted Children’s Services in October 2013 when he knew Father’s name. The Social Worker did call back but it was agreed there were no concerns and Children’s Services would not become involved. 6.3.8. The GP faxed a letter of referral in January 2014 when Mother indicated that Father was having sole care of the baby. The referral by the GP resulted in a telephone call more than a week later after the GP had chased it up. The GP was told that there was a new Social Worker who was unavailable. It was agreed with the Social Worker whom he spoke to that there were no specific concerns about Penny’s care. It does not appear that the risks Father may have posed, once his identity had been established, from his own history were identified or considered. 6.3.9. During the course of this review, the high level of demand on Children’s Services became very apparent. The high turnover of staff and particularly of managers was also a concern. Three weeks after she had made the referral, the Midwife was told when she called that the case had not been allocated and she was given the same response two weeks later. Finally in mid‐June a Social Worker was allocated who made contact with her and the other professionals involved. The GP received one call but when she made contact in January 2014, she did not get an appropriate response. 6.3.10 The timescales for the completion of responses to contacts and referrals are clearly set out in Working Together 2013. All contacts should be responded to within 24 hours but this did not occur in this case. 12 6.4 ASP 2. Managerial Oversight and Supervision, Timeliness of Completion, Endorsement and sharing of assessments Managers have a responsibility to support frontline staff as well as a duty to monitor the effectiveness of the agency and its systems and to check that safeguarding responses are appropriately discharged. There is evidence in this case review, as in previous reviews, nationally and locally, that management oversight and supervisory processes were not robust in Children’s Services and the practice of frontline workers was not fully or consistently supported or challenged. Management oversight of practice and systems was inadequate in Children’s Services. Within other agencies – notably within Health – there was evidence of good supervision and management oversight as well as access to specialist support from in‐house safeguarding teams. 6.4.1 High quality reflective supervision is central to providing effective practice with families and good support for professionals working with families with complex needs. There is a great deal of research and literature to assist managers to develop high quality supervision across agencies4; the best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual families. 6.4.2 Supervision and managerial oversight for all key practitioners should identify poor practice and examples where short cuts are taken to manage organisational demands. This case review revealed that there were several instances when the timeliness of the response to referrals was inadequate in Children’s Services. This was in breach of Working Together 2013 and the local SSCB procedures. 6.4.3 For the health professionals, there is evidence in this review that supervisory practices were generally more robust in most cases in terms of supporting the practitioners or challenging practitioners when they were not persistent in following up concerns. However, it is not clear that the shortfalls in responses from Children’s Services were escalated at managerial level beyond the practitioners’ efforts by health services. 6.4.4 It emerged following the undertaking of an internal case audit in March 2014 that the Core Assessment, said to have been completed at the end of July 2013, was not lodged on the electronic recording system and it could not be found. Although the Team Manager had been involved in the Initial Planning Meeting in June, the Team Manager clearly did not authorise or sign off the subsequent Core Assessment. It is highly likely that the plan to close the case was not agreed and discussed fully in supervision with the Social Worker. It is of note that no referral to early intervention services was suggested which would have been the likely supervisory advice rather than full closure and reliance on universal services plus mental health support. 4Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacott; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012. 13 6.4.5 As it appears that the Core Assessment was not written up until 2014 and, as no formal minutes were ever taken, other agencies relied on their notes taken at the meeting at the end of July 2013. Fortunately, these notes were available and were shared with some others who did not attend including the GP. Only by this means was the GP made aware of the need to contact Children’s Services to share information when Father’s name was known. 6.4.6 It has not been possible to discuss the shortfalls within Children’s Services with the manager and practitioners directly involved. There has been a high turnover over of staff in those teams. Formal disciplinary processes have been undertaken in relation to some of the staff concerned. There was undoubtedly considerable pressure of work within Children’s Services which meant that not all assessments were checked and signed off by a manager. In a previous review of another case in the same time period, it was suggested that the volume of work restricted the amount of time the manager could spend on monitoring assessments and closure of cases. The recent Ofsted inspection in 2015 has also identified the high demand on the services as leading to shortcomings in the service. 6.5 ASP 3: Opportunities to support through early intervention or CAF missed A Core Assessment was completed in June / July 2013. Although it was not appropriately recorded the Social Worker’s findings were shared at a meeting at the end of July 2013. The Social Worker’s recommendation was that the case should be closed whilst the Midwife and other universal services plus mental health services continued to support Mother. There are no formal minutes of this meeting. However, it does not appear that referral to a family support service or a Children’s Centre was considered or agreed. 6.5.1 In a case with such an extensive history and such significant parental vulnerability, early intervention services and the completion of a CAF would have been beneficial and indeed, strongly indicated as a requirement for “stepping down” from social work intervention. 6.5.2 It appears that all the professionals present accepted that case closure was appropriate. It is disappointing that other early intervention was not suggested, discussed or agreed. If a CAF had been in place this would also have provided a formal process for monitoring and reviewing what was happening in the case and for ensuring that joint working particularly across Adults and Children’s Services was well‐integrated. One multi‐disciplinary team meeting was held with the GP and others and this was good practice but there was no formal plan. 6.6 ASP 4: Lack of full consideration of history and the consideration of / role of fathers Although Mother appeared to be highly cooperative and engaged well and proactively with professionals, she adamantly and consistently refused to provide the name of Penny’s Father until after the baby was born. Even then she appears to have not told all professionals consistently what the nature of their relationship was. 14 6.6.1 Many SCRs and the Biennial Reports written by Brandon et al have demonstrated that the presence of significant males in families is often overlooked by professionals or given insufficient consideration. Although CP was believed not to be living in the family, he was nevertheless a significant adult in the life of Penny. CP appears to have been regarded as supportive, but at times, he was also a significantly negative influence for AP and probably Penny. AP described arguments and disagreements occurring on several occasions. AP said these disputes with him lowered her mood. On one occasion she said that he was drinking excessively and was then verbally abusive. He remained a risk that was not known and had not been assessed by anyone. 6.6.2 As identified in previous SCRs, nationally and locally, research advises that it a human tendency to seek only the information that we ‘wish to find’, and the research confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without appropriate question or challenge. 6.6.3 In this case, Mother was cooperative on the face of it and demonstrated that she was committed to the baby and made good preparations and provided good care once the baby was born. The baby thrived ‐ in fact she made significant weight gains which Mother was advised to consider in her feeding. However, although Mother did inform professionals that her relationship with CP was turbulent and caused her stress, there is a variation in the level of detail she discussed. CP’s relationship with Mother was said to relate solely to his involvement with Penny only and they did not live together. Mother did not identify Father till September 2013 – though this was not shared with the GP until later. 6.6.4 Mother shared some information about the nature of her relationship with CP from October 2013. When she saw the GP in October she told the GP that she had left Penny in the care of CP. Later in October, she said to the CPN that she was seeing Father daily. In early December AP was tearful in a telephone call to the CPN saying she was having relationship problems with CP and on a visit later to the Mother she confirmed things were not going well. It was the CPN’s view that Mother’s upset and low mood were reactive to this situation when the Health Visitor called her to discuss the family. 6.6.5 In October 2013 and again in January 2014, the GP made contact with Children’s Services about Father. There was a response on the first occasion to the GP but on the second occasion when the GP was concerned about Father having care of the baby there was no response or action taken. 6.6.6 When Mother contacted the Mental Health Crisis Team in early March 2014, she said she was arguing with Father and feeling very low in mood in reaction to problems with Father. She said she had been weepy for a few weeks and that Father was drinking excessively and was being unreliable. There is no evidence that this further concerning information about circumstances which would have been having an impact on Penny were relayed to Children’s Services. Subsequently, Mother was prescribed anti‐depressants by the GP. At this same point, we now know that Father was seeing his 15 GP and was still taking anti‐depressants. In early April, Mother’s situation seemed to have improved and she was said to be feeling better. 6.6.7 Mother’s initial failure to provide information about Father meant that checks on his background were not carried out at that stage. If they had been significant risks would have been identified. After Penny’s birth, she did disclose his name but by then it appears that an optimistic view – with some justification ‐ was taken because all appeared to be well. It was assumed this would continue. Even when new information came to light from the GP in early March, this did not prompt a new referral. This is not entirely surprising given the various frustrated efforts by the GP and others to achieve a response from Children’s Services during the history of this case. The failure by the Social Worker to undertake full checks on Father when the GP made contact in October 2013 was a missed opportunity. 6.7 ASP 5: Context in which professionals were working ‐ Failure to escalate and challenge effectively inaction by Children’s Services As identified in a previous review, practitioners were clearly working under a great deal of pressure, both in respect of competing demands for time, and the fact that the threshold for intervention was considered high. In previous recent SCRs conducted by SSCB, the practitioners in the review process spoke about the impact of both, commenting that high caseloads could easily encourage professionals to focus more on their own individual responsibilities because multi‐agency working can appear to take more time and maintenance. This high demand, pressure on staffing affected not only Children’s Services but some of the other agencies involved in the case – particularly Health Visiting. 6.7.1 Information from the Practitioners’ Group and the Review Team suggests that in this Local Authority like others, there are diminishing budgets and competing priorities. Research suggests that these factors along with pressures of work result in a tendency to raise thresholds for access as the means of coping. In this case, there was significant initial delay of several weeks in Children’s Services followed by a rapid assessment and closure. 6.7.2 This view of Children’s Services “coping” and making do was endorsed by many of the practitioners who contributed to this review and especially from colleagues in health settings. 6.7.3 The Midwife and the GP were outstanding in their persistence to seek to get the appropriate responses from Children’s Services. However, they were still frustrated at times and it is not clear how or whether they sought to escalate concerns to a higher level. This is an area for consideration by the SSCB. 6.7.4 In the circumstances of the Local Authority Children’s Services being under such unrelenting pressure, high turnover of staff and organisational disarray, there was still 7 7.1 7.2 7.3 T 8 8.1 T 8.2 TTa high – thagencies toFather. If tinformationwould havesee and enPenny. We could haveServices prthe minds professionaAgency leaAll the agen4). The infcontributedGroup wereNot all of twider practidentified obe monitorThe pathwaby a range are linked t The FindinThe Reviewsome practrationale, aof questionthe root caThe findingeach of theexpected tThere are sough largelo be the mhis had occn of concere been impngage with also know e been somimary role tof other pally curious.rning and ancies involvformation cd to the proe able to idethe reportstice within or clarified red by SSCBay for interof key pointo previous ngsw Team idetices happean indications designeduses undergs fall into de findings ao find linkssix findings fly appropriaain focal pcurred it wrn to share portant for tFather – pnow that hme read acrto check ouprofessional. actions takeved in this SCcontained iocess eitherentify persos identified individual aadditional a. rventions innts and deccase reviewentified sixned in the n of its impd to enable pinning thedifferent tyand each ofs between for the Boarate expectaoint for asswould have and escalathe professparticularly he was regross withinut the risks hls to seek enCR completin these rer as a membonal learninin detail, hagencies. Wactions than relation tocisions. The ws in Sundefindings, wway they dpact on thethe Board e finding. ypologies off the typolofindings wrd to considation placedsessing andprovided ete the needsionals worwhen it emistered in t the practihe might pomore inforted Agency eports highber of the Rng. how this leaWhere necet should beo services fsignificant rland. which helpeddid. Each of wider systto strengthf systems isogies. Thishen adoptider, these ad on Childred identifyingither reassd to assess king with Mmerged thahe same Gice. Althougose, it also srmation, toLearning Rehlight that eview Teamarning woussary, the Le undertakeor Baby Peissues are d the teamthe findingems in Sunhen safeguassues, with s is not unung a wholere: en’s Servicesg risks in rurance or aFather’s riMother to tat he was cP practice gh it was should haveo observe aeports (see the individm or the Prauld be transLead Reviewen and whinny was deidentified bm to undersgs is explainnderland anarding by aa clear linkusual, as it e systems a16 s by other elation to additional skiness. It try also to caring for and there Children’s e been on and to be Appendix duals who actitioners sferred to wers have ch should etermined below and stand why ned with a d a series addressing k between would be approach. 17 Management of Systems 1. Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi‐agency work and this was not evident in some of the practice in this review 2. Lack of clarity about the function and titles of meetings; assessments were not all formally recorded and the notes shared leading to a lack of clarity and de‐prioritisation about what had been discussed and agreed Professional‐Family interaction 3. Professionals were too focused on Mother’s cooperative engagement and did not challenge her sufficiently to identify who Penny’s Father was. Her lack of disclosure of information about his identity was accepted as she justified it in terms of the casual nature of the relationship 4. Knowing the identity and background of, as well as the presence and role of males in families is critical to understanding family functioning and assessing risk Multi‐Agency work 5. There were some good examples of joint working and information sharing between the health professionals involved but there was a lack of robust multi‐agency collaboration from Children’s Services. At the same time, when Children’s Services were involved with the family, the decision to close the case and not to refer to early intervention services was agreed by all the other professionals involved Use of Tools 6. The main risk tool used in this case was the Midwife’s Antenatal Vulnerability Assessment. There was no multi‐agency risk assessment tools used and even the Core Assessment, which could have been used for this purpose, was not a joint effort involving all the professionals; we know it was not written up and shared for more than a year Finding 1 Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi‐agency work and this was not sufficiently evident in this case. In this case there was evidence of managerial oversight and challenge in some key agencies with specialist safeguarding advice and support in some cases. However, within Children’s Services there was a considerable delay in allocating the case and referrers were not kept informed. The Core Assessment by the Social Worker was not recorded on the system or authorised by a Manager as required. The impact of competing priorities and limited resources will always impact on service delivery but it must also be recognised that times of transition are periods which increase risk and 18 require strong contingency plans from managers to ensure that vulnerable children are kept safe and that staff are not left unsupported. This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review. Finding 2 The function and titles of meetings were unclear; assessments were not all formally recorded and the notes shared leading to a lack of clarity and de‐prioritisation about what had been discussed and agreed. In this case, the pre‐birth Core Assessment meeting in July 2013 was not formally minuted. This meeting was important as it in effect set out the plan for ensuring that checks were made in relation to Father. Professionals were left to rely on their own notes of the meeting. As the Core Assessment was not written up or on the electronic system in Children’s Services, there was in effect no formal or informal record there of what had transpired and been agreed in that meeting. It seems likely that when the GP spoke to the Social Worker in October 2013 that without a formal reference to what was agreed in that meeting the Social Worker lacked clear terms and advice on the need to check out Father’s history rather than assume all was well with the care of the baby. This issue was also identified within another SCR in Sunderland. Finding 3 Professionals were too focused on Mother’s cooperative engagement and did not challenge her sufficiently to identify who Penny’s Father was. Her lack of disclosure of information about his identity was accepted as she justified it in terms of the casual nature of the relationship. Mother was present at both the interagency professionals’ meetings which were held in June and July 2013. In some ways this was good practice but it is likely to have limited the degree of challenge and the asking of important ”if“ questions about Father and any risks which may have presented. In a number of local reviews, attention was appropriately drawn to the need for some opportunity for professionals to share what ifs and questions without parents being present. Finding 4 Knowing and understanding the identity and background of, as well as the presence and role of males in families is critical to understanding family functioning and assessing risk. Serious Case Reviews have repeatedly highlighted failures by all professionals to effectively engage Fathers or significant males in the family and this was clearly evident in this review. 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Thderland Saf, the followBoard (LSCBng Childrenreas for consure that thorking withcy audits and ensure thas been agn is identifieromote effency workshsult of an ace difficult qupervision rher was verbriefly to anto predict death to aer has beenng for Pennersistent, cve a good ntify and reme areas foere were mathe baby anarly days, tes from pres found safedentified ases involvee implemeneguarding Cing recommB). These r Board to cntinuing anhere is effech children and through hat there isgreed that ed in a caseective jointhops and occident. It wquestions hresulted in ry clear thatnswer the dothe death ny failings on clear thatny. The revcurious andknowledgeesearch the or of practiany good end in suppothe work oevious SCRseguarding ts shortcomied with thntation andChildren Bomendations recommendconsider. 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The moquate and sthe inspecthas identithese actioto the Sunde provided merged fromersight and nclusion of on 11 assessprocedure aow up if asigning andor front‐linoroner that t the view he was seevising Pennng the bell. her is it poionals who rted by prohlighted thered when sumstances require impals workingn’s Servicesost recent isome of thtion. ified a nuons will be mderland Safeto the Sum the findin supervisiothis as a stsments andand procesand when ad developinne practitio20 her death is that a en for this ny but she ossible to knew the fessionals e need for seeking to with the rovement g together s and the nspection e findings umber of monitored eguarding underland ngs of this n for staff tandard in d audits of ss in place additional ng regular oners and 21 managers to share issues and discuss priorities across local services. 10.6 SSCB should in its next review of the effectiveness of early help / intervention, carry out an audit of outcomes for cases which are closed within Children’s Services to identify whether “step‐down” is being robustly managed through CAF and referral to early help services. 22 Appendix 1 The Serious Case Review (SCR) Review Team Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date. One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Management Review Team. Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision‐making or supervisory role in relation to the frontline practitioners working with the family. Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process. Responsibilities of members of the Review Team Represent their agency Understand the broad details of the case under review Ensure that a very broad outline chronology is undertaken Identify key frontline practitioners who were known to the family Undertake tasks related to data collection and analysis Take ownership of the contents of the final report in presenting findings to the SSCB Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub‐committee, it’s function and purpose however, are different in that its’ work is solely to lead and work on a specific SCR. Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology. 23 Appendix 2 Roles and Responsibilities SSCB Chair confirms the decision to hold a SCR commissions on behalf of the Board, the Independent Reviewers agrees to the model used and holds agencies to account for their active involvement in the process ensures that there are sufficient resources in the SSCB Business Unit to support the SCR process ensure Board partners are kept well briefed about the SCR and its progress intervene where difficulties or barriers emerge from agencies SSCB Business Manager is familiar with the model used and acts as a source of information for all who are involved in the SCR process. This can be a stressful and anxiety‐ provoking experience for those unfamiliar with this type of approach ensures that all key parties are kept informed and there is formal sign up from all agencies involved in the SCR convenes all meetings and ensures that these are well documented and minuted works with and to the lead reviewers in terms of access to resources, data collection and contact with key individuals ensures that steady progress of the SCR is maintained keeps the SSCB Chair and the Board briefed about emerging issues and progress manages issues about any parallel processes acts as the key link between the SCR Review Team and the SSCB SCR Review Team Members will be expected to attend all meetings where possible – deputies are not encouraged collect documentation from own agency as and where required read and analyse relevant data undertake discussions with frontline staff from their own and other agencies if agreed and write up these ‘conversations’ support their own staff who are involved with SCR ensuring they receive full and appropriate support throughout the SCR process Identify and facilitate changes within their organisation in response to any emerging practice or policy issues meet /communicate with the staff at the end of the SCR process to discuss agency and professional learning ensure that the required Learning and Reflection report is submitted for inclusion in the SCR final report ensure that information about SCR process is communicated throughout their agency to managers and frontline practitioners 24 ensure required reports are submitted on time read and contribute to draft and final reports take responsibility for addressing any issues, which arise in their organisation in relation to the SCR, including any findings and recommendations Practitioners Group members will be expected to attend Practitioner Group meetings and/or meet with two members of the Review team to discuss their views about working with the family and what factors helped and hindered your practice reflect on their own practice and that of their agency offer support and respectful challenge to other colleagues through their reflective and shared journey read and comment on any draft report circulated by the Review Team Lead Reviewers will offer leadership to the Review Team, chairing meetings and ensuring key tasks are identified and followed through work in partnership with Review team to ensure work is co‐ordinated and progressed offer guidance and support to all individuals involved in the SCR process maintain a reflective log to ensure that lessons can be learnt for future use of this model produce draft reports for the Review Team, offering insights, analysis and challenge and take responsibility for the production of the final report on behalf of the team ensure they have supervisory and mentoring opportunities to provide scrutiny and challenge to their role as lead reviewers Rationale: The role of Business Manager is a vital one and it is essential that this individual understands the key part they play in supporting the SCR. Equally, others who are involved need to be clear about what is expected of them in this way of working. LSCBs may elect to appoint one lead reviewer to lead on the SCR and agree that the second lead reviewer can be an internal appointment from any of the agencies involved. It is important however to note that if this decision is taken, appropriate resources should be made available including external supervision for both reviewers. 25 Appendix 3 Methodological Comments and Limitations 1. As several of the staff and managers who had been involved in the case – particularly in Children’s Services – it was not always possible to seek the views of all those who had been directly involved in the case. 2. The number of SCRs being undertaken in this Authority at the same time clearly impacted not only on timescales but also on the workload and availabilities of the Review Team. On occasions it also made it more difficult for the Review Team to separate one review from another due to the similar nature of the case. However, the lessons emerging from this Review corroborated those already identified and strengthened the messages for the Board. 3. The Review Team have a better understanding of other agency’s learning through this very interactive practitioner/Review Team relationship. Some of the learning enabled individual agencies to better understand the role, function, and practice of their multi‐agency partners in this case. It also challenged agency’s assumptions of one another’s roles and statutory responsibilities. The experience of undertaking conversations with frontline practitioners although time consuming was thought to be beneficial to the SCR process. 4. Feedback from frontline practitioners indicated that they thought the Practitioners Meetings, although not always comfortable, did help them better understand the role of their colleagues and made a difference to their practice. They valued being involved as key practitioners in the SCR process and thought this approach was more inclusive and offered greater learning than previous models. 5. Overall, the experience was thought to be a positive one, but one which was not necessarily any less time consuming than previous approaches. 26 Appendix 4 Progress Report Outlined below is some of the improvement work undertaken by individual agencies and by the SSCB partnership: City Hospitals Sunderland NHS Foundation Trust 1. Invisible Fathers – Work is in progress to check GP records for father/significant others where concerns are raised for any risk factors 2. Documentation supports a robust enquiry and assessment of mother ‐ The Vulnerability Assessment Protocol document has been updated to strengthen the focus on family dynamics. The updated Postnatal Records includes a section requiring midwives to document who is present at each home visit. Used together these improvements will assist midwives to better understand the support network for pregnant mothers. Both will be implemented on 1 January 2016 3. Embedding improvements into everyday practice ‐ Group supervision has been established for community midwives to ensure that the learning from this serious case review is understood. The learning has also been disseminated through the Directorate Safeguarding children group and within level three training for all staff so group supervision will support enhanced reflective practice, learning and challenge and the impact of this will be measured through a recently completed audit of the records Sunderland Clinical Commissioning Group Practices to adopt a system appropriate to their practice to ensure up to date information on children that are subject to a plan, child in need or a looked after child in order to facilitate effective MDT meetings within the practice and information sharing between health professionals GP practices have been given 2 examples of good practice of maintaining up to date information for discussion at MDT meetings The examples also include suggestions of how to ensure the wider primary health care team are kept involved Many practices already have a system in place for this The importance of a good system with be re‐iterated through training, briefing documents and safeguarding newsletters The impact of this will be reflected in practices feeling more confident of which families are known to be at risk and provide an agenda for a structured MDT meeting to discuss these families Recommendations have been made that practices take minutes from MDT meetings and also add comments to relevant patient records as appropriate 27 Multi‐Disciplinary Team (MDT) Meetings continue to be promoted to ensure vulnerable families are reviewed An annual audit has been set‐up and was last completed in July 2015 This has resulted in a productive meeting with midwifery and an impending meeting with the lead for health visitors Attendance at such meetings will continue to be monitored by each agency Implementation of maintaining a spread sheet will aid in conducting productive MDT meetings The impact of this will be audited as per the current annual audit cycle Primary Care to understand the importance of father’s health information being used to inform assessments Midwives will contact GPs where there are safeguarding concerns This can only be done when the mother discloses information about the father Midwives are currently updating their vulnerability assessment proformas, which will be more in‐depth and share a more robust analysis of the family with GPs South Tyneside NHS Foundation Trust (STNHSFT) STNHSFT Safeguarding Children procedures and documentation are currently in the process of being updated Sunderland Safeguarding Children Board The SSCB has instigated the following improvement work: Reviewed and updated the Safeguarding the Unborn Baby ‐ to strengthen the requirement for the Pre‐Birth Child in Need Assessment to include information from other professional assessments including the Vulnerability Assessment Protocol. The assessment will therefore be multi‐agency and include the expertise of partners. The Pre‐birth Child in Need Assessment must also be copied to all professionals working with the family to ensure a shared understanding of what the child’s plan is based on Reviewed and updated the SSCB Vulnerable Baby Training ‐ This is delivered to multi agency staff and includes the learning from SCRs Raised awareness of the learning from the SCRs ‐ developed SCR briefing sheets and delivered multi‐agency learning and improvement workshops. Staff attending the sessions report that they have learnt from the sessions and are applying this to their practice. The impact of this learning will be audited through a further post course evaluation audit The SSCB is currently implementing its Early help Strategy and will undertake an audit in 2016 to understand whether “step down” is being robustly managed (see 10.6) 28 Reviewed and updated the Child Protection/Child in Need Referral form - To strengthen the requirement to access and consider historical family information prior to submitting referrals - To remind professionals that their responsibility does not end once they have made a referral - To remind professionals that they have a professional responsibility to challenge drift/delay using the SSCB Escalation and Challenge Process when required - To require referring professionals to identify fathers and/or any other adult male in the child’s life and clarify their role in relation to the child The intended impact of the improvements is to ensure that referrals to Children’s Services contain robust historical information and a full outline of the family of a child including any adults they have contact with, remind multi‐agency staff of their responsibility to continue to work with families even if they have made a referral to Children’s Services and when multi‐agency professionals don’t receive a response to their referral or they don’t agree with the action taken in response to their referral they must escalate issues to ensure children and young people are safeguarded. Reviewed and updated the SSCB Escalation and Challenge Function and highlighted the process to multi agency staff ‐ The impact of this is to ensure that multi‐agency frontline staff and managers are aware of their responsibility to escalate issues of concern, the process is put into action when required and use of the process safeguards children and young people 29 Appendix 5 References relevant to this Review Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black ‐ Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003‐2005 Brandon M, Sue Bailey and Pippa Belderson ‐ Building on the learning from serious case reviews: A two‐year analysis of child protection database notifications 2007‐2009; DFE 2010 Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson ‐ University of East Anglia & University of Warwick – July 12: New learning from serious case reviews: a two year report for 2009‐2011 Core Assets – Children’s Safeguarding response to “why” questions raised in the SCR re Baby A and Child C May 2014 Department for Education – Working Together to Safeguard Children: A guide to inter‐agency working to safeguard and promote the welfare of children – 2013 DH 2011 Health Visitor Implementation Plan: A Call to Action DH Healthy Child Programme 2009 GMC ‐ Protecting children and young people ‐ The responsibilities of all doctors GMC 2013 NSPCC 2011 ‐ All babies Count Dual Diagnosis Nursing ‐ edited by G. Hussein Rassool (2006) Blackwell Tony Morrison Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003 Weir A and Douglas A (ed.1999) Child Protection and Adult Mental Health – Conflict of Interest? Oxford: Butterworth‐Heinemann Wonnacott, Jane; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012 |
NC52361 | Two cases of non-accidental head injuries and bruising of 14-week-old infants. A bruise was observed on Baby 1 two months prior to injuries; Baby 2 was in the care of their father at the time of the incident. Learning includes: advice on safe sleeping and safe handling needs to be provided to both parents; professionals need to consider how they can meaningfully engage with fathers, including those who do not live with the child; awareness of the impact of having a new baby on fathers as well as mothers; if information about a new baby is not shared directly with a health visitor, it cannot be guaranteed with current systems that all important information will be known by them; even a small bruise on an infant needs to be recognised as a potential warning injury by professionals; family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for attendance. Recommendations to the safeguarding children partnership include: use learning from the next national child safeguarding practice review to explore what can be done to improve the involvement of fathers in work with families with new babies; undertake work to provide a better understanding of the role of fathers and the need to engage with fathers, and consider projects in other parts of the country; seek assurance from partner agencies regarding knowledge and use of the injuries in non-mobile babies policy.
| Serious Case Review No: 2022/C9295 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Child Safeguarding Practice Review STORK – babies with injuries Contents 1 Introduction to the review Page 1 2 Process Page 1 4 Analysis and identification of learning Page 2 5 Conclusion and Recommendations Page 10 This report is strictly confidential. It must not be shared without the agreement of the SCP (Safeguarding Children Partnership ). The disclosure of information (beyond that which is agreed) will be considered as a breach of the confidentiality of the children and agencies involved. Introduction to the review 1. This review considers systems and practice within and between partner agencies in the Safeguarding Children Partnership (SCP) area specifically with regard to the assessment and safeguarding of infants where there are few known pre-disposing risks or vulnerabilities. 2. In order to identify learning and good practice, and to consider the need for improvement action, the review reflected on two cases where babies were the subject of a serious safeguarding incident. 3. The learning identified is in relation to: Bruises in non-mobile babies Involving fathers Late identification of pregnancy Professional objectivity Process 4. Following rapid review processes1 and consultation with the Child Safeguarding Practice Review Panel, the SCP identified that lessons could be learnt regarding the way that agencies work together to safeguard babies2 in the area. 1 A rapid review is undertaken in order to ascertain whether a Local Child Safeguarding Practice Review is appropriate, or whether the case may raise issues which are complex or of national importance and if a national review may be appropriate. The decision is then made along with the national Child Safeguarding Practice Review Panel. 2 5. The CSPR was conducted in accordance with the requirements set out in: The Children Act 20043 (as amended by the Children and Social Work Act 20174) Working Together 20185 Local Multi-Agency Children’s Safeguarding Policy and Procedures 6. In order to identify learning and consider the need for improvement action, the review considered two cases where babies have been injured. Neither of the families considered were known to statutory agencies, other than a period where the mother of Baby 2 was known to children’s social care when she was a child. Baby 1 was 14 weeks old when they suffered non-accidental head injuries. They lived with both parents and an older sibling. There had been no concerns identified about Baby 1 or the family prior to this, although around two months prior to the injuries a bruise was observed on the baby’s forehead. Baby 1’s mother had presented very late with the pregnancy and had requested a termination. This was not possible as a scan showed she was over 35 weeks pregnant. Baby 2 was also 14 weeks old when they suffered non-accidental head injuries and bruising. Baby 2 was in the care of their father at the time of the incident. The parents were no longer a couple. The mother was known to CSC as a child. She told the midwives and health visitor that there had been controlling behaviour from the child’s father in their relationship. 7. Consideration of these cases enabled the review to focus on the systems that were in place and what works well in a strengths-based approach, alongside an exploration of where there may be learning for the system and for multi-agency practice. 8. In respect of the cases considered, personal family details will only be disclosed in this report where it is essential to the learning established during the review. 9. An independent lead reviewer6 was commissioned to work with a panel of local safeguarding professionals from the key agencies. The lead reviewer facilitated practitioner events,7 will speak to the families and produced this report. The lead reviewer and the panel collaborated on identifying the learning and writing recommendations from this CSPR. 10. Agency involvement at the time was considered by each individual agency through the completion of case specific chronologies, which included analysis and the identification of any single-agency learning. From these chronologies and the rapid review information, themes were identified for discussion with the professionals involved in the cases at practitioner events. The events also considered wider practice with infants and systems for assessing and safeguarding babies in SCP area. Analysis and identification of learning 2 It was agreed that this learning review would be undertaken rather than individual child safeguarding practice reviews after consultation with the National Child Safeguarding Practice Panel in July 2020. 3 http://www.legislation.gov.uk/ukpga/2004/31/contents 4 www.legislation.gov.uk/ukpga/2017/16/contents/enacted 5 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 6 Nicki Pettitt is an experienced lead reviewer and has undertaken numerous Serious case reviews and CSPRs since 2009. She is entirely independent of all partner agencies. 7 This was by virtual meeting technology due to the impact of Covid-19 3 The review has established learning in the following areas and each theme will be considered in detail. Thematic analysis Involving and considering fathers Late identification of pregnancy, professional objectivity and bruising/marks in non-mobile babies. Involving and considering fathers8 11. Learning has been identified nationally about the requirement for meaningful involvement with fathers by professionals working with children. In January 2020 the Child Safeguarding Practice Review Panel announced that they have commissioned a new national thematic review which will look at non-accidental injury in children under one. It is understood that one of the strands is about working with fathers. Fathers should always be considered and involved during the pregnancy, at the time of the birth and in the months that follow. There have been a large number of published case reviews where fathers or the partners of mothers are responsible for the death or harm of babies due to unsafe sleeping, shaking and other injuries. The second national review commissioned by the Child Safeguarding Practice Review Panel and published in 20209 states that infants dying suddenly and unexpectedly represents one of the largest groups of cases notified to the panel. 12. Professionals in both of the cases acknowledged that there is an expectation that information predominantly given to mothers is shared with fathers by the mother rather than directly being provided by the professionals involved. In the case of Baby 2, where the parents did not live together and where there was no clear plan at the time of the birth for what contact the father would have, there was a potential gap in systems for expected information sharing. This included key advice in regard to safe sleeping and safe handling not being shared with the father by any professional. This was by no means just an oversight in this case. It is an issue across the system. Advice is provided verbally and in written form to mothers at key points during antenatal and postnatal care. A number of useful leaflets are provided for this purpose in SCP area, for example about coping with crying babies (ICON), immunisations, weaning, and safer sleeping. However the advice and written information is largely provided to the mother and it is clear that this does not always filter through to all of those adults who are likely to have care of the child. In the case of Baby 2 it is now known that the baby was spending one night a week with their father from around six weeks old, and that there had been no professional contact with father. It is possible that no health promotion information had been shared with him. 13. There was also very limited professional contact with Baby 1’s father. This was described by those involved as common in cases where the provision of support is universal and that it can particularly be an issue with fathers/partners who work from 9 – 5, which are the hours that health visitors tend to visit families. It is also an issue when the parents are separated, such as in the case of Baby 2. Baby 1’s father was an experienced father as there was an older sibling. He was seen at a number of visits from the midwives and health visitor but was not engaged with directly other than small talk. Again, this is not 8 This report refers to fathers but they could be mother’s partners, including in same sex relationships 9 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. 2020 4 unusual when the provision of support is universal. What was significant in this case is that the health visitor and midwives spoke to mother about how she felt about having another baby, particularly one that was due just a month after the pregnancy was identified. The same exploration was not undertaken with the father, despite Mother sharing with the midwives that her partner had not wanted any more children. There was no consideration of exploring the impact of a new baby with the father. 14. One of the obstacles to working with fathers/secondary carers is that during pregnancy and immediately after the birth it is the mother who is the midwife’s patient. Engaging with the father would complicate this relationship and simple things, such as storing information provided by the father on the pregnancy notes could potentially be a breach of data protection - although permission could be gained for this. Engaging with fathers as well as mothers is good practice however and is more likely to provide a holistic assessment and intervention. In the cases considered in this review both fathers were known or known about and their details were correctly recorded. One lived with his family and was seen on occasion; one did not live with the mother and was not seen. This led to key information on safe sleeping and safe handling not necessarily being shared and limited knowledge of the child’s likely lived experience. 15. As well as posing a potential risk to children, fathers can also be a protective factor. For example fathers who do not live as part of the immediate family may be capable of caring for and protecting a child. Case reviews show that they are often overlooked by professionals10, often along with the wider paternal family. Sandstrom et al11 made specific recommendations about identifying fathers and male carers, including: ‘being explicit with mothers about the importance of speaking to the father and including him in the process, while also ensuring that she would not be put at risk; speaking separately to the father rather than gathering information solely through the mother; and arranging separate home visits if necessary to explain the relevance of his involvement with the child, communicating a willingness to include him in decisions.’ The biggest issue reported by health visitors in regard to involving fathers is a lack of time, and that currently it is not a mandated contact or currently expected. It was stated during the review that it would be impossible with current caseloads to speak separately with all fathers on universal caseloads. It is acknowledged that it would take flexibility in the system and a change in the commissioning of the service to ensure that fathers and secondary carers are fully involved at this crucial time for their children. 16. In the case of Baby 2 Mother told the midwives that the relationship with the baby’s father had ended in part because he was jealous and controlling. She came across as confident and assertive and was adamant that the relationship was over. She felt it was important that the baby had a relationship with their father however. Questions were asked about this and Mother was clear that the baby’s father had never been physically aggressive and that she did not have concerns about him as a father. Around the time of the birth Mother had wondered whether the father should be present. Both the midwife and the health visitor, who undertook an antenatal visit, spoke to Mother about this and it appears she decided against it. Good support was provided by both practitioners. Following the incident Mother told the police 10 Hidden men: learning from case reviews. Summary of risk factors and learning for improved practice around ‘hidden’ men. NSPCC April 2015 11 Approaches to father engagement in home visiting programs. 2015 5 that the father had been at the hospital and had seen the baby right after the birth. The health visitor saw Mother and Baby 2 at home on three occasions. She enquired about contact between the baby and Father, and on the last visit, around seven weeks before the incident, Mother told her that the baby was staying for one night a week with his father and was very positive about this. She said that father lived with the paternal grandfather. The health visitor was not concerned as Mother reported that the plan was going well. 17. It is important for all professionals to be aware that difficulties can emerge after the birth of a child for fathers (or other secondary carers) as well as for mothers and in families where there were no previous concerns. This can include relationship issues, overwhelming concerns about the amount of responsibility that children bring, and a lack of confidence in the role. There is increasing evidence that fathers can suffer with a form of post natal depression12 which may have been an issue in these cases. The 2018 NICE guidelines on postnatal depression do not mention fathers, and awareness of this as an issue is low13. This is despite the fact that the numbers of men who become depressed in the first year after becoming a father is double that of the general population. Professionals need to be aware of this as a possibility, and consider it when engaging with families, particularly where there are pressures and stresses, as could have been the case in both families considered. 18. In neither case was any consideration given to how the father’s were managing with a new baby and the fathers were largely ‘invisible’ in the records. It is potentially significant that both babies were just over 3 months old at the time of the injuries, as the research states that this is the time when father’s start to struggle most. Research shows that fathers feel isolated during the perinatal period as attention is understandably focused on their partner and new baby. New parenthood is a time of stress and sleeplessness, and both parents are going to be more susceptible to anxiety and a decline in emotional wellbeing.14 This need to be acknowledged and addressed by the professionals working with the families. 19. In 2015 the NSPCC published a report called Hidden Men - Learning from Serious Case Reviews15. It states that ‘men play a very important role in children’s lives and have a great influence on the children they care for. Despite this they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carer.’ In order to ensure that fathers or partners are also acknowledged in work undertaken with mothers and children, there needs to be a review of systems and services, a commitment that organisations may have to provide additional or re-focused resources, and a cultural shift. The two cases considered in this review have identified there is a potential need for such changes across partner agencies regarding the role of fathers in families, and the need to engage with them when assessing, supporting and making plans for all children. This is necessary when they are living in the home or if they live elsewhere but have involvement with the child. 12 Research available from the National Childbirth Trust (NCT) found that more than 1 in 3 new fathers (38%) are concerned about their mental health. It states that one in 10 fathers have PND and appear more likely to suffer from depression three to six months after their baby is born. 13 Community Practitioner magazine November 2018 and #HowAreYouDad? campaign 14 The Dad Project. NSPCC 15 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf 6 20. Research undertaken by The Fatherhood Institute along with the University of Worcester16 concluded that Health Visitors are well placed to engage with fathers of young children and their study provides strong evidence of the usefulness and benefits of training health and family practitioners in father-inclusive practice. It also reflects the need for providers of services to reconsider the need for out of hours’ services, as well as to assess how fathers’ needs and aspirations are acknowledged in leaflets, posters, and group sessions. 21. There was awareness amongst the professionals who were spoken to as part of the review that it is necessary to work with both parents and that father’s are important and significant. This awareness is in place and appears to make a difference when it comes to cases where there are known risks and vulnerabilities and where children are on a plan, be it child protection, child in need or early help. This is less evident in cases where there are no concerns and where the provision of services is universal. This is largely due to the limited time available for midwives and health visitors to spend on cases where there are no or few concerns. In both cases it was a shock to those involved that the babies were so significantly harmed, as there had been so little indication of potential risk. Learning Advice in key areas such as safe sleeping and safe handling needs to be provided and reinforced to both parents, including parents who do not live with the baby if they are to have contact. Fathers need to be seen as equal parents in order to ensure that the needs and risks to a child are met and known. Professionals need to give separate consideration to how they can meaningfully engage with fathers, including those who do not live with the child. This is a challenge in universal cases. Professionals need to be aware of research on the impact of having responsibility for a new baby on fathers as well as mothers. Late identification of pregnancy, professional objectivity and bruising/marks in non-mobile babies. 22. In the case of Baby 1, the mother had attended BPAS17 for a termination of pregnancy. She stated that she’d had a difficult pregnancy with her first child and that she did not plan to have any further children. The scan undertaken found that she was in fact just over 35 weeks pregnant and thus she was unable to have a termination. She was advised to seek urgent ante-natal care and her GP was informed (with her consent.) The midwives involved in the weeks that followed were aware of mother’s wish for a termination and explored with mother how she now felt about having a baby. They were reassured that while it had been a shock Mother was now happy and that her partner and wider family were supportive. This information was not shared with the health visitor, who was not aware until after Baby 1’s injuries that a termination had been requested. There is work being undertaken on the pathways for information sharing in the area. Agreement has been reached that information should be shared when a termination had been sought and not received due to late gestation. Issues of consent have been 16 Burgess, Jones, Nolan, Humphries 2015 17 British Pregnancy Advisory Service 7 identified and it is acknowledged that this will require a change to the local procedures, which is being considered. 23. There was some complexity to the case as Baby 1’s mother worked in a team in the community which included health visitors and family support staff, one of whom was the health visitor allocated to her. This may have had an impact on why Mother did not share the information about the termination, but it is also possible she may have assumed that, as the midwives knew and that the GP had been informed, the health visitor would be aware. Service users often make the understandable assumptions that information sharing between professionals is more effective than it actually is.18 During the antenatal appointment with the health visitor Mother shared her concern that she might not bond with the baby as she had so little time before it was due. The health visitor provided appropriate advice. This conversation made the health visitor think that Mother was open and candid and she had no concerns that Mother was might be concealing any information. Likewise, the midwives had no concern that Mother would not share this information with the health visitor. 24. In the areas covered by the SCP there is no consistency regarding whether health visitors have access to GP or midwifery records. Some GPs surgeries have SystmOne, which health visitors can access, others do not. If a health visitor has concerns about the well being of a child, they would access the GP information either on the system or by calling the GP. There was nothing about the case of Baby 1 at the time that would have led to such an action however. This means that the health visitor was responsible for baby 1 without the potentially significant information about the plan for a termination. Direct information sharing is important if it is known that there is a risk factor that could potentially be a safeguarding issue (in this case the request for a termination that was unable to be performed due to the late gestation.) All health professionals need to take responsibility for sharing information they are made aware of and should not assume that other professionals will have been told or will have access to the information. 25. In this case there were significant time pressures for the professionals involved as Mother had booked so late in the pregnancy. Even within normal time scales there are enormous expectations at the time of and immediately following a baby’s birth and limited time to complete all required tasks. It was acknowledged that health visitors need to be well informed about the family history and the potential risks when they take on responsibility for a child at around 10 days old, but realistically it is only if there are any concerns that there is a verbal handover between midwives and health visitors and checks made with the GP. 26. Immediately following birth, Baby 1 spent some time in the special care baby unit (SCBU). This was due to a concern about their breathing. It is known that there can be a negative impact on bonding between parents and their child when a new baby has to spend time on SCBU. A survey completed by Bliss (an organisation for the parents of babies born sick or prematurely) in 2018 showed that most parents felt their mental health got worse after being on the neonatal unit. It is not known if this had an impact on Baby 1’s parents and their relationship with the child. The standard checks were undertaken with mother 18 The Children’s Commissioner for England. Family Perspectives on Safeguarding and Relationships with Children’s Services. June 2010 8 following the birth and there was no indication of depression, and those professionals who visited after discharge observed a close relationship and good care from the mother and had no concerns. 27. An issue emerged for Baby 1 around eight weeks before the serious incident. A colleague of both mother and the health visitor was engaged in a text conversation with Mother. She was described as both a colleague and a friend. Mother told her that the baby was very unsettled when being cared for by anyone but her. She later said that the baby had a small bruise on the forehead from having ‘head butted’ Father while wiggling. She wrote “it’s an innocent bruise but I feel that if people see it, I’ll be judged.” She also said that she was concerned it would result in a SAFER referral19. The colleague decided to go and see the mother and baby at home that evening. She saw the baby who seemed happy and content and described the mark as very small and pale in colour. She also remarked on how strong the baby seemed when held and that the baby was trying to hold their head up and that this seemed consistent with the description of them head butting the father. The next day the colleague felt she needed some advice about what she knew so she approached a manager. Coincidently the manager had seen the baby that day as Mother and Baby 1 had come into the office. As she had not noticed the bruise, she felt there was no need for any action other than a plan to provide on-going support. The information about the bruise and how unsettled Baby 1 was, and the plan to support was not shared with the allocated health visitor, who in fact visited the family a week later. Mother also did not share any information with the health visitor about the bruise or how unsettled the baby had been. 28. This is potentially an example of ‘professional dangerousness’, a phrase proposed by Morrison20 in 1990 to describe the process where ‘professionals involved in child protection work can behave in a way which either colludes with or increases the dangerous dynamics of a family.’ This was expanded on by Sidebotham et al21 in 2016 where they explored the findings from a large number of serious case reviews and concluded that individual and systemic practice can come together to put a child at risk. In this case what turned out to be dangerous for Baby 1 was; a positive view of the fact that Mother had provided the information about the bruise which she did not need to do; a view, without seeking further advice, that the bruise could have occurred in the way described; the professional and personal relationships which led to a positive view of the mother and a wish not to subject her to the system that would be unleashed should a SAFER need to be put in; and the reluctance to think the unthinkable - that there could have been non-accidental harm inflicted on the baby of a colleague and friend. 29. The professional and friendly relationship between the mother and members of the team undoubtedly had an impact on the response to the bruise, which is understandable. It is difficult to be objective with a colleague and friend. The colleague described being worried which is why she felt she needed to take advice from a manager. The manager does not appear to have properly considered all of the information before deciding there was no cause for concern. This is being dealt with outside of this review. The single agency learning in this case has led to action to ensure that no members of staff are allocated a health visitor from the team where they work, to ensure that the objectivity of assessment is not compromised due to professional and personal relationships. 19 SAFER is the name of the form used in the area to make a referral to children’s social care. 20 The Emotional Effects of Child Protection Work on the Worker. Tony Morrison 21 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. 9 30. It is positive that no assumptions were made that the mother of Baby 1 would be more able to cope without support than other mothers, and that it was recognised that additional support would be needed following the bruise. There is no evidence this support was provided however and as the information was not shared with the health visitor by her colleagues or by mother, they were unable to provide their own professional judgement in regard to the baby and the bruise, and they were unable to provide the additional support that it appears was required. 31. Before babies move on their own and move independently bruises are unusual. An American study22 found that babies that have serious non-accidental injuries have often received less serious injuries previously, so called ‘sentinel’ or ‘harbinger’ injuries. The study found that around a third of infants who had been abused had a previous sentinel injury. This was compared to none of the non-abused infants whose cases served as controls. The most common type of sentinel injury in children who were definitely abused was bruising (80%). This led the author to conclude that "detection of sentinel injuries with appropriate interventions could prevent many cases of abuse." It is possible that in the case of Baby 2 the bruise reported by mother was a sentinel injury and an indicator that there were risks that needed considering.23 32. In the case of Baby 1 there was additional learning identified for partner agencies about the need to address, at the first possible chance, the supervision of contact between parents and babies in hospital if a non-accidental injury is part of a differential diagnosis24. EDT told the hospital that Mother could supervise contact between Father and the baby. This was before any consideration had been given to the timing of the possibly injury and who may be in the pool of perpetrators. This was not challenged at the time. The strategy meeting held just a few hours afterwards reversed this decision and it was agreed that all contact with both parents needed to be supervised. In this case this was not too much of an issue as at the time the baby was receiving 1:1 nursing and had a lot of medical attention, and the decision was changed quickly. In another case however this could put the child at risk. There has been action taken in relation to this particular incident. Learning The need for professional curiosity is essential when there are issues in a case that may lead to additional needs or risks, and professionals should have an open mind to ensure they do not make assumptions about how a family will cope. Without information being shared directly when the responsibility for a new baby transfers to a health visitor, it cannot be guaranteed with current systems that potentially important information will be known by them. When professionals are aware of even a small bruise on a very young child, they need to recognise it might be a warning injury. They need to take action and make appropriate referrals, explaining to parents that they HAVE to do this and follow the Bruising in Non-Mobile Babies policy. 22 Dr Lynn Sheets Children's Hospital of Wisconsin. March 2013. 23 Baby 2 also had a mark on their head which was identified by the health visitor at the new birth visit when Baby 2 was three weeks old. The mark was documented as being present since birth and considered to be a haemangioma. There is no learning identified in regard to this mark. 24 Differential diagnosis is a process where a doctor differentiates between two or more conditions that could be behind symptoms. 10 The benefits of employing support workers from within communities need to be balanced with the risks when there is a potential child protection issue for someone living and working in the area. Family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for the attendance. Conclusion and recommendations 33. Since the injuries occurred in these cases, the ICON25 programme has been launched in SCP area and professionals have been trained in the methods. ICON is a programme developed to help professionals provide advice and support to families in respect of coping with a crying baby to prevent shaking and abusive head trauma. This should help improve the provision of advice about safe-handling and is timely as OFSTED have announced that abuse of babies has increased by a fifth during the COVID pandemic. The programme needs to ensure that it includes the fathers or co-parents as well as mothers and ensure that those not living with the child also receive the advice and support. It is acknowledged that the response to COVID-19 in hospitals (current when this review was undertaken) makes this difficult due to the ban on visiting following a birth. This means the community response is particularly crucial. 34. The current policy in regard to Concealed Pregnancy is being reviewed by the local Partnership Procedures Group to consider what professionals should do if a mother presents very late in her pregnancy. This should also include what needs to happen if the delay in identifying the pregnancy means that a planned termination cannot take place. 35. Good relationships within and between agencies were noted and there is clearly a commitment to safeguarding vulnerable children in the area. The response to the referrals about the injuries were largely good and there are plans in place to protect both children going forward. 36. There has been good cooperation and engagement from agencies with this review process, which has allowed us to identify the learning. It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning in this case, and that changes have been made. 37. The SCP is a new organisation that combines two previous Boards. The partnership is considering the learning from a number of reviews, to consider similarities and shared issues. The previous LSCB serious case review undertaken in 2017 highlighted the need to avoid assumptions about the protectiveness of parents, for example, which was an issue in this case. Question for the SCP to consider: How can the partnership influence the necessary cultural and systemic changes across all partner agencies regarding the role of fathers and secondary carers in families? Recommendation 1: The SCP to request that its partner agencies take the learning from the next national CSPR when it is published and explore further what can be done to improve the involvement of fathers in work 25 ICON stands for I - Infant crying is normal, C – Comforting can help O - Okay to walk away and N – Never ever shake a baby 11 undertaken with families where there is a new baby in the area. They should then provide an update to the SCP on what changes they intend to make. Recommendation 2: That the SCP asks commissioners to undertake a piece of work to provide a better understanding from professionals in partner agencies of the role of fathers, the need to engage with fathers and to consider projects in other parts of the country that are making a difference to all families. Recommendation 3: That the SCP requests assurance from partner agencies regarding the knowledge and use of the Injuries in Non-Mobile Babies policy. Recommendation 4: That the SCP considers that this review is published anonymously by area in the NSPCC library, due to the sensitivity in the case of Child 1. |
NC044971 | Death of a 16-year-old girl, in January 2013, from multiple stab wounds. Adult 1 contacted Child R via social media and convinced her to go to a commercial premises on the pre-text of being offered a job. Adult 1 was convicted of murder and received a 35-year prison sentence. Child R experienced multiple traumas during her childhood, including witnessing the death of a friend, physical assault, cyberbullying and rape. Identifies risk factors affecting Child R, including: going missing from home, sexual relationships with peers her own age, sexually exploitative relationships with adult males, preoccupation with fire, drug and alcohol misuse and self-harm. Adult 1 had a history of: physically and sexually abusive behaviour as an adult and child; cruelty to animals; and diagnosed child conduct disorder. Uses an adaptation of the Social Care Institute for Excellence (SCIE) systems model to present key themes for learning, including: recognition of abuse and risk to adolescents from outside the home; possible systemic bias in using safeguarding frameworks to assess risk to older children; compliance with missing from home (MFH) and child sexual exploitation (CSE) protocols in regard to young people resistant to help and intervention; and effective diagnosis and response to conduct disorder in childhood including the provision of evidence-based parenting programmes.
| Title: A serious case review: ‘Child R’: the overview report. LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 60 Lancashire Safeguarding Children Board A Serious Case Review ‘Child R’ The Overview Report September 2014 Page 2 of 60 Index 1 Introduction and context for the serious case review ................................... 3 1.1 Rationale for conducting a serious case review..................................... 4 1.2 The methodology of the serious case review ....................................... 4 1.3 Reasons for the review and terms of reference .................................... 5 1.4 The scope of the serious case review .................................................. 6 1.5 Particular themes identified by the review group for detailed analysis and examination ............................................................................................ 7 1.6 Membership of the case review group and access to expert advice .......... 8 1.7 Independent author of the overview report and independent chair of the serious case review panel ........................................................................... 9 1.8 Parental and family contribution to the serious case review ................... 9 1.9 Timescale for completing the serious case review ............................... 10 1.10 Status and ownership of the overview report ..................................... 10 1.11 Previous serious case reviews ......................................................... 11 1.12 Inspections of services for children in Lancashire ................................ 11 1.13 Summary conclusion of the review panel .......................................... 11 1.14 Child R ........................................................................................ 18 1.15 Adult 1 ....................................................................................... 21 1.16 Cultural, ethnic, linguistic and religious identity .................................. 24 2 Synopsis of agency involvement ............................................................. 26 3 Analysis of key themes for learning from the case and recommendations ...... 38 3.1 Cognitive influence and human bias ................................................. 39 3.2 Responses to incidents or information .............................................. 41 3.3 Tools for informing professional judgment and decision making ............ 43 3.4 Management and agency to agency systems ..................................... 51 4 APPENDICES .......................................... Error! Bookmark not defined. Appendix 1 - Procedures and guidance relevant to this serious case review ....... 55 Legislation ............................................................................................. 55 The Children Act 1989 .......................................................................... 55 The Children Act 2004 .......................................................................... 55 Safeguarding Procedures ......................................................................... 56 The local safeguarding children procedures .............................................. 56 4.1 Other local procedures relevant to this serious case review .................. 56 National guidance ................................................................................... 56 Working Together to Safeguard Children (2013) ........................................ 56 Common Assessment Framework (CAF)................................................... 57 A step by step guide for front line practitioners (child sexual exploitation) 2012 ........................................................................................................ 57 Guidelines on Prosecuting Cases of Child Sexual Abuse (2013) ..................... 57 Statutory Guidance on children who run away or go missing from home or care (2013) ............................................................................................... 58 4.2 Appendix 2 Specific questions addressed by the expert ....................... 59 1 Page 3 of 60 Introduction and context for the serious case review 1. In January 2013 the body of sixteen year old Child R was found in Blackpool. Child R had suffered multiple stab wounds. Child R had been lured to local commercial premises by Adult 1 on the pre-text of being offered employment. 2. The police arrested 23 year old Adult 1 the same night that Child R’s body was discovered. Despite his denials of involvement he was subsequently charged with murder and was convicted on forensic evidence and given a prison sentence of 35 years. 3. Adult 1 had previously lured another young adult to the same premises and had attempted to assault them but that young person had managed to make an escape. They had not made any complaint or allegation to any service including the police. 4. Child R was a student on a child care course and was living with both parents. Child R had been known to more than a dozen different services over several years that had been trying to help and support Child R. Child R was vulnerable to risks that arose from emotional and psychological difficulties that reflected traumatic experiences and were manifested in aspects of behaviour and lifestyle. 5. The review describes and explores those difficulties and how the various services responded. In exploring these issues the review panel make clear that the only person who is responsible for the dreadful murder of Child R is the convicted perpetrator. 6. Adult 1 had a troubled and isolated childhood. There had been concerns about his lack of social skills and his potential for aggressive behaviour as a child and an adolescent although he had not been assessed or identified as representing a significant and serious level of risk to the public. 7. Adult 1 had a ten year history of having no insight into other people’s feelings, had committed opportunistic assaults, had caused injuries to animals and had admitted a sexual assault of a fellow student. Although these behaviours and history are evidence of previous significant harm to other people they do not provide a definitive prediction about his capacity to inflict the level of violence perpetrated against Child R. 8. Neither the expert psychiatric report commissioned for the review nor the other evidence collated by the review has indicated that it would have been reasonable for an individual professional to have predicted that Adult 1 would kill. Some individual professionals had been concerned about examples of Adult 1’s cruel and aggressive behaviour in adolescence, such as Page 4 of 60 an air gun attack on horses, that in isolation were not enough to have raised significant concerns and invoke multi agency public protection measures. 1.1 Rationale for conducting a serious case review 9. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 4 of Working Together to Safeguard Children (2013)1. 10. The LSCB is required to undertake a serious case review when a child dies and there is cause for concern as to the way in which the local services have worked together. 1.2 The methodology of the serious case review 11. A serious case review group was convened of senior and specialist agency representatives responsible for the methodology and to oversee the scope, collation and analysis of information and to identify the findings and learning from the review. The review was co-ordinated by an independent lead reviewer with appropriate experience and training who wrote this report. Further information is provided in section 1.7. 12. Following the publication of the revised national guidance for the conduct of serious case reviews in England in March 2013, the LSCB had participated in regional work in the north west of England to develop a learning and improvement framework (LIF) to guide the methodology for such reviews. 13. The review group that oversaw the SCR decided to build on the learning that had been developed from four previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and other SCRs that had included a combined domestic homicide review (DHR) had used the framework to present the findings from the review. 14. In consultation with the review group, the professional advisor and the chair of the LSCB, the lead reviewer developed a methodology statement to guide the work of this specific SCR. 15. Work began on compiling a chronology in August 2013. From the collated chronology the review group identified themes for detailed analysis that also took account of information provided by Child R’s parents. In order to ensure that there was sufficient understanding about how and why particular events 1 Working Together to Safeguard Children. A guide to interagency working to safeguard and promote the welfare of children March 2013; also incorporates the revised arrangements for assessment of children that will be based on locally determined single assessment. Page 5 of 60 or episodes developed the review group ensured there was a sufficient level of practitioner and family involvement in the compilation of information and in the development of analysis. 16. An expert forensic psychiatrist was commissioned to provide additional analysis and opinion particularly in regard to Adult 1’s childhood and adolescence. The purpose of that was to establish if there were opportunities to have identified and responded to any evidence of risk in order to inform future practice with children and young people presenting with enhanced levels of complex need. The terms of reference for the expert report are included as an appendix to this report. 17. A practitioner session that involved professionals from the services who had direct contact with and knowledge of Child R was held in November 2013 and was facilitated by an experienced multi agency trainer who developed a framework for collating information during the day. This session was used to outline some of the contributory factors influencing key events and decision making. 18. A further session with practitioners in February 2014 provided an opportunity to discuss the key findings from the review. 19. At the second meeting of the review group there was discussion about how best to examine information in regard to Adult 1. An expert psychiatrist was commissioned with relevant expertise to review information and to provide advice and analysis. Further information is provided in an appendix to this report. 20. The analysis in the final chapter of this report uses an adaptation of the framework developed by SCIE (Social Care Institute of Excellence) to present the key learning within the context of the local systems. This takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children2. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions. 1.3 Reasons for the review and terms of reference 2 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans Page 6 of 60 21. The reason for undertaking this review is that Child R died as a result of non-accidental and multiple injuries inflicted by Adult 1. 22. The case was discussed by the SCR group in March 2013, as to whether or not to undertake a SCR. This being a 'stranger murder', the LSCB would not usually review under those circumstances. At that meeting there was further information required before an informed decision could be made regarding the level and nature of different agencies contact and involvement and whether there were issues to be examined in regard to inter-agency working. 23. When further information had been provided the SCR group made the decision to recommend that the LSCB should undertake a SCR on 7th May 2013; this recommendation was agreed by the vice chair of the LSCB on the 14th June 2013 who was deputising for the independent chair person of the LSCB who was away at the time. 24. The reason for a SCR was to look at any vulnerability around Child R and the type and appropriateness of any help that was provided. 25. The SCR was also required to give consideration as to whether there was anything in Adult 1’s history that could have indicated significant risk to a child or young person and any learning to be identified for professional practice and multi agency working. 26. The review group first met on the 8th August 2013 to agree the scope of the review and a timeline for completion. The scope and methodology of the review was routinely discussed and updated at subsequent review group meetings to take account of any new or emerging information and reflection. 27. The purpose of the review is to establish what lessons can be learned to improve inter-agency working and better safeguard and promote the welfare of children and young people in Lancashire. 1.4 The scope of the serious case review 28. The period under review in respect of Child R is from the beginning of 2009 until the end of January 2013. 29. The following services provided information via a chronology and also participated in collating further information and analysis a) Health services in Blackpool and Lancashire that included: o GP services; o Blackpool Teaching Hospitals NHS Foundation Trust (BTHFT) (provide Hospital services, CAMHS, adult mental health services, Page 7 of 60 Connect Counselling services, Connect sexual health services and School Nursing Services); o Lancashire Care NHS Foundation Trust (LCFT) (provide CAMHS in Lancashire); o Lancashire SAFE Centre (Sexual Assault Forensic Examination service that offers medical examination, advice and support to women, men and children who have experienced sexual assault or rape). b) Young Addaction (young people’s substance misuse services) involved February 2012 until September 2013; c) Awaken Project (run jointly by children's services, health and the police in Blackpool its aim is to safeguard vulnerable children and young people under the age of 18 who are sexually exploited. It also aims to identify, target and prosecute associated offenders); d) Blackpool Education Service e) LCC CAPSS (child and parent support service)(involved briefly through the CIN plan in 2012 and made the referral to Addaction); f) Lancashire County Council (LCC) children’s social care (CSC); g) LCC children missing education service; h) LCC substance misuse service (involvement with Child R); i) Lancashire Constabulary (in relation to criminal investigation of the rape, responding to Child R missing from home and the investigation following Child R’s murder); j) LCC Young People’s Services; k) The HUB based in Blackpool (substance misuse service for young people aged 24 and under, their families, friends and professionals working with them); 30. Lancashire Probation Trust (undertaking a post sentence assessment on Adult 1 that had not been completed when the SCR had been concluded). Information was also sought from members of the families and is described in section 1.8. 1.5 Particular themes identified by the review group for detailed analysis and examination 31. These were: a) Identification and response by services to older children who are at risk of significant emotional, psychological or physical harm and the cognitive, professional and legislative frameworks that are deployed; b) Supporting young people who have been subjected to sexual exploitation or sexual abuse and violence and reconciling the young person’s needs for appropriate counselling and Page 8 of 60 therapeutic support especially when parallel processes such as criminal proceedings are not completed; c) Assessment and making enquiries including history taking on a single and multi agency basis; developing an overarching overview of need and risk; d) Identification of risk to young people from internet and social media; e) Escalation and de-escalation of help in terms of intensity and use of alternative frameworks that include the CAF (common assessment framework), CIN (child in need) and safeguarding arrangement and processes; f) Transition and coordination of help across geographical boundaries and between children and adult services. 32. The review group collated information about the perpetrator to assist in identifying any indicators that he presented recognisable risk of significant harm either to himself or to others. 1.6 Membership of the case review group and access to expert advice 33. The case review group that oversaw this review comprised the following people and organisations; Position Organisation Chair Independent lead reviewer Operations manager Young Addaction School improvement advisor Blackpool Education Service Designated nurse Blackpool Clinical Commissioning Group Acting principal social worker Children’s Social Care Services (LCC) Review officer Lancashire Constabulary Designated doctor Blackpool Teaching Hospitals NHS Foundation Trust Assistant director of nursing – safeguarding children Lancashire Care Foundation NHS Trust Named nurse for children looked after Blackpool Teaching Hospitals NHS Foundation Trust Named nurse for safeguarding children Blackpool Teaching Hospitals NHS Foundation Trust Assistant head of young people’s services Lancashire Young People’s Service (LCC) Clinical director Lancashire SAFE Centre Panel Observers/Support Business manager Lancashire Safeguarding Children Board (LSCB) Page 9 of 60 Support officer Lancashire Safeguarding Children Board (LSCB) 34. The independent author of the overview report attended every meeting of the panel. 35. The panel had access to legal advice from a solicitor in the council’s legal service. 36. Written minutes of the review group discussions and decisions were recorded by a member of the LSCB staff team in Lancashire. 1.7 Independent author of the overview report and independent chair of the serious case review panel 37. Peter Maddocks was commissioned in August 2013 as the independent lead reviewer. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on three previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review. He has participated in training and professional development as a reviewer; this has included specific training in the use of systems learning applied to serious case reviews. 1.8 Parental and family contribution to the serious case review 38. The parents of Child R were made aware of this serious case review when it was commissioned and were very helpful at a time of immense emotional trauma. 39. Child R’s parents felt that the rape that she was subjected to in 2010 aged 14 had an increasingly detrimental impact on her emotional well being and was a cause for the disruption to Child R’s schooling as well as contributing to the risk taking behaviours that she had, such as frequently missing from home and meeting strangers. Page 10 of 60 40. Although Child R had been offered counselling this did not allow Child R to discuss the rape and the impact it had on her and her relationships. Counsellors working with Child R were concerned not to compromise the criminal investigation and prosecution. This is analysed in later sections of the report. 41. Child R’s parents had been worried about Child R’s pattern of going missing from home. They had resorted to trying to secure the house and to control Child R’s movements although this had little or no effect. 42. Child R’s attendance and relationships at school became particularly problematic after the rape in 2010 which had become public knowledge amongst other students. This led to behavioural problems and confrontations and Child R was eventually moved to another school which was followed by further transfers. From Child R’s parents perspective this was a watershed in that it marked a transition out of mainstream education after the second school placement broke down. Child R’s parents’ felt that Child R was increasingly in contact with other people including adults as well as young people who had various problems and challenges. 43. Child R’s parents felt they had to fight hard to get an education placement for Child R. They felt that in spite of the difficulties that Chid R experienced they were able to still talk with their child. 1.9 Timescale for completing the serious case review 44. The case review group met on five occasions between August 2013 and February 2014. The initial chronology of services involvement was completed by September 2013. This overview report was presented to an extraordinary meeting of the LSCB in March 2014. After that meeting the lead reviewer met with Child R’s parents to discuss the findings of the review prior to publication. 1.10 Status and ownership of the overview report 45. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning board for the SCR. 46. Since June 2010, all overview reports provided to LSCBs in England have to be published in full3. This overview report provides the detailed account of the 3 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. This arrangement has been confirmed in the revised national guidance issued in April 2013 and referred to in earlier paragraphs. The coalition government had ended the formal evaluation of SCRs from the 5th July 2012. Page 11 of 60 key events and the analysis of professional involvement and decision making in relation to Child R and her family. 47. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department for Education. 1.11 Previous serious case reviews 48. The LSCB in Lancashire have undertaken ten serious case reviews since 2008. 49. Some of the themes such as sharing of information, coordination and having a single lead professional and the limited focus of assessment have been revealed in some of the earlier SCRs. 1.12 Inspections of services for children in Lancashire 50. All children’s statutory services in England are subject to inspections. In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire. This evaluated safeguarding arrangements as being good in Lancashire with a well managed child protection service; Child R was never subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned and had already had a positive impact. The quality of referrals made by partner agencies seen by the inspectors was good. 1.13 Summary conclusion of the review panel 51. Adult 1’s attempted assault on another young adult shortly before Child R was murdered was not reported to the police or to any other service and therefore there was no opportunity to review any risk associated with Adult 1. 52. The review has provided the opportunity to collate information about a wide range of agency contact with Child R although until the practitioner event in November 2013 the extent of that contact was not fully known about, including by any of the individual people in direct contact with Child R. Serious case reviews have discussed how services can operate within silos and a feature of contact with Child R is the extent to which there was little joint or interagency work. None of the professionals were in charge or leading. Page 12 of 60 53. The review panel have not identified a single event or incident that could have provided an opportunity to respond differently to Child R (or to Adult 1) that would have prevented Child R’s murder. 54. Child R was a child at risk of sexually exploitative relationships. She was sexually assaulted and had been raped. Child R had complex emotional and psychological needs that contributed to Child R engaging in high risk behaviour such as going missing from home (MFH) and using substances. Although Child R was advised and counselled about risk and vulnerability Child R had difficulties in accepting guidance. 55. In assessing whether a child or young person is a victim of sexual exploitation, or at risk of becoming a victim, national guidance4 requires careful consideration should be given to the issue of consent. It is important to bear in mind that: a) a child under the age of 13 is not legally capable of consenting to sex (it is statutory rape) or to any other type of sexual touching; b) sexual activity with a child under 16 is also an offence; c) it is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them; d) where sexual activity with a 16 or 17 year old does not result in an offence being committed, it may still result in harm, or the likelihood of harm being suffered; e) non consensual sex is rape whatever the age of the victim; and f) if the victim is incapacitated through drink or drugs, or the victim or his or her family has been subject to violence or the threat of it, they cannot be considered to have given true consent and therefore offences may have been committed. 56. Child sexual exploitation is therefore a child protection issue for all children under the age of 18 years and not just those in a specific age group. It is clear from the referrals that were made to specialist services that Child R’s vulnerability to child sexual exploitation (CSE) was acknowledged. However, there were problems in how some aspects of follow up help and support was provided. A significant factor was that referrals were made to specialist services that were not commissioned to provide their service in the area that 4 Step by step guide to frontline practitioners Department of Education 2012 Page 13 of 60 Child R lived and therefore cross boundary referrals were dealt with. In spite of that, there were attempts by individual practitioners to try to offer advice and help. 57. Child R was the subject of six initial assessments by CSC although none progressed to more comprehensive core assessment. As a result of one of the assessments Child R was helped through a child in need (CIN) plan that involved the CAPSS (child and parent support service) but she was never assessed and managed as a child at risk of harm. 58. Although there was recognition that aspects of Child R’s behaviour and lifestyle represented risk, it was not escalated or formalised through any of the multi agency assessment and intervention in relation to CSE or missing from home (MFH) frameworks (beyond the processing of information reports). Some of this reflected Child R’s apparent reluctance to engage with some people and services but it also appears to indicate a mindset in terms of how some older children who present with challenging or complex behaviours are helped. There was action taken for example by the police in issuing the abduction notices to older men that are referenced later in the report. 59. It also reflects the additional complications that arise when children live on the geographical boundaries between different services as well as navigating transition points for example between child and adolescent mental health services and with adult provision. Child R lived on the boundary of a much smaller unitary authority that has had to develop strategies and services to focus on children at risk of sexual exploitation although these are services primarily intended to work with young residents of that unitary authority. Child R was not a resident although was known to and received some support from those services. 60. There was shared knowledge that Child R was repeatedly missing from home, was increasingly using alcohol, was involved in a succession sexual relationships with adults and had been assaulted and raped. 61. Child R also instigated incidents which included making at least one allegation that had no foundation. It is clear that by late 2012 and upon turning 16 that Child R became more adamant about asserting independence and went missing from home for more extended periods and refused to return home. By that stage all services had limited powers (or duties) to try to override those views and wishes. 62. There is a pan Lancashire child sexual exploitation (CSE) checklist that identifies behaviours associated with CSE. These include: a) Missing from home or care; b) Physical injuries; Page 14 of 60 c) Involvement in offending; d) Repeat sexually-transmitted infections, pregnancy and terminations e) Absent from school; f) Change in physical appearance; g) Evidence of sexual bullying; h) Vulnerability via the internet and/or social networking; i) Estranged from their family; j) Receipt of gifts from unknown sources; k) Recruiting others into exploitative solutions; l) Poor mental health/self-harm; m) Thoughts of or attempts at suicide. 63. The checklist also identifies vulnerabilities that include: a) Chaotic/dysfunctional household; b) Parental substance use, mental health issues and criminality; c) Domestic abuse and/or neglect; d) History of abuse; familial sexual abuse, risk of forced marriage, risk of ‘honour’ based abuse, physical and emotional abuse; e) Recent bereavement or loss; f) CSE gang association; g) Friends/association with sexually exploited young people, for example at school; h) Learning disabilities; i) Unsure about their sexual orientation / family unaware; j) Homelessness; k) Lacking friends from the same age group; l) Living in a gang neighbourhood; m) Living in residential care; n) Living in hostel, bed and breakfast or a foyer; o) Low self-esteem or self-confidence; p) Young carer. 64. As will become clear in reading this report, Child R’s circumstances reflected more rather than fewer of the factors identified in regard to behaviour and vulnerability although is also important to acknowledge that not all of the factors applied to Child R (and rarely do for children and young people who are sexually exploited). Although it is apparent that some of the people in contact with Child R recognised issues such as CSE it is less evident that other processes including the statutory assessments were able to identify this or the other risk factors as clearly. 65. When processes such as the missing from home protocols and the statutory assessments were invoked they did not provide a good enough opportunity to reveal the full extent of Child R’s circumstances in regard to history, need and risk. For example, the traumatic events in Child R’s early life were largely unknown to everybody who was in contact with Child R. There was also a Page 15 of 60 supposition that Child R primarily needed therapeutic support such as counselling rather than seeing that as one aspect of what should have been a more holistic approach that for example addressed more assertively the risk factors. 66. The exploitative nature of the relationships was not sufficiently or consistently enough identified or explored through more sustained enquiry and assessment. 67. There is no evidence that Child R was targeted by a gang or organised network of abusers. What Child R experienced was emotionally and sexually exploitative serial relationships that in large part arose because of her vulnerability that arose from her emotional history and lifestyle. Child R had experienced significant early childhood trauma that was not known about in enough detail by those undertaking assessments and trying to help. 68. With hindsight, any one of the six initial assessments could have been used to enquire more extensively into Child R’s history and circumstances. The focus of the assessments along with other inquiries that for example arise through the missing from home protocols focussed on Child R appearing to be ‘safe and well’, some reluctance to acknowledge risk and a belief that the family would be able to safeguard Child R. There was a general lack of a holistic approach in these as well as other contacts that took place through education, health and specialist counselling services. 69. The behaviour management approach taken by services such as the schools were largely and not unreasonably focussed on managing Child R’s disruption to pupil’s education. This was further complicated by the introduction of revised behaviour management arrangements in one of the schools that had the effect of accelerating the transfer of Child R from that school. Those arrangements were introduced by a head teacher and no longer apply and were not used by any of the current head teachers. 70. The provision of counselling was in isolation from other services, and was constrained by an apparent misunderstanding by some counselling services about what could or could not be discussed for example whilst criminal proceedings were taking place and along with all the other services had very little historical information and perspective within which to understand Child R’s behaviour and general circumstances. 71. The intention is to highlight the opportunities for learning and improvement. The comments take account of the significant dilemmas and challenges that will face all professionals in criminal justice, education, health or specialist services in trying to provide advice and help to a young person who by their action and behaviour can put up barriers. Page 16 of 60 72. Many people would acknowledge that working with troubled and vulnerable teenagers is difficult. Most people would probably agree that earlier help and support is often more likely to have an influence on later life circumstances. Some of the earlier experiences that Child R had been through such as traumatic childhood bereavement probably had an influence on Child R’s emotional well being as a teenager. There may also be other significant aspects of Child R’s history that are not known about. 73. The rape of Child R in July 2010 was the single event that had most impact on Child R and had repercussions for the rest of her life in terms of the stability and durability of her education placements, her relationships with peers and others, as well as the emotional and psychological harm. 74. The impact of such an experience for any young girl would have been traumatic but for Child R it was compounded by her previous experiences and relative lack of resilience. Resilience is a generic term that in this context describes Child R’s emotional and psychological resources (Child R’s internal world) as well as the external factors that included relationships with significant people such as friends and family. 75. The extent and duration of trauma and difficulty in Child R’s life prior to the rape was largely unknown until the review. Although Child R socialised with a diverse range of people Child R appears to have not had any significant long term friendships since moving to Lancashire. There was also trauma and difficulty within Child R’s family. 76. Having support from significant friends (as opposed to a succession of more casual acquaintances), along with having a positive participation in education are two very significant sources of resilience that were not available to Child R. 77. Aspects of Child R’s behaviour represented a challenge to services such as schools. Support that included behaviour management were influenced and affected by factors such as a change in school policy or key personnel. 78. Child R’s need for emotional and therapeutic support following the rape was recognised although there was misunderstanding about how to manage this in parallel to the criminal proceedings against the person who was convicted of the offence. This centred on a belief on the part of counselling services working with Child R that the rape could not be discussed at all until the criminal proceedings had been completed several months later. 79. The delivery of counselling support was seen essentially as confidential and person centred on Child R; this inadvertently led to some misdirection of counsellors. For example Child R was capable of providing information that was not factual. This is not to criticise Child R who was dealing with so many difficulties in her life. Page 17 of 60 80. There are significant changes and developments taking place in regard to how some services and processes operate. For example a multi agency safeguarding hub (MASH) is now established in Lancashire. This brings to together the key statutory services to manage contacts and referrals in regard to children and young people. The arrangement involves far more coordination of enquiries. The vulnerable child reports that are referred to in the report have been replaced with new arrangements for the protection of vulnerable people. 81. The multi-agency and specialist Awaken Team in Blackpool incorporates the Western Division of the Lancashire Constabulary which includes parts of Lancashire as well as all of Blackpool and South Fylde. The CSC component of the Awaken Team only covers Blackpool. This is the reason that on a joint visit by the team a nurse member of the team was used who, although commissioned to work in the Blackpool area only, did often assist with cases from the entire district covered by the Awaken Team. (In addition, health staff were drawn from Universal services of school nursing, sexual health outreach services and CLA Nurses when the need arose.) An alternative would have been a referral to Lancashire CSC for a joint visit that would have involved a social worker from a non-specialist team. 82. Under new organisational arrangements being implemented by the Lancashire Constabulary from April 2014 the new 'West' division will be created. It is the old 'A' Western division together with 'B' Northern Division which incorporates, Lancaster, Morecambe up to the Cumbria and North Yorkshire Boundaries. In the south of the division is Fleetwood, Cleveleys, Poulton Le Fylde and all the villages in Wyre up to Lancaster. The Awaken and Breakthrough staff will have full cover from all agencies right across the West division. Breakthrough social workers (Lancashire employed) will now cover the South Fylde area. 83. Accompanying the organisational changes there have also been changes to some working practices for example in regard to how information is recorded. For example, Child R had a paper file; now the system is very different. Within the police Sleuth (police investigation and work management system) where the PVP (protection of vulnerable person) database is, there is a CASEMAN computer database. All CSE children, enquiries, investigations are now all on CASEMAN and the enquiry/investigation is updated electronically and time stamped. Any message, comment or enquiry can be placed on there. The CASEMAN is overseen by supervision and it flags to them the date for review etc. They in turn have time parameters to review it. Should the enquiry be made now, it could go on CASEMAN and be tracked. 84. The referral from CAMHS to the adult single point of access service occurred because Child R had become 16. The referral and subsequent response from Page 18 of 60 the mental health practitioner who completed a mental health initial assessment was prompt and sensitive to Child R’s needs. Child R was killed shortly after the adult service had become involved and therefore the review can only provide very limited opportunity for identifying any learning in regard to how such transition is managed. 85. Given the difficulties that occurred in regard to co-ordination of different children’s services the introduction of further services and the extent to which the adult and children’s system can link and be managed by a lead professional is an area not explored by this review. There is learning identified in later sections for example in regard to conduct disorder, delivery of multi-systemic working and supporting individuals with long term psychological difficulties. 86. The final chapter of the report describes the most significant issues identified by the review group for the purpose of improving practice and services. Theses are focussed on the identification of children and young people who are at risk of sexual exploitation, improving the quality of assessment and managing systems for children who are regularly missing from home. 1.14 Child R 87. Child R had five older half siblings and two older step siblings. Child R lived with her parents and a half-brother. The family had previously lived in the Greater Manchester area before moving to Lancashire while Child R was still at primary school. They did not have previous connections with the area. Child R had a friend that Child R had met when they had both started at a nursery although they saw less of each other after the family had moved to Lancashire. This appeared to have been Child R’s only significant friendship; although Child R had a wide circle of contacts none of these appeared to be long term. For example, when Child R went missing from home Child R would often be located in a new place and with different people and who were very often much older. 88. Child R and her parents all used social media. No other hobbies or interests are known in regard to Child R. It was Child R’s use of social media that provided the opportunity for Adult 1 to make initial contact a few days before he murdered Child R. 89. One of Child R’s parents had a serious illness that involved extensive and invasive medical treatment over several years. 90. Child R does not appear to have had any consistent friendships although had numerous contacts with young people and adults. Child R used social media to make contact with other people. Some of those contacts were with older males. It was also a source of bullying. Page 19 of 60 91. According to Child R’s parents, she had one childhood friend who she had occasional contact with after moving to Lancashire. When Child R was still at primary school aged nine when a friend was killed in a road accident. That death coincided with the suicide of a maternal relative. 92. It was shortly after this early traumatic experience that Child R had the first contact with CAMHS in June 2006 when Child R was presenting with behavioural problems and specifically had a preoccupation with fire and a desire to be burned. Child R had not attended the funeral of the friend who it is believed was cremated; Child R’s parents had felt that Child R would be too young to manage that experience. With hindsight, the deaths marked a significant event in Child R’s life that was largely unknown by the various services that had contact with her subsequently. There was also a period of significant and life threatening illness for one of the parents. 93. The second very significant traumatic event for Child R was the rape that occurred in July 2010 when Child R was 14. It was from 2010 that Child R began to come to the notice of several different services and it was when Child R for example began to regularly use alcohol and drugs. 94. Child R was the subject of ten reported crimes with the first having occurred in February 2008. There were seven assaults alleged, a rape that resulted in a prosecution. 95. On some occasions Child R’s behaviour posed a risk to others and included sometimes making serious allegations about other people that were malicious. 96. Child R was the subject of more than ten vulnerable child referrals (VC). These included the following: a) 13th November 2009 this was the first referral to the Awaken Team and refers to the incident described earlier; Child R was interviewed and discrepancies were identified in the account provided; b) 5th July 2010 when a member of the public intervened after finding Child R being raped by an adult male and in an intoxicated condition; the male was subsequently convicted; CSC completed an initial assessment and closed the case on the basis that there was no ongoing involvement required from CSC; the Awaken Team had also closed any continuing involvement; c) 9th July 2010 Child R had met an 18 year old male from Birmingham. An SC1 to CSC was submitted5; 5 The SC1 is a police referral form. Page 20 of 60 d) 8th February 2011 police officers attended an incident where Child R told them the root cause of issues with the family were their excessive drinking. Child R’s parents reported that Child R was in a relationship with a male which Child R denied. An SC1 was sent by email to CSC; e) 28th February 2011 Child R reported having been locked in the house by the parents. The police attended Child R’s home and the parents admitted they had done this to prevent Child R from going missing. Child R showed the officer both arms which had slash marks and said that this was self harming due to living at home. There had also been an argument between Child R and father and Child R had had scalded a hand when chased through the house. An SC1 was sent via e mail to CSC; f) 25th November 2011 Child R had been reported missing from home and whilst absent had been assaulted by an ex partner; Child R’s mother was requesting the involvement of other services as she was at the ‘end of her tether. An SC 1 was sent by e mail to CSC; an initial assessment was completed in early December 2011 and recommended the development of a CIN plan through the parenting support service; g) 7th February 2011 Child R had been reported missing and upon returning a police officer noted Child R had suck or bruise marks to the neck; Child R denied that anything sexual had happened. The following day Child R’s mother reported that Child R had been involved in sexual activity. A section 2 abduction notice was served on the offender6; an investigation commenced with the Aquamarine Team7 and an SC 1 was sent by e mail to CSC; h) 14th February 2012 Child R was reported missing from home. An SC1 was sent to CSC; i) 29th February 2012 Child R’s mother rang to report that Child R was in a relationship with a male aged 29 years. The male had previously been 6 Child Abduction Warning Notices (formerly known as Harbourers Warning Notices) issued under section 2 of the Child Abduction Act 1984 (as amended by the Children Act 1989) are a useful tool enabling the police to disrupt the criminal or undesirable activities of adults who are associating with young people against the wishes of the young persons' parent(s) or local authority carer. Section 2 covers offences committed by a person not connected with the child, who unlawfully takes or detains a child under the age of sixteen. The offence can be prosecuted either way. The maximum penalty on indictment is seven years. The notices tend to be used where arrest/prosecution for any substantive offences is not available or is not appropriate at that time. 7 Operation Aquamarine is a dedicated team of police officers trained to investigate rape and sexual assault cases and provide victims with the support and care that they require. Page 21 of 60 arrested for sexual offences. A section 2 abduction notice was served on the male. Child R did not disclose any sexual activity. An SC1 was sent by e mail to CSC; j) 4th September 2012 concern was expressed regarding Child R who was now aged 16, having a relationship with an adult. Child R’s mother had reported that Child R was in East Anglia; an SC1 was sent to CSC; k) 15th November 2012 concern was expressed by Child R in that the adult who raped Child R was due to be released from prison the following year (this did not relate to any specific notification or date); Child R was described as ‘not dealing with this very well’. Child R’s mother was requesting assistance to help Child R deal with this. An SC1 was sent to CSC. 97. There is no record of what action was taken in regard to the majority of the VC reports. Information about other contact between Child R and services is summarised in chapter 2. 1.15 Adult 1 98. Adult 1 is an only child. He was first referred to child psychiatry services when he was only six years old. He was aggressive, breaking property and hurting other children. He was diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)8 and was placed on a prescription for Ritalin (used to treat attention deficit disorder) (ADD). He was also referred to paediatric services in early 1997 in regard to the possibility of encopresis (soiling) associated with physiological or neurological causes. Adult 1 received treatment through to 2000. 99. Subsequent educational assessments indicated that although he did not have problems with numeracy or literacy he had difficulties in regard to his social and emotional and behavioural skills. When he was ten years old Adult 1’s behaviour and aggression was causing concern along with what was described as sexual touching. He appeared to have a lack of understanding about what was acceptable. He appeared to be quite isolated from peers rarely playing with other children outside of school and with few lasting friendships. He was still being prescribed Ritalin 100. Unusually, Adult 1 had been placed in a pupil referral unit (PRU) from May 1999 until July 2001 whilst still at primary school and never returned to mainstream education. He was placed in a residential specialist school when 8 Oppositional defiant disorder (ODD) is a disorder where children have disruptive and oppositional behaviour that is particularly directed towards authority figures, such as parents or teachers. Page 22 of 60 he reached secondary education in September 2001 and remained at that school until he went to college in September 2006 where he completed a course in the care of small animals until July 2008. 101. An educational psychology report in November 2000 acknowledged that ten year old Adult 1 had significant problems with his behaviour and social relationships and that his ‘interaction skills, communication skills, and social imagination and ability to think flexibly are not at a level normally associated with a child of his age and academic ability’. The assessment included completion of the Devereux Behaviour Rating Scale that placed Adult 1 at the 98th percentile9. The same report concludes that this will effect his development of relationships and ability to behave appropriately but the psychologist did not ‘feel confident regarding the cause of those difficulties’. The assessment provided guidance on teaching strategies and recommended support through CAMHS. 102. He continued to have difficulties in his interaction and relationships with other pupils. In September 2001 he was placed in a specialist school for children with emotional and behavioural difficulties where he remained until he went to a local college in September 2006. In addition to the diagnosis of ADHD Adult 1 displayed behaviour indicative of being on the autistic spectrum10. Adult 1 was the subject of allegations of inappropriate touching of another pupil. 103. In April 2005 the head teacher of the school reported an incident involving 14 year old Adult 1 and an eight year old pupil. A strategy meeting two weeks after the incident decided that Adult 1 did not have the mental capacity to establish criminal intent. The incident was not pursued any further by the police or any other service. 104. In May 2005 when Adult 1 was aged almost 15 years old, he was no longer displaying symptoms of ADHD but was diagnosed with depression. In September 2005 now aged 15, Adult 1 was referred to the GRIP service regarding his sexually inappropriate behaviour (following sexual advances to 9 Devereux Behaviour Rating Scale is used to help objectively evaluate the behaviours of children and adolescents who may be exhibiting moderate to severe emotional disturbance. It is a method of determining to what degree behaviours may be considered extreme in relation to other similar pupils. The scale has four subscales: interpersonal problems, inappropriate behaviour, depression, physical symptoms and fears. Adult 1’s scores were very significant in three areas: interpersonal problems, depression and physical symptoms and fears and significant in inappropriate behaviour and feelings. The total scale standard score was 134 on the 98th percentile. 10 The spectrum is a group of pervasive developmental disorders that have a triad of impairments relating to social interaction, social communication and social imagination. There are other characteristics that differ that include factors such as learning difficulty, behaviours and language. Page 23 of 60 fellow pupils at school). The referral to GRIP was declined because the service was focussed on children under 13 who were living in Blackpool11. 105. The final review at school in July 2006 reported that although Adult 1 had made ‘significant progress educationally and medically’ there had been far less progress in ‘helping him to accept responsibility for his own actions’. 106. In October 2006 Adult 1 was discharged from CAMHS. He was 16 years old. He was regarded as having recovered from ADHD and from his depression. 107. Adult 1 was at college from September 2006 until July 2008. Although Adult 1 was the subject of warnings for plagiarism on two occasions there was no other concern recorded about his behaviour whilst at the college. 108. In late May 2009 Adult 1 who was almost 19 years old used an air rifle to shoot at four horses in a local field. One of the horses was injured. The police arrested Adult 1 at the scene and after he had been interviewed and had made a statement admitting the offence he was cautioned for an offence of criminal damage. 109. In late October 2010 Adult 1 who was 20 years old sexually assaulted a female who had been at college with him. He admitted the offence but CPS recommended that no prosecution should be pursued because they felt ‘there was no realistic prospect of prosecution’. 110. There were no further incidents reported until the sexually motivated killing of Child R in early 2013. 111. Information from the trial of Adult 1 revealed that he was using social media to lure young people to the commercial premises where he killed Child R. 112. Adult 1 had initially met Child R some months previously whilst in Blackpool. Child R was with another person that Adult 1 had known. There was a brief discussion during which Adult 1 mentioned that made contact with Child R via a social media website four days before the murder. 11 The Group Intervention Panel (GRIP) is a multi-agency, short-term, early intervention initiative working with children and young people aged 8-17 years believed to be at risk of becoming involved in crime or anti-social behaviour. It aims to divert children and young people from developing patterns of persistent or more serious offending. (GRIP is a Youth Inclusion Support Panel - YISP). It is not clear why the referral to this service was made at that time. Page 24 of 60 1.16 Cultural, ethnic, linguistic and religious identity 113. Child R’s family is white British. Child R’s parents are not in employment. 114. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007). Child R did not live in those districts. The majority ethnic group is white (97.4 per cent), which covers White British, White Irish and Other White. 115. Child R lived on the boundary between the county and a much smaller unitary authority. The unitary authority has very high levels of deprivation. It is ranked the tenth most deprived area of 326 districts and unitary authorities in England. The area has the lowest levels of achievement for children in education and is below the national average for England. The numbers of children and young people not in education employment or training (NEET) is high. 116. The 2011 mid-year estimates show that the proportion of the population aged 0 to 19 years old in the area of Lancashire where Child R lived is lower than across the county as a whole. 117. Rates of drug and alcohol abuse and smoking amongst young people in Lancashire have improved but remain worse than the England average. The eevidence of high rates of binge drinking in Lancashire is provided by the high number of alcohol specific hospital admissions of young people. The rate of admissions in the North West is much higher than the England average and some parts of Lancashire have rates around double the England rate. The area where Child R lived and the Ribble Valley are the only districts with rates below the England rate. Alcohol-specific hospital admissions of young people in the area that Child R lived are much lower than the England average. The area rate is currently the lowest in the whole of Lancashire. 118. There were 178 victims of CSE in the area that Child R lived in 2012/13. The teenage conception rate for the area is below the England average. The under-16 conception rate for the area has reduced but is still well below the England average. The proportion of young people testing positive for Chlamydia in the area has reduced and is below the England average. 119. The performance of children in the area that Child R lived in the Foundation Stage has improved and is better than the England average. The performance of the area pupils at Key Stage 1 and Key Stage 2 tends to be Page 25 of 60 higher than England, regional and county performance. The performance of the area pupils at Key Stage 4 tends to be better than the England, regional and county performance. 120. A pupil attitude survey of young people in the area suggests that there are a large proportion of pupils that enjoy their education at school. 121. The overall absence rate from the area schools has been improving since 2009 and is still better than the England average. The proportion of persistent absenteeism (i.e. proportion of pupils missing 15 per cent or more of the school year) has increased but is below the England average. 122. The 2011/12 data demonstrates a large decrease in the number of permanent exclusions in the area secondary schools, however the proportion of exclusions remains higher than the Lancashire average and north Lancashire comparators. 123. 2011/12 saw a decrease in fixed term exclusions, along with a reduction in the number of days lost through exclusion. The area holds the second lowest rate of fixed term exclusions across Lancashire, and records the lowest number of days lost through exclusion. 124. The proportion of the area children aged 16 or under, and between 0 and 19, living in poverty was lower than the national, regional, and county average but above the county average. The area had the lowest proportion of child poverty when compared to the neighbouring northern districts. Page 26 of 60 2 Synopsis of agency involvement 125. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the child, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later sections of the report. 126. Therefore, the summary does not contain every contact with Child R; for example Child R was reported as missing from home on 28 occasions between September 2007 and late 2011. Child R also experienced considerable disruption to their education which arose from transfers which are summarised in the report. 127. Child R was generally seen as a pleasant, confident and sociable young girl who was already quite ‘streetwise’ around the local community by the time she went into secondary education. This general presentation remained fairly consistent and may have hidden Child R’s feelings of vulnerability and emotional distress. Child R’s was a friendly individual. For example the local police community support officer (PCSO) had regular contact and chats with Child R who was often out and about in the local area. Child R often attended a youth club run by the PCSO. There were no particular concerns about Child R although Child R was seen as being susceptible to pressure from peers which are not particularly unusual for young adolescents. 128. Child R began to experience bullying at school and at Child R’s mother’s request Child R was transferred to another school during year 812. This was initially a positive move with Child R apparently making some friends. However by year 9 Child R’s attendance and behaviour were beginning to become problematic. This coincided with the introduction of a new behaviour policy in one of the schools that had escalated pupil transfer or exclusion more quickly; this policy no longer applies. Child R moved school again in 2008. This and all the other subsequent transfers in school were due to behaviour and relationship difficulties that Child R had at school. 129. It was in September 2007 when Child R was 11 that a report of missing from home (MFH) was made to the police. Child R lit small fires in the bedroom in November 2007. Child R had wanted to know what it was like to be burned; this appeared to be linked to the cremation of the friend whose funeral Child R had not attended. Bereavement counselling was recommended to help Child R in regard to the friend’s death. The first initial assessment by CSC was completed in December 2007 which resulted in a 12 This is the eighth year after the initial reception into education and is the second year of stage three in the national curriculum and is therefore a significant stage in any child’s education. Page 27 of 60 family support referral to a family centre to help Child R ‘regarding routines, anger management, guidance and boundaries’. 130. In February 2008 Child R was the victim of an assault by several pupils at school that was reported to the police. In April 2008 the family support service began their work in response to the referral in regard to helping Child R with bereavement counselling and anger management; there were eight sessions of work between April and the end of 2008. There were also separate support sessions for Child R’s parents to help with responding to Child R’s behaviour. During the initial sessions Child R disclosed being bullied and information was passed to the school. 131. At a review of the family support work in July 2008 that involved Child R aged 12 and both parents, there was a disclosure of concern by the parents about Child R making contact with people through social media. Further work was scheduled to help Child R keep safe by making Child R aware of the dangers of such contact and there was also separate work with the parents in regard to parenting a teenager. 132. The family support service ended their involvement in November 2008 having concluded that the initial problems in regard to fire setting and relationship difficulties had been resolved. None of the family had attended the final review meeting that arrived at that conclusion. 133. The victim support service had their first contact with Child R in early April 2009 in relation to an incident of Child R being bullied by another young person who was due to start attending the same school at Easter. 134. In June 2009 the second initial assessment was opened by CSC. The assessment was in response to a referral by Child R’s mother to CSC. Child R who had just become 13 had been missing from home on three occasions in recent weeks. Mother described Child R as having eloped with another pupil from school and that Child R was on the verge of exclusion. Neither Child R nor mother responded to an appointment letter and the referral was closed without any assessment work being completed; mother has no recollection of receiving the appointment letter. The electronic record system was updated to show that an assessment had been opened and closed and therefore completed within timescales13. There was no further contact or follow up with Child R’s mother. 13 At this time there was a national assessment framework that was being monitored at local and national levels; a key performance indicator (KPI) was meeting timescales for completing either an initial or core assessment. The coalition government has changed arrangements and placing responsibility on local areas to develop their own frameworks and measures of effectiveness. Page 28 of 60 135. In early July 2009 the PCSO (police community support officer) made a referral to the PAYP (positive activities for young people)14. 136. In November 2009 Child R made allegations to the police of being coerced to pose naked on a social media website. These allegations were investigated which included input from the police high technical crime unit who showed that the downloading had followed explicit ‘chat’. Child R’s mother contacted the Awaken Project operated by the police and CSC to report that Child R was being bullied as a result. Child R was advised about not making false allegations. Child R’s parents were advised about Child R’s use of the internet and social media. 137. A referral was made by the police officer on the Awaken Project to CSC in November 2009 and a third initial assessment was opened. Child R stated that work on keeping safe had already been completed by CSC and did not want to repeat the work. It was noted that Child R’s attendance at school was sporadic. The assessment was closed on the 7th December 2009 with no further action recommended. 138. The police officer on the Awaken Project contacted the school where the head teacher confirmed that the bullying was being addressed by the school but that it was exacerbated by Child R alleging that another pupil had a picture on their phone; when the phone was examined no image was found. 139. In the first half of 2010 there were a number of assaults and confrontations with other pupils. The victim support service had contact in early March 2010 in relation to an assault on Child R which mother had reported was a one off incident. The same service was involved again in early April 2010 following another assault by another pupil at the same school as Child R who had been injured. 140. In the summer of 2010 Child R’s family moved to another house within the same locality and still geographically outside Blackpool and in Lancashire. 141. In June 2010 the young people’s service (YPS) had been notified of 14 year old Child R missing from home and had contacted Child R’s mother to have parental consent to talk with Child R ‘to complete the paperwork’15. 14 Structured activities (including sports and physical activities, attending clubs and societies and volunteering activities) that enable young people 13-19 to voluntarily participate in, or initiate, planned and purposeful activity that holds clear health, learning or social and personal development aims. This will normally involve practitioners or peer-leaders who engage with young people on a one to one or group basis 15 This reference to paper work appears to refer to the county wide joint protocol for managing reports and information about children missing from home (or care). The protocol requires return Page 29 of 60 142. At a meeting with Child R and the YPS, Child R described the circumstances for leaving home having been because of an argument over behaviour in school; Child R had stayed at a friend's house, but would not say who the friend was. According to the account Child R had walked straight there and had not spoken to anybody else. Child R admitted to receiving and ignoring several calls from the police and mother before switching the phone off. The YPS worker suggested that the phone was kept on and for Child R to at least tell parents that things were ok, or to text them with the same details. Further analysis is provided later in the report. 143. Child R had gone missing on previous occasions and each time for a similar reason; an argument with parents followed by Child R leaving the house and ignoring telephone calls. The YPS workers explained about the problems in Blackpool regarding some young people disappearing, and that they were trying to ensure that Child R remained safe. 144. Child R talked about having trouble in controlling temper and wanted to see the school counsellor again; YPS agreed to arrange this. Child R had previously seen the counsellor ‘once or twice’. 145. In July 2010 Child R was raped by a 22 year old who was subsequently convicted 18 months later following a police investigation that also identified that Child R was sexually vulnerable from contacts with other young males and included using alcohol. Victim support also tried to offer support; according to their records Child R was having nightmares and was being subjected to cyber bullying. Child R was awaiting an offer of an alternative school placement. Child R’s phone had been taken by the police as part of their investigation. 146. The implications of the rape were very significant; the male was the boyfriend of a student at the same school as Child R, the crime became widely known and led to relationship difficulties and confrontations between Child R and peers. Child R was the victim of an assault by several other young people. Eventually Child R’s school placement broke down when the school sought to have Child R transferred. 147. Child R’s parents believe that the rape was the single significant event from which Child R went on to develop other difficulties. Although there was recognition that Child R required counselling and therapeutic support in regard to the rape, this was postponed on the understanding that it could not begin until the criminal process had been completed. This was a misunderstanding within the counselling service about the rules and interviews to be completed and also describes a tiered approach to calling intervention meetings if a child goes missing more than five times in a 90 day period or 9 times in the same period. There is analysis in the final chapter about the lack of escalation that occurred in regard to Child R. Page 30 of 60 guidance that the Crown Prosecution Service (CPS) together with the police comply with. 148. The counselling service provided support but did not address Child R’s feelings and emotions in regard to the rape; this did not happen until after the trial had been completed. Discussion of the rape would not have been allowed prior to the trial but the guidelines that applied at the time16 and in the current national and local protocols allowed victims to discuss their feelings and emotions. 149. The counselling service did not consult with the specialist police officers who believed that appropriate counselling was in place. The counselling approach (not the police) in this case was on the basis that such work could compromise evidence for the criminal trial17. The CPS has recently published a new national protocol for prosecuting cases involving the sexual abuse of children that came into force in January 2014. 150. The psychological and emotional damage of a rape, especially on a young adolescent is explored in further detail in later analysis in this report. A past or current history of physical, psychiatric or social problems appear to make it more likely for an adolescent to develop severe depression, psychotic behaviour, psychosomatic disorders, suicidal behaviour and acting out behaviour associated with alcoholism, drug abuse and/or sexual activity. Child R presented with several of these behaviours. Prior to the rape Child R had already had significant trauma and had already received help through CAMHS. 151. Less than a week after the rape, the school made a referral to the Awaken Project to report that Child R had disclosed having contact via social media with an 18 year old from Birmingham and was also having unprotected sex with other young people the same age as Child R. The Awaken Project closed their involvement with Child R the same day; this seemed to be based on an understanding that the Aquamarine Team was involved with Child R; the closure record also stated that Child R and parents had been advised about the risk from the internet and mobile phone use of social media. 152. CSC completed the fourth initial assessment on the 14th July 2010. This noted that 14 year old Child R had informed CSC about drinking alcohol. 16 Provision of Therapy for Child Witnesses Prior to a Criminal Trial: Practice Guidance; Home Office, CPS and Department of Education; 2001. 17 The guidance is accessed http://www.cps.gov.uk/publications/prosecution/pretrialadult.html . The key issue with regard to pre-trial discussions of any kind is the potential effect on the reliability, actual or perceived, of the evidence of the witness and the weight which will be given to in court. Pre-trial discussions may lead to allegations of coaching and, ultimately, the failure of the criminal case. It should also be borne in mind that the professionals concerned may themselves be called to court as witnesses in relation to any therapy undertaken prior to the criminal trial. Page 31 of 60 The rape allegation was associated with Child R having been plied with drink. School attendance was 49 per cent. The initial assessment recommended that a referral to GRIP would be made and the case was closed to CSC; in the event the referral was not accepted. The school were notified of the CSC assessment and decision to close their involvement. 153. Child R was in contact with a number of different professionals through the police and education services. Child R was using alcohol on a regular basis and was continuing to go missing. Child R was disclosing risky behaviour some of which was not reported to the police or to CSC. For example in September 2009 Child R had disclosed, in confidence, to a teaching assistant that a sexual encounter had been interrupted by a male’s father who assaulted Child R and their own child. 154. This information was recorded on the school’s internal system but was not discussed or reported to any other service or professional. Two weeks later a health mentor and a youth worker were also made aware of the same information and again this was not discussed outside of the school. At the end of September 2010 Child R who was aged 14 had a contraceptive implant fitted. 155. By November 2010 Child R was on a final warning from school because of persistent truanting. Child R was planning to take GCSE’s and to then secure an apprenticeship with an interest in becoming a chef. 156. At the beginning of January 2011 Child R was experiencing episodes of fainting that would recur on a regular basis. 157. In February 2011 Child R was referred to the pupil welfare services and was transferred to the pupil referral unit (PRU)18. The PRU is part of alternative education provision and falls within the scope of services that provide education other than at school is intended to help a return to a mainstream school setting. This referral to the PRU was however the beginning of Child R’s transition from mainstream education. It was this transition that Child R’s parents felt introduced Child R to other young people who were experiencing a range of problems and needs and had exacerbated matters for their child. 158. Child R was by this stage presenting as a very troubled young person who was in regular arguments and conflict with peers and continued to be subjected to bullying through the internet and social media. Child R was difficult to engage with at the PRU and did not seem very confident; this was in contrast to the more outgoing and sociable young person that for example 18 This is an establishment maintained by a local authority which is specifically organised to provide education for children who are excluded, sick, or otherwise unable to attend a mainstream or special maintained school. There are 13 pupil referral units in Lancashire. Page 32 of 60 the PCSO had dealt with in 2009. Child R was walking out of lessons and was becoming sexually explicit in her conversations. Child R was referred to the local sexual health team for additional support. Child R was also going missing from home. 159. Child R attended the epilepsy clinic with mother and was seen by a consultant paediatrician who as well as making arrangements for physiological examinations also suggested that Child R made another appointment with the counsellor as a major adverse life event could be an underlying cause of the present symptoms. 160. In mid March 2011 CSC completed the fifth initial assessment; this appeared to be in response to the vulnerable child notification from the police. The assessment concluded that the parents were being ‘protective’ and were able to safeguard Child R (who was continuing to go MFH). The parents had disclosed that they had cut back on alcohol knowing that Child R was upset about this. The assessment noted that Child R was attending the PRU and that the criminal trial regarding the rape had been delayed causing further upset to the family. The assessment led to no further action by CSC and the case was closed. 161. Child R’s mother told the victim support service that she was hoping that Child R could change schools; they had concerns about the people that Child R was mixing with. 162. In May 2011 Child R was referred to the local young people’s counselling service and Child R attended the first session at the end of May 2011 when Child R was advised that discussion about the rape was not possible due to the pending criminal proceedings. The consequences of the rape were discussed in regard to the difficulties that Child R was having in relationships, sleeping and eating. The sessions also allowed Child R to talk about the difficulties that the family had in knowing how to support Child R and in response to the reaction of the perpetrator’s family. 163. At the fourth counselling session in early July 2011 Child R discussed an impending school visit to the prison where the perpetrator was in prison; this appeared to be a fabrication on Child R’s part. At the sixth counselling session Child R described the sessions as being helpful in providing a space to talk without being judged and did not have to hide behind a mask. The counselling was suspended over the school holidays until September 2011. 164. In July 2011 Child R was awarded compensation under the criminal injuries compensation scheme which was paid into a trust fund for Child R’s benefit. In July 2011 Child R transferred to the ACER service (alternative and complementary education and residential service) in the unitary authority as a day student. Child R’s absence from education had required a contact by the pupil welfare service which involved a home visit and a subsequent letter Page 33 of 60 giving notice of legal action if Child R’s attendance did not improve. Following the letter there was a significant improvement in Child R’s attendance. 165. Efforts to re-establish the counselling in late September 2011 were not successful. Although Child R expressed a wish to resume, no arrangement was agreed by Child R to the offers made by the counsellor. The counselling service formally closed their involvement in November 2011. 166. Child R was not in education (although not removed from roll) from September 2011 until December 2011. Child R was now deemed to be the responsibility of the county education services. Child R had been offered a place at a local college but was permanently excluded when Child R made threats to other students who Child R’s parents’ state had been abusing and harassing Child R via the internet. Child R’s parents felt they had to be very persistent in getting an offer of education to be made. A place was made available at a second PRU. This involved attending for one afternoon a week and for the rest of the week to be spent in a work related learning (WRL) placement. 167. In October 2011 Child R had gone missing from home and had phoned home to say that having drunk alcohol Child R did not know the location to be collected from. The police managed to locate and return Child R home. 168. In November 2011 Child R was the victim of assault and battery by an ex-boyfriend. 169. In December 2011 the local child and parent support service (CAPSS) became involved through a child in need plan (CIN). 170. Child R began work in a day nursery in January 2012 although this ended in February after Child R had been challenged about smelling of cigarette smoke and having inappropriate conversations about lifestyle with other workers (drug use, alcohol use and being raped). 171. At the end of November 2011 the police made a further referral to CSC after the latest MFH and Child R’s parents feeling that they were at the end of their tether. This was the 17th incident of MFH. A sixth initial assessment was completed; Child R had commenced drinking again after a period of abstinence. Child R had begun to have blackouts. Child R was associating with older males. Child R’s parent's illness was in remission. The outcome of the assessment was that a child in need plan (CIN) would be developed involving the child and parenting support service (CAPSS) with weekly sessions to be offered for Child R. The first session was in mid January 2012. 172. In January 2012 a further appointment at the counselling service was offered although Child R did not arrive (DNA). A second appointment was Page 34 of 60 offered for late February 2012 but when that was another DNA; the counselling service closed their involvement for the second time. 173. In January 2012 the education diversity service arranged for a college placement for Child R although this broke down almost immediately due to Child R’s poor relationships with other students. 174. In early February 2012 Child R told mother after the 18th incident of MFH that Child R had been raped while MFH; Child R was 15 years old. This was reported to the police who had discovered Child R the previous evening with two adults and had served section 2 abduction notices19. The allegations were subsequently withdrawn. 175. At the end of February 2012 Child R was referred to Addaction the young people’s substance misuse service. 176. In late March 2012 Child R went to the GP with mother. The presenting problem was intentional self-harm having taken an overdose the previous week but Child R had also been making cuts to the arms. The patient history recorded was being sexually assaulted in 2010 and again in 2011. Child R was having flashbacks and had low self-esteem and wanted to die and had taken an overdose the previous week but had told mum. The GP was told that Child R’s behaviour ‘went off rails’ after the rape in 2010 and Child R doesn’t see the point in being good as people can do what they want. Child R reported having no definite plans to kill them self but Child R said wished to die. 177. The GP made an urgent referral to CAMHS (child and adolescent mental health services). During the first CAMHS session three days later with a CAMHS psychologist Child R was ambivalent regarding personal safety and made reference to future attempts at suicide using a different method. 178. Child R was reported to be disappointed that counselling was not working and had feelings of wanting to die for 80 per cent of the time, feeling ambivalent about living, felt hopeless about the future, had an erratic sleep pattern, poor appetite and had lost weight. Child R had self harmed since the 19 Section 2 covers offences committed by a person not connected with the child, who unlawfully takes or detains a child under the age of sixteen. The offence can be prosecuted either way. The maximum penalty on indictment is seven years. Child Abduction Warning Notices (formerly known as Harbourers Warning Notices) issued under section 2 of the Child Abduction Act 1984 (as amended by the Children Act 1989) are a useful tool enabling the police to disrupt the criminal or undesirable activities of adults who are associating with young people against the wishes of the young persons' parent(s) or local authority carer. The notices tend to be used where arrest/prosecution for any substantive offences is not available or is not appropriate at that time. Page 35 of 60 rape July 2010, but had not cut since Jan 2012. Child R’s perception of the problem was it this was due to being raped July 2010 and then a further attack in February 2012 when the police and CPS did not prosecute after Child R had withdrawn the complaint. Child R talked about feeling left with more negative thoughts and feelings. Child R reported having been to the Safe Centre20, but felt that this was of no real help. Child R felt unable to trust anyone, and had in the past been missing from home, and walked around the streets. Child R admitted to occasionally drinking alcohol, but denied drugs or any other substance. A further session was booked in a month’s time. 179. Child R was not assessed as being a risk to others. Child R was identified as being vulnerable due to their level of understanding and placing them self at risk, by absconding and walking the streets alone. The psychologist felt that Child R was willing to engage with services and appeared to have the ability to develop friendships. Child R still had feelings of wanting to die. 180. The second CAMHS session (Child R missed the previously scheduled second session) was with a senior practitioner. Significantly, it was coincidentally two weeks before Child R’s 16th birthday; the protocol is that young people aged 16 or over are referred to adult mental health services rather than CAMHS. 181. During the session Child R presented with several significant issues. Child R had suicidal ideation (a medical term for thoughts about or an unusual preoccupation with suicide) with violent and impulsive plans (to hang from a pier), extreme anger that was externalised, use of alcohol and drugs to manage emotions. Child R had a poor body self image, was reported to have lost weight, at times being sick. Child R was impulsive and physically aggressive to peers. Child R had an overwhelming urge to self harm, but was resisting those urges, but had used self harm as a control mechanism, following sexual assaults. Child R discussed the recent bereavement following the death of a friend (first name was given) who had died as a result of an accident; this incident had exacerbated Child R’s low mood. Child R also had sleep problems and flashbacks, to many years ago after witnessing a friend killed in a hit and run accident (referred to in earlier sections of this report). Child R also had flashbacks to the sexual assaults. 182. Following the CAMHS session the senior practitioner made a referral to the Single Point of Access for adult mental health services in the county because of Child R’s age21. CAMHS would continue to be involved until the 20 The SAFE Centre offers medical examination, advice and support to women, men and children who have experienced sexual assault or rape and is operated by the Lancashire Teaching Hospitals NHS Foundation Trust 21 This is the single point of access for adult mental health services and is through telephone, fax or post. Referrals are triaged by a mental health practitioner. Page 36 of 60 referral was accepted by the Single Point of Access Service. At around the same time, Child R was discharged from the epilepsy clinic. 183. The initial assessment by the Single Point of Access was that Child R should be referred onto the Crisis Team although that service was not able to accept a referral because Child R was not yet 16 years old. 184. In early May 2012 Child R had her last session with CAMHS because of the referral made to the Single Point of Access, and Child R and mother both felt overwhelmed with appointments as they were also seeing a family support worker alongside the addiction worker every week. 185. In the first week of May 2012 the CAMHS senior practitioner made another referral to the Single Point of Access to activate the referral to adult mental health services. Child R had made three attempts to self harm in the previous six weeks. An initial assessment was completed at Child R’s home by a community mental health nurse (CMHN) two weeks later. Child R was discharged from CAMHS at the beginning of June 2012. Child R was diagnosed with post traumatic disorder. A recommendation was made for Child R to participate in cognitive behavioural therapy (CBT). A referral was made to the young people’s counselling service. 186. Child R’s behaviour at the PRU was continuing to be problematic with swearing and being rude. Child R was also continuing to regularly go MFH. 187. Child R and mother completed the Strength’s and Difficulties Questionnaire at the end of July 2012 and technical report was completed and a diagnostic prediction made of high risk to Child R from a behaviour disorder and of medium risk from an emotional disorder. 188. During a home visit by the CMHN in mid August 2012 Child R reported that everything was fine and that they had ‘managed to sort everything out’. Child R continued to report positive improvements during an out-patient appointment at the end of August 2012 that included sleeping much better and that there had been no further incidents of self harm. At the end of August 2012 the CMHN discussed closing involvement now that a referral had been made for counselling. Mother agreed that Child R might be better seeing a counsellor and that this would then not have ‘too many agencies involved’. 189. The day after this conversation the counsellor made a no access home visit to Child R. At the beginning of September 2012 Child R again went MFH. Child R declined to go home having now become 16 years old. Child R was staying with an older male who was suspected of dealing in drugs. This caused particular distress to Child R’s parents who have commented that they felt unsupported in being able to persuade Child R to return home. Page 37 of 60 190. A CIN review meeting at the beginning of September 2012 was informed that counselling had started although there is no recorded evidence that this had happened despite the efforts of the service to set up appointments. Child R had left the county and was reportedly in East Anglia according to a telephone call from Child R. The next telephone contact was allegedly from the West Country. Child R was due to go to college. The CAPSS (child and parent support service) closed their involvement in mid September 2012. The substance misuse service had resumed contact with Child R. 191. The victim support service had their last contact with Child R in late September 2012 after Child R had been assaulted by another female. 192. Child R returned home in mid September 2012 and made contact with the counselling service and attended a counselling session in mid September 2012. During the counselling session Child R alleged a third rape. This was discussed with a member of the Awaken Project. This contact was included in the mental health records but a record was not made by the Awaken practitioner. According to the record, Child R had named an individual who was known to the police and to the Awaken Team. The Awaken partnership worker acknowledged that Child R had a right to make a formal report although this did not happen. There was no further follow up in respect of the allegations. 193. The Young Addaction service closed their involvement at the end of September 2012 and referred Child R to The Hub (another substance misuse service in Blackpool for young people). 194. In January 2013 the counselling service wrote to Child R offering an appointment for counselling. The appointment was not kept. Child R contacted the counselling service to apologise for the DNA and asking for a new appointment. Child R was killed later that same day. Page 38 of 60 3 Analysis of key themes for learning from the case and recommendations 195. Any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable young people and families has to understand why things happen and the extent to which the local systems (people, processes and organisations) help or hinder effective work within ‘the tunnel’22. 196. This chapter sets out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The findings are framed using a systems based typology developed by SCIE. 197. The purpose of using the following framework is to identify the underlying patterns that appear to be significant for local practice in Lancashire. a) Cognitive influence and human bias; b) Responses to incidents and information; c) Tools for informing professional judgments and decision making; d) Management and agency to agency systems. 198. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to the key findings: a) Does the Board accept the finding? b) How is the Board to take this forward? If not, to explain why. c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported? 199. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published. 22 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight. Page 39 of 60 3.1 Cognitive influence and human bias Definition and response to risk for older children; recognition of abuse and risk to teenagers from outside their home; 200. This part of the analysis explores how people working with Child R processed information and attributed meaning or interpreted aspects of behaviour and what it represents in terms of work with vulnerable adolescents who are at risk. 201. The way that people think about the behaviour of another person and how they interact with them has an influence on how information is processed and their judgments are formed. Professionals undertake training and development, and are often very experienced, although they can be subconsciously susceptible to these influences. Further complications arise in working with young people able to articulate views, wishes and feelings that for example may minimise risk. 202. In this particular case, although there was a recognition that Child R was at risk from aspects of behaviour and circumstances, this did not lead to Child R being defined and helped through multi agency frameworks as a child at risk of significant harm although Child R did receive extensive support from many different people and services although this was generally confined to working in agency silos. Child R was also seen by many people as resilient with a positive personality that may have masked underlying needs and emotions and feelings of low self image. 203. The serious case review has collated and analysed information from disparate sources that has revealed a fuller picture of Child R’s circumstances than was available to the people who were trying to help Child R. 204. Vulnerable or troubled adolescents whose lifestyle represents a risk of harm can be a reflection of their underlying needs and difficulties rather than a choice of lifestyle associated with adolescent experimentation and developing greater independence. This is a fundamental principle that needs to inform how vulnerable or troubled adolescents are advised, helped and supported. 205. Child R engaged in risky relationships went missing from home and engaged in other harmful behaviour. This was recognised but the response was generally limited to offering advice. Not all of this can be attributed to the difficulties of service delivery described in other parts of the report. 206. The fact that adolescents are less dependent on carers and have the capacity through their behaviour and their general demeanour and interaction to encourage or reject advice, help and support makes it a challenge for any professional and parent. Page 40 of 60 207. A differential bias in how the needs and risks facing teenagers has been the subject of academic discussion and highlighted in an early examination of serious case reviews that took place in England in 2001-200323. The authors of that study commented that in general, there appeared to be a range of assumptions about adolescents in relation to abuse and neglect which lead to different perceptions of them from younger children who are suffering similar significant harm. 208. Older children are generally thought to be better able to take care of themselves, can avoid physical harm, keep out of the way or ask for help. There can also be unspoken assumptions that perhaps they have in some way brought the difficulties on themselves or that they have at least in some way contributed to the situation they find themselves in. This appeared to be the source of some of the conflict that Child R experienced with other students and some other people. It can also make them a target for more predatory sexual and emotional behaviour. 209. Evidence from this case as well as in national studies, non-attendance at school or involvement in substance misuse can elicit a limited response amongst professionals which focuses solely on the adolescent’s behaviour and not on the wider circumstances in which they were growing up and the triggers for why they behave and interact with their world. 210. There are often family and environmental factors that need a more in-depth assessment and a more coordinated planning of services that may reveal a threshold of concern about harm requiring a child protection plan. Child R was the subject of a CIN plan but not an in-depth assessment that managed to collate information about relevant history and trauma and coordinate the perspectives and involvement of different professionals. 211. The child protection system has been primarily designed to assess risk within the home and a parent's capacity to safeguard and protect their child from harm; this was reflected in the assessments that focused on a judgment as to whether either of Child R’s parents were a risk rather than a wider view of both risk and the sources of resilience that were available to Child R. 212. For teenagers such as Child R, risk exists in their peer groups, schools, neighbourhoods as well as increasingly online; these are all potentially environments that can provide opportunity for harm that any professional and parents struggle to tackle and are demonstrated in this case. 23 Improving safeguarding practice Study of serious case reviews 2001–2003; Rose W and Barnes J; The Open University Page 41 of 60 213. Child protection systems are generally built to protect children from adults who seek to hurt them. The Children’s Commissioner for England’s report and the separate NPSCC toolkit published in November 2013 demonstrate that young people are also harmed by their peers. In this case, Child R was sometimes a perpetrator of harm as well as on others being a victim. 214. When teenagers have been harmed in their peer groups, schools, neighbourhoods, or online, individuals and organisations can be reduced to moving them rather than making those spaces or environments safe for them. In Child R’s case, matters were exacerbated at times when Child R had instigated or aggravated situations. Such behaviour was difficult to manage in a PRU and therefore was much more problematic in a much larger secondary school environment. 215. Professionals are struggling to identify this form of abuse and when they do it is far from clear how they are meant to respond to the child who has been harmed and the child who has caused the harm. Issues for the LSCB to consider in regard to learning and improvement 1. Is there sufficiently good understanding about the nature of risk taking behaviour by vulnerable teenagers and thresholds for escalation into formal risk assessment and management processes? 2. Is there systemic bias about using the safeguarding frameworks to assess and manage risk to older children? 3.2 Responses to incidents or information Dangers of working too much in the moment without any context of history or other agency knowledge; purpose and function of reports about incidents such as MFH; the focus and outcome of assessments of vulnerable teenagers whose lifestyle and ideation represent risk of harm; 216. Child R experienced very significant levels of trauma that were largely unknown to the professionals in contact with Child R. Histories of even relatively minor health or developmental issues can impair parent-child interaction and relationships which can be further compounded by other factors such as high use of alcohol. 217. There was never a full history taken for Child R and the family and therefore a great deal of information still remains out of view. Information that has become clear during the SCR includes the early experience of bereavement and an extended period of grief reaction for Child R. This coincided with the suicide of a relative and the apparently sudden move of the family to Lancashire which disrupted an early and apparently significant childhood friendship for Child R. There was also a serious and long term illness for one of Child R’s parents. Page 42 of 60 218. These were all important factors that deserved more exploration (if they had been known about) when for example a statutory assessment was opened on six different occasions rather than progressing to a core assessment. 219. There was an optimistic expectation that Child R’s parents were able to respond to Child R’s behaviour and difficulties. Although advice and support in regard to parenting was provided there was not enough attention to exploring the style of parenting and how this related to Child R’s needs. 220. Deficits in regard to how parenting assessment and support was provided in regard to Adult 1 during childhood were identified in the expert report for the review. 221. Although there were efforts to involve Child R in a youth club and positive activities that offered the potential for social support and resilience outside of school these became disrupted through relationship difficulties with peers. 222. As Child R developed into adolescence additional needs and behaviours became manifest in respect of risk taking, extreme mood swings, withdrawal and disruption. 223. For the most part, all of this was looked at through a behaviour management perspective that focussed on reducing Child R’s disruption. Matters were further compounded by changes to some of those structures that had the effect of accelerating Child R’s transfer from at least one educational setting. Those arrangements do not apply now. 224. The collation of the inter-agency chronology and the gathering together of practitioners for the analysis and learning event in November 2013 provided evidence of the extent of contact that had taken place across several different services and locations. 225. What also became clear was the extent to which people were largely unaware of contact and involvement by other professionals. Some of this reflected an ethical or philosophical stance for example in regard to providing counselling and preserving absolute confidentiality to Child R. 226. This provided opportunity for Child R to present variations or emphasis on different aspects of information. For example Child R gave accounts of being in court for the sentencing of the adult convicted of raping Child R. 227. The absence of a good enough overview of information was a significant theme to come from the practitioners’ event. Other phrases such as being more persistent and tenacious in following up concerns and information and making a fuss about gaps in information came up more than once. Page 43 of 60 228. Other issues were a reliance on information being provided by Child R and the family rather than taking a more inquisitive approach. The processing of at least ten vulnerable child reports and the six statutory initial assessments did not lead to significant additional information being revealed. 229. The MFH protocol was not fully invoked; this requires the escalation of enquiry as well as oversight by more senior managers if a child or young person is frequently missing from home. Revised national guidance has been published by government and will be considered by the LSCB. This is described in further detail in the next section of the analysis. 230. In spite of this extensive range of contacts and reports, nobody achieved a true overview and the focus remained on responding to the immediate presentation of behaviour. 231. More rigorous collation of the information would have created clearer opportunity to identify the degree of need and risk more accurately more completely. 232. The introduction of the MASH and the implementation of revised reporting arrangements in regard to vulnerable people will provided a greater degree of oversight. 233. Previous serious case reviews have highlighted issues in regard to the importance of enquiring into the individual and family history of children and families. Issues for the LSCB to consider in regard to learning and improvement 1) Is there sufficient clarity and understanding that the missing from home (MFH) protocols apply to children who go missing from home irrespective as to whether they are children who are looked after by the local authority or live with their family, friends or other private arrangement? 2) Are arrangements in place to ensure that contact and referrals in regard to vulnerable teenagers through the MASH are processed and followed up through the relevant risk assessment frameworks? 3.3 Tools for informing professional judgment and decision making The use of risk protocols and frameworks for identifying and following up vulnerable young people; using information for escalation and adaptation of intervention strategies; Page 44 of 60 234. A serious case review will by the nature of the circumstances under which such a process has been commissioned have to examine the judgments and decisions that were influential in a particular case. Simply using hindsight to challenge historic decision making does not help identify how improvements can be achieved. 235. Decision making is of crucial importance. Professional judgment of the different practitioners but particularly in the police and CSC represents complex ethical and legal considerations in regard to the use of any statutory powers or duties and especially when working with young people who will have an increasing sense of independent thought, feelings and wishes. 236. Professional judgments should be based on having relevant knowledge and sound reasoning applied to the circumstances and attributes of the child and their family. That is why issues such as the conduct of assessments and taking adequate histories are so important. 237. Assessment tools should support the comprehensive gathering or ordering of information, to indicate if there is an increased possibility of harm, to guide analysis or to support multi-professional working as well as gathering data for monitoring and service development purposes. 238. A starting point has to be the purpose and understanding of any work processes and protocols that are used to help identify children who are either at risk of significant harm or are in need of services to prevent the impairment of their health or development. 239. There are three significant frameworks that applied to Child R’s circumstances. The first, in the order of chronology, is the MFH joint protocol. The framework describes the action to be taken by the police and local authority when a child or young person (under 16) goes missing from home (or care). 240. Key stages of the process describe the initial reporting and response to locate the child and then a graded response that is intended to identify children at higher levels of risk. The procedures require the police to make a referral to the local authority if there is evidence of the child being sexually exploited or at risk of significant harm. A referral, via the VC police form was sent to CSC on at least ten occasions between November 2009 and November 2012. 241. Not all of those referrals appear to have been logged by CSC; at least they did not show on the chronology of agency contact prepared for the SCR. An initial assessment was completed on six occasions by CSC (and there was an initial assessment by the mental health service point of contact); this never progressed to a more detailed core assessment. Page 45 of 60 242. CSC is responsible for deciding whether a return to home interview is undertaken; this was apparently done on two occasions although not by a social worker. The return interviews are locally mandatory if the child has been missing for more than 24 hours; the majority of Child R’s MFH were for shorter periods. 243. A mandatory return interview is required if the child is MFH on two or more occasions or there are mental health issues or a crime has been committed. Child R had been MFH on 28 occasions was exhibiting symptoms of emotional and psychological distress and was on several occasions located with adults some of whom had sex with Child R under the age of consent. The purpose of the interviews are to; a) To better understand the reasons why the child went missing; b) To explore the circumstances which led to the missing episode(s); c) To inform future prevention strategies; d) To inform any future missing person investigation; e) should that person go missing again; f) To learn of the activities, associates, risks and victimisation involved in the missing episode, and where possible to address those risks with appropriate and proactive strategies such as the use of the harbouring warning notices under the Child Abduction Act (see previous supporting footnotes and were used in this case); g) To identify and address any harm the child has suffered including harm that may not have already been disclosed as part of the safe and well check. 244. The MFH protocol also describes an escalation policy. After five episodes within a 90-day rolling period there should be a first stage intervention meeting. This level of intervention meeting is described in the protocol as the crucial stage in avoiding serious escalation and must, therefore, be given high priority by all concerned. Within four working days of the last episode (reaching the threshold level) these meetings must be held and representatives from each organisation or interested party must be present. 245. The meeting should be chaired by a children’s services manager. After nine episodes within a 90-day rolling period there must a second stage intervention meeting. Within four working days of the last episode (reaching the threshold level) these meetings must be held and representatives from each organisation or interested party must be present. The meeting should be chaired by an independent reviewing officer (IRO) or a children’s services manager, and attendees should include: a) Child (subject to discussion about appropriateness); b) Team manager; c) Social worker or relevant lead professional; d) Local Police Missing Person Coordinator and Page 46 of 60 Champion; e) Parent and or carer, residential unit manager or fostering manager; f) Person who conducted return interview if different to above; g) Other relevant professionals (for example health, education, Youth Offending Teams). 246. The guidance explicitly states that any agency or professional who has increased or serious concerns for a child’s well-being or safety then they may call a multi-agency strategy meeting at any time, regardless of the number of missing episodes. 247. Further strategies should continue to be managed by the senior manager for the area in which the child lives until the risks to the child have reduced and/ or the missing episodes have been reduced or ceased. If there is no reduction in the missing episodes the senior manager must take responsibility for escalating the case up the management hierarchy. 248. It should be noted, however, that the volume of missing episodes is not the only reason to launch an intervention or to escalate the level of intervention. The following are examples of other reasons to initiate or escalate interventions: a) Any case where the risks involved in even a single future missing episode is very high; b) Cases where it has been identified that immediate action is necessary to ensure the well being of the child. 249. None of this escalation policy was applied in regard to Child R and it was not apparent that practitioners had been aware of the full protocol. The only consistent application of the protocol was by the police who completed the safe and well checks after each episode of MFH. The fact that Child R was frequently located well within 24 hours may have contributed to seeing the protocol and framework as not applying to Child R’s circumstances. 250. The MFH protocol draws attention to the risk to children who go missing that includes sexual exploitation and abuse. The point is made even more strongly in national guidance issued as recently as 201324 that children who are most vulnerable to sexual abuse and exploitation are those children like Child R who regularly go missing from home. 24 Statutory guidance on children who run away or go missing from home or care; June 2013. The guidance makes a distinction between children who go missing and those who are absent. Missing: Anyone whose whereabouts cannot be established and where the circumstances are out of character or the context suggests the person may be subject of crime or at risk of harm to themselves or another’; and Absent: ‘A person is not at a place where they are expected or required to be’. Page 47 of 60 251. This is not to suggest that one causes the other but does highlight the heightened risk that goes alongside the other factors that contributed to Child R adopting a risky lifestyle. These were not conscious choices but a reflection of emotional and psychological difficulties that were exacerbated by factors such as substance misuse. The local protocols for CSE described in some detail in earlier sections of the report are the second important framework relevant to this case. 252. The local protocols for CSE in Lancashire are set out in the online safeguarding procedures and have been used to good effect with other young people as evidenced in the regular and routine reports to the LSCB. 253. The procedures include a specific referral form for recording information and for reporting to specialist professionals and groups. The protocol is a more useful framework for dealing with an organised network rather than the individual circumstances of a child such as Child R and serial relationships. There is also an additional dimension as far as defining and sharing a common understanding about what constitutes sexual exploitation. 254. The third framework that has relevance to Child R concerns statutory assessments. Up until April 2013 there was a national assessment framework that distinguished between initial and core assessments. Following the publication of the latest Working Together in March 2013 the responsibility for developing a framework rests with local authorities. The learning from this case is that none of the assessments were adequate for discovering Child R’s history and circumstances. 255. There was an apparent reliance on Child R being ‘safe and well’ after returning from MFH and Child R’s parents were regarded as not posing a risk to Child R. This contributed to the assessments never exploring the underlying reasons and circumstances for Child R’s behaviour and lifestyle. There was also high reliance on counselling providing an outlet for Child R to discuss problems. That was hampered by misunderstanding about what could or could not be discussed in regard to the rape for example. 256. Effective assessment involves knowledge and skills in areas such as child development, emotional and psychological needs of children, retrieving research and other knowledge from electronic sources, appraising its quality and relevance, synthesizing the findings, disseminating knowledge to guide judgments, and applying knowledge appropriately in individual decisions about client care. It also involves talking with other relevant people and collating and analysing information. 257. A fourth and additional area of learning relates to relationship abuse. Risk factors are used to guide prevention work, to identify people who could be at Page 48 of 60 risk. The risk factors of becoming involved in an abusive relationship can be the same as person who is experiencing abuse. a) Experience of violence in the home; b) Depression in childhood; c) Poor mental health; d) Problem drug and alcohol misuse from early age; e) School non-attendance; f) Disruption of family unit / being ‘in care’; g) Sexual relationships; h) Having a child as a teenager; i) Poverty; j) Sexual exploitation and sexualised risk taking. 258. It is important to think about things that can protect young people from being involved in a violent relationship. Some key protective factors are: a) Achievement at school; b) Parents being aware of the young person’s activities and relationships; c) Having a safe haven; d) Support from positive role models; e) Confidence, self-esteem, being able to stand up for themselves; f) Sense of physical, emotional and economic security; g) Belief that others have high expectations of them; h) Participation in engaging and challenging activities ; i) Sense of belonging; j) A strong support network. 259. All schools should be aware of and addressing relationship abuse. While anti-bullying policies are common, a specialised policy that addresses the unique aspects of abuse in young people’s relationships is critical to appropriately safeguarding young people. Central to safeguarding is the teaching through sex and relationship education of what constitutes a healthy relationship. Implicit within this is the challenging of stereotypes such as female passivity and male aggression and the recognition that relationship abuse can happen to anyone, no matter what their gender, social background or sexual orientation. 260. The MFH and CSE arrangements in Lancashire are now overseen by senior managers and are the subject of regular reports to the LSCB. 261. The establishment of a MASH in Lancashire is a very significant development in recent months and will create improved opportunities to develop effective help to children who have similar circumstances to Child R. The collocation of key services such as police and social workers with other Page 49 of 60 specialist staff will create better opportunity to collate information across several different services and reduce the silo working. The MASH will routinely create combined chronologies that can highlight risk more quickly than was available previously. Issues for the LSCB to consider in regard to learning and improvement 1. How does the LSCB assure itself that systems of training and quality assurance are sufficiently effective in ensuring practitioners are accountable for their compliance with relevant professional standards and safeguarding protocols that include those for MFH and CSE in regard to older children who maybe resistant to help and intervention? The diagnosis and response to conduct disorder in childhood; 262. The expert forensic psychiatric report in regard to Adult 1 indicates that he had an undiagnosed conduct disorder from early childhood. Conduct disorder presents with repetitive and persistent patterns of behaviour in which the basic rights of other people are violated. 263. The same report draws attention to how conduct disorder commonly coexists with other mental health problems and that ADHD is particularly prevalent. Adult 1 was diagnosed with ADHD (but not conduct disorder). 264. A diagnosis of conduct disorder is strongly associated with poor educational performance, social isolation and increased incidents of substance misuse and contact with the criminal justice system in adolescence. Conduct disorder is also associated with a significantly increased rate of mental health problems in adult life. 265. The importance of diagnosing conduct disorder arises in regard to the risks to the emotional and mental health of the child and anticipating some of the longer term difficulties they may face. The expert report discusses the proven value of multi systemic approaches as well as using medication such as Ritalin which was prescribed long term for Adult 1 during childhood. There is encouraging research evidence that early identification and treatment of conduct disorder can be effective in preventing the onset of other disorders in later life. 266. The expert psychiatric evidence draws attention to the NICE evidence for promoting the development of more effective interventions. 267. This multi-systemic approach is an intensive treatment focusing on all aspects of an individual’s life and environment including the school and the family. It also focuses on strengths and increasing the individual’s responsibility, it targets sequences of behaviour. The components of this type of treatment approach include broadly; Page 50 of 60 a) Parent training aiming to improve parenting skills. There are many randomised controlled trials suggesting that it is effective for children particularly before they are ten years old; b) Parenting interventions based on social learning theory address the parenting practices identified as contributing to conduct problems; c) Individual skills and anger management. Most of the programmes to improve child interpersonal skills derive from cognitive behavioural therapy (CBT); d) Educational interventions; e) Peer group skills. 268. The development of Adult 1’s sexually inappropriate behaviour in adolescence should have resulted in a referral to the FACTS team25. Multi agency arrangements that can deliver sufficiently integrated help to higher risk children 269. The expert report commissioned for the SCR identified shortcomings in relation to multi agency working and this is reflected also in the analysis in regard to Child R. 270. Both received significant intervention although this was not integrated with other local and specialist services such as CAMHS. The assessments that were completed on both Child R and Adult 1 when he was a child and adolescent were single agency. In regard to Adult 1 he was the subject of some very thorough educational assessment and support although this was done in isolation from the local CAMHS. Both Child R and Adult 1 presented with significant psychological difficulties that were not satisfactorily assessed. Referrals were not made. 271. In regard to Adult 1, his behaviours became less visible in later adolescence and probably reflected the fact that he was in placements where he was under less scrutiny. 272. NICE published guidance in 200626 in regard to the efficacy of parent education and training programmes in the management of children with childhood conduct disorders. The guidance recommends that group based and individual programmes should be available. 273. It is recommended that all parent-training/education programmes, whether group- or individual-based, should: 25 Forensic Adolescent Community Treatment Service for high risk young people. 26 Parent-training/education programmes in the management of children with conduct disorders Page 51 of 60 a) be structured and have a curriculum informed by principles of social-learning theory; b) include relationship-enhancing strategies; c) offer a sufficient number of sessions, with an optimum of 8–12, to maximise the possible benefits for participants; d) enable parents to identify their own parenting objectives; e) incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation; f) be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents NICE Technology Appraisal; g) adhere to the programme developer’s manual and employ all of the necessary materials to ensure consistent implementation of the programme. 274. Programmes should demonstrate proven effectiveness. This should be based on evidence from randomised controlled trials or other suitable rigorous evaluation methods undertaken independently. 275. Programme providers should also ensure that support is available to enable the participation of parents who might otherwise find it difficult to access these programmes. Issues for the LSCB to consider in regard to learning and improvement 1. Does the LSCB have sufficient information through the relevant specialist partner agencies about the numbers of high risk young people with conduct disorder to establish the extent to which current arrangements are better able to identify and refer high risk young people to appropriate services? 3.4 Management and agency to agency systems Coordinating support for children and young people across boundaries and in criminal proceedings; transfer and longer term support to young people with childhood mental health needs as they move to adulthood. 276. Child R’s parents raised their concerns about the delay in being able to access to counselling in relation to the rape. It has been apparent that there had been some professional reticence and caution about not talking with Child R about the rape until the criminal trail had been completed. That took almost 18 months. 277. The CPS had already published guidelines for supporting children who have been victims of sexual assault or exploitation. This guidance is principally Page 52 of 60 addressed to people and organisations involved in the investigation and prosecution of criminal cases although aspects of the guidelines should offer support to improving future arrangements for children such as Child R. 278. The guidelines require thought to be given to how support will be provided before, during and after criminal proceedings. The CPS guidance Provision of Therapy for Child Witnesses Prior to a Criminal Trial is clear that the best interests of the victim or witness are the paramount consideration in decisions about therapy. There is no bar to a victim seeking pre-trial therapy or counselling. Neither the police nor the CPS prevented therapy from taking place prior to the trial in this case and is very well understood by the police. The Investigative Training Centre (CID training) even include it on the Tier 3 (Specialist Witness Interviewing). 279. The guidance draws attention to specific issues that included consultation with the CPS at the outset about the need for and provision of counselling and deals with particular matters that include for example the problems that will occur if a therapist is attempting to distinguish between fantasy and reality. This was a particular area that was not properly resolved within the counseling service in respect of Child R. 280. The review has highlighted issues in regard to delivering services across boundaries in respect of vulnerable children; this includes identifying and working with children at risk of disruption to their education, children at risk of sexual exploitation and delivery of metal health support to teenagers. 281. The review has also been made aware of several counseling services being reduced or removed. This has led to increased waiting lists before young people can access counseling from services such as the SAFE centre. The availability of services that can provide appropriate therapeutic help to children and young people who have been affected by traumatic events and experiences is an important part of promoting emotional and psychological well being. Many of those services are subject to reductions in resources that lead to delays in providing help and are also increasingly operating on a time limited basis. 282. About five per cent of children aged 5-10 display behavioural problems which are sufficiently severe, frequent and persistent that they justify diagnosis as a mental health condition: conduct disorder. A further 15-20 per cent has problems which fall below this threshold but are still serious enough to merit concern. 283. A wide range of risk factors may be implicated in the early development of severe behavioural problems. Particular importance attaches to adverse influences within the family environment, such as maltreatment and harsh, inconsistent or neglectful parenting. Page 53 of 60 284. The availability of appropriate services that can assess and develop parenting support programmes are an integral part of responding to the needs of troubled children and young people. Parenting support programmes significantly cut the risk of children developing behavioural problems and becoming offenders in adolescence and adulthood, a new study suggests. 285. Analysis of research on the effectiveness of parenting programmes in helping address severe child behaviour problems, such as conduct disorder, concludes that they cut by around half the number of young children that meet the clinical threshold for diagnosis. 286. The analysis, by the Centre for Mental Health (CfMH), also finds that every pound spent on parenting support delivers £4 of annual savings to health, education and social care services. 287. The Centre for Mental Health report, Building a Better Future27 finds that the average cost of delivering a 12-week parenting intervention, such as the Triple P and Incredible Years programmes, is £1,300. 288. In comparison, it calculates that the annual costs of severe behavioural problems is £5,000 in funding additional health, social care and education services for young children, and in youth justice interventions for those over 10 years old. The estimated lifetime cost of behavioural problems is £260,000 compared to £1,300 cost per child of a parenting programme. 289. Children with severe behavioural problems are many times more likely to develop drug addictions, leave school with no qualifications, be imprisoned and become a teenage parent. Issues for the LSCB to consider in regard to learning and improvement 1. Does the LSCB have sufficient information about the availability and appropriateness of services to provide sufficiently rigorous parenting support in regard to children presenting with severe behavioural difficulties? 2. Does the LSCB have sufficient information about the availability of counselling and therapeutic support for children dealing with significant trauma including CSE and childhood bereavement? 3. Is the LSCB satisfied that there is sufficient clarity and understanding on the part of counselling services providing pre-trial support to children and young people who have been victims of sexual crimes? 27 Building a Better Future, Parsonage, Khan and Saunders January 2014 Centre for Mental Health Page 54 of 60 4. What arrangements will be necessary to ensure that the county and unitary local safeguarding children boards are both made aware of the issues and point of learning especially in regard to cross boundary access to services for vulnerable children and teenagers? Peter Maddocks, CQSW, MA. Independent reviewer March 2014 Page 55 of 60 Appendix 1 - Procedures and guidance relevant to this serious case review Legislation The Children Act 1989 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act28 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need. Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998. Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. The Children Act 2004 Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements. 28 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Page 56 of 60 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act29 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others. Safeguarding Procedures The local safeguarding children procedures The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review National guidance30 Working Together to Safeguard Children (2013) The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. The guidance in respect of the Framework for the Assessment of Children in Need and their Families was replaced by the Working Together 2013. 29 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 30 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. Page 57 of 60 Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review. Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008. A step by step guide for front line practitioners (child sexual exploitation) 2012 The step-by-step guide complements, and should be read in conjunction with, the Safeguarding children and young people from sexual exploitation1 statutory guidance published in 2009. It is intended for frontline practitioners in the statutory and voluntary and community sectors (VCS). It outlines the actions they should take, as a minimum, if they suspect that a child they are in contact with is being sexually exploited. Guidelines on Prosecuting Cases of Child Sexual Abuse (2013) These guidelines published by the Crown Prosecution Service (CPS) provide guidance primarily fro prosecutors dealing with cases involving child sexual abuse and sexual exploitation. The guidelines include advice on the support that can and should be offered to the victims before, during and after criminal proceedings. Emphasis is given to establishing clear communication between the services and professionals working with victims. Page 58 of 60 Statutory Guidance on children who run away or go missing from home or care (2013) The guidance draws attention to the link between children who go missing from home and child sexual exploitation. The guidance is issued under section 7 of the Local Authority Social Services Act 1970 and describes strategic and operational guidance in respect of children who go missing from home or care. Page 59 of 60 Appendix 2 Specific questions addressed by the expert 1. In regard to anticipation or prediction of any enhanced risk of harm to others, is there any information or evidence that is particularly relevant or significant in the history provided? 2. To what extent is there any evidence of a personality disorder in the subject’s adolescence and if so at what stage was this a diagnostic possibility and what would be the implications for the subject and for professional practice? 3. If there is evidence of a personality disorder is it possible to provide an opinion about the nature or cluster of the disorder? In particular please comment as to whether there was either evidence or a strong indication of the subject being a danger to others and what treatments or interventions would you have expected to have been developed taking account of any significant new developments in research or clinical and professional practice and understanding? 4. What is the significance of the Devereux Behaviour Rating Scale that recorded significant concern about behaviour in late 2000 (98th centile)? Under what circumstances is the scale used and to what purpose? 5. Please consider the incident in April 2005 referenced in the police chronology regarding the sexual assault of an eight year old boy and provide a view on the advice given that the perpetrator did not have mental capacity. In providing that advice, what measures or information would you expect to have been taken into account in reaching such a judgement? 6. What could explain the gaps in presentation of behaviours for example when attending college in 2006-08? 7. Is there significance in the fact that Adult 1 undertook a college course in the care of small animals and the subsequent incident of serious injury to horses? 8. Are there any other specific incidents or information contained within the bundle that deserves any particular comment or analysis for the purpose of learning? 9. Are there any lessons in regard to policy, professional practice on a single or multi-agency basis for risk assessment and behaviour management? This should include any advice on the training or use of tools or frameworks with severely disordered children or young people for professionals such as social workers and police officers who have particular statutory responsibility for identifying persons who can present a risk to children or young people. 10. Is there anything in the bundle that without the benefit of hindsight could reasonably be a predictor to the development of premeditated sexual violence? Page 60 of 60 11. Is there anything in the bundle to indicate, without the benefit of hindsight, a capability of murder? 12. Is there any additional information or evidence that the review panel should be seeking? The Lancashire Safeguarding Children Board is today publishing a Serious Case Review in respect of the case of Child R. In January 2013 the body of a 16 year old from Lancashire was found in Blackpool. She had suffered multiple stab wounds. She had been lured to commercial premises on the pre-text of a being offered employment. A 23 year old man was arrested and convicted of her murder. The murder of a young person in these circumstances would not normally result in a Serious Case Review being undertaken, however the young person who was murdered had been known to a number of services and was known to be vulnerable. The man convicted of her murder was also known to a number of services, had had a troubled childhood and his behaviour and history were of concern. For these reasons a review was commissioned in order to ensure identification of any issues which could improve service responses in the future. The review concluded that there was nothing to suggest that any individual or agency could reasonably have predicted these tragic events. As is always the case however the review provided the opportunity to reflect and all the agencies involved developed action plans to ensure issues arising from this review were appropriately dealt with. All those action plans have been monitored by the Board and have either already been completed or on target to complete within the agreed timescales. The Report raised a number of issues for the Board itself to consider (see page 53) and information is provided below as to the Board’s response. 1. The Board is not satisfied that there is a sufficiently good understanding about the nature of risk taking behaviour by vulnerable teenagers and thresholds for escalation into formal risk assessment and management processes. In response the LSCB is undertaking a review of the training that is available to help practitioners understand why and how teenagers can and do engage in risky behaviour. As part of this training review, the extent to which practitioners understand how to escalate their concerns will also be examined The review includes examining the multi-agency training that is available from the LSCB and other partnership groups (such as Working Together with Families) but also within agencies themselves. The focus is be on whether training equips practitioners with a full and proper understanding of how to work with teenagers whose behaviour can put them at risk. In addition the LSCB is piloting new methods for delivering learning messages to practitioners through '7 minute briefings'. One of these briefings will focus on teenagers, their risk-taking behaviour and how to work with them most effectively. It will also include details of where practitioners can seek advice and guidance. The review and subsequent actions will ensure that the training and learning opportunities for all practitioners are equipping them with the right knowledge and understanding to most effectively safeguard vulnerable teenagers. 2. The LSCB considers that it is possible, as suggested by the review author, that there may be systemic bias about using the safeguarding frameworks to assess and manage risk to older children. As part of the process of review of training and development the Board will ensure that practitioners understand the frameworks and processes that will best assist them in working with teenagers and their families and using them when appropriate. 3. The Board considers that procedures and protocols in place at the time of these events may not have provided sufficient clarity and understanding that the missing from home (MFH) protocols apply to children who go missing from home irrespective as to whether they are children who are looked after by the local authority or live with their family, friends or other private arrangement. The Missing from Home and Care Protocol in Lancashire which was in place at the time this case was active is in the process of being updated and refreshed as a result of changes to national guidance. It did provide for a differential response to the child dependent upon their care arrangements. This has been revised and is to be re-launched. The launch will be used to raise awareness of the importance of this area of work. The refreshed guidance ensures that emphasis is given to children who go missing from their family homes as well as to those that go missing from Care. To coincide with the refresh of the protocol, an audit of responses to children and young people who go missing is reaching its conclusion and the findings of this audit will be reflected in the protocol and its launch. The findings from the audit will also be considered more widely by the LSCB and any relevant actions will be tasked to the LSCB Missing from Home or Care sub group. 4. The Board considers that the arrangements in place to ensure that contact and referrals in regard to vulnerable teenagers through the MASH are processed and followed up through the relevant risk assessment frameworks is still evolving and that care needs to be taken to ensure good practice is in place. The Multi Agency Safeguarding Hub in Lancashire is evolving and developing and their development will be informed by the findings from this review. The LSCB requires regular evaluation reports from the MASH service to ensure their developments are delivering the best outcomes for all children and families, including vulnerable teenagers. As the service is evolving, the LSCB has asked them to theoretically 'walk through' certain scenarios (for example, the incidents involving Child R), to establish how each incident would be managed. This will ensure that changes to the service continuously improve the way vulnerable teenagers are identified and safeguarded. It is clear that had the MASH been in place when the reports of Child R's vulnerability were generated by the Police the response would have been more robust and effective. 5. The LSCB has mechanisms in place to assure itself that systems of training and quality assurance are sufficiently effective in ensuring practitioners are accountable for their compliance with relevant professional standards and safeguarding protocols that include those for MFH and CSE in regard to older children who maybe resistant to help and intervention. The LSCB has a programme of quality assurance and performance management activity that examines how practitioners use protocols and meet standards. This includes the annual section 11 process but also specific thematic audits. The specific issues around MFH have been set out in response to finding 3. The CSE sub group of the LSCB regularly reviews practice around CSE and the findings from this review will be shared with them to ensure their audit and quality assurance work considers the issues from this review. Both sub groups, for MFH and CSE, have to report to the LSCB after every meeting to provide assurance about the rigour of their monitoring processes. The Learning and Development sub group of the LSCB consider all findings from serious case reviews. They will be required to review multi agency training to ensure the findings from this review are reflected in the training they are delivering, and will also ensure their audit of single agency training assesses how agencies are disseminating the learning from reviews to their practitioners. 6. The LSCB acknowledges that at the time of these events arrangements were not in place to identify and ensure high risk young people were referred to appropriate services It did not monitor information through the relevant specialist partner agencies about the numbers of high risk young people with a conduct disorder. The LSCB acknowledges that this review concluded that nobody could have predicted that Adult 1 would commit such a horrific act of violence. However, the LSCB has not previously requested data and information specifically about young people who may pose a high risk to others. As a result of this finding, a task and finish group has been established to consider the numbers of children involved and also the response to them. The LSCB will require this group to feedback their findings and will request agencies make any appropriate changes to better manage associated risks. 7. The LSCB does not currently require agencies to provide information about the availability and appropriateness of services to provide sufficiently rigorous parenting support in regard to children presenting with severe behavioural difficulties. There has been a significant amount of work undertaken through local partnerships to support practitioners who work with parents experiencing these challenges. For example, in March 2014 Lancashire hosted a conference for a targeted audience of practitioners around the emotional health and wellbeing of children and young people displaying difficult behaviour. The conference focused on what is currently available and where any gaps may be, but also on how to make practitioners and families aware of what is available to them. The conclusions from this conference will be available shortly. The LSCB will seek further information from the Children and Young People's Trust about services that are available to support parents in these circumstances. 8. The LSCB does not currently monitor the availability of counselling and therapeutic support for children dealing with significant trauma including CSE and childhood bereavement. The LSCB recently sought information about counselling services available to children who have suffered bereavement as part of a wider piece of work undertaken by the Child Death Overview Panel. However, this issue is much broader, and requires an analysis of wider counselling and therapeutic support to children and young people. As such, the group that is to review services for young people who may pose a risk to others (finding 6) will also be asked to consider this issue when reviewing services that are available. 9. The LSCB is concerned that this review found a lack of clarity and understanding on the part of counselling services in respect of providing pre-trial support to children and young people who have been victims of sexual crimes. It is clear that the lack of understanding evident in this case resulted in a service which not meet the needs of children and young people when they are extremely vulnerable. The LSCB therefore plans to contact all agencies that provide counselling and therapeutic support to children and young people to seek assurance that they are aware of the guidance and would offer children and young people the emotional support they need when they need it. 10. The LSCB has put in place arrangements to ensure that the LSCB in the unitary council has also been made aware of the issues and points of learning from this review, especially in regard to cross boundary access to services for vulnerable children and teenagers. The LSCB and individual agencies in Blackpool are aware of and have had involvement in the review. The LSCB in Lancashire has formally written to Blackpool LSCB to set out planned actions that apply to 'shared services' that work cross-boundary. However, Blackpool LSCB will also be made aware of all other findings so they can take whatever action they deem appropriate; especially for those agencies that only work in Blackpool. 25 September 2014 |
NC52456 | Hospitalisation of 12-year-old boy with a complex range of physical and learning needs admitted with severe weight loss and numerous severe pressure sores in May 2021. Learning includes: a shared digital system is not always a guarantee of effective communication; exercise professional curiosity when there are a high number of absences from school; when domestic violence is known to occur, there should be an assessment of the impact this might have had on the children; there should be robust attempts to engage fathers when they are involved in the child's life. Recommendations include: heads of service/senior managers of education, health and care services working with disabled children with complex needs should ensure that the recommendations in NICE NG213 relevant to their service are implemented; safeguarding training for all professionals who work directly with children with disabilities and complex needs takes into account the research and learning from safeguarding reviews on how and why disabled children are more vulnerable to abuse; promote the importance of 'thinking family' via a campaign aimed at all professionals involved in assessments and/ or with designated safeguarding responsibilities in their setting; agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal; review the CSPR arrangements to ensure all relevant services are included in scope even if they were not initially involved in the rapid review; undertake a systems review to ensure a robust approach to child in need arrangements.
| Title: Local child safeguarding practice review commissioned by The Bradford Partnership – concerning Harry. LSCB: The Bradford Partnership Author: Carolyn Eyre Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Local Child Safeguarding Practice Review Commissioned by The Bradford Partnership - Concerning HARRY 2 Table of Contents Page 1. The Child and the Circumstances Leading to the Decision to Carry out a Child Safeguarding Practice Review 3 2. The Review Process 3 3. Family Circumstances 5 4. The Facts - Summary of Agency Involvement 6 5. Research and Learning from Previous Case Reviews 30 6. Analysis 33 7. Recommendations 43 Appendix Glossary 50 3 1. The Child and the Circumstances Leading to the Decision to Carry out a Child Safeguarding Practice Review 1.1 Harry has a complex range of physical and learning needs due to his diagnosis of chromosome 9 abnormality. He is non-verbal and at the time of the incident, was almost 12 years old. 1.2 Harry was admitted to hospital on the 21st May 2021 with severe weight loss and numerous severe pressure sores; his body weight had fallen by a third since his last recorded weight in November 2020. 1.3 The Bradford Teaching Hospitals Foundation Trust specialist safeguarding nurse made a referral to children’s social care on the 25th May 2021 under the category of neglect. 1.4 The decision to undertake a Serious Case Review was agreed following a Rapid Review conducted on 11th June 2021. 1.5 A criminal investigation was commenced on 26th May 2021 and closed in January 2022; no charges were brought against any party. 2. The Review Process 2.1 This review followed the process outlined in Chapter 4 of Working Together to Safeguard Children 2018. 2.2 A Review Panel with the following membership was established to oversee the review: Carolyn Eyre, Independent Lead Reviewer & Overview Report Author; Child Safeguarding Practice Review Lead, Bradford Safeguarding Partnership; Deputy Designated Nurse, Bradford and Craven Clinical Commissioning Group; Consultant paediatrician /Named Doctor, Bradford Teaching Hospitals Foundation Trust; Named Nurse, Bradford Teaching Hospitals Foundation Trust; Named Nurse for children, Leeds Teaching Hospitals Trust; Chief Inspector, Safeguarding Partnerships, West Yorkshire Police; Head of Safeguarding, Bradford District Care NHS Foundation Trust; Education Safeguarding Officer, Education Safeguarding Team, Children’s Services, Bradford Metropolitan District Council; Service Manager, for CCHDT, Bradford Children’s Social Care; Area Safeguarding Manager, Multi-Academy Trust. 4 2.3 The Review Panel decided that the review should consider a period from January 2018 when the mother requested support and respite services to 25th May 2021 when the s47 referral was made by the safeguarding nurse at Bradford THFT. Agencies which had been involved with the family between these dates were asked to provide chronologies and analytical reports of their involvement including relevant background information which pre-dated this time period. The key learning from these reports has been used to inform this Overview Report. 2.4 Reports were provided by the following agencies: Bradford District Care NHS Foundation Trust; Bradford Metropolitan District Council, Children’s Social Care; Bradford Metropolitan District Council, Education Safeguarding Team; Special schools 1 & 2 attended by Harry; Bradford Teaching Hospitals NHS Foundation Trust; Bradford and Craven Clinical Commissioning Group, Continuing Care Team; Bradford and Craven Clinical Commissioning Group – regarding General Practice; Leeds Teaching Hospitals Trust; West Yorkshire Police. 2.5 Other agencies involved with the family were identified during the review, and reports or additional information were subsequently provided by: Medical supplies provider; Sibling’s primary school; Bradford District Care NHS Foundation Trust, Paediatric Dental Service. 2.6 The terms of reference for this review were set by the Review Panel in consultation with the Lead Reviewer. 2.7 Chapter 4 of Working Together to Safeguard Children 2018 states that the safeguarding partners should seek to ensure that: “practitioners are fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith” “families, including surviving children, are invited to contribute to reviews. This is important for ensuring that the child is at the centre of the process. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively” 5 2.8 In order to fulfil the first of these principles, the Lead Reviewer held a learning together event to which front line staff and their managers were invited. This helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took. This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used. 2.9 The Lead Reviewer met with Harry’s mother and sibling after the police investigation had been closed; Harry was also present. Attempts to meet with Harry’s father and paternal grandmother were unsuccessful. 3. Family Circumstances 3.1 Harry is White British. He has a complex range of needs due to his diagnosis of chromosome 9 abnormality with brain malformations, severe cerebral palsy, congenital heart disease, asthma, visual impairment, epilepsy, scoliosis, global developmental delay and osteoporosis which makes him highly susceptible to bone fractures. 3.2 Harry has a gastrostomy (a feeding tube directly into the stomach through the abdominal wall), although he does eat some food orally. He has no bladder or bowel control, is unable to sit or weight bear; he uses a wheelchair and is entirely reliant on adults for his care needs. His incontinence, low weight and immobility means that he is vulnerable to pressure sores. 3.3 He is non-verbal although he can communicate pleasure, enjoyment, recognises known carers and can call for his sibling’s attention. Carers who know him are able to recognise when he is experiencing pain. 3.4 He has an education, health & care plan (EHCP) and attends a special school. Sibling attends a local mainstream primary school. 3.5 Harry lives with his mother and younger sibling. Father does not live at the same address although he and mother were in a relationship until 2019 and he often stayed at the family home. Paternal grandmother is closely involved with the family, providing practical and emotional support to mother and the children. 3.6 Mother has a difficult and sometimes volatile relationship with her birth family. 3.7 There has been a pattern of violence within the family over a number of years. Mother has experienced domestic abuse, both verbal and physical, perpetrated by maternal family members and her partner, Harry’s father. The first incident recorded by police was an assault perpetrated by her brother during her pregnancy with Harry. The children have been present during some of these incidents. In addition, the 6 parents have been victims of a robbery, threats and intimidation from external parties, possibly linked to drugs. There have been no recorded incidents of domestic abuse since the parents apparently separated in 2019. 3.8 WYP have been involved in relation to the alleged production and /or use of cannabis in 2012, 2019, 2020 and 2021. In March 2019 and January 2021, cannabis production equipment was discovered at the home address of mother and the children along with a separate offence of abstract electricity, where the electricity meter has been bypassed, being recorded. There is a strong indication that father was using the bedrooms for the production of cannabis. There is no evidence in police or CSC records that this information was shared with CSC regarding cannabis production in the household and the potential harmful impact of this activity on the health, safety and wellbeing of the children. 3.9 Harry has had significant periods of absence from school. His attendance in the years 2017-18 (49.7%), 2018-19 (49.5%) and 2019-20 (38.2%) was well below national averages; almost all absences were authorised as medical. Where Harry was absent due to illness or incapacity, the hospital education team was sometimes involved in provision of home tuition. Sibling has an excellent school attendance record. 4. The Facts - Summary of Agency Involvement 4.1 Introduction 4.1.1 This section of the report provides a factual summary of key areas of agency involvement with the family. It is not a comprehensive record of all contacts with the family but focuses on key episodes that are considered to be significant to the way the case developed. 4.1.2 Harry has been known to paediatric health services in Bradford and Leeds since birth. Due to his complex needs, he and his mother have, or have had, contact with a large number of medical professionals including paediatricians, specialist physiotherapy services, occupational therapy, dietetics, community nursing team, school nursing special needs team, orthopaedics and orthotic services. Harry has also been admitted to the Accident and Emergency Department on numerous occasions, including as a result of prolonged or repeated seizures, chest infection, fractures and following a road traffic collision. 4.1.3 Mother and both children are registered with one GP practice. Father is registered with a different practice. 4.1.4 Harry has been under the care of the BDCFT paediatric dental service since 2015. He is seen for routine checks every six months and the dentist reports that mother’s engagement with the service has been positive. Harry was not seen as planned in April 2020 due to the pandemic; however, face to face appointments were reintroduced and Harry was seen in April 2021 and early May 2021. The dental service uses a RAG rating for safeguarding and Harry has always been considered to be ‘low risk’. 7 4.1.5 Harry attended special school 1, a provision for children aged 2 - 11, until the end of year 6 in July 2020. It was anticipated that he would transfer to special school 2, which caters for children aged 11 – 19, that September as stated in his EHCP. He was placed on the school roll but mother was unhappy with the placement and indicated during the Summer term 2020 that she intended to appeal for a place in a neighbouring local authority. In the event, his last attendance at special school 1 was in February 2020 and at the point he was admitted to hospital in May 2021 he had never been on site at special school 2. 4.1.6 Bradford Children’s Social Care (CSC) first had contact with the family in July 2009 when Harry was one-month old following a referral from the Health Visitor due to concerns that mother’s brother was living in the household. It was confirmed to CSC by the Youth Offending Team that the brother was no longer at the address and the case was closed although there is no further information in CSC records to indicate why the Youth Offending Team was involved or what risk the individual might pose. 4.1.7 Between 2009 and 2018, CSC received 12 contacts from West Yorkshire Police; two contacts from maternal family members, one contact from a member of the public and three referrals from professionals working with the family. The professional referrals included one from the children’s centre requesting support and respite care in 2013; it was noted in CSC records that a Common Assessment (CAF) was in place and no further action was required. In 2015, BTHT paediatrician 2 made a referral to Children’s Social Care due to concerns regarding possible neglect and disguised compliance; it was believed that mother had not been collecting or administering Harry’s anti-epileptic medication and was not being truthful about this. A child and family assessment was completed by CSC with no concerns identified and it was recommended that a health-led CAF should be put in place. 4.1.8 It is recorded on the SystmOne safeguarding node for both Harry and his sibling on 9th February 2016 that the school nursing special needs team had been informed by GP4 that mother was not collecting prescriptions for Harry’s anti-epileptics. It was noted that the same concerns had been raised the previous year with CSC but the case had been closed. CSC and GP records indicate that a month later, in March 2016, GP6 in the same practice contacted CSC to advise that the concern in February 2016 had been resolved as Harry had received his medication from the hospital. CSC noted that they were not made aware of the concern in February. 4.2 Key episode 1 – Parents’ and children’s experiences of violence, aggression and domestic abuse 4.2.1 The first agency record of mother’s experience of domestic abuse was an assault perpetrated by her brother in March 2009 when she was pregnant with Harry. Between February 2010, when Harry was 8 months old, and February 2019, records indicate that there were fifteen incidents involving West Yorkshire Police (WYP). There have been no recorded incidents involving the police since 2019; mother has told the reviewer that she and father separated that year. 8 4.2.2 Many of these incidents were recorded as domestic abuse including verbal abuse between father and mother. Father was cautioned twice in this period, both during 2011, when mother was pregnant with Harry’s sibling. Mother also experienced a further assault perpetrated by family members and both parents were victims of crimes perpetrated by unknown adults outside the family. A house robbery in 2013 and harassment experienced by father in 2017 were suspected to be linked to debt or the production of cannabis. 4.2.3 West Yorkshire Police completed a domestic abuse, stalking and harassment (DASH) risk checklist on each occasion that they responded to a domestic incident between mother and father. The risk was categorised as standard or medium each time. Attending police officers informed CSC that there was a child with complex needs living in the household, the parents were stressed with little sleep and that the house was ‘extremely untidy’. Following an incident in November 2013, WYP made a follow up referral to CSC to request respite services for the family although there is no reference to this referral in CSC records. 4.2.4 Of the 15 incidents between 2009 – 2019 known to have been notified by WYP, only nine were recorded in CSC records; the outcome is recorded for each of these as ‘no further action’. 4.2.5 It was clear from individual agency records and the learning together event that the history of violence was not known to professionals involved with the family since 2018. Special school 1 had known Harry since he was very young but there was no information regarding domestic abuse in his CPOMS file, the school’s digital child protection record. The sibling’s primary school staff know both parents well but were unaware of the history and understand that the parents are still in a relationship. There was no record of domestic abuse in Harry or his sibling’s health record on SystmOne, the clinical healthcare recording system used by GPs, school nursing team and primary care services. 4.2.6 The GP practice was a notable exception. The journal section of mother’s SystmOne record included information regarding incidents of domestic abuse in 2012 and 2014 and reference also to cannabis being grown in the house. This information was not copied across to Harry or his sibling’s health records as the incidents predated the introduction of the SystmOne safeguarding node in 2015. On the 10th February 2021, mother had a telephone consultation with GP8 regarding minor illness; records show that the GP noted the historic concerns of possible domestic abuse and the 2015 / 2016 entries regarding Harry’s medication. On 28th April 2021, in responding to a telephone appointment relating to Harry, GP8 again noted the previous concerns from 2015 and 2016 but also that Harry was under the care of several secondary care professionals; there was evidence of mother proactively seeking medical advice and there had been no safeguarding concerns highlighted in Harry’s medical records since then. The GP was not aware that Harry was subject to a CiN plan. 4.2.7 Although the information was available to SW2, the Single Child and Family assessment undertaken by CSC since 2019 did not adequately consider the history of violence and domestic abuse and there is no consideration of the impact on the children. It is observed in the CSC single agency report that, given the nature of the Children with Complex Health & Disabilities Team (CCHDT), referrals are made to request 9 services (s17) rather than to respond to safeguarding concerns (s47) and SW2 approached the assessment purely in terms of services that might be offered to Harry and his family. 4.2.8 There is no indication in agency records that mother ever disclosed her experiences of violence and domestic abuse to health or education professionals or with the social worker. 4.2.9 At the learning together event, professionals considered the potential impact of violence and aggression on mother’s attachments with both children, particularly as she had experienced assaults during both pregnancies. However, health professionals and school staff observed that mother did have a strong bond with both children. 4.2.10 Professionals discussed how Harry and his sibling might have experienced the incidents of domestic abuse where they were present. Although Harry has profound learning disabilities, he will be sensitive to mood and atmosphere and may have felt fear or distress even though he could not articulate this. The primary school reports that the sibling has shown none of the negative indicators associated with children living with domestic abuse. 4.3 Key episode 2 - agencies’ understanding of the relationships within the family 4.3.1 Many of the practitioners involved with Harry understood mother to be a single parent with lone carer responsibilities. Father was generally not recorded in medical notes as present at appointments and there was little understanding of his involvement with Harry. GP records Practice insights: “If we had known about the domestic abuse, we might have made more careful observations during home visits and recorded more thoroughly.” “More careful assessments of mother’s wellbeing and capacity to cope with (his) complex care needs.” “We have known him from birth and we have not had any of this information." “For home tuition they would complete it in his room and take toys to enhance that. [If home tuition team had known] they may have found a reason to go elsewhere [in the house] or been more approachable.” 10 indicate that all contacts were with mother except one call in September 2019 regarding a rejected request for an x-ray. Father was registered with a different GP practice. 4.3.2 Harry’s mother appears to have attended all his appointments and to all his physical and emotional needs and the LTHT reviewer noted that father appeared ‘absent’ from every appointment entry reviewed. However, during two episodes where Harry was admitted to hospital (May 2020 and September 2020), information was gathered on the ward regarding the names of both parents and other significant people in his life. 4.3.3 There are records of mother and Harry attending BTHT hospital appointments with the maternal and paternal grandmothers on occasion, including an incident in 2015 recorded in CSC records where both grandmothers had been verbally abusive. During a telephone call with mother in August 2019 to follow up a missed clinic appointment, the paediatrician asked appropriate questions regarding who lived in the family home and what family support was available. Mother stated that she, Harry and his sibling lived in the home, father visited regularly and picks up sibling but “does not provide care to Harry because he is scared”. Paternal grandmother was also identified as a significant person. 4.3.4 Harry’s schools both recorded mother as the main contact and had little formal interaction with father although staff from special school 1 said at the learning together event that father was known to see the children most days, he did sometimes collect Harry from school and was seen during home visits. Father did not attend the annual reviews of Harry’s EHCP although he was invited. 4.3.5 Special school 2 did not have any contact with father regarding Harry’s non-attendance and neither the school nor the local authority SEND team sought his view on mother’s expressed intention to appeal for a different school. 4.3.6 Sibling’s school reports a good relationship with both parents; father regularly brings or collects from school. School staff also know Harry and say that his sibling is very happy when their brother comes to their school events; and likes friends to meet him. 4.3.7 The medical supplies provider had contact details for both parents and routinely called father if they were unable to contact mother; they were successful in speaking to father twice during the period 2018 – May 2021. On one occasion, he stated that he was not directly involved in the care needs of his son and the company should contact mother. On the second occasion, father confirmed that there was still a supply in the house and no delivery was required. 11 4.3.8 In January 2020, SW2 recorded in the case file that father “is very much involved in Harry/children’s lives.” She subsequently made two unsuccessful attempts to contact father during the assessment. At the learning together event, it was noted that a single child and family assessment under s17 is a voluntary process and parents cannot be required to engage. Since the incident that led to this case review, father has shared, during assessments and child protection planning meetings, that he found it difficult to engage with professionals because he feels some terminology is hard to process. 4.3.9 Mother told the Lead Reviewer that father has a close relationship with the children and visits frequently but does not feel confident managing Harry’s care needs; she said that father had once witnessed Harry being resuscitated and this had affected him deeply. 4.3.10 Paternal grandmother is a key adult in the lives of Harry and his sibling but was not included in the single assessment undertaken by SW2. Mother told the Lead Reviewer that she has a strong bond with paternal grandmother and describes her as ‘like a mother to me’. 4.3.11 There is little evidence of a holistic ‘Think Family’ in CSC assessments of Harry’s wider network of significant people; his father, his sibling and grandmother. Initial requests to CSC for support had made reference to mother’s desire to spend quality time with Harry’s sibling. However, from the point that the case was referred to SW2, there is no evidence that the sibling’s needs were ever considered and there was no contact with her school to ascertain whether they had any concerns. There is no evidence of any assessment of how sibling might be impacted practically or emotionally by growing up with a brother with profound needs. The primary school DSL reflects that this has been a common theme since the incident in May 2021 and that the s47 multi-agency conferences and review meetings have barely touched on any needs the sibling might have. 12 4.3.12 Most frontline practitioners at the learning together event were not aware of the “Think Family” approach; this was not the case for senior health professionals with a designated safeguarding responsibility or for frontline professionals working in Leeds. The Bradford education safeguarding team confirm that “Think Family” is not covered in Designated Safeguarding Lead training for schools. 4.4 Key episode 3 – mother’s requests for services / support 4.4.1 Referrals/ requests for support were made to CSC on mother’s behalf by a range of professionals between 2013 and 2018; these included the children’s centre (2013) and numerous referrals from paediatrician 1 (between 2015 – 2018). Mother had expressed concerns prior to 2018 that she needed support but requests for respite services became more frequent from 2018 onwards; CSC received a referral from the occupational therapist in October 2018 for regular respite to enable mother to have quality time with Harry’s sibling. Sibling’s primary school CPOMS record indicates that a SW made enquiries, stating that a request had been received for support for mother; the primary school advised that they had no safeguarding concerns regarding the sibling. CSC also made contact with special school 1 to ask whether school had any concerns regarding Harry. The school had no concerns; no further information was received from CSC and the school made no additional enquiries of mother. CSC records show that the case was stepped down to Early Help. Practice insights: There was almost universal acknowledgement that mother was seen as the primary carer and that more opportunities could have been provided for father to be included. Mother consistently described herself as a single parent and was considered to be so even by professionals who had frequent contact with father. Professionals formed a view of the family structure based on what they were told rather than what they were seeing: - “We can be guilty of not having included dad. Dads can be uncomfortable. I thought dad was at work but he was upstairs - I made an assumption.” “The more you know adds up to one big picture - you need to know the tiny things.” 13 4.4.2 At a paediatric appointment in Bradford in December 2018, mother reported that a referral to the local children’s hospice had been rejected because Harry did not meet their criteria. She also shared that the occupational therapy service was planning for adaptations to the home. Recognising that Harry’s needs were not being met and that mother was ‘struggling’, paediatrician 1 made a referral to Early Help services. 4.4.3 There is no record in the paediatric notes of an outcome to this referral. However, in March 2019, Harry was seen in clinic with mother and grandmother and paediatrician 1 recorded that mother was pleased that support was to be put in place to secure a new mattress. Mother told the paediatrician that Harry had bed sores; the paediatrician checked and observed that the site was dry. 4.4.4 In August 2019, paediatrician 1 telephoned mother following her failure to bring Harry to a clinic appointment. The paediatrician asked what family support was available and, with parental consent, made a second referral to social care for Early Help although there was a three-week delay before this was completed. The paediatrician received no feedback from CSC regarding the referral and asked mother at an appointment in November 2019 whether the referral had led to any outcome; mother responded that she had an appointment with them the following week. At this point, SW1 had already undertaken the first home visit but this was apparently not shared with paediatrician 1. 4.4.5 Following telephone contact with mother in October 2019 where mother informed the school that the social worker was to make a referral for respite services, special school 1 made a referral to the regional children’s hospice but this did not meet the threshold. There is no evidence that the school considered any other actions or services that could be put in place. The school did not ask mother for any further information regarding the social worker’s name, contact details or why s/he was involved. 4.4.6 During this time period, it was recognised that Harry’s wheelchair may no longer be suitable. Paediatrician 1 made a referral to wheelchair services and then followed this up on a regular basis. Mother was noted to be concerned about Harry’s disrupted sleep patterns and discomfort; a referral was made for a sleep system assessment although this was subsequently delayed by cancelled appointments in December 2019, once by the company and once by mother, and then the suspension of home visits in the initial stages of the pandemic. The sleep system was eventually delivered and set up in May 2020. 4.4.7 Following discussions with mother in March 2020 and a supervision meeting on 28th April 2020, SW2 made a referral to local respite services and submitted a continuing care pre-assessment checklist to the Continuing Care Team (CCT) for a care package. Both referrals were unsuccessful; the respite provider was closed due to Covid. The continuing care pre-assessment checklist had been completed without any health input; some sections were left blank. CCT reviewed SystmOne where the school nursing team records indicated that they had not seen Harry since January 2020 due to his “non-attendance at school as a result of not having a suitable wheelchair”. CCT also noted that Harry was dormant on the CCNT caseload, indicating that no current nursing was required. CCT notified the SW within 5 days that Harry did not meet their criteria, and provided a clear explanation for this. 14 4.4.8 Following discussion in supervision in May 2020, SW2 made a referral to the Children’s Community Support team (CCST) sleep clinic. On the 2nd February 2021, the CCST notified SW2 that they had agreed with mother to close the referral due to lack of progress; CCST recounted repeated unsuccessful attempts to work with mother and her failure to provide the sleep diaries needed for analysis. SW2 asked mother about the CCST decision to close the referral; mother’s response was that Harry had been ill. This was not challenged by the SW despite sleep issues being identified as one of Harry’s unmet needs and the reason for requests for respite, which was still not available to the family. 4.4.9 On the 12th February 2021, SW2 advised mother in a telephone call that SENDIASS, an independent support service provided by Barnardo’s, had closed the case; their attempts to contact mother since October 2020 had met with no response. Mother informed SW2 that she had been busy and needed time to herself. SW2 appears not to have challenged mother despite this being the second service to report a pattern of non-engagement within the same month. 4.4.10 During the same telephone conversation, mother stated that Harry was “currently struggling with bed sores” and that she had been waiting a significant period of time for an air mattress to be provided by the hospital; this was to support Harry’s spine which had been damaged during a seizure. SW2 contacted the children’s community nursing team on the 26th March 2021 to request support in securing the air mattress due to recurrent pressure sores; she said that mother had reported the team to be unhelpful. The nursing team advised that they had spoken to mother in February but she had indicated that Harry had no current pressure sores and she had no support needs. CCNT had offered a home visit but this had been declined. The CCNT recorded the information from SW2 as a complaint and action was taken the same day – a staff nurse contacted mother by telephone but she again stated that there were no current pressure sores and declined a home visit. CCNT attempted to contact the SW the same day to provide feedback and telephone contact was made on the 6th April. 4.4.11 At the paediatric appointment on 11th May 2021, conducted by phone, mother shared a significant amount of information regarding Harry’s unmet needs. She reported that Harry had no suitable wheelchair following advice from LTHT spinal and orthopaedic clinic in February 2021 that the new wheelchair was not suitable. House adaptations had still not been actioned so she was having to lift Harry manually. She believed that he needed a new bed and a bath seat. He had pressure sores and was reported to be in significant pain, requiring Oramorph once or twice a day to manage this, and was still on the waiting list for local respite services. The paediatrician recognised that mother was struggling to meet Harry’s needs and agreed to put in a new referral to the regional children’s hospice on the basis that his clinical situation had changed. The paediatrician also requested a home visit for Harry from the child development service; this home visit on the 21st May led to Harry’s admission to hospital. 15 4.5 Key episode 4 – the single child and family assessment 4.5.1 In September 2019, paediatrician 1 made a referral to CSC for support for mother and Harry; it was considered that the referral met the threshold which led to an initial home visit by SW1 on the 11th October. Mother shared a significant amount of information regarding Harry’s complex needs; she also stated that Harry was not currently attending school. SW1 recorded that mother was a single parent and that she struggled to take the children out or find activities suitable for both children. 4.5.2 Although it is not recorded in CSC records, SW1 contacted the school nursing special needs team on the same day that the referral had been received from the paediatrician; this was not recorded on the safeguarding node of SystmOne or in CSC records. SNSN advised SW1 that school nursing team could not comment on the referral and advised the SW to contact the referrer directly. SW1 commented that they thought Harry’s problems were “medical and not for social care.” 4.5.3 Following the home visit, the referral was processed and allocated to SW2 from the children’s complex health and disabilities team (CCHDT). It took one week to process the referral and allocate a named SW – this should have been completed within 24 hours. As a result, there was a one-month delay from receiving the referral to commencing the assessment. 4.5.4 Four weeks later, with no progress made, the case was closed and re-started. The manager’s reason for this was the delay in allocating the case. Assessments should be completed within a maximum of 45 days; the CSC reviewer noted that closing and reopening the case - in effect, re-starting the statutory timeframe clock - was not the correct process. As a result, Harry was recorded on the system as a child in need (CiN) in November 2019 but the plan included no identified needs due to lack of assessment. 4.5.5 SW2 undertook a home visit on the 22nd November 2019 during which mother provided contact details for father and the names of a range of professionals involved with Harry. At this point, SW2 did not contact father or any agency apart from the paediatrician’s secretary to Practice insights: “We were not aware of those referrals - had we known we would have wanted him in school as much as possible.” “Disguised compliance is to wilfully mislead but if you are in crisis, disguised compliance may be a coping strategy - ‘’I’ll tell them what they need to hear’” 16 request copies of clinical letters. She did not ask to speak to the paediatrician directly; as the referrer, a conversation with paediatrician 1 should have been an important part of the assessment. 4.5.6 SW2 recorded in the case file in January 2020 that they intended to contact father to gather his views as “he is very much involved in Harry/ children’s lives.” The SW subsequently recorded in the case file that two unsuccessful attempts were made to contact him, in January 2020 and again in April 2020 in advance of the CiN meeting. 4.5.7 In February, Harry was discussed in supervision; the only action recorded by the team manager was for the SW to complete the assessment. The following day, in contravention of statutory guidance, a management decision was made to close and restart the incomplete single assessment with the rationale given as SW2 had been absent from work due to illness. 4.5.8 In telephone calls between mother and SW2 during February, mother indicated that Harry was still not attending school due to lack of an appropriate wheelchair, and that there were continuing challenges around Harry’s sleep difficulties. Mother reported that paediatrician 1 and the school were making appropriate referrals. The CSC reviewer noted that SW2 accepted mother’s information at face value; she did not contact either agency to confirm that Harry could not attend school, and no consideration of the potential impact on him. 4.5.9 At a home visit in March 2020, mother and SW2 discussed a referral to respite services due to Harry’s disrupted sleep. There appears to have been no analysis of the impact of Harry’s non-attendance at school on anyone other than mother. Mother also indicated that she intended to appeal the school allocation and SW2 agreed to speak to the local authority SEN team. There is no information in CSC records to indicate whether Harry was seen at the home visits or any observations of his presentation. 4.5.10 From March 2020, all contacts between SW2 and mother were via video conferencing or telephone call due to the pandemic. SW2 asked whether the children’s community nursing team (CCNT) were involved with the family; mother indicated that they were but only on an emergency basis. SW2 failed to contact CCNT to clarify their involvement with Harry and involve them in the single assessment. 4.5.11 The first CiN meeting was held on the 27th April 2020. A CiN meeting is intended to be multi-agency in order to gather all the relevant information from partner agencies and allow key professionals to contribute to the plan but there is no evidence that any health professionals were invited and the only attendees were mother and SW2. There is no information available to this review regarding SW2’s failure to engage the many health professionals involved with the family or the context in which SW2 was working. 4.5.12 The SW had emailed special school 1 on the 22nd April to request an update for the CiN review meeting. The email was vague and did not make clear whether the school was invited to the meeting. There is no record on CPOMS of the email from SW2 on 22nd April 2020 requesting 17 information; however, the school stated in an email to the SW that they were having difficulty contacting mother by phone and she was not replying to messages. 4.5.13 Special school 1 case record indicates that they became aware that Harry was a child in need on 24th April 2020 when the local authority provided a list of children known to CSC for the purpose of identifying vulnerable children who should or could attend school during the first lockdown. The school states that they were unaware of Harry’s CiN status before this point although the school records show that mother had made reference to the social worker in October 2019 and they had received an email from the SW on 22nd April 2020, two days before the local authority list was received. The school did not make a record on CPOMS of Harry’s status as a child in need; as a result, this information was not passed to special school 2 during the transition phase. 4.5.14 Minutes of the CiN meeting were circulated to special school 1 and mother on 19th May 2020; copies were not sent to any health or other professionals involved with the family. All information in the health section of the completed plan appears to have been provided by mother. 4.5.15 Harry was seen by SW2 during a virtual meeting with mother on 21st May 2020. Mother stated that paediatrician 1 had requested an emergency appointment with wheelchair services and that Harry’s anti-epilepsy medication had been adjusted due to an increase in frequency of seizures. There is no evidence that SW2 considered this information in the light of the 2015 referral and she did not contact the paediatrician to confirm the reliability of mother’s information. 4.5.16 During a virtual visit in June 2020, mother informed SW2 that Harry had bed sores which may be as a result of his new sleep system and that she was awaiting a call from the physiotherapist. Mother advised SW2 that she has experience in caring for his pressure sores. SW2 appears not to have explored the issue of Harry having pressure sores any further and did not contact the physiotherapist to confirm the information or seriousness of pressure sores in a child with complex needs. 4.5.17 Mother made reference to the social worker in a telephone conversation with the school on 2nd June 2020 when she advised that she intended to appeal for a different secondary school to the one allocated and, as a result, the SW had told her not to complete the transport application. The school did not make any enquiries with the SW at this point, nor did they make a record on CPOMS. 4.5.18 In case supervision on the 23rd June 2020, it was agreed that Harry should be stepped down to ‘stable’ despite the significant range of unmet needs identified; Harry was still not attending school, the wheelchair issue had not been resolved, respite care had not been sourced, adaptations to the home had not been forthcoming and Harry was experiencing bed sores possibly caused by the sleep system intended to improve his quality of life. There is no information in the supervision notes to indicate the rationale for this decision. Marking the case as ‘stable’ meant that the frequency of visits could be reduced from 4-weekly to every 6 - 8 weeks. 18 4.5.19 In October 2020, SW2 was involved in email correspondence with special school 2 and the local authority SEN team regarding Harry’s non-attendance at school and mother’s intention to appeal the placement. SW2 subsequently emailed the SEN team on 20th October to request a written update for the CiN review meeting which was, in theory, happening the same day. 4.5.20 There is no evidence that a virtual review meeting took place on the 20th October 2020; the only information recorded was provided by mother. This was not challenged by the Team Manager who agreed the ‘minutes’ of the meeting but did not add any comments. The contributions of school and health professionals, and an opportunity to triangulate information provided by mother, would have provided an opportunity to challenge assumptions and identify routes to meeting Harry’s unmet needs. The CSC reviewer describes this CiN meeting as a paper exercise and, as such, “a complete failure in respect of multi-agency working and information sharing.” 4.5.21 On the 4th February 2021, the local authority Service Manager for integrated assessment and psychology contacted the executive head teacher regarding concerns raised by the SW at the lack of remote learning provision for Harry. This was the first time that special school 2 became aware that Harry had a named social worker; there appears to have been no attempt to contact the social worker to clarify the reason for their involvement or to share information regarding his non-attendance. 4.5.22 In February 2021, mother told SW2 that Harry once again had pressure sores but that a specialist air mattress to be provided by the hospital had not yet arrived. SW2 did not record whether she had checked that medical attention had been sought. Mother also stated in an email on the 22nd February that paediatrician 1 had prescribed morphine due to spinal damage caused by a seizure; the wheelchair was now unsuitable and LTHT was to contact wheelchair services regarding this. She also stated that the orthopaedic consultant in Leeds had advised that Harry should not attend school due to the fragility of his bones. This is not corroborated in any LTHT records. SW2 advised mother to inform the school that it was not safe for him to attend. 4.5.23 Information from mother to SW2 in February 2021 suggested that a number of health professionals were actively involved in meeting Harry’s needs and this was accepted at face value. Mother also indicated that special school 2 was undertaking weekly welfare checks with Harry and mother; it appears that SW2 understood these to be home visits rather than weekly telephone calls to mother and led her to believe that partner agencies were involved in physically monitoring Harry’s wellbeing. SW2 recorded in the file “[Mother] is a proactive mother and engages well with professionals to advocate Harry’s needs.” This assessment can only have been drawn from information provided by mother as there is no record of SW2 communicating with health services. The assessment is also at odds with the two agencies closing their cases that month due to lack of engagement from mother. 4.5.24 On 25th March 2021, SW2 sent email invitations to mother and a range of staff from special school 2. The case file notes that an email was also sent to the local authority SEN team administrator. No health professionals were invited. 19 4.5.25 A CiN review meeting was recorded to have taken place on the 13th April 2021. No professionals attended this meeting. At the learning together event, the DSL stated that it was school policy to only attend the CiN review meetings of pupils for whom there were safeguarding concerns. A report was provided by special school 2 in which it was stated that there was good communication with mother but they were unable to comment on Harry’s likes and dislikes, social interaction, communication or what is not working well “because due to Covid situation haven’t had the opportunity to meet Harry yet.” The school also provided an update regarding the arrangements for remote learning. 4.5.26 Minutes of the CiN review meeting were circulated to special school 2, paediatrician 1 and the SEN team. SW2 recorded in the minutes that Harry was currently unable to attend school or access the community due to the lack of a suitable wheelchair; this was not correct. The information mother had provided to SW2 eight weeks previously was that he could not attend due to the risk of fractures during moving and handling. SW2 did not verify the information with a health professional or challenge mother on the discrepancy. There appears to have been no consideration of what impact his inability to leave the house might have on Harry. 4.5.27 On 30th April 2021, SW2 undertook a virtual visit and records that Harry was seen. Mother informed SW2 that pressure sores had settled, Harry was managing to eat orally as well as via his feed system, that he had been to the dentist the week before and that special school 2 was still undertaking weekly welfare visits. This implies that Harry was being physically seen by a range of professionals. 4.5.28 On 19th May 2021, SW2 made a request to Team Manager for permission to continue with virtual visits due to mother’s desire to continue to shield Harry. SW2 recorded in the notes “There are no safeguarding concerns in respect of Harry or the family.” SW2 made a telephone call to inform mother of the agreement to continue with virtual working, during which mother stated that she had requested an appointment with the paediatrician due to Harry not gaining any weight despite having all his feeds and additional oral feeding. She also stated that his pressure sores had returned so she intended to ask paediatrician 1 to arrange for an air mattress. Mother told SW2 that she feels paediatrician 1 is not taking her concerns seriously. There is no evidence that SW2 re-considered her assessment of risk in the light of the new information. 4.5.29 Harry was admitted to hospital 2 days later. 20 4.6 Key episode 5 – Harry’s absence from school 4.6.1 Harry missed significant periods of education at special school 1, ostensibly due to his complex health needs, an accidental fracture and a road traffic collision. His attendance in the years 2017-18 (49.7%), 2018-19 (49.5%) and 2019-20 (38.2%) was well below national averages but almost all absences were authorised. Where Harry was absent due to illness or incapacity, the Hospital Education Team was involved. 4.6.2 During 2018, the Nutrition and Dietetics service made a number of requests to SNSN for a weight check. SNSN advised that this was not possible due to Harry not attending school. 4.6.3 In March 2018, Harry developed problems with a protruding plate in his hip which led to conflicting accounts regarding whether he could attend school. SNSN recorded that mother had been advised to seek advice from the GP regarding the protruding plate. During a hospital appointment with paediatrician 1 on 13th March 2018, mother stated that school was refusing to allow him to attend. The paediatrician was supportive of Harry returning to school. Immediately after the hospital appointment, there was good information sharing with colleagues in Leeds and Bradford, facilitated by SNSN. A part time timetable was agreed, commencing on 15th March although he only attended one session of the next ten. 4.6.4 Due to subsequent surgery, Harry did not attend school again until the 9th September that year. 4.6.5 At an appointment with paediatrician 1 in March 2019, mother stated that Harry’s school attendance was good; at this point, he had attended 10 of a possible 94 sessions since the start of the January term. Practice insights: The current CSC team manager reflected that, while closing and restarting an assessment was unacceptable practice, the CCHDT was holding a high number of complex cases at the time: - “We’ve learnt that if an assessment came in and workers were off sick, they got left. Then when a new worker came, we would close or restart. We don’t do that now.” “We did try to involve dad and he didn’t want to engage. We had no power to pursue him - he didn’t want to; he was in the background.” 21 4.6.6 On 6th February 2020, special school 1 recorded that Harry had been advised not to use his wheelchair for medical reasons. There is no record of who provided this information or of the school making attempts to confirm that this was the case. 4.6.7 Four weeks later, school staff undertook a home welfare visit during which the mother informed school staff that a complaint had been made to wheelchair services, that the waiting list was long, and that the paediatrician and physiotherapist had also contacted wheelchair services. There is no evidence that the school followed this information up with health colleagues. Home tuition (one half day per week) was arranged but mother cancelled this two-weeks later due to the pandemic. 4.6.8 Like all schools nationally, special school 1 closed on 18th March 2020 as part of the national lockdown. In line with Government advice, the school drew up a document for all pupils, prioritising vulnerable children who should continue to attend school; this group included children of critical workers and those with a social worker. Harry was recorded as ‘safer at home’ due to his complex underlying health needs. The school was not aware at this point that Harry was subject to a child in need plan and should have been included in the priority group. 4.6.9 Special school 1 reopened fully in June 2020 in line with Government guidance. At this point, Harry could have returned to school but mother had received a letter from BTHT confirming that he was clinically vulnerable so he was recorded on the school register as ‘shielding’. 4.6.10 Harry reached the end of primary education in Summer 2020 and should have transferred to special school 2 for the start of year 7 that September. In May 2020, special school 1 offered support to all Year 6 parents to complete documentation such as transport applications. On 2nd June, mother informed the school that she intended to appeal for a different school closer to home but in a neighbouring local authority and that her social worker had advised not to complete the transport form. There is no evidence that the school attempted to contact the social worker to clarify her involvement or advice. 4.6.11 The school care team and school nursing teams from special schools 1 and 2 met in June/ July 2020 to complete health assessments and hand-overs for pupils in Year 6. It was noted that Harry may not join special school 2 in September as mother was appealing for another school. 4.6.12 Harry did not join special school 2 in September 2020 and the transport service later confirmed that no transport application had been received from Harry’s parents. 4.6.13 Parents would normally be expected to continue to send their child to school regularly while appealing for an alternative placement; for a child who has an education, health and care plan, it can take many months for the changes to take effect. Weekly welfare calls were made to mother but the school made no attempt to instigate attendance procedures and there is no evidence that the school made contact with father to ascertain his views on Harry’s continued non-attendance. Between September 2020 and February 2021, special school 2 did little 22 to engage with Harry or to provide remote learning opportunities. The school had technical difficulties in setting up remote learning for a number of pupils; they did provide learning packs to some shielding pupils but these were not provided to Harry. No explanation has been provided by the school for this omission. 4.6.14 In November 2020, there was a further national lockdown although schools remained open to vulnerable children; this included guidance on working safely with children like Harry who require aerosol generating procedures (AGP). However, the transport provider’s policy was not to transport any pupils who require AGP; mother was advised of this. 4.6.15 In a telephone call with SW2 on 9th February 2021, the deputy head teacher (DHT) asked whether Harry should be attending school. SW2 recorded in the case file that her response was that Harry may be better accessing remote learning due to his clinical needs but advised the DHT to verify this with the school nurse or paediatrician. There is no information in the CSC records to indicate that the DHT provided SW2 with feedback on the school nursing/ paediatrician’s view on whether Harry should be attending school. The school file for Harry makes no reference to the telephone conversation with SW2 on 9th February 2021 or any indication that the DHT did contact health professionals for clarification of Harry’s status. However, SNSN records show that an email was received from DHT enquiring as to whether Harry had a shielding letter or should be attending school. SNSN confirmed that mother had received a shielding letter although SNSN had not seen this. 4.6.16 In fact, mother had received a letter from BTHT in July 2020 informing her that Harry no longer needed to shield. 4.6.17 Mother informed paediatrician 1 on the 1st December 2020 that Harry was still not attending school. There appears to have been no discussion of the reasons for this or whether it was in his best interests. The paediatrician was aware at this point that there was a named SW but made no attempt to contact them to discuss Harry’s needs or any plan in place to reintegrate him at school. 4.6.18 There is no information in LTHT records to indicate whether clinicians were aware that Harry had not attended school since February 2020. 4.6.19 On 22nd February 2021, mother informed SW2 that the orthopaedic consultant in Leeds had advised Harry should not attend school due to the risk of fractures. SW2 advised mother to inform the school. Harry had attended clinic on the 19th February but there is nothing in medical records to corroborate mother’s information. 4.6.20 Between February and March 2021, the school continued to make weekly calls to mother who reported that Harry was unwell and in pain, had been hospitalised due to a seizure and, on 9th March 2021, that Harry’s wheelchair was unsuitable and she was awaiting a response from wheelchair services. There is no evidence that special school 2 made attempts to contact health services or the social worker to confirm that partner agencies were aware that Harry was in pain although they did contact wheelchair services. 23 4.6.21 Harry did not attend any school between 5th February 2020 and his admission to hospital on 21st May 2021. 4.7 Key episode 6 – Harry’s weight loss 4.7.1 As a result of his chromosome 9 abnormality and other health conditions, Harry is very small for his age. He is fed via a gastrostomy (PEG), a feeding tube which is inserted through the skin of the abdomen, but he also eats soft foods orally. The sensory experience of eating, tasting and swallowing is important to a child’s development but oral food should be in addition to, not a replacement for, tube feeds. His slow growth is recognised; his weight has been carefully monitored for a number of years and the feed prescription is adjusted by a dietician as required. The established system is for the GP to generate each prescription on request from the external medical supplies provider and send a paper copy to the provider for delivery. 4.7.2 Weight measurement was a standard task at his BTHT paediatric appointments. In December 2018, a small drop in weight was noted by paediatrician 1 and the dietician was informed. At hospital appointments in Leeds, his weight was also usually recorded. Family health records indicate that Nutrition & Dietetics sent regular tasks to the GP regarding adjustments to Harry’s prescriptions for feed. 4.7.3 All children placed in a special school in Bradford have an initial health assessment arranged by the School Nursing Special Needs team (SNSN). SNSN use the initial health assessment to inform any care plans needed in school and also staff training needs. SNSN liaises closely with other health services involved in a child’s life and can undertake routine tasks allocated by other health professionals. SNSN was closely involved Practice insights: “He had hives, breathing difficulties, lots of seizures. Sometimes it was deemed that school all day was too much - so that was why he had a medically authorised part time timetable.” “If he had been at school, mum would have had a break.” “We are extremely concerned about provision of equipment; it’s a huge challenge - we do our best but things go wrong.” “With no wheelchair for 9 months, he was stuck in the house. Even in that lovely weather.” “Mum gave different people different reasons for him not attending school.” 24 with Harry at special school 1. Routine weight checks were undertaken on request, except during periods when Harry was not attending school, and the recorded weight was uploaded to SystmOne each time. This included weighing Harry four times between January 2018 and November 2019 at the request of the Nutrition and Dietetics service. In January 2018, his weight was recorded as 13kg. Subsequent weights were recorded as 13.2kg (March 2019), 14.6kg (July 2019) and 15kg (November 2019). On one occasion, the SystmOne task from the dietician states that Harry’s feed had been increased due to poor weight gain. 4.7.4 SNSN team records rarely included information on Harry’s appearance, presentation or communication. On two occasions, his weight was taken by a health care support worker (HCSW) and uploaded to SystmOne. As a delegated task, the expectation would have been that the HCSW discussed the outcome of the task with a school nurse but this did not happen. 4.7.5 Prescriptions for Harry’s feed were for a monthly amount. GP records indicate that in the years 2018 to 2020, the prescriptions requested by mother via the medical supplies provider were for the equivalent of 6 months, 9 months and 3 months. In the period from January 2021 to May 2021 and Harry’s admission to hospital, only one prescription was requested. The GP in attendance at the learning together event reflected that, while robust systems exist to identify patients over-ordering, a GP practice has no way of monitoring how often prescriptions should be requested or picking up concerns when those medicines do not seem to be being collected. The Designated Nurse later confirmed that interpretation of feed ordering requires specialist knowledge together with close monitoring of the child’s weight, taking into account factors such as whether a child is able to supplement enteral tube feeds with oral food and whether this could potentially reduce the volume of feeds ordered. GPs do not have this specialist knowledge and rely on the dietetics service to monitor children and advise on prescription. 4.7.6 The medical supplies provider stated in their report that Harry’s feed was not always requested at the point their system indicated that stock at home would be getting low. In this situation, the provider routinely contacts patients to ask whether a delivery is required. From January 2018 to May 2021, the provider made 13 (2018), 22 (2019), 20 (2020) and 8 (Jan 2021 to Harry’s admission) attempts to contact the parents. There were frequent difficulties in contacting the parents; of the 63 attempted calls, 29 were not connected, mobile phone numbers were often unavailable or the person answering would end the call. The medical supplies provider introduced a system of automated text reminders in an attempt to address this. The provider called both mother and father’s numbers each time; they were successful in speaking to father twice during the period 2018 – May 2021. On one occasion, he stated that he was not directly involved in the care needs of his son and the company should contact mother. On the second occasion, father confirmed that there was still a supply in the house and no delivery was required. 4.7.7 The medical supplies provider has a team of safeguarding nurses but concerns regarding Harry’s feed delivery pattern and difficulties in contacting parents were not escalated as a safeguarding concern. 25 4.7.8 The dietician stated at the learning together event that their service has no way of knowing how many prescriptions for feed are issued by GPs. The medical supplies provider did not contact the dietician at any point to inform them of the difficulties contacting mother and making deliveries. 4.7.9 Mother has told the review that the reason she did not order the amounts expected was that the medical supplies provider frequently delivered double quantities; the provider has been able to check stock systems and states that this is not the case. 4.7.10 When the pandemic began in Spring 2020, all BTHT appointments moved to telephone consultations which meant that Harry was not weighed in clinic after February 2020 when a small weight loss was noted. From this point on, almost all weight information recorded in the BTHT medical records was provided by mother. 4.7.11 During a telephone consultation with the paediatrician in July 2020, mother reported that Harry was tolerating his feeds well and she believed that he had put on weight because she had had to loosen his trousers. 4.7.12 During a telephone appointment with the dietician on the 10th November 2020, it was noted that Harry had lost 1.2kg since May 2020. Mother was advised that she could contact CCNT if she had further concerns re weight loss, otherwise the next weight would be in clinic in January 2021. The dietician subsequently made contact with CCNT to request a home visit to weigh Harry. It is not clear whether the weight loss of 1.2kg was reported by mother or a reflection on the historic weight recordings from before the pandemic. However, the dietician’s decision to give mother options including weighing him herself, allowing CCNT to visit the home or wait for the next clinic appointment indicates that there was no significant concern in the dietician’s mind. 4.7.13 CCNT responded immediately with an offer to weigh the same day; mother responded that she had transport problems. Subsequent attempts by CCNT to weigh Harry met with difficulties. A home visit was arranged for two days later but this did not take place due to mother stating that she was currently locked in the house. The visit was rearranged for three days later. On the 16th November 2021, CCNT recorded that mother was still having problems with the door and had advised that she would weigh Harry herself and call them with the result. In a further contact the same day, mother stated that she had no batteries in the scales and would go out the following day to purchase new batteries which appeared to be at odds with being locked in. On the 17th November, mother reported Harry’s weight to be 14.12kg. 4.7.14 There was no evidence in the case notes that CCNT had explored with mother why she was locked in or whether the family would be able to escape in an emergency. When the Lead Reviewer visited Harry and his family, further information was sought on this incident. Mother stated that, at the time, the front door was stuck and the back garden was very muddy due to work being undertaken; she said that the CCNT had physically visited the home but were not prepared to cross the mud. CCNT later reiterated the information in their records; they did not visit the family home because mother advised that they would not be able to enter the house. 26 4.7.15 In January 2021, mother informed SW2 that Harry was waking in the night hungry despite his feeding system being on; after eating orally, he would go back to sleep. Mother stated that she had requested a call from paediatrician 1 to discuss this. There is no evidence in the case file that SW2 explored this further with mother or asked how she knew he was hungry. The SW did not contact the paediatrician or dietician to confirm the feeding arrangements in place and whether oral feeding was acceptable. 4.7.16 It was known that Harry could eat some food orally, for example, soft puddings or cereal. Attendees at the learning together event discussed how important it is to some parents of children with complex needs that their child can engage in ‘normal’ life experiences wherever possible and it was felt that mother may attach this importance to Harry eating orally. Special school 2 observed that his current care plan states how much feed he should have each day “unless he has eaten orally at lunch time;” there is no guidance on how much oral food is needed in order not to provide the PEG feed. 4.7.17 Harry was seen in the orthopaedic clinic in Leeds on 20th April where it was noted that he had pressure sores. Mother indicated that she was awaiting a prescription for dressings which implied that these had been assessed by a medical professional and the appropriate treatment prescribed. LTHT clinicians provided mother with appropriate dressings as an interim measure. Harry was described by clinicians as ‘emaciated’ although he was not weighed as there were no suitable horizontal scales immediately available in the clinic area. An offer was made to admit Harry as an in-patient which mother declined; it was agreed with mother that LTHT would refer Harry back to community services in Bradford which happened the following day. 4.7.18 Harry was seen by the BDCFT paediatric dental service on 26/04/21 and 05/05/21 as reported to the social worker by mother. The paediatric dental service records indicate no safeguarding concerns at those two appointments although there is no information recorded regarding his presentation. The dentist confirms that their observations and records relate primarily to a child’s teeth. The dental service uses a RAG rating to categorise potential for safeguarding concerns and Harry was considered to be ‘low risk’. 4.7.19 In a telephone call on the 19th May 2021, mother told SW2 that she had made an appointment with paediatrician 1 for the following week due to Harry seemingly not gaining weight despite having oral food and all his tube feeds. 4.7.20 On admission on the 21st May 2021, Harry’s weight had fallen by more than a third since his last measurement by a professional in November 2019. 4.7.21 Once he had been admitted to hospital and was receiving the prescribed feed regime, Harry gained weight rapidly. 4.7.22 At the learning together event, it was discussed that during the period from March 2020 to May 2021, some professionals, such as the SW and paediatrician, regularly saw Harry on screen and were reassured by this even though he was often covered by bedding. In addition, staff 27 at special school 2 saw Harry remotely but did not know him so would not have been in a position to identify that he had lost a significant amount of weight in a relatively short period of time. Others expressed regret that the continuation of telephone appointments due to Covid had prevented them from identifying Harry’s weight loss. They also acknowledged that even if they had had sight of him on screen, it is unlikely that they would have been able to identify weight loss or pressure sores. 4.8 Key episode 7 – the impact of Covid-19 4.8.1 When the pandemic emerged in March 2020, national guidance in was that people should stay at home if at all possible, should maintain social distancing and should not enter other people’s homes; this would be particularly pertinent to a child with complex medical needs and his family. All agencies had to find new ways of working. Government guidance and legislation was evolving rapidly and there was confusion regarding the ‘stay at home’ edict. 4.8.2 Bradford Child Development Centre (paediatrics) cancelled or rearranged all non-urgent appointments; all other appointments were via telephone. Practice insights: “It would be useful to have a pro-forma from dietetics and expectations for primary care – there are lots of systems to stop over ordering but not under ordering” “We could have a system of automated delivery every month but that could lead to stockpiling. Receiving the feed wouldn’t necessarily have meant it was used.” “The feed has a limited shelf life; it would end up in the bin.” “A child may not grow if they only have 6 months’ feed over 12 months.” “Mum was plausible, and we have trusted - doubtful - the feed he was on. His weight is always low - it was accepted.” “We relied on what mum said he weighed on the scales at home, which indicated gain. It possibly led us done the wrong path.” 28 4.8.3 Despite moving more than half of their appointments to virtual or telephone consultations, LTHT recognised Harry’s needs and demonstrated good practice in continuing to offer him face to face appointments throughout the pandemic. 4.8.4 CSC moved rapidly to introduce remote multi-agency meetings. SW2 noted in Harry’s case file on 30th March 2020 that a remote CiN meeting was to be arranged and partner agencies would be invited to attend virtually or to submit a report instead. The CSC reviewer notes that this was incorrect; only as a last resort would a report suffice. 4.8.5 In theory, schools closed in March 2020 as a result of the first national lockdown. However, Government guidance was quickly issued, making clear that schools should provide care for the children of critical workers and vulnerable children; this included children who have a social worker. At this point, the school was not aware that Harry had a social worker. The multi-academy trust issued an emergency safeguarding response procedure to all its academies in March 2020, setting out a tiered structure for identifying risk and need and the expected levels of contact schools should make with children. The MAT tier 1/ priority 2 group included all children with a special educational need or disability. 4.8.6 As a priority 2 group child, staff at special school 1 maintained weekly contacts with mother, including telephone calls and home visits to deliver milk and food vouchers. On two occasions in Spring 2020, school staff spoke to mother or a male adult in the garden but Harry was not seen. Covid guidance at the time was not to enter other people’s homes. In the early stages, there was also daily contact with mother via DoJo, a digital communication system, although mother became less responsive over time. During one telephone call, mother told the school that she had not yet been able to use the food vouchers provided. This was a missed opportunity; the school was aware that Harry did not have a wheelchair but showed no curiosity about whether mother was able to leave the house to buy food and other essentials and what support network the family might have in place. 4.8.7 SNSN instigated a monthly welfare call system for children not attending school; mother was contacted in April and June 2020. In May 2020, mother contacted the team because the suction machine was not working; she reported that a new one should already have been provided but she hadn’t heard anything. Mother was advised to contact community nursing or the physiotherapist. 4.8.8 School records indicate that in May 2020, the school safeguarding team concluded that Harry was safe; “Mum always asks for support and help and think she would continue to do this at this time.” It appears that the school came to this view on the basis of their previous interactions with mother, despite not seeing Harry directly and with no contextual information regarding his status as a child in need. In June and July 2020, staff from special school 1 made home visits for Harry’s birthday and to deliver his graduation box. Harry was seen on both occasions. 29 4.8.9 Special school 2 would normally have transition visits for pupils joining the school – due to the pandemic, this was not possible in the year that Harry was due to join them. The SNSN team did have a transition meeting with special school 2 where it was stated that Harry may not join in September as mother was appealing for a different placement. 4.8.10 Special school 2 did not implement the direct weekly contact with Harry expected by the MAT. At the learning together event, the DSL reflected that they were not aware of his status as a child in need and that, due to their Covid risk assessment, they did not carry out home visits for pupils unless they had concerns for that child’s welfare. There is no satisfactory explanation for the discrepancy between the MAT safeguarding response procedure and the school’s risk assessment. 4.8.11 The annual review of Harry’s EHCP was undertaken by telephone call with the mother on 12th January 2021. Harry was not seen and there was a missed opportunity to confirm which services and professionals were involved in his life; as a result, no other agencies were invited to the review meeting. The school states that this was because the information had not been shared with them; as good practice, the school should have asked the parents as part of the preparation for the annual review meeting. The SNSN team, who had been involved in writing the health section of the plan in previous years, was not asked to contribute. 4.8.12 In March 2021, mother made references to the long wait for a suitable wheelchair in two phone conversations with special school 2. The school contacted wheelchair services who reported that they could only provide a minimal service due to the pandemic. There is normally a wheelchair clinic operating in school although Harry could not access this as he was not attending 4.8.13 Special school 2 experienced technical difficulties in setting up remote learning for pupils not attending school; in the event, this was not resolved until Spring 2021. This meant that school staff had no sight of Harry from September 2020 to April 2021. 4.8.14 Special school 2 stated in their report for the CiN review meeting in April 2021 that they had not yet met Harry due to Covid. The pandemic may have had some impact on Harry’s attendance but was not the main cause; the mother’s given reasons for non-attendance over that seven-month period included the intention to appeal for a different school, Harry’s ill health, and the lack of a suitable wheelchair. Although Covid may have delayed the necessary wheelchair assessment, this was only relevant from February 2021 onwards. 4.8.15 At the learning together event, some practitioners expressed feelings of regret and guilt that they had not seen Harry during the pandemic even though this had mostly been out of their control. It was acknowledged that all agencies and individuals had to establish new ways of working very quickly in a previously unknown situation. 4.8.16 It was also acknowledged that many of the contributory factors were in place before the pandemic; for example, the failure of the SW to engage partner agencies in the single assessment or subsequent review meetings, Harry’s extended periods of non-attendance at school and 30 the repeated failure to secure respite services despite mother’s requests from 2018 onwards. The historical concerns regarding Harry’s anti-epileptic medication and possible parental neglect in 2015 were also considered significant. 4.8.17 Practitioners wondered whether mother’s failure to engage with services and apparent attempts to prevent professionals from seeing Harry might be related to fear of him being exposed to Covid. However, it was not possible to explore this further with mother as part of this review. 5. Research and Learning from Previous Case Reviews 5.1 Little was written about the abuse of disabled children before the mid-1990s when the introduction of the Disability Discrimination Act 1996 and research published by academics1 led to a national conference2 and the creation of the National Working Group on Child Protection and Disability. 5.2 American research in 20003 estimated that disabled children are 3.4 times more likely to experience abuse or neglect, and ten times less likely to be referred to statutory agencies. 5.3 In January 2003, the NSPCC published ‘It doesn’t happen to disabled children’ which identified a number of factors that may increase the risk to this group of children, including: - Diagnostic overlay – indicators of abuse are assumed to be as a result of the disability. 1 Westcott, H 1993; Morris, J 1995; Westcott, H & Cross, M 1996 2 Kennedy, M / Triangle: Violence against disabled children and adults, Oct 1999 3 Sullivan and Knutson, 2000 Practice insights: “It was hard to contact parents of children with complex needs on the phone; they were busy looking after their children’s cares.” “We thought he was being seen but that was also virtual.” “Although we were seeing him [on a screen] we always saw him with a blanket, and we didn’t recognise the weight loss.” 31 Rule of optimism – professionals delay intervention in the hope that the child’s situation will improve on its own. Reluctance to challenge – also referred to as the ‘halo’ effect, professionals feel compassion for the parent(s) and tolerate inadequate/ poor parenting that would not be accepted from the parent(s) of a non-disabled child. Barriers to communication, including professionals feeling ill-equipped to talk to children using augmentative and alternative communication. 5.4 The Department for Children, Schools and Families issued non-statutory multi-agency advice, Safeguarding Disabled Children4, in 2009. This identified that disabled children are more vulnerable to abuse as a result of social attitudes and assumptions about disability, learned compliance, a reluctance to challenge carers, barriers to communication and the skills gap in Children’s Social Services. The guidance made a number of recommendations to local safeguarding children boards (LSCBs). The document remains live on the DfE website. 5.5 In 2012, Ofsted published a thematic inspection report5 ‘Protecting disabled children’. They found that disabled children account for 14% of all children in need but only 3.8% of children on a child protection plan and observed that “In many of the child protection cases examined by inspectors, where neglect was the key risk, children had previously received support as children in need for a long time. Despite the lack of improvement for the child there were delays in recognising that the levels of neglect had met the threshold for child protection.” The same year, a DfE analysis of serious case reviews between 2009-2011 identified that 12% of reviews related to a disabled child6. 5.6 NSPCC revisited their 2003 research ten years later7 and concluded that insufficient progress had been made in relation to some of the factors that increase vulnerability; there was evidence that diagnostic overlay, reluctance to challenge poor parenting, lack of child-focused assessment and a skills gap between professionals who work predominantly with disabled children and those who work in child protection were still prevalent. 5.7 Serious case reviews and child safeguarding practice reviews published are now held on a national repository managed by the NSPCC; thematic analysis of these reports is produced periodically. In 2016, the NSPCC8 published a briefing on cases since 2010 relating to deaf and disabled children which identified key issues which can impair professionals’ ability to recognise abuse in this group: Parents can feel overwhelmed by the number of professionals working with them. 4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/190544/00374-2009DOM-EN.pdf 5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/419062/Protecting_disabled_children.pdf 6 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184053/DFE-RR226_Report.pdf 7 https://www.northumberland.gov.uk/NorthumberlandCountyCouncil/media/Child-Families/Safeguarding/2014WeHaveTheRightToBeSafe.pdf 8 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children 32 Health professionals often had the best knowledge of a family’s situation but saw child protection issues as outside their remit. Different information was shared with different professionals, resulting in no one agency having a complete picture. Barriers to communication, including reliance on parents to interpret what their children were saying. Signs and indicators of abuse and neglect were assumed to be related to the disability. Lower standards of care expected of parents and a reluctance to challenge. Focus on health needs to the exclusion of wider issues including safeguarding. The impact of high levels of dependency on parents. 5.8 Most of the themes identified in the above guidance documents and research findings are evidenced in this review. As described elsewhere in this report, Harry’s poor weight gain and, at times, weight loss were attributed to his medical condition rather than a consideration of potential neglect. The positive impression of mother as a capable and attentive ‘expert’ carer led to an over-reliance on her assessments of Harry’s needs and impeded professionals from applying critical thinking; for example, when two health services closed referrals within the same month due to mother’s non-engagement, SW2 did not challenge this. Professionals received conflicting information about Harry’s circumstances or needs but opportunities to verify the information were missed; for example, mother gave special school 2 a series of different explanations for Harry’s non-attendance between September 2020 and May 2021 but the school made no attempt to contact health professionals or the social worker for confirmation. Some professionals were led to believe that others were having direct contact with Harry when this was not the case and the social worker’s failure to invite health services to the CiN meetings resulted in no agency having a full understanding of Harry’s life. 5.9 Of the 265 case reviews published nationally since 2019, 11 relate to a child with a disability (4%) although it should be recognised that the actual number of cases may be higher; the key word search relies on the child’s disability being referenced in the report and, as noted by the DfE in 2012, this does not always happen. 5.10 “Disguised compliance involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement” (Reder et al, 1993) and is identified as a contributing factor in 206 of the 1694 case reviews available on the NSPCC repository. In an NSPCC briefing paper9 published in 2019 which analysed cases from 2014 onwards, typical behaviours included: Parents and carers can develop good relationships with some professionals whilst criticising or ignoring others. This can divert attention away from parents’ own behaviour. 9 https://learning.nspcc.org.uk/media/1334/learning-from-case-reviews_disguised-compliance.pdf 33 Parents and carers may manipulate professionals and situations to avoid engagement or intervention. Sometimes practitioners are over optimistic about parents’ and carers’ progress and ability to care for the child or their promises to engage with services. Practitioners tended to accept information from parents and carers as fact without displaying appropriate professional curiosity and investigating further. In some cases, disguised compliance was suspected or discussed but no actions were put in place to tackle this. 5.11 Harry’s mother demonstrated behaviours typical of disguised compliance; for example, she told the paediatrician that the school would not permit Harry to attend whilst informing the school that the orthopaedic advice had been that Harry should not attend, and told the social worker that she felt the paediatrician was not taking her concerns regarding Harry’s weight seriously. There is also a significant pattern of requesting services and then not engaging, as with the sleep clinic and when the community team offered a home visit. The NSPCC analysis identifies that disguised compliance is sometimes suspected by agencies; however, professionals involved with Harry held mother in high regard and there is nothing to suggest that disguised compliance was ever considered. 6 Analysis 6.1 Inter-agency working and information sharing 6.1.1 We identified many examples of robust intra- and multi-agency information sharing during this review, particularly in relation to health partners. This was facilitated in some cases by shared digital systems. A shared digital system is not always a guarantee of effective communication but some professionals applied a robust approach to reading files and cross-checking the information they received; for example, GP8 who noted the historic information in the journal and safeguarding nodes of SystmOne during an appointment with Harry and his sibling. 6.1.2 The Bradford School Nursing Special Needs (SNSN) team is well placed to facilitate communication between school, home and partner health agencies, often being the most effective route for rapid information exchange; this is particularly the case with other health services using the same digital record, SystmOne. SNSN team members could and did clarify information with the GP, Nutrition and Dietetics Team, occupational therapy and others when needed. One example of this was in September 2018 when SNSN contacted GP for confirmation that Harry no longer had food allergies rather than rely on information from the mother. They then followed this up during a face to face contact with mother. 34 6.1.3 SNSN records indicate regular liaison with school staff at special school 1 and team members were proactively involved in writing the health aspect of Harry’s education, health & care plan (EHCP) in 2018 and 2019. The team regularly updated the health care plan with new information from other health services and were responsible for updating the epilepsy care plan and asthma plan on an annual basis. 6.1.4 It appears that SNSN team had a very different relationship with special school 2. They were not asked to contribute to the EHCP review in January 2021. It is not clear where the school sourced the information to populate the health section of the EHCP; some of the information may have been provided by mother or from previous EHCPs. It may be that this different interface affects all children with health needs at special school 2 or it is possible that the issue was specific to Harry’s extended period of non-attendance and the knowledge that mother was appealing for a different school. The school nurse did contact their equivalent in the preferred school to check whether they had any additional information. 6.1.5 BTHT records indicate that the physiotherapist was proactive in communicating with other health services, particularly paediatrician 1 and the sleep system company. They also made regular contact with mother. 6.1.6 On 21st April 2021 LTHT physiotherapist demonstrated good practice by contacting the BTHT physiotherapist to share observations of Harry during a clinic the previous day. It had been observed that Harry had pressure sores, an increase in seizures, he was in significant pain and there were concerns regarding his stature. The LTHT physiotherapist confirmed that this would be put in writing by the LTHT orthopaedic paeditatrician topaediatrician 1.. However, there was a significant delay in generating the clinical letter, which although was dictated on the day of the clinic appointment, was not sent out until 8th June 2021 due to significant challenges in administrative support at the time. The LTHT physiotherapist recorded that the outcome of the telephone call was that BTHT physiotherapist would follow up with the family and initiate support with their local team. The LTHT physiotherapist reflected later to have felt reassured that this would initiate increased support for Harry. 6.1.7 The BTHT physiotherapist did not communicate the information with any other health professionals at BTHT. The BTHT physiotherapy service holds paper records so the information was not available to heath colleagues via SystmOne. 6.1.8 The two special schools did not always communicate effectively with each other or with partner agencies, particularly where information was provided by mother. During the transition phase, special school 1 failed to inform special school 2 of Harry’s status as a child in need, despite the schools having a shared digital recording system. Special school 1’s explanation for this is that the Head teacher/ DSL was on long term absence and then left although the information from the local authority and contact from the SW had been received prior to this and could have been recorded and passed to the new school by any of the deputy designated staff. 35 6.1.9 Opportunities to verify mother’s explanations for Harry’s absences from school were missed; for example, when mother informed special school 2 that the orthopaedic consultant had advised that Harry could not attend school due to the fragility of his bones, the school did not contact LTHT to confirm this. This is likely to have been due in some part to the interface between special school 2 and SNSN. 6.1.10 West Yorkshire Police shared information appropriately with CSC following each domestic abuse incident they were called to. They also followed this up with requests for service when they identified concerns around cannabis use in the house and the impact this might have on Harry, the house being ‘extremely untidy’ and, on one occasion, recognition that mother was struggling and might benefit from respite or support. 6.1.11 It should be acknowledged that the last recorded incident of domestic abuse predates the introduction of Operation Encompass (OE) in the Bradford district. Current practice would be that each incident is notified to OE who then inform the school. 6.1.12 The medical supplies provider endeavoured to maintain robust communication with parents. However, given the level of concern they clearly had, it would have been good practice to escalate the situation to their own safeguarding team and/ or to inform the dietetics and nutrition service. 6.1.13 Too often, mother controlled the communication flow and was able to provide different information to different professionals without challenge. Once SW2 became involved in November 2019, she inadvertently facilitated this. 6.1.14 CSC did not demonstrate effective communication with partner agencies, either historically or during the period of this review. CSC received 15 notifications of domestic abuse, substance use and family support needs from the police over a ten-year period but there is little evidence that this information was triangulated or shared with professionals working directly with the family or that duty social workers sought contextual information from health professionals on any additional risk or impact the home circumstances might have on a child with complex needs. Similarly, CSC did not share information with partner agencies before closing the referral in 2015. 6.1.15 SW2’s failure to engage partners in the single assessment or subsequent CiN meetings is inexplicable. As a social worker in a team working with children with complex health needs, she should have been well aware of the critical importance of a holistic assessment. Unfortunately, SW2 was not available for the learning together event so the opportunity to explore this further was not presented. Similarly, the CCHDT team manager should have sufficient experience to recognise the importance of inter-agency communication, particularly in cases of complex 36 need, but supervision records indicate that SW2 was never challenged on the failure to involve professionals involved with Harry and his family. 6.1.16 It seems reasonable to conclude that, although there were other contributory factors, failures in inter-agency communication hinged on the fact that professionals involved with Harry were unaware of his status as a child in need. SW2 did make contact with individuals in order to pursue specific tasks but did not make clear the nature of her involvement; it is also noted that professionals did not ask for this information. If professionals had been involved in the CiN meetings, they would have been able to contribute to a holistic assessment, provide clarity regarding some of the information provided by mother and ensure the subsequent plan was robust. 6.2 How professionals understood and responded to the wider concerns of domestic abuse and drug usage within the relationship and the impact of this on the children. 6.2.1 It is clear that, with the exception of CSC and one GP, professionals were unaware of the history of domestic abuse within the family. Mother’s experiences of verbal and physical abuse perpetrated by father and other members of her family, including during both pregnancies, had the potential to disrupt her attachments with her children and to impede her coping strategies and support network but this was never addressed in assessments. 6.2.2 It is known that Harry and his sibling were present during some of these incidents but there appears to have been no assessment of the impact this might have had on the children. Harry’s profound learning disabilities make it impossible to seek his views on those incidents although he would have been aware of and reactive to negative stimulus. Although his sibling shows none of the indicators often associated with children living with domestic abuse and appears to have a strong bond with both parents, there has been no opportunity for professionals to explore this with her; for example, through the safeguarding curriculum at school. 6.2.3 Mother states that Harry and his sibling have no relationship with their maternal grandmother due to the violence and aggression perpetrated towards mother in the past. 6.2.4 The CSC case records include nine notifications of domestic abuse from WYP, members of the extended family and, in one case, a member of the public. It is expected that SW2 had access to this contextual information yet there is no evidence that it was taken into account during the single assessment or discussed with the CSC manager in supervision. 37 6.2.5 Professionals working with the family during the period covered by this review had no knowledge of the concerns around cannabis production and use in the family home and at father’s address. There is no evidence in police records or CSC case files that WYP informed CSC of the incidents. 6.2.6 In the CSC case file, there is one contact in August 2014 from maternal grandmother who alleged that father was growing cannabis and taking drugs in the family home. The outcome was recorded as no further action. On the same date, Family Health services noted in the sibling’s health record that there had been a discussion with a social worker during which reference was made to mother’s partner allegedly growing cannabis. 6.2.7 School staff at the learning together event commented that they had never smelt cannabis on Harry. 6.3 Application of the “think family” concept 6.3.1 Working together to safeguard children (DfE 2018) says: “Research has shown that taking a systematic approach to enquiries using a conceptual model is the best way to deliver a comprehensive assessment … (including) the capacity of parents or carers (resident and non-resident) and … the impact and influence of wider family and any other adults living in the household.” The Social Care Institute of Excellence (SCIE) presents ‘think family’ as an opportunity to take a holistic view of the strengths and needs of all family members and how these inter-relate; for example, parental mental health and a child with disabilities or health conditions. 6.3.2 ‘Think family’ was not evident in Harry’s case. Professionals’ focus was on mother’s needs and/ or the needs that she described on Harry’s behalf. Professionals rarely interacted with Harry’s father and there is very little information relating to his sibling in case files or records. Mother was the recorded main contact, attended appointments and contacted agencies when Harry was ill or needed services. 6.3.3 Most professionals understood mother to be a single parent and lone carer, including those who had regular contact with father; this is how she described herself. It appears that professionals, for example at special school 1, formed a view of the family structure based on what they were told rather than what they were seeing. The exception was sibling’s primary school who had regular contact with both parents and understood them to be in a relationship. 6.3.4 Research has existed for many years around the barriers that inhibit professionals from engaging with fathers as carers and, specifically, the role of fathers in family assessments. Properly embedded, the ‘think family’ approach should resolve some of these barriers but SW2 made 38 only two attempts to contact father between November 2019 and May 2021, both of which were unsuccessful. Parents cannot be required to engage with a single child and family assessment under s17 of the Children Act 1989; however, SW2 recorded in the case file in January 2020 that father was “very much involved” and should have made robust attempts to engage him. 6.3.5 Paternal grandmother has a significant supporting role to mother and the children; this was noted by SW2 although she did not go on to involve grandmother in the single assessment. 6.3.6 In 2018, a SW contacted the sibling’s school to make enquiries as a result of the referral from the occupational therapist. The school has never had contact from SW2. There is no evidence of the single assessment addressing how Harry’s sibling may be impacted practically or emotionally by growing up with a brother with such profound needs. The primary school DSL states that this has been a common theme since May 2021 and that multi-agency conferences and review meetings have barely touched on any needs the sibling might have. It is significant that the primary school was not included in the original scope for this review and therefore did not have the opportunity to contribute to the learning together event. 6.3.7 Hospital staff demonstrated good practice in collecting the details of all family members on two occasions when Harry was admitted. The GP practice had recorded father’s details although he was registered with another practice. 6.3.8 Professionals at the learning together event were not confident about the ‘think family’ approach and few had received training on this, designated health professionals for safeguarding and LTHT attendees being the exception. The education safeguarding team states that ‘think family’ is not covered in the two-day DSL training in Bradford. 6.3.9 It was noted that Bradford has, for the last four years, bought into the ‘signs of safety’ approach and that this may have drawn professional practice away from ‘think family’; however, there is no evidence that SW2 was applying signs of safety principles to Harry’s assessment. 6.4 Single and multi-agency training on safeguarding children with disabilities 6.4.1 All LTHT professionals are provided with specific training on safeguarding children with autism and learning disabilities, which includes information regarding the specific risks faced by children who are non-verbal. 39 6.4.2 The Bradford Partnership has, until 2020, offered two levels of face to face multi-agency training relating to disabled children – a general awareness course and ‘safeguarding disabled children – working in the margins’, a more in-depth content for professionals who work specifically with children with disabilities. The higher level training addressed learning from serious case reviews and research. It is not clear whether those training courses are available post-Covid. 6.4.3 The education safeguarding team does not offer specific training, either to staff in mainstream settings, special schools or to DSLs. Neither special school 1 or 2 provide staff training on the specific risks faced by children with disabilities and complex needs. 6.4.4 Social workers in Bradford access regular staff training. However, the CCHDT manager states that training on the specific risks faced by children with disabilities and the challenges of supporting these children is not currently available to social workers in that team. 6.4.5 Most, if not all, practitioners at the learning together event were aware of the risks associated with disguised compliance. However, responses to the presentation indicated that many were not aware of the research relating to disabled children and increased vulnerability, or the themes of diagnostic overlay, the expert parent and the ‘rule of optimism’. 6.4.6 If training has been available, the evidence of this case is that learning from research and previous case reviews has not been embedded in practice. 6.5 The lived experience of Harry, including observations of the parents’ interaction with Harry and whether there was an over reliance on the self-reporting or so called “expertise” of the parent(s) 6.5.1 Professionals had high regard for mother’s ability to meet Harry’s needs; she was seen as a proactive advocate who sought help and advice when needed. Mother was directly observed, by the physiotherapist and school staff, to be proficient in managing Harry’s medical and care needs such as lifting and turning and, during the pandemic, her judgment that Harry might have an infection or be in pain was at times considered sufficiently reliable for doctors to raise a prescription including, in February 2021, for Oramorph. 6.5.2 Professionals continued to hold this positive view even when faced with evidence to the contrary; for example, SW2 recorded that mother “is a proactive mother and engages well with professionals to advocate Harry’s needs,” in the same month that two services informed her that they were closing their case due to mother’s lack of engagement. The SW became focused on finding solutions for the challenges that mother was describing rather than on what life is like for Harry. 40 6.5.3 There was an over-confidence in mother’s ability to coordinate services and equipment; it was recognised that Harry had unmet needs over a sustained period of time but professionals accepted mother’s narrative that another agency was following this up or that delays were unavoidable. 6.5.4 As a direct result, Harry became invisible to services, particularly during the pandemic although there was some evidence of this pattern of behaviour prior to March 2020. Mother requested services or support but declined home visits or assessments, for example, for support from the sleep clinic or when the CCNT offered to visit the home to weigh Harry. He was removed from the orthotics service caseload twice due to not being brought to appointments, first in August 2018 and again in March 2020. There was no evidence in case files that the orthotics service tried to contact mother to clarify the reason for non-attendance or considered what impact the failure to provide orthotic support might have on the child. 6.5.5 Harry’s non-attendance at school due to the lack of a suitable wheelchair was a recurring theme during the period of this review. In March 2022, the Ofsted/ CQC joint area review of SEND provision in Bradford identified provision of equipment as an area of development; “The coordination and oversight of access to specialist children’s equipment, such as wheelchairs, is poor. Parents and carers often have to chase services to make sure that children and young people with SEND receive much needed equipment in a timely manner.” 6.5.6 Paediatrician 1 made an initial referral for a wheelchair assessment in November 2019 and then repeated efforts to chase this up; the chair was received in August 2020. Other professionals, including special school 1 and SW2, were aware of the lack of wheelchair but there is no evidence that the practical implications of this for Harry were considered – he spent most of those nine months in the house – or the increased pressure this was placing on a parent who had already been asking for respite for over a year. Following a period of non-school attendance due to mother indicating that she would appeal the placement, she informed SW2 and special school 2 in February 2021 that Harry could not attend due to the fragility of his bones and the unsuitability of his new wheelchair. Neither the SW nor school contacted the orthopaedic consultant to confirm this. 6.5.7 Harry was known to be susceptible to pressure sores. Health professionals believed that mother was adept at recognising and treating these; when she rang the community nursing team for advice, they offered a home visit but she declined this, assuring them that Harry was fine. Over a period of months, she told professionals that an air mattress was being ordered or was arriving imminently; it was hoped that this would reduce Harry’s frequent pressure sores and make him more comfortable. Professionals accepted this information at face value and did not follow it up. 41 6.5.7 Harry is very small for his age and his medical diagnosis causes poor weight gain although he should not lose weight if feeding well. Prior to the pandemic, his weight was carefully monitored by a range of services including the SNSN team and at hospital clinics. When weight loss was identified, professionals accepted without challenge mother’s assurances that he was feeding well orally in addition to the feeds. From March 2020, remote appointments meant that the paediatrician and others had to rely on mother’s verbal reports of Harry’s visual appearance; for example, in July 2020 when mother reported that she believed he had put on weight because she had to loosen the waist on his trousers. In November 2020, when mother advised the CCNT that they would not be able to enter the house to weigh Harry due to a problem with the door, it was agreed that mother would weigh him herself and her report of his weight at 14kg was accepted as reliable. 6.6 Diagnostic overlay 6.6.1 When CSC accepted the referral from paediatrician 1 in November 2019, SW1 expressed a view to the special needs school nursing team that Harry’s needs were medical rather than social. This view persisted throughout the period under review. 6.6.2 Mother informed SW2 when Harry had pressure sores, that he was waking up hungry during the night, that she believed he may have lost weight. SW2 does not appear to have challenged mother or sought confirmation that she was seeking appropriate medical attention at these times. It seems likely that SW2 felt she had less expertise than mother and that the symptoms and indicators were unavoidable effects of his disabilities. 6.6.3 Health practitioners also accepted the potential indicators of neglect as symptoms of Harry’s complex diagnoses. The BTHT case files indicate that an increase in seizures led to a change in his anti-epileptic prescription; there appears to have been no consideration of the referral made by paediatrician 1 in 2015 when it was realised that mother had not been administering Harry’s anti-epileptic. Similarly, the paediatrician and dietician were both aware of his lack of weight gain and sometimes weight loss but were reassured by mother’s reports that he was feeding well. 6.6.4 A number of professionals, including the social worker, paediatrician and dietician, only had remote visual contact with Harry or telephone contact with mother. If they felt any disquiet regarding the information that mother shared regarding Harry’s deteriorating health, they were under the impression from mother that other professionals were having direct contact and would be able to complete physical checks. 6.6.5 When Harry was seen in person at Leeds on 20th April 2021 he was described as ‘emaciated’ and ‘in obvious discomfort’. The practitioner recalled later that mother ‘looked like she had given up’ although this was not recorded at the time; an offer was made to admit Harry as an 42 in-patient but mother declined this. It was agreed that Harry would be referred back to community services and that LTHT would make contact with Bradford colleagues the following day. The Leeds physiotherapist made contact with her Bradford colleague on 21st April 2021 as agreed with mother. The LTHT orthopaedic consultant wrote to the GP and paediatrician 1 flagging Harry as a possible ‘child in need’ but no safeguarding concerns were identified. At this point LTHT were unaware that Harry was already identified as a ‘Child in Need’ by social care due to other reasons. The letter was received at the GP practice on 11/06/21. 6.7 The voice of the child 6.7.1 Based on agency records shared during this review, it is clear that Harry had no voice despite coming into contact with a range of professionals experienced in working and communicating with disabled children. Although he is non-verbal, Harry can communicate pleasure or pain and is able to recognise known carers but his mood is rarely recorded in his case files following health appointments, social work visits, etc. 6.7.2 Some professionals did not routinely record Harry’s physical presentation – his clothing, hygiene, alertness, whether he looked comfortable, felt warm or cool - unless there were concerns; when pressure sores were being assessed, for example. One notable exception was the SNSN team, but they were unable to make any direct observations once he stopped attending school in February 2020. Remote appointments as a result of the pandemic also impeded professionals’ opportunities to observe Harry directly; as noted by a practitioner at the learning together event, he was often covered by a blanket and mother’s reports of him being well were accepted rather than asking for the screen to be brought close to him. 6.7.3 Harry does not have the cognitive ability to make choices or express his wishes; professionals should therefore have demonstrated in their records how they determined his best interests. This rarely happened during the period of the review, partly due to the lack of face to face interactions and an increasing reliance on mother’s assessment of Harry’s needs. This is particularly relevant to SW2 as there is no evidence in the CSC records of the voices of Harry or his sibling being taken into account during the single assessment. 6.7.4 The paediatric dentist was the last professional to physically see Harry prior to his admission to hospital on 21st May 2021. There is no record of Harry’s physical presentation at that appointment; if he was in discomfort as he had been days earlier at the orthopaedic clinic, this was not recorded. 43 7. Recommendations In addition to the recommendations made and actions taken by individual agencies as set out in section 8 below, this report makes six further recommendations. During the writing of this report, NICE has published new guideline NG21310 on working with disabled children and young people with complex health needs. The guideline includes 18 recommendations and a baseline self-assessment tool. Recommendation 1 – Heads of service/ senior managers of education, health and care services working with disabled children with complex needs should ensure that the recommendations in NICE NG213 relevant to their service are implemented, specifically recommendation 1.1. Recommendation 2 – Safeguarding training for all professionals who work directly with children with disabilities and complex needs takes into account the research and learning from safeguarding reviews on how and why disabled children are more vulnerable to abuse. Recommendation 3 – The Bradford Partnership should promote the importance of ‘thinking family’ via a campaign aimed at all professionals in Bradford involved in assessments and/ or with designated safeguarding responsibilities in their setting. Recommendation 4 – All agencies should review their existing training programmes to ensure that it is clear to practitioners that all children should have a voice, including those who are pre- or non-verbal. Recommendation 5 - The Bradford Partnership should review the CSPR arrangements to ensure all relevant services are included in scope even if they were not initially involved in the rapid review. Recommendation 6 – The Bradford Partnership should undertake a systems review to ensure a robust approach to Child in Need arrangements. 44 Appendix 1 – Glossary Acronym / term CCHDT Children’s Complex Health & Disabilities team CCNT Children’s Community Nursing team CCST Children’s Community Support Team CCT Continuing Care Team CIN Child in Need/ s17 of the Children Act 1989 CNS Clinical Nurse Specialist CPOMS Child Protection Online Management System CSC Children’s Social Care DASH Domestic abuse, stalking and harassment risk assessment DSL Designated Safeguarding Lead EHCP Education, Health & Care Plan SNSN School Nursing Special Needs Team WYP West Yorkshire Police |
NC049388 | Death of a nine year old mixed heritage girl (AW), and her three year old brother (BW) in January 2017. The children died at the hands of their mother who used over the counter sleeping tablets, painkillers and methadone. The mother (Ms W) took her own life. Ms W was in a relationship with the father of the children from the age of 14 years until October 2015 when she asked him to leave the family home. She reported that she had an unhappy childhood and she had felt depressed from the age of 14. Ms W had suffered from postnatal depression after the birth of both children. In the months leading up to the deaths Ms W had been experiencing housing problems and was living in temporary accommodation .The family moved five times in the period June - August 2016. It was also thought that Ms W was in debt. The children were described by their school and nursery as being well cared for and having no problems. They appeared to be happy and talked about family life, revealing no concerns. Recommendations include: understanding the impact of a parent's mental health on the children and how professionals should 'think family' in order to understand the possible wider impact and risk within the family; professionals should be curious when children do not attend or have appointments cancelled, and move from the response 'did not attend' to 'was not brought'. Uses a hybrid systemic model of analysing agencies individual management reports and agency chronologies. The review panel found nothing to suggest that the children's deaths could have been predicted.
| Title: Serious case review on W Family. LSCB: Greenwich Safeguarding Children Board Author: Ann Duncan Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review on W Family 2 1. Introduction. Ms W the mother of AW and BW is thought to have killed her two children prior to taking her own life. At the time of this tragic incident the children were aged nine and three. Ms W had left a number of notes indicating her intention to take her own life. The family were experiencing housing issues and were living in temporary accommodation provided by the Royal Borough of Greenwich through their Housing Options Support Service (HOSS). Five days before the tragic event, Ms W had been notified that the Independent Review was likely to uphold the decision made by Greenwich that she was Intentionally Homeless1. The family had moved five times in a period of three months (June – August 2016). There were also questions about whether Ms W had debts, which she was worried about. The Greenwich Safeguarding Children Board (GSCB) in consultation with the relevant agencies recommended that the case met the criteria to carry out a Serious Case Review (SCR) as set out in Chapter Four of Working Together to Safeguard Children 2 The Independent Chair of GSCB endorsed this decision. The purpose of a SCR is to seek to understand what happened and why it happened in the context of local safeguarding systems, rather than solely the actions of individuals relating to a single case. The case under review is an example of local working arrangements at the time that the work was undertaken. It was agreed that the timeline for this review would be from April 2015 – January 2017. The Terms of Reference and scope of the review were agreed and are set out in Appendix 1. The case is subject to a Coroner’s inquest, the Coroner set out a number of lines of enquiry that the inquest would pursue; these are included in Appendix 2. The Coroner also instructed that the suicide notes should be made available to the Serious Case Review Panel. Much of the background information concerning the family was obtained from Police statements prepared for the Coroner’s Inquest by family members and friends and would not have been known by professionals working with the family at the time. The professionals working with the family were: staff at the school and nursery, housing and health. Information that was not known at the time has been put in italic for ease of understanding. Other sources used to inform the report were provided from a chronology of agency contacts with Ms W and her family or between agencies by the key practitioners involved. This was used to create the Timeline for analysis. Stakeholder agencies provided Independent Management Reviews (IMRs) describing and analysing their agency involvement and work in a systemic way. 1 1 Intentionally homeless means that you could have avoided becoming homeless. 2 Working Together to Safeguard Children, 2015: Published by the Department for Education for HM Government. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf. 3 A Serious Case Review Panel with two Independent Reviewers and representatives from the key agencies who are independent of the service delivery or direct management of the case analysed the material. Where necessary, the Panel sought clarification about information or actions. A Serious Case Review should avoid hindsight and seek to learn from what information was available and known, or what practitioners could have known at the time that they made their assessments and plans. It should also be proportionate. Its purpose is primarily to learn about how local safeguarding systems were and are operating and if any changes may be required as a result of the wider lessons from the case. 2. Executive Summary and Key Lessons Case History: Ms W reported that she had an unhappy childhood as a result of problems that her parents had had. An assessment was undertaken when she was a child and it concluded that the threshold for child protection had not been met. Ms W had been in a relationship with the father of both children from the age of 14 years until October 2015 when at the age of 25 she asked him to leave the family home. There had been some volatility, which had been referred in 2010 to both the Police and Children’s Services. Professionals involved formed the view at the time that Ms W tended to minimise the marital difficulties, and did not want to take matters further. Ms W also claimed that she had felt depressed from the age of 14 and had suffered from postnatal depression after the birth of both children. However, Ms W turned down any additional support offered to her including Early Help and appeared to be coping with the circumstances that she found herself in. In the months leading up to this tragic event Ms W had been experiencing housing problems and was living in temporary accommodation provided by the Royal Borough of Greenwich through their Housing Options Support Service. HOSS is set up to prevent homelessness wherever possible. HOSS deal with about 10 ‘homeless families’ a day and have a caseload of 500 families. The family had moved between privately rented accommodation and Local Authority (LA) housing in the Royal Borough of Greenwich and the London Borough of Bexley. The family moved five times in under three months from June – August 2016. Five days before the fatal incident Ms W had been informed that the Independent Review carried out by the London Borough of Southwark, at her request, was likely to uphold the decision of Intentional Homelessness and outlined the reasons for this. This was not the final decision and Ms W was invited to make further representation about her circumstances. However, it is not clear whether Ms W was aware of what help could be offered to her by services regarding her housing needs. It was also thought that Ms W was in debt although this had not been substantiated, nor the possible cause of the 4 debt identified. Ms W was known to have a car and reference is made to parking fines that were not paid immediately and the amount owed spiralled very quickly. Family members also assisted financially when they could. Ms W was reportedly in a recent relationship with the ex-partner of a friend. She became pregnant; understood to be as a result of the relationship. Ms W experienced a miscarriage in January 2017. On two occasions, in the 15 months up to the deaths, Ms W had expressed ‘feeling suicidal’. The first was over the phone to the Department of Works and Pensions (DWP) in October 2015 when she was querying why her benefits had been stopped and she said that ‘she owes so much money there was no point in going on for her or her children.’ This was appropriately referred by the Department of Works and Pensions to the Police, who followed it up with a welfare check3. Ms W explained to the police that she was frustrated with DWP after her benefits were cut but had no intention of harming herself or the children. The second time was when she had a phone consultation with her GP in August 2016. The GP made an urgent referral for a Mental Health Assessment (MHA) for low mood and thoughts of suicide. The Mental Health Assessment concluded that there was no suicidal ideation and the plan was for Ms W to see her GP for follow up and that the GP could prescribe antidepressants. Ms W again contacted the GP by phone requesting a prescription for antidepressants; an appointment was made for a face-to-face consultation in order to reassess her mood prior to commencing the antidepressants, which Ms W did not keep. A letter was sent by the GP practice asking Ms W to contact them, this was during the period when the family had moved five times in three months. It is now known that the letter was sent to an address that the family was no longer living at, as Ms W had not notified the practice of her new addresses The children were described by the school and nursery as being well cared for and having no problems. They appeared to be happy and talked about family life, revealing no concerns. AW had attended the same school from Reception class, there were no concerns identified by the school and AW was making good progress. BW commenced nursery in April 2016 (the nursery was not attached to the school) and attended term time only for two half days (1-4pm) and all day on a Friday (9-4) BW was funded for his term time place under the two-year-old funding scheme which was awarded for economic reasons. There were no concerns in relation to BW. Neither the school nor the nursery staff saw anything to suggest that Ms W might be struggling to cope with the children or any signs of depression. There were no concerns about their care and Ms W came across as a competent parent, there were no visible signs of neglect or of harm to the children. AW was occasionally late for school; her mother drove her to school and sometimes got caught up in traffic. 3 The term ‘welfare check’ has become established as common parlance across all UK police forces, applied when an external agency requests that police visit someone who is believed to be vulnerable, or at risk for a wide variety of reasons. In the majority of cases the responsibility for these checks, or the management of the specific risk or vulnerability should not fall to the police. (Briefing note Metropolitan Police 2015) 5 Ms W and her two children were found dead by the police in their temporary house, empty packets of over the counter sleeping tablets and painkillers were found alongside a two-thirds empty bottle of methadone. A series of messages were written on the wall with reference to betrayal and loss and personal letters to family members explaining her actions were found within the property. The toxicology reports state: Ms W: Methadone detected in the blood at concentration that lies within range encountered in fatalities. A significant amount of alcohol was also detected. AW: Methadone detected in blood at concentration that would have yielded toxic effects, if not a fatal outcome. Diphenhydramine was detected in higher quantities than a therapeutic dose. BW: Methadone detected in the blood at concentration that lies within range encountered in infant fatalities. Diphenhydramine was detected in higher quantities than a therapeutic dose. Ms W was not prescribed methadone. Key lessons: Headlines. Understanding the Impact of a Parent’s Mental Health on the Children and how professionals should ‘Think Family’ in order to better understand the possible wider impact and risk within the family. When children do not attend or there are repeated cancellations and rescheduling of appointments professionals should be curious about why and move away from the term ‘did not attend’ to ‘was not brought’. These key lessons will be discussed more fully in the report. 3. Family details 6 4. Ms W’s, AW and BW profile. 4.1. Ms W Ms W was a white British woman and had lived in southeast London all her life; she had attended local schools and went on to attend college. Ms W appeared to come from a close-knit family who were supportive to one another. Ms W’s parents continued to have health and social needs in adulthood. Ms W was not a drug user but expressed worry about possibly becoming dependent upon drugs and was wary about drinking alcohol although she did drink occasionally. Ms W had a number of stress factors that she was dealing with in the months leading up to the incident: a relationship with a friend’s ex-partner that resulted in a pregnancy and subsequent miscarriage, homelessness, possible debt and the loss of the friendship with her ‘best’ friend who had previously provided a lot of support to Ms W. These were combined with an underlying ‘depression’ which seems to have continued following the birth of the second child; she reported having post-natal depression with both children to family, but not to professionals. The few practitioners who had met Ms W described her as polite but she did not share her world with professionals. It is unclear as to whether she was protecting her privacy or was wary about sharing information with professionals for other reasons. When Ms W did divulge information or reported domestic problems she tended to minimise these. She did not tell the school, nursery or GP about the frequent changes of address or any stress or debt problems, or risk of homelessness. On both occasions when she was reported to be ‘suicidal’ she quickly refuted that she meant it and maintained that she had said it more for effect. While the children were at school / nursery Ms W spent a great deal of her day times with a friend from childhood; this friendship ended shortly before the incident occurred. Ms W appeared to have a good relationship with her ex partner’s sister (paternal aunt) who she stayed with shortly before the fatal incident. She also had regular contact with her own family, who saw no signs of her being suicidal. 4.2. AW. AW was a nine year old girl of mixed heritage. AW had attended the same faith school from September 2012 when she joined Reception class. During her time at the school she was described as popular with her peers, a smiley child and was talented at art. AW went on ‘sleepovers’ with her friends. AW talked at school about her grandparents and about her father and brother BW, and about days out with the family. She was performing at expected academic levels for her age, was well behaved and her attendance record was good. When Ms W told the school that she had separated from AW’s father, the school arranged four 1:1 therapeutic play sessions for AW; and there was nothing about her in these sessions, which would suggest that she was unhappy. The staff had no concerns for AW’s wellbeing. 7 4.3.BW. BW was a three year old boy of mixed heritage. BW started at the nursery school in April 2016, at the time he was described as unconfident and a solitary child. During his time at the nursery he had grown in to a confident and chatty child who enjoyed imaginative role-play and making things. He was described as a ‘smiley boy’ because he was always smiling. BW was a happy, healthy three year old, who was reported to have had a strong bond with his mother and sibling; he didn’t talk about other family members. BW was always well presented and was never angry. BW was slightly behind in his language skills and social interactions for his age but the Nursery staff had no concerns for BW’s wellbeing, or his care. 5. Timeline and Key Events Prior to the timeframe for this SCR, Royal Greenwich Children’s Services received a copy of a notice of eviction letter for Ms W from Housing Options Support Service on the 29/01/15. A contact and referral4 episode was created and a letter sent to Ms W reminding her of her responsibility towards AW and BW and inviting her to contact Children’s Services if she needed assistance. This episode was closed on the same day. Ms W then made a self-referral on the 20/02/15, as the family was homeless. A Child and Family Assessment was to be completed however this assessment was closed six days later without completion as Ms W stated that she was receiving support from her friends and family to access private rental accommodation. The case was closed on the 02/03/15. The timeframe of public agency involvement with the Family being reviewed has been divided in to four phases: Phase 1 April 2015- December 2015 In April 2015 the family moved from Thamesmead to Abbey Wood. At the point at which the family moved in to the area covered by the East Greenwich Health Visiting Team the Health Visiting records reveal that Ms W had a past history of vulnerabilities which included growing up with parents with health and social problems, brief involvement of Social Care in another local authority in her childhood. Later she experienced some difficulties around her mental health, including post-natal depression following the birth of both her children. It was also recorded that the family had financial and housing problems. The family had been in receipt of the Universal Health Visiting Service5 following the birth of BW. At the time, this decision was made the Health Visitors 4 Advice, information and signposting to help and support for the child and family: Protocol for assessment and threshold guidance-Royal Greenwich Children’s Services, 2015. 5 “The universal level of service is offered to all children, young people and families. This includes offering the Healthy Child Programme, signposting and referring, and monitoring referrals to other professional groups”. 8 considered that there was no information that was made available to them during their contacts with the family to put them onto a Universal Plus6 caseload. They made this decision based on no concerns being identified and Ms W “presenting normally”. However, if they had asked more questions, especially about previous vulnerabilities and followed up post-natal mental health systematically further information could have been collated to potentially inform this decision. There was an opportunity at the point of moving in to the area to review the offer of a Universal service but because the family moved within the Greenwich borough, the Health Visiting Standards at the time were, that contact was made by phone rather than a home visit (this is still the case). During a telephone conversation with Ms W she informed the Nursery Nurse (NN) that BW was under the dietetic service for possible cow’s milk protein allergy and was currently on antibiotics for a urinary infection. Information was sent to Ms W about Child Health Clinics in the local area. BW was discharged from the dietetic service in August 2015 as he ‘failed to attend’ (was not brought). The Did Not Attend (DNA) policy states that a letter is sent and if there is no response then there is no further follow up. At the end of October 2015, a member of the Department of Work and Pensions (DWP) staff called the Police to report concerns for Ms W after she had told the worker on the phone, in a conversation about her benefits being stopped, that “she owed so much money there was no point going on for her or her children”. Police Officers attended the family home and completed a welfare check. Ms W explained that she had become frustrated with the DWP after they had cut her benefits. She stated that she had no intention of harming herself or her children but was pleased that it provoked a reaction from DWP to respond to her. She reported that her benefits were going to be re-instated in a couple of days and she had secured a loan from a friend in the interim. The Police Officers were satisfied that there were no immediate concerns. A Merlin report7 was created and shared with Royal Greenwich Children’s Services on the same day. Royal Greenwich Children’s Services undertook agency checks and reviewed the information and made a referral to the Early Help Service to assess what support Ms W may require. In November the Early Help Service sent a referral to the Health Visiting Team and advised the Health Visitor (HV) to follow up with the family. This was another opportunity for the Health Visiting team to undertake a home visit to assess the needs of Ms W and her children and review the need for support. However, the Health Visiting Team contacted Ms W by phone and accepted her assurances that she was all right. Following this discussion, the Health Visiting 6 Universal plus service is offered to all children, young people and families who have been identified with additional needs and /or risk factors, who may require short-term interventions or longer follow up. 7 Merlin is the name given to the police system used to record and notify the local children’s services of incidents to which the police have been called where a child was present. The notification is sent irrespective of whether the incident related to the child. The child’s presence is sufficient to trigger a notification. 9 plan was for the Nursery Nurse to contact Ms W in December 2015 to arrange BW’s 2-year developmental review; this seemed appropriate. Ms W had a termination of pregnancy in November 2015 following the failure of the morning after pill. Ms W did not bring BW to his review on three different occasions. On the third appointment Ms W arrived late and the review was unable to be completed due to the fact that the Nursery Nurse needed to be at another appointment; Ms W was offered an appointment for three days later which she subsequently cancelled and requested another appointment. There appeared to be no professional curiosity as to why the appointments were not kept by Ms W and there has been no evidence found whilst conducting this review that professionals considered the significance of these missed appointments, or that this may have been disguised compliance.8 In the middle of November the Police completed a second Merlin (five weeks after the first one) when Ms W reported that the father of the children was outside the property and was angry as they had separated (but had remained living together in the property) and she had finally asked him to move out the previous day. The Merlin was received by Royal Greenwich Children’s Services but was not uploaded on to the electronic file. The Early Help Practitioner had difficulty making contact with Ms W. When contact was made Ms W declined an Early Help Assessment. However, Ms W was offered further advice on accessing the Together for 2’s nursery provision and the case for Early Help was closed at the end of January 2016. Phase 2 January 2016- May 2016 In January 2016 BW attended Queen Elizabeth Hospital Emergency Department, following an accident on a climbing frame and the Health Visiting Team were notified. This prompted the Nursery Nurse to contact Ms W by telephone, a message was left asking Ms W to rearrange the overdue developmental review for BW and contact the Health Visiting Team; this did not happen and was not followed up by the Health Visiting Team. BW started Nursery in April 2016. In April, the mother attended the Housing Options and Support Service and completed a Client Housing Information Form (HOSS1) detailing her housing situation; her landlord, who had applied for a Possession Order due to rent arrears, had served her with a Section 21 Notice (Notice to Quit). Ms W had acquired the privately rented property by making a false declaration about her income but it was now unaffordable. Ms W had been looking for alternative private rented accommodation but had been unsuccessful. Ms W cancelled the follow on appointment with Housing Options and Support Service and did not attend a further four appointments. In early May the caseworker sent the mother a ‘Minded to’ letter (This is a letter HOSS use when they have completed 8.involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention 10 enquiries and before issuing a decision that the applicant has made themselves ‘intentionally homeless’). This is the second time that the mother engaged with a service seeking support and then did not follow through with the scheduled appointments. The Housing Options and Support Service officer made the appropriate level of contact and carried out enquiries as per legal and good practice requirements. An “intentionally homeless” decision would mean the Council does not have a duty to secure permanent accommodation but would have limited duties to provide temporary accommodation for a reasonable period. When the Housing Options and Support Service are due to make a negative decision, which states that a family is “intentionally homeless’ a ‘Minded to’ letter is sent giving the applicant the chance to make further representation. This gives the applicant the opportunity to provide any extra information, which may change the decision and gives them the chance to offer mitigating information and factors defending their actions. The Housing Options and Support Service officer recognised the risk that the family would be homeless and on that basis referred to Royal Greenwich Children’s Services Multiagency Safeguarding Hub, as there were dependent children in the family. There is a Joint Working Procedure with MASH for Intentionally Homeless cases which is currently being updated.9 Phase 3 June 2016- September 2016 By the middle of August the investigation into homelessness was concluded and the finding was that Ms W was Intentionally Homeless; a letter was sent outlining the decision. The Housing Options and Support Service moved the family on the same day to a three-bed roomed property in Woolwich for an interim emergency period. Royal Greenwich Children’s Service was notified and a Contact and Referral episode was opened and a letter was sent to the family offering support and then closed the same day, as was the standard response to eviction by Royal Greenwich Children’s Services, at that time. Ms W submitted a request for an Independent Review of the Intentional Homelessness decision to be carried out and cited delays with payment of her housing benefit and the arrangements she had tried to make to clear her rent arrears in mitigation of her circumstances. 9 FAMILIES WITH CHILDREN UNDER 18 11.29. It is important that social services are alerted as quickly as possible to cases where the applicant has children under 18 and the housing authority considers the applicant may be homeless, or threatened with homelessness, intentionally. Section 213A(2) therefore requires housing authorities to have arrangements in place to ensure that all such applicants are invited to agree to the housing authority notifying the social services authority of the essential facts of their case. The arrangements must also provide that, where consent is given, the social services authority are made aware of the essential facts and, in due course, of the subsequent decision on the homelessness case. 11 In the middle of August Ms W had a telephone consultation with a GP. She told the GP that she was depressed and felt suicidal. The GP was unaware of the previous occasion when she expressed suicidal thoughts to the Department of Works and Pensions worker over the phone. The GP made an urgent referral for Ms W to have a Mental Health Assessment (MHA) as Ms W was expressing low mood and had thoughts of suicide. Ms W collected the referral letter, which included that she was the sole carer of her two children from the GP surgery later that day (it is unclear as to whether she was seen by a GP at this time or collected the referral letter from the reception area in the practice) Ms W presented herself at Queen Elizabeth Hospital Emergency Department (QEH ED) BW was with her, a Mental Health Liaison Psychiatric Nurse carried out a Mental Health Assessment and recorded: Previous history of depression from 14 years of age The circumstances that she has experienced over past six months have made her feel low. Made homeless by her landlord; housed in temporary accommodation Feels stressed and under pressure and what will happen to her and her children in 20 days time Separated from her partner in 2015 Ms W sometimes felt like drinking alcohol to cope with stress but considered this as not a good option and did not want to become drug or alcohol dependent (she had seen the impact of this in others) Things are out of her control- started crying when she would not normally do so States her children are her protective factor No report of psychotic symptoms or delusions, denied any regular use of alcohol No suicidal ideation The plan was for Ms W to see her GP for follow up and that the GP could prescribe antidepressants, if necessary. The Adult Mental Health Liaison Administrator sent the Care Plan and discharge summary to the GP electronically. The assessment completed by the psychiatric nurse was comprehensive and the risk assessment took in to consideration the fact that the Ms W was stating that the children were her protective factor. The psychiatric nurse could have explored Ms W’s family background including the level of support that they provided as well as any other support networks that were available to Ms W and her children. (Children should never be considered a protective factor for parents who feel suicidal) Ms W again had a telephone consultation with the GP the next day, and requested anti-depressants, the GP asked Ms W to come in for a face-to-face appointment, which was appropriate. This appointment was not kept and although the GP practice sent a routine Chase Up Letter to Ms W at her home address asking her to contact the GP practice there was no response. It is now known that Ms W had not given the practice her latest address. The practice did not to follow this up further and this was a missed opportunity to get a better understanding of Ms W’s mental wellbeing and to consider 12 safeguarding in relation to the children. Whilst recognising that there is no national framework in place that outlines the GP responsibility to consider dependents of patients, the National Society of Prevention of Child Cruelty (NSPCC), identified from learning gained from a number of serious case reviews that GP’s must: ‘Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant care responsibilities. Consider their capacity to care for children safely. Record this information in medical records and emphasise it in referrals and correspondence about patients10 It is worth noting that over the course of the timeline Ms W had 27 consultations with her GP, only four were face-to face consultations. This included four requests for Emergency Contraception when she was prescribed the morning after pill. This method of contraception failed on one occasion, which resulted in a termination of pregnancy. AW was not seen by the GP during the timeframe of the review and BW was not registered with the practice. As a result of the mental health consultation, the Sister in charge at the Emergency Department (ED) at Queen Elizabeth Hospital sent a modified Common Assessment Framework (CAF) for Emergency Department referrals to Royal Greenwich Children’s service Multi Agency Safeguarding Hub. The form indicated that this form had also been shared with the Health Visiting and School Nursing Services (but there was no evidence found during this review that it was shared). Although at the time there was a Liaison Health Visitor in post the review has been unable to determine whether this case was discussed with the post holder. The information that was shared on this form was limited and did not include the details of the Mental Health Assessment, set out above; meaning that vital information was not shared with Multi Agency Safeguarding Hub. When the referral was received the Administrator within the Multi Agency Safeguarding Hub Team sent an email to the Social Care Practice Manager (PM) who outlined in an email, the need for a Contact and Referral episode to be created and allocated to a social worker for further follow up in gathering information, completing a risk analysis with the view of making a recommendation on whether a Child & Family Assessment was required. Mistakenly this information was not viewed as a new referral, the Team Administrator added it to the Contact and Referral episode opened and closed on the 15.08.16. (Two days earlier); hence the case was not re-opened and the proposed action was not followed up. This was a missed opportunity to make contact with the family. Changes have already been implemented within the Multi Agency Safeguarding Hub in that all managerial decisions are now recorded on Framework-I (the electronic case record system) and not in separate emails; which will reduce the chance of human error. 10 https://www.nspcc.org.uk/preventative-abuse/childprotection-system/casereviews/learning/gps-primary-healthcare-teams/. 13 The psychiatric nurse was aware that the referral had been made to the Multi Agency Safeguarding Hub by the Sister in the Emergency Department but did not record this information on the health RiO system (electronic health records). The Mental Health Assessment was recorded on Ms W’s RiO health records but the Health Visiting Team were unaware of this assessment as the psychiatric nurse did not send a form alerting the team to this assessment and the Health Visiting Team remained unaware of the Mental Health Assessment and that Ms W was feeling depressed. At the end of August, the Health Visitors were identifying missed developmental assessments on their current caseload, the Nursery Nurse identified that BW was overdue his two year developmental assessment and was still not registered with a GP, a message was written in the Health Visitor communication book that a home visit was required. The message was not acted on. Systems are now in place to ensure the messages are actioned and signed off when completed. This was another missed opportunity to make contact with the family. Phase 4 October 2016-January 2017. In October 2016 Ms W informed AW’s class teacher at a parent’s evening that she had separated from her partner, in fact they had been separated for over a year. AW was given four therapeutic 1:1 play sessions, during this time AW talked of a normal family life and no concerns were raised. Ms W informed the nursery on the 16.01.17 that she was taking the children on holiday due to personal reasons for one week. About this time staff in the nursery had been made aware from another mother whose child also attended the nursery that Ms W was allegedly in a relationship with that mother’s ex- partner. The two mothers had been good friends and used to spend most of the day together at either the friend’s house or the friend’s mother’s house. Ms W also informed AW’s school that the family were staying with her sister-in- law whilst dealing with housing issues and AW would be absent from school for one week. It is now known (after the deaths) that the family went to stay with the paternal aunt, outside London, for one week as Ms W felt threatened following the disclosure of her relationship with a friend’s ex-partner. Ms W had talked with the paternal aunt about moving AW to a school nearer to where the aunt lived as she was finding it difficult to get her to her current school due to the traffic. Ms W also thought about moving away from Greenwich and making a fresh start. Ms W also disclosed to the paternal aunt that she was pregnant, later in that week she reportedly had a miscarriage. On the 25/01/17, the London Borough of Southwark Reviews Team sent A ‘Minded to’ letter to Ms W (the Reviews Team had been commissioned to undertake the independent review of Greenwich’s previous decision of Intentional Homelessness). It stated that they were likely to uphold the decision of Intentional Homelessness and gave the reasons for this. Ms W was asked to 14 make any further submission within seven days, and that this timeframe was negotiable. Royal Greenwich Children’s Services Multi Agency Safeguarding Hub was notified and sent out the standard response letter for pending evictions, which reminds the parents about the responsibility to provide accommodation for their children, and inviting Ms W to contact Royal Greenwich Children’s Services. Changes have been made to this process, in that staff working in the Multi Agency Safeguarding Hub now attempt to speak to the family directly following receipt of the notification from Housing Options and Support Service. The sharing information protocol between Housing and Royal Greenwich Children’s Services is being updated. AW returned to school on the 26.01.17 and was present on the Wednesday, Thursday and Friday of that week. The staff had no concerns about AW on her return to school. BW returned to the nursery on the Friday, he was dropped off late and collected early, which was unusual. A staff member asked Ms W if she needed to talk to anyone, this was not because Ms W presented as depressed, sad or anxious on the day but because she had taken BW on holiday for ‘personal reasons’ and nursery staff knew that she was no longer friends with the mother who had told staff that Ms W was allegedly in a relationship with her ex-partner. Ms W and her two children spent the Friday evening with the maternal grandmother and enjoyed a Chinese Takeaway meal together. Ms W told the grandmother that they were going to ‘chill’ over the weekend. Ms W and her two children were found dead in their home on the Monday. 6. Family Views and Perspectives. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Letters were sent to key members of the family, including the children’s father, inviting them to contribute. Following a telephone conversation with one of the Independent Reviewers the family decided that they did not wish to be any further involved as it was too distressing and they wanted to respect Ms W’s privacy. In that conversation Ms W was described by her family as a strong person but a very private individual, who had been affected by depression since the birth of B. She also had housing problems. She was a good mother to her children. The family were close and had not picked up any signs of suicide. In a brief conversation with one of the Reviewers the father said he would consider sharing his views. However, he did not respond to further attempts to involve him. 7. Practitioners’ and Managers’ Perspectives. 15 A half-day Practice Learning Event (PLE) was held on the 4.07.17 and was attended by 11 practitioners from the relevant agencies; the school and nursery were the only practitioners at the event who had met and knew the family. The Practitioners were given a summary of the timeline and a summary of the emerging lessons identified by the Serious Case Review Panel. The purpose of the Learning Event was to obtain the Practitioners’ experience of the case and understand the operation of local systems at the time the case was being managed to assist with understanding what happened and why. Debt: The practitioners’ group had no awareness of any issues relating to debt, there were no visible signs of debt, Ms W ran a car, and the children were well dressed and looked well cared for. Ms W was always up to date with payments for BW’s lunch at the nursery. Geography: it was noted the school and nursery were in different areas and different boroughs to the family home - lateness at school was not caused by Ms W taking BW to nursery as he went in the afternoons on Monday and Wednesday and all day on Friday. Mother’s network: little was known about what Ms W did during the day, the school was aware that she did have a couple of friends and would chat with them in the playground. The nursery commented that she was ‘isolated’ although had a strong friendship with another mother who also had a child at the nursery. Little was known about the father of the children. The school was aware of the paternal grandmother’s link to the parish in Thamesmead. Feedback from the Practitioner Learning Event was positive and for most of the attendees this was the first time that they had a full understanding of the events that led up to the tragic incident. A comment was made by one of the practitioners at the Learning Event that ‘it is hard to imagine temporary accommodation being described as home.’ 8. Lessons learnt: 8.1. Understanding the Impact of a Mother’s Mental Health on the Children and how Professionals should ‘Think Family,’ in order to better understand risk within the family. Published case reviews tell us that professionals sometimes lack awareness of the extent a mental health problem may impact on parenting capacity. This may result in a failure to identify potential safeguarding issues. The learning from these reviews highlights that professionals must recognise the relationship between adult mental health and child protection. Adult and children’s services need to work together to safeguard children when there is a parent with mental health problems. (NSPCC 2015) There were limited opportunities for a full assessment in this case and Ms W kept agencies at arm’s length, providing reassurance that she was managing 16 the situation. When the Department of Works and Pensions contacted the Police following Ms W stating that ‘she owed so much money there was no point going on for her or her children” the police carried out a welfare check and were reassured that after speaking to Ms W that there was no immediate risk of significant harm and made the appropriate referral to Children’s Services via a Merlin. It is always a difficult call for police officers when asked by other agencies to carry out a welfare check as they can only make a judgement based on the presentation of the situation at the time, and whether the children are at risk of immediate significant harm. The Mental Health Assessment was thorough and the outcome of the assessment was that Ms W may benefit from commencing anti-depressants and should discuss this further with her GP. The psychiatric nurse who carried out the mental health assessment was unaware of the previous threat of suicide that Ms W had made to the worker at the Department of Works and Pensions. It might have been helpful if the nurse had explored what support networks Ms W had. Some information was available to practitioners about her past mental health including: depression, post-natal depression and two episodes of ‘feeling suicidal’ although not all of the practitioners involved with her care had the complete picture. The first time that Ms W had threatened suicide the police completed a Merlin and shared it with the Multi Agency Safeguarding Hub. This resulted in a referral to Early Help, which Ms W declined. There is always a challenge to practitioners about accepting the self reported assurance, in this case by Ms W that all was well and that she had no intention of ‘taking her life’ Professionals should remain curious. . There was a missed opportunity to address Ms W’s depression when she did not attend the follow up face-to-face appointment arranged by the GP, following her telephone request to commence anti-depressants. While an adult may make such a choice not to attend a medical appointment the GP should have considered a referral to health visiting or other child based services in order to consider whether there was any impact on Ms W’s ability to care for her two children. Services in health and social care are still predominantly commissioned for adult or children rather than for families, the consequence of this is that there is a danger that the impact of risk within the family is not fully understood which potentially leaves adults and children vulnerable. The challenge for the safeguarding system is how to break down professional barriers to achieve change in culture, so that all practitioners see their clients in the context of their family, including where a person with mental health difficulties has responsibility for the care of children or vulnerable adults. Services must ‘Think Family’ and be willing to work with other service providers. In this case there were risk factors present but they were viewed in isolation and as ‘one-offs’ and were mitigated by acceptance of the self-reporting by Ms W that all was well. Information sharing did occur between some agencies when there were concerns about suicidal ideation. As already stated the two occasions when Ms W expressed feeling suicidal were not known by all of the professionals. In part 17 this was due to the fact that the circumstances did not meet the safeguarding threshold. The full understanding of the stresses surrounding the family were not known. 8.2. When children do not attend or there are repeated cancellations and rescheduling of appointments by parents professionals should be curious about why and move away from the response ‘did not attend’ to ‘was not brought’. Recent research into health agency ‘Did not attend’ policies has shown inconsistency and that they can, at times, be a systemic defensive response by agencies to help manage large workloads.11 Non-compliance with appointments may be a parent’s choice but it may not be in the child’s best interest. Repeated cancellations and re-scheduling of appointments for children should be treated with curiosity. A shift away from using the term did not attend (DNA) to was not brought (WNB) would help ‘maintain a focus on the child’s ongoing vulnerability and dependence, and the carer’s responsibilities to prioritise the child’s needs. In some cases it may be considered a sign of neglect, although in this case there was no evidence of neglect. In this case Ms W did not follow through on appointments for B on a number of occasions for the two year developmental assessment. Nor did she follow up the consultation with the GP for the possible prescribing of anti-depressants for herself. This raises questions about how busy services assess whether to terminate a service for either children or possible vulnerable adults after a failed appointment, or series of failed appointments. 8.3. Areas of Good Practice The school provided 1:1 therapeutic play sessions for AW following the disclosure that the parents were no longer together. They clearly knew AW well and provided a comprehensive observation of progress and development during her time at the school. The family was very complimentary about the school. 11 Munro, Eileen (2012) Review: Children and young people's missed health care appointments: reconceptualising 'Did Not Attend' to 'Was Not Brought' - a review of the evidence for practice. Journal of Research in Nursing, 17 (2). pp. 193-194. ISSN 1744-9871 and Lisa Arai, Terence Stephenson & Helen Roberts; The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS; Archives of Disease in Childhood, March 2015; http://adc.bmj.com/content/early/2015/03/16/archdischild-2014-307294 18 The nursery provided detailed observation reports on BW and developmental milestones; and sought to reach out to Ms W in January 2016 to enquire if she needed assistance and wished to talk, as they were aware of stresses in the breakdown of her relationship with her longstanding friend The Police carried out two welfare checks on the family five weeks apart, one at the request of another agency and the second following a call from Ms W. The Police made an assessment of the situation at the time and made the appropriate referrals following completion of the visits. However, it must be remembered that a welfare check is only an interim, cursory and emergency measure, the Police are making a judgement as to whether the children are at risk of immediate significant harm on information before them – they do not have information on history held by other agencies. The Mental Health Assessment was good; the problem was that it was not followed through. The Housing Options and Support Service followed the National Code of Guidance for Intentional Homelessness and made appropriate referrals to Children’s Services, given that the family would be vulnerable if found to be intentionally homeless. 8.4. Care and Service Delivery Points. The use of an internal email rather than recording directly on to the Royal Greenwich Children’s Services client database system led to an Admin / human error in Children’s Service which resulted in the second referral following the Mental Health Assessment, two days after the notification from Housing Options and Support Service, not being re-opened; despite there being actions to be under-taken. Royal Greenwich Children’s Services has now rectified this issue and all communication and management instruction is put directly on to the client database system. The standard letter sent by Royal Greenwich Children’s Services when informed of a possible eviction of a family may not have been sufficiently encouraging to a parent to seek advice and support or how Children’s Services may be able to assist them. This approach has been amended and a revised Royal Greenwich Children’s Service – Housing Protocol is being brought into place. Children’s Services now seeks to make direct contact to speak with the parent in possible homelessness cases rather than relying on a letter. Staff working for Oxleas NHS Foundation Trust followed the ‘Did not attend policy’ where-by one letter is sent to the parent and if no response there is no further follow up. This review has questioned whether this is an appropriate response when dealing with children (or vulnerable adults) and whether the Trust or Clinical Commissioning Group should consider a ‘was not brought’ policy for children and vulnerable adults. 19 The use of technology to aid communication and the better use of time such as, telephone consultations and Skype between patient and GPs is on the increase and therefore safeguards need to be built in to ensure that any early warning signs are managed safely and effectively. GPs need to remember to consider what caring responsibilities people who present with mental health issues may have and the impact on their ability to care. There was insufficient curiosity about the possible impact on AW and BW – a ‘Think Family’ approach is needed – See the Social Care Institute for Excellence Guide: https://www.scie.org.uk/publications/guides/guide30/introduction/thinkchild.asp http://www.education.gov.uk/publications//think-family. GP practices must have a system to follow-up patients who fail to respond or do not present at booked appointments to review their mental health wellbeing; especially where that patient has responsibility for children or vulnerable adults. A Did Not Attend Policy of a simple letter giving one more chance to respond may be insufficient as a global solution. An information sharing process is in place between community mental health and health visitors; the alert was not sent in this case and therefore the Health Visitor was unaware of Ms W’s depression. Nurseries and schools should ensure that they have contact details for use in emergencies, and that addresses are checked, at least annually. 9. Conclusion. The view of close family members was that in the final weeks after New Year Ms W was finding things tough but that she was coping and was looking forward to how life might be better. Although there are a number of areas from this review where we have learned that practice to support parents with mental health and/or homelessness issues could be improved, the panel have found nothing to suggest that this tragic tragedy could have been predicted. Ms W was seen as a good mother who appeared to be coping with the circumstances that she found herself in. The children were well cared for and neither the school nor nursery staff had any concerns about AW and BW. The family was assessed by the Health Visitors following the birth of B as meeting the Universal Health Visiting Service. Although there were some clear risks identified the decision was made to offer the Universal Service. It could be argued that some short term interventions with the family at this point under the Universal Plus service may have been beneficial, however this work would have been time limited. Ms W was offered services or appointments on a number of occasions but chose not to accept them or follow them up. She was seen as competent in 20 managing her affairs, and professionals accepted her assurances that all was well and that she did not need any further help or support. The professionals who were in contact with her in the months leading up to this tragic event were not aware of all of the stresses that she was under, particularly around housing, the number of moves, an unexpected pregnancy that ended in a miscarriage, and the loss of a friendship that had provided a great deal of support to her over a number of years. To those professionals who met her, who were few, she appeared to be a good mother, to be coping and to have (mental) capacity. Her care of AW and BW was good and they were happy children, developing well. There were no concerns about their care and wellbeing and their voices were appropriately heard through the school and nursery. On the two occasions practitioners saw Ms W where suicidal ideation was a possibility she either retracted and/or was found not to be at risk of suicide. Although offered a follow up assessment for treatment for depression, possibly through medication, she did not follow this up. Agencies did try to reach out to Ms W but although she sometimes agreed this on the phone she did not follow through these offers. There were no grounds, given her apparent capacity and the children’s good care to compel her to use services, under either children's or mental health legislation. The family met the threshold criteria for early help services, which were offered but declined, as Ms W said that she was receiving help from her family. She has been described by family and friends who knew her well as a private person who, despite her depression, was resourceful and managed her life and parenting despite the increasing stresses. There was no complete picture held by any agency of the stresses she was under or how they were affecting her mental health. Her family's view was that her strong love for the children led her to take them with her when she could no longer face things and planned to take her own life. 10. Recommendations Lesson: Understanding the Impact of a Parent’s Mental Health on the Children and how professionals should ‘Think Family’ in order to better understand the possible wider impact and risk within the family. Recommendations: 21 1. The Greenwich Safeguarding Children Board had agreed work to implement a multi-agency ‘Think Family’ approach prior to the conclusion of this review. It is recommended therefore that the Board should complete introduction of that work by March 2018 and agree to review its impact by March 2019. 2. The Greenwich Safeguarding Children Board should ask the relevant Health Commissioners to review arrangements in GP Practices to ensure that the welfare of children is considered when assessing the mental health of parents and carers. Lesson: When children do not attend or there are repeated cancellations and rescheduling of appointments by parents professionals should be curious about why and move away from the response ‘did not attend’ to ‘was not brought’. Recommendation: 3. The Greenwich Safeguarding Children Board should ask all agencies to review their policies for when children and vulnerable adults ‘do not attend’ scheduled appointments to ensure that in making a decision to terminate a service for non-attendance proper attention is given to the vulnerability of the patient or service user. For children an approach of ‘was not brought’ should be considered and a service should not be terminated without considering any risks of doing so. Ann Duncan, Lead Independent Reviewer November 2017 22 Appendix 1: Scope of the review Agency Chronologies and Agency Individual Management Reports (IMRs) will cover from 1st April 2015 and conclude at the date of incident (30th January 2017). If agencies hold records on the parents and of the children prior to this period, the background information and a note of any significant involvement should be summarised in the IMR. Methodology A hybrid systemic model of analysing agencies’ IMRs and agency chronologies from a multi-agency perspective has been agreed. Practitioners who worked with the child or family in the period under review, and their first line managers, will be expected to contribute to the review, as set out below. This methodology is reflective of the principles set out in Working Together, as well as meeting the needs of Greenwich LSCB. In evaluating the work undertaken, judgement should not be based on hindsight but on the rationale for the actions taken at the time with the, then, known or knowable information. Hindsight may add to the lessons but not the judgements. Any Actions identified from IMRs for each agency should be undertaken immediately. The final SCR Report will be fully anonymised. The SCR Panel will make recommendations to the GSCB about any actions, which are required, arising from the lessons learned. The anticipated completion of the SCR will be September 2017 depending on progress of the reports and notwithstanding consideration of parallel processes, which may cause delay. Publication of the final report will be mindful of the timescale of the inquest. Family involvement Relevant family members will be informed of the SCR and will be invited to contribute to the process. Other family members or members of the family’s network will be invited to contribute as appropriate. Staff involvement Practitioners and their line managers, who were directly involved with the family, will be involved in the review through individual meetings with the IMR Authors within their own agency. There will also be a multi-agency Practitioners’ Learning Event, led by the Independent Reviewers. This will promote effective learning, and enable the collation of the practitioners’ perspective. The GSCB expects Agencies to release and support practitioners in contributing. The Practitioner Learning Event took place on the 5th July. 23 Membership of SCR Panel Need to put full names in Chair of Panel - Malcolm Ward, Independent Consultant Author of SCR/Lead Reviewer – Ann Duncan, Independent Consultant Greenwich Clinical Commissioning Group CCG- Anita Erhabor, Designated Nurse for Safeguarding Greenwich Children’s Services –Henrietta Quartano Head of Quality Improvement Oxleas NHS Foundation Trust – Jane Downing Head of Safeguarding Children, Lead Named Nurse Greenwich Community Services, Carol Sewell Housing Access and Allocations Manager, Metropolitan Police – Ben Voss Detective Sergeant, Specialist Crime Review Group Pre-School Alliance- Lisa Graham Education Commission Catholic Diocese of Southwark- Yvonne Epale, Education Officer Greenwich Adult Safeguarding Service – Peter Davis Service Manager GSCB Dan Timariu (left August 2017) Business Manager GSCB – Zakk Cartlidge, Business Support Officer (minute taker) Agencies to complete IMRs Greenwich Children’s Services; Greenwich Housing, Oxleas NHS Foundation Trust Primary Health Care/GP for children and parents School Nursery Metropolitan Police Service Greenwich Adult and Older People Services 24 Analysis of involvement The individual management reviews need to consider the events that occurred, the decisions made, and the actions taken, which indicate that practice or management could be improved. Particular strengths of practice should also be acknowledged, where applicable. Consideration should be given to not only what happened but also why something did or did not happen. Consider the following areas: Events in the case What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Professional awareness – was this sufficient to effectively respond to: The needs and the lived experiences of the children? The needs of both parents? Cultural, identity and other diversity issues within the family? Potential indicators of abuse, e.g. the impact of the toxic trio: (mental health, drugs and alcohol, domestic abuse)? History - Were historical facts known or sufficiently taken into account: The parents’ history Any other previous involvement of either parent with adult or children’s services, the police or probation etc. Policies and procedures – were these effective: Did practice accord to Working Together 2015 and/or the London Child Protection Procedures? Any local multi agency policies or procedures Any individual agency policies or procedures Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquires made, in light of assessments? Were records systematically reviewed to evaluate and assess risk? Quality of the work – was this good enough? Voice of the children 25 Information sharing Thresholds for intervention Assessments Decision making Record keeping First line managerial oversight, including supervision Appropriate involvement of senior managers and their accountability Were there any deficiencies due to organisational capacity – resources, staffing problems, or other underlying systemic issues, which impacted on the work etc.? Were there any professional disagreements? Outcomes: Was the application of threshold appropriate given the available information? Nicky Pace Independent Chair Greenwich Safeguarding Children Board April 2017 Appendix 2: Whether mother was mentally ill or had post natal depression What were the stress factors in her life leading up to her death Whether she intended to take her life and that of her children when she knew what she was doing. Did intoxication affect her decision-making? Whether the children were at risk of abuse or recognised to be? Whether mother was at risk of suicide and whether it was recognised Whether she should have been allocated a universal plus health visiting service. Whether the deaths were preventable – were there any care or protection service failings, in particular the recognition of risk or vulnerability and communication problems between Mental health and Health Visiting services 26 |
NC046124 | Death of an 8-month-old boy in December 2013. Baby L was found not breathing at home; post-mortem showed he had an acute upper respiratory tract infection at the time of his death. Baby L and his siblings were subject to child protection plans between September 2012 and November 2013; at the time of Baby L's death they were subject to Child in Need plans. The home environment was often dirty and cold and children were exposed to passive smoking. Parental history of substance misuse, domestic abuse and offending. At the time of the incident mother and father were separated, with the father having supervised contact with his children. Identifies examples of good practice, including: child protection conferences arranged so mother and father could attend separately to reduce the risk of intimidation; and the potential consequences of non-engagement with children's services were clearly explained to the mother. Identifies areas for improvement, including: delay in recognising the impact that recurring incidents of parental substance misuse and domestic abuse were having on the children; lack of information provided to the father about the impact his lack of engagement with services could have on his future contact with his children; insufficient assessment of the potential safeguarding role of the children's grandparents; lack of challenge to the mother's repeated understatement of her levels of alcohol consumption; and failure to regularly review, update and circulate child protection plans. Uses the Significant Learning Process (SILP) methodology to systematically assess why the incident occurred, identify incidents of good practice and strengths that can be built on. Recommendations for the safeguarding children board include: all assessments should include an understanding of each child's lived experience; practitioners should ensure that fathers are aware of the implications of failing to engage with services and work should be done to raise awareness of the dangers of parental smoking.
| Title: Serious case review: overview report: subjects: Baby L (aged 8 months), Sibling 3 (aged 4 years), Sibling 2 (aged 6 years), Sibling 1 (aged 11 years). LSCB: Sunderland Safeguarding Children Board Author: Adrienne Plunkett Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Sunderland Safeguarding Children Board Serious Case Review Overview Report Subjects: Baby L: (Aged 8 months) Sibling 3: (Aged 4 years) Sibling 2: (Aged 6 years) Sibling 1: (Aged 11 Years) Lead Reviewer: Adrienne Plunkett Final Version: 25 February 2015 2 CONTENTS: PAGE 1. Background to the circumstances 3 2. Background to Serious Case Reviews 3 3. Introduction to SILP 4 4. Process for this SCR 4 5. Introduction to the family 6 6. Engagement with the family 7 7. Pre-Scoping Period 7 8. Scoping Period 10 9. Thematic Analysis 25 • Agencies’ response to domestic abuse • The children’s lived experience • Quality of assessments • Quality of inter-agency communication • Child protection processes • Parental smoking • Management oversight and supervision 10. Findings • Good practice 45 • Areas for improvement 47 11. Developments underway 48 12. Conclusion 51 13. Recommendations for SSCB 53 Appendix A: Terms of Reference and Agency Template Appendix B: Key single agency recommendations Appendix C: Glossary Appendix D: References 3 1. Background to the circumstances 1.1 This Serious Case Review concerns a family of four children, the youngest of whom, Baby L, had suffered with respiratory difficulties since soon after birth. In December 2013, at the age of 8 months, Baby L was found not breathing at home and, despite attempts by the Paramedics and Accident and Emergency Department, it was not possible to resuscitate him. The post-mortem showed he had an acute upper respiratory tract infection at the time of his death. 1.2 The family had been known to a range of agencies for many years due to a history of alcohol and drug related domestic abuse. The children became the subject of Children Protection Plans following a domestic abuse incident in September 2012, during which Sibling 1 had sustained an injury. The Child Protection Plans ceased in November 2013 and at the time of the death of the youngest child, the children were the subject of Child In Need Plans. 2. Background to Serious Case Reviews 2.1 Local Safeguarding Children Boards (LSCBs) have a statutory duty to undertake Serious Case Reviews (SCRs). Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs, including the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) sets out an LSCB’s responsibility for: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 2.2 Working Together to Safeguard Children 2013, Chapter 4,1 contains guidance as to when and how to undertake a SCR. It emphasises the importance of each LSCB developing a Learning and Improvement Framework and outlines that case reviews should be completed in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; 1 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2013. 4 • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings 2.3 Working Together 20132 also encourages LSCBs to use a variety of models for undertaking SCRs, including the systems approach. The Significant Incident Learning Process (SILP) is one such model. 3. Introduction to the Significant incident Learning Process (SILP) 3.1 The SILP methodology reflects on multi-agency work systemically and aims to answer the question why things have happened. Importantly it recognises good practice and strengths that can be built on. SILP is a learning model which engages frontline staff and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. . 3.2 The SILP model of review adheres to the principles of: • Proportionality • Learning from good practice • Active engagement of practitioners and managers • Engagement with families • Systems methodology 3.3 SILPs are characterised by a large number of practitioners, managers and Agency Report Authors coming together for a Learning Event. Agency Reports are shared in advance with participants and the perspectives and views of all those involved are discussed and valued. This same group then comes together again to consider the first draft of the Overview Report at a Recall Event. 4. Process for this Serious Case Review 4.1 On 21 February 2014 Sunderland Safeguarding Children Board’s (SSCB) Independent Chair made the decision to undertake a Serious Case Review in respect of the children. It was agreed that the criteria to do so had been met under Paragraph 8.5., Working Together to Safeguard Children 2013.3 Furthermore a decision was taken that this SCR would be undertaken using the SILP methodology. A Scoping Meeting to discuss the Terms of Reference (Appendix A) was held on 3 September 2014. 4.2 SSCB recognises that there has been a delay in completing this SCR. There were initial deliberations as to whether the case met the criteria for 2 DCSF, 2013. 3 DCSF, 2013. 5 undertaking a SCR as there was a medical explanation for Baby L’s death, but as the impact of neglect could not be ruled out, the Board recognised that there were lessons to be learnt and it was decided to initiate the process. There was a further delay due to the demands on the SSCB of undertaking a number of SCRs at the same time. 4.3 The Scoping Period for this SCR is 1 January 2012, 6 months prior to the injury to Sibling 1 in July 2012, which was the trigger for the Initial Child Protection Conference, to 20.12.2013, the date of Baby L’s death. 4.4 Agencies were asked to provide a brief background of any significant events and safeguarding issues in respect of the children prior to the scoping period, e.g. domestic abuse episodes, substance misuse and treatment, referrals to Children’s Social Care, Early Help. This material would be used primarily to provide the background context and therefore needed to be concise and summarised, highlighting any particular learning points. An exception to this was the Police, who were requested to provide full background information regarding their involvement with the family prior to the scoping period. 4.5 Agency reports were commissioned from: • Police (Including MARAC information) • Children's Social Work Service • Children’s Services’ Independent Reviewing Service • NHS Foundation Trust (Health Visiting and School Nursing) • Acute Hospital (Paediatric and Midwifery Services) • General Practitioner • Ambulance Service • Education (Schools) • Substance Misuse Service • Domestic Abuse Service, via the Commissioner 4.6 In addition, agencies which had limited involvement with the family were requested to provide a brief report of their involvement for information. These included: • Probation Service • Registered Social Landlord • Early Help 4.7 It should be noted that in October 2014, following contact with the Commissioner, an Agency Report was requested from the Domestic Abuse Service, but was not received. 4.8 The Learning Event was held on 24 November 2014 and the Recall Day on 22 January 2015. All the Agency Reports were shared with the participants prior to the Learning Event, so that they had a wider understanding of agencies’ involvement. The draft Overview Report was then circulated to participants 6 prior to the Recall Day, in order that it could be checked for accuracy and the findings and recommendations fully discussed on the Day. The Overview Report was amended following this discussion. 4.9 The Learning Event was attended by practitioners, managers and Report Authors from the Police, the Acute Trust, NHS Foundation Trust, Clinical Commissioning Group, Father’s GP Practice, Education, Children’s Social Care, Independent Reviewing Service and Substance Misuse Service. The Recall Event was attended by the same agencies. The Probation Service was invited to both Events, but did not attend, neither did the Mother and children’s GP or the Domestic Abuse Service. 4.10 The Lead Reviewer for this SCR was Adrienne Plunkett; a qualified Social Worker, with a MA in Child Studies. Ms Plunkett has substantial experience working in Children’s Social Care, including as a senior manager, and has managed a Local Safeguarding Children Board, holding responsibility for commissioning SCRs. Ms Plunkett is a trained SILP Lead Reviewer and was supported in this SCR by Paul Tudor. 4.11 Mr Tudor had a 20 year career with the NSPCC leading teams who were responsible for child protection systems. For 22 years Mr Tudor has been an Independent Safeguarding Advisor, conducted many Serious Case Reviews, and pioneered the SILP methodology in April 2010. 4.12 In the Overview Report the names of family members have been anonymised and ages are as at the time of Baby L’s death in December 2013. 5. Introduction to the Family 5.1 Genogram Mother Aged 27 years Uncle Sibling 1 Aged 11 years Sibling 3 Aged 4 years Baby L Died aged 8 months Father Aged 30 years Sibling 2 Aged 6 years Paternal Grand-mother Maternal Grand-mother Paternal Grandfather Maternal Grandfather (Deceased) Aunt Uncle 7 5.2 The family is White British, both Parents having lived in the local area all their lives. It is understood that for some of his childhood the children’s Father lived with his Grandparents. 5.3 During the time of the review, the family lived in privately rented housing in an area of social deprivation, with high levels of unemployment and above the national average number of children receiving free school meals. 6. Engagement with family members 6.1 An important element of a SILP SCR is the engagement with significant family members, so that their views of the services offered to the family can contribute to the process and can inform the learning and hence development of services. 6.2 Arrangements were made for the Lead Reviewer and SSCB Business Manager to meet with the Parents individually on Tuesday, 18 November 2014. The Father was unable to attend, but the meeting with Mother went ahead. The purpose of meeting was to ascertain her views of the services offered to her prior to Baby L’s death to see if there was any learning, i.e. what agencies did well and what they could do better. Overall, Mother gave a positive view of agencies’ engagement with the family and her views have been threaded through this Report. 6.3 Further attempts were made by the Lead Reviewer to meet with the Father, but he was unable to attend. Attempts have also been made to obtain the views of the Grandparents. However, the Paternal Grandparents did not respond to the appointment letter and did not attend the proposed meeting. The working hours of the Maternal Grandmother have led to difficulties with making arrangements to meet with her. 6.4 Consideration was given as to how best to obtain the views of Sibling 1 and it was agreed this would be undertaken by the family’s current Social Worker. Sibling 1 confirmed that she had understood the reasons why Children’s Services became involved with her family and that this was in relation to her Father’s anger and alcohol misuse. Sibling 1 felt that she had been able to talk to the Social Worker and also to her Teacher at Primary School. Her view was that things had improved for the family. However, she worries about her father and would like him to accept the help offered. 7. Pre-Scoping Period 7.1 The Scoping Period for this SCR starts in January 2012, i.e. six months prior to Sibling 1’s injury which triggered the child protection process. However, agencies were asked to provide details of any significant events prior to January 2012, which may have relevance to the Scoping Period. 7.2 The first contact with the family appears to have been by the Police in December 2005 due to an incident of domestic abuse, which was notified to 8 Children’s Social Care (CSC). Over the next 6 years there were at least 11 further instances of domestic abuse. 7.3 These incidents were closely linked with alcohol and drug use by both Parents. They included incidents when Father was at the family home drunk and abusive and when the Police arrived he left, others resulted in physical assault and injuries to Mother. Incidents of particular note include November 2007 when Father was intoxicated and assaulted Mother, January 2009 when both parties were drunk and Father assaulted Mother, June 2010 when Mother was intoxicated and assaulted a Police Officer and May 2011 when Mother sustained significant facial injuries. Some of the incidents occurred when Mother was pregnant, i.e. October 2006 and March 2009. It is recognised that domestic abuse in pregnancy is an indication of increased risk of harm to a woman and her unborn child. Mother consistently refused to co-operate with pursuing criminal charges in respect of these assaults. 7.4 In terms of the welfare of the children during this time, when the majority of incidents of domestic abuse occurred they were reported to be with their Maternal Grandmother. The Police did observe that the condition of the family house was dirty and run-down on a number of occasions. 7.5 In the majority of domestic abuse incidents the Police completed Child Concern Notifications (CCN) which were sent to the Police Central Referral Unit and to CSC as either a notification or referral. A notification is sent with no expectation of action and a referral is made with the expectation that some action will be initiated by CSC and the Police will be updated accordingly. Most CCNs were sent as notifications, rather than referrals. The latter appear to have been sent when there were concerns about the state of the home, e.g. dirty and run-down, rather than concerns about the risk to the children from the domestic abuse in the household. None of the referrals resulted in CSC undertaking an Initial Assessment during this time. 7.6 Following the incidents Domestic Violence Notifications were also completed for Police internal use. In line with the Multi-Agency Risk Assessment Conference (MARAC) process, these notifications assessed Mother as very high, high, medium risk or standard risk. At times during 2009 she was assessed as very high and high risk. High risk is when there has been four or more incidents of domestic abuse in the previous 6 months. It does not appear that there was any link between the level of assessed risk to Mother and whether a referral or notification was made to CSC, indicating that an assessment of high risk to Mother was not viewed as high risk of harm to the children. 7.7 Mother’s safety was discussed at a MARAC in March 2009. At this time Mother was pregnant, was viewed as being at high risk and offered the support of an Independent Domestic Violence Advocate (IDVA). Reports from Education indicated no concerns regarding the children. Mother refused to engage with the IDVA and the case was closed to the IDVA in April 2009 and remained 9 open to MARAC. Following the serious incident in May 2011, the Police contacted Mother regarding safety planning, but she again refused support and safety measures offered. 7.8 In January 2006 Mother attended the ante-natal clinic for a booking-in appointment. She had bruising to her face and arms and a referral was made by the Midwifery Service to CSC. There is no record in Children’s Services of this referral, however, a copy has been provided to the Lead Reviewer by the Acute Trust’s Report Author. The referral noted that the Midwife had spoken to the family’s Health Visitor, and that there was a history of domestic abuse, and that Mother had been referred to the substance abuse clinic. The referral had an added note that the Midwife had spoken to a Social Worker. There is no record of the Midwifery Service following up the referral with CSC. 7.9 In March 2006, Mother had a miscarriage and Midwifery records note that she had been using cannabis. A referral was reportedly made to CSC, however, again there is no record of this in CSC’s records. 7.10 In November 2007 and February 2009, there are indications in the records that CSC was to undertake Initial Assessments, however, there is no record of these actually being completed. In May 2011 CSC had a telephone discussion with Mother and at this point she spoke of ending her relationship with the Father. It was agreed an Initial Assessment should be undertaken if she reconciled with him. 7.11 In June 2011 the Health Visitor made a referral to the Early Intervention Service. The referral was in respect of Sibling 3 and noted there were ‘boundary issues’ with managing her behaviour. It also referenced recent domestic abuse. The CAF Panel, held early in July 2011, agreed that two services should be offered; a nursery place and the involvement of a Family Support Worker (FSW). The aim of the work was to support Mother with behaviour management. A home visit was undertaken in July 2011, Mother agreed to undertake the Nurturing Programme due to start in September 2011, but she did not want individual support from the FSW. In the event Mother declined to attend the Nurturing Programme, stating things had improved as there had been no further incidents of domestic abuse. Therefore, there was no real engagement with the service. The Agency Report Author notes that Parents need to engage voluntarily with early intervention services, however, the agency would now make greater attempts to engage with the family. 7.12 Mother had held a tenancy with a Registered Social Landlord between 2003 and 2011. During this time there were numerous tenancy breaches relating to the Father’s anti-social and criminal behaviour and an Acceptable Behaviour Agreement was put in place. Mother terminated the tenancy in 2011 and 10 moved to privately rented accommodation, which was very close to the Maternal Grandmother’s (MGM) home. 7.13 From June 2010 Mother was subject of an 18 month Community Order to the Probation Service, for the assault on a Police Officer. Probation made a referral to CSC at the end of 2011, due to a domestic abuse incident. Father was the subject of a 12 month Community Order with supervision and 150 hours unpaid work from July 2011 for handling stolen goods and allowing himself to be carried in a stolen vehicle. He was classified as a Prolific and Priority Offender, which entailed enhanced supervision by a multi-agency team. Father’s co-operation with the Order was poor, with several breaches. 8. Scoping Period 8.1. January 2012 – Sibling 1’s injury 8.1.1 It is understood that Father spent much of his childhood in the care of his Grandmother and her death early in 2012 had a significant impact on him. He presented to the GP in February 2012 reporting an extremely high level of drug and alcohol use and was referred to Substance Misuse Service. He was seen again by his GP in March 2012 due to difficulties with substance misuse and then on a number of occasions requesting ‘sick notes’ for Probation to explain why he could not fulfil the requirements of his Order. There appears to have been no consideration by the GP as to whether Father had any parental responsibilities and no referrals were made to CSC. 8.1.2 In April 2012 the Foundation Unit (Education) made a referral to CSC. Sibling 3, aged 2 years 10 months at this time, had stated that his Father ‘punches mam in the face’. The staff spoke to the MGM who confirmed that the older children had said similar things to her. The Foundation Unit also informed the Comment: There is a picture of periodic, alcohol/drug related, domestic abuse incidents in the family during the Pre-Scoping Period. Whilst the Police followed procedures, and a MARAC held and CSC informed of the incidents of domestic abuse, it would appear that neither the Police nor CSC considered the pattern of domestic abuse. The views of the children were not gained and there is no evidence that the long term impact on them was considered. Given that reports to the Police of domestic abuse are often the tip of the iceberg, it can be assumed that this was the pattern of life for the children. The failure of CSC to undertake an Initial Assessment meant that there was no engagement with other agencies and a wider view of family life was not gained. However, there was no follow up or challenge by the agencies which made referrals during this time. 11 Health Visitor. CSC has no record of this referral nor of any action taken in response. The Unit continued to monitor Sibling 3’s wellbeing, but did not follow up the referral with CSC. No action was taken by the Health Visitor. At the Initial Child Protection Conference in September 2012 the Social Worker reported that Sibling 3 had laughed when she made this statement, so there was concern that she was desensitised to the domestic abuse she was witnessing, i.e. it had become a normal part of her day to day life. 8.1.3 The Health Visitor undertook Sibling 3’s three year developmental assessment in June 2012. She was reaching her developmental milestones, and had good communication skills, but was still using a bottle and dummy and attendance at the dentist was advised. 8.1.4 In May, June and July 2012 there were further domestic abuse incidents. In May 2012 CSC made attempts to contact Mother by phone and letter, but she did not respond and no further action was taken. In June 2012 the children were present during the incident and, when spoken to by the Police Officers, Sibling 1 said that her Father was ‘often abrupt’ to her. Following the referral to CSC, Mother was seen by a Social Worker. She stated she wanted to end the relationship with the Father and was planning to seek an injunction. CSC agreed no further action. 8.1.5 In July 2012 the Neighbourhood Policing Team were alerted to the domestic abuse and Mother was assessed as medium risk. 8.2. Sibling 1’s Injury to Initial Child Protection Conference (ICPC) 8.2.1 On 25 July 2012 during a domestic abuse incident Sibling 1 intervened to protect her Mother and sustained a fracture to her left little finger, which had been trapped in a door slammed shut by her Father. Sibling 1 was taken to the Accident & Emergency Department by her MGM. She was admitted and her finger required surgery. Hospital staff identified quickly that this was a child protection matter, the Designated Doctor was informed and referrals made to CSC and the Police on the same day. Sibling 1, aged 9 years, was Comment: During this time there were less domestic abuse notifications, but there were two significant referrals to CSC, one from the Foundation Unit and the other from the Police. These are of particular note as they related to views expressed by the children and gave a flavour of what life was like for them. Set against the earlier history, these should have been given substantial weight. There is no evidence that the Foundation Unit or Health Visitor followed up on the referrals in April 2012 or of discussions with Safeguarding Leads in their agencies. It is not known whether Father’s GP was aware of his parenting responsibilities, but following his presentation to his GP in February 2012, it is of note that the GP did not discuss with the Health Visitor or Named GP indicating a lack of consideration of his role as a parent, a failure to ‘Think Family’. 12 spoken to by a Social Worker in hospital. She stated that her Parents fight, it had been happening for a long time and she was fed up with it. There are no records of the other children being seen at this time. 8.2.2 There were conflicting accounts of this incident. Mother said that Father had gained access to the home through the garage, but Sibling 1 said that her Mother had let him in. It appeared the Parents had been drinking for much of the day. There was no reason not to believe Sibling 1’s account of the events. 8.2.3 There are no records in respect of a Strategy Meeting being convened, or of a multi-agency meeting being held prior to Sibling 1’s discharge from hospital. Section 47 enquiries commenced on 25 July 2012, but were not concluded until the date of the Initial Child Protection Conference (ICPC) in September 2012. A Core Assessment was not commenced. An electronic hospital discharge summary was sent to the Health Visitor and School Nurse, but not to CSC. Hence there was no multi-agency risk assessment or planning during this time, leaving Mother and the children highly vulnerable. 8.2.4 In August the Police visited Mother and offered victim support. It was agreed Mother would be referred to the Domestic Abuse Service. 8.2.5 Following Sibling 1’s injury arrangements were made for Mother and the children to stay with the MGM. There is no record of a written agreement with the Parents concerning these arrangements or regarding Father’s contact with the children. 8.2.6 MGM reported to CSC that on 30 August 2012 Father had been phoning Mother for many hours. Mother had not answered the phone and at 4.00 a.m. he had come to the MGM’s home calling for her. MGM had asked him to leave, he was abusive but left. 8.2.7 There was a delay in the Social Worker requesting a date for the ICPC and this was held in September 2012, 6 weeks following Sibling 1’s injury. The children were made the subjects of Child Protection Plans in the category of emotional abuse, which tends to be the category used for children living in situations of domestic abuse. The Government guidance in force at the time, Working Together to Safeguard Children, 2010, 1.34, states that Emotional Abuse may involve ‘seeing or hearing the ill-treatment of another’.4 Initiating the Public Law Outline, i.e. the process prior to commencing legal proceedings, was to be considered by the Local Authority if the Parents failed to engage. 8.2.8 The school reported that the children were well settled, their attendance and attainment being satisfactory. A report was requested from the GP for the Mother and the children, but this was not provided. It was not identified that 4 Working Together to Safeguarding Children, 2010 13 Father had a different GP from the Mother and the children and therefore no information was requested from, or shared with, his GP. 8.2.9 Mother told the Lead Reviewer was that once the children were made the subject of Child Protection Plans she felt she knew what she had to do, otherwise the children would be taken away, which included: • End her relationship with the children’s Father • Attend Service for women experiencing domestic abuse • Attend Substance Misuse Service • Attend meetings, e.g. Core Groups 8.3. ICPC to Review Child Protection Conference (RCPC) 8.3.1 Three days after the ICPC the Father went to the family home, intoxicated, and was removed by the Police. Mother was assessed as at high risk of domestic abuse by the Police and the information was passed to the PVP Sergeant for management. 8.3.2 The first Core Group meeting was held on 17 September 2012, the allocated Social Worker was not available and another Social Worker stepped in. The task of the first Core Group meeting is to develop the Child Protection Plan (CPP), drafted at the ICPC. However, there is no evidence that the CPP was developed and circulated to family and agencies, nor are minutes of this meeting available. There was a further Core Group on 8 October, the one planned on 7 November 2012 was cancelled and rearranged on 15 November 2012. Child protection monitoring visits were made to the family Comment: After the long history of domestic abuse and parental substance misuse, it was Sibling 1’s injury which finally triggered the child protection procedures. From Sibling 1’s injury until the ICPC there were no multi-agency plans in place to safeguard the children, e.g. a written agreement with the parents regarding living arrangements and contact with their Father, which meant that Mother and the children were extremely vulnerable. It appears that the lack of a timely Strategy Meeting contributed to the subsequent absence of multi-agency co-ordination. In addition, agencies may have been less concerned as Mother and the children had gone to live with the MGM and hence were considered to be safeguarded. The failure to identify that Father had a different GP meant that highly significant information was not available to the ICPC. There is a record of Sibling 1 being spoken to by a Social Worker, but not the other children. This was a missed opportunity to gain the children’s views and develop a much-needed picture of their lived day to day experiences. 14 on 26 September, 3 October, 24 October and 8 November 2012. Recording indicates that the children and home were viewed as appropriately cared for. There is no recording of the children being spoken to and the reasons for the CPPs discussed with them. In September 2012 Mother is reported as being uncertain about ending her relationship with the children’s Father. 8.3.3 In September 2012 the School Nurse undertook health assessments; Sibling 2 required an optician’s check and Sibling 1 a dental assessment. Head lice was reported to be a recurring problem for Sibling 1. Both children were obese and had high BMIs. Referrals to the Lifestyle Activity and Fitness (LAF) Team were discussed with Mother, but she declined on the basis that she could not cope at that time. At a review six months later, undertaken by the new School Nurse, Mother agreed to referrals and the children attended appointments with LAF in May 2013. Mother recognised that the School Nurse had provided advice regarding managing the children’s weight. 8.3.4 On 3 October 2012 Mother’s safety was discussed at a MARAC meeting, due to the three alcohol related domestic abuse incidents in May, June and July 2012. Actions agreed included offering Mother support from the Domestic Abuse Service in obtaining a Non-Molestation Order, but she did not accept this. She did, however, accept extra security being fitted to her house, e.g. panic alarm, safety locks. Also both Parents were to be referred to the Substance Misuse Service. 8.3.5 Following Sibling 1’s injury Mother and the children had been living with the MGM. On 4 October 2012 there was a discussion between the Social Worker and School Nurse about the family returning to their own home and this was agreed. It is positive that this discussion took place, but there is no record of a discussion with the other Core Group members. The timing of this discussion is interesting as it was only a matter of a few days before the next Core Group meeting and there was no reason why the arrangement could not continue until then. 8.3.6 The Social Worker visited Father on 7 November 2012. He had recently been released from Prison, where he stated he had completed a detoxification program. Father agreed to make contact with the domestic abuse and substance misuse services. This was the first home visit to Father since the injury to Sibling 1 in July 2012. 15 8.3.7 The RCPC was held on 19 November, 2012. Reports regarding the care of the home and children were positive, but neither Mother nor Father had engaged with the domestic abuse or substance misuse services. In addition, Father had not engaged with Probation or the Mental Health Service. At this Conference the previous recommendation that Children’s Services should consider commencing the Public Law Outline (PLO) was removed. It is not clear why this decision was taken given the Parents’ lack of engagement, which indicated a lack of understanding of the causes for concern. 8.4. First RCPC to Pre-birth Child Protection Conference 8.4.1 The first Core Group after the RCPC was held on 11 December 2012, then on 8 January 2013 and 5 February 2013. In January 2013 the school reported that Sibling 2 was anxious in unfamiliar situations and in February 2013 that both Siblings 1 and 2 presented as anxious and reluctant to talk about their home life. 8.4.2 Mother had attended an appointment with the Substance Misuse Service in January 2013 and reported that she had reduced her alcohol intake since separation from the children’s Father. In February 2013 she was offered a service by an organisation offering services to women who had experienced domestic abuse. 8.4.3 In January 2013, just three days after the Core Group meeting, Mother had a consultation with her GP, having had a positive pregnancy test at home two weeks earlier. She had an appointment with the Midwifery Service the same day. Mother thought she was 31 weeks pregnant, but was confirmed to be 28 weeks. The Father of the unborn baby was the same Father as the older children. The Midwife completed the Vulnerability Tool, which was sent to the Health Visitor in February 2013. The purpose is to share information, Comment: It is interesting to note that the recording of home visits focussed on the home conditions and care of the children, rather than the reasons for the CPPs, e.g. the children being exposed to domestic abuse. There is a record of a discussion, and agreement, between Social Worker and School Nurse about the family returning home, which raises the question why this discussion could not wait until the Core Group meeting, four days later. This would have been a multi-agency discussion, involving Mother and Father, and the Core Group could have ensured that adequate safeguards were in place for Mother and the children. There was a lack of engagement with Father, with the first visit to him taking place in November 2012, i.e. four months after the injury to Sibling 1. The CPPs continued at the RCPC, but the recommendation to consider PLO was removed. It appears that consideration was not given to the fact that both Parents’ lack of co-operation was in itself a risk factor. 16 highlighting vulnerabilities and risk factors, which will identify if additional support and referral to CSC are required. 8.4.4 There were discussions at the time as to whether this was a concealed pregnancy. The CCG Report Author notes that a concealed pregnancy is when: • An expectant mother knows she is pregnant, but does not tell any professionals • When she tells another professional, but conceals the fact that she is not accessing antenatal care • When a pregnant expectant mother tells another person/s and they conceal the fact from all agencies 8.4.5 0n 15 January 2013 Police were called to the family home. Allegedly the Father had broken into the house through the garage and climbed into bed. He was removed by the Police in handcuffs. The children were at home and reported by the Police to be frightened and hiding under a duvet. The Police assessed Mother as being at high risk and informed CSC of the incident. In line with guidance the case was considered at MARAC on 6 February 2013, due to four or more reported incidents in six months. It was again recommended that Mother be supported by the Domestic Abuse Service and confirmation of Father’s involvement with the Substance Misuse service be confirmed. Parents again failed to engage. 8.4.6 Child protection monitoring visits to the home were undertaken in December 2013 and March 2013. In December Mother had bruising to her eye and stated this had been caused by a fight in a nightclub with another woman. Mother was pregnant at this time. In March 2013 the Social Worker discussed with Mother her lack of engagement with the Substance Misuse Service, which had offered 1:1 support. Mother stated she did not have difficulties with alcohol, but the Social Worker encouraged her attendance. 8.4.7 The Social Worker visited the children at school in February 2013 following the domestic abuse incident in January 2013. The children talked of being frightened by previous incidents and Sibling 1 said that she was happier having supervised contact with her Father. 8.4.8 On 12 February 2013 a Strategy Meeting was held regarding the unborn baby; the decision was made to convene a Pre-Birth CPC. This was held on 6 March 2013 and the unborn child was made the subject of a CPP in the category of neglect. The other children were not considered at this Conference. Recommendations included that a Legal Brief should be held and contact with Father should be supervised. 17 8.5. Pre-birth CPC to RCPC 8.5.1 On 20 March 2013 at the ante-natal clinic Mother stated that she had been using cannabis and tested positive for cannabis on urine toxicology. The Substance Misuse Midwife referred Mother to the Substance Misuse Service and informed the Health Visitor. The Midwife also tried to contact the Social Worker, but was unable to do so and spoke to the Out of Hours Service. 8.5.2 Core Groups appear to have been planned, but did not take place on 11 March, 8 April and 25 April 2013. The School Nurse contacted the Social Worker on 9 April 2013 to ascertain the new date. The Social Worker was unable to attend the meeting on 25 April 2013 at short notice, so the practitioners who attended held an Information Sharing Meeting, as recommended in SSCB’s Inter-agency Procedures in such circumstances. A Core Group meeting should then be held within 10 working days of the Information Sharing Meeting, but this did not take place. 8.5.3 A child protection monitoring visit was undertaken on 28 March 2013, when the home conditions were noted to be ‘adequate, but cold’. Mother was dressed in her coat and scarf. 8.5.4 Baby L was born on 20 April 2013. The Midwife requested a pre-discharge meeting with CSC. There were difficulties with the Social Worker’s availability, but the Midwife persisted and a meeting was held. It was agreed that Mother and the children would reside with the MGM following discharge in order to provide support and establish a routine. 8.5.5 The Social Worker and Team Manager made an unannounced home visit on 26 April 2013 to see how Baby L was progressing following his discharge from hospital. They found Mother at home with two males, with evidence that they had been drinking alcohol, e.g. cans in garden and kitchen. Mother said these males were her cousins. Sibling 3 was present, but the other children were with Grandparents, Baby L being with his MGM. Despite the purpose of the visit, Baby L was not seen. At the subsequent RCPC the Team Manager Comment: The Learning and Recall Events debated whether Mother’s pregnancy had been concealed. Mother had a pattern of late bookings, but she had known for at least two weeks that she was pregnant and had chosen not share this with professionals, e.g. at the Core Group. It is likely that Mother would have been worried about how she would explain the pregnancy to professionals as she had stated that she had not been in a relationship with the Father for some time. On balance, this would appear to be a concealed pregnancy. It was important for agencies to consider this factor, as it was an indication of how honest Mother was being with the practitioners working with her. 18 commented that she believed that the Father was in fact one of these two males. Another visit was attempted on 1 May 2013, but the family was not at home. 8.5.6 As required the post-natal 24 hour Vulnerability Assessment was completed by the Midwife and received by the Health Visitor on 26 April 2013. This Assessment identifies any risks to the baby. The Health Visitor undertook the Primary Birth Visit on the same day. Baby L was clean and well, although he was ‘snuffly’. Safe sleeping was discussed with Mother. The assessment by the Health Visitor included revisiting ‘the issues related to health and safeguarding risks’. No concerns were identified regarding post-natal depression or low mood. A further visit by the Health Visitor was undertaken on 3 May 2013 and Baby L was clean and well presented, although he had ‘snuffles’ and a slight rash. He was seen later in the day by the GP with thrush and an upper respiratory tract infection. 8.5.7 In respect of the Public Law Outline (PLO) a Legal Brief was held on 19 April 2013 and it was agreed that PLO would be initiated. The plan was that the Pre-proceeding Letter would be provided to Legal Services by the Social Work Team by the end of April 2013 and a PLO meeting with those holding Parental Responsibility be held on 10 May 2013. However, due to staffing difficulties the letter was not prepared and the PLO meeting did not take place. 8.5.8 The RCPC was held on 15 May 2013. It was agreed that the CPPs would continue, but the category would change to neglect. Sibling 1 had written a letter to the Conference Chair expressing her wish that her Father should be allowed to return to the family home. PLO was not being taken forward, but the reasons for this are not clear. Comment: No Core Groups were held during this period, which meant that the CPP for Baby L was not developed or circulated to agencies and the Parents. There is evidence that the School Nurse contacted the Social Worker for a date for the Core Group, but not that other agencies did so. There is no evidence of escalation or discussion with Safeguarding Leads. It is positive that Core Group members held an Information Sharing Meeting in April when the Social Worker was unable to attend, but of concern that the next Core Group was not held within 10 working days, as required in SSCB procedures. Three child protection monitoring visits were attempted, in March, April and May, but the children were only seen on 28 March. The visit in April, a few days after Baby L’s birth, is noteworthy, as the aim was specifically to see how Baby L was progressing. However, this was not achieved. This meant that Baby L had not been seen at home by CSC prior to the RCPC, when he was aged approximately 4 weeks. This was an important time for the family, given the addition of a young, vulnerable, baby to the family. 19 8.6. Second RCPC to third RCPC 8.6.1 The Core Group planned in April 2013 was cancelled and the first Core Group since 5 February 2013 took place on 24 May 2013. By this time a new Social Worker had been allocated to work with the family. At this time Baby L was in hospital and the MGM was caring for the other children. The school reported that the children were happier. The school raised concerns about information sharing by CSC and the delay in the allocation of a new Social Worker. 8.6.2 The next Core Group took place on 21 June 2013, but the one planned for 15 July 2013 did not take place due to the unavailability of the Social Worker. Again an Information Sharing Meeting was held by the practitioners present, but the next Core Group was not held within the ten day period. Core Groups were then held at regular intervals on 23 August, 19 September and 18 October 2013, with the next RCPC taking place on 5 November 2013. 8.6.3 At the Core Group in June 2013 Mother had commenced working with the Domestic Abuse Service and was undertaking the Freedom Programme for women who have experienced domestic abuse. The children were again reported to be more confident and Siblings 1 and 2 were attending appointments regarding their weight. In August and September 2013 Mother was continuing to engage with the Domestic Abuse Service and had also attended appointments with the Substance Misuse Service in respect of her use of alcohol. The children were having contact with their Father at the Paternal Grandparents home at the weekend. 8.6.4 Regular child protection monitoring visits were undertaken in May, June, July, August, September, October and November 2013. Whilst there were some concerns noted about the home, e.g. piles of ironing in May 2013, bathroom needed cleaning in June 2013, overall the home conditions were viewed as satisfactory with age appropriate toys for the children. Previously it had been noted that the home was cold, but in November 2013 it was noted to be clean and warm. There were some concerns about the sleeping arrangements, i.e. Mother sleeping with the three youngest children, and safe sleeping was discussed. The children presented as relaxed at home and with their Mother. In July 2013 they told the Social Worker that they were happy at home and enjoyed seeing their Father on Saturdays at the home of their Paternal Grandparents. 8.6.5 Mother told the Lead Reviewer that the most recent Social Worker had been helpful to the family. Mother was aware that the children needed to be at home when the Social Worker visited and on the visits she had talked to children and played games with them. Mother was grateful to the Social Worker for raising money for bunk beds. 20 8.6.6 On 18 July 2013 Sibling 3’s 4 year developmental assessment was undertaken at home by the Health Visitor. She was clean and well-presented and reaching all her developmental milestones. 8.6.7 Mother had her post natal check with the GP on 4 June 2013. The GP assessed Mother’s mood as good and noted she was receiving support from the MGM. It was not established whether Mother was smoking and required cessation advice. The CCG Report Author references the NICE Guidelines and the fact that health risks posed to babies from smoking both antenatally and following birth are substantial in that more than a quarter of sudden and unexpected deaths in infancy are attributable to smoking. 8.6.8 On 12 June 2013 Baby L had his six week check with the GP; his development was normal. Mother was given advice about the Smoking Cessation Clinic, but did not take this up. There was no discussion about the Child Protection Planning as would have been expected. The Health Visitor conducted the 6/8 week development assessment the next day. Baby L was smiling, a feeding routine had been established and he was developing on 9th centile. The Health Visitor subsequently undertook Baby L’s three/four month developmental assessment on 13 August 2013. He was clean and well presented. His development was good, he was gurgling and there was ‘lovely interaction’ with his Mother. 8.6.9 However, during this time there were growing concerns about Baby L’s physical health: • 3 May: Taken to GP with Upper Respiratory Tract Infection (URTI) • 20 May: Inpatient for 7 days with bronchiolitis • 8 July: Taken to GP with diarrhoea & vomiting • 15 July: Referred to Paediatric A & E Department by GP and admitted overnight due to shortness of breath and poor feeding • 25 July: Admitted to hospital with chest problems. Discharged same day • 2 August: Referred to hospital by GP, unwell and irritable • 5 August: Taken to A & E Department due to shortness of breath, admitted for observation • 13 August: Taken to A & E Department due to shortness of breath • 9 Sept: Out-patient review. Still coughing and mediation prescribed • 20 Sept: Taken to A & E Department with bronchiolitis and viral rash. Discharged same day • 24 Sept: Taken to Hospital by ambulance from GP Surgery due to respiratory distress. Oxygen required. Admitted to hospital • 22 October: Seen by GP. Happy and feeding well. Still wheezy and had nappy rash 8.6.10 The Agency Report Author for the Acute Trust noted that ‘it is widely accepted that children often have between 10 and 12 infections per year 21 and respiratory problems usually account for a large proportion of these. These respiratory illnesses are usually minor and do not require admission to hospital. Baby L had an above average number and severity of respiratory infections’. He had a number of medical investigations that concluded these infections were caused by a range of viruses and bacteria. His immune function was checked and was normal. It was recognised that Mother was a smoker and there is overwhelming evidence that children of smokers have an increased number of respiratory infections. The Report Author noted that ‘while smoking is detrimental to a child’s health, it is so common that it is not specifically judged of being a sign of neglect.’ The Author also comments that the evidence in respect of a cold atmosphere increasing the frequency or severity of respiratory infections is scant, although there is some evidence that the ‘envelope’ that covers the virus becomes more rigid in cold conditions making it harder for the body to fight the virus. 8.6.11 The NHS Foundation Trust Report Author provides helpful information about Bronchiolitis, inflammation of the bronchioles, the smallest air passages of the lungs. This usually occurs in children less than two years of age with the majority aged between 3 – 6 months. The symptoms include shortness of breath, wheezing and coughing, with some children also having feeding difficulties. Bronchiolitis is most commonly caused by a virus and the treatment of bronchiolitis is focused on the symptoms. 8.6.12 Advice includes: • Washing hands of the child and adults frequently • Washing toys and surfaces regularly • Keeping new born babies away from people with colds and flu • Preventing children being exposed to tobacco smoke 8.6.13 The Hospital followed procedures in terms of informing the GP and Health Visitor of Baby L’s admissions and discharges. However, there was no direct verbal communication between hospital staff and health staff in the community, and CSC was not informed of Baby L’s admissions. This means that a holistic view was not taken of Baby L’s health needs or consideration given to social factors which might have impacted on his health. 8.6.14 In the main Mother was viewed as accessing medical services appropriately when Baby L was unwell. Hospital staff noted that Mother stayed with Baby L during his admission, including overnight, and was observed to meet his needs. However, the GP noted on 2 August 2013 that Mother was ‘frustrated’ at ‘being back and forth’ to the hospital. There was also concern on 24 September 2013 when Baby L was taken to the GP surgery for routine immunisations and was found to be very unwell with another respiratory illness. An ambulance was called and Baby L was taken to hospital from the surgery. He was admitted and required oxygen. The surgery was concerned about Mother’s response to Baby L’s illness on this occasion and whether she had 22 not been aware of how unwell he was. Alternatively she may have been worried about making a fuss/being too demanding or she may have been somewhat over-whelmed by the demands of caring for Baby L. Mother was upset and agreed to the Practice Nurse contacting the Health Visitor about arranging additional support. The Practice Nurse did this, but no contact was made with the Social Worker. 8.6.15 Mother explained to the Lead Reviewer that the Health Visitor had visited every two weeks following Baby L’s birth and had provided the following advice regarding his health, which she had found helpful: • Not to smoke in the house (in garden) • Wash hands after smoking • Place Baby L on his back to sleep • Put Baby L to sleep in the Moses basket or cot 8.6.16 Mother also commented that Sibling 3 had similar breathing difficulties. Heating in the home was a problem as it was ducted and got very hot very quickly, so she had to keep turning it off. 8.6.17 It was recognised by health practitioners that there is a link between parental smoking and the increased risk of respiratory infections in babies and Mother was provided with information about Smoking Cessation Clinics by both the GP and the Health Visitor. However, it does not appear that this was pursued very robustly. 8.6.18 There continued to be occasional domestic abuse incidents during this period. In June 2013 there was a verbal altercation in the street, both Baby L and Sibling 3 were present. The Police assessed Mother as high risk of domestic abuse. In September 2013 Father came to the property and Mother refused to let him in, Baby L was present and asleep. Mother appropriately contacted the Police on these occasions. 8.6.19 There were two significant events during this period. On 24 July 2013 the Police received an anonymous referral from a male alleging that Mother was intoxicated whilst caring for the children. Police attended the property. A baby could be heard crying and, despite trying for 10 minutes, the Police had difficult rousing Mother. Access to the property was obtained with the assistance of the MGM and, when Mother was woken, she was aggressive and abusive to the Police. Alcohol could be smelt on her breath. The children were at home and were left in the care of Mother and the MGM. On the visit on 6 August 2013 the Social Worker discussed this incident with Mother, who stated that she had been shocked which was why she lost her temper with the Police Officers. She acknowledged she had had two cans of lager and agreed to self-refer to the Substance Misuse Service. 8.6.20 On 5 October 2013 Mother contacted the Police as Father was sending harassing text messages. He had come to the family home and was banging 23 and kicking the door, demanding to see the children. The Police attended and Father left. The Police reported that the children were home, they were ‘unharmed and seemed unaffected by this incident’. On 16 October 2013 the Social Worker discussed this incident with Mother. She acknowledged that she had ‘had a couple of drinks’, but had been fit to care for the children. 8.6.21 Following the incident Mother was again the subject of discussion at MARAC on 20 October 2013. This was a re-referral, due to four incidents of domestic abuse in four months, as per MARAC guidance. It was noted that Mother had engaged with both the Domestic and Substance Misuse Services and the Substance Misuse Service was working with Father. 8.6.22 Mother referred herself to the Substance Misuse Service and had three brief sessions with the Hospital Liaison Team on 12 September, 27 September and 15 October, 2013, totalling 30 minutes. The Social Worker advised the Service of the concerns, although the Mother told the worker that she only drank on Saturday nights when the children were not with her. The Service provided was very much at the ‘lower level of support’ and a fuller assessment was arranged. 8.6.23 In respect of the Father, there was an incident towards the end of July 2013 when he was taken to A & E by the Police in the early hours of the morning. He had been drinking heavily and been arrested. He alleged to the Police that he had taken a cocktail of ecstasy, codeine and diazepam tablets. He refused blood tests, was observed for five hours and discharged. This information was shared with his GP, but it was not shared with CSC either by the Hospital, the Police or the GP, despite the children being the subjects of CPPs. 8.6.24 The Social Worker visited the Father on 17 October, 2013. He denied any involvement in the recent incidents, but did agree to refer himself to the substance misuse and domestic abuse services. This appears to be the second visit to Father in twelve months. 8.6.25 A RCPC was held on 5 November 2013. The Social Worker had completed a Parenting Assessment with Mother, which was noted to be positive. Reports from the school and health regarding the children were positive. The children were attending school regularly and progressing well academically, with homework completed on time. Siblings 1 and 2 had attended clinic appointments in respect of their weight. Baby L’s attendances at hospital for respiratory difficulties were noted. The GP’s report raised concerns about Mother’s lack of understanding of Baby L’s health needs and noted her continued smoking. There had been less reports of domestic abuse and Mother was engaging with agencies, including the Domestic and Substance Misuse Services. The Domestic Abuse Service was not represented at the RCPC and did not submit a report. The Substance Misuse Service was present, 24 but similarly did not submit a report. Father had failed to access any of the services offered to him. 8.6.26 Mother talked to the Lead Reviewer of feeling very nervous about attending the domestic abuse group sessions, but found it was okay once she got there and these had been helpful. She felt it was a ‘really good’ service. She had attended 11 out of 12 sessions, but did not complete the final session, due to Baby L’s death. She has also found the substance misuse service helpful, although she only ‘drank at weekends’ and is ‘not a heavy drinker’. 8.6.27 It was unanimously agreed at the RCPC that the CPPs should cease but, in recognition of the family’s long-standing difficulties, that robust Child In Need Plans (CIN) should be put in place. The Chair of the RCPC recommended that these should continue for a further six months in order that the family would continue to receive support. 8.7. RCPC to Baby L’s death 8.7.1 On 14 November 2013 Mother failed to attend an appointment with The Substance Misuse Service. The purpose of this appointment was to commence a comprehensive assessment, i.e. to gain a fuller understanding of her alcohol use. A follow up letter was sent, but there was no response, so no further appointments were offered or attended. 8.7.2 Baby L’s health difficulties continued. He attended for a review with the Consultant Paediatrician on 16 November 2013 and was prescribed a Comment: This appears to be a more settled time for the family. There were occasional domestic abuse incidents, when Mother contacted the Police. Mother had engaged with the service for women experiencing domestic abuse, but had had minimal engagement with the Substance Misuse Service. She advised that she only drank at weekends when the children were not with her. However, there was evidence that this was not in fact the case and this was not challenged. Father had failed to engage and remained an unassessed risk. During this period there was a change of Social Worker and from then Core Groups were held, and child protection monitoring visits undertaken, regularly. The children were seen at home by the Social Worker and Health Visitor, and appeared to be well and happy, but there is little recorded as to their feelings and views, hence it is difficult to gain a picture of their lived experiences and whether life had changed for them. Baby L’s development was good, although there were concerns about his health needs. Given the Parents’ long standing difficulties, going back to 2005, it was early days to assess the impact of mother’s engagement with services and whether this would be maintained and make a positive difference for the family. 25 salbutamol inhaler. He was taken to the GP on 18 November 2013 with a wheezy cough and nappy rash and was seen by the Health Visitor at home on 3 December 2013 when he was chesty. Mother felt that the inhaler was helping his breathing difficulties. The Health Visitor discussed the risk of second-hand smoking and again suggested the Smoking Cessation Clinic. Mother declined this, indicating a lack of appreciation of the dangers of smoking around young babies. Baby L’s weight had increased from 50th to 75th centile. It was noted the home was clean, tidy and appropriately furnished, with age appropriate toys. The house required a new boiler, as there was only ducted heating in the house. 8.7.3 The Social Worker visited the family on 2 December. The children continued to be happy and relaxed at home. The bedrooms and bedding were noted as appropriate. 8.7.4 On 4 December Baby L was taken to hospital by ambulance, due to breathing difficulties and not feeding. He was admitted and discharged three days later on 7 December, with a referral to the Ear, Nose and Throat Clinic. On 11 December the Health Visitor was informed by the hospital that on admission Baby L had nappy rash, which ‘looked bad’, and concerns had been noted about mother’s lack of interaction with him, e.g. lack of reassurance during medical procedures. CSC were not informed of these concerns. It appears that the nursing staff were aware of Baby L’s history and the previous child protection concerns. However, the Consultant dealing with B at this time was not aware of the history and in the discussion with the Agency Report Author the Consultant stated that if he had known he would have had a discussion with the Social Worker prior to Baby L’s discharge. 8.7.5 The increased risk of respiratory infections in babies due to parental smoking is well recognised, but it does not appear that, despite Baby L’s continuing health difficulties, this was given due regard and the risks discussed robustly with Mother by hospital or community staff. 8.7.6 On 16 December the first CIN Review Meeting was held post the RCPC. This was attended by Mother, Social Worker, Health Visitor and the school. Things had continued to go well and the school reported that the children had increased in confidence, were making good academic progress and were communicative with staff. Baby L’s health continued to be a cause for concern, but it does not appear that the Acute Hospital’s concerns were shared. A unanimous decision was taken to cease the CIN Plans, once contact had been made with the Father, despite the recommendation from the Chair of the RCPC that these should continue for six months in order to consolidate the changes. 26 8.7.7 On 20 December Mother called an ambulance as Baby L had been found not breathing. Despite attempts by the paramedics and hospital staff it was not possible to revive him. The post-mortem indicated an acute respiratory infection, rather than a chronic disorder. The Police reported that the house was very cold, extremely untidy, without satisfactory bedding. This was a different picture to that gained by recent home visits by the Social Worker and Health Visitor, so raises a question as to whether there had been a deterioration in home conditions in a short space of time. It was known that there were difficulties with the heating in the house and Mother had reported this. 9. Thematic Analysis The analysis section of the Overview Report will consider, and reflect on, the information above, which has been collated from the Agency Reports and discussions at the Learning Event and Recall Day. The emerging themes are identified and discussed in sections, leading to the lessons that need to be learned from this SCR and recommendations for SSCB. It is important to guard against hindsight in drawing conclusions and to bear in mind the context that practitioners were working in at this time. The Emerging themes include: 1. Agencies’ response to domestic abuse 2. The children’s lived experience 3. Quality of assessments 4. Quality of inter-agency communication 5. Child protection processes � Strategy meeting � Initial Child Protection Conference � Core Group working � Child Protection Planning � Decision Making: Public Law Outline 6. Parental smoking 7. Management oversight and supervision Comment: Approximately six weeks after the RCPC, which had ceased the CPPs, the decision was taken to end the CIN Plans despite the clear recommendation that these should continue for six months in order to support Mother in maintaining the changes made. ‘Step-down’ from a CPP to a robust CIN Plan can be very effective in working with families, supporting and promoting change, but only if sufficient time is allowed for changes in families to become embedded. 27 9.1. Agencies’ response to domestic abuse 9.1.1 In this case there is a substantial history of alcohol and drug related domestic abuse dating back to 2005 and a significant number of notifications and referrals were sent to CSC by the Police in the years following 2005 until the child protection referral in 2012 in respect of Sibling 1’s injury to her finger, which triggered the child protection processes. 9.1.2 A number of these incidents were serious: • Jan 2009: Both Parents drunk, Father had punched Mother in the face. Arrested for assault and criminal damage • June 2010: Altercation between Mother and Father, both intoxicated. Police attended and Mother assaulted a police officer • May 2011: Mother sustained facial injuries and bruising. Father arrested for assault occasioning actual bodily harm. Mother refused treatment 9.1.3 There were also instances of domestic abuse when Mother was pregnant in October 2006 and March 2009. Pregnancy is recognised as a time of increased risk for women and the unborn child. 9.1.4 There were additional indications of domestic abuse in the home. In January 2006 Mother had a miscarriage and there was evidence of bruising, which led to a referral to CSC. In April 2012 Sibling 3 told staff at the Foundation Unit that ‘dad punches mum in the face’. When this was discussed with the MGM she commented that the older children have said similar things to her. 9.1.5 The process for dealing with instances of domestic abuse was discussed at the Learning and Recall Events. It appears that Police routinely sent Child Concern Notifications (CCN) following incidents of domestic abuse, as either notifications or referrals, to CSC. Referrals tend to be when children are identified in the family/present at the incident. The volume of incidents and notifications that the police were dealing with at any one time meant that they were unable to thoroughly assess the notifications before sending to CSC, e.g. link with previous incidents and identify patterns. The high volume is evidenced by the fact that in the last year the Police have dealt with 36,000 incidents of domestic abuse. 9.1.6 In respect of CSC’s response to the notifications between 2005 and 2012, there were broadly four types of responses: • No further action: 2005, 2006, 2007, 2008, 2009, 2010 • Recommendation to undertake an Initial Assessment, but no evidence this was undertaken: 2007 and 2009 • Unsuccessful attempts to contact Mother, followed by NFA • Contact made with Mother: 2011, telephone discussion, agreed Initial Assessment to be undertaken should Mother reconcile with children’s Father 28 9.1.7 The risk to Mother was considered at one MARAC prior to the Scoping Period and three during the Scoping Period. These are regular local meetings where information about high risk domestic abuse victims is shared between local agencies. By bringing all agencies together at a MARAC, a risk focused, co-ordinated safety plan can be drawn up to support the victim. 9.1.8 Mother was regarded as high risk at the MARAC Meeting in April 2009, the support of an IDVA was offered but declined by Mother, so the case was deregistered from MARAC 12 months later by the Detective Inspector. Following incidents in May, June and July 2012 Mother’s safety was discussed at the MARAC Meeting in October 2012 and support was offered for her to obtain a Non-Molestation Order, but again she did not co-operate. Further incidents led to subsequent discussions at MARAC in February 2013 and October 2013. For a considerable time Mother was reluctant to engage with the support being offered, apart from the fitting of some safety measures to the home. It is not apparent that consideration was given by the agencies represented at MARAC to the fact that this lack of co-operation indicated a lack of appreciation by Mother of the continuing danger to which she was exposed and the risks of harm to the children, which increased the risks. 9.1.9 Police reports indicated that the children were often not at home, but in the care of the MGM, when the incidents of domestic abuse occurred. However, there would have been occasions when, at the very least, they would have seen their Mother with facial bruising, e.g. in February 2009 and May 2011. It is recognised that incidents reported to the Police can be the tip of the iceberg, however, there was little attempt to talk to the children and understand the impact on them. The few discussions held with Sibling 1 indicated that she had a real sense of her Parents’ difficulties 9.1.10 There was a long term history of domestic abuse incidents in this family, but none of the agencies were looking at the pattern, risks and the long term impact on the children, rather tending to deal with each incident in isolation. The MARAC Process appeared to have had little impact, due to the Parents’ lack of engagement. Co-ordinated Activity Against Domestic Abuse (CAADA) is undertaking a review of the functioning and effectiveness of the MARAC processes in Sunderland and will be reporting on its findings and recommendations. 9.1.11 Mother told the Lead Reviewer that she had been advised to call the Police whenever Father came to the house and when she did this the Police always came out straight away. There seemed to be some confusion by Mother as she thought she had a Restraining Order with a Power of Arrest, but the Police were not aware of this. In fact, the records do not indicate that a Restraining Order was in place during the Scoping Period. 9.1.12 It should be noted that the Police Force has shown commitment to developing its service to the victims of domestic abuse. In 2012 victimless 29 prosecutions could be pursued and in 2013 the DASH (Domestic Abuse, Stalking and Harassment) risk assessment model was adopted, which helps to decide the level of intervention. Additionally there have been developments nationally; in 2014 the Domestic Violence Disclosure Scheme (Clare’s Law) and Domestic Violence Protection Notice/Domestic Violence Protection Orders were introduced. 9.2. The children’s lived experiences 9.2.1 The importance of seeking the views and feelings of children and young people and gaining a picture of their lived day-to-day experiences has been consistently highlighted in research arising from SCRs.5 An understanding of the impact of parental difficulties on children can be obtained not only from what the children say directly, but also by how they behave and from the observations of other significant people, especially family members, who can speak on their behalf. 9.2.2 From the Agency Reports and discussion at the Learning Event, it appears that until there was a change of Social Worker in April/May 2013, there was limited direct communication with the children. However, there were occasions when there were spotlights on to the children’s world which, if drawn together, would have provided an overview. These included: • April 2012: Sibling 3, aged 2 years 10 months, told the staff at his Foundation Unit that his ‘dad punches his mam in the face’. The MGM confirmed the older children had said similar things to her • June 2012: Police attended a domestic abuse incident. The children were present and Sibling 1 told the Police Officers that her Father was often abrupt and rude to her • July 2012: Sibling 1 was injured when she intervened to protect her Mother during a domestic abuse incident. Sibling 1 spoke of being angry and fed up with her Parents’ arguing • January 2013: Police attended a domestic abuse incident, Father was arrested for Breach of the Peace and harassment. The incident occurred in full view of the children, who were reported by the Police to be frightened and hiding under a duvet • February 2013: Children told the Social Worker that they had been frightened by the previous incidents and Sibling1 said that she was happier to be having supervised contact with her Father 5 Ofsted, The Voice of the child: Learning lessons from Serious Case Reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010, 2011. 30 9.2.3 Evidence has been gained through this SCR that the children were living in a family where there had been long term issues of domestic abuse and substance misuse. However, their views, wishes and feelings were not sought. Research suggests that children are much more aware of such parental difficulties than parents and agencies believe. Gorin’s literature review, Understanding what children say,6 examined what children say about living in families where there is domestic violence, parental substance misuse and/or parental mental health problems. The research highlighted that one of the most striking themes was the level of awareness that children have about what is going on within their family, reporting witnessing and experiencing a high level of violence and parental conflict. Children talked about experiencing a range of feelings including love and loyalty, feeling frightened, sad, angry, embarrassed and isolated. 9.2.4 This Research has resonance for this SCR, as it is clear when the children were spoken to that they had a knowledge of what was happening between their Parents. There were occasions when they would have seen their Mother with facial injuries. Undoubtedly they would have experienced the feelings referred to above. 9.2.5 During the period when the children were the subject of CPPs, there is one example, in February 2013, of the Social Worker speaking with the children away from the family home about what was happening at home and it does appear that the children were able to speak openly. However, this appears to be the only time that this happened. All other contacts with the Social Worker were within the family home and the children were seen together rather than individually. In addition, it is not clear that on these visits the Social Worker spoke to the children about their experiences at home, certainly this is not recorded. 9.2.6 The Government guidance in force at the time of the SCR, Working Together to Safeguard Children 2010, Chapter 5,7 states that the Lead Social Worker should develop a relationship of trust, a ‘therapeutic relationship’, with the child. The Lead Social Worker should see the child, alone when appropriate, in accordance with the Child Protection Plan, and regularly ascertain the child’s wishes and feeling, keeping the child up to date with the Child Protection Plan. The Lead Social Worker should record in the child’s Social Care record when the child was seen, who else was present and the reasons for deciding, or not, to see the child alone. 9.2.7 The Ofsted Thematic Report, Voice of the Child, 2011,8 which looked at the findings of SCRs found that the child was either not seen by the professionals 6 Sarah Gorin, Understanding what children say: Children’s experiences of domestic violence, parental substance misuse and parental health problems, National Children’s Bureau, 2007 7 DCSF, 2010 8 Ofsted, 2011 31 involved or was not seen frequently enough. In other cases, even when the child was seen, they were not asked about their views and feelings. SCRs also stressed the importance of ensuring that practitioners’ observations are clearly recorded and the consequences which can arise when this does not happen. 9.2.8 During the Learning Event the school noted that the children are very quiet, which is similar to their Mother. However, this quietness could be interpreted in another way. The NCB research,9 suggests that professionals should be proactive in talking to children, particularly if there are signs that they may be experiencing problems at home, e.g. being withdrawn or unusually quiet. Children’s accounts of coming into contact with professionals in relation to domestic violence indicated that, in some cases, professionals did not speak directly to them. 9.2.9 The staffing difficulties in CSC during the earlier part of the Scoping Period for this SCR undoubtedly impacted on building a relationship, and engaging, with the children. There were difficulties in the recruitment and retention of Social Workers and managers, leading to a high level of agency staff. 9.2.10 The lack of engagement could also relate to the focus of agencies’ attention being on the needs of the Parents rather than the needs of the children, a factor identified in many SCRs. Ofsted noted that practitioners tended to focus too much on the needs of the Parents, especially when working with vulnerable Parents, and overlooked the implications for the child.10 9.2.11 This lack of engagement with the children meant that agencies did not have an understanding of their lived, day to day, experiences nor of the risks to them from their parents’ difficulties and whether things had changed over time. 9.3. Quality of Assessments 9.3.1 The importance of timely, good quality, robust, assessments cannot be overstated. However, there are a number of key aspects and points in this case where the assessments were lacking in quality. These included: • Prior to the injury to Sibling 1 there were a large number of CCNs and referrals regarding domestic abuse from the Police to CSC. Each of these incidents appear to have been dealt with as single event, rather than considering the ongoing pattern of domestic abuse and the impact that this would undoubtedly be having on the children. There appears to have been a misplaced unquestioning acceptance that the couple had separated. Many of the Police notifications/referrals 9 Gorin, 2007 10 Ofsted, 2011 32 led to no further action, on two occasions there was a recommendation for CSC to undertake an Initial Assessment, but this did not take place, and on another there was a decision to undertake an Initial Assessment should the Parents reconcile • Following Sibling 1’s injury, Mother and the children went to stay with the MGM. There is no evidence of a multi-agency risk assessment being undertaken, nor of a risk management plan being put in place. This meant that there was no safeguards in place during the vulnerable period from Sibling 1’s injury until the ICPC, which was held 6 weeks later • One of the recommendations of the ICPC in September 2012 was that a Parenting/Risk Assessment would be undertaken. No timescale was set for this, but at the time the statutory timescale for a Core Assessment to be undertaken was 45 days, however, it would appear that the ‘Parenting Assessment’ was not completed until October 2013. A key element of a Core Assessment is in gaining an understanding of the Parents’ own backgrounds and the potential impact of this on their parenting capacity. It was interesting to note that at the Learning Event, and in Reports, agencies were able to provide very little information about the Parents’ own histories • The assessment of Father was not completed. From records it appears that only two home visits were made to him and the Paternal Grandmother and he failed to co-operate with the assessments and services offered to him. An understanding of his mental health needs was never achieved, although at each of the CPCs a recommendation was made that Father should ‘fully engage with mental health professionals to address his depression’. Hence, as noted in the CPC minutes, he ‘remained an unassessed risk’. There lacked a full understanding of the nature of his contact with the children and of the impact of his substance misuse and mental health difficulties on this. He attended Conferences but did not participate in the process. He had never been to the children’s school or attended Parents’ Evenings. Working Together 2013, Chapter 10,11 highlights the need for agencies to ‘Think Fathers’, noting that Fathers can have a significant impact on outcomes for children. It highlights that Children’s Services can often be ‘Mother focussed’, without giving due regard to the role of the Father • There is evidence that both Maternal and Paternal Grandmothers (PGM) provided support to the family. The children appear to have regularly spent time with their MGM at the weekends and she, together with Mother’s sister, also took the children to school and collected them. The PGM had been supervising her son’s contact with the children following the injury to Sibling 1. However, whilst the 11 Working Together to Safeguard Children, 2013, DCSF. 33 Grandmothers were seen by Social Workers and invited to CPCs, there is no evidence that a thorough assessment was undertaken of the role they played in the family and could play in safeguarding the children. Nor was there an understanding of their views of the day to day care the children were receiving. This was a significant gap in information • An assessment of the Parents’ substance misuse, both alcohol and drugs, and an understanding of the impact of this on their parenting capacity, was never gained. There were a number of examples of one or both Parents being intoxicated when the Police attended and Mother tested positive for cannabis use during two pregnancies (2006 and 2013). Father failed to engage with the Substance Misuse Service. Mother also declined to accept the service until September 2013, when she self-referred to The Substance Misuse Service, although this involvement was at a very superficial level. It appears that, despite the evidence in July and October 2013 of Mother’s ongoing alcohol use, this was not sufficiently challenged. An appointment was offered for a more comprehensive assessment in November 2013, but not attended by Mother. The University of East Anglia’s Report, Neglect and Serious Case Reviews highlights that; ‘Parents tended not to be honest with professionals about the extent of their alcohol or drug dependency and its impact was therefore often underestimated by professionals involved with the family.’12 The CCG Report Author references the Peter Connelly SCR (2010) which suggested that the responses parents and carers may make to inquiries may be ‘self-serving, minimising, misleading, evasive and in some cases untruthful’. In this case there was no challenge or escalation by agencies • From a young age Baby L had significant health difficulties, leading to a number of hospital admissions. There is no evidence that, given he was a child with a CPP, there was a multi-agency assessment of his health needs and whether any additional services were required. There were no pre-discharge planning meetings. The Report Author for the City Hospital notes that because discussions with the Health Visitor and Social Worker did not take place, ‘the opportunity to consider the social issues in conjunction with medical issues was missed’ 9.3.2 There are two elements with regard to assessments which have been identified in SCRs nationally and which would appear to have relevance for the work with this family. These are disguised compliance and the ‘toxic trio’, i.e. domestic abuse, substance misuse and parental mental health needs 12 Neglect and Serious Case Reviews: A report from the UEA commissioned by NSPCC, UEA/NSPCC, 2013. 34 9.3.3 The NSPCC Briefing: Disguised compliance: Learning from case reviews, March 2014,13 defines disguised compliance as ’parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and to delay or avoid professional intervention.’ There would appear to be some evidence that Mother displayed disguised compliance. Until mid-2013, her co-operation with agencies was limited. It was clear from the Lead Reviewer’s discussion with Mother, that she had an understanding of the minimal requirements of the CPPs in terms of co-operation with CSC. However, there was a history of non-engagement with the Early Intervention Service and with the support offered by the Police. In addition, it was not until September/October 2013 that she began to engage with the Domestic Abuse and Substance Misuse Services. In fact, even then the engagement with The Substance Misuse Service was at a ‘low level’ and the appointment for a more in-depth assessment, which would have involved greater challenge, was not kept. There is also a view from health practitioners that Baby L’s pregnancy was concealed from agencies working with the family. 9.3.4 The term 'Toxic Trio' has been used by Ofsted14 to describe the combined issues of domestic abuse, mental ill-health and substance misuse which have been identified as common features of families where harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people. Working Together to Safeguard Children 201015 notes that these issues rarely exist in isolation and there is a complex interaction between the three issues. All these three issues were present in this case, but there is no evidence that this was recognised by agencies. 9.3.5 Information provided for the SILP would indicate that consideration had not been given by practitioners or managers to the significance of either disguised compliance or the toxic trio in this case and importantly the impact on the risks to the children. 9.4. Quality of inter-agency communication 9.4.1 The safeguarding of children and young people is dependent on effective communication between agencies. This includes clear and timely information sharing, actions being agreed and recorded and any lack of 13 Disguised compliance: learning from case reviews. What case reviews tell us about disguised compliance, NSPCC, March 2014. 14 . New learning from serious case reviews: a two year report for 2009 – 2011, Research Brief, Department of Education, 2012. 15 DSCF, 2010. 35 agreed action being followed up. There are indications in this review that communication between agencies was not always fully effective. 9.4.2 Returning to the time prior to Sibling 1’s injury, there were a number of key points when information was shared by agencies following which action by CSC would have been anticipated. Examples of this include the following referrals: Midwifery in 2006 when Mother had attended with bruising, the Police in February and December 2009 and May and August 2011 and the Foundation Unit in April 2012 following Sibling 3’s disclosure. However, there is no intervention recorded by CSC in response to these referrals and no follow-up by the referrer. It is not sufficient for agencies to simply pass information to CSC, referrers retain a responsibility to ensure this is followed up appropriately and to escalate if necessary. 9.4.3 The Foundation Unit had a clear disclosure from Sibling 3 that she had seen her Father hitting her Mother in the face, plus MGM had provided further information to support this. Yet there was no follow up by the Unit, or by Community Health, when CSC did not respond to the referral. Similarly, the Midwifery Service were concerned about domestic abuse in pregnancy, a time of increased risk for women and the unborn baby, and would have known that there was a young child in the household. As discussed earlier, the Police appear to be unable to follow up on notifications/referrals unless there are criminal proceedings. 9.4.4 It has been noted that the Midwife completed the Vulnerability Form in respect of Baby L’s pregnancy and sent this to the Health Visitor and GP. However, the CCG Agency Report Author commented that she would have expected Midwife to follow this up with a verbal discussion with the Health Visitor and GP. In addition the GP had given Mother a written note to take to the Midwife, which should have been supported by a verbal discussion between the GP and Midwife. 9.4.5 There was a failure to identify that Father had a different GP to the Mother and children, this meant that important information was not shared with his GP and the GP was not approached for information for the Child Protection Conferences. 9.4.6 The Acute Trust’s Agency Report Author has noted the regular written communication between the hospital and community services in respect of Baby L’s admissions and treatment at the Hospital, e.g. with the Health Visitor and GP, but highlights that there was no direct verbal communication. The Author also highlights the lack of communication with CSC. Despite, the hospital staff being aware that Baby L was/had been the subject of a CPP (for neglect), it appears that no consideration was given to the home circumstances and the care he was receiving and whether this was 36 impacting adversely on his health. There were no pre-discharge planning meetings. Had staff been more aware of the concerns around the home conditions, e.g. smoking, problems with heating, this might have triggered a pre-discharge meeting. There is also an argument that the Health Visitor and Social Worker should have sought further information and advice regarding Baby L’s health difficulties and the implications for his day to day care. 9.4.7 The Acute Trust’s Safeguarding Procedures state that the Named Professional should be informed when a child with a CPP is admitted to Hospital to ensure the necessary communication takes place. This was put in place following a SCR completed in 2011 (Baby A and Child C) when there were similar concerns about discharge arrangements. This was not done in this case, if it had been then the communication referred to above would have taken place. 9.5. Child Protection Processes 9.5.1 As has been identified through this Report, there are a number of examples of where child protection procedures were not adhered to or where their implementation could be improved on. • Referrals 9.5.2 As already discussed there were a number of referrals made to CSC, which did not trigger appropriate children protection processes. • Strategy Meeting 9.5.3 The Acute Trust correctly informed CSC and the Police about Sibling 1’s presentation at hospital with the injury to her finger and both the Police and CSC responded in a timely way, Sibling 1 and her Mother were interviewed and Father was arrested for assault. However, there is no evidence that a multi-agency Strategy Meeting, as required in SSCB’s Child Protection Procedures, where agencies could share information and action be agreed, was held. Also there is no evidence that the other two children were spoken to at this time. 9.5.4 There was a lack of a risk assessment and of a multi-agency risk management plan to safeguard the children, e.g. arrangements for contact with their Father. Discussion at the Learning Event concluded that the lack of a timely Strategy Meeting meant that agencies did not come together and jointly plan the way forward, setting the scene for the lack of robust multi-agency planning. 37 • Initial Child Protection Conference 9.5.5 The ICPC was held on 4 September, 2012, 6 weeks after the injury to Sibling 1. This should have been held 15 working days after the Strategy Meeting, which agreed to the Section 47 investigation. It was confirmed at The Recall Event that the Social Worker did not make a request to arrange the ICPC until 24 August 2012, 4 weeks after Sibling 1’s injury. The lack of a timely Strategy Meeting could have led to this delay in arranging the ICPC. 9.5.6 Information for the ICPC was requested from the Mother and children’s GP but not provided. Father’s GP was not identified. Given Father’s history this was a serious gap in the information available to the conference. • Core Group working 9.5.7 From May 2013, Core Groups were held regularly and there is evidence that this promoted more effective multi-agency working and helped to engage Mother proactively in the CPP. 9.5.8 In the earlier stages of the child protection planning the functioning of the Core Group, and hence the implementation of the CPP was inconsistent and weak. The role of the Core Group is to develop the outline CPP, put together at the Child Protection Conference, and each member of the Core Group has a responsibility to ensure that the Plan is implemented. The first Core Group took place on 17 September 2012, the Lead Social Worker was unwell, but another Social Worker stepped in, which was good practice. However, there appear to be no minutes from this meeting and the CPP was not developed or circulated to Core Group members, including to the family. 9.5.9 Another Core Group was held on 8 October 2012, again no minutes are available and the CPP was not updated. The Core Group on 7 November 2012 was cancelled and rearranged on 15 November 2012. Further Core Groups were held post the RCPC on 11 December, 8 January and 5 February 2013. Core Groups then appear to have been cancelled on 11 March and 8 April 2013, which meant that there was no Core Group between the Pre-birth CPC held on 6 March 2013 in respect of Baby L and his birth in April 2013. On 9 April 2013 the School Nurse requested the date for the next Core Group and this was arranged for 25 April 2013. However, the Social Worker was unable to attend, so the practitioners present held an Information Sharing Meeting. This was very soon after Baby L’s birth, so the cancellation was not timely. There is no evidence that this was then escalated as a matter of concern. In addition there is no evidence that any of the practitioners sought the advice of Safeguarding Leads in their agencies in respect of this matter. 38 9.5.10 SSCB’s Child Protection Procedures state that Information Sharing Meetings can be held when the Social Worker is unable to attend at short notice. However, the next Core Group should be convened within 10 working days, which did not happen in this case. 9.5.11 The next Core Groups were held on 24 May 2013 (over three months since the last one on 5 February 2013) and 21 June 2013. On 16 July 2013 the School Nurse again asked the Social Worker for the date of the next Core Group. Further Core Groups are then held on 23 August and 19 September 2013. 9.5.12 There was a gap in Core Groups between February and May 2013, which was a significant time for the family with the birth of Baby L in April 2013. It appears this was because the Social Worker was unwell. A new Social Worker was allocated to the family in May 2013 after which Core Groups become more regular. 9.5.13 Until this change the Core Group had not performed its function of reviewing the progress of the CPPs, evaluating the protective factors and level of risk to the children, analysing the significance of all the information available and updating the CPP as necessary. For example there does not appear to have been consideration of the Parents’ failure to engage with the domestic abuse, substance misuse and mental health services and how this impacted on the risk to the children, nor of the support and protection offered by the Grandparents. • Child Protection Planning 9.5.14 At the ICPC in September 2012 the children were made the subjects of CPPs under the category of emotional abuse. Sibling 1’s views about her Parents’ fighting were shared with the Conference. The CPP included: • Parents to engage with domestic abuse and substance misuse services • Father to engage with mental health professionals and Probation • Parenting/Risk assessments to be completed by the Social Worker (No date for completion) • Announced and unannounced child protection visits to be undertaken by Social Worker (No frequency) • Health Visitor/School/School Nurse to undertake a monitoring role • Referral to be made to Child and Adolescent Mental Health Services 9.5.15 The CPP does not appear to have been SMART - specific, measurable, achievable, realistic, with timescales. Without realistic timescales it is very difficult to measure and evaluate progress. Concern was raised at the Learning Event about the use of the term ‘monitoring’ in CPPs, as it lacks 39 clarity and purpose. In addition, there was the lack of a contingency plan should the parents not comply or the plan not progress. 9.5.16 By the RCPC in November 2012 the Parents had failed to engage with agencies and there were worries that they were not taking seriously the concerns of professionals. The parenting/risk assessment remained outstanding, so that the Father remained ‘an unassessed risk’. However, it was noted that his contact with the children was supervised and no concerns were reported about this. This could be seen as contradictory, as if the Father remained an ‘unassessed risk’ how could the contact be considered to be safe? Reports in respect of the three children were positive, their health was good and they were progressing well at school. However, there was no information in relation to the children’s views about how things were going at home. The decision of the RCPC was that the children should remain subject to CPPs, which were fundamentally unchanged, although a timescale of 10 weeks was set for completion of the parenting assessment, i.e. by February 2013. 9.5.17 In March 2013, the Pre-birth CPC in respect of Baby L was held. Children’s Services held the view that this was a concealed pregnancy, as Mother had not booked into Midwifery Services until she believed she was 31 weeks pregnant and had not taken up opportunities to reveal her pregnancy to the Social Worker. At this time Father had failed to engage with the Parenting Assessment. Mother had attended an appointment with the Substance Misuse Service and had stated that alcohol misuse was no longer a feature for her. The Service had recommended that she attend an alcohol awareness group, but she did not feel confident to do this. Therefore, an individual session was offered, but Mother did not attend. Similarly, Mother had attended two sessions with the Domestic Abuse Service and a group was recommended, but she failed to attend. The Service was of the view that Mother was minimising the impact of domestic abuse on the family. Baby L was made the subject of a Pre-birth CPP under the category of neglect. 9.5.18 At the Learning Event the view was expressed by practitioners that this Conference was something of a turning point for Mother, due to the straightforward approach taken by the Chair of the Conference, who conveyed clearly to mother the potential consequences of her failure to engage with the services being offered. 9.5.19 At the RCPC in May 2013 Parents had still failed to engage with the domestic abuse and substance misuse services and, given the concealed pregnancy, there were concerns about how open and honest they were being with professionals. The Parenting Assessment had still not been completed, despite a timescale for completion of February 2013. The decision was that the CPPs would continue, but there would be a change of category from emotional 40 abuse to neglect. It is not clear from the minutes why this decision was taken and this was discussed at the Recall Event. It appears that the concerns about domestic abuse had lessened and the threshold for a CPP under the category of emotional abuse was no longer met. There were, however, some concerns about the children’s care which indicated neglect, e.g. Siblings 1 and 2 being overweight, home cold, lack of routine. It could be questioned as to whether the threshold for CPP under the category of neglect was also actually met. The CPPs remained virtually unchanged, although a recommendation was added that ‘Father’s contact to remain fully supervised with all of his children all of the time’. This is the first time that there was a recommendation in respect of Father’s contact with the children. 9.5.20 Leading up to the RCPC in November 2013, Core Groups had been held monthly. The Social Worker and Health Visitor had regularly visited the home and conditions were considered to be satisfactory, although sometimes cold, with evidence of toys for the children. The children appeared happy and relaxed. 9.5.21 Mother had started to engage with agencies. She had almost completed the Freedom Program with the Domestic Abuse Service, which reported that she had gained a greater understanding of domestic abuse. Whilst there continued to be occasional incidents with the children’s Father, Mother contacted the Police appropriately. She had also had some engagement with the Substance Misuse Service and had ‘been receptive to advice’. 9.5.22 The Social Worker had completed the Child Protection Toolkits with the children and they were happy and enjoyed seeing their Father at weekends. They were all continuing to make good progress at school and there were no problems with attendance. In fact, Sibling 1 was making exceptional academic progress. 9.5.23 Baby L’s health difficulties were noted, as well as the fact that Mother sought medical advice appropriately, although the GP’s report raised concerns that Mother did not fully recognise the seriousness of Baby L’s condition and continued to be a smoker despite his chest problems. Both the GP and Health Visitor had recommended Mother attend the Smoking Cessation Clinic, but she had declined to do so, indicating a lack of understanding of the impact of this on Baby L’s health and unwillingness to prioritise his needs. 9.5.24 Some concerns still persisted. There had been two incidents since the RCPC in May 2013, which were at variance with Mother’s claim that she only drank on Saturday nights, when the children were with their PGM, i.e. 24 July 2013 when the Police had difficulty rousing Mother and 5 October 2013 when there had been a domestic abuse incident and Mother admitted she had had ‘four cans’. 41 9.5.25 There were no written reports from the domestic abuse or substance misuse services and The Learning Event highlighted that the RCPC was under a misapprehension regarding Mother’s work with the substance misuse service. The Agency Report Author was clear that the intervention had been at a very low level and had not looked in any depth at Mother’s use of alcohol and how this might impact on her parenting capacity. An assessment was being arranged to complete this work. There appeared to be a general lack of professional curiosity and challenge about Mother’s alcohol use. 9.5.26 Father had not engaged with CSC’s assessment or with the domestic abuse, substance misuse and mental health services and remained ‘an unassessed risk’. The long term concerns were in relation to domestic abuse and whilst there did appear to be less incidents reported to the Police, a MARAC had been held on 30 October 2013, less than a week before the RCPC, due to three reported incidents within a six month period. Therefore, it was difficult to hold a view that the domestic abuse had been resolved. The information from MARAC was available to the allocated Social Worker, but not available at the RCPC. 9.5.27 Therefore, whilst there were positive signs of progress in terms of Mother’s engagement with services and the children were progressing well, there were ongoing concerns. The issue for consideration by the Conference was whether the progress would be sustained and built on if the CPPs ceased. 9.5.28 The unanimous decision of the RCPC in November 2013 was to end the CPPs and this decision was discussed at length at the Learning and Recall Events; in particular whether this decision was over-optimistic and, hence, premature. It is important to be mindful of hindsight and to consider this decision from the perspective of the workers at that time. 9.5.29 The definitions of over-optimism include ‘unjustifiably optimistic’ and ‘a tendency to look on the more favourable side of events or conditions and to expect the most favourable outcome’. The Study of SCRs which had been undertaken between 2001 and 200316 identified the failure to protect vulnerable children as a result of a number of factors, including ‘over optimism particularly about parenting capacity in difficult situations’. The Biennial Analysis of SCRs undertaken between 2007 and 201117 found that ‘there was a reluctance to make negative professional judgements about a parent’. 16 Improving safeguarding practice: Study of serious case reviews 2001 – 2003, Research Report, Department for children, schools and families, 2008. 17 Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009, Research Brief, Department for Education, 2010. 42 9.5.30 On balance, the Recall Event concluded that the decision to cease the CPPs, and put in place robust CIN Plans, was reasoned and evidence based. Working Together 2013 outlines that a child should no longer be the subject of a CPP if ‘it is judged that the child is no longer continuing, or is likely, to suffer significant harm and therefore no longer requires safeguarding by means of a child protection plan.’18 There was a lack of evidence that the children were at risk of significant harm or that the threshold for a CPP under the category of neglect; defined in Working Together 2013 as ‘The persistent failure to meet a child’s basic physical and /or psychological needs, likely to result in the serious impairment of the child’s health or development’, was met. CIN Plans can be effective in managing situations where the risks to the children have reduced and in supporting families to maintain changes made. 9.5.31 The period of child protection planning was discussed with Mother. Her view was that she had been given the opportunity to comment on the information presented to the Child Protection Conferences, being asked for her views after each of the agency reports. Mother felt that she had done everything that she had been asked to do in the CPPs and that things in the family had changed. She talked about having more control and the children now being in a better routine. Father used to interfere and undermine her position with the children. • Decision making: Public Law Outline (PLO) 9.5.32 The Public Law Outline (PLO): Guide to Case Management in Public Law Proceedings, which came into force in April 2010, aimed to streamline the procedures for dealing with public law children's cases. The first stage of the procedure is a Legal Planning Meeting (known as Legal Brief in the SSCB area), which is the opportunity to consider the case in a legal context and for the Social Work Team to receive legal advice. If the advice is that there are sufficient grounds to proceed, the Social Worker prepares a Letter before Proceedings, which is sent to those with parental responsibility, and a PLO (Pre-proceedings) meeting is arranged within 10 days of receipt of the letter. The purpose of the meeting is to agree what actions will be taken in order to avoid the need for care proceedings to be initiated. A review of the PLO is held after three months. 9.5.33 The decision making in respect of PLO in this case has been traced through the minutes of the Child Protection Conferences, discussion at the Learning Event and further information received from CSC. At the ICPC in September 2012 there was a recommendation that ‘the Responsible Team Manager 18 Working Together to Safeguard Children 2013: A guide to inter-agency working to safeguard and promote the welfare of children, HMG. 43 should decide whether they wish to hold a legal meeting to discuss PLO or Care Proceedings’. In the CPPs this is developed to ‘Team Manager to consider Legal Brief with a view to proceeding to Public Law Outline (PLO) if Parents do not engage with services/CPP’. 9.5.34 At the RCPC in November 2012 it is noted that the ‘PLO is not required at this point’. The reasoning behind this decision is difficult to understand given that both Parents had clearly failed to engage with services and hence with the CPPs. Father had not co-operated with the Probation Service or followed up on obtaining a referral to the Mental Health Service through his GP. Neither parent had accessed services in relation to domestic abuse or substance misuse, which were at the root of the family’s difficulties. Until these issues were resolved it was unlikely that changes would be sustained, as evidenced by continued Police call-outs. 9.5.35 The recommendations of the Pre-birth CPC held in respect of Baby L in March 2013 included what appears to be a standard recommendation – ‘The responsible Team Manager to decide whether they wish to hold a legal meeting to discuss PLO or care proceedings’. A Legal Brief, the first step in the PLO process, took place on 19 April 2013, attended by the Social Worker and Team Manager. It was agreed that the PLO would be initiated; the Letter before Proceedings would be submitted by the Social Worker to Legal Services by 25 April 2013 with the aim of holding a PLO meeting on 10 May 2013. Due to staff absence the letter was not sent, nor the PLO meeting held. 9.5.36 At the RCPC in May 2013, it was noted that ‘PLO proceedings started’, although in reality, they had barely progressed. Then at the RCPC in November, 2013, when the CPPs ceased, there was no reference to PLO. 9.5.37 At the Learning Event, CSC shared that when case responsibility was transferred in May 2013, the new Social Work Team were advised that PLO should not be pursued, as there had been difficulty providing a consistent service to the family. So, the family were to be given the opportunity to engage with the new Social Worker. 9.5.38 Therefore, there is a picture that the PLO did not progress as proposed due to the staffing situation in CSC and the change of Social Work Teams. This led to a lack of clear, child centred, planning. There was a different Social Worker and Team Manager at each of the Child Protection Conferences, which may also have contributed to the lack of a consistency in decision making. This could be viewed as evidence of ‘start again syndrome’,19 where workers put aside knowledge of the past and focus on the present. 19 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003 – 2005. DCSF, 2008. 44 9.5.39 The Senior Manager from CSC informed the Learning Event that a new, quality assured, decision making process in respect of PLO is being introduced in the Local Authority. This will encourage greater consistency and remove discretion from individual Team Managers. 9.6. Child in Need Planning 9.6.1 At the RCPC in November, 2013, when the CPPs ceased, CIN Plans were put in place and the Chair of the Conference recommended that the Plans should continue for six months. There was evidence that Mother had begun to engage more with services, e.g. domestic abuse, and was taking appropriate protective action when Father came to the family home, but, there was a view that she continued to need support to maintain this progress. CIN Plans can be used effectively as a ‘step down’ in such situations. 9.6.2 The first CIN Review Meeting was held 5 weeks later in December. The Health Visitor and Social Worker had visited since the RCPC and reported positively. Baby L’s health difficulties had continued and he had had a further admission to hospital. During this admission concerns were expressed by staff about Mother’s interaction with him, although this was not shared with the Social Worker. Mother had not attended the appointment with the Substance Misuse Service, the aim of which was to undertake a more comprehensive assessment. 9.6.3 The decision was taken at the CIN Review Meeting to cease the CIN Plans, following discussion with Father, and ‘step down’ to Early Help. This decision was reflected on at the Learning and Recall Events. There was an indication that the Team Manager in CSC had been concerned that the workload demands on the Social Work Team meant that they were unable to provide a full service and that the family would receive increased support if the case was ‘stepped down’ to Early Help. 9.6.4 The discussions concluded that this decision was over optimistic and premature, given the length and nature of family’s difficulties. It was very early to judge whether Mother was able to sustain the changes she was making. In addition, little consideration appears to have been given to Baby L’s needs or to the impact of his health difficulties on the family overall. There is some indication from the Police that home conditions may have deteriorated somewhat at the time of Baby L’s death. 9.6.5 It is recognised by CSC that during a significant part of the Scoping Period for this SCR, the Service was experiencing difficulties with the recruitment and retention of Social Work staff, both Social Workers and managers, and was 45 operating with a high level of agency staff. This inevitably impacted on the service offered to the family. As is noted in 11.1 below, CSC have undertaken a Service Review and currently have an Improvement Plan in place, which will address many of the issues identified in this SCR. 9.7. Parental Smoking 9.7.1 Baby L suffered with respiratory infections and had breathing difficulties from a very young age. The increased risks to babies of parental smoking, both antenatal and postnatal, is well recognised, e.g. asthma, allergies, SUDI. The British Lung Foundation advises parents that ‘Protecting your child from tobacco smoke is one of the best things you can do to give your child a healthy start in life, because tobacco exposure is a big risk for increased breathing and lung conditions in children. This is especially true if the mother smokes during pregnancy. Therefore avoiding smoking anywhere where children are present reduces this risk’. 9.7.2 Various health practitioners, e.g. GP and Health Visitor, spoke to Mother about the risks from smoking and advised her about not smoking near the baby and washing her hands after smoking. It was noted that the home did not smell of cigarette smoke, nor were there full ashtrays. Mother was encouraged to attend the Smoking Cessation Clinic, which she declined. However, it does not appear that this was pursued very vigorously or picked up by staff in the Acute Trust. There was a lack of a coordinated approach. Closer liaison between the Acute Trust and the services working with the family in the community may have led to a greater focus on the issue. This was a missed opportunity to intervene. 9.7.3 It is likely that a high percentage of parents smoke in the area where the family live. Research by the NHS Health Development Agency and Action on Smoking and Health (ASH) shows that smoking is highest in the least advantaged social groups at 70% and that 54% of children living in lower socio-economic households are likely to be exposed to tobacco smoke compared to 18% of children in professional households. The rate of quitting smoking is significantly lower in the lower socio-economic groups and there has been very little change in the prevalence of smoking amongst those living on low incomes over the past 30 years.20 9.7.4 It may be that workers in this area are accustomed to high levels of parental smoking and to parents’ reluctance to access Smoking Cessation Clinics and may not pursue this as vigorously as workers in those areas where smoking is now less common. 20 Smoking and Health Inequalities, NHS Health Development Agency and ASH. 46 9.8. Management Oversight and Supervision 9.8.1 Working Together to Safeguard Children 2010, Chapter 4,21 states that to ensure children are protected from harm requires sound professional judgements to be made. It recognises that this is demanding work that can be both distressing and stressful and that all those involved should have access to advice and support from peers, managers, and Named and Designated Professionals. Those providing supervision should be trained in supervision skills and have an up to date knowledge of the legislation, policy and research relevant to safeguarding and promoting the welfare of children. Supervision should enable the supervisor and supervisee to reflect on and evaluate the work undertaken. Supervisors should be available to practitioners as an important source of advice and expertise and may be required to endorse judgements at certain key points in time. Supervisors should also record key decisions, and the rationale for them, within the child’s case records. Supervision should be both educative and supportive and facilitate the supervisee to explore their feelings about the work and the family. Effective supervision needs to be regular and provide continuity. 9.8.2 The lack of use of the Designated and Named staff and Safeguarding leads within agencies, i.e. Acute Trust, NHS Foundation Trust and CCG, has already been referred to, as there were a number of instances when their advice should have been sought and concerns escalated. 9.8.3 The NHS Foundation Trust Agency Report notes that in 2013 the School Nurse was new to her role and experienced long periods unsupervised due to capacity issues within the team. The School Nurse acknowledged with the Report Author that at times she felt overwhelmed with the demands of the post. At other times safeguarding supervision was available, but it did not provide strong objective oversight and challenge at points where this should have occurred. 9.8.4 It is also concerning that the CSC Agency Report notes a total lack of evidence of supervision and management oversight during the period under review. The importance of reflective and challenging supervision for Social Workers is well recognised. This is particularly so when working with families where there are long term difficulties as workers can become overwhelmed by the family’s difficulties. The earlier analysis in respect of the implementation of procedures, the timeliness and quality of assessments and progress with regard to the PLO may reflect this apparent lack of supervision and management oversight. In addition, it is important that Managers record decisions made, as well as the rationale for these. 21 DCSF, 2010. 47 10. Findings 10.1. Good practice • The School provides support to the community, families and children which it serves, e.g. Breakfast Club and After School Clubs. Mother certainly sees the school as very supportive • Child protection concerns were quickly identified by hospital staff following Sibling 1’s presentation with the injury to her finger, the Safeguarding Lead was informed and CSC and the Police were both notified • The departing Social Worker and the newly allocated Social Worker both attended the Initial Child Protection Conference • Mother attended all of the Child Protection Conferences and Father attended four of the five meetings. The Conferences were arranged so that Mother and Father could attend separately to reduce the risk of intimidation and ensure Mother’s safety. Parents were provided with individualised minutes of the Conferences • The potential consequence of non-engagement were explained clearly and honestly to Mother by the Independent Chair of the Pre-birth Child Protection Conference in March 2013. This is viewed as something of a turning point for Mother • On at least two occasions the School Nurse contacted the Social Worker to confirm the date of the next Core Group, i.e. escalated concern about the delay • At the Core Group in May 2012, the school raised concerns about communication with CSC and the delay in allocating a new Social Worker, i.e. provided challenge • Following Baby L’s birth, in the face of some resistance, the Midwife persisted with the request for a pre-discharge meeting and this was arranged, i.e. provided challenge • Between May and November 2013 the newly allocated Social Worker undertook child protection monitoring visits within timescales and arranged regular Core Groups. This consistency of approach encouraged greater engagement by Mother with the CPPs and contributed to her improved co-operation with agencies • The Substance Misuse Service has a small team based in the Hospital to whom staff can refer, this means that the service is easily accessible • The Health Visitor and School Nurse routinely shared information with the Mother and children’s GP following Child Protection Conferences and Core Group meetings • The Chair of the Child Protection Conference wrote to Sibling 1 after she had prepared the Conference Toolkit for the RCPC in November 2013 48 • The Midwife completed the Ante Natal Vulnerability Assessment, highlighting the potential risks to the baby, in a timely way and sent this to the Health Visitor and GP • The children’s health assessments by the Health Visitor and School Nurse were completed in accordance with the Healthy Child Programme • Education and Health reports were prepared and shared with Mother prior to the Child Protection Conferences • The Practice Nurse discussed her concerns about Mother’s lack of understanding about Baby L’s health needs and need for additional support with the Health Visitor • GP’s report for RCPC in November 2013 highlighted concerns that Mother did not recognise the seriousness of Baby L’s condition and that she continued to be a smoker despite his chest problems • The underlying causes of Baby L’s respiratory difficulties were fully investigated by the Consultant Paediatrician • The Paramedic Crew’s effective use of advanced life support techniques 10.2. Areas for improvement • Lack of understanding of the children’s day to day lived experiences. The children’s views, wishes and feelings were not evidenced in assessments, nor in the decisions and actions taken • Delay in responding to the pattern of substance misuse related domestic abuse incidents and recognising the impact of this on the children • Lack of follow up by agencies of referrals made to CSC and of evidence of the use of Safeguarding Leads within organisations for advice and escalation of concerns. An agency’s responsibility does not end with the referral to CSC • Importance of timely, good quality, assessments, with evidence of the children’s lived, experiences and thorough analysis of the risks and protective factors • It should be made clear to a Father that when, despite efforts by practitioners to involve him in assessment and planning, he has demonstrated a lack of engagement, this will have an impact on future plans, e.g. an application may need to be made to court for contact with his children • Insufficient assessment and engagement with the children’s Grandparents in order to develop a full understanding of their role within the family and their potential to provide support and safeguard the children 49 • Lack of challenge in respect of parental substance misuse, despite evidence, over a long period, that Mother’s use of alcohol was not as she described • Lack of robust multi-agency Core Group working, i.e. CPPs were not regularly reviewed, updated and circulated to all members. CPPs should be SMART; actions clear with timescales. The term ‘monitoring’ should not be used, as this does not convey what action is necessary • Importance of ensuring the right information is presented to Conferences (in written form) and to Core Groups • Lack of engagement with all the family’s GPs. The importance of identifying if members of a family have more than one GP • Need to ensure improved hand-over when patients with histories of substance misuse, domestic abuse and mental health difficulties change GP, so that the new GP is aware of the key risks posed to, and by, the patient • Lack of multi-agency consideration of Baby L’s health needs and of the impact the social and home circumstances may have on these. Named Doctor in the Acute Trust should be informed of all children with a CPP who are admitted to Hospital, but was not in this case • All front-line practitioners should take responsibility for actively promoting messages about safer sleeping and the dangers of parental smoking 11. Developments already underway 11.1 Children’s Social Care 1. The Council initiated a Service Review and now has an Improvement Plan in place, which is supported and scrutinised by a multi-agency Board. This includes: � Children’s active involvement in assessment and care planning to ensure their needs are better understood � Introduction of a Protocol for caseload management, including a Workload Management Tool � Protocol in respect of ‘step down’ from specialist services to early intervention, and of ‘step up’ � Review of the capacity of the Independent Reviewing Service (IROs/Conference Chairs) � Improving quality and effectiveness of Child Protection Plans (Signs of Safety) � Ensuring Core Group members are fully aware of their role, to be audited in case file audits 2. Multi-Agency Safeguarding Hub (MASH) is now in place to ensure the consistent application of thresholds and management of risk, timely 50 and good quality assessments and appropriate signposting and tracking 3. A quality assured, decision making process in respect of Public Law Outline is being introduced, which will encourage greater consistency and remove discretion from individual Team Managers 4. The electronic recording system is being upgraded in order to provide improved management performance information. This will monitor arrangements for Core Groups and flag up those which have been missed 5. A Principal Social Worker has been appointed, whose focus is the development of Social Work practice in the authority. Training, including seminars, is underway to develop Social Work skills and practice 6. Strategic Plan is in place to address the recruitment and retention of Social Workers 7. In line with Government guidance a new single assessment will be introduced during 2015 8. Supervision Policy has been revised and supervision records are audited bi-monthly 9. Reflective case file audits are undertaken monthly by senior managers, including the Director of Children’s Services and Head of Service 11.2 Independent Reviewing Service 1. A review of capacity of the service has been undertaken which has led to an increased in number of Independent Chairs 2. Improvements to: • Conference Agendas: Re-launched to enhance information sharing • Format and timely distribution of CPPs to facilitate SMART planning, with clear contingency plans • Child Protection Conference minutes: Work to improve format 3. A challenge log has been introduced which evidences increased challenge regarding delays in progressing CPPs and Care Plans for looked after children 4. An Independent Chair/Independent Reviewing Officer has been identified to link with each of the social work teams to share knowledge and expectations 11.3 Education 1. Lack of a consistent standardised method of documenting and storing notes/events at the school is being addressed 51 2. M/A Advisable for education to adopt a set template and procedure for recording events and episodes, including a chronology of telephone calls and emails to professionals 3. Developing skills to constructively challenge other professionals 11.4 The Substance Misuse Service 1. A representative of The Substance Misuse Service now attends SSCB 2. Procedures in staff handbook have been developed. Staff are taken through the procedures during induction and asked to sign that they have read and understand the contents 3. Procedures and training now includes briefing and direction for staff attending Core Group meetings 4. Established dedicated Safeguarding Hub which: � Provides training, coaching and support to staff � Manages more complex cases and offers support to staff which concerns about less complex cases 5. Introduced triage assessment completed at the point of referral in order to determine the level of need and act accordingly 6. Do Not Attend (DNA) protocol introduced 7. Enhanced safeguarding supervision arrangements 8. Guidance and training for writing reports for safeguarding meetings has been provided. Reports are checked and signed off by a manager and upcoming Core Groups/m/a meetings are discussed at the daily complex needs Safeguarding Hub meetings 9. Discussions underway with organisation which can offer lower level of support for those who do not meet The Substance Misuse Service criteria and a pathway is being developed for referral/signposting to this organisation 10. The Substance Misuse Service now attends weekly Care Navigation Meetings, which discuss cases of concern. These meetings are useful in sharing information and managing risk 11. The local authority, as commissioner of services, has appointed a Safeguarding Manager for Substance Misuse 11.5 Acute Hospital 1. DNA policy has been developed in 2014 to address potential safeguarding concerns that a child not being brought for a medical appointment may indicate 2. Infants have own single set of records with a copy of any safeguarding concerns in their notes, including the pre-birth arrangements (An additional copy is kept in the maternal notes.) Mother’s electronic 52 records are flagged with a VIP flag to indicate that there are safeguarding concerns 3. The role of the Paediatric Liaison Nurse is being reviewed, with the intention of a greater focus on safeguarding children and young people 11.6 NHS Foundation Trust 1. The School Nurse Health Assessment documentation is being reviewed to ensure this incorporates the views, wishes and feelings of the child. This Assessment is undertaken with children who have identified health needs and with all children subject to protection plans 2. Information following attendance at multi-agency meetings is copied to fathers’ GPs when known 12. Conclusion 12.1 This SCR was undertaken as Baby L and his siblings had been the subjects of CPPs, which ceased shortly before his death. The CPPs had been made in the category of neglect and there were questions for the SSCB as to whether neglect could have been a contributory factor in his death and whether agencies had worked effectively together to safeguard Baby L and his siblings. 12.2 From a very young age Baby L had a history of bronchiolitis, inflammation of the airways (bronchioles), which caused breathing difficulties and necessitated admission to hospital on a number of occasions in his short life. The cause of his death was recorded as an acute respiratory infection. 12.3 Despite his health difficulties, Baby L was gaining weight, developing well and achieving his developmental milestones. He was a responsive and happy baby, showing a good attachment to his Mother. Whilst there was some concern expressed as to whether Mother fully understood his health problems, in the main she sought, and acted upon, medical assistance appropriately. 12.4 At the time of Baby L’s death, family life was more settled and reports from the school were positive regarding his siblings. However, it is apparent that they were not living in optimal conditions, with the background of domestic abuse and substance misuse in the family, plus the home conditions were not well suited to a baby with Baby L’s health difficulties. It had been noted that the home was sometimes cold, which can impact on respiratory conditions, but more significantly, Mother continued to smoke. 53 12.5 Research highlights the strong link between parental smoking and increased risk of respiratory infections, as well as the higher prevalence of smoking in low income families. Some would argue that parental smoking constitutes the neglect of a child, but the power and influence of cultural norms should be recognised. 54% of children in lower social-economic groups, as Baby L, are likely to be exposed to tobacco smoke. The impact of this on practitioners working in the area needs to be considered, i.e. whether they accepted parental smoking as the norm. As one of the Report Authors notes, while smoking is detrimental to a child’s health, it is ‘so common that it is not specifically judged as a sign of neglect’. 12.6 Whilst weaknesses in multi-agency working have been identified in this SCR, these tended to be historical and, at the time of Baby L’s death, agencies had been working more effectively together for six months and Mother had been demonstrating greater engagement with the services offered to her. The one area of weakness with regard to addressing Baby L’s health needs was the lack of direct verbal communication between community services, both Health and Social Care, and the Acute Trust, and of a multi-agency plan to address these. 12.7 Sadly, Baby L died due to an acute medical condition. However, it does appear that parental smoking was a significant modifiable factor, which was likely to have impacted adversely on his health. If he had been living in a smoke free environment, it is possible that he would have been less susceptible to the frequent infections that he was experiencing. 13. Recommendations from Serious Case Review Agency Report Authors have identified single agency recommendations, which are listed in Appendix 3. However, the Lead Reviewer has additionally identified two further recommendations as below. 13.1. Single agency 1. When undertaking Section 47 Enquiries and/or assessments, Children’s Social Care should ensure that thorough checks are made with other agencies and care is taken to identify whether family members are registered at the same GP Practice in order that full information is obtained 2. Independent Reviewing Service should add a question to the Invitation List for Child Protection Conferences asking if all family members are registered with the same GP Practice and identifying who the GPs are 54 13.2. For Sunderland Safeguarding Children Board The Lead Reviewer has been made aware of recent SCRs undertaken by SSCB, notably Baby A and Child C, and of the fact that recommendations have been made previously which are relevant to this SCR. These include: • SSCB should examine the processes it has in place so the Board can be assured that statutory assessments, and those agreed at multi-agency meetings, take place within agreed timelines, are robust and of good quality • SSCB should ensure that frontline practitioners have an understanding of the impact of the toxic trio, i.e. domestic abuse, parental substance misuse and mental health needs • SSCB should assure itself that effective escalation policies are in place and well understood by all partner agencies • SSCB should re-evaluate how multi-agency plans relating to children in need and child protection are formulated and recorded, using where possible an agreed template which places the child at the front of the deliberations and allows for realistic and meaningful monitoring and review • SSCB should ensure there is a robust process for regular scrutiny and challenge of CIN and CP Plans • SSCB should consider ways in which the Board can be satisfied that practitioners who chair multi-agency meetings relating to the safeguarding of children and young people, have the requisite skills, knowledge and confidence to do so assertively • The SSCB should develop learning opportunities for managers across all agencies to improve their skills and knowledge about reflective supervision and the links this has with better outcomes for children Therefore, rather than repeating the same, or similar, recommendations, it is recommended that the Board should seek assurance that momentum is continuing in addressing the above in a timely way. Below are the recommendations arising from this SCR: 1. SSCB’s Child Protection Procedures and training should embed the principle that all assessments should include an understanding of each child’s lived, day to day, experience, regardless of their age, level of understanding or communication skills, and that this should influence the decisions made and actions taken. Practice should be audited through single agency and multi-agency and case file audits 2. Practitioners and managers should ensure that Fathers are aware that a failure to co-operate, and engage with the services offered, will be given consideration in assessments and will have an impact on decisions made and actions taken 55 3. SSCB has undertaken a multi-agency audit of agencies’ responses to families where there has been a pattern of domestic abuse (3 incidents in 6 months), to identify whether the response is timely and effective. SSCB should take forward any recommendations made in response to the findings of this audit 4. Co-ordinated Activity Against Domestic Abuse (CAADA) is undertaking a review of the Multi-Agency Risk Assessment Conference (MARAC) processes in Sunderland. SSCB should receive a copy of this Report and work with the Community Safety Partnership to ensure that the recommendations are progressed in a timely way. If not highlighted in the CAADA review, consideration should be given to the involvement of the Acute Hospital Trust in the MARAC Process 5. SSCB’s procedures and training should emphasise that an organisation’s responsibility does not end with a referral to CSC, but continues until there is agreement about the action to be taken, if necessary invoking the escalation procedures 6. SSCB should receive assurance that the role of Safeguarding Leads, e.g. Designated and Named Doctors and Nurses, is widely understood and promoted within organisations 7. SSCB should consider ways of strengthening Core Group working, in order that Core Group members are fully aware of their individual and collective responsibilities to develop, regularly review and update the Child Protection Plan. This could include the development of a SSCB leaflet for members of Core Groups 8. SSCB should seek reassurance from the Acute Trust and CSC that there is improved communication and closer liaison, e.g. telephone conversations, pre-discharge meetings, between the key agencies when a child who is the subject of a Child Protection Plan has a chronic health condition and/or is admitted to hospital to ensure that increased vulnerabilities are recognised and acted upon 9. SSCB should work with NHS England and the Clinical Commissioning Groups to strengthen the engagement of GPs in safeguarding and, through its Performance Framework, monitor the contribution of GPs to Child Protection Conferences 10. SSCB should promote health education regarding the dangers of parental smoking (e.g. through activities of the Child Death Overview Panel) 56 TERMS OF REFERENCE APPENDIX A Sunderland Safeguarding Children Board TERMS OF REFERENCE & PROJECT PLAN SUBJECTS: Baby L: (Aged 8 months) Sibling 3: (Aged 4 years) Sibling 2: (Aged 6 years) Sibling 1: (Aged 11 Years) 57 1. Introduction: The Children’s Social Work Service’s first became aware of Baby L’s family in December 2005 when they received a referral from the Police concerning an incident of domestic violence from Baby L’s Father and Mother. The Police made a total of 12 notifications and referrals in relation to domestic abuse perpetrated on the children’s Mother by the Father between December 2005 and July 2012. These incidents were longstanding and severe, including verbal aggression, harassment and physical violence which have led to Mother being injured and have also occurred whilst she was pregnant. Father had not engaged with any services around his alcohol misuse and the violent and aggressive incidents appear to be when Father is under the influence. Mother had also been reported to be intoxicated on some occasions. In July 2012, Children’s Services received a referral from the Police. Mother had been asleep in bed when Father accessed the property, woke her, accused her of cheating and punched her to the face causing injury. Sibling 1 awoke to arguing between her Parents and attempted to intervene to stop this. As Sibling 1 was running, Father had slammed a door shut and her finger became caught. Sibling 1 later attended Sunderland Royal Hospital with an open fracture to her finger which required surgery. A Section 47 investigation was undertaken. On 4 September 2012, an Initial Child Protection Conference was held and Siblings 1, 2 and 3 became subject to Child Protection Plans under the category of Emotional Abuse. By late September 2012 Mother was unsure if she wished to maintain her relationship with Father. On 3 October 2012, the family was discussed at MARAC panel. It was reported that there have been domestic violence incidents in May, June and July 2012 and Father was under the influence of alcohol on all of these occasions. Father was in custody until October 2012. Mother was provided with extra locks and security for her home due to the risk Father posed to her. Between early September 2012 and December 2013 a further 6 referrals were made to Children’s Services in relation to Father harassing Mother and he received custodial sentences during this time due to harassing Mother. Mother was referred to the Substance Misuse Service as part of the Child Protection Plans although there was a delay in her engaging with the service and, also, with the Domestic Abuse Service which she was also referred to. On 19 November 2012, the Police made a further referral to Children’s Services as Father had attended the home address and Mother had activated her alarm. On the same day a Review Child Protection Conference was held when the children remained subject to Child Protection Plans, under the category of emotional abuse. Professionals agreed that progress had been made, but Mother had not engaged with the domestic abuse or substance misuse services. Father had not engaged with Probation and been sent to prison. 58 On 14 January 2013, Children’s Services were advised by the Midwifery Service that Mother had attended a booking in appointment and was thought to be around 31 weeks pregnant. It was later established she was 25 weeks pregnant and she reported that the Father of the baby was the same as the older children. This was despite both Parents claiming to no longer have a relationship with each other. A Pre-birth CPC was held on 6 March 2013 in respect of the unborn baby, who was also made subject to a Child Protection Plan under the category of emotional abuse. By this point Mother had not engaged with the domestic abuse or substance misuse services. Father had not engaged with any services. At the Review Child Protection Conference held on 15 May 2013, the children remained subject to Child Protection Plans under the category of neglect. Baby L was born on 20 April 2014 and required medical intervention, including hospitalisation, on a number of occasions for Bronchiolitis. On 5 November 2013, a Review Child Protection Conference was held. Mother was said to have engaged well with agencies and completed nearly all of her work with the Domestic Abuse Service, which had given her a positive report. Father had not engaged with services for his alcohol misuse or domestic violence, however, his contact remained supervised once a week. There were no concerns in relation to Mother being able to meet the children’s health and education needs and although Baby L was unwell quite frequently Mother acted appropriately and sought medical attention when required. The decision was to end the Child Protection Plans in favour of Child In Need plans. On16 December 2013, a Child in Need meeting was held. There were no concerns expressed from school, the children were doing well and there were significant improvements with their confidence. Siblings 1 and 2 were exceeding academically. Health visitor reported that Baby L was chesty again and Mother had taken him back to the hospital the previous week. He may have a blockage but they were going to look at this further in the New Year. It was agreed that given the progress the family had made consideration would be given to the case closing to CSWS once further discussions had taken place with Father about his engagement with agencies. Baby L was found unresponsive by Mother in his own bed at 2:50 a.m. on Friday, 20 December, 2013. He had recently had a virus. Baby L was subject to a Child in Need plan at the time of his death. The SSCB Chair agreed on 21 February 2014 that the criteria for a Serious Case Review was met in respect of Baby L and further that this should be undertaken using the Significant Incident Learning Process (SILP) methodology. 59 2. Statutory Framework: Working Together to Safeguard Children, 2013, states that Serious Case Reviews should be undertaken in ‘every case where abuse of neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child’. They should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings. Working Together Chapter 4, further states: • LSCBs may use any learning model which is consistent with the principle in this guidance, including the systems methodology recommended by Professor Munro. And that • There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice. (Working Together to Safeguard Children, March 2013) 3. Scope of Serious Case Review: 3.1. Subjects: Baby L: (Aged 8 months) Sibling 3: (Aged 4 years) Sibling 2: (Aged 6 years) Sibling 1: (Aged 11 Years) 60 Whilst the children are the subjects of this Serious Case Review, agencies should also include relevant information in respect of the Parents, in particular the GP. The Parents are: • Mother: (Age 27 years) • Father: (Age 30 years) NB: Ages are at the time of Baby L’s death in December 2013. 3.2. Timeframe: 1 January 2012, 6 months prior to the injury to Sibling 1 in July 2012, which was the trigger for the Initial Child Protection Conference, to 20.12.2013, the date of Baby L’s death. 3.3. In addition Agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of the children, e.g. domestic abuse episodes, substance misuse and treatment, referrals to Children’s Social Care, Early Help. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. An exception to this is the Police, which is requested to provide full background information to its involvement with the family prior to the scoping period. 4. Chronology: Agencies are asked to populate key events on the chronology template. It is essential that this is limited to significant events only, which impacted, or had potential to impact on the outcomes for the children. 5. Agency Reports: Agency reports will be commissioned from: • Police (Including MARAC information) • Children's Social Work Service • Children’s Services’ Reviewing Service • NHS Foundation Trust (Health Visiting & School Nursing) • Acute Hospital (Paediatric and the Midwifery Service) • General Practitioner • Ambulance Service • Education: Schools 61 • Substance Misuse Service • Domestic Abuse Service, via the Commissioner • Early Help/Intervention Service Agencies which had limited involvement with the family are requested to provide a brief report of their involvement for information. These include: • Probation Service • Early Help • Registered Social Landlord 6. Generic Analysis: a. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? b. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. c. Demonstrate whether your agency/service heard and responded to the child’s voice. d. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. e. Were professionals proactive in escalating concerns and effecting challenge where appropriate? f. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? g. Did your agency identify any issues of ethnicity, diversity, language, culture (e.g. poverty)? If so, how did your agency address these issues? h. Is there any evidence that multi-agency safeguarding training supported the practitioners in this case or is training identified as lacking in a particular area? i. Identify examples of good practice, both single and multi-agency. 62 7. Particular areas for consideration: a. Was the decision to cease the Child Protection Plans and step down to Child In Need Plans evidence based and was there a good level of understanding of the children’s lived experiences at this time? What progress was subsequently made in implementing the Child In Need Plan? b. What was agencies’ understanding of the impact of the parental substance misuse, both drugs and alcohol, on the day to day care of the children? Was there any evidence of disguised compliance from either or both Parents? c. What were the inter-agency arrangements for sharing information about domestic abuse in the family and what was agencies’ understanding of the impact of this on the children? Were the interventions that were taken in response appropriate and effective? d. Is there a common understanding of SSCB’s Threshold Guidance? Is there any evidence of an over-tolerance of neglect, i.e. high threshold, and was the impact of neglect considered in respect of the children’s individual needs, e.g. the family’s sleeping arrangements, Baby L’s health needs. 8. Engagement with the family: SSCB has already informed the Parents that this Serious Case Review is being undertaking and the purpose has been explained to them. Further contact will be made to invite them to participate in the form of a home visit/ interview/correspondence/telephone conversation. Their contribution will be woven into the text of the Overview Report and they will be given feedback at the end of the process. In view of the young age of the children, they will not be invited to contribute directly to the SCR, but wherever possible their views and experiences will be included in the Review and in the Report. Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 9. Documentation: The “bundle” for the Learning Event will comprise: • Integrated Chronology • Agency reports 63 10. Timetable: Scoping Meeting (Terms of Reference) and Authors’ Briefing 3 September 2014 Draft Terms of Reference to SSCB 10 September 2014 Commissioning letters to agencies 26 September 2014 Agency Reports submitted to SSCB 7 November 2014 Agency Reports quality assured 7 - 14 November 2014 Distribution of material to all attendees 14 November 2014 SILP Learning Event 24 November 2014 Draft Overview Report distributed 5 January 2015 SILP Recall Day 22 January 2015 Distribution of Overview Report 9 February 2015 Presentation to SSCB 25 February 2015 64 Key single agency recommendations: APPENDIX B Below are the key single agency recommendations, as identified by the Lead Reviewer. • Children’s Services: 1. IT system should be developed to ensure the children’s individual voice and experience is captured. This should be monitored through the monthly case file audits. • NHS Foundation Trust: 1. Health professionals should follow up with statutory services when information is shared a child may be at risk of significant harm. 2. Health professionals should receive reflective safeguarding supervision which is open and supportive, focusing on the quality of decision, risk analysis and improving outcomes for children and young people. 3. Health professionals should be confident to constructively challenge when concerns persist with regard to children. 4. The role of the Safeguarding Advisors in professional challenge should be revisited. • NHS England/Clinical Commissioning Group: 1. GP safeguarding children meetings to have an agenda with list of families to be discussed and formal minutes to be taken. 2. CSC to review their policy to ensure both parental GPs are contacted for information as part of an initial assessment and Section 47 enquiries. • Acute Hospital: 1. Should be an accurate recording of family structure to aid the holistic understanding of the family in which a child live and evaluation of the safeguarding risk. 2. Must ensure that any child or YP admitted to the ward with known CP concerns or a CPP, SW and HV should be contact during the admission by the ward staff to alert them to the admission and Father any relevant community information. This would ensure a more timely transfer of information and ensure a safe discharge plan, with consideration of a discharge planning meeting. 3. The PLF and Paediatric Liaison process should be reviewed to optimise the City Hospitals info sharing of safeguarding issues. 65 4. Robust system to ensure discharge letter consistently sent to HV/School Nurse/SW when appropriate in addition to GP. 5. Hospital to consider how to meet responsibilities with regard to DA/MARAC 66 GLOSSARY APPENDIX C LSCB: Local Safeguarding Children Board SSCB: Sunderland Safeguarding Children Board SCR: Serious Case Review SILP: Significant Incident Learning Process CSC: Children’s Social Care A & E: Accident and Emergency Department MGM: Maternal Grandmother PGM: Paternal Grandmother CCN: Child Concern Notification (Police) ICPC: Initial Child Protection Conference Pre-birth CPC: Pre-birth Child Protection Conference RCPC: Review Child Protection Conference CPP: Child Protection Plan PLO: Public Law Outline CIN: Child in Need MARAC: Multi Agency Rick Assessment Conference IDVA: Independent Domestic Violence Advocate 67 REFERENCES APPENDIX D Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2010. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, Schools and Families, March 2013. Disguised compliance: learning from case reviews. What case reviews tell us about disguised compliance, NSPCC, March 2014. Ofsted, The Voice of the child: Learning lessons from Serious Case Reviews. A thematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010, 2011. Improving safeguarding practice: Study of serious case reviews 2001 – 2003, Research Report, Department for children, schools and families, 2008. Department for Children, Schools and Families, Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003 – 2005, DCSF 2008. Department for Children, Schools and Families, Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005 – 07, DCSF 2009. Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009, Research Brief, Department for Education, 2010. New learning from serious case reviews: a two year report for 2009 – 2011, Research Brief, Department of Education, 2012. 68 Sarah Gorin, Understanding what children say: Children’s experiences of domestic violence, parental substance misuse and parental health problems, National Children’s Bureau, 2007. |
NC047783 | Death of a girl, Bethany, aged 19 months on 11 April 2015. Cause of death was inconclusive after an open verdict at the inquest. Both parents had learning difficulties and troubled childhoods. Concerns were expressed by professionals from pre-birth onwards as to the parenting capacity of both parents. Bethany had been the subject of a Child Protection Plan for Neglect from October 2013. The parents received Early Support in parenting Bethany, and later a Care Order was put in place for Bethany to remain in her mother's care with the support of professionals and extended family when the father moved out. After key family members withdrew their support, the Care plan was in breach and the process to take Bethany into care was started. Bethany died before steps towards removal could be completed. Findings include: the assessment of parental capacity is essential; vulnerability of the parents should not override the needs of the child; over-reliance on extended family support in planning; there were issues of professional bias. Recommendations include: the LSCB should examine parental assessment processes; be able to identify and respond to neglect; ensure multi-agency challenge processes are in place for child protection plans lasting longer than 9 months.
| Title: Serious case review: Bethany: overview report. LSCB: Central Bedfordshire Safeguarding Children Board Author: Amy Weir Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Central BedfordshireSafeguardingChildren BoardSerious Case ReviewConducted underWorking Together to Safeguard Children 2015BethanyOverview ReportLead ReviewerAmy Weir MA MBA CQSWFebruary 25th 2016Updated October 18th 20162 | P a g eFinal draft 25/2/2016 updated 18.10.2016SCR BethanyDate of birth: September 2013Date of death: April 2015Ethnic origin: White UKLIST OF CONTENTS1. Introduction and Background to the Review32. The Review Process43. The Family as Known to Agencies and Brief History64. Bethany’s Experience and Family Involvement in the Review195. Findings – Themes and Areas of Significant PracticeASP1. Timely and prompt response to the pregnancy but the assessmentcompleted was not comprehensive.ASP 2 Prompt response made to concerns after Bethany’s birth and a ChildProtection Plan was made.ASP 3 There was a drift in the case and delay in completion of the CognitiveAssessments and PAMs and there were several changes of social worker.ASP 4. An appropriate response was made once the specialist assessmentwas received.ASP 5. The plan made at Court faltered but the Court was not informedimmediately as the Judge had requested216. Conclusions and Summary297. Recommendations for The LSCB338.Next Steps – Progress Report and Learning379. Next steps - Progress Report / Learning38AppendicesAppendix A - Family and Significant others and GenogramAppendix B - Scope and Full Terms of Reference of the ReviewAppendix C. - List of References3 | P a g eFinal draft 25/2/2016 updated 18.10.20161.Introduction and background to the review1.1This Serious Case Review (SCR) was commissioned following the death of a youngchild, aged nineteen months. It considers the circumstances in which she died andwhether the services, which were received by the family from a range ofprofessionals, provided the best response required to address her needs and to keepher safe.1.2All the names in this review have been anonymised. The child is known as Bethanywithin this report. Bethany was born in September 2013. When she was nineteenmonths old, her mother found her lifeless in her bed. The cause of death wasinconclusive but there was evidence of vomit in her lungs and of swelling of the brain.A police investigation was initiated as the conditions in which Bethany were foundappeared to suggest that she had been neglected prior to her death and, that thispoor care, may have resulted in her death. Her mother was arrested and charged withcausing neglect to a child. However, this charge is no longer being pursued.1.3As stated above, there were parallel proceedings in relation to the death of Bethany.Her mother was subject to criminal proceedings for the neglect of Bethany. This casehas now been discontinued due to lack of evidence. The author has been providedwith relevant information from the criminal investigation to inform the serious casereview.1.4An Inquest was held from 13th to 14th September 2016. This concluded with an openverdict. The Coroner described the care of Bethany as “chaotic”. Her mother told thecourt that she thought her parenting was “alright” and that she was “doing a goodjob.” The Coroner described mother as being “fabricating and being unreliable”.1.5The circumstances of Bethany’s death led to the decision in April 2015 by the Chair ofthe Central Bedfordshire Safeguarding Children Board (CBSCB) to undertake a serious4 | P a g eFinal draft 25/2/2016 updated 18.10.2016case review. The Working Together 2015 criteria for commissioning a SCR were met asfollows:Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functionsof LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases inspecified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation toserious case reviews, namely:5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partnerson lessons to be learned.(2) For the purposes of paragraph (1) (e) a serious case is one where:(a) abuse or neglect of a child is known or suspected; and(b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is causefor concern as to the way in which the authority, their Board partners or other relevant personshave worked together to safeguard the child.2.The Review Process2.1This review has been conducted with due regard to the principles of fairness,impartiality, thoroughness, accountability, transparency and above all with a focuson the experience of the child, Bethany. The consideration of her interests andexperience has been the central focus of the review. The circumstances in whichBethany died have affected all those involved in the review. her family members,and all of those staff who worked closely with the family.2.2The time period covered within this Serious Case Review is from 1st March 2013 upto and including 11th April 2015 the day of Bethany’s death. This time period hasbeen chosen to cover the date when Olivia’s pregnancy was known to agencies up toand including the date of Bethany’s death. Any additional historical informationrelevant to the review going back before these dates (e.g. within the parents’ ownchildhoods) has also been fully considered in the review.5 | P a g eFinal draft 25/2/2016 updated 18.10.20162.3Amy Weir, who is an experienced independent safeguarding expert, was appointedas the independent reviewer. A Panel of senior managers was formed to support theprocess. Amy Weir wrote this report with the support of the SCR Panel.2.4.1The full terms of reference for the review are appended to this report. Critical pointsin the case were considered in the SCR. Possible reasons for actions taken at thetime and learning and improvements needed have been identified – including thesignificance of these insights for current practice. Where there was evidence of goodpractice in the case, this has also been noted. These findings will inform the CBSCB’sLearning and Development Plan and the responses to them will be embedded inlocal practice through that plan.2.5The investigation has examined key documents and spoken to staff and practitionersdirectly and indirectly through the involvement from each agency of experiencedsenior managers, who have had no direct involvement in this case. Local practitionershave been brought together to consider, discuss and comment on the findings of thereview. The root cause analysis “fishbone” approach to identifying key contributoryfactors has been used. The aim of this has been to gain an understanding of how theinteraction between the various factors influenced the way practitioners respondedto, and provided services to, Bethany and her family.2.6Bethany’s mother and father were contacted to inform them that this review wasbeing undertaken. They were asked whether they would like to contribute to thereview. Both parents expressed a wish to contribute to the review. Father was seen on18th August 2015 and mother was seen on 24th September 2015. Father’s mother andstepfather were also seen on 24th September 2015. These views provide importantinsights into what happened to Bethany and to the events during Bethany’s lifetime.2.7Mother’s extended family members, including her mother and her brother, werecontacted and spoken to about the review. However, they did not agree to contribute6 | P a g eFinal draft 25/2/2016 updated 18.10.2016to the review.2.8As Bethany’s case was subject to care proceedings brought by the Local Authority atthe time of her death, the author has been given access to the transcript of thehearing held shortly before Bethany’s death. The Judge involved in the case and thesolicitor for the child have also been interviewed as part of the review process to elicittheir views on what can be learnt from the case.2.9The critical points and issues in the history were identified and the areas to considerwere set out in the terms of reference which are appended to this report.2.10 The review report sets out the findings – including the possible reasons for actionstaken or not taken at the time were considered:What factors contributed to practice decisions at the time?What could have been improved?What good practice occurred?2.11The significance of these insights for current practice is also explored.If the same event occurred now – what factors would influence the response?What learning and improvements have already been implemented?What is working well now and what still needs to be improved?3.The Family as known to Agencies and a brief history3.1Bethany and her family were known to Central Bedfordshire Council (CBC)Children’s Services prior to her birth, and throughout her life; Bethany had beensubject to a Child Protection Plan under the category of Neglect from October2013 to the date of her death in April 2015.3.2At the time of her death Bethany, aged nineteen months, was living with hermother, Olivia Fisher. Bethany’s father, David Lamb, had moved out of the familyhome at the beginning of March 2015, after a Family Court hearing. Central7 | P a g eFinal draft 25/2/2016 updated 18.10.2016Bedfordshire Council had applied for an Interim Care Order in relation to Bethany.The court agreed, pending a full hearing of all the evidence, that Bethany shouldremain in her mother’s care on the basis that members of the extended familyagreed and gave undertakings to provide additional support to Olivia to help hercare for Bethany. The local authority also continued to visit and support thefamily.3.3Bethany died three weeks after the court hearing. Her mother found herunresponsive in her bed in the early afternoon. Olivia called her own mother whocame. An ambulance was called and paramedics came speedily to the home but,within ten minutes, Bethany was pronounced dead. Bethany was reported to havebeen found in her room in an open cot bed with a nappy on; the nappy was laterfound to weigh one pound which was estimated to be two full bladders of urine. Theambulance staff who attended advised that Bethany had been dead for some time.The room was hot, there was vomit on the bed and Bethany was found at the bottomof the bed with her head hanging over the end of it.3.4Over the next few days, Olivia provided several slightly different accounts of whathad happened to Bethany. The postmortem subsequently carried out wasinconclusive about the cause of death although it is known that there were signs ofbrain swelling and vomit in her lungs.3.5Bethany’s mother has another child, Bethany’s older half-brother Scott - now agedseven years - Olivia cared for him until 2012 but at the end of that year, it was clear thatshe was struggling to care for him and he moved to his father’s care. He remains in hisfather’s care subject to a Residence Order in another local authority. Scott had regularcontact with his mother about four times a month and sometimes stayed the night.After Bethany’s death this contact ceased when Central Bedfordshire Councilinformed the other local authority of Bethany’s death.3.6Olivia, Bethany’s mother has learning difficulties. She is twenty-eight years old. Itappears that she was in care and then adopted as a young child. She attended a8 | P a g eFinal draft 25/2/2016 updated 18.10.2016school for children with special needs as a child. She was described at school asbehaving badly, having poor concentration and being inattentive.3.7David, Bethany’s father, has learning difficulties. He is thirty-three years old. Heattended the same special needs school as Olivia and this is how they knew eachother. As a young child, he was said to have poor listening and attention skills whichhave limited his development and cognitive ability. His parents separated whenDavid was two years old. His father took David from his mother on two occasionswhen David was two years old and he had to be recovered by Police with a briefperiod of being in care. After that he was brought up by his mother with whom hehas a good relationship.3.7.1The family moved three times during Bethany’s lifetime. This included one veryshort move to temporary accommodation prior to the family receiving permanenthousing. This meant that several different professionals were involved with thefamily during the nineteen-month period of Bethany’s life.3.8 Prior to Bethany’s Birth – March to September 20133.9.1In March 2013, when Olivia was about three to four months pregnant with Bethany,she was referred to Central Bedfordshire Council Children’s Services by the midwife.The midwife was concerned from Olivia’s presentation about whether Olivia wouldbe able to cope with the demands of caring for a newborn baby. These concernsalso arose because of the information the midwife had that Scott was not beingcared for by her and that Olivia had known difficulties in parenting Scott.Information that both Olivia and her new partner David - father of the unborn child -had learning difficulties raised further concerns about whether they could look afterthe baby safely. The midwife made further contact with Children’s Services at thebeginning of May 2013 about her concerns. This referral resulted in an InitialAssessment being undertaken.9 | P a g eFinal draft 25/2/2016 updated 18.10.20163.9.2The records show that the family was known to Central Bedfordshire Council aswell as to the other local authority’s Children’s Services, where Scott’s father lives,because of the decision by Scott’s father to become his carer rather than Olivia. Inthese private law proceedings during 2012, a Central Bedfordshire Council socialworker completed a Section 7 report and Scott was placed with his father. Thedifficulties which Olivia had experienced in parenting her first child, Scott, weretherefore known.3.9.3During her pregnancy with Bethany, Olivia was reluctant to be involved withChildren’s Services. However, she did cooperate with the completion of a coreassessment which was completed by a social worker. The family was referred to asupportive pre-birth parenting service, Mellow Bumps, in early May 2013. A Childin Need meeting to review progress was convened at the family home at the endof June 2013 just as the core assessment was completed; the assessmentrecommended that the case be closed in Children’s Social Care and that an EarlyHelp package of support should be delivered through Mellow Bumps and Babies,and children’s centre support. A referral for this Early Help was made at thebeginning of July 2013 and the case was closed to Children’s Social Care a few dayslater. Olivia attended Mellow Bumps a pre-birth parenting course. She attendedfive out of six sessions and the staff providing the course did not raise anyparticular concerns.3.10After Bethany’s birth – Bethany 0-3 months - September 2013 to December 20133.10.1 Bethany was born in early September 2013. It was a normal delivery andBethany weighed 8lb 8oz. There were no particular concerns raised at thehospital before the baby went home. The midwives who visited the family athome after this did not raise any immediate concerns.3.10.2 A children’s centre worker contacted Children’s Social Care in early October2013 after David, Bethany’s father, had called to say he was worried about10 | P a g eFinal draft 25/2/2016 updated 18.10.2016how Olivia was coping with caring for Bethany. David also stated that he wasconcerned that Olivia was saying she might harm the baby. The children’scentre worker also said that she had wider general concerns about Olivia’sand David’s parenting of their young baby. The relationship between Oliviaand David was not always positive and it was reported that there were fightsbetween them and David had been bruised. There was also the concern thatOlivia had said she felt depressed and was worried she may harm Bethany.However, this was clarified later by Olivia who said she had been feeling soexhausted and down that she was concerned she may not care properly forBethany rather than pose a risk of deliberately harming her.3.10.3 The next day, a Strategy Meeting was held involving Police, Health andChildren’s Social Care. It was reported that David had committed someoffences though the details were not clearly recorded. Olivia was found tohave previously been in charge of a child, her son Scott, whilst intoxicated. Itwas reported at this meeting that Olivia’s IQ was between 50 and 70 – wellbelow the average of 100. It was stated that she was struggling to cope withBethany’s feeding and reflux problems. The GP reported that he did not feelOlivia was depressed but rather that she was struggling to cope with thevaried needs and demands of a newborn child. A visiting matrix for each ofthe professionals involved was agreed and the Early Help worker referred thefamily to the Early Intervention Outreach Worker for adults with LearningDifficulties. The aim was to raise the level of family support being provided tosupport the parenting of David and Olivia. It was realised that there wasmissing information about the parents’ backgrounds and it was agreed toseek that information from other Local Authorities who had known them.3.10.4 Following the section 47 investigation, an Initial Child Protection CaseConference (ICPC) was convened a week later. From the referral made in May2013 to October 2013 when the Initial Child Protection Conference was held,Central Bedfordshire Council Children Services and Health staff workedtogether to ensure a high degree of support was provided. The family were11 | P a g eFinal draft 25/2/2016 updated 18.10.2016visited several times a week in order to support the basic care of Bethany -feeding, home hygiene, parenting skills. Family members also visited thefamily to support them.3.10.5 At the ICPC in mid-October 2013, it was agreed that the risk of significantharm to Bethany was high and that that Bethany should become subject to aChild Protection Plan under the category of Neglect. There was discussion atthe conference about the parents’ ability to care for Bethany and theirapparent lack of confidence to parent; it was suggested that Olivia and Davidmay not always understand the support and guidance being offered giventheir learning difficulties. The view was that, given their presumed lack ofconfidence, a high level of support and monitoring was required to keep hersafe and well cared for. The Chair of the conference suggested that acognitive and specialist parenting assessment related to their learningdifficulties should be undertaken; a PAMs assessment was therefore to becommissioned. Adults Social Care was also requested to assess the parents’cognitive functioning and a visit was undertaken shortly afterwards.3.10.6 After November 2013 further concerns emerged. The maternal extendedfamily were helping the parents but in November 2013, Olivia’s brother andpartner reported they were stepping back in terms of the support they wereto offer Olivia and David in caring for Bethany. In December 2013 two markswere noted to Bethany’s head. A Strategy Meeting took place and a ChildProtection medical was immediately undertaken. The conclusions were thatno injuries were specifically noted during the medical and parents were notthought to have caused physical harm. However, there was still much concernabout their overall ability to care for, and parent, Bethany. There were alsofrom time to time issues raised about Olivia’s older child, Scott, and the factthat Olivia and David were struggling to cope and manage his behaviour whenhe visited for contact most weeks.12 | P a g eFinal draft 25/2/2016 updated 18.10.20163.10.7 There was a significant amount of interaction and service involvement – bothfrom a variety of Central Bedfordshire Council Children’s Services and Healthprofessionals - with the family throughout Bethany’s life and pre-birth.Children’s Social Care (CSC) was involved with the family for most ofBethany’s life - March to July 2013 (pre-birth) and October 2013 to her deathin April 2015. There were five different social workers (as well as one socialwork assistant), and in the local area Family Support Team there were threechanges of social worker over six months. There were three different linemanagers.3.10.8 As well as the Children’s Social Care involvement with a social workerallocated to the family, there was extensive Early Help support. The FamilyIntervention Support Service (FISS) was involved throughout October 2013 toApril 2015 and FISS workers were consistently involved. There were 145 visitsin total to the family home – though the family was not always at home.Intensive support was offered to the parents on these visits and there wasalso further contact including telephone conversations with family members,extended family, and attendance at professional meetings (Child ProtectionCase Conferences, Core Groups) by FISS staff. Central Bedfordshire CouncilEarly Intervention Outreach Service (EIO) was also involved from August toNovember 2014.3.10.9 From the early days following Bethany’s birth, the relationship between Davidand Olivia was strained. Both the parents and Olivia’s family reported thatthey felt too many professionals were involved. David expressed concernsabout how Olivia cared for the baby and her son Scott when he came forcontact. Olivia complained that David sought to control her and her familysupported her in this view.3.11Bethany aged 3 months to 1 year 3months – January to December 20143.11.1 There was a delay in identifying who should undertake the PAMs assessment and in thefunding for it being agreed. A Central Bedfordshire Council resource panel had to agree13 | P a g eFinal draft 25/2/2016 updated 18.10.2016the funding and in January 2014 this was refused because it was believed that aninternal member of staff could do the assessment. The resource panel asked for theEarly Intervention Outreach Worker (EIO) for learning disability and the Adult LearningDisability Team to contribute to the social worker’s assessment and the PAMs fundingwas refused on that basis. However, it was subsequently discovered that the EIO wasnot qualified to complete a PAMs assessment. The EIO only worked with the family fromOctober to November 2014 following a request from the Early Help social worker butdid not do the assessment. The Core Group decided to end the EIO involvement aboutsix weeks later because it was felt that there were too many professionals involved.3.12.2 The view of the social worker involved at that time was thought to beoptimistic. It is clear that this social worker, who was only allocated the casefor a short period, did not hold the same level of concerns in respect of Oliviaand David’s capacity to parent Bethany as some other professionals involveddid. The records show that when the case was reallocated in May 2014, moreprogress was made and a more appropriate view was taken of the parents’parenting difficulties.3.12.3The funding for PAMs was refused initially in January 2014, it was notrequested again until July 2014 – a six-month delay. It is unclear what thereason for the delay was. It is not clear that there was any further discussionabout whether PAMs was the most appropriate assessment, given the delayand frustration of the original child protection conference recommendation inOctober 2013 that a cognitive assessment and a PAMs should be completed.The PAMs was commissioned to be undertaken by an independent socialworker in September 2014. There was delay with the independent socialworker having difficulty in seeing Bethany who was frequently in bed whenvisits were made. It was not completed till December 2014 and it was actedupon by Central Bedfordshire Council in January 2014.3.12.4 The need for a cognitive assessment to test the parents’ functional capacity14 | P a g eFinal draft 25/2/2016 updated 18.10.2016had been identified at an early stage. Although an adults’ social workercarried out an assessment through a home visit with the social worker, thiswas not a full cognitive assessment. Attempts to commission a fuller cognitiveassessment of both parents were frustrated. The local NHS provider oflearning disability services did not agree to undertake this assessment. Theservice was not commissioned to provide parenting assessments, and on thatbasis the referral was declined. It was clarified that the referral was in fact fora cognitive assessment, which is a routine referral, however it was suggestedthat this may not have been in the parents’ best interests and the referralremained declined.3.12.5 The concerns continued to be acknowledged and the information wascollated by the most recent social worker. There continued to be a high levelof visits to the home, shared between the social worker and FISS workers.There were occasions during this period where it was felt by the social workerthat other professionals were being too sensitive to the needs of the adultsand not recognising the needs of Bethany and this was addressed by her at aCore Group meeting in November 2014 when the meeting was informed thatfurther legal advice was being sought.3.12.6 The family moved twice during this period of involvement and, when intemporary housing, it was felt they coped better because they had access toon-hand support from the warden at the temporary accommodation. Thefamily then chose to accept housing in a relatively isolated village which wascloser to their family.3.12.7 There were indications from mid-2014 that the concerns about Bethany’swelfare and safety were not shared proactively by all the professionalsinvolved or some were not voicing the concerns they held about the family.Focusing on the welfare of Bethany was sometimes lost in the light of thesignificant support needs and increasingly strained relationship between15 | P a g eFinal draft 25/2/2016 updated 18.10.2016Olivia and David. The social worker challenged the lack of full consideration ofthe concerns by some professionals.3.12.8 As a result of these shared concerns, a legal planning meeting was held inOctober 2014. The concerns were domestic abuse between the parents, theparents’ lack of understanding of what may pose a danger to Bethany andtheir neglect of her basic care. There were concerns about the impact onBethany of David’s alcohol use, the parents mixing with unknown peopleparticularly those met on the internet and those persons being brought intothe home whilst Bethany was present. Olivia admitted to meeting this man onthe internet. The couple acquired a dog and professionals were concerned atthe parents’ lack of understanding of the risks it may pose to Bethany. ThePublic Law Outline process was started and parents were informed of this at ameeting with them and their legal representatives in November 2014. It wasnoted that the PAMs assessment had been started with an expectedcompletion date of mid December 2014.3.12.9 Olivia alleged in this meeting that David was drinking heavily and was verballyabusive to her. David had previously been bruised by Olivia but both of themsaid there was no violence between them. David agreed to the alcohol servicehe was attending providing information about his drinking and he also agreedto find suitable alternative accommodation. A review meeting was to be heldat the end of February 2015.3.13Bethany – aged 1 year 3 months to 1 year 5 months - Care Proceedings -January to April 20153.13.1 Throughout the Early Help / family support services maintained a high levelof visits to the family whilst they were awaiting the PAMs assessment.When the PAMs report was finally submitted to the local authority inJanuary 2015 it raised serious concerns about Olivia and David’s capacity toparent. It was shared with the Legal Department of Central BedfordshireCouncil and as a result, Care Proceedings were instigated in February 2015.The assessment had concluded that Bethany’s parents were not able to16 | P a g eFinal draft 25/2/2016 updated 18.10.2016meet her needs.3.13.2 Although the PAMs report was dated mid-December 2014, it was notreceived by the social worker until January. It was then decided thatproceedings should be commenced. Towards the end of January, theassessment was shared with the parents and their solicitors. At a reviewPublic Law Outline meeting at the beginning of February 2015, the parentswere informed that it was the intention of the local authority to commencecare proceedings. All the papers for court were sent in early March 2015.3.13.3 There were two court hearings held a week apart in mid-March 2015 to consider thelocal authority’s application for an interim care order. The local authority appliedfor an Interim Care Order, with a care plan for Bethany’s removal from her parents’care. It was thought the Guardian would support this. However, an adjournmentwas proposed by mother’s solicitor. The application to adjourn was on the basisthat support could be offered by the extended family and this needed to beexplored to enable the court to have all reasonable options before it. There hadalready been three family group conferences held to identify what support thefamily could provide. It is not clear whether the Judge was aware of this. Davidinformed the court that he would move out. The application to adjourn wasopposed by the local authority but the court granted an adjournment and the orderstated:“The court being of the view that such a step is necessary to ensure that the right toa fair hearing and family life is complied with.”3.13.4 The court reconvened just over a week later. There were oral submissions by thelegal representatives of the parties. The local authority’s application for an InterimCare Order was opposed by Olivia, David and the Guardian. Within her judgment, theJudge expressed serious concerns for Bethany’s welfare, agreed that she hadsuffered emotional harm but did not sanction removal. Instead, she decided thatBethany should not be removed into care on the basis of the support plan put beforethe court by the family with some parts included by the local authority as they wereobliged to do. The family members were spoken to by the Judge to ensure they17 | P a g eFinal draft 25/2/2016 updated 18.10.2016understood the commitment they were giving to support Olivia to care for Bethany.3.13.5 Following the direction of the court, the agreement was for the FISS worker tovisit twice a week and for the social worker to visit once a week – the otherdays were to be covered by family members.3.13.6 Central Bedfordshire Council had formed the view that David was no longer apositive influence particularly since major arguments were occurring betweenDavid and Olivia. David was therefore asked at court to agree to leave thehome which he did. Some of the maternal extended family members had notbeen as involved with the family for a significant period of time but they gavean undertaking to the Judge that they would offer support in providing a highfrequency of visits along with an increased level of visits by the FISS team.3.13.7 This was all on the basis of further assessments to be undertaken in respectof Olivia and David’s cognitive functioning and within a timetable to concludethe case within 26 weeks. A cognitive assessment of both parents wasrequested by the court.3.13.8 At the end of March 2015, Olivia told professionals that she had gone to apub with a man she hardly knew and taken Bethany with her; she alsoadmitted smoking cannabis in the garden with him. The social workerinformed the LA’s solicitor and told Olivia that this was unacceptable. A fewdays later on 31st March 2015, Olivia said that she was worried about herfeelings for Bethany. She said her family was suggesting that Bethany wouldbe better off with someone else. Over the next few days, despite repeatedefforts the professionals could not get access to the home and Bethany wasnot seen by any professional. On 2nd April 2015the FISS worker and a socialwork assistant sought advice from a manager as they had still not managed tosee Bethany. The GP was contacted who said he had seen Bethany and hadno concerns.18 | P a g eFinal draft 25/2/2016 updated 18.10.20163.13.9 On 4th April 2015, the FISS worker could not get in but she could hear thebaby crying inside; she alerted the social worker. The worker called andtexted mother but she did not respond to either. The FISS worker visitedagain an hour later. The worker sent a further text message to mother to askher to make contact within one hour or the Emergency Duty Team and thePolice would be contacted. The FISS worker telephoned MaternalGrandmother who confirmed that she was with mother and child at thetime of the call.3.13.10 The gap in professional contact between 4th to 7th - Saturday to Tuesday- was only on the Sunday and Monday. This was because of thefamily plan as set out in court which expected family members to carry outvisits.3.13.11 On 7th April 2015, access was gained by the FISS worker but Bethany was notseen as she was with her father’s family. The house was dirty and untidy withthe bed stained and an old baby milk bottle and a dirty nappy on the floor.3.13.12 The next day David contacted the Police stating that he thought Olivia wasusing drugs and drinking; Police visited on 8th April 2015and could find nosigns of this and, as a result, formed the view that the call had been malicious.Children’s Social Care was informed of the referral but there does not appearto have been any direct liaison between the agencies; it is likely thereforethat the police officers attending were not aware that Bethany was subject toa child protection plan. The police referral to children’s services after the visitdid not indicate any cause for concern; mother did not appear to be underthe influence of any substances and the police officer found no evidence ofany alcohol/drug use or any other persons present. Bethany was upstairs inbed. Mother did admit that she had smoked some cannabis a few weekspreviously but she denied being a regular drug user.19 | P a g eFinal draft 25/2/2016 updated 18.10.20163.13.13 On 9th April 2015, the social worker visited the home. Mother, maternalgrandmother and Bethany were present. The concerns about Olivia’sinappropriate use of Facebook were discussed. It was felt Olivia wasrealising that even with immense family support she was struggling to carefor Bethany.That same day the paternal aunt and uncle, Katie Lamb andElliot Green stated that they no longer wished to be assessed to care forBethany and had pulled out of being part of the support plan. The socialworker who spoke to a duty solicitor said that the Judge had been clear thatif there were any issues with the plan the matter was to be returned tocourt. By the following week there would be gaps in the support plan so thiswas discussed. The social worker said that she would speak to the maternalgrandmother to see if she could help pending this matter returning to court.The duty solicitor advised the social worker that to return the matter backto Court would need an updating short statement and care plan as removalwas being sought and the statement needed to update the court on thebreakdown I support from the paternal family due to ‘personal reasons’. Thecourt was not informed directly of this change in circumstances as the socialworker was to prepare a statement and next steps were going to beconsidered at a meeting to be held early the next week.3.13.14 The local authority solicitor wrote to the social worker confirming what hadbeen agreed as a temporary solution. She also informed mother’s, father’sand the Guardian’s respective solicitors about what had happened andconfirmed that the local authority would be seeking to return this matter tocourt. There was no response to these emails within the records.3.13.15 On 10th April 2015, Olivia was with her mother and was seen by the FISSworker. Olivia told the worker that she had agreed for Bethany to be adopted.She said she had agreed because the family could not maintain supporting herto such a high degree. The FISS worker sent an alert to the social worker thatday. The next day, Bethany was found dead. The local authority intended to20 | P a g eFinal draft 25/2/2016 updated 18.10.2016return to court the next week and the social worker had drafted a statementabout the new concerns.4.Bethany’s Experience and Family Involvement in the Review4.1Olivia and David appeared to be happy about the pregnancy and made preparationsfor the baby and attended pre-birth sessions to support them. There were noimmediate concerns after her birth and she went home with her parents.4.2For the first few weeks of her life, Olivia seemed to manage caring for Bethany. Shebreastfed Bethany for the first two weeks but did not sustain it beyond that briefperiod. There were no immediate concerns about the quality of care.4.3However, within a few weeks, the Health Visitor and others started to be concernedabout how difficult the parents found it to retain information and to follow advice.Both parents needed a great deal of prompting to meet Bethany’s basic care needs.There were many professionals visiting the home throughout Bethany’s life. Visitswere carried out up to six times a week. Bethany therefore had several differentadults to interact with and to provide her with care. When these other adults werenot present, the level of care dipped and Bethany appears to have been neglected.Above all, some professionals realised the real problem was that Olivia could notempathise with Bethany nor appreciate and foresee her basic needs.4.4The parents took Bethany to the children’s centre and she would have benefitedfrom these trips. However, particularly as she became older and more demanding, itappears that she spent more time in her room. When the PAMs assessment socialworker visited, she was said to be asleep and in her room on many occasions.4.5Bethany is likely to have experienced a considerable amount of conflict in the home.By September 2014, Olivia and David’s relationship, which had been poor for a longtime, seemed to be over though they still lived together. It is clear that Bethanywould be adversely affected by their arguments and their own preoccupations whichdistracted them from caring for her. It seems he was drinking heavily and she wasspending a great deal of time on Facebook and other social websites.21 | P a g eFinal draft 25/2/2016 updated 18.10.20164.6The Guardian visited the home just before the first Court hearing and saw Bethanyjust weeks before her death. It was her observation that Bethany had very littlespeech and seemed scared and watchful when her mother raised her voice. Bethanywent to her parents but she was much more interested in the FISS Worker when shearrived.4.7Bethany’s parents had wanted to care for her but it appears that she was neglectedand not consistently provided with the basic care and comfort she needed. On theday of her death, there was evidence that she had been left alone in her room for anextended period without being changed or attended to.4.8Father, David has clearly been very distressed by the death of his daughter. He wasinterviewed and said he felt that he did most things for Bethany after the first fewweeks when Olivia cared for her. After that Olivia felt low and said she thought shemight hurt the baby. He did the cooking, housework and made the bottles up forBethany4.9He said that Olivia spent a great deal of time on her mobile and on the internet andafter May 2014 she provided very little care to Bethany. They started arguing. Forexample, Olivia bought a dog and David was unhappy about this – the dog growled atBethany and left hairs everywhere. In September 2014, he came home to find asemi-naked man in the house. Olivia carried on using web-based dating sites andDavid looked after the baby.4.10David said that during the PAMs assessment, Olivia kept Bethany upstairs out of theway. The situation deteriorated after Christmas 2014. Olivia accused him of drinkingand he was. The relationship seemed to be over and the plan was not working – thehouse was dirty and untidy. David agreed to leave but he was worried about whetherOlivia would look after Bethany.4.11Mother, Olivia was seen as part of the review process. David was also in the homewhen we visited. She has also been very distressed by Bethany’s death. She is stillconcerned that the cause of Bethany’s death is not clear.22 | P a g eFinal draft 25/2/2016 updated 18.10.20164.12Olivia felt that some of the support they were given was useful but there wereproblems. It is her view that she did not need help in caring for the baby; it wasDavid who needed the help. There were many different workers and they werealways in and out. Her brother and his wife originally helped but they dropped outand she was not happy about that.4.13Olivia said that in Bethany’s last week in April 2015, her brother had spoken to herand had advised her to have Bethany adopted as they both had been. She said thatshe had decided that was the right thing to do and had told the social worker whoadvised that there would need to be a Court hearing. The day after this Bethanydied.4.14David’s mother and step-father were seen at their request. Paternal grandmotherused to look after Bethany twice a week. They have found Bethany’s death difficultto bear.4.15Paternal grandmother said that it had been very difficult having so many differentsocial workers involved – she said there were five or six. As soon as they were usedto one social worker they would go and they would have to start again. This was alsodifficult for Olivia and David. The FISS workers were by contrast able to providecontinuity.4.16In her view, it was taking David and Olivia a long time to understand what wasrequired of them and they were not getting it fast enough. Olivia thought she wascoping better than she was; paternal grandmother felt this was not really challengedin core group meetings and most often professionals said how well Olivia was doing.4.17The maternal extended family – particularly Olivia’s mother and her brother havedeclined to be seen for the review.5.Areas of Significant Practice (ASP)5.1ASP1. Timely and prompt response but the assessment completed was notcomprehensive. (Pre-birth).23 | P a g eFinal draft 25/2/2016 updated 18.10.20165.1.1The midwife correctly and appropriately referred the family to CSC when she knewabout mother’s background and she perceived that both parents had learningdifficulties. Her initial view that they would need additional support was right. CSCpicked up the case and initial and core assessments were completed. At the sametime pre-birth services were provided to the family and they cooperated well withthis.5.1.2This pre-birth assessment recommended that Early Help and family support servicesshould be provided through a CAF. The case would be closed in CSC and steppeddown to Early Help and Health. From July to September 2013, the parents werecooperating and when Bethany was born there were no additional concerns. Thepre-birth Core Assessment did not draw fully on contributions from other agenciesand it lacked detail about the parents’ history including the level and nature of theirown parenting and learning difficulties. Olivia’s inability to care for Scott without ahigh level of support from her own mother was not fully explained. It did not statethat they lived with her mother when he was a baby and it was grandmother wholooked after him. Scott had only recently been transferred to his father’s care andthis was also a strong indicator that Olivia was likely to struggle to parent Bethany.This was also a missed opportunity to specify the need for specialist assessment ofthe parents’ functioning or perhaps even a residential family assessment which couldhave been indicated given the history. The decision to close the case in CSC wastherefore premature but a well organised range of Early Help services were planned,offered and taken up. As a result of this safety net the early difficulties were pickedup promptly and child protection processes put in place.5.2ASP 2 Prompt response made to concerns after Bethany’s birth and a ChildProtection Plan was made. (Bethany 0-3 months - September 2013 to December2013).5.2.1In the first few weeks, a high level of support was provided. Despite this someconcerns about whether Olivia and David could care for Bethany emerged from anearly stage which suggests that the pre-birth Core Assessment was over optimisticabout the level of support which would be needed and had not taken sufficientaccount of the parental history. The midwife continued to visit beyond the usual 1024 | P a g eFinal draft 25/2/2016 updated 18.10.2016days and up to the 28th day after birth. The Health Visitor also was seeing the familyfrequently and suggesting to David that he needed to be at home to support Olivia incaring for Bethany. Things were not going well within the first few weeks. Olivia wastired, saying she might harm Bethany. David said Olivia was hitting him. Davidadmitted that he was drinking heavily. Bethany was having feeding problems withreflux and suffered from recurrent oral thrush.5.2.2Appropriately, CSC called a strategy meeting. At this early stage, the strategymeeting rightly identified the need for a further core assessment as well as aspecialist assessment of the parents’ intellectual and cognitive capacity. A referralwas made for Adult Learning Team assessment of parents. An initial assessment wascompleted promptly by an Adults’ social worker However, when it was identifiedthat a full cognitive assessment of the parents was required, the NHS providerservice refused to provide this. That service did not see itself as responsible forcontributing to the assessment of parenting in that way. The service also suggestedthat it would not be in the parents’ interests for this assessment to be completed.This was worryingly un-child focused approach.5.2.3Problems continued to emerge during October 2013. David stated that he could notleave Bethany with Olivia. The house was untidier. In mid-October 2013 David andOlivia were complaining about the level of support being provided saying it wascausing stress. A family group conference was planned. The ICPC was held on 30thOctober 2013 and there was a clear view that Bethany was at risk of significant harmthrough neglect and should be subject to a Child Protection Plan. At this point, theplan to continue the intensive level of support was maintained with the Chairrecommending that a cognitive and PAMs parenting assessment should becompleted. Four family members including the parents were present and the Chairmet them prior to the conference.It was identified that due to a lack of self-confidence the parents do not alwaysactually understand guidance that is given about Bethany's care and untilprofessionals are satisfied that both parents fully understand and can apply safe25 | P a g eFinal draft 25/2/2016 updated 18.10.2016parenting skills a high level of support and monitoring was required. Minutes ofICPC 30/10/135.3ASP 3 There was a drift in the case and delay in completion of the CognitiveAssessments and PAMs and there were several changes of social worker. (Bethanyaged 3 months to 1 year 3months – January to December 2014).5.3.1 There were many different professionals involved with Bethany during her lifetime.There were five social workers though the most recent one has been involved sinceJuly 2014. There were four different health visitors reflecting the family’s threemoves. Undoubtedly, having so many changes of staff in such a short period of lessthan two years, must have led to difficulty in providing continuity of planning andmonitoring and a tendency to “start again” when a new professional becameinvolved. However, it was positive that many of the family support workers wereinvolved consistently throughout.5.3.2Coordination of the plan was carried out through the child protection meetingswhich were held regularly. The parents and often family members were alwayspresent and this is likely to have inhibited full disclosure of worries and concerns.Professionals had no opportunity to share or voice concerns together outside thatcontext which may have led to some earlier and more realistic appraisal and need tochange the plan given the continuing problems they were having in getting theparents to heed advice and guidance and to learn how to care for Bethany as shewas developing and growing. In separate supervision sessions, there is evidence thatthe social worker and the health visitor were able to voice these concerns. Followinga group supervision session for health visitors in November 2013, the health visitortold the social worker that it was clear that mother’s capacity to parent was notgoing to change however much intervention was in place given her inability toempathise with Bethany. There is evidence in the records but also from thediscussion with practitioners that during the first half of 2014 there was a lack ofsharing of true perspectives on the seriousness of the problems.5.3.3Child protection meetings were held regularly but additional independent reviewwas lacking. The professionals involved attended the child protection meetings and26 | P a g eFinal draft 25/2/2016 updated 18.10.2016consistently supported the family with a range of different services. The childprotection conferences were able to provide some monitoring of progress but thosemeetings could not be the only source of critical challenge. It was encouraging andperhaps over reassuring that the parents and family members attended the childprotection meetings but robust challenge may have been difficult with them presentthroughout. It is clear from the minutes that both the parents and other familymembers would argue away the concerns which were being raised and dispute thefacts. It is of note that the PAMs assessment – an independent assessment – wasawaited and hung over proceedings. There was a high professional focus on theneeds and issues of the parents. The extensive, intensive family support providedcompensated for their lack of basic parenting skill and meant that their parentingcould not be fully tested.5.3.4By November 2014, professionals were clear that Olivia and David were notmanaging to parent Bethany appropriately and it was likely that they would never beable to do so. A Family Group Review Meeting was held at the end of November2014 attended by Olivia, David, her mother and his mother. The continuing concernsof professionals were shared. The need to identify alternative carers for Bethanywas discussed if it was found that the parents were not capable. The view agreedwas that Olivia would be better able to cope with single parenting with additionalsupport than David would. This seemed to be at variance with the evidence from thepast year that David had provided most of the hands on care to Bethany.5.3.5The last child protection conference was held but the PAMS was still awaited. Thechild protection conference held in mid-December was attended by the author ofthe PAMs assessment though he did not share the details of it. The Chair’s view wasthat the parents had engaged with the plan and worked with professionals but notedthis had only really been since the commencement of the pre-proceedings process.As in previous meetings, Bethany was said to be developing well and reachingmilestones despite two falls, David was said to be providing most of the care.Concerns about David’s drinking and the parents’ ever deteriorating relationshipwere also discussed. It is not clear why the PAMs report was not made immediately27 | P a g eFinal draft 25/2/2016 updated 18.10.2016available at that point because, if it had been, it is clear that the court proceedingswould have been started in December; instead a rather uneasy conference occurredin the face of uncertainty and a lack of clarity about the next steps. Olivia said shewas going to work in a pub over Christmas which she duly did leaving Bethany withDavid as well as Scott for a period. A review PLO meeting date was set for 26thFebruary 2015 which seemed to be a long gap given the high levels of concerns andthe local authority’s intention to remove Bethany from her parents’ care.5.4ASP 4. An appropriate response was made once the specialist assessment wasreceived. PAMS received - Care Proceedings initiated. Full range of placementoptions needed to be presented. (January to March 2015)5.4.1It was not until the end of January that the PAMs report was received and sharedwith parents. During January core group and family group meetings were held. Davidand Olivia were still living together in the house. There were signs of deterioratingcare of Bethany with dirty milk bottles left out and Bethany being left alone in herroom for extended periods. Bethany was heard growling when she wantedsomething rather than seeking to speak which is likely to have indicated that she wasdistressed. On another occasion, Bethany was purple with cold and mother had to beprompted to put clothes on her. David was depressed, on medication and drinking.There was conflict between the parents. The situation was not improving and thereceipt of the PAMS report led to the decision to go to court.5.4.2Planning for the court proceedings and the evidence required seems to have beenlimited by the delay in receipt of the PAMs. The case was presented on the basis ofthe PAMs assessment and the social worker’s statement. Despite discussions inNovember 2014 about the need to investigate alternative family carers this waspartially but not fully completed - no viability assessments had been completedthough some discussions had occurred. Given that the local authority was seeking anInterim Care Order and for Bethany to be removed from her parents’ care this wasan omission. It led to the Judge making an adjournment and contributed to theJudge’s decision not to remove Bethany on 20th March 2015 even though sheacknowledged that there was evidence that she was suffering harm.28 | P a g eFinal draft 25/2/2016 updated 18.10.20165.4.3There had been active engagement by the local authority with the extended familyand four family group conferences had been held but it is not clear that this wasbrought to the Judge’s attention. In the search for alternative carers, on the 9thDecember 2015, father informed the social worker that paternal grandmother wasunwell with leukaemia. Maternal grandmother offered to have Bethany on a shortterm basis but could not do so long term because her husband had Parkinson’sdisease. Mother had not spoken with her brother and his partner for nearly a yearand when they were put forward as potential carers, on the 4th March 2015 theydeclined to be assessed because they said they had their own children to care forand had a poor relationship with Bethany’s mother. However, they then appeared atcourt with her on the 11th March 2015 and signed the written agreement saying theywould initially visit her every day for two hours. Despite these approaches to theextended family, the outcomes of these approaches and formal viability assessmentswere not written up or presented to the court. Options for placing Bethany withfamily members were therefore not fully explored, though there had beendiscussions with family members, and the court was only presented with the optionof removal from mothers’ care with no familial option as a result.5.4.4It may be that the Judge had only limited time to read and acquaint herself with allthe papers prior to the hearing but it may also be that the local authority did notpresent strongly enough at court how much communication there had been withfamily members about providing alternative care for Bethany. The Guardian alsoidentified that there was no cognitive capacity assessment of the parents but onlythe PAMS parenting assessment. These issues resulted in further delay and interimdecision-making in relation to Bethany. The court was provided with a positivedevelopmental assessment, drawn from a developmental checklist, by the healthvisitor which did not identify any concerns about Bethany’s development and thiswas out of kilter with the local authority’s opinion and the Guardian’s observationsof Bethany when she visited the family.5.4.5The Guardian visited Bethany at home and was very concerned about her lack ofspeech, and her positive interaction with a professional in contrast to her response29 | P a g eFinal draft 25/2/2016 updated 18.10.2016to her parents; the home was cold and untidy. When her mother shouted, Bethanywas said to have been very frightened.5.4.6 The first Court hearing before Lay Judges on 11th March 2015 was adjourned. TheGuardian supported the application for an ICO because she was concerned aboutmother’s interaction with Bethany. The maternal family proposed providing moresupport and the Guardian having spoken with the Child’s solicitor changed her mind.The Guardian was a new and inexperienced Guardian and the Child’s solicitor wasvery experienced and highly regarded by the court. Bethany was to stay with Oliviawhilst the family put together support with the local authority and David was tomove out.5.4.7No witness evidence was taken by the court. During the period between the first andsecond hearing on 20th March 2015 – 9 days in total - various concerns about thequality of care were noted. Bethany was cold, Olivia had to be prompted to feed her,the baby was left alone in room with a large television and mother did not respondwhen Bethany hurt herself. Comments were made by the Health Visitor that thewider family were minimising the impact of the couples’ cognitive deficits in relationto the parents’ functioning on a day to day basis. The court did not agree Bethany’sremoval into care and a support package was agreed with the extended family.5.4.8 It was appropriate for the Guardian to take account of the advice given but she alsoneeded to consult with her manager when it was clear that her professional view ofwhat she had seen at the home and of Bethany did not accord with the solicitor’sadvice. It is always more difficult to justify removing a child in cases of neglect butthere was in this case such a long history here of no progress by parents, of emergingbehavioural problems in the child and the Guardian’s own initial analysis of thechild’s lived experience.5.5ASP 5. The plan made at Court faltered but the Court was not informedimmediately as the Judge had requested. (March to April 2015)5.5.1Some high risk behaviours by mother were recorded but there was no immediatereturn to Court. These behaviours showing that she continued to find it impossible to30 | P a g eFinal draft 25/2/2016 updated 18.10.2016prioritise Bethany’s needs, were noted after the court hearing. These have been setout earlier in this report. In particular, on 31st March 2015, Olivia said that she wasworried about her feelings for Bethany. Legal advice was sought by the social workerand it was agreed that the social worker should prepare a fresh statement to updatethe Court.5.5.2On 9th April 2015, two days before Bethany’s death, the extended family memberswho had told the court they would support the plan decided to withdraw from thesupport plan. The social worker who spoke to a duty solicitor said that the Judge hadbeen clear that if there were any issues with this plan the matter was to be returnedto Court. Although the solicitor informed the other parties about what had happenedand confirmed the local authority would be seeking to return this matter to court,there was no response to these emails. It does not appear that the court wasinformed of the failure of the plan; it is not clear why this did not happen but theemphasis which the Judge placed on her being informed if the plan failed as soon aspossible may not have been fully appreciated. On 10th April 2015 the day beforeBethany died, Olivia told the family support worker that she had agreed for Bethanyto be adopted. Given this and other continuing concerns, children’s servicesintended to return to court the following week. Her death over the weekend couldnot have been predicted.6.FindingsFourteen findings or underlying patterns, in the management of the case have beenidentified. These have helped the panel and the reviewer to understand why some practiceshappened in the way they did. Each of the findings is explained with a rationale, anindication of its impact on the wider systems in Central Bedfordshire and a series ofrecommendations follow to enable the Board to strengthen safeguarding by addressing theroot causes underpinning the finding.There was much positive effort and good practice in this case to provide support to theparents and to keep Bethany safe. There are also some areas for further consideration anddevelopment.31 | P a g eFinal draft 25/2/2016 updated 18.10.2016The findings fall into different typologies of systems issues, with a clear link betweeneach of the findings and each of the typologies. This is not unusual, as it would be expectedto find links between findings when adopting a whole systems approach. There are fourteenfindings for the Board to consider, these are:Patterns of Management of Systems1. The concerns about whether Olivia and David would be able to care were identified atan early stage. Early help was provided soon after she saw the midwife and later afterthe birth when problems arose, child protection processes and additional supportwere used to keep Bethany safe.1.1 The ante-natal midwife identified the vulnerability of both parents and referred herconcerns on. An assessment was completed and a detailed plan was put in place toprovide support to the parents prior to birth.1.2 Pre-birth early help and ante-natal support tailored to their needs was provided tothe family. Mother was able to attend a parenting group. Both parents were in touchwith the children’s centre. The need for specialist assessments of parenting capacityand cognitive functioning was identified at an early stage.1.3 Midwives and the health visitor provided advice and support and additional visitingwhen the baby was born. Additional visits were made and every effort was made toensure that the parents understood and followed the advice given.1.4 When the parenting difficulties were identified, there was a very high level ofprofessional engagement. High levels of support were provided, the child protectionprocesses were followed with regular case conferences and core groups being held.2. The assessment of parental capacity and motivation is an essential requirement tokeep children safe. When parents have learning difficulties or other particularneeds, it is important to use specialist tools to assess their cognitive and practicalparenting skills. In this case, there appears to have been a lack of a clear system forsuch specialist assessments. This resulted in a cognitive assessment not beingcompleted and delay in achieving a clear assessment of the parents using the PAMstool.32 | P a g eFinal draft 25/2/2016 updated 18.10.20162.1 Although it was realised that additional expertise and assessment were required,there was a lack of a clear system and arrangements for these to be delivered in atimely manner. There was no clear interagency pathway for a specialist parentingassessment geared to addressing the needs of parents with learning difficulties. As aresult, there was delay in commissioning and undertaking of specialist parentingassessment and access to learning difficulty expertise.2.2 The system for joint working between adults’ services – in the LA and in Health - andchildren’s services in relation to parents with a learning difficulty was not clearlydefined. Expectations were not clear and there is evidence that the overridingrequirements of child protection should be the primary focus for all.3. The management of cases of neglect and measuring its impact is challenging. In thiscase, child-centred timescales were not set or imposed for parental improvement.3.1 There is no evidence throughout the life of the case that either parent was able toretain and put into practice this advice in any real or sustained way.3.2 Professionals compensated for the parental shortcomings and carried on trying to dotheir best for the child. There was a lack of testing at some points of how wellparents were really coping.3.3 The family were dependent on the professional support which acted as a safety netand as a buffer seeking to ensure Bethany’s needs were being met.4. There was a discrepancy between the view of the Court and that of the LocalAuthority about the urgency to bring Bethany into care. The Guardian initiallysupported the local authority position but probably, through her inexperience as aGuardian, changed her mind after conversation with the child’s solicitor; followingher visit to the family home on 10.3.2015, the Guardian spoke to child’s solicitorabout her observations and concerns. The Guardian later stated that the child’ssolicitor had said “…there was not enough information to remove Bethany, he saidwhat I had seen was a short snapshot of a day and the parents would argue this wasnot reflective of their general care of Bethany.” The child’s solicitor held to his viewand the Guardian acquiesced. In her report, the Guardian did not reflect acompelling analysis of her opposition to the local authority plan probably because33 | P a g eFinal draft 25/2/2016 updated 18.10.2016she was conflicted about supporting the plan for the child to remain with mother.The child’s solicitor is very experienced and was of the view that there wasinsufficient evidence for the child to be removed at this stage of the proceedings.The court system as well as time constraints for the Court did not require or enabledirect evidence to be heard from the local authority or the Guardian even thoughthere was no consensus amongst the parties about the action required.Patterns of Professional-Family interaction5. The vulnerability and needs of the parents were considerable. Professionals tendedto be parent–focused and at times they were distracted by parental excuses andexplanations about why they were not following the advice given to them. Thismeant that the impact of the parental behaviours on Bethany was not alwaysobserved or responded to.6. The parents and members of the extended family were involved in child protectionmeetings and in family group conferences and every effort was made to engagethem. Father was explicitly involved by professionals; he was visible and generallycooperative. He was very actively involved in caring for Bethany and professionalsperceived this and supported him. Considerable efforts were made to engage with,and involve, the extended family through Core Groups and Family Groupconferences.7. The contribution of the extended family involvement was not fully tested andseems to have been over-relied on in planning.8. Professionals engaged very positively with Bethany and sought to provide her withpositive stimulation. They did this by modelling good parenting to the parents butunfortunately the advice was not followed when Bethany was solely in the care ofher parents.Patterns of Professional Bias9. The professionals in each agency who were involved with the family lacked thespecialist knowledge and expertise to work with adults who had learning difficulties.34 | P a g eFinal draft 25/2/2016 updated 18.10.201610. Given that Bethany was such a young child and that there was almost dailyinvolvement with her, it appears that it was not easy for professionals to identifythat her development was being impaired. The developmental summary providedto the Court by the health visitor suggested that she was developing within normallimits; when the Guardian visited the family at home with a fresh pair of eyes shewas immediately concerned about Bethany’s development, lack of speech and heranxious response to her mother. In fact, the professionals who were in frequentcontact were concerned and frustrated that intervention did not occur sooner.11. There is also an indication that agencies were not always sufficiently challenging ofeach other over several months of concerns about the care of Bethany, the lack ofimprovement in her care and the parental shortcomings. The presence of thesevulnerable parents and other family members may have impacted on how preparedprofessionals were to discuss concerns. There were also several changes of socialworker and this is likely to have hampered planning, monitoring and consistentconsideration.12. When the assessment of the parents’ capacity was being considered by an adults’service, there is evidence that a focus on equalities considerations in relation to thelearning disability and difficulties of the parents’ needs and rights of parents mayhave taken precedence over the needs of Bethany. For the most part this was notthe case but there was at that point a focus was on Parents’ Rights rather than theirParental Responsibilities. A cognitive assessment requested from one agency wasnot provided because there was no agreement that this should be provided by thatagency and because it was seen as “detrimental to parents”.Patterns in Multi-Agency work13. Agencies worked together through the child protection process to try and ensurethat she was kept safe and that her welfare was being promoted. Child protectionprocesses and plans were in place and regular reviews and monitoring of progresswere carried out.35 | P a g eFinal draft 25/2/2016 updated 18.10.201614. When the child protection plan was not keeping Bethany safe, legal advice andaction was taken. Legal advice was regularly sought and prompt responses wereprovided. When the plan was faltering in April 2015, the social worker contactedLegal straightaway and there were plans made to have a new working plan inpreparation for Court.7.Conclusions and Summary7.1Bethany was a very vulnerable young child who was totally dependent on herparents for her care and safety.“Babies are almost entirely dependent on their immediate caregivers. A parent’scapacity to respond appropriately to the motions and needs of their babies has aprofound impact. Becoming a new parent is a major transition; there are times whenevery parent feels under pressure and may struggle to cope with the stresses andresponsibilities of their role. But, for very young parents, or parents facing additionalchallenges in their lives such as mental illness and domestic abuse, this can be aparticularly difficult time.”NSPCC 2011 All Babies Count7.2 Both Bethany’s parents had experienced troubled childhoods. Both her parents havelearning difficulties and appeared to find it very difficult to put Bethany’s needs firstconsistently. There were concerns about both parents’ stated learning difficultiesand the impact of this on their capacity to parent Bethany, to keep her safe and topromote a thriving and happy childhood for her. There were reports of violence inthe relationship and issues with alcohol for both parents, but in particular David.7.3 It seems that the stress of parenting led to difficulties for them in caring safely forBethany. Unfortunately, in many respects and, for some time, they presented asappropriately committed to caring and cooperated well with a wide range ofinterventions designed to develop and improve their parenting capacity. Theintensive support provided by services as well as the support of extended familymasked the real difficulties they were experiencing and the impact this was having36 | P a g eFinal draft 25/2/2016 updated 18.10.2016on Bethany. In reality, they were not coping with caring consistently for Bethany andas her needs for stimulation grew, they struggled even more.7.4 There was much positive practice in this case. The midwife rightly identified thepotential vulnerability of Bethany’s parents before she was born. She providedadvice to them and informed other health professionals of the possible need foradditional support when the baby was born.7.5 A whole raft of support was provided through the FISS service with a considerablecommitment from all those staff who were involved. It was clear at the practitioners’event how much effort had gone into trying to do the best for Bethany.7.6 It is clear that the difficulties which Bethany’s parents experienced in caringconsistently and safely for her were predicted. Significant levels of support wereprovided to them but their capacity and willingness to respond were not alwayssufficient. When it became increasingly clear that they could not parent Bethanyeffectively, the LA sought to remove her.Summary view:7.7 Every effort was made by all the agencies involved to keep Bethany safe, it is unlikelythat her death could have been prevented. It was also not predictable to anyone as itwas believed that she was not at immediate risk and that the wide range of serviceinvolved could protect her.7.8 It is very clear that all the professionals who were involved with Bethany and herfamily did their utmost to help her parents to care for her and to keep her safe.There was a strong commitment from staff and evidence of exceptional efforts beingmade to support the family.7.9 The demanding behaviour of the parents, their learning difficulties and othervulnerabilities led on some occasions to there being an over-focus on their needsrather than Bethany’s. Again, professionals wanted to give David and Olivia every37 | P a g eFinal draft 25/2/2016 updated 18.10.2016opportunity to succeed. The Chair of the child protection conferences has said thatstaff were: -“so keen not to penalise them both for their learning difficulties, and to ensure theirright to family life, that we may have at times lost sight of Bethany’s needs andrights” (IRO1).7.10 This happened despite a clear awareness and intention to be child-centred.Professionals and the Court at times lost sight of the fact that every parent has aparental responsibility towards their child. There are rights as adults - including theparticular rights of an adult with a disability - and the right to enjoy a family life.However, children also have rights which in law are paramount and the parents holdparental responsibility for the child. In Court the risks and harm to Bethany were notregarded as immediate and there was a concern that her family should have everyopportunity to care for her. The right to family life principle was an important factorin the Judge seeking to involve the extended family and in not agreeing to removeBethany.7.11 Bethany’s needs and experience tended to be “lost” in the focus on her parents’needs and issues and the life of the family. An enormous amount of time, resourcesand effort were expended to support the parents and to involve the extendedfamily. The high level of need of the parents distracted the professionals. Theoutcome was that professionals tend to compensate for the parental neglect ofBethany and they were making the best of what was not very good.7.12 Meanwhile both parents – but particularly mother - tended to fall in line when shehad to and feign compliance with the advice given. There is no doubt that motherhas learning difficulties and she did struggle to retain information but an elementof her just not wanting to bother was observed by professionals. It seems that shehad little capacity to tune into Bethany’s needs or to empathise with her. Thesituation was that Olivia had some potential to care for Bethany but she found ithard to do so consistently and it seems that she had her own preoccupations andwas easily distracted from caring for Bethany. Olivia was not able consistently toprioritise caring for Bethany over considering her own needs and preoccupations.38 | P a g eFinal draft 25/2/2016 updated 18.10.2016The history of her inability to care for Scott had previously demonstrated that shedid not have the capacity to live independently and care for a child.7.13 Although David provided a significant amount of care to Bethany, he did struggle,frequently questioned his ability to care and is unlikely to have been able to carealone and without significant prompting and guidance. He was willing and helpfuland loving and caring but just was not able to manage care of Bethany due to hislearning difficulties.7.14 It seems that Bethany’s needs were never wholly met by Olivia and David. Oliviamanaged for two or three weeks when Bethany’s needs were more straightforwardto meet. As Bethany developed the amount of information, guidance and supporther parents required in order to meet her emotional needs and need forstimulation grew exponentially and both Olivia and David struggled. Theprofessionals became increasingly frustrated about the lack of progress andapparent effort made. In addition, David and Olivia’s relationship becameincreasingly strained, Olivia bought a large dog and David became more stressedthrough hearing of his father’s serious illness and Olivia’s behaviour towards him.7.15 The neglect Bethany suffered was an insidious threat to her which she hadexperienced in varying degrees throughout her life. It was known that her parents’care was neglectful and it was also known that this was affecting aspects of herbehaviour and development. The extended family knew that Olivia and David hadsignificant difficulties in caring though it seems they underestimated how risky thesituation was for Bethany. The extended family sought to help Olivia and Davidattending child protection meetings, calling in occasionally and finally, reassuringthe Court that they could manage to keep Bethany safe. However, in reality thecouple needed more help than they could provide and within a week or so, theextended family withdrew much of what they had agreed to provide.7.16 After such long and intensive involvement and support to the family, it was right forthe local authority to seek to remove Bethany from her parents’ care in March2015. The indications were that they would never cope either singly or togetherwith Bethany’s increasing needs. Once the plan agreed at Court had faltered, the39 | P a g eFinal draft 25/2/2016 updated 18.10.2016local authority needed to inform the Court and return the matter to court as soonas possible. The social worker was preparing a statement for this to occur. Theimmediacy of the risk could not be foreseen. Unfortunately, such is the insidiousand unseen impact of neglect that it can result in long term serious affects as wellas immediate suffering and even death. The impact of this immediate suffering isnot always fully appreciated. The death of Baby Paul, aged 15 months, in Islingtonin 1994 which was the subject of an independent investigation, clearly evidencedthat severe neglect of a very young child may be fatal.8.Recommendations for LSCB to consider and action8.1Each of the agencies involved with the family has identified a number ofrecommendations. The implementation and impact of these actions will bemonitored by the Central Bedfordshire Safeguarding Children Board.8.2In addition, the following recommendations are made to the LSCB. They reflect thekey learning from this review. The Central Bedfordshire Safeguarding Children Boardshould: Ensure that the following are in place and monitoring the effectiveness ofthe arrangements for: -8.3Parental assessment processes (single and multi-agency) including consideration ofparticular circumstances such as parental learning difficulty, domestic violenceshould be reviewed and updated.8.4Identifying and responding to neglectful care – both physical and emotional neglect.8.4 a. Develop and implement the neglect strategy. The role of the Police and theprocess for the collation and presentation of multi-agency evidence particularly inrelation to cases of neglect should be included in the strategy.8.4 b. Ensure staff are trained together across agencies to implement the GradedCare profile system and to make sense of all the information available whilstmaintaining a focus on the needs of the child.8.4 c. Promote the use of professionals’ only meetings to measure and reviewconfidentially progress or lack of it in relation to individual cases of neglect.40 | P a g eFinal draft 25/2/2016 updated 18.10.20168.4.d. The significant and possible fatal impact of severe neglect and absence of carefor a very young child should be kept in mind within the interagency management ofcases of neglect.8.5Develop working links with the Family Justice Board so that the LSCB canunderstand, influence and support the Court’s work with children in public andprivate law proceedings.8.5.a This should include sharing of the local approach to neglect using the GradedCare Profile tool with the local Family Justice Board.8.5.b The expectations of both the Judiciary and of the local authority and otherpartner agencies in relation to the presentation of evidence and of making the casefor legal intervention and action should be shared.8.6There is a need to clarify standards and expectations for joint working arrangementsbetween children’s and adults’ services along a continuum from support /advice todirect joint working but above all to ensure that the paramountcy of the child’sneeds is the guiding principle.8.7Oversight of Child protection cases. Ensure that additional multi-agency challengeprocesses are established for all children subject to a child protection plan for morethan 9 months.9.Next steps - Progress Report / Learning9.1Since this review was established a number of measures have been put in place torespond to the learning from the case.There are now new threshold documents and a robust pre-birthassessment template and process in place.A new strategy for managing cases of neglected has been implemented.9.2A further LSCB response is attached to this report outlining further progress whichhas been made.42 | P a g eFinal draft 25/2/2016 updated 18.10.2016Appendix A - Family and Significant others and GenogramAppendix B - Scope and Full Terms of ReferenceTerms of ReferenceSERIOUS CASE REVIEW CHILD – BETHANY FISHERIntroduction:Bethany Fisher was an open case to Central Bedfordshire Council, Children’s Services andhad been subject to a Child Protection Plan since October 2013 for concerns about neglect,domestic violence and parental capacity to care for her. Both Bethany’s parents are believedto have a learning difficulty. Following concerns about domestic abuse within the parents’relationship Bethany’s father was asked to leave the family home.A legal planning meeting was held in October and Care Proceedings issued in February 2015following an independent assessment which concluded that Bethany’s parents were notable to meet her needs. Although application was made to remove Bethany from herparents’ care this was not agreed. The case was adjourned on the 11th of March 2015 foralternative placement options within her family to be considered. An intensive supportpackage has been in place which included daily support visits from her family andunannounced visits by the social worker and Family Intervention Worker.Bethany was found to have died on 11 April 2015 while at home in the care of her mother.Bethany was reported to be found in her room in an open cot bed with a nappy on. Thenappy was later found to weigh one pound which was estimated to be two full bladders ofurine. On her mother finding Bethany dead at approximately 1.45pm Bethany’sgrandmother called the ambulance. The ambulance staff who attended advised thatBethany had been dead for some time, the room was hot, there was vomit on the bed andBethany was found at the bottom of the bed with her head hanging over the end of the bed.At post mortem the cause of Bethany's death was given as inconclusive although it is knownthat there were signs of brain swelling and vomit in her lungs.Decision for Serious Case ReviewBethany’s case was referred by Central Bedfordshire Council, Children’s Services on 13 April2015 as she had died in her mother’s care and neglect was known to be a factor within hercase history. Her case was considered by the CBSCB Case Review Group on 15 April 2015and it was agreed that the criteria for a Serious Case Review were met under Regulation44 | P a g eFinal Draft 18/10/20165(2)a and b(i). Alan Caton, Independent Chair, agreed a Serious Case Review must always becarried out in these circumstances. Agencies have been formally notified that a Serious CaseReview is in progress as well as Ofsted, Department for Education and the National Panel.Principles and ApproachThis review has been commissioned in accordance with the new statutory Working Together2015 which came into effect on 26 March 2015. It is therefore being conducted under theguidance at Chapter 4, Section 18 of Working Together (2015)The purpose of a Serious Case Review is to:establish what lessons are to be learned from the case about the way in which localprofessionals and organisations work individually and together to safeguard andpromote the welfare of childrenidentify clearly what those lessons are both within and between agencies, how andwithin what timescales they will be acted on, and what is expected to change as aresult; andrecognise good practice and improve intra and inter-agency working and bettersafeguard and promote the welfare of children.Serious Case Reviews should be conducted in a way which:recognises the complex circumstances in which professionals work together tosafeguard children;seeks to understand precisely who did what and the underlying reasons that ledindividuals and organisations to act as they did;seeks to understand practice from the viewpoint of the individuals andorganisations involved at the time rather than using hindsight;is transparent about the way data is collected and analysed; andmakes use of relevant research and case evidence to inform the findings.LSCBs may use any learning model which is consistent with the principles within workingTogether (2015), including the systems methodology recommended by Professor Munro.For this review it has been agreed to conduct a systems methodology with a Lead Reviewer.The Lead Reviewer will also chair the Serious Case Review Panel. Following a commissioningprocess, the Lead Reviewer has been confirmed as Amy Weir (MA MBA CQSW).The agencies involved in a Serious Case Review should draw up Single Agency LearningReview Reports. These should be based on a comprehensive chronology of involvement by45 | P a g eFinal Draft 18/10/2016the organisation and/or professional(s) in contact with the children and family over theperiod of time set out in the review’s terms of reference.This chronology should clearly set out when the children were seen and, where ageappropriate, whether the wishes and feelings of individual children were sought. Theyshould briefly summarise decisions reached, the services offered and/or provided to thechildren) and family, and other action taken.The Individual Management Review should consider the events that occurred, the decisionsmade, and the actions taken or not taken. Where judgements were made, or actions takenindicate that practice or management could be improved. This information will be utilisedand considered at a practitioner learning event to get an understanding not only of whathappened but why something did or did not happen. The nature of supervision acrossagencies should be addressed alongside frontline practice.The historical information and the actions or inactions of agencies should be consideredalongside the findings, recommendations and actions taken in response to other relevantlearning reviews conducted by CBSCB. New recommendations should only be made wherethere are significant differences in the findings from this review. This should be made clearin the overview report.The commissioning and production of Single Agency Learning Review Reports must followthe CBSCB guidance with particular attention being given to SMARTER recommendationsand a comprehensive action plan. The Serious Case Review will identify good practice bothin the Single Agency Learning Review Reports and in the Overview Report.The Single Agency Learning Review Reports and Overview Report will be anonymised byauthors according to the anonymisation grid issued.Key lines of enquiryThe review will consider whether there was information which was known to agencies, orshould have been known, that should have identified that Bethany was at risk of harm. Allagencies should consider the historical information they hold and if there is significantlearning from this it should be appropriately referenced and brought into the review. Thefollowing key lines of enquiry have been identified by the Case Review Group as the focusfor the review:What relevant historical information prior to Bethany’s birth was known to theagencies about the background and experiences of Olivia and David? Was thisinformation effectively shared to ensure that appropriate decisions could be madeto ensure Bethany was protected from any known risks?What was the quality of the multi-agency information sharing, assessment, riskanalysis and decision-making in the reported injuries to Bethany in December 2013?46 | P a g eFinal Draft 18/10/2016Is there evidence that the procedures for injuries to pre- mobile babies werefollowed and was sufficient weight and consideration given to the possible risks toBethany remaining in her parent’s care?Did the professionals working with Bethany and her family have the requiredknowledge, skills and experience regarding the identification of and requiredresponse to possible child neglect, alcohol and substance misuse and domesticabuse? Were there any gaps in practice that may have impacted upon theoutcomes for Bethany?Was there sufficient focus and assessment of the likely impact of the parent’sreported substance and alcohol misuse on their capacity to parent Bethanyeffectively?Was the PAMS assessment commissioned by Central Bedfordshire Council,Children’s Service sufficiently thorough, did it consider all the risk issues and did itresult in appropriate recommendations?Is there evidence of robust assessment and analysis of parenting capacity; apparentlearning difficulties and ability to change that is based on known history as well as thecurrent case presentation?What was the quality and robustness of the multi-agency pre-birth assessment? Didthe decision to close the case accord with the risks identified?Did the assessment of parenting capacity consider sufficiently whether David couldassume the role of main carer for Bethany given his reported stronger emotionalattachment and ability to identify risks for Bethany?Was there professional over-optimism in her parents’ ability to parent Bethany andmeet all her daily living needs and to keep her safe?Was sufficient focus placed on the neglect that Bethany experienced and was thereany consideration of whether it met the threshold for a criminal investigation?How robust was the Child Protection Plan and what evidence is there of how well theagencies involved engaged with the Child Protection Plan? Did agencies believe theplan would keep Bethany safe? If not, is there any evidence of any agency providingeffective challenge and was the escalation procedure implemented appropriately?How effective was the core group in ensuring that the Child Protection plan, processand procedures were adhered to and that the plan provided clarity of expectation andthe timescales for action?Consider how the extended family’s view of family functioning was used in theassessments and risk analysis undertaken.47 | P a g eFinal Draft 18/10/2016Was practice sensitive to the racial, cultural, linguistic and religious identity and anyissues of disability of the child and family, and were they explored and recorded? (Thisshould address any broader aspects of "culture", i.e. housing, benefits, potentialpoverty, and the social and economic environment in which this family lived).Was there sufficient management accountability for decision making?Is there sufficient evidence of robust challenge where there was professionaldisagreement about the best course of action to ensure Bethany was safeguarded?Were all necessary actions taken in this regard? (This should specifically includecomment on the interface between Central Bedfordshire Council Legal Services,CAFCASS and the court in reference to the decision of the judge not to removeBethany from her parent’s care)Were the workers within agencies sufficiently alert to the potential for parents to‘disguise compliance’?Did the needs of Bethany remain paramount throughout the period?With hindsight what, if anything, could have been done differently and what impact, ifany, such action may or may not have had on the outcomes for Bethany?Time period over which events should be reviewedThe scope of this Serious Case Review is from 1st March 2013 to 11th April 2015.Agencies will need to consider the period from 1st March 2013 up to and including 11thApril 2015 the day of Bethany’s death. This time period has been chosen in consideration ofthe date when Olivia’s pregnancy was known to agencies up to an including the date ofBethany’s death.Single Agency Learning Review Reports should cover this time period as a minimum. Wherethere is additional involvement going back beyond these dates (e.g. within Olivia andDavid’s own childhoods) that is relevant to the review agencies should provide a summaryof their previous involvement within the Individual Management Review.Involvement of Family MembersBethany was living with her mother at their family home at the time of her death. BothOlivia and David’s extended family had significant contact with Bethany during her lifetime.At the current time CBSCB is awaiting further information regarding the family members’involvement in any police investigation and whether they can be approached.Should there be information and/or learning to be gained from the involvement orcontribution of Bethany’s family members this will be agreed between Alan Caton as theIndependent Chair and Amy Weir as the Independent Overview Author.48 | P a g eFinal Draft 18/10/2016Amy will facilitate the family contribution liaising with agencies as necessary. Anyrequirement to involve family members will be communicated to Individual ManagementReview authors as necessary who will agree a named lead to take responsibility forcoordinating the contacts with the family. The SCR Panel will keep this under review throughthe process and identify appropriate resources to facilitate the process.Bethany’s parents will be written to by Alan Caton as the Independent Chair to advise themof the Serious Case Review being commissioned and to request consent for access to theirrecords. Should their direct involvement not be appropriate due to parallel proceedingsthey will be contacted again and asked if they wish to contribute their views directly to theIndependent Overview Author or in some other way at an appropriate point in the review?Arrangements will be made to offer them feedback at the end of the Serious Case Reviewprocess. As described above, consideration will also be given to making contact with anyother significant members of the family such as Olivia and David’s extended family.Organisations to be involved in this SCRThe following organisations/services in Central Bedfordshire will be asked to submit SingleAgency Learning Review Reports and will be members of the Serious Case Review panel.Bedfordshire PoliceBedfordshire Clinical Commissioning GroupCAFCASSCentral Bedfordshire Council - Access and Inclusion ServiceCentral Bedfordshire Council - Adult Social CareCentral Bedfordshire Council - Children Social CareCentral Bedfordshire Council - Legal ServicesEast London Foundation TrustNHS EnglandSouth East Partnership University TrustA statement of information will be sought from:Bedford Hospital Foundation TrustCourts and Tribunals Judiciary - Family Court DivisionEast of England Ambulance Service49 | P a g eFinal Draft 18/10/2016Lister HospitalAt this stage it is not known whether there are any relevant interests outside the mainstatutory organisations such as voluntary or independent organisations. If the chronologyidentifies the involvement of such organisations the CBSCB Business Manager will link withinthem as necessary.It is anticipated that agencies will cooperate and fully engage in the process. In the unlikelyevent of a failure to cooperate with the review, this will be initially addressed by the CBSCBBusiness Manager and escalated to CBSCB Independent Chair with the relevant Boardmember or Chief Officer of the agency where necessary.Involvement of organisations in other LSCB areasThere is no known involvement of agencies in other LSCB areas at this stage. Where this isidentified it is the responsibility of the CBSCB Business Manager to bring this to theattention of the Serious Case Review Panel and Independent Chair.Legal AdviceThe use of legal advice will be kept under constant consideration throughout the process ofthe Review.Commissioning of an Independent Author and Panel ChairAn Independent Overview Author and Panel Chair have been appointed who has noprevious connection to the CBSCB, Case Review Group or any organisation that potentiallyshould have been involved in the case. Amy Weir is self-employed and has considerableexperience of working within the safeguarding arena, specifically with LSCBs and conductingSerious Case Reviews. She will draw together all the elements from the Single AgencyLearning Review Reports, offer engagement with the family members and analyseprofessional practice into the Overview Report and Recommendations to the CBSCB. Shewill also provide guidance to the Case Review Group, IMR authors and commissioners onquality assurance of the IMR’s.The Overview Author should follow the guidance within the CBSCB SCR Toolkit using thestandard CBSCB template. Should the Board regard the report to be of poor quality or fail toratify the final report there will be an agreed independent mediation process to resolve theissues. This will ensure that the final report meets the standards required by the CBSCB andalso addresses the pertinent learning.Expert OpinionDue to the issue of adult learning difficulties the use of expert opinion in a consultativecapacity around this issue will be considered throughout the process of the Review.50 | P a g eFinal Draft 18/10/2016Other Parallel ReviewsParallel reviews are as follows:CDOPThe case will be reviewed by the CBSCB Child Death Overview Panel in accordance withChapter 5 of Working Together 2015.Coroner's InquiriesPolice are currently liaising with the Coroner’s Office in relation to their inquiry and at thisstage there are no other known investigations. The timescales for the Coroner’s inquiry arenot yet known but any implications arising from the inquiry will be communicated to theCBSCB Business Office by Central Bedfordshire Police’s nominated representative who willliaise with the Coroner’s office to ensure that relevant information can be shared withoutincurring significant delay in the review process. Where delay is likely the Coroner will beasked for advice on how to address this within the Serious Case Review process.Criminal InvestigationsBedfordshire Police are conducting an investigation into the circumstances of Bethany’sdeath and this is being handled by the Major Crimes Unit. Olivia was recently charged withthe neglect of Bethany and is currently held on remand. The Head of Public Protection willkeep the CBSCB Business Manager informed of any developments and any possible conflictsof interests in relation to this Serious Case Review. The Serious Case Review Panel will havedue regard to the national guidance “Liaison and information exchange when criminalproceedings coincide with Chapter Four Serious Case Reviews or Welsh Child PracticeReviews - A Guide for the Police, Crown Prosecution Service and Local Safeguarding ChildrenBoards”Media coverage/enquiriesThere has been some media interest in this case and statements have been issued byBedfordshire Police. This will be kept under review to ensure that any public, family andmedia interest is appropriately managed before, during and after the review. It has beenagreed within the communications plan that Bethany and other family members will not beidentified. The Serious Case Review Panel is also to give consideration into how Olivia andDavid and other family members will be informed of the findings of the SCR. This will be inliaison with the Chair of the LSCB and Core Business and Improvement Group who willdevelop and implement a media strategy.SCR Timescales51 | P a g eFinal Draft 18/10/2016A timetable has been scheduled according to the attached timeline with dates for thesubmission of the Single Agency Learning Review Reports, Panel meetings, the presentationof the Overview Report to the CBSCB; and the submission of papers to Ofsted is targeted for15 October 2015.Liaison with Ofsted, Department of Education and the National Panel will be by the CBSCBBusiness Manager who will update them on progress with the SCR and liaise where thereare any requests for extensions required (e.g. due to criminal proceedings).52 | P a g eFinal Draft 18/10/2016Appendix C - List of ReferencesBrandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, JaneDodsworth and Jane Black - Analysing child deaths and serious injury through abuse andneglect: what can we learn? A biennial analysis of serious case reviews 2003-2005Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious casereviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis &Matthew Megson - University of East Anglia & University of Warwick – July 12: New learningfrom serious case reviews: a two year report for 2009-2011Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – 2013Department for Education - Safeguarding Children in whom illness is fabricated or induced -2008DH 2011 Health Visitor Implementation Plan: A Call to ActionDH Healthy Child Programme 2009Islington Area Child Protection Committee (1995) – Independent review by The Bridge of thedeath of Baby PaulNSPCC 2011 - All Babies CountOfsted 2014 – In the child’s time: Professional responses to neglectOfsted 2015 CIN assessments thematicPAMS Parenting Assessment Manual Software Sue McGaw – need a footnote for this.Revised Ed 2014 first published 1998. Assesses parenting basic skills.Can Parents with LD parent? 1. Purposeful abuse infrequent by parents (Booths, 2005;Whitman 1994)2. Neglect -omission not commission (Booths, 2005; Tymchuk& Andron,1990)3. Parental Risk Factors: Cognitive functioning & ability to learn(Tymchuk, 1992;Feldman, 1997) |
NC50692 | Disclosure of abuse and asking to be taken into care by 16-year-old female child, who had been living with her mother, step-father and half siblings in March 2016. Extensive contact with various services during much of Madison's childhood for slow physical growth and speech development; records describe hair pulling, faltering growth and frequent absences from school and minor or unexplained injuries, looking underweight and frequently hungry. Her birth father died of a heart attack when Madison was an infant. Mother disclosed to GP that she did not love Madison. Children's social care were involved over a period of years identifying Madison as a child in need; section 47 enquiries were undertaken. In February 2016, the school nurse received a chronology of extensive child protection concerns from March 2003 to February 2016. Madison was taken into foster care in March 2016. The family are White British. Learning includes: the need to distinguish between behaviour that might indicate cruel rather than neglectful care; children more readily disclose information to adults such as teachers or health practitioners with whom they can trust; professionals must be aware and sceptical about how parents may seek to influence how information is processed; recognition and response to self-harm. Investigatory model for collating information with analysis using elements of a learning review model. Recommendations to the LSCB: to ensure the voice of the child is sought by professionals to appropriately inform judgements and decision making during enquiries and assessments; to ensure that chronologies are appropriately collated and analysed to inform judgements and decision making when concerns are raised in regard to child abuse.
| Title: ‘Madison’ (SCR PN16): the overview report. LSCB: Nottinghamshire Safeguarding Children Board Author: Peter Maddocks Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 58 A serious case review under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 ‘Madison’ (SCR PN16) The overview report Commissioned by the Nottinghamshire Safeguarding Children Board February 2018 Page 2 of 58 Contents 1 Introduction ................................................................................................... 3 1.1 Context of the serious case review ............................................................... 3 1.2 Rationale for conducting the serious case review............................................ 4 1.3 The methodology and scope of the serious case review ................................... 5 1.4 Information about Madison and the family .................................................... 7 2 Summary of contact by services and significant events ........................................... 8 2.1 Summary prior to November 2012 ............................................................... 8 2.2 November 2012 and discussion of a CAF ..................................................... 12 2.3 Disclosures at school and self-harm ........................................................... 12 2.4 Decision to undertake section 47 enquiries and social work assessment ........... 13 2.5 Madison goes missing from home .............................................................. 15 2.6 Madison identified as being a child in need ................................................. 15 2.7 Paediatric review and referral to CAMHS .................................................... 16 2.8 Further disclosures of self-harm and abuse ................................................. 16 2.9 Children’s social care withdraw and mother declines CAMHS involvement ........ 17 2.10 Anonymous referral of concern about Madison ............................................ 17 2.11 CAMHS consultation identifies concerns in absence of children’s social care ...... 18 2.12 Disclosures of self-harm and allegations of physical abuse in 2015 ................... 19 2.13 Referral to MASH and social work assessment ............................................. 21 3 Appraisal of professional practice in this case ..................................................... 25 3.1 Voice of the child and their personal history and identity ............................... 26 3.2 Contact, request for service and enquiries ................................................... 28 3.5 Managing parental control, disengagement and resistance ............................ 33 3.6 Communication between professionals and use of local multi-agency frameworks 35 3.7 Quality of assessment and plans ................................................................ 36 3.8 Use of the local escalation processes .......................................................... 38 4 Analysis of key findings for learning and improvement ......................................... 40 4.1 Chronology and history as context for enquiries and assessment ..................... 41 4.2 Balancing the needs and views of the child and parents ................................. 42 4.3 Child focussed enquiry and assessment and dealing with competence ............. 44 4.4 Promoting opportunities for the views, wishes and feelings of children to be explored and understood ................................................................................... 45 4.5 The learning and improvement for the Nottinghamshire Safeguarding Children Board to consider ............................................................................................. 47 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry: .................................................................. 48 Appendix 2 Membership of the case review team ...................................................... 49 Appendix 3 Ten pitfalls and how to avoid them ......................................................... 50 Appendix 4 Biographical summary of the independent reviewer ................................... 51 Page 3 of 58 1 Introduction 1.1 Context of the serious case review 1. This serious case review examines the professional support given to a female child between the 1st November 2012 and March 2016, who for the purpose of the review is referred to as Madison. 2. There is no single index incident or event that triggered the review. Madison made disclosures/allegations of abuse and asked to be looked after by the local authority in March 2016 aged 16 years old. Madison had been living at home with her stepfather, mother and half-siblings. 3. There is a history of contact with several different services. For example, schools recorded concerns about Madison over several years dating back to primary education and had convened a number of multi-agency meetings and made referrals to children’s services who had undertaken five assessments in 2003, 2006, 2008, 2010 and 2012. The GP service also had considerable contact over several years. In November 2012 the community paediatrician made a referral to CAMHS (child and adolescent mental health services) in relation to bullying, self-harm and grief reaction following the death of Madison’s birth father (in 2000) and queried the possibility that Madison was experiencing emotional abuse. 4. Enquiries by the police and local authority in March 2016 involved Madison’s four half-siblings being placed with relatives and Family Court proceedings were initiated. Those proceedings were ended in April 2017 when Madison’s half-siblings returned to live with mother and Madison’s step-father. Madison was not a party to those proceedings having been deemed old enough to consent to being looked after by the local authority without the consent of a parent or a court order. 5. Following a parallel criminal investigation by the police a file was referred to the Crown Prosecution Service (CPS) in the spring of 2017. A review of the evidence by a barrister resulted in the CPS declining a prosecution in March 2017. The reason for declining the prosecution and the factors that were considered are not disclosed to a third party including to a serious case review. The CPS are required to assess whether there is enough evidence for ‘a realistic prospect of conviction’. This means that magistrates or a jury are more likely than not to convict. If a conviction is judged less likely, then no matter how important or serious the matters might be, a charge cannot be authorised. 6. A copy of the detailed narrative history was made available to the police senior investigating officer together with a request that the CPS were also given access to the information and asked to confirm that there was no additional information not previously considered by the police or the CPS. 7. The serious case review has no role in the parallel procedures and does not investigate allegations. The role of the review is to analyse the quality of the professionals’ Page 4 of 58 response to information for the purpose of learning and development as it applies to events from November 2012. 8. In compliance with government guidance set out in Working Together to Safeguard Children (2015), the review addresses whether the concerns being raised by professionals were enquired into and assessed with an appropriate level of rigour and whether there are lessons to improve future arrangements and inter-agency working and to better safeguard and promote the welfare of children. 9. For the purpose of clarity the use of acronyms is kept to the minimum. Family members are referred to by their relationship to Madison such as mother, stepfather or half-sibling. Madison has four half-siblings all of whom are younger. The eldest sibling is Sibling 1 and the youngest of the four siblings is Sibling 4. The respective ages of the four half-siblings in March 2016 was 14, 12, 11 and 9 years old. Professionals are referred to by their roles such as teacher, school nurse, GP, police officer or social worker for example. 10. There are four schools referred to in this report that Madison attended at different times from 2004. The first three are primary schools. Madison attended School 1 from February 2004 until April 2005 when she was transferred at her parents request to School 2 until September 2006 when she was again moved at her parents request to School 3 before Madison transferred to secondary School 4. 1.2 Rationale for conducting the serious case review 11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires local safeguarding children boards to undertake a review in accordance with the criteria and procedures that are set out in chapter four of Working Together to Safeguard Children (2015). 12. A local safeguarding children board should always undertake a serious case review when a child has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the local safeguarding children board or other relevant persons have worked together. 13. The circumstances of Madison’s allegations and disclosures were discussed by the serious incident review sub group of the Nottinghamshire Safeguarding Children Board on the 15th June 2016. The panel agreed that the criteria for a statutory serious case review were met. Madison appeared to have suffered emotional and physical abuse over several years and there were issues to be examined in regard to what different organisations had known about Madison. There were concerns also that physical signs that could have been indicative of abuse were not recognised and that along with the evidence of emotional abuse and physical injuries had been insufficiently understood and enquired into. 14. The recommendation was ratified by Chris Few, the independent chair of the Nottinghamshire Safeguarding Children Board, on the 24th August 2016. Page 5 of 58 15. The expected timeline for completion of a serious case review described in national guidance is six months from the date of commissioning. The timeline for completion of the review is determined by the independent chair of the local safeguarding children board who can take account of factors that may have an impact on the timeline. This includes parallel processes such as the police investigation of the circumstances of Madison’s disclosures already described at the start of this report. 16. This had implications for being able to schedule discussions with Madison or to contact either mother or stepfather. 17. The overview report is the property of the Nottinghamshire Safeguarding Children Board as the commissioning board and when published will be the final and public record for the review. 1.3 The methodology and scope of the serious case review 18. The review was conducted from the outset on the basis that this overview report would be published in full and without redactions. It was written on the basis that Madison would be given an opportunity to provide information to the review and to see the report and to discuss the content given her age and apparent level of understanding. Similarly, Madison’s mother was given an opportunity to provide information to the review. 19. The methodology used to conduct the serious case review draws on best practice in proportionately balancing the need for sufficient rigour in regard to investigating the circumstances of professional involvement with Madison taking account of the parallel criminal investigation and securing the level of appropriate and informed reflection about the complex human, legal and organisational systems for the purpose of learning and improvement. 20. In the absence of a specific index event and the fact that the review is examining professional contact and decision making over several years the methodology primarily used an investigatory model for collating information from agencies with the analysis using elements of a learning review model for analysing the latent underlying conditions and identifying the various contributory factors that influence local systems and practice. 21. All services who had contact with Madison between November 2012 and March 2016 were required to provide a chronology of relevant and significant contact or information. 22. Organisations who were identified as having significant involvement with Madison provided a written account of their contact and their agency analysis against the terms of reference set out in the appendix that included an appraisal of learning for that service together with any action for implementing learning and improvement. These reports were provided by the following agencies: Page 6 of 58 a) Nottinghamshire Healthcare NHS Foundation Trust (NHCFT) regarding the provision of CAMHS, health visiting, school nursing services; b) Nottinghamshire Police in regard to contact with the family and associated people and the criminal investigation of the circumstances of Madison’s allegations/disclosures; c) NHS Nottingham West Clinical Commissioning Group (CCG) in relation to the delivery of GP based health care services; d) A report was provided on behalf of the schools and associated educational support services in relation to Madison; e) Nottinghamshire Children, Families and Cultural Services Children’s Social Care in relation to contacts, referrals and assessments in relation to referrals and conduct of enquiries and assessments; f) Nottingham University Hospitals NHS Trust (NUHT); provided hospital treatment. 23. An information report was provided by the Nottingham City Council Children’s Integrated Services regarding the referrals made to the city’s social care services in 2000. 24. Information was collated about; a) The extent to which evidence of emotional, physical or sexual abuse along with self-harm was disclosed, observed, recognised and understood by professionals; this should include how any historical information prior to November 2012 was considered; b) The extent to which Madison’s level of development was considered, enquired into and understood and what implications this had for earlier disclosure or intervention; c) The quality and rigour of professional response at a single and multi-agency level; this will include how significant information or incidents were dealt with through contact, assessment or enquiry and action planning; d) The quality of advice, support and supervision for professionals and the oversight of arrangements for children at risk of significant harm; e) Identifying issues in regard to the capacity or resources of agencies across the continuum from delivering appropriate early help through to more assertive and statutory intervention when required. Page 7 of 58 25. The panel supporting the work of the review was comprised of senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review and reporting to the Nottinghamshire Safeguarding Children Board. The panel representation encompassed senior and specialist professionals from children’s education and social care services, criminal justice and health organisations. Information is included in an appendix to this report along with the relevant biographical details of Peter Maddocks the independent reviewer and author of this report. 1.4 Information about Madison and the family 26. Until March 2016 Madison lived with her mother, stepfather and four half-siblings in a district of Nottinghamshire that has a relatively low level of deprivation compared to other areas in the county. All of the family are white British and English is their first language. There is no recorded information about any particular cultural or religious affiliation. 27. Mother worked as a shop assistant until the birth of Madison in 1999 having married Madison’s birth father in 1997. According to the GP’s records, Madison’s birth father died in early 2000 from a heart attack at the age of 31 years when Madison was not yet two. Mother was in the process of starting divorce proceedings. It is understood that mother already knew stepfather who is self-employed. He is the primary source of income for the family and works long hours. 28. Madison attended four schools in the county; three were prior to secondary education. Three school transfers occurred between February 2004 and September 2006 although the family have lived in the same area throughout. 29. After the parallel proceedings had been concluded Madison agreed to speak with the independent reviewer in May 2017. Madison was supported by two specialist trauma care practitioners who are working with Madison. 30. Madison found it difficult to accept and to understand why no further action was being taken in response to her disclosures. Madison described that it had taken a little while of being looked after by a foster carer to realise how different the care provided at home had been. 31. Madison asserted that her stepfather and mother had controlled the discussions between Madison and professionals and that professionals had not done enough to speak to Madison or to her half-siblings independently and away from home and from their parents. Page 8 of 58 2 Summary of contact by services and significant events 2.1 Summary prior to November 2012 32. There has been extensive contact with various services during much of Madison’s childhood. 33. In 2000 when Madison was only a few months old and Madison’s father was still alive, concerns about risk of harm were being raised with the city social care services. At that time the concerns appeared to be in relation to domestic abuse. There were reports of Madison being seen with bruises and Madison was the subject of section 47 enquiries in Nottingham city although were not taken to a child protection conference. This early history was not known to the county services when they began to get referrals from 2003 onwards. 34. Paediatric services had contact with Madison for several years from 2001 in regard to slow physical growth and speech development, falls and headaches. At the age of five, Madison was assessed to be about 18 months behind her peers. It is of note that by the time that Madison was in secondary education she managed to achieve five GCSEs at a grade C or higher. 35. There were numerous presentations to primary health care. Mother suffered from perinatal and post-natal depression when pregnant with Madison’s half-siblings; the pregnancies occurred at short intervals and mother appeared to be responsible for caring for the sibling group due to the stepfather’s long working days. 36. When Madison started primary school there were referrals to support services which included psychology, education welfare and speech therapy. Historical records held by the education service describe hair pulling, faltering growth and frequent absences from school. There are also records of minor or unexplained injuries, of Madison looking underweight and being frequently hungry. Various referrals for specialist assessment or support were declined by mother on several different occasions. There is a long history of Madison not being brought to appointments although some of these were rearranged. 37. The first recorded information that Madison’s care and treatment at home was of a poorer quality compared to her half-siblings was in September 2003. The county children’s social care services received their first referral from a concerned member of the public who reported that Madison was kept under surveillance by CCTV in her bedroom. Enquiries by social care services that included consultation with the health visiting service were completed and the case closed. 38. In 2004 Madison was sent to live with a relative for a short period of time when mother and stepfather reported that they needed a break from her behaviour. It was around this time that mother had first shaved Madison’s head to prevent her pulling her hair out. It is notable that the concerns and behaviours that mother and stepfather Page 9 of 58 complained of at home at this and later times were not observed at school or in other settings. 39. In May 2004 Madison suffered a fractured left elbow. It was described at the time as a substantial fracture although there was a four hour delay before mother and stepfather had taken Madison for emergency treatment. No referral was made to children’s social care services. 40. The first of several professionals or multi-agency meetings that have been convened over the years took place in October 2004 although did not include children’s social care services who were not involved with Madison at that time. The meeting discussed difficulties that various professionals had in visiting the home as well as Madison’s poor school attendance at School 1, constant hunger, the fractured elbow, mother’s emotional and physical health and Madison not being brought to health appointments. 41. In 2005 there were efforts to encourage mother and stepfather to participate in a positive parenting group at a local family centre. The positive parenting group is based on an evidence based programme that provides practical methods to develop skills, confidence and strategies to support parents in meeting the needs of their children. It is intended to help any parent irrespective of their circumstances. There was minimal engagement (and eventually the family centre closed their involvement in early 2006). 42. In 2005 the education welfare service gave notice that Madison’s school attendance needed to improve. Shortly afterwards the parents requested a change of school that would mean a longer journey for Madison; this took place in April 2005 when Madison was moved to School 2. Professionals interpreted this at the time as parents wanting to escape the increasing level of attention about Madison. 43. In November 2005 the school contacted children’s social care services to discuss a bruise to Madison’s face. The outcome was for no further enquiries at that time. 44. In May 2006 a multi-agency meeting convened by the education psychology service discussed Madison’s continuing poor attendance record, bruising to Madison, negative comments being written in Madison’s home school diary, her continued hunger, the parents continuing to report difficulty in managing her behaviour at home, her poor language development and the reluctance by the parents to engage with advice and support being offered. The education psychologist contacted children’s social care after the meeting who agreed that a social worker would attend a follow up review meeting. 45. In June 2006 mother consulted the GP about her concerns that she did not love Madison; this information suggests that there were difficulties in mother’s bonding with Madison over the years. She also discussed Madison’s scratching of arms and her head banging. During the same consultation mother was clearly hoping that paediatric services were going to provide a diagnosis that would confirm that Madison had a diagnosable condition to explain the problems. Page 10 of 58 46. In July 2006 children’s social care accepted a referral from the health visitor which began an involvement by social workers until 2008 on the basis that Madison was a child in need rather than a child in need of protection. The referral described mother’s concerns that Madison had ADHD and/or autism and self-harm (pinching). 47. Madison was moved to School 3 in September 2006 at the request of the parents who appear to have again been concerned at the increasing attention from services. 48. In October and November 2006 School 3 contacted children’s social care to report information that included a bruise that Madison said was the result of colliding with a table at home, as well as her comments that she had not been fed on a Sunday and had been placed facing a naughty wall at home. The community paediatrician wrote to children’s social care in October to confirm that a referral had been made to the CAMHS and expressing the concern that Madison was being emotionally abused. In December 2006 the school reported a mark to Madison’s back. Social care services were already working with Madison and the family. The information was considered by the social care staff working with Madison who concluded that additional child protection enquires were not required. 49. In December 2006 the perinatal mental health consultant psychiatrist advised the GP about concerns regarding mother’s bonding with Madison and the apparent scapegoating of Madison. 50. In early 2007 Madison was admitted for an in-patient paediatric assessment to explore Madison’s emotional responses and reasons for her failure to thrive. Mother did not visit much and although Madison was needy of physical contact she looked to receive this from hospital staff rather than from her mother. Madison had a large appetite when at hospital. In spite of the apparent queries about neglect, no contact was made with children’s social care services to tell them about this information and consequently children’s social care services were not represented at the multi-agency meeting in March 2007 that was chaired by the paediatrician. The parents continued to decline involvement by the family centre. 51. In May 2007 as a result of a home visit by the paediatrician and children’s social care and threats that child protection procedures would be invoked, the parents agreed to participate in work with the family centre during which they continued to deny that they treated Madison differently to their other children. The parents attempted to change the paediatrician. At the same time mother was consulting the GP about her poor quality of sleep, low mood and stress. 52. Children’s social care services completed a further assessment in 2008. This described a positive picture of relationships within the family noting that the parents refuted the view of professionals that they were not meeting Madison’s emotional needs. The assessment identified several positive aspects in parenting and the family relationships and the GP reported that Madison had gained more than two kilos of weight. The case was closed to children’s social care services. Page 11 of 58 53. In January 2009 and again in May 2009 Madison was presented at the hospital emergency service with vaginal bleeding. She was not spoken to on her own nor was the consultant paediatrician consulted or asked to examine Madison and therefore no specialist medical assessment was conducted in order to establish whether the bleeding was indicative of abuse. In that regard the response was not sufficiently rigorous or compliant with professional and procedural standards. No contact was made by the hospital with children’s social care services although a check was made as to whether Madison was the subject of a child protection plan. 54. A multi-agency meeting in March 2009 discussed several examples of Madison being treated less favourably compared to her siblings; dirty and worn clothing and shoes; poorer quality of lunch box provided from home; her hair cut short and her low weight. Madison also continued to regularly have bruises. 55. In February 2010 the school told children’s social care services that Madison had bruising and was being treated differently and less well than her half-siblings. A trainee social worker was allocated the task of reviewing the history of concerns and the services that had been offered. Children’s social care services did not participate in a multi-agency meeting in March 2010 but the trainee social worker did attend the following meeting in April 2010. The parents were at the meeting and denied there was any basis to the concerns being discussed. A social work assessment was completed although the parents did not accept the concerns and Madison was ‘reluctant to talk’. The parents agreed to improve their ‘supervision’ of Madison and the case was closed to social care services in May 2010. 56. In September 2010 Madison moved to secondary school. In September 2011 the school contacted social care to report bruising and scratches to Madison. She was described as a socially isolated child. It was decided that social work involvement was not required. 57. In November 2011 Madison went missing for about two hours after school. The parents walked out of a return to school meeting. 58. In January 2012 Madison went missing again after school. The police completed a ‘safe and well’ visit. 59. This review is the first occasion when information has been collated from the various individual agency records and presents a compelling account about Madison’s needs and circumstances over several years before 2012. It indicates a considerable level of resilience on her part. 60. This historical information establishes the context for assessing whether its significance was appropriately recognised and taken into account when more recent referrals and enquiries were being conducted from 2012 up until February 2016. Page 12 of 58 61. A great deal of the information that is held in various agency records was not known to children’s social care services. Some of this is attributable to information not being reported or discussed with children’s social care when significant information was being discussed; this included the concerns and in-patient assessment to explore Madison’s slow development and the occasions when Madison presented with vaginal bleeding. It is also the case that there were opportunities when assessments or enquiries were made to seek information from relevant organisations and suggests that historically those processes were not as complete as they would certainly be expected to be under current standards and expectations of professional practice. 62. Education and health professionals had concerns about how Madison’s emotional and physical needs were being met over several years. Historically, the concerns and queries raised about Madison’s slow physical growth and development was not explained by organic or physiological factors and Madison has often been hungry and reported missing meals at home. This, together with two presentations with vaginal bleeding were not investigated through formal safeguarding enquiries and assessment because referrals were not made to children’s social care services or to the police at the time to establish if there was evidence of abuse or not to be investigated. There were injuries not fully reconciled and on one occasion there was a delay of several hours in seeking medical care and treatment for a significant injury. There were incidents of going missing from home and self-harm. 2.2 November 2012 and discussion of a CAF 63. On the 1st November 2012 the school contacted children’s social care services regarding a seven centimetre graze to Madison’s shoulder blade. Madison said that the injury had resulted from a collision with the corner of a table at home while playing with the siblings. Children’s social care suggested that a CAF (common assessment framework) should be considered by the school; the school were sceptical because of previous discussion with the parents who had made clear they would not want to participate in a CAF. 64. Madison did not arrive at school the following day; mother reported that the absence was because of bullying at school. Madison had been having some difficulty with some of her peers which on some occasions was thought to have been instigated by Madison and on other occasions was not. The school police liaison officer was asked to visit; this was a local police community support officer. 2.3 Disclosures at school and self-harm 65. On Friday the 9th November 2012 Madison, aged 13 years, told a pastoral support worker of being threatened the previous evening with a knife by mother after being in the lavatory. According to the information that was recorded by the police 48 hours later, the issue was mother feeling that Madison had not urinated enough. Madison agreed to speak with the school nurse during a scheduled session on the 19th November 2012. A referral was also made to children’s social care. Page 13 of 58 2.4 Decision to undertake section 47 enquiries and social work assessment 66. The same day, the team manager decided the outcome was s47 enquiries and a strategy discussion. The decision to conduct an s47 enquiry before the strategy discussion had taken place implies a misunderstanding about the purpose and process of discussing the content and significance of information with relevant professionals and developing a strategy and agreeing the conduct of the enquiries and pre-dates the MASH (multi-agency safeguarding hub). In fact, the organisational arrangements at the time for convening strategy discussions that are described in paragraph 73 created the circumstances for social care to make the decision to undertake a visit before a strategy discussion. The social worker contacted mother and stepfather who gave consent for Madison to be spoken to. 67. Later the same day a social worker saw Madison at school with the school’s designated teacher (for safeguarding). The teacher told the social worker about concerns raised by other students about Madison being physically assaulted, cutting to her wrist with a pencil sharpener blade or metal can, ripped pyjamas and inadequate bedding (no pillows or duvet). It was also reported that concerns went back to primary school. Madison’s height and weight were reported as being lower than expected although no specific measurements are recorded or apparently discussed. 68. Madison told the social worker that she had been in the lavatory when mother had shouted at Madison saying that she was taking too long and that when Madison had come out, mother had pointed a knife at Madison in the kitchen. Madison said the knife had been very close to her and that she had felt ‘a bit frightened’. The social worker noted that Madison presented as scared and looked anxious although does not clarify in any recording whether this may have been Madison’s usual demeanour with a stranger professional or inferring worry about other factors such as the reaction from the family. Madison did not disclose any physical chastisement. The social worker noted that Madison had scratches on her arm/wrists which Madison said she had done and that she cut arms when worried. Madison also reported being bullied at school. 69. The social worker visited mother and stepfather later the same day and also saw the other children and spoke to them alone in the home. Mother explained that she had the knife in her hand and had waved it about while telling Madison off. She said she was telling Madison off for spending too long in the lavatory. The social worker noted Madison was very timid in front of her mother and stepfather, and looked ‘worryingly’ at the social worker and then at them. Again there is no record of clarification or inference about the significance or reason. None of the other children made any disclosure of abuse, and the social worker concluded there was no evidence to suggest Madison was being physically abused. Page 14 of 58 70. On Sunday the 11th November 2012 the police opened a CATS1 (case administration and tracking system) entry in regard to the referral to the child abuse investigation unit (CAIU) from children’s social care and their request for a strategy discussion in regard to the information from the 9th November 2012. 71. On the 12th November 2012, the social worker made a second visit to the family, and saw Madison, although not alone. The recording is very brief and notes that Madison presented as being ‘more happy’; mother and stepfather said they had spoken with Madison about bullying, and that they had also spoken to the school; they had discussed a CAF which the parents had agreed to; Madison had been given a communication book to share information between the school, Madison and her mother and stepfather. 72. On the 12th November 2012 the designated teacher sent an email to the school nurse regarding concerns about Madison being bullied and the evidence of self-harm as a background for the scheduled session with Madison on the 19th November 2012. A second email to the school nurse later in the morning informed the school nurse about the disclosure regarding the incident with the knife on the 8th November 2012. In that email the issue in regard to the lavatory was mother’s concern that Madison was constipated. 73. The police and children’s social care service had a telephone strategy discussion on Tuesday the 13th November 2012 (and was after the social worker had already spoken with the parents and to Madison). At this time the practice for arranging a strategy discussion was to send an email to the police to formally request the discussion and provide some details of the case. An email had been sent to the police by social care on the Friday afternoon. The information had come in to children’s social care mid-afternoon who judged that they needed a social worker to make a prompt visit given the information they had received. When the strategy discussion subsequently took place, it was agreed that children’s social care would conduct their own single agency enquiry and update the police, having already undertaken two lone visits with Madison. The strategy discussion did not involve the school who had instigated the referral. 74. On the 14th November 2012 the school nurse received two further emails from the school. These described that Madison had run away from school on the 13th November 2012 having been called names and having had some belongings taken from her by other students. Friends had brought Madison back to school and to the inclusion centre. The second email described a conversation that Madison had with a teacher describing a hatred of school and that Madison wanted to kill herself. 1 CATS (Case Administration and Tracking System) is the Nottinghamshire Police vulnerable person case management system since 2007. The system has three core modules; child protection, domestic abuse and vulnerable adults; although it can also manage any type of public protection incident. The CATS system was developed in the absence of a national database for child protection, and in light of the recommendation in Lord Laming's Report into the death of Victoria Climbié that Chief Constables must ensure their police force has in use an effective child protection database and IT management system. Page 15 of 58 75. Madison did not attend the scheduled session with the school nurse on the 19th November 2012. 2.5 Madison goes missing from home 76. On Monday the 19th November 2012 Madison went missing for just over two hours after school and did not return home until she was located at a local supermarket by her stepfather. The police were requested to attend after Madison had been returned home and reported that Madison was ‘safe and well’. Madison had told a friend earlier in the day of a plan to run away to grandparents because Madison ‘did not like her life’. Madison had also scratched her arms and had expressed thoughts of jumping from a bridge. 77. School staff were provided with advice about preventing verbal bullying of Madison. The designated teacher attempted to contact children’s social care services but struggled to get through on the phone. The school nurse was updated by email that Madison was having a ‘particularly difficult time due to receiving persistent unpleasant comments from a number of students’. 78. Madison did not attend school on the 21st November 2012; mother said this was because of the bullying and that Madison was too frightened. Madison was asked to write down what they would like to have done to make her feel safer. No information has been provided as to whether Madison ever did this. The school decided to convene a multi-agency meeting. 2.6 Madison identified as being a child in need 79. On the 21st November 2012 an agency children’s social care team manager providing temporary cover decided that a child in need plan was required but in contradiction to this also decided to close the case; ‘Concerns about Madison, which require CIN Plan. No concerns whatsoever in relation to siblings, therefore, s47s to be written up, briefly, and NFA. TM will then close.’ 80. On the 22nd November 2012 email correspondence between the designated teacher and the social worker discussed concerns that the parents appeared to be deflecting concerns away from home and focussing on the bullying at school and that there were ‘lots of concerns over a long period of time’. 81. A meeting on the 26th November 2012 at school discussed the support required to get Madison back into school. The meeting was attended by mother and stepfather along with the social worker and school nurse. Stepfather was described as very aggressive and unwilling to listen to any plans the school had. He wanted the two ‘bullies’ removed from the school and stated that Madison would not attend school until this had happened and that they would educate Madison at home; Madison subsequently moved to another class where she had a good relationship with the class teacher. Page 16 of 58 82. In the interview with the education IMR author, the designated safeguarding lead in the school reported that moving the two boys would not have been appropriate as one of them had social difficulties of his own and was in that class specifically because of a good relationship with the form tutor. On the same day the two students reported being accosted by stepfather in the playground and threatened because of the account they had given of an in-school incident involving Madison. 83. After the meeting the social worker asked the school nurse to refer Madison to CAMHS regarding the self-harm and to seek the consent of mother and stepfather. 2.7 Paediatric review and referral to CAMHS 84. On the 27th November 2012 mother and Madison were seen by a consultant paediatrician at the community paediatric clinic. They discussed the bullying and the self-harm that had involved using a blade from a pencil sharpener. Madison was described as subdued and unhappy. The paediatrician recommended that Madison should attend school and use the support of a mentor or counsellor. The paediatrician also made an ‘urgent referral’ to CAMHS. The referral letter included information about a history of the half-siblings bullying Madison and of Madison being treated differently. The letter mentions that Madison’s birth father was believed to have died as a result of suicide; this is incorrect. The letter was routinely copied to the GP practice. 85. A multi-agency meeting was convened by the school on the 3rd December 2012; this was apparently the first date that stepfather could attend due to his work commitments when arrangements were being made on the 21st November 2012. The designated teacher reported to colleagues at school that the social worker had advised that a CIN plan was not required because the plan of support had already been developed by the school and other services. The social worker had apparently expressed doubts that the parents would engage in a CAF and had advised that the level of engagement should be monitored as an indicator of future referrals to children’s social care. 2.8 Further disclosures of self-harm and abuse 86. On the 13th December 2012 the PE (physical education) teacher told colleagues by email that Madison was very low and having a very tough time and kept saying that she hated school and wanted to kill herself and had placed the cord for opening and closing window curtains around her neck. The incident was reported to the school safeguarding team. This appeared to be a one off incident involving the use of cords or any ligature. 87. In a confidential internal email to pastoral care staff at school on the 14th December 2012, the designated teacher summarised concerns about Madison. This included being uncertain how long children’s social care were going to remain involved and that Page 17 of 58 they had not escalated to CIN or to a safeguarding plan. Madison had been given a private notebook to record concerns to be only shown to specific staff. 88. On the same day Madison’s mother consulted the GP practice about a headache that Madison had complained of for two days. A consultation with the GP noted ‘no particular stress at moment but been bullied at school from start of term until three weeks ago’. There was no apparent discussion about the self-harm or referral to CAMHS that the GP should have been alerted to via the consultant paediatrician. 2.9 Children’s social care withdraw and mother declines CAMHS involvement 89. On the 28th December 2012 children’s’ social care decided, having completed an assessment, that there was no role for them as Madison’s needs could be met through universal services and that there were no concerns around safeguarding and that agencies could ‘monitor and support’. The case was formally closed on the 24th January 2013. 90. On the 7th January 2013 the school nurse made a phone call to discuss the CAMHS referral with mother who told the school nurse that she had discussed the referral to CAMHS with Madison who was not keen to follow this up feeling that she was no longer self-harming. Mother was advised by the school nurse that a referral could be made at any time to CAMHS. 91. Madison told the school nurse during a one-to-one appointment on the 13th January 2013 that had initially been arranged for the 19th November 2012 of being generally happy at home and at school although there had been an incident of name calling Madison had spoken with a member of staff and the issue had been sorted out. Madison had lots of friends but mother did not like Madison going to out-of-school activities. Madison had no hobbies or activities but said that her home life was busy. Mother had discussed the CAMHS referral and had decided that it was not necessary. The school nurse made clear that Madison could change her mind at any stage. 92. On the 29th January 2013 the CAMHS clinical psychologist phoned the consultant paediatrician who commented that Madison had appeared very withdrawn at their last contact. The paediatrician was concerned that Madison was suffering neglect and was being treated differently at home from her half-siblings. It was agreed that a CAMHS consultation should be arranged for professionals working with Madison to attend on the 27th February 2013. 2.10 Anonymous referral of concern about Madison 93. On the 21st February 2013 an anonymous referral was made to the NSPCC reporting concerns about the emotional abuse of the children. The caller described having had concerns for about two years but reported that Madison had been heard screaming that morning. The referrer reported that there was often screaming and shouting and arguments to be heard. The caller said that Madison was the priority concern as she Page 18 of 58 always seemed to be shouting ‘get off me’ or ‘let me out’. The information was reported to the MASH who decided that no action was required as it was deemed usual for a household ‘with five children to be noisy’ and that previous assessments had been completed and agencies were ‘monitoring the children’. 94. The social worker wrote to NSPCC and mother/ stepfather to say that the threshold was not met, and there was no role for children’s social care services. 2.11 CAMHS consultation identifies concerns in absence of children’s social care 95. The CAMHS consultation meeting for professionals on the 27th February 2013 was attended by the paediatrician, the designated teacher, the school nurse, the clinical psychologist and the clinical nurse specialist. Children’s social care services were not invited to the meeting; the reason is not known or recorded. The purpose of the meeting was to discuss how CAMHS might be able to offer support due to concerns about the impact of Madison’s experiences upon their mental health and to discuss if there were safeguarding concerns. 96. According to the minutes recorded by health ‘extensive safeguarding concerns were discussed’ and it was unclear to the professionals at the consultation meeting as to why children’s social care had closed the case; it was agreed that the paediatrician would make a further referral to children’s social care services (which was never actioned); a chronology was requested from school. 97. On the 5th March 2013 Madison and mother went to the hospital (NUH) for a routine paediatric clinic review. It was noted that the self-harming had ‘discontinued’; there was no physical evidence during the consultation of bruising or self-harm marks although it is not made clear what if any physical examination was completed. There was a discussion about the consultation with CAMHS and the decision to help work on improving mother and Madison’s relationship instead of a psychological evaluation. Mother declined any help or support saying that the relationship between Madison and mother and stepfather was good; it was documented that Madison could ‘speak to them freely’. The note of the meeting appeared to largely rely on mother’s views and opinions rather than any distinct information from Madison although it was noted that there was good rapport in the clinic between Madison and mother. It was noted that Madison was well below the 0.4th centile (compared with 9th at the age of two)2. Madison was not brought to three subsequent appointments between March and September 2013. 98. On the 5th March 2013 the GP received a letter from the paediatrician summarising the CAMHS consultation meeting and the concerns discussed. The clinical nurse specialist also wrote to the GP on the 14th March 2013 regarding the consultation and 2 Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals. They are called centiles and not per centiles. If a parameter such as height is on the 3rd centile, this means that for every 100 children of that age, 3 per cent would be expected to be shorter and 97 taller. On the 97th centile, 97 would be shorter and 3 taller for example. Page 19 of 58 also confirmed that a referral was being made by the paediatrician to children’s social care (which was not done) for an assessment and that CAMHS were closing the file in regard to Madison. CAMHS also wrote to the GP describing documented concerns regarding safeguarding and the relationship between Madison and mother. 99. On the 20th March 2013 the school made a note of a student reporting an email from Madison saying that she had cut herself and would show the marks to the student. 100. On the 8th July 2013 the school nurse spoke with mother to highlight that Madison had only had the first dose of HPV vaccination (human papillomavirus) due to Madison’s absences from school. The school nurse agreed to arrange catch up on the HPV. 101. On the 9th July 2013 Madison reported being ‘subjected to a number of unpleasant and sustained examples of verbal bullying’ at school. 102. On the 24th September 2013 mother and Madison attended for the paediatric clinic review. Mother reported that Madison was being subjected to ‘teasing’ by her peers but was taking ‘no notice’ of it. Madison was reported to be sleeping well. It was noted that Madison’s BMI (body mass index) had declined from previous clinic reviews3. This was significant given Madison’s already small stature 103. The GP received a letter from the paediatrician confirming discharge back to the GP. This was the first record of information to the GP since the earlier correspondence following the CAMHS consultation six months previously. 2.12 Disclosures of self-harm and allegations of physical abuse in 2015 104. On the 25th February 2015 Madison spoke with pastoral care staff at school. Mother and stepfather did not want Madison to go to college to study textiles. Madison did not feel that staying on at school to study for A-levels would suit her. There had been lots of arguments at home about this. Madison also reported being hit by her half-siblings and Madison was just told to shut up when trying to say anything about sixth form. This meeting with the pastoral team was the first record in the school safeguarding file since July 2013. In the interim, Madison had consistently reported that everything was all right when asked. As part of the agency review for this serious case review it has been identified that there had been many examples of arguments between Madison and other students but no single incident had needed escalating during the months from 2013. 105. On the same day another student spoke to pastoral care staff and reported that stepfather had been ‘hitting Madison again’ and that her half –siblings were telling 3 Body mass index (BMI) is a measure of body fat based on height and weight that applies to male and females. The BMI categories are: Underweight = <18.5 Normal weight = 18.5–24.9 Overweight = 25–29.9 Obesity = BMI of 30 or greater Page 20 of 58 Madison to kill herself. The student did not know what role mother had in regard to the information. The student appeared to feel that mother was scared of stepfather. The student reported that the half-siblings has been scratching Madison’s arms but had put socks on her arms when the marks became obvious and had put pins in the socks and arm. Madison was not making any disclosure herself. 106. On the 21st May 2015 Madison was taken to the hospital emergency department complaining of suffering pain in her chest for a week. Madison had seen the GP on two occasions and had been prescribed an anti-acid over-the-counter medication and blood samples had been taken. An ECG (electrocardiogram) and blood tests confirmed that Madison was not suffering from a significant condition or illness; a differential diagnosis of abdominal migraine was noted4 in the hospital records although subsequent notification to the school nurse stated that a diagnosis was unspecified. Madison continued to complain of pain. 107. On the 11th August 2015 the school nurse wrote to mother and stepfather to highlight that Madison had yet to have vaccinations for diphtheria, tetanus and polio. It was recommended that they contact the GP to arrange to have those vaccinations completed. 108. On the 11th September 2015 a student asked to speak with the school’s designated teacher for safeguarding. The student reported that during the previous term Madison had been telling this student about stepfather but had not wanted the information to be shared with anybody else. Information included Madison being made to get a Saturday job in order to contribute towards the cost of electricity; stepfather ‘whipping’ Madison with a belt; stepfather making Madison wear socks over her arms when going to bed and putting pins in the sock; white scars on the arms; the half-siblings scratching Madison’s arms until they were bleeding. When the designated teacher spoke with Madison she said that there was nothing wrong. 109. A report to the designated teacher for safeguarding from a member of teaching staff on the 14th October 2015 summarised that Madison was not being allowed many options about what to do after Year 11 and was under pressure from mother and stepfather to continue at the school into the 6th form. 110. On the 15th October 2015 Madison attended a dermatology clinic regarding a skin mole. There was no comment about any evidence of skin lesions or self-harm inferring there were none to be noted. 111. On the 19th October 2015 Madison arrived at school dressed in a shirt with no jumper despite the weather being cold and saying that the jumper was not allowed until after the half-term break. Madison claimed a half-sibling had hidden other clothing belonging to Madison. 4 Abdominal migraine is an idiopathic disorder (one in which a cause cannot be identified) typically occurring in about four per cent of infants, toddlers, children and adolescents. Abdominal migraines usually happen in young people who will later suffer from migraine attacks. Severe abdominal pain can occur with migraine attacks in adults as well. Sometimes they are called stomach migraines or migraines of the stomach. Page 21 of 58 2.13 Referral to MASH and social work assessment 112. On Thursday the 23rd February 2016 the school nurse received a chronology from the school of ‘extensive child protection concerns’ in regard to Madison dating from March 2003 through to February 2016. 113. On the 23rd February 2016 a teacher found out that a half-sibling had thrown away all of Madison’s textile work and all of her ICT (information and communications technology) work. 114. On 25th February 2016 Madison showed the school’s pastoral care staff a video clip on Madison’s mobile phone of her hair being gelled as a punishment by mother following an argument with her half-siblings and mother watching and laughing; Madison does not like gel in her hair. The video clip had been recorded by one of the half-siblings and sent to Madison. In interview with the education IMR author for this review, the school’s designated safeguarding lead commented that ‘Madison knew that once these videos were seen she would be believed and this gave her the chance to disclose again and to be believed, unlike in 2012.’ 115. Madison was scared of mother and stepfather finding out anything had happened again because they had threatened ‘to kick Madison out of the house’. Madison also reported not sleeping well due to stress about sixth form and arguments with her stepfather. A half-sibling also kept wishing Madison to be dead. Madison was denied contact with her friends outside of school. Madison also described being required to put school and homework second to looking after and helping her younger half-siblings. Stepfather felt that school was a waste of time for Madison who would end up stacking shelves and was making Madison to feel generally worthless because of being told to go to her birth father’s grave. Madison was scared of being forced to leave home but felt that she could not keep it ‘bottled up any longer’. The designated lead tried to phone the MASH but was unable to get through on the phone so emailed for advice. After a subsequent discussion with the MASH the school made a referral which included the video described in the previous paragraphs. 116. After the school day had ended Madison had a further discussion with school staff to say that she had told them mostly everything and felt better and did not want to hide it anymore. Madison said ‘Sometimes I think about doing stupid things and that maybe I would be better off dead like they keep saying’. Madison had never said anything like this before. Whilst Madison was with the teacher, mother sent Madison a message asking ‘Why have you gone to Lower School?’ (Madison had been seen by a sibling and reported to mother). This resulted in Madison collecting A3 paper from the teacher and then returning back within seconds with her mother on the phone and Madison saying in to the phone: ‘Ask Miss ‘A’, I was getting paper. Do you want to speak with her?’ Madison handed the teacher the phone who spoke briefly to mother and explained that all was well and Madison was collecting paper for a sibling (who doesn’t go to this school but is often asked by home to collect some paper). The incident was significant in regard to the thoughts of self-harm and the degree of Page 22 of 58 control and coercion and the extent to which the siblings had been drawn into the controlling behaviour and surveillance of Madison. 117. This was followed up the following day (Friday) with further information from the school being sent to MASH regarding an argument the previous evening and a further argument that morning when Madison had attempted to complete homework in the school library. There were also emails on the school system which included a video of Madison being made to stand in the corner of a room at home as a punishment. The emails also show mother telling Madison what to do or not to say in regard the sixth form. Emails between mother and one of the half-siblings refer to Madison. 118. The information from school was processed by children’s social care on Monday the 29th February 2016 and a new social worker visited school and spoke to Madison who confirmed longstanding physical and emotional abuse from mother, stepfather and half-siblings. The family were not informed of the visit or of the discussion, taking account of Madison’s concerns. On the child enquiry form that records the information the social worker has collated that Madison had been known since 2004 (although there are records that go back to September 2003 in county and earlier contact with city social care services that was not identified until the review) and an anonymous referral of Madison having bruising to the face, was underweight and was petrified of mother and stepfather. 119. On the 2nd March 2016 the pastoral support assistant informed colleagues that Madison had reported a further argument at home with a half-sibling and stepfather. The half-sibling was alleged to have said they wished Madison was dead and that neither stepfather nor mother wanted Madison around and that the half-sibling wanted Madison to be hurt and did not know why Madison existed. 120. On the 4th March 2016 a team manager in children’s social care decided that enquiries and assessment should be conducted under section 47 (Children Act 1989) and permission would be sought to make arrangements for Madison to become looked after under sec 20 of the same Act. Section 20 allows the arrangement to be made with agreement rather than going to court and securing an order. Madison was aged 16 and therefore in law was regarded as having the legal and mental capacity for giving or withholding consent on important decisions regarding arrangements about where she should live as well as other matters such as health care. It means though that the local authority had no parental responsibility which remained entirely vested with mother (and stepfather if he had acquired parental responsibility for Madison). 121. On the same day Madison was visibly upset at school and told school staff that she did not want to go home. Madison felt that she could not ‘keep things in’ and felt frightened of being hurt by the family if they become aware that Madison was making disclosures. School made contact with children’s social care and spoke with a social worker. It was agreed that Madison should go home for the weekend rather than trying to make any other arrangements in a rush, to reassure Madison and that children’s social care would be in contact with Madison on Monday. Page 23 of 58 122. On Monday 7th March 2016 mother phoned the school to ‘rant and rave’ about Madison being kept behind after school on the previous Friday. The pastoral assistant spoke with Madison later who reported being questioned about why she had been so late coming from school and that mother and stepfather did not believe Madison who had said that she was doing an English Controlled Assessment. Mother had obtained a copy of Madison’s timetable so that a half-sibling could monitor Madison’s whereabouts. Madison reported being hit by a half-sibling and also by stepfather. 123. A strategy discussion on the 8th March 2016 decided that a joint enquiry by children’s social care services and the police would be conducted. It was agreed that Madison would become looked after within ten days to allow arrangements for an appropriate carer to be identified and that the half-siblings would be video-interviewed on the day that Madison was placed with a foster carer. 124. Madison continued to be expected to help the half-siblings and to complete homework for at least one of them. 125. On the 10th March 2016 Madison alleged that mother and stepfather had both hit and had pulled her hair the previous evening during an argument. Madison also reported that her mother was even angrier with Madison because she was not getting any additional money for Madison. 126. On the 11th March 2016 Madison made further disclosures at school about her treatment at home. This included the family having taken control of what Madison wears and hiding Madison’s glasses and calling Madison ‘the step’ (as in stepchild). Madison also reported being woken in the middle of the night by mother who had removed a blanket from Madison’s bed saying that Madison was not allowed to have it. Madison had become cold and had not slept. 127. On Monday the 14th March 2016 further disclosures were made by Madison at school. This included being made to wear clothing to school that hid the scratches caused when stepfather had tried to grab Madison. It was also reported that Madison had a nervous tic of tapping her fingers when anxious and mother and stepfather had devised a punishment that initially had involved a hand slap but now involved striking Madison’s fingers with the inner cardboard roll from cling film. The school safeguarding file states that photographs of injuries were photographed and sent to children’s social care. The injuries were to both of Madison’s legs on the back of the knees. 128. On the 15th March 2016 Madison reported that stepfather on the previous evening had grabbed Madison by the arm and punched a hand. Pastoral care staff noted that there were marks on Madison’s hand. Photographs were taken and sent to children’s social care. Madison also expressed concern that when Madison was no longer living in the family home one of the half-siblings may become vulnerable. 129. On the 16th March 2016 Madison was moved to a foster care placement with her consent. Mother and stepfather were informed of the section 47 enquiries being Page 24 of 58 undertaken. The four half-siblings were spoken to separately at school by a social worker and a police officer; none of them reported any concerns or worries. Page 25 of 58 3 Appraisal of professional practice in this case 130. It is apparent that the review has collected a much more comprehensive account than was achieved during the assessments for example. In addition to the concerns already summarised it highlights areas such as Madison’s early years, the style and quality of her attachment, mother’s apparent isolation from support and levels of control and resistance that have not been explored. 131. When enquiries were made prior to 2016 they tended to focus on the immediate presenting issue or information. Efforts to provide advice, help and support relied primarily on the voluntary engagement by mother and stepfather and which was largely absent. They did not accept that there were issues or concerns and were influential in how information was processed at critical points. 132. An obvious question is what caused the response to be significantly different in February and March 2016. There are several factors. Madison was 16 and had the legal and the cognitive capacity to be heard independently and to make decisions for example about where she wanted to live. It ensured that Madison had the opportunity to talk to a social worker independently of a parent. The MASH had become more established and was providing more rigorous processing and triaging of information than had been apparent previously and was less reliant on decision making by any one single agency and created access to lead professionals who assisted in navigating the process of contacts and processing of information. 133. There was also a different social worker who had no previous contact or knowledge about Madison or her family and who was seen as taking a more child focussed and proactive approach to enquiring into and finding out about Madison’s circumstances and concerns. 134. There was also the additional and tangible evidence available for example through video recordings and e-mails about aspects of Madison’s life and treatment at home. 135. The difference in 2016 was that rather than be overly influenced by what previous enquiries and assessments had recorded there was a fresh approach to how information was investigated by social workers and by the police. 136. This review follows others in the county that identify significant levels of historical dissonance and disagreement between children’s social care services and other practitioners from education and health that were not escalated through protocols that are designed to resolve differing thresholds of concerns about a child. 137. The people who have the most contact with children and have the best developed relationships are those who are more likely to observe or to receive information about a child’s circumstances and notice the subtle patterns that will be less obvious to more cursory acquaintance. The people who often know the most about a child are not those who have the statutory powers to investigate and assess. Page 26 of 58 138. Madison’s story emphasises the importance of mechanisms such as strategy discussions to help inform judgments about the relevance and significance of information and to develop appropriate strategies for conducting enquiries and has to include anticipating and thinking about how to deal with obstruction and resistance. 139. The statutory guidance published by the government in Working Together to safeguard children emphasises the importance of a child centred approach and highlights that safeguarding systems are less effective when the needs and views of children are lost sight of, or the interests of adults are placed ahead of what a child is saying or indicating in their behaviour for example. 140. The guidance also includes a summary on page 11 of what children say they need from professionals to help keep them safe. This includes having adults who take notice when things are troubling children, that there is sufficient understanding about what is happening, to be heard and to be understood and that action is taken; that children need an on-going and stable relationship of trust with those providing help and support; the child’s views need to be respected with an expectation that they are ‘competent’; that the child will have information and involvement in what will happen and an explanation about the outcome and reasons of processes such as enquiries and assessments; the child will have support in their own right as well as being a member of their family; and have access to advocacy to assist them in putting forward and having their views, thoughts and feelings considered. 141. The findings from the review include how professionals listen to, and give appropriate weight to the views, wishes and feelings of children; collate sufficient history of the child and their family including any previous concerns or contacts; are sufficiently aware and informed about the significance of self-harm; understand and are able to investigate information and evidence about emotional and physical neglect; are suitably alert to how a parent or primary care giver responds to concerns about a child; and how to escalate concerns within appropriate frameworks if and when the response by statutory services is deemed insufficient. 3.1 Voice of the child and their personal history and identity 142. Madison criticises how some professionals sought to understand and listen to her. For example, she feels that social workers prior to February 2016 did not spend long enough with her or with her half-siblings talking with them and independently from their mother and stepfather. Madison is critical about the extent to which her views and information had been given sufficient credence alongside the views for example of her mother and stepfather as well as her step-siblings. In this last regard Madison had felt let down at the time of the meeting with the independent reviewer that although now living with a foster carer there has not been a good enough explanation about decisions made in the parallel processes. 143. Following the meeting with the independent author and the NSCB Development Manager in May 2017, the Service Director, Children’s Social Care Services met with Page 27 of 58 Madison to discuss the circumstances under which the judge in the Family Court proceedings had decided to conclude the application and the half-siblings were returned to stepfather and mother. 144. There are examples of where professionals have sought to listen to what Madison had been saying and to understand Madison’s circumstances although it has been less evident in how it informed the statutory enquiries and assessments up until February 2016. Unsurprisingly, Madison has spoken the most to people in regular contact for example at school or spending time for example on the paediatric ward in 2006. It was the professionals with an ongoing relationship with Madison who heard and noticed information that was then interpreted or given less weight for example during social work enquiries when the views of mother and stepfather appeared to become far more influential. 145. Madison’s independent voice was insufficiently recorded in enquiries and assessments completed by social workers prior to February 2016 which were limited and were influenced by what mother or stepfather said. A different inference was given by different professionals to the various issues that were raised by Madison. 146. There was a notable gap of several months between 2013 and the spring of 2015 when nothing was observed or recorded at school regarding Madison’s circumstances. Children’s social care involvement had ceased in early 2013. Madison told the independent reviewer of feeling that that she had not been listened to when referrals were made to social care services and she was not given enough opportunity to speak independently away from the influence of mother and stepfather. She lost confidence in any substantial action being taken and became concerned about the repercussions at home. 147. The implications of children feeling they are not being listened to with enough care and attention has featured regularly in serious case reviews and over several years. 148. In 2010 Ofsted5 published a study of 67 reviews describing how key professionals such as social workers did not see children frequently enough or did not ask the child about their views and feelings; key professionals did not listen or give sufficient weight to the adults who tried to speak on behalf of a child or talk to professionals who could provide important information about the child; parents or the child’s carer prevented key professionals from seeing or listening to a child; professionals could become distracted and preoccupied with the needs of the parent or the parents’ wishes and overlooked the implications for the child. 149. The extent to which there is so little factual information about Madison’s history on important issues such as her early years and the loss of her birth father is an indication of inadequate history and context for enquiring into more recent issues. 5 Ofsted (2010). The voice of the child: learning lessons from serious case reviews. A thematic review of Ofsted’s evaluation of serious case reviews from 1 April to 30 September 2010. London: Ofsted Page 28 of 58 3.2 Contact, request for service and enquiries 150. There were four contacts with children’s social care between November 2012 and February 2016. 151. The first contact on the 1st November 2012 concerned a seven centimetre graze to Madison’s shoulder blade. Children’s social care services did not accept the contact as a referral, advising instead that a CAF should be used. There is no record on the part of either children’s social care or the school as to how far either agency drew attention to the prior history that included minor but unexplained injuries and a poor level of engagement with previous offers of advice and help through a CAF. 152. The second contact a week later on the 9th November 2012, concerned Madison’s account of mother waving a knife the previous evening; this was processed as a referral with the decision to undertake enquiries under s47 of the Children Act 1989. A request for a strategy discussion with the police for the purpose of planning the enquiries was made the same day but was not processed for 48 hours and the discussion did not take place until the 13th November 2012; four days after the original referral. By that stage the social worker had already spoken with Madison at school and had visited the family on two occasions and had already made a decision that Madison had not been subjected to any abuse including physical threats. The strategy discussion did not involve any other professionals who had originally raised the concerns. The police and children’s social care services are now co-located with other agency partners in the MASH which provides greater opportunity for more timely strategy discussions involving all of the relevant agencies. 153. When the social worker had first visited the school to speak with Madison, the school’s designated teacher had informed the social worker about concerns raised by other students regarding Madison’s home life; this included allegations of physical assaults, inadequate bedding and her ripped pyjamas. There was also a discussion about self-harming behaviour and that this and the other concerns went back over several years to primary school. The social worker observed scratch marks on Madison’s arms. None of these additional concerns apparently featured in the conduct of enquiries or were raised in the subsequent strategy discussion with the police. 154. The conduct of the enquiries had a narrow focus on whether Madison had been threatened with a knife. Although there is a description of Madison looking frightened there is no recorded evidence in regard to how Madison’s feelings were explored and the enquiries were closed down on the basis of mother and stepfather’s explanations and reassurances. Madison went missing from school on the 13th November and again on the 19th November 2012. The narrative that was accepted was that Madison was being bullied at school and this was the cause of Madison being upset and unhappy; this was a narrative that the parents raised more than once. The social inclusion co-ordinator’s concerns that this was deflection by the parents was not accepted by children’s social care. Page 29 of 58 155. The decision to close the enquiries was made on the 21st November 2012 by an agency team manager who despite having agreed that Madison was a child in need (CIN) and that a plan was required, stipulated that the case would be closed. The decision was made unilaterally and although it is apparent that other agencies did not comprehend the rationale, no individual attempted to escalate the concerns. It is not known what other factors the team manager was dealing with at the time such as overall workload or availability of social worker capacity that may have been an influence. The decision looks contradictory and was not challenged at the time. 156. The third contact in February 2013 via the NSPCC from a member of the public reported concerns about screaming and shouting over several months and of emotional abuse; it resulted in the recently established MASH deciding that no further action was required on the basis that large households were intrinsically noisy, that there had been recent assessments and that agencies were monitoring the children presumably through the plan that children’s social care were not party to. The latent conditions for downplaying or minimising concerns arising from potentially flawed enquiries and undue optimism about the monitoring through health and school are noted. 157. Although education and health professionals discussed their concerns at various meetings that included multiagency meetings at school and a CAMHS consultation there was no further contact with children’s social care until February 2016. There is no evidence of paediatric challenge in regard to the three appointments that Madison was not brought to. 158. The fourth and final contact with children’s social care in February 2016 was processed as a referral and allocated to a social worker who had no previous contact or involvement with Madison or with the family. The referral coincided with a chronology being collated for the first time by the school and Madison having video clips on a personal mobile phone as well as on her school email account. 159. The initial contact with MASH sought advice via email having not managed to get through by telephone. The referral was made on the Thursday 25th February 2016 which was followed up the following day with further information. The referral was not apparently processed until Monday 29th February 2016 when the social worker made a visit to the school to speak to Madison. The decision to undertake s47 enquiries was made a week after the initial contact when the decision was made to seek authorisation for Madison to be placed with a foster carer. A strategy discussion with the police did not take place until the 8th March 2016 which again did not involve any of the professionals who had extensive contact and information about Madison or had initiated the referral although there were daily conversations taking place between school and the social worker. 160. The purpose of the strategy discussion is to agree a plan for the conduct of enquiries and the logistics of coordinating tasks that involve specialist police officers and social workers that will be more complex where there is a sibling group to consider as well as the nature of the concerns. Although there was a great deal of communication on Page 30 of 58 a daily basis between different people and organisations, this is not a substitute for a strategy discussion. 161. The strategy discussion confirmed that a joint enquiry by the police and social care would be completed. By this time the social worker had already had direct discussions with Madison and there were daily conversations taking place in school. Madison was placed with a foster carer on the 16th March, over two weeks after the initial referral. 162. In summary, the extent to which a mind-set had been established for processing information about Madison contributed to limited enquiries being made until February 2016; the process of conducting strategy discussions was beset with delay and did not share all of the relevant information and excluded participation by professionals initiating the concerns. There was limited consideration of any previous history; the first time that a chronology was developed was in February 2016. The creation of the MASH in December 2012 has been accompanied by an improved format for recording enquiries and assessment which includes past history and a more structured consideration of factors such as resilience and considering what information is unknown. 3.3 Responding to cruelty, neglect and emotional harm 163. Government guidance and local procedures generally describe harmful treatment of children as being abuse that can be one or a combination of different categories ranging from emotional and physical abuse through to sexual exploitation of a child. Child cruelty is more often than not discussed at the point at which charging decisions are being made. In other words the mind set during enquiries is generally not about cruelty but establishing whether there is evidence that a child has or is suffering harm from abuse. 164. Child cruelty is an offence applicable to a child under 16 and incorporates neglect as set out in the Children and Young Persons Act 1933. The law does not define ‘wilful’ but guidance from the Attorney General6 clarifies that it means ‘deliberately doing something which is wrong, knowing it to be wrong or with reckless indifference as to whether it is wrong or not’. 165. It is rare for professionals to use the language of cruelty or to discuss whether parental action is wilful or not. 166. There are many reasons for this, not least a well-founded desire to work with parents some of whom are dealing with a multitude of challenges and difficulties. There are circumstances however where a discussion is necessary as to whether parental behaviour may be crossing a threshold in regards to consciously and deliberately treating a child in a particular and wrong fashion that represents wilful 6 Attorney General’s Reference No 3 of 2003 [2005] 1 Q.B. 73 cited by the College of Policing https://www.app.college.police.uk/app-content/major-investigation-and-public-protection/child-abuse/key-definitions/ accessed on 12th July 2017. Page 31 of 58 cruelty. It has to be considered as a formulated hypothesis that guides the planning and conduct of enquiries. 167. Neglect is a notoriously difficult area for professional practice. Except for the most extreme and clear examples of a child’s basic physical needs not being met it can be problematical getting professionals from different disciplines to develop a consensus about what constitutes significant harm for a particular child. 168. Identifying and responding to neglect requires a focus on what is happening to the child and how are they being affected rather than what parents want to describe or attribute. 169. Neglect is also more complex to identify and assess due to being a constellation of factors that occur over time rather than being one defining event or incident. 170. Having information collated into one definitive record is a foundation for identifying and evaluating the significance of different factors. An assessment by a social worker under the Children Act 1989 should provide an opportunity to collate information from different sources whether it is part of s47 enquiries or is being conducted as a child in need assessment under s17. 171. Failure to thrive and developmental delays can be a manifestation of neglect and therefore needs to be considered and as far as possible ruled in or out as possible factors; it is important that appropriate assessments are completed to establish whether there is anything other than the primary care and family environment to explain what is happening to a child. Referrals were not always made to children’s social care services; some of the contacts such as when Madison was seen at the hospital with vaginal bleeding sought information, for example about whether Madison was the subject of a child protection plan, rather than being a referral of concerns. The information from health does not appear to have been factored in to the assessments prior to February 2016. This included primary health practitioners such as the GP as well as specialist paediatric services. 3.4 Madison’s self-injury or self-harm 172. The serious case review panel was divided as to whether Madison’s self-injuring behaviour such as her hair pulling was representative of self-harm. Some of the difficulty lays in the lack of detail recorded at the time and there is little information recorded about the factors that were contributing for example to Madison pulling her hair. The referral to CAMHS was clearly an effort to give an opportunity to explore concerns about self-injury. It is a fact that there is no evidence that Madison ever sought to injure herself so seriously as to threaten her life. 173. Research shows that many of the children and older adolescents who harm themselves are struggling with intolerable distress or unbearable situations. Common problems include physical or sexual abuse, feeling depressed, feeling bad about themselves and relationship problems with partners, friends, and family. Children may Page 32 of 58 be more likely to harm them-self if they feel that people don’t listen to them, they feel hopeless, isolated, alone, out of control or powerless; feeling as though there's nothing they can do to change anything. 174. It is because self-harm can be a vital sign of something being wrong in a child’s life that it is important that it does get appropriate, well informed and sensitive attention from professionals and deserves comment in this review. 175. The term self-harm covers a wide spectrum of behaviour and severity and is a behaviour that can escalate and result in serious injury or worse whether intentionally or not. 176. Madison’s pulling of hair was first reported in 2006 when she was still in primary school. Trichotillomania is a condition where a person feels compelled to pull their hair out although this is not a diagnosis that has been made in regard to Madison7 and is not a matter that the serious case review is in a position to give any opinion. Diagnosis requires a careful assessment by a suitably qualified and experienced professional. Diagnosis needs to distinguish between behaviour that is for example a tantrum rather than behaviour that is comforting the child. For children and adolescents with trichotillomania, hair pulling is focused and/or automatic. When it is focused, the children who pull their hair intentionally do so as a way to relieve distress or tension. For example, they pull their hair out as a relief for their overwhelming urge to pull hair and they may develop a ritual for hair pulling, such as finding the right hair to pull. When hair pulling is automatic, children will pull out their hair without even realising they are doing it. For example, pulling hair while reading, watching television or when bored. For school children aged 5 to 12 years trichotillomania may be a simple habit or a sign that the child is anxious or under stress. When children start pulling their hair at this age, there is typically other causes for the problem, which may be school-related stress and/or an indication that something is worrying the child. It is often difficult for children at this age to put their feelings or troubles into words so they may pull hair as a form of relief for their stresses. Finding out what might be causing stress to the child is important, and was a motivation in making the referral to CAMHS. 177. Evidence of any self-harm should not be ignored although the response needs to be appropriate and to not be an overreaction. Collecting basic information such as the history of self-harm, the frequency of incidents, the types of methods of self-harm, the triggers, the psychological or emotional purpose for the child of the self-harm, the extent to which they are disclosing and are open to support along with any indication of suicidal ideation and/or behaviours are what an assessment should be exploring with the involvement of specialist consultation as and when appropriate. 7 A diagnosis will be guided by certain criteria such as repeatedly pulling out hair that results in noticeable hair loss, repeated attempts for them to stop pulling out their hair, the hair pulling causes additional distress at school or in social situations, and the hair loss is not due to another skin or medical condition, or the symptom of another mental disorder. Page 33 of 58 178. In very general terms children and young people fall within two broad categories of risk from self-harm. Lower risk is associated with little history of self-harm, a generally manageable amount of stress for the child and evidence of some positive coping skills and external support. 179. Higher risk is more likely to be associated with children and young people who have a more complicated profile; they report more frequent or longer term self-harm behaviour, use methods with a higher degree of lethal consequences and /or who are experiencing chronic internal and external stress with fewer positive sources of support or have less well developed coping skills. 180. Although Madison’s self-harm was the subject of a referral to CAMHS which resulted in mother declining any involvement, the formal enquiries and statutory assessments became more preoccupied with other matters such as for example whether mother had been threatening Madison with a knife. Some of this doubtless reflects a tendency to deal with more tangible issues. The self-harm was also largely treated as an issue that CAMHS was expected to deal with. 181. Recognising and exploring self-harm is one important aspect of understanding the child’s voice being visible evidence of wishes and feelings about aspects of their life that are stressful and difficult to deal with. The voice of the child can be manifested in several different ways. It is not just what children say but also what they cannot or will not talk about and about their behaviour and interaction with others around them. 182. Further guidance developed by the county council’s education psychology service has been published in an electronic format and is available through the Nottinghamshire Safeguarding Children Board website and on the county’s school portal. Additionally, a copy of the guidance has been sent to all head teachers in the county. The guidance includes signposting to local and national support for school staff, individuals, peers as well as parents/ carers. 3.5 Managing parental control, disengagement and resistance 183. The extent to which mother and stepfather controlled how information was presented and processed by different professionals is significant. It occurred in regard to the various health assessments that were conducted historically and also continued to influence how social care for example conducted some of their enquiries during the scoped period from November 2012. The control was displayed in displays of verbal anger, threats to make complaints or to change key professionals or schools and threats of legal action (in 2008). This has influenced how decisions have been made and had repercussions for Madison who is now ostracised by her family. 184. There was significant dissonance in the level of difficulties and problems being reported by Madison’s mother and stepfather in regard to behaviour compared to when at school for example. Page 34 of 58 185. The thwarted attempts by different professionals to explore concerns was raised for example by some school staff although was not explored in any of the formal enquiries and assessments. Parental resistance has featured in other reviews in the county and other areas of the country. 186. The level of disengagement has had implications for Madison having access to services such as CAMHS. Additionally, other aspects of Madison’s health care needs for example in regard to immunisations were delayed. 187. There has been a reluctance to acknowledge concerns that have been raised at various times and both parents declined to participate for example in work with the local family centre; on occasions they have sought legal advice to emphasise their opposition. They have denied that Madison was treated differently to their other children in spite of the evidence that was collated by the school in particular. 188. There is evidence from serious case reviews and from research that highlights the importance of exploring and understanding how a parent or care giver responds to concerns and is processing information. Are professionals dealing with parents who have the capacity and insight to acknowledge that there are issues to address or are they facing attitudes and behaviour that is obstructive and uncooperative or the there are other barriers to understanding? Three broad categories of uncooperative behaviour are identified from practice and research. a) Hostile and threatening behaviour; which produces damaging effects, physically or emotionally, in other people including professionals; b) Non-compliant behaviour; involves proactively sabotaging efforts to bring about change or alternatively passively disengaging; c) Disguised compliance (often manifested as disguised resistance); involves significant adults in a child’s parenting and care not admitting to their lack of commitment to change but working subversively to undermine the process. 189. The non-acceptance of needs or problems produce different forms of resistance and, indeed, even parents within one household may respond differently to concerns. In several works, Bentovim (1987 and 20048) argues that parents’ failure to take responsibility for their children’s circumstances, their dismissal of the need for change or treatment, their failure to recognise their children’s needs and the maintenance of insecure or ambivalent parent and child attachments are all key indicators of a poor prognosis in regard to a diagnosis that a child has suffered or is at risk of suffering significant harm. 8 Bentovim, A., Elton, A. and Tranter, M. (1987) ‘Prognosis for rehabilitation after abuse’, Adoption and fostering, vol 11, no 1, pp 26–31. Bentovim, A. (2004) ‘Working with abusing families: general issues and a systemic perspective’, Journal of family psychotherapy, vol 15, no 1/2, pp 119–135. Page 35 of 58 190. To complicate matters considerably, parents may say that they accept the need for change, and can even appear motivated towards that end, whereas, in reality, they are actually opposed or indifferent. From the evidence provided to the review the only time that there appeared to be some co-operation was in response to children’s social care services indicating that they would escalate their level of intervention. 3.6 Communication between professionals and use of local multi-agency frameworks 191. There was a great deal of communication between different services going back several years. 192. Although Madison was identified as being a child in need in November 2012 the decision taken by the agency team manager was to close the case and therefore no CIN plan was put in place. 193. Most of the meetings convened by school and health based professionals from time-to-time to discuss concerns about Madison were outside of the local frameworks or pathways to services. 194. The CAMHS consultation meeting did not involve either of the two agencies that have the statutory responsibility for conducting enquiries, namely the police and children’s social care services. Although there was a decision to make a referral to children’s social care services this was not done. The reason for this is not known. 195. The strategy discussions that were conducted in regard to enquires under s47 were completed after action had already been decided by children’s social care, although there was a great deal of contact between the police, social care and education, the logistics of coordinating the availability of specialist police and social care professionals and making sense of information about a child, requires a structured appraisal and plan that is updated and reviewed. Strategy discussions are not one-off events. 196. There were other occasions historically, for example when Madison was presented at hospital with vaginal bleeding on two occasions within six months, where the level of communication within agencies such as the hospital, or with other services such as children’s social care, did not achieve a good enough level of enquiry and resolution as to whether Madison was abused or not. 197. The IMR from the hospital has described work done by the trust to ensure improved responses are being achieved when children present with signs or symptoms that might be indicative of sexual abuse. Supported by this and previous reviews, a Genital Symptoms Flowchart being developed and introduced in NUH and also across the region (Flowchart for health professionals when a child / young person presents with genital symptoms). If the flowchart been in use it would have resulted in a referral to children’s social care being made, due to the initially unexplained vaginal bleeding. Page 36 of 58 198. This pathway has been developed to aid GPs in recognising sexual abuse and provides guidance on action which should be taken. To complement the work in the hospital work has also been undertaken with primary health services. Child sexual abuse, child sexual exploitation and managing disclosures of sexual abuse have been addressed in GP Protected Learning Time (PLT). In 2014 a session on child sexual abuse (recognising sexual abuse) was delivered by a consultant paediatrician. Child sexual exploitation was a theme at PLT in 2015. This training was delivered by Designated Nurse for Safeguarding Children. In 2016 training was provided in relation to managing disclosures of sexual abuse. Survivors of child sexual abuse were involved in the delivery of this training. Recognition of child sexual abuse has also been addressed in GP Safeguarding Leads training across the clinical commissioning groups. 3.7 Quality of assessment and plans 199. Assessment of a child’s needs and circumstances is the foundation upon which effective statutory professional help is provided when a child is in need or requires safeguarding from significant harm. Four assessments had been completed prior to 2012. 200. There is little information about Madison’s early life including the impact of her birth father’s death, the quality or type of attachment that Madison had with mother (or stepfather); the developmental and growth issues and concerns about self- harm are areas that were not explored and led to a reliance on the conflicting narratives between Madison and other members of the family. 201. An effective assessment explores the capacity of parents to meet the particular needs of a child and takes account of the emotional, psychological and physical resources including the quality and style of care giving by each of the parents. Very little information has been available about stepfather. Mother has clearly faced her own emotional and physical challenges and appears to have taken a great deal of the responsibility of parenting a large sibling group where there had been little space between successive pregnancies and births. 202. An assessment cannot just be a narrative. It requires professionals to analyse the significance of information that is collated (and the significance of any information that is not available or cannot be verified). 203. In developing an insight into the level and nature of risk to a child there has to be an exploration of what protective factors or sources of resilience can be identified alongside the factors that indicate vulnerability for a child. 204. For example, research indicates that older children with good attachment, good self-esteem and a good relationship with a sibling combined with a higher IQ will indicate higher levels of resilience compared to another child. In this case the assessments have not revealed and explored this sort of information clearly enough. Page 37 of 58 205. Similarly, parental history of domestic abuse, significant substance misuse, chronic psychiatric illness, isolation, experience of being abused as a child, having been looked after and had multiple placements or are fearful of the stigma or suspicious of statutory contact are contra indicators to consider alongside protective factors that include positive social support, a positive parental childhood, good parental health (mental and physical), education including workplace qualification and stable employment. The assessments do not provide sufficient information on these factors. 206. Family and environmental factors that are significant in regard to indicators of vulnerability include a run-down neighbourhood, a poor relationship with school, poor social support, poverty and social isolation. The factors in regard to protection and resilience include a committed adult for the child, a good school experience, strong community and good services and support. The assessments do not provide sufficient information about these factors. 207. It is noted that Madison experienced a disruption to her education when mother and stepfather chose to move Madison in response to queries being raised and despite apparently having friends at school she had very limited contact with them or with other social and activities outside of the school. 208. Assessment, as described in national guidance, should be a dynamic and ongoing process that has the capacity to analyse information and respond to the changing needs or risk faced by a child. A good assessment helps avoid delay in providing help and can monitor and record the impact of any services delivered to the child and family. The focus should be on the child. The assessment needs to show appropriate rigour in checking relevant information and providing a record of evidence that can demonstrate appropriately balanced judgments are being made. 209. Assessment also has to involve specialist knowledge and expertise to explore specific areas of risk or need. Examples from this particular case include the evidence of slow development in Madison’s early years that involved paediatric admission and assessment but did not involve children’s social care services; the presentation with vaginal bleeding that did not involve either a consultant paediatrician, a specialist medical assessment or involvement by children’s social care. Work has already addressed this and been described in previous sections. 210. Assessment also has to have the ability to formulate or hypothesise about a child’s needs and circumstances. This is important for example when a child is presenting with self-harm or delayed development or with physical symptoms such as vaginal bleeding. Seeking the views of all relevant parties including parents is important but should not just be taken at face value. 211. Asking parents and extended families how they parent or to explain the reason for behaviour or physical symptoms is not always the most reliable way of finding out what is happening in the home. Watching parenting in action and looking at how a child interacts, behaves and generally presents themselves can be much more Page 38 of 58 informative. What is the quality of the child’s clothing and their quality of nutrition for example? 212. Interaction is not the same as 'attachment'. Parents may overcompensate or put on a display for strangers and particularly professionals who have positions of authority but parents are generally not able to sustain this for extended periods of time. A child cannot be assumed to have a secure attachment style because they are smiling or by just observing a parents behaviour or listening to their assurances. Determining the quality of attachment is a skilled and sometimes prolonged task that will not be achieved for example through a short process of enquiry and initial assessment. In this case mother apparently had concerns about the quality of attachment with Madison that she tried to raise with the GP. Many children who are abused are compliant and eager to please. Children can be torn between trying to protect their parents from coming to the attention of the authorities and the child protecting them-self. Children can also feel coerced and become anxious about the repercussions of telling somebody in authority about what is happening. 213. In this case there are none of the classic signs of concern detected or discussed that are common in serious case reviews that examine the abuse of children such as significant mental illness or substance abuse. The early history of domestic abuse was unknown to most of the services. Little information is apparently captured about the daily lived experience at home for Madison and for her half-siblings. Referrals about noise and shouting were regarded as the expected characteristics of larger sibling households rather than signifying a household where there is chaos and/or abuse. 214. Our understanding of the harm caused to children by neglect has grown. It is now better understood that children who are emotionally deprived are more likely to develop mental health problems, have less well developed social and relationship skills, and become involved with the criminal justice system. 215. Neglect does not have to be wilful and as discussed earlier in the report there is no statutory definition in regard to what is wilful but it is generally understood to be deliberately doing something which is wrong, knowing it to be wrong or with reckless indifference as to whether it is wrong or not. There is no definable threshold for when a minor neglectful act becomes a criminal offence. For the purpose of criminal prosecutions, each single incident must be examined in the context of other acts or omissions in which the poor treatment of a child arises. 3.8 Use of the local escalation processes 216. As with all human behaviour and interaction, people can make ill-informed judgements or not take the correct action for a variety of reasons. A great deal of child protection work and especially in regard to issues such as neglect and emotional abuse rely on professional judgment. The same legal system that gives powers and responsibilities to protect children also sets out legal protection for parents and families on matters such as privacy and a right to family life without interference from Page 39 of 58 the state. A great deal of child protection work is not about gross acts of cruelty that can be seen for what they are but rather are far more nuanced and opaque. 217. The Nottinghamshire Safeguarding Children Board recognises that professionals can disagree about a judgment or decision and has published a policy and pathway for professionals to escalate their concerns if they believe another professional is taking a wrong decision and is unwilling to discuss it9. 218. The Pathway to Provision is the written policy and guidance describing the respective thresholds for identifying and responding to children in need or requiring protection. This framework has been in place since 2010 with the latest updating (version 6) in 2017. Multi-agency problem solving meetings (MAPS) introduced in 2014 and evaluated in 2015 have provided an additional opportunity for reflection and challenge when cases become stuck or unresolved. 219. The escalation procedure sets out the following advice. 220. ‘Problem resolution is an integral part of interagency working to safeguard children. It is often a sign of developing thinking within a dynamic process and can indicate a lack of clarity in current procedures or approach. Professional disagreement is only dysfunctional if not resolved in a constructive and timely fashion. 221. Effective working together depends on an open approach and honest relationships between agencies and a commitment to genuine partnership working. As part of this there needs to be a system in place to enable disagreements to be resolved to the satisfaction of practitioners and organisations involved. The aim should be to resolve difficulties at practitioner level between organisations, where this is possible, but where not the disagreement should be escalated until a resolution is achieved. Disagreements should not be left unresolved. 222. Disagreements could arise in a number of areas, but are most likely to arise around thresholds, roles and responsibilities, the need for action and communication. 223. Although it is apparent that several professionals had misgivings about the slow pace of response at critical moments, none of them used the escalation procedure which was last updated in July 2015. 9 Resolving Professional Disagreements (Escalation Procedure) Page 40 of 58 4 Analysis of key findings for learning and improvement 224. Themes described in other recent serious case reviews in the county are also present in this review; to some extent this reflects the historical timeframe that predates, for example, the implementation of MASH and the development of the neglect and assessment toolkits. 225. The learning from the review includes; a) Systems for collating and sharing information about patterns of care and behaviour that represent neglect of a child; distinguishing between behaviour that might indicate cruel rather than neglectful care; b) Children more readily disclose information to adults such as teachers or health practitioners with whom they have regular contact and have been able to develop trust; c) Professionals with statutory powers of enquiry and investigation such as social workers and police officers have far more limited time or opportunity to achieve similar levels of trust; d) Enquiries and assessments need to give sufficient emphasis and focus to the voice and presentation of the child as well as to information provided by people in regular contact with the child; e) Professionals, particularly when conducting enquiries, being sufficiently aware and sceptical about how parents or other adults may seek to influence how information is processed; f) Resolving difference of opinion between professionals who are trying to raise concerns with statutory services such as children’s social care services and the use of escalation processes; g) Recognition and response to self-harm. 226. The review recognises that significant changes have been taking place particularly in regard to how contact, referral, enquiries and assessments are conducted. A previous SCR (NN16) called on work to be undertaken on developing self–harm policies across schools in the county. Schools have been provided with guidance in responding to self-harm. The guidance on self-harm in the county safeguarding procedures was updated in April 2017. The establishment of the MASH provides better opportunity for professionals from different disciplines to process the significance of information being presented and for following up and clarifying. 227. Similarly, there has been significant work undertaken in regard to the neglect of children specifically and in June 2014 the local authority published a social work practice briefing entitled Working with Children at Risk from Neglect. 228. The introduction of flowcharts supported with training is improving the capacity of health professionals to investigate and diagnose child sexual abuse and exploitation. Page 41 of 58 229. The key findings arising from this serious case review are therefore intended to complement the developments in services and practice and the findings of earlier reviews rather than duplicate previous recommendations and include; a) Having access to a relevant chronology of information to provide context for enquiries and assessments; b) The danger of losing sight of the needs and views of the child and placing the interests or views of adults ahead of these; c) Children’s loss of confidence when professionals are unable or unwilling to take sufficiently effective action in response to their concerns; d) Children expecting to be treated as having competence, to be informed and engaged in the process of enquiry and assessment and expect to have explanations and to be informed about what decisions are being taken and why; e) Promoting opportunities for the child’s views, wishes and feelings to be heard and understood. 230. In providing any recommendations, reflections and challenges to the Nottinghamshire Safeguarding Children Board, there is an expectation that there will be a response to the key findings in regard to the following: a) An indication as to whether the Nottinghamshire Safeguarding Children Board accepts the findings; b) Information as to how the Nottinghamshire Safeguarding Children Board will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 231. The Nottinghamshire Safeguarding Children Board will determine how this information is managed and communicated to relevant stakeholders. The formal response should form part of the publication of the serious case review. 232. This review has provided the most comprehensive collation of information in regard to Madison and her concerns about her circumstances prior to becoming looked after. 4.1 Chronology and history as context for enquiries and assessment 233. This review has considered detail about events prior to 2012 to make the point that potential signs about risk or unmet need were largely out of sight in the disparate records kept by different agencies. Matters were compounded when undue reliance was given to the single agency enquiries by children’s social care services and undue confidence was given to the robustness of previous assessments influencing subsequent enquiries. 234. None of the services had a complete chronology of contact and concerns regarding Madison until early 2016. The school collated a chronology for the first time in Page 42 of 58 February 2016 although this had been discussed in 2013. The point has been made that it was at school that Madison’s circumstances were raising most concerns over several years. 235. A clear chronology of events can show where risks lie although it can be hard to find the time to do them especially if the immediate presenting information simply seen at face value is not triggering concerns about a child’s safety. The analogy of a jigsaw only revealing the real picture when disparate pieces are brought together into a coherent whole is often used to describe the difficulties when responding to neglect for example. 236. Serious case reviews regularly highlight that abuse and neglect is more likely to be identified and therefore prevented from continuing when a good chronology has been collated. It is the underlying patterns in history and behaviour that can be detected and the isolated event or incident that appears insignificant and can be down played in isolation can be identified as a warning sign when it is placed in its proper context. 237. Unless a child’s history is visible and easily accessed, opportunities to intervene more effectively will be missed. It is critical to understanding what is happening to a child and helps inform judgments for example when and where a more assertive and authoritative approach is required rather than alternatives that rely simply on goodwill or consent that are solution focussed or strength based interventions. If a child is experiencing wilful maltreatment in whatever form, it is important that this is recognised. 238. Postponing chronologies until several years have passed or concerns have reached a level where statutory intervention has been agreed mean that the task of collating a chronology is time consuming and complex and intervention has probably taken longer than it should have. Professionals are not negligent in ignoring the value of chronologies; the pressure of work that all of the various people working with or coming into contact with Madison are considerable. 239. The point to be made is that although it is social workers who are often expected to collate a chronology, this case illustrates that the same discipline is important for other services and practitioners. In particular, schools and health workers who come into contact with children on a regular basis have to be able to see information in an appropriate context. It cannot rely on memory or episodic note taking. Clearly the style and detail of a chronology in a school or clinic setting will be different to the chronology that a social worker can be expected to collate in regard to court proceedings for example but the central principle and benefit is the same and gives additional weight if and when contact and referrals to one of the statutory services is required. 4.2 Balancing the needs and views of the child and parents 240. Safeguarding systems falter when the needs or views of a child are subsumed by the views or interest of significant adults such as a parent. Page 43 of 58 241. Parents will naturally want to have an opportunity to express their views and wishes regarding their child. Although parents may indicate a willingness to cooperate this can disguise their true levels of cooperation or understanding. In this particular case there was an example when teaching staff were reluctant to raise concerns to avoid Madison being moved for example to another school. 242. Children face many barriers in talking about what is causing them distress and if and when they do disclose information may retract statements in response to what a parent may say or the response of a professional. 243. Children can be scared, feel they are to blame for breaking up a family, are not sure what ‘normal’ is in regard to other families, feel embarrassed, do not want to get people into trouble, believe they have dropped enough hints or given enough indication but this has been missed or disbelieved and they begin to feel ‘what is the point’. 244. Children need time and reassurance to be able to openly talk about what might potentially constitute abuse. This was a significant concern for Madison that has continued beyond the decision to live with a foster carer and the conduct of subsequent enquiries. Madison worries about her half-siblings. 245. Understanding the barriers that a child has to overcome and the resilience that they need to have requires more than human empathy. Professionals who have responsibility for conducting enquiries need to have a secure theoretical base and a systematic and structured approach to planning and conducting enquiries and assessments. 246. Managerial oversight should ensure that there is clear evidence about how the child’s views, wishes and feelings have been adequately secured during enquiries and assessment. 247. The MASH is providing a triage for informing the initial scoping of enquiries which provides further rigour in the processing of initial information and making decisions about the most appropriate level of help and support. The MASH is not a substitute for detailed strategy discussions. 248. In this particular case, the occasions when supervision did not provide a sufficiently clear record of how effectively Madison’s views had been secured included the closing of the s47 and child in need enquiries in December 2012 and relied on a relatively narrow line of investigation. There was no oversight of the referral in 2013. During the enquiries in March 2016 Madison told the social worker that mother and stepfather had given Madison an ultimatum during the previous enquiries that if Madison talked about abuse again they would not want Madison to remain at home. The team manager did not ascertain whether Madison had expressed any views about the timescale for any arrangements for Madison to be placed with a foster carer in March 2016 and for her to return home on the Friday afternoon. The strategy discussion that Page 44 of 58 guided the enquiries did not include the school staff who had extensive and ongoing contact with Madison, although it is acknowledged that there was a great deal of discussion with school staff. 4.3 Child focussed enquiry and assessment and dealing with competence 249. In law, all children 16 and over are treated as having competence to make significant decisions such as medical treatment or where they wish to live. In addition to the principle of competence all children over the age of 16 are presumed to have the mental capacity to make and communicate a decision. The principle of competence and capacity is predicated on a child having sufficient understanding about a particular matter being decided and the associated options and consequences, has the ability and capacity to retain and weigh the information in regard to the associated benefits and disadvantages and can communicate their decision. 250. The law is therefore clear that at 16 children have clear rights to be consulted and to be listened to in regard any concerns they might be raising but also in regard to any decisions being made that affect them. In practice children’s competence is not that clearly presented and the transition from assent to active consent is gradual. A definitive standard for competence assessment in children does not exist and it is left to individual practitioners to make their own judgement that also needs to take account of the specific circumstances of the matter in which the child’s competence and capacity is relevant. 251. Madison wanted her views to be heard; she felt that although specific teaching staff demonstrated that they were listening to what Madison was saying and took her views seriously this was less evident for example when social workers spoke with her. Teachers noticed when Madison was troubled and showed a good understanding that action was needed. 252. Child focussed enquiry has to recognise children and young people as individuals with rights that are distinct from a parent for example including being able to participate in major decisions about them consistent with their age and understanding. They also expect to have an explanation about the outcome of enquiries and assessments. 253. Madison has expressed her disappointment at not having a clear and direct explanation about the decision made by CPS. She was disappointed not to have been consulted about being made party to the family court proceedings. A meeting with the Service Director, Youth Families and Social Work provided an opportunity to discuss the circumstances under which the Family Court made the decision to end the proceedings brought by the local authority. Page 45 of 58 254. The NSPCC published a summary of research identifying ten pitfalls in the conduct of enquiries and assessment and how to avoid them10 that are reproduced in an appendix to this report given their applicability to the learning from this review. The first of the pitfalls is that an initial hypothesis is formulated on incomplete information and accepted too quickly. 255. The commentary on practice earlier in this report encourages practitioners to develop a hypothesis or formulation about a child’s circumstances that goes beyond the face value of information presented for example by a parent. The pitfall is that practitioners become committed to a particular hypothesis or viewpoint and do not seek out information that may disconfirm or challenge it. In this case there were key episodes, for example when Madison was presented at hospital for paediatric assessment, or with vaginal bleeding, the self-harming and information about cruel or neglectful treatment that invited a formulation to be confirmed or challenged more robustly. 256. What the pitfalls do not articulate is the susceptibility of practice and decision making to human bias and influences. Humans do not think and act according to algorithms. We have an inbuilt tendency to selectively search for information that supports or confirms our beliefs or hypothesis that we have already made. It effects how we perceive the world and process information, how we encode or give meaning to that information and interpret the significance and relevance of it to our judgments and decisions for example in regard to whether a child is at risk or not. 257. This process of confirmation bias helps us structure our world and also with developing problem solving strategies and is an especially valuable resource in responding to the circumstances and information associated with complex child safeguarding practice. It is both a strength that is also a weakness and can be barrier that can blunt our curiosity, have an impact on our critical thinking and lead to polarisation and divergence between different individuals and organisations. 258. This can be most explicitly manifested, for example, in discussions about thresholds and the extent to which a child’s circumstances have reached a point at which statutory involvement for example by children’s social care is necessary. If the acceptance of a referral or the conduct of fuller enquiries and more detailed assessments rely on a confirmatory bias that assumes evidence or information has already established at the outset about the nature and degree of need or risk it blunts curiosity and also creates the latent conditions in which the true nature of risk or need remains hidden or misunderstood. 4.4 Promoting opportunities for the views, wishes and feelings of children to be explored and understood 10 Broadhurst. K, White. S, Fish. S, Munro. E, Fletcher. K, and Lincoln. H (2010); Ten pitfalls and how to avoid them. What research tells us. NSPCC Page 46 of 58 259. Madison’s resilience in dealing with her home circumstances and the extent to which her voice was downgraded shows an unusual cognitive and emotional capacity on her part. 260. Doubtless, being enrolled at good schools with effective pastoral care and committed staff who clearly were taking notice of what she said was important. Effective participation in education is an important source of resilience. 261. For children to speak about abuse or things that are causing them distress takes great courage and their need for effective emotional and practical support will be considerable. 262. The conduct of enquiries require appropriate planning to achieve better levels of situational awareness that take account of all relevant information. Planning should include appropriate professional advice and support that is informed by research and evidence of good practice. 263. The work already taking place in the county is an example of how arrangements are being improved. It will often be people like teachers who are hearing or observing information about a child’s circumstances rather than social workers who have far more limited contact with a child. 264. The people who know a child well and have a longer term perspective can be very effective in helping to combat the confirmation bias that might beset professional enquiries already discussed in earlier parts of this report. Loss of situational awareness in multiagency teams of professionals can result in poor or damaging outcomes. 265. Situational awareness is the ability to identify, process, and comprehend the critical elements of information about what is happening to the team with regards to the core task, for example, of achieving protection of a child. Loss of situational awareness is manifested when for example people become fixated on one element of information to the exclusion of new information, there is a reliance on ‘gut instinct’ and there are unresolved discrepancies. 266. The panel are agreed that well directed enquiries and assessments and applying the type of learning that has been described in other sections of this report are the best assurance that Madison and other children are properly heard and understood. Fundamentally, these rely on people always managing to find the right response. 267. Lessons are being learnt in ensuring that professionals who feel that their concerns are not getting an appropriate response will use escalation processes. 268. Professionals who are raising concerns about a child need to satisfy themselves that the concerns and circumstances of the child are being properly understood and be willing to use the escalation processes if required. Designated lead professionals have an important role in offering advice to their colleagues and if necessary help in using the protocols. Page 47 of 58 269. The extent to which children’s wishes and feelings are ascertained and taken account of is now part of Ofsted’s framework for inspecting the arrangements made by local authorities to protect children. As part of that inspection process the importance of independent advocacy has been raised and several local authorities have been advised to improve or establish access to independent advocacy as part of child protection arrangements. 270. Madison has been clear in saying that she feels her concerns, views and wishes were not considered enough when formal enquiries were being undertaken. 271. Changes such as the implementation of the MASH, the work in regard to improving strategy discussions, developing practice in regard to assessment and self-harm and the protocols for managing investigation and diagnosis of sexual abuse are creating a more robust context for responding to children. 272. The focus on promoting the escalation procedures with professionals and the evidence that this is being increasingly done with good effect leads the panel to make no further findings or recommendations. 4.5 The learning and improvement for the Nottinghamshire Safeguarding Children Board to consider 1. Does the Nottinghamshire Safeguarding Children Board have sufficient information and confidence about how the voice of the child is sought by professionals and appropriately informs judgments and decision making during enquiries and assessments? 2. Is the Nottinghamshire Safeguarding Children Board satisfied that policy and guidance in regard to the recognition and response to self-injury or self-harm by children supports appropriate professional practice and is being implemented effectively enough across multi-agency partnerships that include schools, primary health and youth work settings? 3. What information does the Nottinghamshire Safeguarding Children Board have that chronologies are appropriately collated and analysed to inform judgments and decision-making when concerns are raised in regard to child abuse including neglect by organisations providing services to children? 4. The Nottinghamshire Safeguarding Children Board should ensure that appropriate professional briefings and practitioner learning events on the findings from this review are completed. Page 48 of 58 Appendix 1 Terms of reference identified by the serious case review team for further investigation by the key lines of enquiry: 1. Comment upon the extent to which the information, views, wishes and feelings of PN16 were sought and recorded appropriately in regard to significant points of contact and whether at any time the views or comments of parents were influential in how information from or about PN16 was processed. 2. Collate and provide analysis about your agency’s response to any disclosures of self-harm and/or suicidal thoughts including third party disclosures. 3. Collate and provide analysis about your agency’s response to any reports of emotional or physical abuse. Was the response compliant with expected professional standards and internal procedures and with NSCB/NCSCB Interagency procedures? 4. What assessments or enquiries were made by your agency as a result of information received and how effective these were these in addressing risk and promoting PN16’s safety and well-being? 5. What indicators in regard to behaviour or other aetiology presented by PN16 could have been indicative of abuse including self-harm were observed and recorded by your agency and were they sufficiently recognised and acted upon appropriately? 6. Collate and comment upon the effectiveness of information sharing and case coordination within your agency and with other relevant agencies. 7. Are there any issues in relation to the training, knowledge or workload capacity of people in your agency that is relevant to understanding how PN16’s needs were recognised and dealt with? Page 49 of 58 Appendix 2 Membership of the case review team Service Director, Youth Families and Social Work Nottinghamshire County Council Inspector Nottinghamshire Police Acting Service Director Education, Standards and Inclusion Nottinghamshire County Council Associate Director for Safeguarding and Social Care Nottinghamshire Healthcare NHS Trust Director of Quality and Performance Mansfield and Ashfield Clinical Commissioning Group (CCG) Associate Designated Nurse for Safeguarding Children NHS Newark and Sherwood CCG (working on behalf of NHS Newark and Sherwood CCG, NHS Mansfield and Ashfield CCG, NHS Nottingham West CCG, NHS Nottingham North and East CCG and NHS Rushcliffe CCG) Head of Safeguarding Nottingham University Hospitals NHS Trust Group Manager, Historical Abuse Nottinghamshire County Council Group Manager, Safeguarding and Independent Review Nottinghamshire County Council Development Manager (child deaths) Nottinghamshire Safeguarding Children Board Independent reviewer (author of this report) Professional support Child Death Administrator Nottinghamshire County Council Page 50 of 58 Appendix 3 Ten pitfalls and how to avoid them11 1. An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it. 2. Information taken at the first enquiry is not adequately recorded, facts are not checked and there is a failure to feedback the outcome to the referrer. 3. Attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored. 4. Insufficient weight is given to information from family, friends and neighbours. 5. Insufficient attention is paid to what children say, how they look and how they behave. 6. There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk. 7. Initial decisions that are overly focused on age categories of children can result in older children being left in situations of unacceptable risk. 8. There is insufficient support/supervision to enable practitioners to work effectively with service users who are uncooperative, ambivalent, confrontational, avoidant or aggressive. 9. Throughout the initial assessment process, professionals do not clearly check that others have understood their communication. There is an assumption that information shared is information understood. 10. Case responsibility is diluted in the context of multi-agency working, impacting both on referrals and response. The local authority may inappropriately signpost families to other agencies, with no follow up. 11 Broadhurst. K, White. S, Fish. S, Munro. E, Fletcher. K, and Lincoln. H (2010); Ten pitfalls and how to avoid them. What research tells us. NSPCC Page 51 of 58 Appendix 4 Biographical summary of the independent reviewer The safeguarding children board commissioned Peter Maddocks as the independent reviewer who has written this overview report. He has over thirty-five years’ experience of social care services the majority of which has been concerned with statutory services for children and families. He has experience of working as a practitioner and senior manager in local authority services and of working in national inspection services and with the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and statutory inspections in relation to the safeguarding children. He has undertaken independent agency reviews and has provided independent overview reports to several local safeguarding children boards in England and Wales as well as regularly working on domestic homicide reviews for several community safety partnerships. He has not been employed by any of the services contributing to this serious case review. He has completed training for overview authors and independent reviewers including the application of systems learning and participation in masterclass professional development. Page 52 of 58 Addendum The independent reviewer identified learning and improvement for the Nottinghamshire Safeguarding Children Board (NSCB) to consider as follows. 1. Does the NSCB have sufficient information and confidence about how the voice of the child is sought by professionals and appropriately informs judgments and decision making during enquiries and assessments? NSCB response Training - an anonymised case study highlighting the learning from Madison’s experiences will be utilised in professional training. Audits – there is now a specific question asking how professionals have captured the ‘voice of the child’ in all NSCB multi-agency audits Policy and guidance – A new practice guidance document “Good Practice Supporting the Voice of the Child” was included in the Interagency Safeguarding Children Procedures in January 2018 The annual Section 11 audit requires NSCB member organisations to provide evidence as to how young people contribute to the planning, delivery and evaluation of services. The NSCB Executive receives regular updates from the Local Authority on how social workers capture the ‘voice of the child’. 2. Is the NSCB satisfied that policy and guidance in regard to the recognition and response to self-injury or self-harm by children supports appropriate professional practice and is being implemented effectively enough across multi-agency partnerships that include schools, primary health and youth work settings? NSCB response Nottinghamshire County Council Education Department, together with the Child and Adolescent Mental Health Service (CAMHS), have produced specific guidance ‘Young People & Self-harm: Guidance for Schools’. This has been introduced at a launch event in November 2017 and seven workshops are being held during the spring 2018 term across the county for education professionals working in secondary schools. Policy and guidance – the ‘self-harm and suicidal behaviour’ chapter of the Inter-agency Safeguarding Children Procedures was updated and strengthened in February 2018. A new website has been developed by Nottinghamshire County Council Public Health in partnership with Notts NHS Healthcare Trust, ‘Health for Teens’ which is available for young people to access support for their emotional and physical health and wellbeing. The NSCB jointly funded the project and contributed to the consultation during its development. The website links young people to appropriate local health and wellbeing services, and supports young people to manage their health and wellbeing. It features interactive content, films and quizzes written by experts and includes topics as wide ranging as exam stress to anger management, and from spots Page 53 of 58 to alcohol. It also offers a text service where teenagers can text their school nurse for confidential health advice and support. Training – an e learning course ‘Self-harm and Suicidal Thought in Children and Young People’ is available for professionals via the NSCB website. 3. What information does the NSCB have that chronologies are appropriately collated and analysed to inform judgments and decision-making when concerns are raised in regard to child abuse including neglect by organisations providing services to children? NSCB response Health and Nottinghamshire County Council colleagues are involved in ongoing work through the ‘Connected Nottinghamshire Board’ to link IT systems which will provide further opportunity to produce effective chronologies. Policy and guidance – the Interagency Safeguarding Children Procedures contain a practice guidance document ‘Guidance for Practitioners: Completing Chronologies and Genograms.’ This guidance was updated in May 2016. Nottinghamshire Schools have been provided with a sample ‘Child Protection Confidential File’ audit template which contains a question on use of chronologies. Schools have been provided with guidance on the use of chronologies and some secondary schools are investing in IT solutions which allow them to produce a chronology. In 2016 NSCB completed a multi-agency neglect audit which featured a question on the use of chronologies. The audit identified deficiencies in the use of chronologies and an action plan was developed to address this. Training – NSCB has held two multi-agency training workshops each year in 2015/16, 2016/17 and 2017/18 on neglect, which included input on the use of chronologies. 4. The NSCB should ensure that appropriate professional briefings and practitioner learning events on the findings from this review are completed. NSCB response NSCB will publish the Serious Case Review Produce a Learning Bulletin giving a summary of the key learning points from the review Include the learning in the NSCB newsletter for professionals Include the learning in relevant multi-agency training including ‘Working Together’, ‘What’s new in safeguarding?’ and ‘Learning from Serious Case Reviews’ workshops NSCB member organisations have a responsibility to cascade the learning in their own agencies. Page 54 of 58 Individual agencies who contributed to the serious case review were requested to provide an update on actions taken by their organisations relating to issues identified in the review. Response from Nottinghamshire Clinical Commissioning Groups (CCGs) Child sexual abuse, child sexual exploitation and managing disclosures of abuse have been addressed in GP Protected Learning Time (PLT) across Notts. CCGs from 2014 to 2018. In 2016 additional training was provided in relation to managing disclosures of sexual abuse. Survivors of child sexual abuse were involved in the delivery of this training and addressed over 500 GPs and practice nurses across Nottinghamshire. Recognition of child sexual abuse was addressed in GP Safeguarding Leads workshops across the CCGs in 2016. Consultant Paediatricians in Nottinghamshire developed a ‘Flowchart for health professionals when a child/ young person presents with genital symptoms’. This pathway is to aid GPs in recognising sexual abuse, and provides guidance on action which should be taken. It is now incorporated into the NSCB multi-agency practice guidance. “Madison’s Story” has been shared with Safeguarding Leads across the Notts. Health Community, and learning and themes have been shared and discussed at the Notts. Safeguarding Children Health Partnership Group and the Nottinghamshire CCG Safeguarding Committee. A briefing was included in CCG Newsletters, September 2017, to emphasise the importance of health professionals offering young people time alone when there are possible safeguarding concerns or where they have information about concerning behaviour, to afford opportunities for disclosure of abuse. A safeguarding template has been developed for GP SystmOne records, which prompts professionals to respond to risk factors. The CCGs have communicated with Health Education England in relation to the lessons learned from this case to inform GP training programmes We continue to promote the message of listening to the voices and experiences of children and young people at every opportunity, and have confidence that there is greater understanding of this across the NHS community as a result of the actions above. Page 55 of 58 Response from the Nottinghamshire Healthcare Foundation Trust Escalation continues to be highlighted across the Trust both within briefings to staff from reviews and within safeguarding training. The issue was also recently highlighted at the Leadership council as a key theme from the learning from reviews. Over the coming months we will be rolling out a programme of Lesson Learned seminars across the Trust, to encourage staff to reflect on the learning from reviews and how this should impact upon their own practice and that of their teams – escalation will be included within this workshop. It will also be included in learning shared with our safeguarding link practitioners. The Trust has a clear escalation process in place in line with the multi-agency procedures. Escalation is now monitored by the divisional safeguarding leads. Where themes are identified, they are raised across the divisions via divisional safeguarding forums and are discussed with appropriate colleagues in partner agencies. CAMHS consultation - Following on from another recent SCR that the Trust was involved with, consideration was given to reviewing the consultation model. It was felt that the model itself is a sound model with a focus on supporting the professionals involved with a child at a time when active therapeutic intervention is not in the child’s best interests. The model was quality assured in order to confirm it is fit for purpose. All CAMHS consultation cases are now discussed during the practitioner’s safeguarding supervision to assist the practitioner to reflect on whether the consultation is effective and if it is remaining focused on the specific needs of the child and family. This process ensures the voice of the child is heard and can support the practitioner to identify when escalation is required. Embedding these discussions within the practitioner’s supervision also ensures that all CAMHS consultation cases have robust managerial oversight. The safeguarding supervision framework has recently been reviewed and relaunched, with specific training for managers who are delivering supervision. It is anticipated this will result in more robust supervision – the model is being externally evaluated by the University of Nottingham. In this case a CAMHS follow up consultation was available to professionals but was not utilised. The profile of the availability of these CAMHS consultation follow-ups has been raised and as a Trust we can now evidence that these are readily conducted. The learning from this review will be shared upon publication via a written briefing to staff as well as through the ‘Lessons Learned’ events, two ‘Safeguarding Matters’ events and via the safeguarding link practitioners meetings. Page 56 of 58 Response from Nottingham University Hospitals Trust Nottingham University Hospitals (NUH) have been involved in the production of the ‘Was not Brought’ animation and this has been embedded into the safeguarding training provided in 2017. The term Was Not Brought is now being widely used when children fail to attend appointments rather than ‘Did not attend’. This is to help staff acknowledge that children need to be brought to medical appointments by parents or carers. This clearly places the responsibility onto parents to ensure that children and young people have their medical needs met. The newly produced Flowchart for health professionals when a child/ young person presents with genital symptoms or injury clearly sets out the process to follow when a child or young person presents at NUH with symptoms which may be caused by sexual abuse. This group of patients are now routinely being seen by, or discussed with the community paediatrician who has expertise in this area. If there is a disclosure of sexual assault/ abuse by the child or young person then an immediate referral is made to the police and children’s social care. Safeguarding training at NUH includes the need to listen to the ‘voice of the child’ and encourages staff to be curious and alert to the fact carers may sometimes give the appearance of cooperating with agencies to avoid raising suspicions and that this may not give an accurate picture of what life is like for the child (disguised compliance). The importance of completing chronologies (a list in date order of all the major changes and significant events in a child’s, adult’s or family’s life) has also been promoted. Chronologies assist in identifying concerns and help professionals to better understand what is happening in the life of a child or young person. To help clinicians (doctors etc.) provide better care of children with long and complex histories NUH are undertaking work to consider including a problem list within children and young people’s electronic records. These lists are already included in the letters written by the community paediatricians. This allows clinicians to better understand existing/ historical concerns which assist with the formulation of appropriate plans of care including, where appropriate safeguarding plans. Page 57 of 58 Response from Nottinghamshire County Council (NCC) Children’s Social Care Quality Management Framework – an ongoing framework for the regular auditing of individual cases by managers across the department, including senior managers. Increasingly this audit programme has been complemented by seeking direct feedback from children and young people who have had involvement of a social worker. This work is undertaken by Social Work Practice Consultants and colleagues from the Quality and Improvement service, independent from the social workers involved. Feedback is then disseminated to social work staff and managers – focused on what young people have experienced as working well and what is viewed as unhelpful. The Child and Family Assessment process has been in place since February 2016; this is complemented by increased focus on the use of specific tools to promote evidence-based assessments. This includes the use of the Safeguarding Assessment and Analysis Framework – which is a national model to promote robust assessments, systemic analysis to predicting the likely outlook for the child in cases where there are safeguarding concerns. The revised Child and Family Assessment has a specific focus on the ensuring that the voice of the child is listened to with a section of the assessment exclusively dedicated to ascertaining and recording the views, wishes and feelings of the child. The Pathway to Provision thresholds document is well-embedded since its first launch in 2010. This enables a shared understanding across agencies of thresholds for referrals to early help/social care and also signposts professionals to the use of the escalation process if there are disagreements between agencies as to the nature of intervention provided. Managerial oversight of children in need cases has been strengthened by the introduction of specific guidance. This is also subject to the routine auditing of cases under the Quality Management Framework. Multi-agency Problem Solving Meetings were introduced in 2014 to provide an opportunity for professionals to consider together cases where there is concern as to lack of improvement in outcomes for a child. The effectiveness of the work of the Multi-Agency Safeguarding Hub (MASH) has been kept constantly under review to ensure a robust response to new referrals and timely throughput for assessment where required. When needed, additional staffing has been agreed to ensure that there is adequate capacity within the MASH. Improving the effectiveness of strategy discussions has received senior management oversight with a specific group of managers from social care, Quality and Improvement, and the police engaged in taking this work forward. This is to ensure that all relevant professionals are included at the outset in agreeing the appropriate way forward and actions to be taken. In 2016 all Team Managers attended workshops Page 58 of 58 led by the Principal Social Worker and Group Managers regarding their role and responsibilities when chairing strategy discussions. Improved processes for obtaining information from GPs are now in place in the MASH. Social workers have been provided with a new and improved training programme including: o Assessing Risk and Sexual Abuse – several events run since September 2016. All Newly Qualified Social Workers access this training during their assessed and supported year of employment o Direct work with children workshops – over 20 events run since March 2016. In addition all Newly Qualified Social Workers access a Communicating with children course during their assessed and supported year of employment Response from Nottinghamshire County Council (NCC) Education Education Department staff will undertake work to identify the reasons for continuing issues with escalation by schools. We will identify and examine examples of casework where escalation has worked effectively to resolve professional disagreements. We will identify the factors that contributed to these successful outcomes. This will look, inter alia, at the role of the education representative on MASH. We will interview a sample of school staff with safeguarding responsibilities in order to: establish what their understanding of the process is; explore why they have or have not used it; consider what further arrangements regarding escalation they would find helpful. We will use the information from the above work to inform ongoing training for school safeguarding staff. |
NC52784 | Death of a 16-year-old boy in December 2020 by three young people over a drug debt. All four young people had a history of involvement in either drug supply at street level and or involvement in anti-social behaviour and violence between young people. Learning includes: understanding safeguarding within adolescence as a developmental life stage; the importance of considering the dual identities of young people as victims and perpetrators of harm; practitioners needing to hold the concepts of the autonomy of the young person and their dependence in healthy tension; the role of poverty and inequality as a driver for harm and adversity; the importance of providing a personalised and tailored response; the role of adultification - seeing children as older and more responsible than they are chronologically or developmentally; whether the current legal and policy framework facilitates or inhibits effective responses to extra familial harm; the importance of a trauma informed approach to working with young people where practitioners look for what lies beneath a young person's behaviour; the connection between young people's trauma and unmet developmental needs; and viewing trauma through developmental and relational lens enables better sense making of young people's worlds and the impact of their experiences. Recommendations include: commit to the implementation of the national exploitation principles when published; develop a range of early intervention services to support children and families at risk of or in the early stages of child criminal exploitation; ensure that practice always explores the strengths within the immediate and wider families of children at risk of or being criminally exploited; and recruit workers with the personal skills to undertake relational work with children and families and gives them the training to develop those skills further and time to develop relationships with children and families which do not preach or judge.
| Title: Child safeguarding practice review: overview report: Child F. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: Colin Green Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. ChildSafeguarding Practice Review Overview Report: Child FAuthor: Colin Green Date: May 2023 Publication Date: May 2023 Page 2 of 32 Contents 1. Executive Summary ............................................................................................ 3 2. Reason CSPR Undertaken ................................................................................ 4 3. The Murder of F .................................................................................................. 4 4. Context of Adolescence ................................................................................... 5 5. Information Available to the CSPR ................................................................ 5 6. Family Contexts ................................................................................................... 6 7. Educational Contexts ......................................................................................... 7 8. Contact with Services of Each Adolescent ................................................. 11 9. Family and Young People's Contributions to the Review .................... 15 10. Practice Learning Event .................................................................................. 20 11. Analysis and Response to the Key Lines of Enquiry .............................. 22 12. Partnership Learning ....................................................................................... 28 13. Recommendations ........................................................................................... 32 Page 3 of 32 1. Executive Summary This review is about F and the three young people involved in his murder. Two, G and H, were convicted of his murder and J of a lesser offence. All four young people had a history of involvement in either drug supply at street level and or involvement in anti-social behaviour and violence between young people. This history started in early adolescence. Three were being criminally exploited from age 11 to 14 years to deal drugs primarily cannabis but H was involved in dealing crack cocaine and heroin. None of the young people recognised that they were being exploited at the time but do so now. Three of the four came from families where they were exposed to domestic abuse at a young age and had other adverse childhood experiences. All four had difficulties at school and underachieved educationally. H attended the same school for the whole of his secondary education and J the same secondary school from year 8. They both benefited from the continuity this provided and the consistent interest of the adults at school, offering care, support and advice to themselves and their families. Conversely the secondary education of F and G was disrupted. They were permanently excluded from mainstream schools and once placed in a pupil referral unit did not have consistent educational input. For G his involvement in education was limited for all of years 10 and 11. All the young people had some involvement with statutory services. For G and H this had been considerable at various points in their lives. These two young people had Child Protection Plans (CPP) for Child Criminal Exploitation (CCE) which came at a late stage in their involvement in exploitation. For G this involvement made little difference for him or his family. For H the involvement was welcomed and found helpful by his family who also used their own resources to try to help H move away from the lifestyle they saw as harmful to him. The families of F, G, H and J were all expressing concern about their young people in different ways. The families felt at a loss as to what to do. They felt under threat themselves from those exploiting their children and did not have confidence that statutory agencies could protect them if they shared all they knew with those agencies. Professionals working with the young people also felt uncertain as to what they could do to make a difference. They undertook their discreet roles as best they could but were aware that what they had to offer was not enough to change how the young people behaved or draw them away from being exploited. In retrospect they could see there was little effective coordination between the work of the different agencies and practitioners. The conclusions and learning from this review are similar to 'Safeguarding Young People – risks, rights, resilience and relationships' edited by Dez Holmes1 and other reviews primarily the 'National 1 Safeguarding Young People – risks, rights, resilience and relationships edited by Dez Holmes. Jessica Kingsley 2022 Page 4 of 32 Review – It was hard to escape Safeguarding Children at Risk of Criminal Exploitation'2 and the '2014 to 2017 triennial analysis of serious case reviews'34. The recommendations are to take forward the learning from those reviews adapted for the local context in Lancashire including the commitment to implement the national exploitation principles when published. In addition the importance of the following needs to be recognised: • Developing a range of early intervention services to support children and families at risk of or in the early stages of CCE • Ensuring that practice always explores the strengths within the immediate and wider families of children at risk of or being criminally exploited • Recruiting staff with the personal skills to undertake relational work with children and families and give them both the training to develop those skills further and time to develop relationships with the children and families they are supporting, which do not preach or judge. 2. Reason CSPR Undertaken F was murdered on 23rd December 2020 and was 16yrs and 5 months old when he died. At the time of the murder, G was 16ys and 4 months, H 18yrs and 11mths and J was 17yrs. G and H were convicted of his murder and J was convicted of conspiracy to commit section 18 assault. All four young people had contact with a number of statutory services in the period prior to F’s murder and earlier in their childhoods including consideration of whether they were subject to CCE. Lancashire Safeguarding Children Partnership agreed that the criteria for a CSPR had been met on the grounds that this case exposed gaps in partnership working across Lancashire when responding to CCE. It was agreed that carrying out a CSPR focussing on CCE would support and direct the work already taking place. 3. The Murder of F F was murdered in a planned attack over a drug debt of £25. Reports indicate that all four young people involved knew each other and were involved in street level supply of drugs. The Police had information of previous violence between F and G and H. Following the convictions of G, H and J, F’s parents said in a statement that “Their son died at the hands of 'three heartless cowards' in an 'unprovoked attack'. We will remain incomplete without F. His cheeky laughter will never again be 2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/870035/Safeguarding_children_at_risk_from_criminal_exploitation_review.pdf 3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869586/TRIENNIAL_SCR_REPORT_2014_to_2017.pdf 4 https://seriouscasereviews.rip.org.uk/local-safeguarding-partnerships/ #lscb_vulnerable Page 5 of 32 heard in our home. The sentences given today will never reflect the pain and devastation with which we are living each day.” 4. Context of Adolescence 4.1 At the time of F’s murder H, aged 18 was an adult, F and G were 16 yrs and J was 17yrs. Convention would be to describe them as young people. This term allows for consideration of emerging adulthood. The term ‘youth’ refers to a 14–25-year-old reflecting the UN definition and takes account that the adolescent brain continues to develop until the mid-twenties for many people (Sawyer et al, 2018)5. In thinking about their lives and how services might respond to their needs it is important to consider the life stage they were in. Being a young person or adolescent is a time of profound change6. There are major alterations in biological, emotional, and social spheres of human development. There are specific vulnerabilities which may link to previous adverse experiences. These adversities may extend beyond the ’10 Adverse Childhood Experiences (ACEs) commonly identified, based on Felletti et al’s original ACEs study7. The study focused on intrafamilial adversity and did not include structural trauma, inequalities and situational vulnerability due to housing, poverty etc. Being a young person is a time of experimentation, separation from family, the establishment of a life centred outside the family, the development of close friendships and when first romantic and sexual experiences occur. There are few people who do not experience highs and lows as a young person or who did not take part in activities they later regret or would later see as foolish or risky. An issue for this review is considering how being a young person was potentially different for F, G, H and J in ways that led to the tragedy of F’s murder. How could services have responded better to their needs as young people so that their lives were more like their peers? 5. Information Available to the CSPR 5.1 While all four young people who are the subject of this CSPR were known to a number of public agencies in Lancashire, what was known about their lives by those agencies was limited. Adolescence is a time when children develop their lives outside the family which may include new relationships not known to their family. Young people will decide what they will or will not share with adults whether within their family or when they are in contact with agencies. They exercise greater autonomy over their own information, compared to younger children. 5 Sawyer S, Azzopardi P, Wickremarathne D and Patton G (2018) ‘The age of adolesence’. The Lancet Child and Adolescent Health. 2(3): 223-228 6 Coleman and Hagell in Safeguarding Young People edited by Dez Holmes. Jessica Kingsley 2022 7 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D., Spitz, A. M., Edwards, V., … Marks, S. J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Page 6 of 32 5.2 All four of these young people were involved to various degrees in the supply of drugs in their local area, in using drugs and in violence between local gangs. What public agencies knew about this will be described later but what is certain is that public agencies only knew about a fraction of what was going on. This was also almost certainly true for the families of the four young people. 5.3 There were adults involved in supplying drugs to these young people who were not visible to public agencies, with the exception, to some degree, of the Police. These adults must have played a significant role in the lives of the young people both in terms of the trade in drugs as dealers and suppliers and in setting the “culture” within which the young people operated as street level dealers. 5.4 This would have included the commitment to secrecy, hostility to the Police and the use of violence to enforce norms of behaviour within the dealing/supplying network. It was known that there were members of the young people’s extended families who were part of organised crime groups or who had a history of involvement in drug use and dealing. What role these people played with the individual young people was not known to agencies. 5.5 The aspects of these young people’s lives which were unknown or unseen to public agencies were very significant and important in considering what might have provided a better response to the needs these young people presented, including how to keep them safe. 6. Family Contexts 6.1 F lived with his mother and two younger brothers. His father lived nearby and was in regular contact with F. F’s parents were from the middle east. F was born in the UK. F was a healthy child. The only significant area of contact with specialist health services was an assessment for whether F had Attention Deficit Hyperactivity Disorder (ADHD). This was assessed by the local Child and Adolescent Mental Health Service (CAMHS) in October 2019 and in March 2020 it was concluded there was not enough evidence for a diagnosis of ADHD. F’s mother was seeking an explanation for his aggressive behaviour but once ADHD was not evidenced, what lay behind F’s behaviour and his mother’s concern about this was not followed up. The Family had no contact with Children’s Social Care or other specialist services prior to July 2019. F’s murder has traumatised his family. He was a loved and cared for child. 6.2 J lived with his mother and an older sister. J’s family were of South Asian Pakistani heritage. J was born in the UK. His father lived separately from the family and his parents were divorced. There was a considerable history of domestic abuse in the family of which J’s mother was the victim. In 2017 this led to a child protection plan for J. J was upset by his parents’ divorce. There are indications that the family experienced a sense of shame in their community about the divorce. The Family would also have placed a high value on maintaining privacy about family matters including from public agencies. 6.3 G lived with his mother and an older sister and younger half-sister. G’s father was of black Afro-Caribbean heritage and his mother white British heritage. He was born in the UK. His father lived in Lancashire and was in regular contact with G through most of his childhood. Page 7 of 32 6.4 G’s family had had extensive contact with children’s services from when he was 6yrs. This related to extensive domestic abuse where G’s mother was the victim. His father was not the perpetrator of the abuse to his mother. This abuse was sufficiently serious to lead to three Child Protection plans over the years. G’s mother loved and cared for him and although G loved his mother, he did not take notice of her or his older sister's concerns about his behaviour or the risks associated with his drug dealing. 6.5 H lived with his mother and her partner and four younger half siblings. H’s parents were white British heritage and H was born in the UK. H also lived with his father and his father’s partner for a time away from his hometown and with his maternal grandparents from early 2020 in his home town in Lancashire. There was a history of domestic abuse where his mother was the victim, but this did not lead to child protection or child in need plans for H and his half brothers and sisters. His Family were aware of his involvement in drug supply and wanted to help him change his life, which was why he went to live with his father and then his maternal grandparents. 7. Educational Contexts 7.1 Within national reviews of young people involved in violent crime there is a strong association with exclusion from school89, school absence and being in a pupil referral unit. With this context it is worth considering the educational history of these four young people. 7.2 F. F completed his primary education and there are no indications of serious difficulties while he was in primary school. He transferred to a local comprehensive school to start his secondary education. During F’s time in Year 9, he was getting into difficulties at this school and a managed move to another secondary school was tried but failed, and he returned to his original school. He was placed for “respite” at a Pupil Referral Unit (PRU). He remained on roll at his school and returned there at the start of Year 10, September 2018. His attendance in the school year 2017/18 was 95%. 7.3 F’s behaviour at his school in Year 10 deteriorated and he was permanently excluded because of drug related issues. He was found in school with a quantity of cannabis. He returned to the PRU in March 2019. 7.4 F was unsettled at the PRU and was for the rest of Years 10 and 11. He was on a personalised timetable. The PRU arranged external provision with a local vocational centre. F was not identified as having any special educational needs. 7.5 The PRU opened a Common Assessment Framework (CAF) to support the family in June 2019. At the PRU, F sometimes arrived under the influence of cannabis and was very aggressive towards staff but not to other young people. On one occasion, he took drug paraphernalia to an off site activity. His mother worked with the school but did not believe what she was told about her son. She found it hard to accept the negative information the school provided 8 Irwin-Rogers, k., Muthoo, A., Billingham, L. (2020) Youth Violence Commission Final Report 9 Longfield, Anne, Commission on young lives Page 8 of 32 about F’s behaviour and what he was involved in. The PRU described F as alternating between fight and flight modes of behaviour and that his dysregulated behaviour was not helped by his cannabis consumption. He could be polite and respectful. 7.6 When Covid lockdown started, F’s mother contacted the PRU for advice as F was still going out and not following the guidance in place at that time. The Headteacher of the PRU spoke to F, who his mother had reported to and then he adhered to the Covid rules. By June 2020, F was considering college applications and seemed to be making positive choices about this. F gained level 3 in GCSE Maths and English. His Cognitive Ability Test (CAT) and Academic Achievement Battery (AAB) scores were very variable which is usually an indication that a student has missed education and in some areas is working well below what they are capable of. For example, F had an expressive communication score of 104 and Math reasoning score of 102, whilst also having a Reading score of 69 and Reading comprehension score of 88. The GCSEs, AAB and CAT scores suggest F had the ability to do much better in education. He could have accessed a normal secondary education curriculum, if his needs could have been better met in the educational setting/mainstream school. 7.7 J. J completed his primary education and transferred to a local secondary academy school in September 2015 to commence Year 7. At the start of the next academic year, in September 2016, his parents selected to move him to another academy school as they wanted him to attend an Islamic ethos education establishment. He completed his secondary education at this school in June 2020 at the end of Year 11. J had no identified special educational needs. 7.8 J was temporarily excluded three times in Years 10 and 11 for a total of 11 days following assaults on other pupils. He was never at a point where he was considered for permanent exclusion or a move to another school. A total of three exclusions, including one for five days, was unusual within this school’s pupil population. 7.9 J was an able pupil, when he attended and worked well, he got good results. In Year 11, his attendance was 82% which indicates persistent absence. He left school with eight GCSEs or equivalents which included achieving grades 7 and 6 in Science, 6 in English Literature and 5 in English Language and Maths. J had good relationships with most teachers and in particular with his Head of Year and his English teacher. He responded well when people put in time and effort with him. 7.10 J’s school saw that they were providing ‘normality’ for him. There was routine and stability at school. J’s school were aware that this was different to his life outside school. They were aware of his negative behaviour outside school and that he was involved in street level crime and what his school described as gang related activity10. The school was never told specifically about any of J’s drug related offences. There were never any indications of J dealing drugs in school or that he ever smelt of cannabis at school. 10 Caution is needed in the use of ‘gang’ terminology. It is not clearly or consistently defined, which can drive racialised interpretations. Page 9 of 32 7.11 The school had most contact with J’s mother and some contact with his father. They had contact with an older brother who they saw as a positive influence. The school held a Team Around the Family (TAF) meeting as there were issues at home related to J not accepting his mother’s authority. His older brother tried to help with this. 7.12 School was not aware of J being involved in any structured positive activities outside school. He was a good athlete, but he did not follow this up. 7.13 H. H left school in July 2018. H had been permanently been excluded while at primary school aged 8 years old and subsequently attended a special primary school. He attended a special school for children with Social, Emotional and Mental Health (SEMH) needs for the whole of his secondary schooling. He had an Education Health and Care Plan (EHCP) that reflected his additional educational needs. H’s special educational needs were primarily related to his behaviour. His academic attainment was poor, but this reflected on him missed schooling and/or his behaviour was a reflection of his frustration at not being able to learn. He would have been able to access the secondary curriculum. H was literate and numerate. He was good at sports, in particular football. 7.14 H did present difficult behaviour in school, but he could also be engaging and charming with staff. H could be quick tempered and aggressive in school. He had a number of fixed term exclusions for aggression to staff including assaulting the head teacher. He was remorseful after these aggressive episodes. His school were able to manage his behaviour and he was not excluded. 7.15 H’s school was aware he was involved in the supply of drugs outside school and saw that H was pulled towards this more than being in school. They observed he “had” to answer the phone he used when involved in supplying drugs. His mother worked well with the school and was keen for H to do well. She supported the school in trying to ensure he did access education and took the opportunities the school offered. The school’s view was that H could manage further education or an apprenticeship. H could talk to staff and explain what the matter was including why he lost his temper, and he did respond to a restorative approach. 7.16 School made a number of referrals to Multi Agency Safeguarding Hub (MASH), Early Help and initiated a Common Assessment Framework (CAF). They referred H to the school’s Family Support Worker. 7.17 G. In Year 6 of his primary school, G’s behaviour meant school was struggling to meet his needs due to his complex emotional, social and educational needs. He had 1 to 1 support from a teaching assistant. He transferred to a local secondary school. He was permanently excluded from that school in the Easter term of Year 8, when he was 12 yrs old. The permanent exclusion was for bringing cannabis into school, and threats made to the school headteacher. 7.18 G was dyslexic and struggled with basic literacy. He was thought to have difficulties with speech and language. His difficult behaviour in school included sexually explicit and abusive language within the school environment. However, G’s CAT and Wide Range Achievement Page 10 of 32 Test (WRAT) scores suggest he was of low average ability and that he could access a normal secondary curriculum. 7.19 Following exclusion, G moved to a PRU where he was initially settled, and an effort was made to reintegrate him into another mainstream secondary school which failed. He returned to the PRU. Staff in the PRU felt that after this ‘failure’ G seemed to give up. Following the unsuccessful attempt to reintegrate him into a mainstream school, G struggled to settle back into education within the PRU. The PRU asked for a statutory assessment for an EHCP, which was undertaken and recommended specialist provision. G was in Year 9 when this request was made. The category of need identified for G in the EHCP was Specific Learning Difficulty (SPLD) and SEMH. 7.20 The EHCP was completed in October 2018 near the start of Year 10. The EHCP noted that G was hypervigilant. Research shows that hyper-vigilance (along with other Post Traumatic Stress Disorder related symptoms) in children is linked to experiencing domestic abuse, which was a feature of G’s childhood. 11 He struggled to maintain attention in a classroom environment as he had such high levels of alertness and found being seen on a 1 to 1 basis, in a quiet room, easier. 7.21 Before the specialist provision was identified G was referred to an unregistered provision, found by the Lancashire Special Educational Needs (SEN) team. This was not acceptable to the PRU, where he was still on roll, as they could not quality assure the provision themselves. The disagreement about what provision was suitable for G between the PRU and the SEN team must have been confusing for G and his mother. The back and forth about this educational provision caused relationships between education services, G and his mother to deteriorate. Responsibility for the problems in finding him a suitable educational placement lay with the ‘system’. G experienced this as another educational failure. G was then offered a place at a special school. 7.22 Following this episode, G did not engage well at the PRU. He had a 1 to 1 timetable. He regularly came into the PRU, got into trouble and was sent home. G had good days, where he was reported to be delightful by staff, other days when he was verbally aggressive and his behaviour was unregulated. G was well presented, liked to look good and appeared well cared for. G liked Food Technology and was good at Sports and other physical activities such as Jujitsu but did not always engage well with sports. 7.23 In May 2019, towards the end of Year 10, G was on roll at a local special school. It appears his attendance from this point forward was very poor. By his own account, G said that he hardly attended school in Years 10 and 11, as he was out in the community dealing drugs. G had no educational provision after he left school in July 2020. There seems to have been no post 16 tracking, even though G had an EHCP. It appears no agency, other than perhaps the Police, had ‘eyes’ on G. 11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193214/ Page 11 of 32 7.24 Education summary and analysis. F, G and H all had significant difficulties in engaging and settling in education due to their complex needs/difficulties, which were expressed in their behaviour and educational settings being unable to meet their needs. G and H had EHCPs. H spent most of his education in special schools. H benefited from the continuity of attending one secondary school, he and his mother were able to develop relationships with the staff from which H benefited. 7.25 G and F were permanently excluded from their secondary schools and attended the local PRU. The reasons for their permanent exclusions were serious matters and it is simplistic to think that their schools had any very clear alternative. The issue is what is the response to such exclusions. Their educational experience was fractured. They did not build up positive relationships within their educational provision. For G, the changes of provision and ‘failures’ of new provision often undermined his already tenuous engagement with education. 7.26 J stayed in his secondary school and left with some good GCSEs and good prospects for his future. His school believed they were a haven for him, and he found in school positive relationships with adults he saw as wanting to help him. The evidence for this was in the progress he made in school and the positive relationships he had with a number of staff. 7.27 The educational experience of these four young people emphasises the importance of school as a place for positive relationships and continuity of care (for J and H) and how for F and G the absence of these qualities led to further disengagement from education and missed opportunities for positive relationships with adults and peers. 8. Contact with Services of Each Adolescent 8.1 All four young people knew each other and were connected through friendship, in the case of G and H, and through their involvement in the supply of drug and related street gangs. They lived relatively near each other. F and G had both attended the same PRU. The agencies who knew them were not aware of their connections or did not focus on the possible connections between them. The approach of the agencies was to work with each adolescent as an individual. Good practice in contextual safeguarding emphasises the need for group work where safe to do so.12 Summary of Agency Contact: 8.2 NHS services: F, G, H and J were all physically healthy young people with limited contact with NHS services including their GP. Much of the information from NHS agencies reflects their participation in multi-agency forums, which discussed the four young people e.g. Child Protection conferences. The GP referred F to CAMHs as noted in paragraph 8.3. The GPs were aware of the Child Protection Conferences (CPCs). There were one off contacts, such as, J being seen by Liaison and Diversion while in Police custody in July 2019 and G’s attendances at A&E in September 2020, when he was found unconscious in a hotel room. He was with others who called an ambulance. G was 15yrs at the time. All four young 12 https://www.contextualsafeguarding.org.uk/blog/spotlight-5-building-on-friendships-to-create-safety/ Page 12 of 32 people had a number of health professionals involved in their care. They did not receive a holistic assessment from these health professionals in relation to their physical, social and emotional needs at the points where concerns about their involvement in criminal exploitation were emerging. 8.3 Child and Adolescent Mental Health Services (CAMHS): CAMHS assessed F for ADHD in 2019, concluding there was insufficient evidence to make a diagnosis in March 2020. The request for assessment came from F’s mother reflecting her concern about his behaviour. His mother wanted an explanation for his anger. When ADHD was not diagnosed, this was the end of any exploration of F’s behaviour and needs. CAMHS answered the question they were asked, but did not explore F’s difficulties any further. H was referred in July 2019 about his difficulty managing anger and attended with his mother for an initial contact, but there was no further contact. Children’s Social Care (CSC) and the Children and Family Wellbeing Service (CFWS). 8.4 F had no contact with CSC. He was referred to the CFWS in July 2019 by his school due to the unsafe situations he was finding himself in and his anger, aggression and drug use. He was closed to the service after anger management sessions were completed. His mother said nothing had changed. There was a request from CAMHS to the CFWS for support, but the service was unable to engage him into any work. 8.5 J’s family had a history of domestic abuse and there was a CPP for this reason from July 2017 to July 2018. In June 2019, concerns were raised about J being criminally exploited, but his mother declined an assessment which led to no further involvement. 8.6 G and his family had an extensive history of involvement with CSC from when G was in primary school. This was mostly related to domestic abuse and the consequent impact of this on G and his siblings. In August 2019, G had a CPP because of emotional abuse and physical abuse related to criminal exploitation and the high risk of harm to him from this. Those working with G while on the CPP found he was very guarded. G was reluctant to engage in any conversations. He was distressed when professionals came to his home. He saw himself as protecting his family and taking on their burdens. There is no evidence that G was providing financial help to his family from his illegal earnings. Contact was on G’s terms and reflected his level of distrust of public agencies, their staff and possibly his fear from those who he was supplying drugs. Professionals cannot guarantee the safety of a young person who discloses illegal activity. A failure to engage may be a young person keeping themselves safe from reprisals for being seen as a ‘grass’. 8.7 G was closed to CSC in May 2020 when the risk was assessed as low, and the case transferred to the CFWS from the CSC exploitation team. Red Amber Green (RAG) or scored risk assessments are deeply flawed. They are applied inconsistently, based on variable evidence, can screen out some young people and can be used as a gatekeeping mechanism for services.13 The aim of the work with the family wellbeing team was to support G to be ready for college in September 2020. G did not engage with this support, his mother did and 13 https://tce.researchin practice.org.uk/risk-assessing-child-sexual-exploitation/ Page 13 of 32 completed a parenting programme. In November 2020 there was a further CSC assessment due to the family, G’s older sister, expressing serious concerns about the risk he was at, with indicators of CCE such as carrying knives. G denied he was engaging in or ensnared in high-risk activities. This led to a strategy meeting to consider what to do next to protect G. G’s mother and sister felt dissatisfied with the response recevied from CSC and Police with regards to protecting G. 8.8 H and his family had considerable contact with CSC, with fourteen contacts and referrals between 2003 and 2019 of which, four led to assessments. These contacts and assessments were domestic abuse related. H was first identified as being involved in the supply of drugs in February 2019. In February 2019, there was a further incident of child to parent abuse between H and his mother. While the case was open, information was given about H’s criminal associations and he was assessed as at risk of CCE and risk of serious violence. This led to a CPP for H. The information made clear that for some time, H had been subject to pressure from adults in relation to dealing drugs and felt under threat in the community including from people in his wider family. His mother was concerned about him carrying knives and his selling drugs. She had reported him having drugs in the house. This indicates the importance of taking opportunities to treat protective parents such as H’s mother, as partners in work with their children. 8.9 While H was reserved and did not always feel safe enough to trust professionals, he did confide in those working with him and his mother shared important information about H and her concerns about the risks to him. 8.10 In October 2019, H was assessed as at high risk of CCE and that the CPP was not working in helping protect him. In January 2020 H moved to his grandparents in the same town and this together with him being in regular work he liked was seen to have reduced the risks to him and the case was closed in March 2020. Youth Justice Service (YJS) 8.11 F was sentenced to a six-month referral order for affray in September 2019. The offence was committed in November 2018. The affray was an arranged fight between groups of youths. F was assessed as at low risk of reoffending, low risk of serious harm and medium risk for safety and wellbeing. The comments made in paragraph 8.7 about the weaknesses of scoring or RAG rating systems apply to the way the risks to F were assessed. F completed the referral order successfully in April 2020. His compliance reduced towards the end of the order. He had no further contact with the YJS. The work done with F while on the referral order did not give any indication of his being involved in drug dealing and related activities. This became clear after his murder. On face value F engaged well, was polite and pleasant. He seemed to like to please and keep people happy. 8.12 J had his first contact with the YJS in November 2020 following a charge of theft in July 2020. J was referred to the Out of Court Panel and a Community Resolution was issued. J said he wanted to distance himself from a gang lifestyle when seen for assessment prior to the Out of Court Panel. This was an important statement from J and should have led to an active response. Page 14 of 32 8.13 G had no contact with the Youth Justice Service. 8.14 H had a referral order in February 2016 for lighting a firework in a public place. H was open to the YJS from September 2019 to June 2020. He had two convictions for intent to supply heroin and crack cocaine in February 2019 and three convictions for possession and intent to supply crack cocaine, heroin and amphetamine in May 2019. In September 2019, H was sentenced to a referral order which he completed. 8.15 H reported he started to use cocaine at the age of 14 years, which was in 2016. He was given cocaine instead of money for dealing drugs. He was identified as at risk of CCE in May 2019 and that he was groomed by an Organised Crime Group (OCG) member. H’s compliance with the referral order was described as good. His move to his grandparents was positive as was his working in a job he liked. Assessments from the midpoint of his order showed reduced risk of serious harm to others and of reoffending. 8.16 The relatively limited or no contact with the YJS for all four young people is in contrast to the extent of their contact with the Police. Police 8.17 F had continuous involvement with the Police from March 2018, when he was 13yrs, to his murder in December 2020. The involvement was initially about assault and bullying allegations made by F at his school, which were resolved by community resolution. F was arrested four times between November 2018 and April 2020. F was arrested for attacking, with others, victims with a baseball bat and metal poles. In October 2019, his phone number appeared on an analysis of a drug dealers phone records. F was spoken to at home by a member of the CCE team with his mother. F denied being involved in dealing drugs. F should have been seen alone. He said he was not under threat. In January 2020, Police intelligence indicated F was a main dealer heavily involved in the supply of drugs in a particular area and was carrying knives. In May 2020 he was found close to controlled drugs, which could not be attributed to him. The Police concluded F was involved with drug users and placing himself in an extremely vulnerable position. The framing as ‘placing himself at risk’ suggests F was seen as responsible without considering the pressures there may have been on him or how far he was the subject of exploitation. In October 2020, F was found with cannabis and this was dealt with by Police resolution. 8.18 J was recorded as throwing stones at taxis and smashed a neighbour’s window between November 2018 and January 2019, he was 15 yrs old. Police also recorded J being assaulted by a gang of males. Police submitted a youth referral to the Youth Justice team. In June 2019, he was seen in the company of an adult known to be part of an OCG. He was arrested twice in 2020, for a fight and for theft, but no charges resulted until the charge of theft leading to the Out of Court panel in December 2020. These contacts did not lead to a safeguarding alert. 8.19 G was reported missing three times in 2016, he was 12 yrs in August 2016. The police records show a first link with drugs in September 2018, when G was 14 yrs. His mother reported him missing and found evidence of G dealing crack and smack (heroin). The Police knew G was Page 15 of 32 involved in numerous incidents of violent behaviour in 2018/19. He was recorded as assaulting others three times and being assaulted four times by gangs of youths. The Police believed these incidents were gang and OCG related. These incidents led to a strategy meeting with CSC in July 2019 and G being placed on a CPP. 8.20 In August 2020 G was reported missing several times and that he was carrying knives. In November 2020, G’s sister was very concerned about his drug dealing and that he was carrying knives and a machete for his own protection. This led to a further strategy meeting in December 2020. His sister, though a young adult, was another potential ally for those working with G. 8.21 H was 13yrs when he was dealt with by a community resolution for pushing the Deputy Head of his school and damaging his school. In March 2019, there was an Initial Child Protection Conference (ICPC) related to concerns about H’s behaviour and his identification as a victim of CCE. He had been arrested in February 2019 for possession with intent to supply crack, cocaine and heroin. He was arrested in May 2019 for intent to supply crack, cocaine and heroin. The offences were linked to a wider investigation of an OCG. H said he was being groomed to sell drugs and both H and his mother reported threats to his life. Police recorded CSC as believing H was being exploited by adult males. There was conflict between H and his mother about his drug use and this was part of the reason he moved to his grandparents in January 2020. The concerns about H’s links to an OCG and him being exploited were again recorded in July 2020. In July 2020, H received a serious stab wound to his hand and would not tell the Police about this assault. H had been chased by males with a machete. 8.22 The Police were working to disrupt the OCGs but it is not clear that there was a systematic effort by the Police to disrupt the street level drug supply networks that these young people were part of. 9. Family and Young People's Contributions to the Review 9.1 The parents of the four young people who are the subject of this review were all written to about the review and offered the opportunity to talk to the reviewer. Two mothers have taken up this offer. The report summarises the key points from the discussions with the mothers and in one case with maternal grandparents. 9.2 The mothers and one child’s grandparents talked warmly about their child and their place in the family. They recognised the troubled aspects of their behaviour and the difficulties they had brought to their families, but they were loved and valued members of their families. 9.3 The Mothers of G and H were clear that their children were being exploited from early adolescence. Their views were that both young people had been groomed from early adolescence and that this was known to CSC and other agencies. For example, H was hanging around from age 13 yrs with older males. G’s mother was also aware he was carrying weapons. G and H’s mothers knew of incidents, where G and H were injured in assaults or when running away from those attacking them. For both mothers, their sons did not listen to them and Page 16 of 32 their mothers’ distress when they were injured or under threat seemed to make no impression on the two young people. 9.4 Both mothers saw changes in their children’s appearance and demeanour, which they attributed to drug use, principally cannabis. They were aware of the money their children had and what they were buying with this, which was beyond what their families could provide. Both Mother’s said they could make adequate material provision for their children, though money was always tight. 9.5 G’s mother knew G was under threat, but recognised that G was in too deep to the lifestyle, to get out on his own. She was aware that the focus of his life was his life on the streets. G’s mother wanted him to be moved out of his hometown by CSC. 9.6 G and H’s mothers knew their children were scared at times. They were aware of serious consequences for their children and for their families, if either their children, or they told the Police or other agencies about their offending. Both families felt under threat and intimidated at times and had little confidence that the authorities could effectively protect them in their homes. H’s mother described how those exploiting H climbed through windows of her house and threw stones at the house. At times H’s mother paid his drug debts to try to reduce the risk to H. H’s family tried to get him out of his local town, and this was why he went to live with his father for a period when he was 16yrs old. 9.7 For G’s mother, the CPP made no difference as by that stage G was unwilling to work with services, though there were times he would sit and talk to his key worker and ask to be moved from his hometown. This was an opportunity to consider what disruption activities or wrap around service could have helped protect G. G was also not sharing what was happening in his life with his mother. It was evident that G’s mother had little influence on his behaviour. 9.8 For H’s family their experience of help following H’s two convictions for drug possession in 2019 were more positive though they did not see the CPP as making a difference. The Family felt the help they received was valuable, including helping the family move to a neighbouring town. This was even though the move of home meant the younger children in the family changing schools and disrupted their local friendships. H moved to his grandparents. He got a job which he liked, and which paid a reasonable wage. His grandfather tried to instil in H positive work habits including making sure he got to work on time and taking on any overtime that was available. 9.9 The support workers from the exploitation team and Youth Offending Service (YOS) were valued as people who listened, showed genuine concern for H and his family, and were trying to make a difference. The regular and frequent time spent with H and his family by these workers was valued and made a difference. 9.10 H’s family saw how this positive progress was disrupted by H suffering a hand injury in a machete attack and he then gave up his job. This disruption to his life made him more vulnerable to getting reinvolved in drug dealing again, the friends who were involved in this Page 17 of 32 and related behaviours. H’s family see a direct connection between the injury, not keeping his job and H getting involved in the murder of F. 9.11 Parents were positive about the efforts their children’s schools made to engage them in education and keep them in school. H’s school kept in touch with his mother who felt they did well with him. For H, support from CSC in 2019 and 2020, including the exploitation team and YOS, was good. 9.12 H’s mother contrasted this experience with previous experience with social workers who she felt tried to tell her what to do and judged her. This was also how G’s mother felt about some previous social workers. The parents felt they could not contact the Police or help them because of the potentially serious consequences for them and their other children. What could have made a difference? 9.13 The parents said they felt very stuck when they knew their children were dealing drugs and working for the older men. They could not tell on them directly because of the potential consequences for their children and their families. Both children were violent to their mothers and homes when high or could not get cannabis. Both mothers tried to protect their children as best they could with limited resources and choices available. H’s mother thought availability of workers, like those she found helpful from the exploitation team earlier, might have helped. People to talk through the dilemmas she faced and who she felt were sympathetic to her and liked H would have helped. These practitioners needed to not judge or preach. 9.14 Both parents thought earlier involvement would have helped, especially when their children were younger, such as, when they were just starting to get involved in drug dealing. They thought more help with taking them out and trying to engage them in positive activities might have helped. 9.15 The three young people involved in F’s murder were written to and asked if they wished to contribute to the review. G and H agreed to meet the reviewer. G 9.16 G was seen in April 2022 with his social worker at the Young Offenders Institution (YOI) where he has been since being sentenced. G described himself as very closed and not willing to tell, even those he had trust in, such as his mother and father what was happening. He did not want to “put weight” on them. G described himself as a “tight person”, “a proper confidential child”. He knew his family were concerned about him, but he thought that anything major he shared would be passed on. He felt his family had not been in his situation and had not learnt to handle what he was now handling. G contrasted his adolescent life with what was happening when his father was his age. 9.17 G said he would have felt weak if he had told people his problems, even at age 13yrs. G said he did not see himself as having choices, he just acted. This was linked in his mind to his view Page 18 of 32 that no one groomed or made him do things that he did not want to. G saw himself as making his own destiny. G said he was never "battered" by those higher up. Social Workers 9.18 G felt social workers did nothing for you and tried to force something out of you. There was an expectation that you would share information with them “full whack – like no tomorrow” from a first interview. G contrasted this with the approach of a social worker he had known when he was younger, who worked with the family when he was 10/11 yrs old, who took it slowly and spent time with him. G recalled this social worker was with the family for three years and did help. This social worker was with the family following G’s mother being beaten up. G said he has flash backs of his mother being beaten up. Education 9.19 G recalled choosing the friendship group at his secondary school who got into trouble. He was the class clown. G recalled stopping going to the PRU and related provision in Years 10 and 11 as he was making money dealing drugs. This was his daytime activity. Involvement in drug dealing 9.20 G linked his making money to not wanting to ask his mother for money and that the dealing gave him access to material things he wanted. He was making more money than anyone he knew in a regular job, which made a regular job unattractive. G said, he knew nobody with a regular job. 9.21 G said the violence was about jealousy and territory. There were fights, where he inflicted injuries, and where he was injured. His mother’s distress at his injuries seems to have had no effect on him. There was a normalisation of violence. G felt he needed knives and a balaclava to protect himself when dealing drugs. 9.22 G said he smoked cannabis every day and this removed his feelings. He described himself as like a fizzy bottle shaken and about to explode and the cannabis helped him manage these feelings. He did not care about anyone except himself, and this lack of feeling, G attributed to his cannabis use. This suggests G’s drug use was a form of self-medication. 9.23 G said that when we was 15/16 yrs old he began to process more of what he had gone through and was going through and became more future orientated. Up to that point, he lived in the moment. As a 15 yr old, he felt he was already independent and had already grown up. G was very clear, he saw himself as in charge of his own destiny at this time. G saw himself as having earned all he had got. When G said he was ready to leave his hometown to his social worker, he meant it, but he could not tell the whole story of why he needed to leave. He provided no detail of what was going on to enable the social worker to justify such a move. 9.24 G did recognise that there were those who were bigger than those like him selling drugs on the street. He noted that it was not the ‘kids’ who started it. He implied, these were the people who supplied weapons to young people like him. Page 19 of 32 H 9.25 H now sees that at aged 12/13yrs old he was “groomed” to sell drugs. This was not how he saw it at the time, but he can see this now. What happened to H was described as grooming by Police and his solicitor following his arrests for possession of drugs in 2019. H told Police he was forced to sell drugs. He said when younger, he was oblivious to what was happening. He did not care, including the impact on his mother of his selling drugs. H described falling asleep in school and the use of two phones in school, one of which was his drugs phone. What H described matched what his school had described about this behaviour in years 10 and 11. H, when younger, was hiding drugs for older people. He did not listen to his mother, who was trying to deal with what she saw H involved in. H’s mother forced him to go to school and he would “kick off” and resist her efforts to get him to school or otherwise behave better. 9.26 H described himself as a well-known kid, who hung around the local shop. People he met there, some of whom were from outside his local town, led him into drug dealing. H said that at 13 he would do anything he was asked to. He did not see it as exploitation, but more being looked after by older mates. H said that when dealing, he made £1000 a week, which was shared with G. 9.27 H described being in and out of selling drugs. He would stop and then get drawn back in. He found cocaine addictive and he was given cocaine in exchange for selling drugs, which drew him back in and meant he had drug debts he had to repay through dealing. After his convictions for possession in 2019, he and his family were harassed and his mother moved out of his local town. H said it was hard to get out of dealing and he did not listen to others. He did not know what prison was like. His family were all people who worked in regular jobs. His mother tried to put boundaries in place. 9.28 When asked about why he had got into drug dealing, H said he saw older people leading a good life. They could buy what they wanted, however, H said that his mother always got him what he needed, and he was provided for, but he wanted more. Family relationships 9.29 H is close to his maternal family. After a period of living with his father, H returned to his mothers’ home, but felt the house was very full and his grandparents agreed to help by taking him in as long as he worked. His maternal grandparents had always been part of H’s life. This family support was important for H and was helping him break away from his involvement in drug dealing. School and education 9.30 H recalls being excluded from primary school aged 7/8 yrs old, when he threw a chair. He then went to a ‘behaviour’ school. H liked it and saw it as good for him. He had anger problems and liked the 1 to 1 attention. At school, H loved Maths and PE. In Years 10 and 11, H was a peer mentor at his school, which he liked. In Year 11, he was quiet in school, but was only there 60 to 70% of the time. He liked Science, as it was a hands-on subject. He liked Food Technology for the same reason. At H’s secondary school, H said he tried to be Page 20 of 32 respectful. He liked two staff members that were involved in professional football and he listened to them more than female staff. Child Protection Plan (CPP) and involvement with YOS 2019 9.31 H did recall the time there was a CPP and the meetings he attended as part of this. He had no distinct memory of the social work involvement with him and his family. H described what was said as going in one ear and out the other. H agreed that social care and others were right that he was being exploited. However, he saw the money being made and as he got older, thought he knew it all. H recognised he did not listen to others but also saw that some of the people he associated with were scary as he knew what they were capable of. H could see his mother was worried about him and her ex-partner was angry with him because of H’s behaviour. H saw his mother as being on her ex-partners side not his. 9.32 H did recall his involvement with the YOS. The YOS worker did check up on him and worked with his mother. Contact with the Police 9.33 H said the Police knew he was involved and he did not cooperate with them. H could not say what was going on. He did get stopped and searched but only found with drugs twice. These two occasions when he was caught led to him having a drug debt. Carrying a knife and experience of violence 9.34 H said until F’s murder he never carried a knife. He said knife carrying was common amongst those involved in selling drugs and that it hyped everyone up. H was aware of violence on the estate where he was brought up. There were men with guns and knives. Those involved seemed to get an energy from this behaviour. H said he has been attacked a few times. What might have made a difference 9.35 When asked what might have made a difference, H identified the absence of his father in his life when younger. He contrasted this to the role that the father of his brother has played. For example, the consistent interest of his brother’s father in his brother playing football. H's brothers father was there to support H’s brother while H’s father was absent and when H stopped playing football at 12 or 13 yrs of age, there was no one to get him back into playing. 10. Practice Learning Event 10.1 The practice learning event provided an opportunity for the practitioners who had worked with F, G, H and J to share information about this experience and reflect on what might have made a difference. The information shared is included in the account of agency work with F, G, H and J. It was evident that practitioners had thought carefully about their work with the four young people. There was a shared conclusion that all four young people were very entrenched in the situation they found themselves in and that the interventions, the practitioners had delivered had not been effective in addressing or identifying their needs. Page 21 of 32 10.2 Practitioners noted the lack of power of their offer compared to the material rewards drug dealing offered alongside the unseen people with influence on the young people’s lives who are members of their community and in some cases of their wider families. 10.3 The discussion of what might have made a difference included the following points: • The importance of the young person having ownership of the plan for them and the related issue of how to engage them sufficiently in developing their plan • Earlier intervention, including when there are difficulties in school, trying to maintain children in mainstream school and when this cannot be done providing continuity of education and school placement. • The importance of community engagement and the role that community and youth workers could play in this work. • How to engage fathers. • Using trauma informed approaches at every stage. • Flexibility and autonomy for family support workers to adapt programmes to the child and family circumstances. Time to try to get to the underlying issues for the young people. • Services are too targeted – need workers who have no agenda, who have time to get alongside young people without having to deliver a programme or intervention. Structures that allow the development of relationships over time - 6 to 12 months.14 • Addressing the needs of and providing containment for parents who feel overwhelmed by the behaviour of their children and the risks their children face and by their own issues. • Long term impact of domestic abuse • Recognising the importance of family values, including desire for privacy, sense of shame and how a family may fear being seen in their community as a result of their children’s behaviour or adult problems such as divorce or separation. There was a lack of evidence of how cultural and family values had been considered in practice with these four young people. 10.4 Practitioners’ views of what needs to change: • Earlier intervention – the CCE service is only working at level 4 when behaviour and involvement in CCE is very entrenched. Need an earlier assessment and services that can be offered in response. • Education provision that does not meet needs or sufficiently engage or address difficulties early enough or with sufficient intensity of intervention. • Unassessed health needs and ensuring there is a lead professional for health needs. • Ensuring A & E attendances are recorded within wider interagency system. • Communication and access to a central record held by the GP for the multi-agency system. • Lack of suitable placements if a child needs to move out of the area • Benefits of open access youth services. Everything is now too targeted. Open access provides greater insight into communities and helps provide access to trusted adults. • Are CPPs useful for young people facing CCE given the parental deficit model the CPP is based on? What alternatives could work better? 14 https://tce.researchinpractice.org.uk/slowing-down-for-stronger-momentum-in-tackling-child-exploitation/ Page 22 of 32 11. Analysis and Response to the Key Lines of Enquiry What was known and understood about the risks to F, G, H and J by each agency individually and collectively across agencies? 11.1 While a considerable amount of information was known about each of the young people who are the subject of this CSPR, this information was about a small segment of their lives. The information that was known to public bodies was shared through mechanisms, such as, the CPC that were held for H and G and when J and F were involved with the Youth Justice Team, but none of this amounted to a full bringing together of all the information, potentially available from all agencies. The risks to H and G were recognised through their being subject to CPPs, but the CPPs were of relatively short duration and in retrospect, it is hard to see that when G’s ended, any significant change had been made to the underlying risks he faced. 11.2 The sense is of quick, transactional ‘throughput’ type work, which was not sufficiently purposeful, or thoughtful or young person centred enough. For H it appeared risks had reduced, but this did not recognise the limits of what was known about his life and his relationships with those who placed him at risk or might lead him into further serious offending. The risks to F and J were not well articulated, F and his family declined assessment by CSC and the level of risk he faced was not fully understood. This was also true for J. This raises an important dilemma about how to reconcile working with parents as partners with situations where the child’s best interests invite assessment without parental consent. 11.3 G and H’s families were very concerned about the risks they faced and shared information with Police and CSC. A question for the review is whether this information was given sufficient weight or acted upon or whether professionals recognised how difficult it was for families to share such information or the risk they might be taking in doing so. J and F’s families were less engaged but neither of their cases escalated to the formal mechanisms of CPP which might have provided a means for sharing information. Were F, G, H and J identified as at risk of CCE in each agency and collectively? 11.4 G and H were identified as at risk of CCE. This was clearest for H who with his mother talked about the exploitation he had experienced and was experiencing. G disclosed nothing about his relationships, but the information from the Police and his family made clear that he was being exploited even if he did not identify with this description of his circumstances. 11.5 For F and J, they denied being exploited and were not identified as being subject to CCE. This judgment rested on the absence of evidence of them being pressured to be involved in drug dealing and youth violence. Given their ages at the time and that they were involved in drug dealing with the drugs supplied by adults not identifying them as exploited suggests a degree of control and volition which does not recognise that the adults were exploiting them whatever J and F’s views were. 11.6 Though G was identified as being at risk of CCE he saw himself as involved in dealing drugs as a choice. Given his age and circumstances, it would not be appropriate to see him as in Page 23 of 32 control of his destiny in this way. A young person does not need to self-identify as a victim of exploitation to be treated as one. Asserting to a young person like G that they are a victim or being controlled could be upsetting to a young person who has built a mental model where they are a tough seasoned adult in charge of their own destiny. This sense of agency, however misguided, can be an important part of the scaffolding they build to feel safe and have some control. All four young people were being exploited whatever their views of the level of control they had of their situation. Was information shared about F, G, H and J who were at risk of CCE in a timely and effective way? 11.7 The formal mechanisms of strategy meetings, CPCs and Multi Agency Child Exploitation (MACE) discussions were used with these young people. There were weaknesses in what was shared. On occasions, the Police did not share information provided to them anonymously and which was not otherwise evidenced. This is a sensitive judgment to make about when to share information which cannot be substantiated. It may be useful for the Partnership to offer guidance on what constitutes information or intelligence and why and when it needs to be shared. The schools seem to have been included some of the time but not always and it is not evident that consideration of how these four young people were at school was given sufficient weight or what might be learnt from their educational history fully considered. The weakness in information sharing was the consideration given to what agencies did not know or what they might infer from the limited information available. This led to an optimism that levels of risk were reducing or a view that having completed the assessment, YOS and CP processes this would have reduced the risks without positive evidence this was the case. For example, for H, G and F simply because there was no new offence or nothing new known, their risk was assessed as reduced without a deeper reflection about whether anything had changed for the young people and what might have been hidden from view. What interventions and offers of help were tried with F, G H and J and what if any was their impact? 11.8 F, G, H and I were all subject to some level of intervention which perhaps provided a level of reassurance which was not substantiated by evidence of change in the young people’s lives. F, I and H had interventions from Youth Justice which focused on their offending. They completed their orders successfully and were believed to then be at lower risk. G and H had considerable contact with CSC when on a CPP and with specialist CCE team workers. These workers completed programmes with H and G, but subsequent events suggest this work made minimal change in their outlook or was superficial relative to the other more powerful influences on their behaviour and views of their world. For example, when the CPP ended for G in May 2020, and he was stepped down to the Children and Family Wellbeing Service, G did not engage with the service at all. H did appear to do better after the end of his CPP, but this seemed related to actions his family took when he moved to live with his grandparents. By the time G and H were subject to CPP because of CCE, their behaviours and levels of distrust of agencies were entrenched. The CPPs did not last long enough for relationships to develop with young people who may feel under threat from adults in the community, they will see as much more influential than the professionals they were engaged with. Page 24 of 32 11.9 The interventions with F and J were only touching the surface as the nature of their involvement with inappropriate adults and the supply of drugs or the nature of their exploitation in drug dealing and street activities was much deeper than was seen by the services working with them and their families. 11.10 It is hard to see that the specific interventions aimed at reducing risks from CCE were effective. They were not early enough or powerful enough to outweigh the other influences on these young people’s lives which drew them into offending and violent behaviour placing themselves and others at risk. The kind of work that might have made a difference is described in the evaluation of service for children who are at risk of sexual exploitation in Wigan and Rochdale.15 Education Interventions. 11.11 J had stable schooling and seemed to have benefited from the support he had at school. He had academic and social support from school which was available to all students who might at some point be struggling. 11.12 F was at the PRU following his permanent exclusion and efforts were made to provide a tailored programme to meet his needs. 11.13 H had stable schooling at his special school and while there were regular difficulties there was a good partnership between the school and his mother and they were able to maintain his place. 11.14 G’s secondary education was disrupted and from Year 10 it is not clear if he was in school. His needs were not met, and he moved away from school and education in Year 9 and never reengaged. What contact was made with F, G, H and J’s families and what work was undertaken with them? What did their Family’s understand about the risks to their children? 11.15 There was contact with all the families which was almost exclusively with the mothers of the four young people. F’s mother was concerned about his behaviour which she attributed to ADHD. This was not confirmed in an assessment by CAMHS which disappointed her and there was no further exploration of what lay behind F’s aggressive behaviour. F’s mother did work with the CFWS on risk taking behaviour, anger and aggression and F’s drug use but felt nothing changed. 11.16 J’s mother declined an assessment for CCE and there was very little contact with her. The declining of the offer could have been responded to with a more tenacious and curious response. 15 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/601976/Child_sexual_exploitation_project_Wigan_and_Rochdale_evaluation.pdf Page 25 of 32 11.17 H’s mother was actively involved in work with his school and was an important source of information about the risks to him. Her conflict with H arose when she tried to set limits to his behaviour. H’s mother valued the relationships with workers from the YOS and child exploitation team. These workers were persistent and had time to get to know H and his mother and were felt to have made a difference. 11.18 G’s mother was actively involved in the CPP and with his sisters in providing information about the concerns for G. She reported him missing and his drug dealing. G’s mother took part in parenting programmes with CFWS. 11.19 For each adolescent there were opportunities to engage with their mothers. There were efforts to help the mothers understand the risks to their child. G and H’s mothers were very aware of the risks to their child. The lack of engagement with F and I’s mothers makes it harder to judge how far they appreciated the risks to their child. J’s mother’s English was limited and the one more substantial interview with her used J’s sister to interpret. This was not appropriate, to have the kind of conversation needed to fully explore J’s mother’s understanding of the risks J faced. F’s mother’s concern about his behaviour was explored with a limited focus on ADHD as a possible cause and when that was not confirmed nothing else was offered to engage F’s mother or address her worries about F. Was contact made with F, G, H and I’s fathers and what if any role did they play in their lives? 11.20 All the father’s played a role in the lives of their sons. H went to live with his father for a time which seemed to be part of his family’s efforts to keep him safe and out of his local town. G saw his father and his father tried to engage him in some constructive sports activities. F at times worked with his father in his father’s business. J was in conflict with his father over his father’s behaviour. None of the professionals had any significant contact with the fathers. Some efforts were made to contact them, but it appears they left contact with agencies to the mothers. Whether more persistent efforts to engage the fathers would have worked is unknown. No father has responded to the efforts made to involve them in the CSPR. How well did practitioners working with F, G, H and I and their associates communicate and develop joint plans of intervention? Did they take a systemic view of their work with F, G, H and I? 11.21 There were no joint plans outside the CPPs. There is no sense of their being a systemic view which looked at the wider context of these young people’s lives or how they might connect together and connect with the other young people engaged in negative behaviour. They all lived and socialised within a limited geographical area. There was no peer-group mapping or contextual safety planning. What was understood about F, G, H and J’s lived experience including how they saw themselves in their community, their emotional and mental health, their motivations and their experience of agencies? Page 26 of 32 11.22 The agency reports suggest very little was known about the lived experience of the four young people. There is little sense of reflection on how the world looked to these young people or of curiosity, tenacity or creativity in thinking about their lives. For example, how did they see the ‘choices’ they made and how they might respond to or describe pressures on them to deal drugs. There is little reflection on their relationships with adults in their extended family and neighbourhood networks who drew them into offending, including drug dealing and associated violent norms of behaviour. There is no consideration of how they saw opportunity or lack of it. There was little consideration of what was changing, if anything, as a result of any intervention. The impact for three of the four of adverse experiences and trauma earlier in their childhoods, such as, exposure to serious domestic abuse is not given significant consideration. 11.23 Their experience of agencies was largely transitory and transactional. Apart from school, their relationships with agencies were over relatively short periods of time and not ones where relationships of trust and depth could easily develop when the starting point is one of deep distrust. Where there was continuity of schooling, this did allow positive relationships to develop. Conversely, where continuity was broken this made disengagement from schooling much more likely. The experience of their familiess was also of episodic involvement with social workers or YOS workers. Persistence was limited and it is hard to see evidence of the families feeling they or their children had been helped. 11.24 All four had deep distrust of the Police likely to reflect family and community views of the Police. There was more positive contact with PCSOs but with the warranted officers contact was about enforcement. Those who worked closely with the Police, such as, Youth Justice and CSC will have been seen as people with whom sensitive information could not be shared. Did any practitioner form a relationship of any depth with F, G, H and J and if so, what enabled this? 11.25 There is no evidence that any practitioner had a depth of relationships with any of the four young people. J had several positive relationships reported by his school. These were school focused and did not mean J shared what was happening in his life outside school with these adults. H’s school saw him positively and had a good relationship with his mother. These relationships helped keep H and J in school. G was very guarded and by the time he was being seen by a practitioner from the CCE team, he was very unwilling and possibly felt unsafe to disclose anything of consequence about his life. This is why engagement needs to be early before an entrenched sense of fear or loyalty to those exploiting a young person has developed. H was less guarded, but the ‘rules’ the young people lived by would not have allowed significant disclosure about their offending behaviour or about harms they had come to as a consequence or threats they felt they were under. What were the key factors in F, G, H and J’s educational difficulties and how were these difficulties addressed? Page 27 of 32 11.26 All four young people presented behaviour difficulties in school. J’s were the least acute and he stayed in his secondary school and achieved reasonable GCSEs at the end of key stage 4. With more application he could have done significantly better. 11.27 F was permanently excluded and went to the PRU where he had a one-to-one programme due to his continuing behavioural difficulties. He could access the secondary curriculum. What was driving his behaviour was not explored beyond the assessment for ADHD which concluded there was not enough evidence for a diagnosis. This gives a sense of gatekeeping rather than needs-meeting and is an indication of overstretched services. 11.28 H had an Education Health and Care Plan (EHCP) and was attending a special school. His behaviour and emotional regulation were the primary issues which inhibited his being in mainstream school and making better educational progress. There was limited thinking about why he behaved as he did. 11.29 G started his secondary education in mainstream school but was excluded, went to the PRU and then had a failed reintegration to mainstream after which his engagement with education was limited. He had an EHCP. As for F and H, there was very limited thinking about what his behaviour meant including his emotional dysregulation and what might help him with his behaviour. His fractured secondary education meant he did not develop any positive relationships with his teachers or schools. Did F, G, H and J and their families face any material difficulties that may have affected their health and development and if so, were these addressed by any professional? 11.30 The records do not suggest that any of the families had serious material difficulties, but it is not clear whether this is because the issue was explored, and a conclusion reached there were no issues or the issues were not explored. They all lived in relatively deprived areas of their hometown. They appeared to have stable housing. H and F’s families were in work. G and J’s mothers were not in work and their fathers were not part of the household. These families were dependent on benefits. G in his account says that desire for a better material life and not having to ask his mother for money was a motivator for his involvement in drug dealing. Did practitioners consider issues of identity, race and culture in their work with F, G, H and J and their associates? 11.31 This is not evident in the Individual Management Review (IMRs). The ethnicities of the four young people were diverse. The family norms of J and F may well have influenced the willingness of their mothers to share information with those working with their children but the implications of this are not explored in the IMRs. The use of J’s sister as a translator suggests weak consideration of issues of identity and culture. How was practice with F, G, H and J and their associates and family affected by Covid 19 and related changes in working practices? Page 28 of 32 11.32 The Covid 19 pandemic limited face to face contact with practitioners during the lockdown phase. This had an impact on how the later stages of the referral order programmes for F and H were conducted – they went online. F’s mother sought advice from his school about this not keeping to Covid restrictions. This was another aspect of his behaviour and demonstrated that F did not appear to respect his mother’s authority. Were practitioners effectively supervised and managed when working with F, G, H and J and their families and associates? 11.33 The IMRs and timelines do not suggest there were any gaps in supervision and management of those working with F, G, H and J in terms of whether standards for supervision and management were met. The gap was in whether supervisors and managers were able to help practitioners move beyond meeting their own agency expectations to take a wider view of each young person and consider the wider system within which they lived, their lived experience and what this might mean for the intervention from their agency and for the agencies working together. 11.34 Practitioners might have been having 1:1s with managers of a frequency that meets standards, but it is hard to see how ‘effective’ supervision could have been in place. 'Effective' suggests there was a space for hypothesis forming and testing, thinking deeply about anti-discriminatory practice, case formulation, being challenged to think creatively about options, using family feedback to inform planning, reflecting on gaps in knowledge, processing fears and anxieties, etc… Crucially, this kind of supervision would have needed to extend beyond social work. This issue of how to supervise and reflect with the multi-agency professionals who are holding the family could be a key one for the partnership to grapple with. If extra-familial harm is a multi-agency issue, then what is the multi-agency offer to support ethical, informed practice? 12. Partnership Learning 12.1 In considering partnership learning, it is worth reflecting on how far the circumstances of the four young people who are the subject of this review and their involvement in CCE are similar or different to findings from academic work on safeguarding young people, notably 'Safeguarding Young People – risks, rights, resilience and relationships' edited by Dez Holmes16 and other reviews primarily the 'National Review – It was hard to escape Safeguarding Children at Risk of Criminal Exploitation 17 and the '2014 to 2017 triennial analysis of serious case reviews'1819 12.2 It is not surprising there is a great deal in common between the findings from academic work, the national review, the triennial review of serious case reviews and this review. From 16 Safeguarding Young People – risks, rights, resilience and relationships edited by Dez Holmes. Jessica Kingsley 2022 17 National Review – It was hard to escape Safeguarding Children at Risk of Criminal Exploitation 2020 18 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869586/TRIENNIAL_SCR_REPORT_2014_to_2017.pdf 19 https://seriouscasereviews.rip.org.uk/local-safeguarding-partnerships/#lscb_vulnerable Page 29 of 32 Safeguarding Young People, the key learning points to consider are: 1. Understanding safeguarding within adolescence as a developmental life stage 2. The link of individual development and structural factors in promoting healthy development and behaviours 3. The importance of considering the dual identities of young people as victims and perpetrators of harm i.e. not making a criminal justice response to a welfare issue 4. Practitioners needing to hold the concepts of the autonomy of the young person and their dependence in healthy tension. This in turn enables practice to integrate protection and participation. 5. The role of poverty and inequality as a driver for harm and adversity. 6. The importance of providing a personalised and tailored response. There are no typical victims and perpetrators. 7. The role of adultification – seeing children as older and more responsible than they are chronologically or developmentally. 8. Whether the current legal and policy framework facilitates or inhibits effective responses to extra familial harm. 9. The importance of a trauma informed approach to working with young people where practitioners look for what lies beneath a young person’s behaviour. 10. The impact of early attachment and later experiences of risk and harm. 11. The connection between young people’s trauma and unmet developmental needs 12. That viewing trauma through developmental and relational lens enables better sense making of young people’s worlds and the impact of their experiences. 13. That attachment experiences and trauma are not hard wired or destiny. Change and development are possible, but this needs practitioners who feel safe and able to develop relationships with young people. 14. That participation and empowerment focused approaches are essential features of safeguarding for young people. They need to own their plans if they are to be effective. Professionals should avoid mirroring the coercive dynamics that young people may have experienced as part of being exploited in how they seek to protect young people. 12.3 From the National Review the learning points were, together with reflection on how far they apply to this review: 1. Boys from black and ethnic minority backgrounds were more vulnerable to CCE – 3 of 4 young people involved in this review were from ethnic minority backgrounds. Was the practice sufficiently culturally sensitive and were opportunities taken to involve the voluntary sector where there was reluctance for families to engage? 2. Known risk factors except for exclusion from school were not always good predictors of CCE. Most in the national review sample were not know to CSC. This was not true for this review where 3 of 4 were known to CSC and 2 had long histories of CSC involvement. 3. Exclusion from mainstream school was a key trigger point for escalation of risk. The National Review identified the need for immediate wrap around support to compensate for the lack of structure and sense of belonging and rejection that exclusion from mainstream school can cause. 2 of 4 in this review were excluded from school and 1 was Page 30 of 32 at a special school. Early warning signs of exclusion could have been a chance to target help earlier. 4. There was a lack of confidence about what to do to help and little reliable evidence of what works. In this review, the efforts to address CCE were ineffective. Staff need a comprehensive professional development offer that includes group supervision, case clinics, ‘I’ve got stuck panels’, co-working and that is open to all partners. 5. Trusted relationships are important. Building a trusted relationship between the child and a practitioner was essential to effective communication and risk management. This takes time and skill with persistence, tenacity, creativity and the ability to respond quickly being the key qualities required form practitioners. No one had this kind of relationship with any of the four young people who were subject to this review with the possible exception of staff at J’s school but this relationship was school focused and did not encompass what was happening in his life outside school. 6. Responding at critical moments can make a difference e.g. school exclusion, physical injury and arrests. There was no vigorous response at such critical moments for the 4 young people who are the subject of this review. 7. Parental engagement was nearly always a protective factor. Parents and extended family need effective support in helping manage risks. The parents of all four young people were engaged to some degree and for one parent this was helpful and made a difference. In retrospect there was not sufficient energy and persistence in engaging parents and wider family. 8. Moving children and families to somewhere else works in the short term but is not an effective long-term strategy. This is pertinent to considering whether G’s request to be moved should have been responded to. For this to be successful would have meant putting in place a supporting strategy to make the move a success and help G and his family with what would come next.20 Moving H was helpful and his time living with his grandparents was positive. 9. More priority to disrupting perpetrator activity for these four young people, the Police were engaged with them, but it is not clear how far there was a wider strategy to disrupt the criminal networks they were part of. The Police have powers to help disruption.21 10. Comprehensive risk management arrangements can make a difference. In this case, the CPPs for G and H did not make a difference. The risk management arrangements were not effective. 12.4 The National Review recommends a practice framework. The key features of this are: 1. Identification of individual children who are at risk of serious harm through use of data, mapping exercises, local practitioners’ knowledge and work with communities to get a detailed picture of those at risk. This group of children would be those who are identified as being at the most extreme risk, where criminal exploitation is known to be a feature and they are involved in county lines and gangs. 20 https://www.contextualsafeguarding.org.uk/our-work/research-projects/securing-safety/ 21 https://www.gov.uk/government/publications/child-exploitation-disruption-toolkit/child-exploitation-disruption-toolkit-accessible Page 31 of 32 2. Intensive and dedicated work with individual children and their families to build good relationships. A specialist team (perhaps part of an existing service) comprising practitioners from a mix of disciplines and with significant experience of working with young people. The important qualities are persistence, tenacity, creativity, flexibility and ability to respond quickly. 3. Team make-up will vary, but could include both part-time and full-time staff from the following disciplines: police, youth offending, social work, clinical expertise, voluntary sector, youth work, teachers, family support workers. 4. Members of the team who can work closely with parents and provide dedicated support to help them manage the risk in a way which is perceived to be supportive and empowering. Family group conferences and group work with parents are a strong feature of this work. They should be applied from early help and not just as a part of high-risk response. 5. Use of a shared practice model which is known to be effective, such as systemic practice. The seven features of practice described in the evaluation of the Innovation Programme outline the key factors which have been found to be associated with positive outcomes. These are: • Using a clear strengths-based practice framework. • Using systemic approaches to social work practice • Enabling staff to do skilled direct work • Multi-disciplinary skill sets working together • Undertaking group case discussion • High intensity and consistency of practitioner • Having a whole family focus with a proactive approach to helping the family be active partners. 6. A dedicated budget for the team and permission for them to work flexibly. This will enable practitioners to step outside routine procedures so they can respond to individual characteristics of the family, be more creative and make decisions which are not risk averse. Confidence and autonomy are key factors. These practitioners need to be able to respond at speed to critical moments. 7. Comprehensive risk management plans which are reviewed frequently and in response to changes or heightened risk. Work with the courts to facilitate the use of electronic tags and curfews and intensive supervision arrangements. 8. Members of the team are available in the evenings and weekends to respond immediately if they are alerted to an incident or information which indicates a heightened level of risk. For example, they may need to remove a child immediately from a location and take them to a safe place. We have heard of examples of this being done, with the child’s consent, and where it has enabled a breathing space and time for the child and family to consider their situation and options. Page 32 of 32 9. Capacity to provide an immediate, high quality, full-time timetable for children who are permanently excluded at the point of exclusion, with no time lag. This will involve working with head teachers before the point of exclusion. The timetable could include employment or activities such as music or football which are known to be popular with young males. 13. Recommendations 13.1 Given the common features between this CSPR and the National Review Findings, a good starting point for considering recommendations is to consider whether the National Review recommendations provide a template which with local adaptation should be implemented in Lancashire. 13.2 A recommendation of the National review was the development of exploitation principles. These are being developed now and the Partnership could commit to their implementation when published. [Note: The current draft of the principles is now available to the partnership.] 13.3 Recommendations for the Partnership: a. Commits to the implementation of the national exploitation principles when published. b. Develops a range of early intervention services to support children and families at risk of or in the early stages of CCE c. Ensures that practice always explores the strengths within the immediate and wider families of children at risk of or being criminally exploited d. Recruit workers with the personal skills to undertake relational work with children and families and gives them the training to develop those skills further and time to develop relationships with children and families which do not preach or judge. |
NC52242 | Injuries to a 9-year-old girl in January 2018. C67 was taken to hospital after presenting at school with blood in her underwear. Medical examinations identified injuries to her bottom and vaginal area, with professionals judging the injuries non-accidental. Police investigation has been unable to ascertain how the injuries were caused and no one has been charged. C67 lived with her 12-year-old sibling C68 and their mother and father. There were concerns about parenting capacity and the home environment. C67 and C68 were made subject to child protection plans for neglect, which was later changed to risk of emotional harm. Both children displayed sexualised language and behaviour from an early age, but C68 changed his behaviour once in secondary school. Family is white British. Learning includes: parents require effective education programmes that are delivered in a timely manner to assist them in effectively coping with family life and improve the lives of children; there is a lack of confidence that decision making will be robust in similar cases where there has been a non-disclosure by a child but sexual abuse is suspected. Recommendations include: review the current process of the allocation of parental education programmes (including Triple P) to ensure that they are delivered at the earliest opportunity; review and identify all available options to improve the current provision of services for adolescents with complex behavioural issues; review training and guidance in respect of non-disclosure issues in sexual abuse cases.
| Title: Serious case review C67 and C68: incident 22nd January 2018. LSCB: Torbay Safeguarding Children Board Author: Paul Northcott Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. GSC- Official Page 1 Safeguarding Children Board Serious Case Review C67 and C68 Incident: 22nd January 2018. Author: Paul Northcott Date review report completed – 4th March 2020. GSC- Official Page 2 Contents 1. Introduction 2. Summary 3. Timescales 4. Confidentiality 5. Methodology 6. Author of the Overview Report 7. Equality and Diversity 8. Dissemination 9. Background Information 10. Overview 11. Analysis 12. Conclusions 13. Lessons to be Learnt 14. Recommendations GSC- Official Page 3 The Torbay Child Safeguarding Practice Review Panel met and carefully considered the report with the understanding and acknowledgement that it had been a significant period of time since the serious safeguarding incident that prompted the learning review. The learning review had been delayed at the start and took six months to complete. The recommendations from the report were fully considered in August 2020 and a single agency and multi-agency action plan was created acknowledging that there is still more to do in terms of partnership and multiagency working. The New Safeguarding Partnership arrangements will hold the strategic responsibility for the implementation and oversight of the multi-agency learning that has arisen from this and other learning reviews. It was acknowledged that a main area for recommended action had already received a significant amount of development, improvement and on-going quality assurance. The Children’s Social Care Practice Improvement Plan with its oversight and challenge from the improvement board had identified and actioned a number of key changes. Specifically the MASH processes and practice has been subject to review in October2019 and continues to be scrutinized through a regular examination of the data and dip samples of case with children and their families. The resolution of professional dispute is work that is underway and an ongoing area that requires significant improvement. Preface The subjects of this review are C67 and C68 who are brother and sister. C67 who was aged nine at the time that the incident happened has been described by those that knew her as a bright and articulate girl with a great sense of humour. Whilst she exhibited continuous behavioural problems during the period designated for this review those that worked closely with her have since identified that her demeanour must have been a sad reflection of the helplessness and frustration that she must have felt due to the circumstances in which she found herself. C68 who was aged twelve at the time of the incident has been described as a timid and withdrawn boy who loved to escape reality through playing computer games. He loved mathematics at school and going to Boys Brigade. C68 whilst initially showing signs of concerning behaviour has since integrated well into school and has been progressing well in terms of academic achievement and his own personal development. GSC- Official Page 4 1.0 Introduction 1.1 This is the serious case review report of an incident involving C67 and C68, which was undertaken on behalf of the Local Partnership Safeguarding Children Board. This review examines the multi-agency response and support that was provided to C67 and C68, and their family prior to an incident when C67 was taken to hospital which occurred on the 22nd January 2018. 1.2 The key purpose of this serious case review was to; Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; Identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result; and As a consequence, improve inter-agency working and better safeguard and promote the welfare of children. 1.3 Serious case reviews should be conducted in a way which1: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 1.4 This serious case review was not initiated as part of any disciplinary process. However, had information emerged during the course of the review that may have indicated that 1 Working Together to Safeguard Children (2015) ; now (2018). GSC- Official Page 5 disciplinary action was required, then individual agencies would have been asked to consider their own procedures. 1.5 This report considers the contact and involvement that agencies had with the family of C67 and C68 between the dates of 7th April 2017 (when the initial assessment of C67 was closed) through to the 22nd January 2018 as this was the date that C67 was admitted to hospital. 1.6 In addition to agency involvement this review has also sought to examine relevant background information and explore a hypothesis that local professionals have the ability to recognise concerning sexualised behaviour but are not able to articulate their professional judgement or give sound rationale to support action being taken. This refers to disproportionate weight given to a disclosure and physical evidence as opposed to professional opinion and the signs of impact trauma and abuse. 1.7 The review was also asked to consider the effectiveness of the local Professional Differences (Escalation) Policy to establish whether there is a lack of confidence in invoking the policy by practitioners. 1.8 By taking a holistic approach this review has attempted to identify appropriate solutions to make the future safer for children and young people. 1.9 Every effort has been made to conduct this review process with an open mind-set and avoid hindsight bias, and any other bias toward any one agency or individual involved. 2.0 Summary 2.1 C67 and C68 were both living in in a household together with their mother (MOC), who was aged fifty, and their father (FOC) who was aged fifty-three. At the time of the incident involving C67 she was aged nine and her brother was twelve. An elder brother aged twenty-one lived with his paternal grandmother elsewhere in the country. 2.2 The family had been known to Children’s Services following an initial referral in 2009. After that date, and as a result on their interaction with the family, professionals from a number of agencies (Education, Social Care, Health) continued to raise concerns about the levels of neglect within the family and negative parenting. The concerns of neglect related to all of the members within the family household. In response to these GSC- Official Page 6 concerns those within the household were offered a range of family support services from both the statutory and non-statutory sectors. During this time there was a divergence of views amongst the agencies with regards to the levels of parental engagement and their ability to change their behaviour and improve the environment in which they lived. 2.3 Despite agency involvement C67s’ behaviour within school continued to raise concerns. C67 was continually aggressive and violent to both staff and other pupils and used sexualised behaviour and language that was inappropriate for her age. 2.4 On the 11th September 2017 a strategy discussion took place due to the concerns that were being raised by Education professionals but this concluded that there was no physical evidence of harm and no specific disclosures had been made. A Section 47 enquiry2 due to C67’s vulnerability to Child Sexual Exploitation (CSE)/Child Sexual Abuse (CSA) and increasing risk of becoming criminalised. 2.5 On the 2nd October 2017 both of the children became the subject of child protection plans under the category of neglect. A review child protection conference was held on the 18th December 2017 where the category was changed to a risk of emotional harm. 2.6 On the 22nd January 2018 C67 presented at school with her mother saying that she had fallen and had bruised her genital area. When blood was seen on her underwear C67 was taken to hospital and following an examination it was identified that she had injuries to her bottom and vaginal area. Medical professionals conducting the examination concluded that the injuries were non-accidental and had been caused through blunt force trauma. 2.7 Both C67 and C68 were accommodated by the Local Authority in separate placements and an interim care order (ICO) was granted in February 2018. A police investigation was also commenced but to date those investigating the incident have been unable to ascertain how the injuries had been caused and by whom. No one has been charged with offences relating to the injuries that C67 sustained. 3.0 Timescales 2 A Section 47 enquiry means that CYPS must carry out an investigation when they have 'reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. GSC- Official Page 7 3.1 This case was considered at the Partnership Serious Case Review (SCR) Subgroup on the 7TH February 2018. Following careful consideration of the SCR criteria, (as set out in Regulation 5 of the Local Safeguarding Children Boards Regulations 2006) and following further discussion the Independent Chair of the Safeguarding Children’s Board was satisfied that there was evidence to support that the threshold for ‘serious harm’ (Working Together 2015) had been met. 3.2 The Independent Chair recommended that the circumstances leading to C67’s injury be explored through a serious case review. This decision was supported by the National SCR Panel on the 28th February 2018. 3.3 The lead reviewer was appointed on the 24th May 2018 and the review was commenced on the 21st October 2017. The delays in appointing the lead reviewer and commencing the review were due to the ongoing police investigation. 3.4 On the 19th March 2019 the first panel meeting was held but the review had to be further postponed in light of additional information coming to light that could have progressed the police investigation. The review recommenced in July 2019. 3.5 The review concluded on 4th March 2020. 4.0 Confidentiality 4.1 The findings of this review are confidential. The Information obtained as part of the review process has only been made available to participating agencies, and the appropriate professionals within them. 4.2 The content of the report has been anonymised to protect the identity of the victim, perpetrator, relevant family members and all others involved in this review. The pseudonym/s are as follows; Family composition and pseudonyms used; Victim – C67. Victims sibling - C68 Victim’s mother – MOC. Victim’s father - FOC. GSC- Official Page 8 5.0 Methodology 5.1 The Partnership Safeguarding Children’s Board determined that a systems approach should be utilised to move beyond the specifics of the case and to determine the deeper underlying issues that are influencing practice more generally. 5.2 The aim of the review was to look openly and critically at individual and organisational practice to see whether the case indicated that changes could or should be made to agency policies and practice, in order to improve the frontline delivery of services. 5.3 The Board arranged for all relevant agencies to check their records about any interaction that they had with the family. Where it was established that there had been contact, the Board ensured that all agencies promptly reviewed relevant documents, and they were then asked to provide a chronology detailing the specific nature of that contact. 5.4 Each agency’s chronology covered details of their interaction with C67, C68 and their parents, and whether they had followed internal procedures. 5.5 In addition to the chronologies that were submitted the report writer reviewed relevant minutes from meetings and previous serious case reviews3. Where necessary specific professionals were individually interviewed to clarify issues that were identified in relation to agency response. Policies and procedures were also reviewed. 5.6 A multi-agency workshop was also held which involved those frontline professionals that had interaction with the family. 5.7 The MOC and the FOC were also spoken to on an individual basis as part of the review process. 3 Serious Case Review Overview Report Child JS (2008); Serious Case Review C18 (2010); Serious Case Review Overview Report Child 24 (2011); Serious Case Review Child C40 (2014); Serious Case Review C42 (2014). GSC- Official Page 9 6.0 Author of the Overview Report 6.1 The Partnership Safeguarding Children Board appointed Paul Northcott as the independent author of the serious case review report on 24th May 2018. Paul is a safeguarding consultant specialising in undertaking safeguarding reviews and currently delivers training in all aspects of safeguarding. 6.2 Paul was a serving police officer and had thirty-one years’ experience. During that time he was the previous Head of Public Protection, working with partner agencies, including those working to deliver policy and practice in relation to child safeguarding. He has also previously been the senior investigating officer for complex child abuse investigations and homicides. 6.3 Paul left the police service in February 2017 but had spent the previous seventeen months working regionally and nationally prior to that time. During that time he had no involvement with local resources or the policy and practices of the Devon and Cornwall Police. Paul also had no operational oversight of the resources that were deployed in this case during the period covered by the terms of reference. 7.0 Equality and Diversity. 7.1 This review adheres to the Equality Act 2010 and all nine protected characteristics (age, disability, gender re- assignment, marriage and civil partnerships, pregnancy and maternity, race, religion and belief, sex or sexual orientation) were considered by the report writer as part of the terms of reference and throughout the review process. 7.2 All members of the family were white British nationals. Their religious and philosophical beliefs are not known but there has been nothing identified as part of this review that would indicate that such beliefs impacted on their life choices or the services that they received. 7.4 No barriers to accessing services in relation to inequality were identified. 7.5 The review process found no evidence that the family were directly discriminated against by any individual or agency based on the nine protected characteristics. 8.0 Panel Members GSC- Official Page 10 8.1 The review panel consisted of the following members; Designated Nurse for the relevant Clinical Commissioning Group (CCG) Business Manager for the relevant Local Authority Local Authority Partnership Co-Ordinator An independent Education Dedicated Safeguarding Lead (DSL) A detective Chief inspector for the Police Head of Service, Safeguarding and Quality Assurance 8.2 In addition to the panel members the report was reviewed by an independent Head of Operations, CAMHS and Specialist Children’s Services. 9.0 Overview 9.1 This overview will summarise what information was known to the agencies and professionals involved with the family and includes detail imparted by the FOC and the MOC. 9.2 C67 and C68 lived in a three bedroomed house, together with their natural parents. The family had lived at the premise for nine years. Professionals described the house as very dirty, chaotic and totally neglected (home visit 01/04/17 -Education). The interior of the house was dark and all of the rooms needed to be redecorated. The air within the house was described as thick with damp and mould. There was no apparent stimulation for the children in that there were no toys or games in any of the rooms. Clothes and belongings were strewn about the house, and there was cat faeces on the carpets and a strong smell of urine. There was also reports of fleas. 9.3 Those professionals who entered the house described it as dark, poorly decorated and there were no toys visible. The FOC described how he and his wife would struggle to maintain an adequate and safe environment for the children and that on occasions a relative would assist with housework. 9.4 In terms of sleeping arrangements both C67 and C68 had their own bedrooms. GSC- Official Page 11 9.5 C67’s bedroom was described as unclean and dirty. There was nothing welcoming about the room and it had a bare carpet. When Social Care professionals visited the bed would be unmade and there was clutter on the floor. They described the room as ‘not reflecting her identity’. Reports show that C67 originally slept on top of a bunk bed but this had been later changed to a single bed. 9.6 C67 has been described by Education professionals as extremely bright and perceptive. She was articulate and would often read books. C67 was also described as having a great sense of humour. She did however have low self-esteem and struggled to mix with her peers. Her Boxhall profile4 (20th Sept 2016) described her as Insecure, fragile self-image and self-defeating attitudes Profound lack of trust in others and resists making an attachment Feels undervalued and is nursing a severely injured sense of self. This is expressed in self damaging anger 9.7 C68 was described by professionals and his mother and father as the polar opposite to his sister. He is quiet and unassuming. Teachers working in his primary school stated that could come across as ‘Nerdy’ and overly helpful’. His friendship group whilst at primary school were girls. Concerns had been raised as far back as 2009 about him engaging in sexualised behaviour. 9.8 Since moving to a comprehensive school C68 has been described as settled and a model pupil although he doesn’t openly share his feelings. Unlike his sister C68 has no self-esteem issues. C68’s main passion is to play computer games which according to professionals he uses to escape reality. 9.9 The children lived in what was described by professionals as a dysfunctional household where the relationship between their mother and father had broken down. Agencies described their parents as showing little emotional warmth and their mother would often shout at the children. The MOC would often present to some professionals as angry and argumentative, particularly to those members of staff who were in C67’s primary school, and to others she would readily comply with their requests. 4 Boxall Profile - Online assessment tool for social emotional and behavioural difficulties for children and young people. GSC- Official Page 12 9.10 The MOC of the child was known by agencies to be the dominant force in the family (FIT assessment 2016/17) and was described by C68 as being overly protective of him. A report by the family support worker in 2012 (3rd May 2012) identified that the FOC would not challenge his wife about her parenting skills despite him being aware of the negative impact that this was having on C67’s behaviour. He was described by FIT workers as ineffectual (single assessment June 2017). 9.11 The MOC demonstrated clear signs of frustration when dealing and interacting with C67 and this was witnessed by staff at the primary school. There were also many occasions where the MOC would refuse to deal with her daughters behaviour often blaming the primary school for the concerns that were being raised and stating that it was down to bullying (interview with MOC, although there was no evidence of this from school records). The FOC explained that the MOC would simply state that she would not attend C67’s school despite being asked to do so in the hope that teaching staff would address C67’s behaviour prior to her returning home. The MOC would state to those professionals who were working with the family that C67 would not display disruptive and sexualised behaviour at home. 9.12 It was believed that the FOC had little control within the relationship although the narrative from the MOC was that she would need to seek his permission before any decisions were made. The FOC stated that he would simply work and then come home leaving his wife to predominantly take care of their children. The impression provided by him was that he tried to avoid any form of confrontation at all costs and simply wanted a quiet life. 9.13 The FOC when spoken to as part of the review stated that he felt that he was a lodger in his own home and that he would hide himself in his bedroom. On reflection he concluded that he had taken his ‘eye off the ball’ in that he made few decisions about family life and that he was not actively involved in the daily activities of his children. 9.14 The FOC stated that on looking back he wasn’t sure that they were ever suited as a couple. He stated that after the MOC fell expectantly pregnant with the brother of C67 and C68 the two of them had married. At that time he didn’t feel ready to be a father. 9.15 When spoken to the FOC stated that their relationship had broken down some nine years previously and the two of them essentially led separate lives. The FOC stated that his wife slept on the settee in the living room area and that he slept in the main bedroom. He claimed that whilst his wife would say that this was due to her going GSC- Official Page 13 through the menopause and that she was constantly feeling hot he felt it was purely to avoid contact with him. 9.16 The MOC and the FOC would appear to have few friends and a limited social life. The FOC liked to go to the pub on occasions whilst the MOC liked to play bingo. The FOC worked in a local slot machine casino and the MOC has stated that she would occasionally work in a charity shop although the majority of her time was spent at home. There was a limited income coming into the household. 9.17 When asked what they did as a family the FOC stated that they would go on holiday to Blackpool and Dawlish and that they would go out into town together on occasions. 9.18 Professionals describe how there was little stimulation for the children within their home environment. The FOC has however stated that he and his wife would play computer games with the children and that the MOC was good at reading to them. The FOC also stated that the MOC would play board games and complete jigsaws with the children (although professionals going to the home saw little evidence of these activities taking place). 9.19 The family had been known to Children’s Services since 2009, and this was due to concerns about neglect and negative parenting. As a consequence the family had received support from Children’s Social Care and Health services. During this period core assessments were completed and the family had early intervention and Family Intervention Team (FIT) support. It was reported that following this intervention agencies had seen ‘sustained positive change by parents (Single Assessment – 17th January 2017). 9.20 The two children attended the same primary school (C68 from the 2nd April 2012 until 26th August 2017 and C67 from the 5th September 2012 until the 26th September 2017). Both C67 and C68 had good attendance records but they would regularly turn up for school unwashed and in a dishevelled state. There were also continuing concerns raised by school in relation to the children turning up tired and unable to effectively study. C67 would often have to lie down in the reading corner in the school to rest and catch up with sleep (January 2016). Concerns were also raised that both of the children were not receiving a nutritional diet (9th May 2017-School). 9.21 Whilst at primary school both C67 and C68 used inappropriate sexualised language from an early age (2009). As C68 became older his behaviour changed and once in GSC- Official Page 14 the secondary school environment no further concerns were raised by those professionals who were teaching him. 9.22 C67 however showed increasingly aggressive and sexualised behaviour in the classroom. This behaviour included assaulting her peers and teaching staff on a daily basis and had escalated in its frequency and severity in the time frame covered by this review. 9.23 Due to her behaviour C67 was given intensive one to one support within her school however she continued to assault those around her. As a result of the level of risk to her peers and members of staff she was permanently excluded from school (as detailed in the section 10.0). 9.24 Following her exclusion C67 had to attend a specialist centre for young people experiencing complex social, emotional and mental health difficulties, before being moved to another school to continue her education. Whilst she responded well to these changes those professionals working with her continued to be concerned about her behaviour and the underlying causes behind it. 9.25 On the 22nd January 2018 C67 attended her school together with her mother and it was alleged that she had fallen and had bruised her genital area. On ascertaining the true nature and extent of the injury C67 was taken to hospital by teaching staff and following examination it was identified that she had injuries which were considered by medical professionals to be non-accidental. 9.26 After concerns had been raised a further assessment was undertaken and both children were taken into care. Care proceedings were then initiated by the Local Authority. 9.27 Following the incident both parents have separated. The FOC has stated that in his view he is better off separated and living a ‘single man’s life’ then he was staying in the relationship and that he is grateful that the children were taken into care in terms of their own welfare and support. GSC- Official Page 15 10.0 Condensed Chronology 10.1 Whilst the terms of reference are specific in relation to dates it was felt that a short summary of previous concerns should be included in this section of the report as they were seen as relevant by the review panel. These included; 2009 Referral from primary school – C68 showing sexually explicit behaviour. 2011 C67 attended A&E - Cuts to buttocks/Vagina. Injuries deemed to be accidental. Core Assessment undertaken which resulted in early intervention through family support and parenting. 2012 Concerns raised by SureStart regarding negative parenting (Emotional Impact C67). Parents had significant support by SureStart. Children and Young Person Services (CYPS) records state that ‘the father has some insight as to the impact of mother’s behaviour and parenting style but is not able to challenge her. Further core assessments were completed which by January 2013 identified sustained change by the parents. 2015 Referral from C67’s school- Disclosure from C68 that there had been a sexual incident involving his sister and a friend when his friend stayed over. C67 had offered the winner of the game that they were playing sex and his friend accepted. The children were described by C68 as lying on the bed with clothes on and moving up and down. He stated that the other child had sex with his sister. S175 assessment undertaken. The MOC didn’t want to pursue a criminal charge and was content with CYPS involvement. It was stated in CYPS records that there ‘were concerns about C67s sexualised behaviour but no disclosures and no obvious reasons why she behaved in this manner. There was no further action taken in this matter as the school were closely monitoring C67. 2016 Early Help Assessment received from C67’s school. The MOC had disengaged with support options. C67 had been excluded as she had assaulted teachers. At that time it was agreed that C67’s school could remain the lead professional. 5 Section 17 of the Children Act 1989 states that it is the general duty of every local authority to safeguard and promote the welfare of children within their area who are in need; and so far as it is consistent with that duty, to promote the upbringing of such children by their families GSC- Official Page 16 2017 (13/01/17) Referral from C7’s school- Concerns raised about C67’s sexualised behaviour- graphic conversation about sex and saying that her father and brother come into her room when she is sleeping (although she later denied this). CYPS records state that her school have significant concerns about C67’s behaviour and their ability to manage it. A strategy meeting was held and the family were open to an assessment team until the 07/04/19. It was recorded that Targeted Help were to support the family when the case was closed. 10.2 Below is the condensed chronology of events that are relevant within the scope of the terms of reference. Date Episode or event of concern 18/04/2017 Education received a letter from Children's Services stating the case had been closed and there was no further involvement with Social Worker. The DSL from C67’s school contacted the Family Intervention Worker regarding the schools concerns about this. 19/04/2017 School challenged decision by CYPS to close the case. 24/04/2017 Entry is CYPS records which states that they discussed personal space with MOC and she stated that the FOC ‘does not get into bed with C67 now for cuddles’ and she puts her to bed. 28/04/2017 Following increasing concerns about C67’s heightened anxiety and needs, as well as further information C67’s school agree to escalate the Safeguarding concerns. Multi Agency Safeguarding Hub (MASH) referral submitted. 08/05/2017 MASH referral regarding concerns raised by Personal, Social and Emotional Development (PSED) Team/ Young Men’s Christian Association (YMCA) regarding general hygiene, head lice, tiredness and staying up late on iPad. 11/05/2017 The deputy head of safeguarding at school spoke to CYPS as they were concerned about the case being closed. CYPS records state that FIT work completed and as they ‘works on consent basis there is no work identified to complete and no role for FIT ‘….this remains an education concern to be managed with a support plan and package. 12/05/2017 MASH Referral sent by school. SEN witnessed C67 being verbally aggressive to her dad shouting, ‘Get away from me you freak’. 18/05/2017 C67 was violent towards a member of staff and was excluded 3.5 days. 22/05/2017 Child Adolescent and Mental Health Services (CAMHS) assessment reports that ‘parent do not feel the need for CAMHS involvement and [MOC] refused to fill in questionnaires. The FOC did fill them in and the outcome showed no real issues which seemed incongruent to what school was seeing. The CAMHS worker stated that the parents were blaming the school. 23/05/2017 MASH referral put in by DSL. GSC- Official Page 17 25/05/2017 C67 attacked a member of staff with scissors. C67 excluded for 3 days. 28/05/2017 MASH referral sent by school. 30/05/2017 Referral from C67’s school- escalating concerns about C67’s behaviour which was becoming increasingly aggressive. C67 was having support from a specialist school and the YMCA. She was also seeing an Educational Psychologist. 31/05/2017 Decision by CYPS to undertake a single assessment. 01/06/2017 Single Assessment commenced(completed 22/08/2017) 13/06/2017 Review report received from the Outreach Service supporting C67. The report stated that C67 was interacting and having group sessions and presented no issues to them. C67 'shuts down' when you talk about negative behaviour or home life and will start talking in baby voice. Concerns with parents with regards to parent often appearing defensive. 22/06/2017 C67 shows sexualised behaviour in school including slapping bottom of Thrive6 Lead and sexualised dancing. Hyper vigilance is escalating. 23/06/2017 Completion of 12 week specialist outreach work with C67 which reported high levels of concerns in 22 out of 46 areas and that there had been no improvement in her behaviour. 27/06/2017 PSED team reporting concerns that relationships breaking down where they had been positive as C67’s threats increase and behaviour has changed again. 29/06/2017 C67 was violent to staff. 04/07/2017 School reported that C67'S behaviour was extreme and erratic on arrival at school. 05/07/2017 C67 repeatedly assaulted a member of school staff causing injuries. C67 excluded for 4.5 days. 07/07/2017 Special Educational Needs Medical Assessment conducted with C67 by a paediatrician diagnosed; 1.Challenging behaviour (with previous school exclusions) 2. Apparent avoidance attachment style with limited strategies for recognising and managing emotions. 12/07/2017 Multi Agency Meeting held at primary school. Apologies received from Social Worker. C67assaulted a member of staff and was permanently excluded. 17/07/2017 Specialist outreach school conducted a home visit. Professionals were shocked by the condition of the home. During the home visit the MOC raised her concerns that C67 had told her school that something bad had happened to her. On asked the MOC to explain further she said that C67 had told staff she had had sex with a T Rex. The MOC went on to say that she had never touched her children and told them about the incident that occurred in 2011. 17/07/2017 Specialist school made a referral to children’s services. They were told that an initial assessment had been completed and that the case was closed. 22/08/2017 Single Assessment because of Child In Need. The outcome was continued Family Support. 6 Thrive is a therapeutic approach to help support children with their emotional and social development. GSC- Official Page 18 11/09/2017 Strategy Meeting – Outcome – S47 enquiry due to C67’s vulnerability to CSE/CSA and increasing risk of becoming criminalised. 18/09/2017 Child in Need (CIN) Meeting And Plan because of Child In Need. Outcome of Continue Family Support and move to Initial Child Protection Conference (ICPC). 27/09/2017 Allegation of Emotional Abuse with status of Substantiated. Decision of Case Conference. 02/10/2017 Initial Child Protection Conference (ICPC). 02/10/2017 ICPC – Concerns raised regarding C67s sexualised behaviour and language at school beyond a normal eight year olds understanding. It was noted that C67 stated “don’t like it when dad comes into my bed”, She has specifically talked about ‘a willy going in her vagina’. C67 does not trust adults, little emotional warmth from parents to C67. Disguised compliance by parents. Decision to move to Child Protection (CP) Plan - Category of Emotional Abuse. 05/10/2017 C67 seen by support worker and would not discuss why she was worried. She said her worries were ‘locked inside the worry monster’. Her family was discussed and C67 happily talked about her mum and brothers but refused to speak about dad saying only that she hates him. 10/10/2017 Core Group Meeting And CP Plan because of Child Protection. Outcome to continue family support. 13/10/2017 Planned home visit to complete family Health Needs Assessment. MOC reported that C67 has never not displayed any sexualised behaviour at home, and her behaviour at home has never been of concern. 16/10/2017 Core Group Meeting and CP plan. Parents and paternal Aunt in attendance. Outcome- Continued family support. 25/10/2017 Triple P7 support started. 13/11/2017 Core Group held. 20/11/2017 C67’s specialist school had seen a dramatic change in her behaviour describing her as swearing, threatening with scissors and emotionally dysregulated. The MOC was spoken to and stated that nothing had changed at home but went on to say that the only thing she could think of was that the FOC had taken her swimming on his own but that they had gone in separate changing rooms. 28/11/2017 Team around the Family (TAF) Meeting held to discuss school's concerns about C67. 11/12/2017 Core Group Meeting held. 15/12/2017 Single Assessment because of CP Review. 18/12/2017 CP review conference. Decision was made for the children to remain on a CP plan. Concerns raised that C67 is emotionally ‘shut down’ and seems more afraid of sharing her worries and feelings with adults. C67 has ‘a fragile relationship with her dad. C67 has shown sexualised behaviours/used sexualised language and we do not know where this came from. Minutes state that ‘We are worried she has been sexually harmed. 7 Positive parenting programme. GSC- Official Page 19 27/12/2017 C67 referred to CAMHS after several angry/violent outbursts CAMHS felt she had the necessary inputs in place. 04/01/2018 C67's first day at a new school- phased start. C67 was full-time by the end of week 1. During this first week, C67 tried to run and scale the gate several times. C67 used inappropriate language and swore. 11/01/2018 Triple P Parenting Programme ends today. 13/01/2018 During TED8 work, C67 made disclosure re brother and her dad coming into her bedroom and 'acting silly' and she does not like it but became very withdrawn and refused to talk about it more. C67 then stated, 'They've come into my bedroom whilst I was sleeping'. She then totally disengaged. This was shared with [Local Authority] Education Safeguarding Service (TESS), along with concerns about her increasingly violent behaviour. This resulted in a strategy meeting and a further assessment was agreed. 15/01/2018 Core Group meeting. 15/01/2018 Core Group 19/01/2018 C67 disruptive in school and assaulted a teacher. At end of the day the FOC attended to take C67 home. The FOC asked ‘where my cuddles’, and C67 are shouted ‘No!’ and ran away. 22/01/2018 C67 arrived ten minutes late with mum. Mum said C67 had slipped on a leaf and injured herself. Mum was very agitated. C67 was wiggling on her seat and referred to her bottom stinging, but not as much as the last time when she hurt herself on the telly. C67 went to the toilet and reported that there was blood in her pants. She said, "There's dry blood in my pants at the front…but it's drippy at the back." She reported "It's a bit sore, red and grazed." C67 first said she slipped on a leaf, then changed this to log and bush. CYPS records state that ‘this is particularly concerning in the long history of concerns that she is being sexually abused’. 22/01/2018 Dr spoke to C67 asking her if anybody had touched her in her private areas. The MOC said she had been touched there when she hurt herself with the television - the Drs touched her then. 22/01/2018 The MOC was spoken to at the hospital and she was described as agitated saying, "They are going to blame me." Police records state that at hospital C67 ‘openly spoke about the bleeding from her privates but when asked if anything had happened such as anyone had touched her she closed down straight away and looked at her mum’. 22/01/2018 C67 had to wait for several hours for a female doctor. No social worker was available to attend hospital. Two teaching assistants had to stay with C67 for her physical examination. Throughout the day between 12 and 5.30 pm contact had been made with children’s services. Education records state that C67’s social worker was unavailable and the duty worker told the paediatrician to send C67 home. 8 TED- Tasks for Emotional Development test. This test is designed to assess the social and emotional development and adjustment of children" by means of projective techniques. GSC- Official Page 20 22/01/2018 A doctor came to examine C67. Her mother accompanied her throughout the examination, as she was very distressed. Every time the Dr tried to talk; the MOC talked over her. It was hard for C67 to speak. 22/01/2018 Education/Health records state that Children’s Services had told the hospital staff that C67 could go home. The paediatrician was not happy about this, so admitted C67 onto the ward for the night. 22/01/2018 The MOC was described as still very agitated, taking lots of phone calls from dad, crying and repeatedly saying she hadn't touched her children. 22/01/2018 School staff settled C67 into bed and left the hospital. 22/01/2018 C67 and C68 were already the subject of a child protection plan- following the assessment both were taken into care and proceedings were initiated. 23/01/2018 Education contacted CYPS to express concern that it was still school staff supporting C67 at hospital. 11.0 Analysis 11.1 This part of the overview will examine how and why events occurred, information that was shared, the decisions that were made, and the actions that were taken or not taken. It will consider whether different decisions or actions may have led to a different course of events. The analysis section will address the terms of reference and the key lines of enquiry within them. It is also where any examples of good practice are highlighted. 11.2 This analysis considers the previous sections within this report, the content of the chronologies that were submitted by agencies, and the feedback that was provided in the meetings held in response to this review. 11.3 Neglect 11.3.1 Nationally neglect is seen as the most prolific form of maltreatment and often presents that greatest challenge in getting a response from agencies and for professionals working with families.9 11.3.2 Concerns in relation to neglect had been raised as far back as 2011 by Health and Education professionals. These concerns had originated from an incident which had occurred at home when C67 had been injured after falling on an object and sustaining internal injuries which, following investigation, were deemed to be accidental. The details of this incident, whilst outside of the time parameters set for this review, become pertinent in relation to how some professionals later viewed C67’s behaviour (this will be explored further in paragraph 11.7). The incident did however lead those that were involved with the family to be concerned that the children were not being effectively supervised or care for by their parents. 9 Nicolas (2016) GSC- Official Page 21 11.3.3 Concerns had also been raised in respect of negative parenting and the fact that both of the MOC and the FOC were completely unmotivated to make any changes to their lives. The MOC was seen as dismissive of her two children whilst the FOC had little to do with them or any apparent influence in how they were being brought up. 11.3.4 From the conversations that took place with the MOC and FOC as part of this review it would appear that the MOC favoured C68 and consequently emotionally neglected her daughter. The level of emotional neglect and why it was occurring was never fully explored by agencies dealing with the family (as identified in minutes, the chronology and the practitioner’s event) and this was a missed opportunity to identify some of the underlying issues affecting the family and the possible causes of C67’s behaviour. 11.3.5 There was also physical evidence of neglect in that the appearance of both children was often poor, they were not washed and their personal hygiene was of a low standard. Records show that those in Education regularly saw the children in dirty clothes, with head lice and there were also concerns that they were not receiving adequate nutrition. 11.3.6 Professionals were also aware of the poor living conditions in which C67 and C68 lived in and this is evident in minutes of assessments and meetings. In line with practice numerous professionals (CYPS, Education and Health) did attended the home address. Social care professionals found the house to be in a poor state of repair and there were little signs of books and other items that would stimulate the children. As a consequence professionals had attempted to work with the family to improve their home environment. 11.3.7 Those professionals that were allowed into the house were often confined by the parents to the living room and they describe how all other doors would be closed prior to their arrival. Although there was a reluctance by the parents to allow professionals to see the rest of the house social care staff did ensure that all rooms in the house were checked. Such professional curiosity10 should be seen as good practice. 11.3.8 All of the professionals working for the agencies involved in the case clearly recognised the signs of neglect and appropriately made referrals to the MASH. As a result of these referrals the family received support through the FIT. The level of support that was being provided by services in relation to the issue of neglect would appear to have been adequate and in line with the Partnership Neglect Strategy. 11.3.9 It would appear from the records made available to the review and from the practitioner’s event that many of the professionals who had been involved in this case were seeing neglect as the primary issue which was affecting the family. The CYPS manager on the panel felt that often the term neglect was used in its wider 10 Professional curiosity is the capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value. GSC- Official Page 22 context and the understanding of interfamilial abuse was limited. As a consequence of this focus on neglect in this case and the absence of a disclosure those dealing with the family lost sight of the fact that sexual abuse could have been occurring in the family. 11.3.10 As a result of the failure to look at all of the available information C67 and C68’s case was closed on the 7th April 2017. The consequences of this are discussed throughout the later sections in this report. 11.4 Parental Relationship and Behaviour 11.4.1 No one agency would appear to have had a full picture of the dynamics in the relationship or fully explored them with the couple. From the minutes of meetings, the chronology and the practitioner’s event it would appear that the impact of the couple’s behaviour on their children was therefore never fully assessed and the risks truly appreciated. In part this was due to both the MOC and the FOC failing to be honest with professionals, a lack of robust challenge and elements of disguised compliance (see section 11.5). 11.4.2 Due to the dominance of the MOC, and her attitude to her husband, professionals suspected that there may have been domestic abuse occurring in the household. A family support worker described how they felt that the MOC could be ‘seen as a perpetrator of domestic abuse’. The level and type of abuse could not however be ascertained from agency records and from the practitioners focus group. There would appear to have been no further exploration in relation to domestic abuse by agencies. There were however no formal reports of such incidents and the MOC and the FOC where unlikely to have discussed such issues due to their mistrust of agencies. 11.4.3 Both the MOC and the FOC when spoken to as part of the review process denied that there was any violence or abuse occurring in the relationship. They also stated that the children did not witness any violence or abuse although both acknowledge that there were numerous verbal arguments between all members in the household. 11.4.4 Both parents contradicted each other with regards to who was the main instigator of the arguments. The MOC stated that the father used to shout at the children whilst the FOC stated that it was his wife. The FOC did however state that there were occasions when he would shout but intimated that this was at his wife. The FOC stated that such arguments would arise through frustration as on occasions he would come home from work and he felt that his own needs were being neglected. 11.4.5 The FOC stated that the MOC would regularly argue with C67 and would say that ‘if anything was to happen to the kids she would fight for [C68] and not [C67]’. 11.4.6 In terms of abuse involving the children the FOC stated that he had witnessed his wife on one occasion (sometime after he had completed his Triple P Programme) grabbing hold of C67’s hair and slamming her face into a chair. The MOC had done GSC- Official Page 23 this in retaliation to C67 spitting at her. This incident had never been reported to agencies. 11.4.7 The MOC was described by some professionals as argumentative, dismissive, defensive and immature. She was also seen as unpredictable when being approached about her daughter’s welfare and behavioural issues. Professionals felt that the MOC was the sole disciplinarian in the household and that she dominated her husband in all areas of family life. 11.4.8 The MOC would appear to have exerted a consistent level of coercion and control over her husband (school entry dated 15/01/2018 and on his own admission) and this would constitute a form of domestic abuse. The MOC also exerted a similar level of control over her children. 11.4.9 Controlling or coercive behaviour does not relate to a single incident, it is a purposeful pattern of behaviour which takes place over time in order for one individual to exert power, control or coercion over another. The Cross-Government definition of domestic abuse and abuse11 outlines controlling or coercive behaviour as follows; ‘Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour’. 11.4.10 The impact of coercive control on an individual’s mental and social wellbeing is now considered to be so serious that it became an offence in law in January 2016, under the Serious Crime Act 2015. Elements of coercion and control include; Deliberate use of alternative moods. Excessive jealousy and possessiveness. Isolation-preventing partner from seeing family or friends. Control of the partner’s money. Control over what the partner, who they see, where they go, what they think. 11.4.11 In this case there were also elements of financial abuse in that the MOC had taken control over the bank card and would give the FOC what he termed as ‘pocket money’ each week. 11.4.12 Agencies also suspected that the MOC and/or the FOC controlled the behaviour of both children. Close working with C67 resulted in the YMCA stating that they believed that C67 had ‘been trained to stay quiet when asked certain questions or when working with new people’ (12th July 2017 multi agency meeting). 11.4.13 The FOC stated that on looking back at their relationship he believed that his wife was suffering from depression (there is mention of this in Health records in 2008) 11 Domestic Abuse; Home Office (2016) GSC- Official Page 24 although he didn’t recognise it at the time. He stated that her depression was due to the fact that she was unable to get over the death of her brother who had died some years previously in a car accident. From agency records (Health) it would appear that some level of depression was acknowledged but she was never formally treated for the condition. 11.4.14 Both the MOC and the FOC were known to drink alcohol although how this affected their behaviour towards C67 and C68 is unclear. Records do not provide an indication about how much they would drink, or how often and this would not appear to have been explored with agencies. Both parents when spoken to as part of the review process stated that alcohol did not play a big part in their relationship. The FOC stated that he was unable to afford to drink and that he never drank more than three pints of lager on any one occasion. 11.4.15 There is reference in CYPS records which states that C67 had stated that her father would enter her bedroom when drunk where he would then fall asleep. C67 also stated that her father would be annoying when he had been drinking. From the records seen as part of this review neither of these statements were fully explored in terms of the risk that it presented to her. 11.4.16 C67 graded her father as being two out of ten and stated that he would be ' drinking beer all the time, getting drunk.[and was] .annoying and silly'. She also described him as 'bossy, annoying and lazy'. There was no acknowledgement that these scores could have been attributable to abusive behaviour. 11.4.17 Although research is inconsistent there are findings that indicate that parental alcohol abuse can be associated with the sexual abuse of children 12 . The information disclosed by C67 in terms of how her father would behave when he had been drinking alcohol together with it being a known disinhibitor in terms of sexualised behaviour should have been explored further by agencies. 11.4.18 The FOC was asked why C67 would have rated him so low and he stated that he believed it was because he played his music two loud, that he would tell ‘dad jokes’ and that he would tell her off. 11.4.19 The FOC stated the he felt that he was largely unsighted about C67’s behaviour. He stated that the MOC had kept much of the information about her behaviour from him. He was unable to provide a rationale as to why this had occurred other than the fact that she predominantly dealt with the child care issues. The FOC felt that he only found out about the extent of C67’s behavioural problems when he attended one of the child protection conferences. 11.4.20 On review there is nothing to suggest that any one agency failed to effectively communicate with the FOC. For the school the MOC was the primary point of 12 Widom et al (2001) GSC- Official Page 25 contact as the FOC rarely picked C67 up. Evidence in agency (Health, CYPS and Education) records would appear to show that he was kept informed. 11.4.21 From the documentation provided to the review it would appear that whilst professionals knew of some of the dynamics that were occurring in their relationship individuals providing support to the family did not have a full overview of exactly what was happening within the household. The meetings held as part of safeguarding practice did not illicit this information (see section 11.9 in relation to improvements required concerning practice). 11.4.22 In order to change their behaviour and assist the MOC and the FOC in coping with their children they were offered parental education programmes. There is no evidence that the MOC took up these opportunities but the FOC attended the Triple P parenting programme and an understanding your child’s mental health course. The FOC stated that the Triple P Parenting Programme was particularly beneficial in terms of broadening his knowledge in how to deal with family related issues. The FOC stated that he felt that he should have been offered this course earlier and that this may have equipped him with the skills and knowledge that he needed to support his children more effectively (Recommendation 1). 11.5 Disguised Compliance 11.5.1 Agencies were initially positive in terms of the progress that the family was making following early intervention work. CIN work initiated in terms of concerns relating to neglect appeared to show positive results with agencies believing that the MOC and the FOC had responded well to the services that were offered and provided to the family. Records state that there ‘were improvements in the family’s relationships with each other and the home was cleaner and more welcoming environment. 11.5.2 As a result of the intervention taking place professionals working in agencies such as CYPS and C67’s specialist school stated that both parents appeared to be listening to the advice that was being given and were making changes. Such changes led to the case being closed (11th May 2017) following single assessment as the MOC ‘reported that things were fine at home and the challenging behaviours from C67 only occurred in school’. As a consequence this led to CYPS concluded that C67 remained an education concern to be managed with a support plan and package. 11.5.3 Conversely there were also concerns being constantly raised that the FOC was colluding with the MOC (report by family support worker in May 2012) and that they were exhibiting the traits of disguised compliance (CAMHS records 26/05/2017) Those that undertook the Triple P and Thrive programmes questioned whether the parents were truly engaged and those working in Education continually witnessed and were concerned about how the parents were presenting. 11.5.4 Disguised compliance involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement. This was recognised in the ICPC held on the 2ND October 2017 when it was suggested that a GSC- Official Page 26 piece of direct work should take place with the parents to explore disguised compliance and an accurate understanding of the family dynamics. It is not clear from records that this piece of work actually took place. Nationally numerous serious case reviews have identified that the failure to identify those parents that are displaying false compliance and lead to an over optimistic view of engagement from family’s and progress in terms of safeguarding outcomes for children13/14. 11.5.5 In this case professionals displayed elements of over optimism15 in terms of the MOC and the FOC having the ability to adequately look after their children. 11.5.6 What became clear from the practitioners events was that the behaviour displayed by their parents would vary considerably depending upon which agency they were dealing with. Those agencies that knew them well such as C67’s school would witness the MOC being extremely volatile and aggressive on occasions. Often the MOC would minimise concerns and deny that there were any risks in relation to C67. It would appear that she would exhibit this behaviour in an attempt to avoid taking any form of responsibility for the way in which her daughter was behaving. 11.5.7 From the practitioners event it was clear that the MOC had developed positive relationships with certain professionals such as those working in Social Care as she knew that they would have an impact of her future with the children. The MOC was however hostile to many others, particularly those who challenged her. They describe her as being hostile, unpredictable and extremely argumentative. One professional described how her behaviour on some occasions boarded on being ‘vile’. This type of behaviour was particularly evident to the staff at C67’s primary school who repeatedly called her to account. 11.5.8 The persistence of the staff at the school in terms of trying to get the MOC and FOC to acknowledge and address the behaviour of their daughter should be seen as good practice. 11.5.9 Schools, Health and Social Care professionals recognised that there could have been elements of disguised compliance involved in their interaction with the parents and would act accordingly. 11.5.10 Whilst professionals were alive to the fact that both the MOC and the FOC could be non-compliant consideration was not given to fully understanding why this behaviour was taking place. If it was considered then the details were not fully recorded in agency records. The MOC constantly created confusion and disruption in an attempt to prevent professionals from developing a full picture of what was actually happening in the family. 11.5.11 In this case professionals were over optimistic about the progress being made within the family and the ability of the MOC and the FOC to adequately care for C67 and 13 NSPCC Information Service (2014) disguised compliance: learning from case reviews London: NSPCC. 14 Kettle, M et al (2017) 15 The rule of optimism means that professionals are likely to give clients (parents) too many chances which is an adverse outcome for children in far too many cases. GSC- Official Page 27 C68. This was confirmed by the FOC who stated that little progress or change actually took place following intervention and in his belief agencies should have recognised this. 11.6 Evidence of Challenging the Parents 11.6.1 Despite the dominance of the MOC there was evidence of challenge by professionals. The staff in C67 and C68’s primary school would try and talk to their parents in response to the concerns that had been identified. This is evidenced in school records and the full chronology (an example of which related to C68 when his parents were challenged as to why he was continually turning up at school tired). Engaging challenging and resistant families has been identified nationally as being key to improving outcomes for vulnerable children16. 11.6.2 The ability to challenge and work constructively with the family was undoubtedly hindered by the unpredictability of the MOC’s behaviour. The MOC would try and manipulate professionals and there would appear to have been an acknowledgement by many of the professionals that worked with the family. 11.6.3 Those professionals at the focus group stated that they were not concerned about the impact that challenge would have in terms of their relationship with the family. The information gained from the family and which is recorded across agency records should have provided sufficient information which could have been used to rigorously challenge both parents, particularly with regards to sleeping arrangements and possible signs of abuse (this will be explored in section 11.9). 11.7 C67 and C68’s behaviour 11.7.1 Both C67 and C68 showed concerning behavioural traits which were recorded in agency records but not fully explored from a holistic multi agency perspective. 11.7.2 The FOC described C68 as being a quiet and laid-back child. In relation to his daughter however he stated that she would ‘fly off the handle’ and attack people at school, home and at his relatives address. He stated that she had threatened him three or four times with a knife (this information was not known to agencies). He couldn’t recall seeing C67 attacking her mother but stated that he wasn’t present in the house for the majority of time. 11.7.3 When asked why C67 acted like she did he stated that she was more intelligent than her years and that ‘she felt that she couldn’t control her emotions’. 11.7.4 C67’s mother painted a different picture of her daughter. She had told those at her school that she never saw any violent or sexualised behaviour at home and on many occasions blamed the school for the way in which she acted. When interviewed as part of the review process the MOC did however recall two incidents where C67 had threatened her husband with violence. On one occasion she had tried to attack him 16 SJHeed (2012) GSC- Official Page 28 with a screwdriver and on another with a knife. Again the details of these incidents are not recorded in agency records and demonstrate just how both the MOC and the FOC kept details from those professionals that they were working with. 11.7.5 Despite the interventions that were being put into place C68’s behaviour continued to decline during the period covered by this review (as highlighted in outreach assessments 22/06/2017, THRIVE assessments 06/07/2017, Boxall profile 06/07/2017). C67 was physically assaulting and being threatening to both staff and pupils and despite her school working with her there would appear to have been no specific trigger events. C67 had also threatened to commit suicide. One to one working and specialist support all failed to identify the underlying causes that made her behave in the way that she did. Professionals described how she ‘was emotionally shut down and scared to share her feelings with adults’ (Review conference 18/12/17). 11.7.6 The level of sexualised behaviour shown by C67 was also escalating in terms of the way that she was speaking and acting. All of this behaviour was not age appropriate and continually gave those working with her cause for concern in terms of sexual abuse. The MOC had initially explained that this behaviour could be attributable to C68 watching inappropriate videos on YouTube. When spoken to as part of the review she was adamant that the children hadn’t watched anything inappropriate. This behaviour will be explored further in section 11.9. 11.7.7 A number of explanations were put forward to explain C67’s behaviour including the possibility of her being autistic (originated from her parents) and /or suffering from the trauma in relation to an event that had occurred earlier in her life. The educational psychologist (Conference minutes dated 10th October 2017) stated ‘her emotional development is delayed’ and the ‘root of her difficulties may be complex interaction of developmental/relational trauma and low levels of self-esteem and resiliency’. 11.7.8 The theory that her behaviour could be attributable to a traumatic event originated from the event in 2011. Health professionals however differed in their opinion as to the affect that this had on C67. 11.7.9 The evidence relating from trauma was however questioned (07/07/17) with a paediatrician stating; “On the above evidence and discussion from professionals meeting I can see no other indicators at present for further assessment for an underlying disorder causing C67's present difficulties’ In a letter to the GP (27/07/17 received on the 15/08/17) the paediatrician states; “I am …… not consistently seeing evidence that supports a neuro-development disorder or post traumatic response.’ 11.7.10 From the information contained within Health and CYPS records the explanation of the possible causation of C67’s behaviour in terms of childhood trauma would GSC- Official Page 29 appear to have clouded decision making and practice in terms of recognising and effectively dealing with the possibility of abuse within the family setting. None of the theories that had been identified would appear to have been fully explored and no autism assessment was carried out. The practitioner’s event identified that no additional or long-term support or intervention had been put into place to address any of the issues that had been raised as possible causes of C67’s behaviour. 11.7.11 C67 had been referred to CAMHS due to her complex behaviour and they had started to see her from February 2017. Whilst there were attempts to engage with her an entry dated the 26/05/17 states that the MOC had repeatedly told C67 that she did not have to talk to the CAMHS worker (this was later denied by the MOC. As a result of this repeated intervention by C67’s mother CAMHS closed the case as they had concluded that c67 had no mental health issues and due to what they describe as non-compliance. CAMHS at that time suggested that health psychology team might be in a better position to work with C67 to address any possible trauma (related to the incident when she was two years of age). 11.7.12 A further referral had made to CAMHS but this failed to meet their threshold. Those at the practitioners group stated this would not be unusual in these circumstances as in C67’s case there was no clear diagnosis of mental health and she was subject to social worker involvement. There is nothing to suggest that CAMHS had failed in terms of their obligations but practitioners felt that in the absence of any other specialist support for those with complex behavioural needs this was a missed opportunity to engage with C67. 11.7.13 C67 had also been the subject of an Education, Health and Care Plan (ECHP) and relevant assessments including oversight from an Educational Psychologist and whilst this had not identified the root cause of her behaviour some practitioners felt that this intervention could have occurred earlier (Recommendation 2). 11.7.14 As a consequence of the lack of clarity about her mental health needs there was no clear pathway identified to help support her. Those present at the practitioners event felt that there were delays in getting effective mental health advice and support for C67. Practitioners stated that this was a common occurrence for children with complex needs (Recommendation 3). 11.7.15 There was also an inability to gain C67’s trust and disagreement amongst professionals as to why her behaviour was deteriorating which ensured that agencies continued to deal with her presenting needs and behaviours rather than fully considering other types of abuse. At the time neglect and emotional abuse appeared to be the primary factors driving decision making. In making those decisions the needs of C67 would appear to have been lost and she was not placed at the centre of practice. C67 would appear to have fallen between services in view of the inability to effectively identify the underlying causes of her behaviour. 11.7.16 Professionals at the practitioner’s event agreed that C67 presented as a complex case with no one agency having the ability to effectively understand or diagnose the underlying issues that were causing her to behave violently and sexually. Due to GSC- Official Page 30 this complexity all practitioners acknowledged the need to work more effectively together and that opportunities to fully share information were not exploited (this will be explored further in later sections of this report). 11.7.17 The ability to help C67 and understanding what was making her behave in the way that she did was also compounded by the fact that she would on occasions fabricate stories (19/04/17). Reports from her primary school, the YMCA and the PSED team in her specialist school all state that C67 had been fabricating stories about going on holidays, events and trips. 11.7.18 Practitioners have stated that in complex cases like C67 there are limited options available to them for referral and support to other agencies (other than CAMHS), particularly in relation to those children and young people who are violent and require anger management services (Recommendation 4). 11.8 Support for C67 and C68 11.8.1 Professionals continued to try and engage with C67 throughout the time period covered by this review. C67’s school were determined to try and prevent her from being permanently excluded and as a result had invested a great deal of time and resources in supporting her despite her levels of aggression and violence. They recognised that it was likely that school represented a safe place for C67 and despite the difficulties in managing her behaviour they felt that they were experienced at understanding her needs. 11.8.2 The school itself is experienced in dealing with families similar to this particular one and with children with behavioural difficulties. As a result they have introduced specialist staff and intervention strategies to enable them to cope with the demands placed upon them by children such as C67. These included multiple PSED check ins Three forty five minute nurture/counselling sessions per week Two forty five minute THRIVE sessions with a PSED Lead TPR. Four PSED check outs with an attachment worker. 11.8.3 The strategies used to help C67 also included funding specialist support from the YMCA. The school were particularly complimentary about the input provided by the YMCA in terms of their ability to interact and deal with C67. The level of commitment shown to C67 and the efforts made by staff members should be seen as good practice. 11.8.4 The investment made by one particular Community Care worker in the safeguarding and supporting families’ team is evident throughout the chronology and from the minutes of relevant meetings and the practitioner’s event it is clear that they were seen as a pivotal link with C67. The levels of support shown by this individual was exemplary. GSC- Official Page 31 11.8.5 As a result of C67’s escalating behaviour and an inability to reach thresholds the primary school attempted to hold a multi-agency meeting. On this occasion they state that there was good attendance by all agencies except for social care. A social care representative would have been key to this meeting delivering effective outcomes in terms of the support that could have been offered to C67. Whilst there is an acceptance that there are finite resources with CYPS this particular meeting in terms of the level of concerns raised and the history of the family should have been prioritised. There is a feeling amongst agencies that where cases don’t reach threshold and are held by single agencies there is limited support from CYPS (Recommendation 5). 11.8.6 To counter this the CYPS member on the panel has stated that there is often an expectation by schools for CYPS support although there are other avenues that are available and may be more suitable such as psychology and behaviour specialists. The panel member felt that schools need to be specific as to that support they are requesting. 11.8.7 Despite the considerable efforts of her primary school they were unable to keep C67 in mainstream education due to the level of violence that she displayed. On the 27th of September 2017 C67 was formally taken ‘off roll‘at her primary school and was permanently excluded due to her behaviour. At this point the school recognised that no matter how much intervention they had put into place they were unable to manage her effectively and safely within the school environment. This assessment was made after a sustained period of intervention by the school and in the interests of both the staff and pupils that she would have had contact with. In respect of the action taken and from the information provided to the review the school followed correct procedures and notified all relevant parties. 11.8.8 The FOC stated that in his view C67’s school ‘did what they could do under the circumstances’ in fact he described them as ‘doing a great job.’ 11.8.9 On leaving her school C68 had been provided with additional support at a specialist centre for young people experiencing complex social, emotional and mental health difficulties. The aim of the centre is to support children to move back into mainstream provision or to another specialist school that can meet their needs. Keep safe work 17 was also conducted on a regular basis with C67. These were positive steps taken by those working in Education to ensure that C67’s needs were specifically met with the aim of addressing her behavioural issues. 11.8.10 Although C67 was the only female pupil at the school there was provision with it to specifically support her. Prior to her arrival an assessment was completed and she was deemed suitable and capable of ‘holding her own’. Staff at the school stated that despite her being the only female pupil she was not isolated and made some good friends. The alternative to this provision would have meant that she would 17 Keep safe work- work conducted with children to reinforce boundaries and acceptable behaviour. GSC- Official Page 32 have had to be taught in the community where she would have been even more isolated and possibly at risk of further abuse. 11.9 Evidence of sexual abuse 11.9.1 There was no direct evidence that sexual abuse was occurring within the family environment. Neither C67 nor C68 had made any verbal disclosures to professionals that they were being physically or sexually abused. 11.9.2 The behaviour of both C67 and C68 did however cause concerns amongst those professionals that they came into contact with. Both of the children had displayed sexually explicit behaviour and language from an early age (2009). This behaviour was particularly evident to those working with the children in their school. This behaviour was clearly documented within their records and included; Sexualised language by both C67 and C68 beyond their years. Sexualised dancing by C67. C67 thrusting her hips in a sexual manner. C67 ‘snogging’ her hand stating that she was practicing kissing. C67 kissing a member of school staff on the cheek. C67 passionately kissing dolls. C67 touching herself in a masturbatory way. 11.9.3 On 12th January 2017 C67 was writing a story about a monster named Rex. C67 stated ‘that looks like sex’ and when asked what she meant she replied’ well it’s when he puts his willy in my fanny. He can also kiss my fanny and the willy can also go in the bottom’. The staff member asked C67 what she meant by this and she stated that she had seen this and then named two children in her class. C67 then closed down and wouldn’t say anything further. The matter was raised with TESS. 11.9.4 On the 13th January 2017 following advice from an attachment worker the school carried out a ‘Three houses 18‘activity. C67 asked the person with her to draw her house and when she described her bedroom she went quiet. When asked if she had any worries about any of the rooms she stated’ Well I don’t like it when C68 comes into my room and swears and I don’t like it when dad comes into my room and sleeps in my bed and acts silly.’ When asked what she meant by silly she withdrew but later said ‘they have come into my room whilst I was sleeping’. This information was shared with TESS and an initial assessment was carried out. 18 Three Houses enables social workers to discuss a child's likes/ hobbies/strengths/protective factors, dislikes/worries & risks related to the child and dreams/hopes/wishes. GSC- Official Page 33 11.9.5 Within the school the staff worked hard to identify the causes of the sexualised behaviour and language working with both children to identify their concerns. In order to do this both children were seen on an individual basis and a variety of methods were used (as demonstrated above) to help them to articulate what was happening to them. On many occasions C67 was asked to talk about her negative behaviour and home life but in response would repeatedly regress to talking in a baby’s voice. 11.9.6 Despite the attempts that were made neither C67 nor C68 disclosed the underlying issues that were causing them to behave in the way that they did. The school that both of the children had initially attended worked hard to create an environment within which the children could feel confident and comfortable to make disclosures should they have wanted to do so. This included one to one work particularly with C67. This approach should be seen as good practice. 11.9.7 Social Care professionals did view C67’s sleeping arrangements but no one appeared to identify and collate all of the issues that would have caused concerns in terms of the risks of sexual abuse. These risks included Father allegedly entering her bedroom at night. FOC allegedly sleeping in her bed with her. C67 having to remove her father from her bedroom C68 waking her up to play hide and seek. C68 getting into her bed. 11.9.8 The sleeping arrangements in the house were not clear and concerns had been raised by individuals working with the family and through referrals. C67 had told professionals working in Social care that her father would sleep in the lower bunk of her bed (as discussed at ICPC 02/10/2017). This however contradicted C68’s account who had described how C67 slept in bottom bunk as the top one was full of toys. 11.9.9 The FOC was challenged over his behaviour by CYPS and he admitted that he would sometimes get into bed with C67 when it was cold (although he denied that this took place when spoken to as part of the review). The FOC however insisted that his actions were not inappropriate. 11.9.10 C68 had stated that his father did not sleep in C67’s bed but an entry in CYPS records dated the 24/04/17 demonstrates that both parents were challenged over this and the issues of personal space and that the MOC stated that the ‘[FOC] does not get into bed with [C67] now for cuddles and [the MOC] puts [C67] to bed’. The MOC on this occasion reiterated that everyone respects each other’s space and C68 and C67 only go into each other’s room when invited. GSC- Official Page 34 11.9.11 There is further evidence of this in the conference record stated 2nd October 2017 where it is recorded that [C67] says that she ‘dislikes Dad in her bed’. 11.9.12 There is little evidence in the information that was made available to the review that these arrangements were holistically considered, challenged further or regularly reviewed. There was also no evidence that agencies seriously considered these factors in terms of the possibility of abuse occurring in the household. If the parents were robustly challenged about the comments that were made then they were not recorded in the information provided to the review. 11.9.13 The issue of the children using sexually explicit language and exhibiting sexualised behaviour was explored in single assessments (17/01/17, 01/06/17) at strategy meetings (11/09/17), CIN Meeting (18/09/17, 11/12/17) core group meeting (16/10/17) and ICPC (02/10/17) but only in a superficial way. There was no real analysis of why it was occurring or formal recognition that abuse could be happening in the family setting. The mangers oversight in the CIN meeting (18/09/17) stated that ‘ the assessment has not evidenced that C67 has experienced sexual harm- which frankly is a worry that professionals have considered… however what has been evidenced within the assessment is that C67’s behaviours are extreme and unexplained’. 11.9.14 The inability to comprehend the whole of the circumstances and history as documented in the records held by agencies led to a mixture of conclusions. In 2017 a single assessment was completed (01/06/17) which concluded that there was 'No evidence to suggest that C67 has seen or experienced sexual harm’ and that ‘it is my concern that should Children’s Services involvement continue, the pattern of disguised parental compliance and [C67] being encouraged not to talk to professionals will also continue’. As a result the case was closed to the single assessment team at that time. 11.9.15 CIN, Strategy meetings and case conferences had concluded that C67’s 'sexualised behaviour remained ‘unresolved'. Despite concerns from individual professionals the underlying reasons and risks within the family were not fully explored and assumptions effectively challenged. 11.9.16 On the 11th September 2017 a strategy meeting was held in relation to C67’s ‘sexualized comments and unregulated behaviour which if they continue will increase her vulnerability to CSA/CSE and an increasing risk of being criminalised’. This led to a decision being made that her case met the criteria for a S47 enquiry and on the 2nd October 2017 an ICPC was held and a unanimous decision was reached that there was a need for a CP plan under the category of emotional harm. 11.9.17 Many of the professionals that were spoken to during the review believed that in view of the extreme nature of her behaviour the escalation to a section 47 inquiry came too late and that previous interventions had failed to truly address the issues raised. This was commented on by the FOC who also felt that intervention by CYPS could have occurred earlier although when challenged he couldn’t articulate why this should have happened. GSC- Official Page 35 11.9.18 As part of the terms of reference the review panel were asked to consider the following; ‘Do …professionals have the ability to recognise concerning sexualised behaviour but are not able to articulate their professional judgment or give sound rational to support action being taken?’ 11.9.19 This hypothesis was tested with staff at the practitioner event. Those present felt that they had the experience to recognise the signs of sexual abuse but stated that whilst they believed that sexual abuse was occurring in the household they felt frustrated as they were unable to prove it. 11.9.20 The South West Child Protection Procedures (2019) states that; ‘Children may disclose sexual abuse directly and verbally while others may attempt to disclose by non-verbal means including changes in their behaviours, requiring those around them not just to focus on the behaviour but why the behaviour may be happening.’ 11.9.21 From the details provided by practitioners and from the information gathered as part of this review it would appear that some professionals, whilst recognising the signs of abuse still lack the confidence to deal with situations where no formal disclosure has been made and find it difficult to identify the appropriate course of action that should be taken to protect the child concerned. The CYPS on the panel felt that professionals had become deskilled at responding to sexualised behaviour and sexual abuse (although Child sexual Exploitation response was clearer)- (Recommendation 6). 11.9.22 The disclosure of abuse to an appropriate person is often seen as key in commencing the process of protecting a child and can often provide professionals with the confidence and ability to mitigate risks, implement process and deliver effective safeguarding. Where such a disclosure is not made then professionals admit that child protection processes become infinitely more difficult to co-ordinate and deliver 19. There continues to be a feeling amongst some staff that if the circumstances don’t meet the threshold required by the judicial system (family court or criminal) then often they feel disempowered to act and fully intervene in family life. 11.9.23 Professionals found it difficult to fully understand C67’s needs and despite numerous efforts they were unable to penetrate the barriers that C67 had built around herself. In this case it was commented by a CYPS manager that ‘the inability of professionals to recognise possible sexual abuse has prevailed throughout this case and that this had a profound impact on how agencies responded to C67. The decisions made by agencies at the time have closed down subsequent inquiries of sexual abuse’. 19 McElvaney et al(2020) GSC- Official Page 36 11.9.24 Whilst those involved in this case felt that they had adequate safeguarding training it has become apparent that this is somewhat generic in content and fails to adequately deal with such complex issues as non-disclosure in those cases where sexual abuse is believed to be occurring. There is also a lack of practical guidance readily available to staff. The South West Child Protection Procedures has only a small section in relation to the ‘barriers to disclosure’ and provides little detail or signposting for staff concerned about such issues (Recommendation 7/8). 11.9.25 The lack of confidence that some staff have was discussed at the Panel meeting where it was felt that too much emphasis is sometimes placed on reaching a court standard level of proof and on contravening the human rights of the parents. A senior manager within Social Care felt that in some cases such as this staff are failing to correctly follow the procedures contained in Working Together 2018. In this case panel members questioned why legal thresholds were being used at the referral stage. The expectation should be for an assessment with agency contribution and beyond the CIN status there may be enough to proceed to a child protection conference where legal requirements could be considered. The child protection plan dated the 11h December 2017 stated that a legal planning meeting would take place if ‘concerns escalate’. Practitioners and managers have stated that there were continua attempts to escalate their concerns but there was a failure to listen to them. 11.9.26 The Partnership should ensure that staff are clear about the thresholds for evidence in criminal and civil proceedings. There should also be a particular focus on those cases where the evidential threshold for criminal proceedings is not met but the probability of abuse having taken place is high and what this means for decision making and practice (Recommendation 9). 11.9.27 In this case many professionals felt that whilst C67 had not made a formal disclosure she was actually attempting to reach out to them for help through her behaviour. 11.9.28 There were numerous opportunities for all professionals to share concerns and discuss the underlying causes of C67’s behaviour and yet the processes that are currently in place did not appear to have facilitated such discussions. Professionals have been unable to articulate why this is the case but some felt that this was a reoccurring theme. 11.9.29 There was also an acceptance that those attending Core Groups, Strategy meetings and ICPC’s should have a comprehensive oversight of all issues within a case. These forums however are often frustrated in delivering an effective service through time pressures, lack of attendance, poor information exchange and an inability to truly analyse the information effectively. In this case practitioners believe that there was a lack of effective information sharing and multi-agency discussion. In respect of the strategy meeting the CYPS panel member felt that the multi-agency discussion was lost due to the chaotic nature of the meeting, that C67’s voice wasn’t heard, and that no action was taken to limit the presence and influence of the MOC.(Recommendation 10). GSC- Official Page 37 11.9.30 Those at the practitioner’s event were asked whether they believed that there was a lack of confidence amongst staff when dealing with adolescent children. There was agreement amongst those in the group that this was not a barrier to delivering support and services. 11.9.31 Both the MOC and the FOC when interviewed as part of the review process denied that any sexual abuse was occurring in the family. 11.10 Thresholds 11.10.1 In this case it was felt that the early referrals were not followed up effectively and this resulted in delays regarding statutory interventions. 11.10.2 Practitioners felt that the thresholds used by CYPS struggle to capture some forms of abuse and as a result some children falling outside of the criteria that has been set. This was true of C67’s case. Numerous referrals had been made by those in Education (28/04/17) but their referrals failed to reach threshold within the MASH despite them feeling that they were comprehensive in relation to their content. 11.10.3 Practitioners felt that often the referrals are reviewed in isolation and a failure to consider the full history of a family. There is an acceptance that in order to be effective the MASH requires an holistic approach. Some professionals felt that there was an inability to get the case past threshold and that there was a failure of the MASH to fully appreciate the case in its entirety when making its decision. As a result C67’s school felt that they were left to continually manage a level of behaviour which had reached such a level that they felt poorly equipped to deal with and where statutory intervention was required. 11.10.4 Within the threshold process practitioners believe that there is also no flexibility to provide allowance for professional judgement. In this case those working in C67‘s school were used to dealing with children with severe behavioural problems and they state that C67 was at the extreme end of the scale when compared with her peers. Despite the referrals that were made they felt that their professional voice and concerns were not being listened to. Practitioners felt that where referrals are made by those with substantial experience then the MASH should have the capacity and capability to speak personally to refer in such circumstances. 11.10.5 In this case the school felt that C67’s behaviour had reached such a point that they had no choice but to consider using permanent exclusion in order to force decisions to be made about her care and for her voice to be heard. The fact that this course of action was even considered indicates that the current system of referral and levels of thresholds requires review (Recommendation 11). 11.10.6 Within the Local Authority concerned there is a recognition that there is no central team which is able to collate all of the information together and provide an holistic oversight to cases. Those on the panel felt that the Multi Agency Safeguarding Hub (MASH) had become a processing unit and had lost sight of the opportunities that GSC- Official Page 38 could be achieved through true multi agency discussion and decision making (Recommendation 12). 11.10.7 This case has left a number of professionals questioning whether agencies acted quickly enough and at the correct level. There was an acceptance that there was a great deal of activity by some agencies but that this may have provided false reassurance to some professionals. Many believed that the activity that was taking place was making a difference when clearly it wasn’t in this case (as evidenced in C67’s scores in her assessments). On reflection professionals felt that intervention should have occurred earlier through the correct application of thresholds. 11.11 Escalation and Assessment 11.11.1 Those at the practitioner event were aware of the escalation process and appeared to be confident in using it to address operational issues where agreement could not be reached. There is evidence recorded in agency records of the escalation process being used in this case (Education/SEN). 11.11.2 There were occasions however when the process was used by such agencies as Education but its effectiveness was frustrated by other operational practices. Interviews conducted with those working in C67’s school identified that they had tried to escalate referrals and request a review of her case but that this had no impact (multi agency meeting 12th July 2017). 11.11.3 On occasions the schools efforts to escalate were frustrated as they were informed that their concerns would be addressed at the next formal meeting. Often these meetings were cancelled and therefore they had to commence the escalation process again in order to address the same issue. This is inefficient and could potentially place children and young people at risk. Effective supervision and oversight of cases should ensure that this does not take place and that escalations are dealt with immediately. 11.11.4 There is a clear escalation and professional differences policy should practitioners want cases to be reviewed in terms of their thresholds. These documents should be continually circulated to ensure that all staff are aware of their contents (Recommendation 13) and its effectiveness should be quality assured on a regular basis (Recommendation 14). The review identified that whilst professionals openly discuss escalation often some professionals fail to take the responsibility to do so or follow their actions through. 11.12 Managerial Oversight, Supervision and Workloads 11.12.1 Within the chronology there is evidence of managerial oversight and supervision taking place in this case, but on the detail provided it was difficult to assess the GSC- Official Page 39 quality of that input or whether it adhered to agency and the local partnership policy20. 11.12.2 At present frontline staff with CYPS would appear to be highly committed and motivated. Feedback from practitioners has indicated that case load is not a particular issue at present but current bureaucracy within the system, created through performance management regimes, means that they are unable to have the time to effectively manage allocated cases and fully review all case documentation. Often professionals rely on verbal briefings from those already involved rather than looking at case papers. Such bureaucracy would appear to have increased as a result of the pressures brought about by the Authority being in intervention and the need to satisfy external scrutiny and inspection. One practitioner reflected that; ‘so much emphasis is placed on form filling which simply benefits the system not the kids’. 11.12.3 In the light of this feedback the CYPS needs to continue to review current process to ensure that it’s not adversely affecting the services which they are striving to deliver (Recommendation 15). 11.12.6 Effective supervision is therefore vital in allowing practitioners to have the time to read and understand cases and in ensuring that comprehensive summaries are completed. This is particularly important when there have been considerable changes in staffing with Children’s Social Care which has on occasions created instability. Such supervision should ensure that there are comprehensive summaries in Child Protection Conference reports and that assessments provide sufficient information for professionals to make decisions. (x ref Recommendation 15). 11.12.7 There continues to be a feeling amongst frontline staff that Social Care have moved from preventative work to becoming purely a reactive service and therefore practices are currently failing children and their families. 11.13 Post Incident Management 11.13.1 Following the disclosure C67 was taken to hospital by staff from the educational establishment that C67 was attending. They were advised at the time that there was no one available from CYPS to take over this role. During the practitioners event it was identified that this was in fact not the case. CYPS representatives stated that they had made the decision on the information available at that time and that in their view it would be more effective if the staff members accompanied her until it was established what had actually happened. Those working in CYPS believed that this decision would be in C67s’ best interests as she would be supported by people that she trusted. 20 [Local Partnership]SCB Child Protection Supervision across the Partnership. GSC- Official Page 40 11.13.2 Those members of staff who accompanied C67 to hospital on the 22nd January 2018 felt that the lines of communication from CYPS were extremely poor and that they were ill-equipped to deal with the situation that they were faced with. They stated that this had been clearly articulated to CYPS. The members of staff who accompanied C67 felt that CYPS should have attended earlier to provide them with advice and guidance particularly about risk and the protection that she required (Recommendation 16). 11.13.3 There was also confusion in relation to information sharing when C67 was taken to hospital. During the practitioners group it was ascertained that at the time those working at C67’s school were concerned that the MOC was going to attend the hospital with her daughter and that this was inappropriate giving the circumstances and the possible nature of her injury. Whilst attempts were made to convey the seriousness of the situation to CYPS the MOC was allowed to travel with her and remain at the hospital (often alone with her daughter). At the time C67 had stated that she didn’t want her mother present. In these circumstances this should be seen as poor practice and failed to reduce risk or give C67 any opportunity to disclose what had happened to her. The staff from the school felt that they should have been provided with specific advice on how they should have dealt with this situation. (Recommendation 17). 11.13.4 The school had also contacted CYPS for an update in view of the impact that it was having on their staff who were at the hospital. On that occasion CYPS informed the school that they were unable to share any information about the welfare of C67 or circumstances due to data protection issues. Again this shows poor practice and awareness about the legislation as all agencies should have been working together at that time to deliver services in the best interests of C67 (Recommendation 18). 11.13.5 During the practitioners event it was established that following the initial strategy discussion at the hospital there was a great deal of confusion about what was actually happening and whether the injuries that C67 had sustained were in fact non accidental. 11.13.6 The paediatrician involved in the management of C67’s case raised concerns in terms of the decisions that were made by the children’s services manager and police officer at the hospital. During the strategy discussion the paediatrician states that it was clearly discussed that there were concerns that ‘there was a high suspicion of sexual harm occurring in the family’. All of those present accepted that there were many indicators of abuse but no disclosure by C67. The paediatrician stated that they had made it clear to those in the meeting that they had a high level of suspicion that C67 presented with injuries of sexual abuse and was advising that a specialist sexual abuse examination needed to be arranged immediately. The initial strategy discussion document states that the paediatrician was clear that C67 ‘needs to be given the opportunity to speak so that any abuse can be stopped’. 11.13.7 The strategy discussion concluded that there was ongoing concern regarding sexual abuse, that a specialist examination was to be requested to take place the next day GSC- Official Page 41 and that parental consent for that examination was to be obtained. Those taking part in the call discussed a place of safety for C67. The paediatrician then documented that the children’s services manager said there is ‘no disclosure, only suspicion of sexual abuse and therefore insufficient evidence to reach threshold for S47 and admit to place of safety’. It is further documented that the police and children’s services manager felt that allowing C67 to go home that night placed her at no greater risk than the risk she has been at for the last few years. They concluded that legally they could not make her stay in hospital. 11.13.8 The paediatrician was shocked by this opinion and of completely the opposite view as they believed that if C67 went home, potentially to the perpetrator of the abuse, her safety was at great risk, as was evidence for the specialist examination the next day. 11.13.9 The paediatrician had a further concern in relation to the understanding of the police and CYPS representative in relation to the threshold requirements for a Section 4721 inquiry, and the apparent influence that this had on their decision-making. They stated that on the day in question it would appear that the manager was of the view that the ‘evidence’ had to be a ‘disclosure’ or ‘allegation’ from C67 herself. The manager did not appear to consider any of the previous flagged or highlighted behaviours of C67 that other agencies had raised as signs of possible sexual abuse. It was the paediatrician’s opinion that the manager appeared to hold the view that ‘suspicion’ of sexual abuse was not sufficient evidence to invoke the need to keep C67 in a place of safety whilst investigation took place. This was challenged at the time by the paediatrician and the issue was eventually resolved as C67 was kept at the hospital. 11.13.10 This issue was discussed at the practitioners event with no clear resolution. CYPS re-visited the meeting minutes and have since stated that it was the Police who had stated they could not do anything at this stage and therefore the child could go home (this is recorded on the Strategy discussion record). CYPS stated that were applying for an Emergency Protection Order (EPO) for court at the time and therefore they would not have sent the child home. 11.13.11 On the information available to the review it would appear that there was a lack of clarity in terms of the options discussed amongst agencies to protect C67 on the day that she presented with her injuries. The accounts provided by the paediatrician and social care vary which would indicate that either there was a failure to share all information or that the individuals misinterpreted what was being discussed. The records held of the conversations that took place would also appear to be inaccurate and subject to individual interpretation. It is essential when dealing with victims of abuse that all information is accurately shared, recorded and that this should take place in a timely manner (Recommendation 19). 21 A Section 47 enquiry means that CYPS must carry out an investigation when they have 'reasonable cause to suspect that a child who lives in their area is suffering, or is likely to suffer, significant harm. GSC- Official Page 42 11.14 Voice of the Child 11.14.1 There is evidence within the chronology that the children were being listened to and their views sought (single assessment 01/06/17). On the 18th November 2015, for instance, Children Services state that the children’s wishes and feelings have been explored and they indicate that they are ‘happy, loved and well cared for by their mother’. The level and detail of recording of their views was however inconsistent in much of the documentation that was reviewed (Recommendation 20). 11.15 Leadership 11.15.1 As a result of the review it has been identified that there is a feeling amongst staff that there has been a lack of leadership in terms of multi-agency working. Staff have recognised that there is a need for a commitment to a programme of development and learning which will take the Local Authority area forward in terms of robust working practices. The transition from a Local Safeguarding Children’s Board to a Partnership has compounded this issue as has high levels of staff turnover. The new partnership is seen as an opportunity to rectify this situation and deliver effective training and development opportunities. 11.16.2 Senior managers within the Local Authority area accept that further work is required to develop and implement integrated pathways for children and their families to ensure effective outcomes in terms of safeguarding and child protection (Recommendation 21). 12.0 Conclusions 12.1 C67 and C68 were growing up in a dysfunctional household with little emotional support from their parents. The house in which they lived was poorly maintained and there were concerns from professionals that they were being neglected both physically and emotionally. 12.2 From an early age both children used sexually explicit language and behaviour which was considered beyond their years. Whilst C68 stopped such behaviour his sister C67 continued to become more explicit and violent as she progressed through primary school. This behaviour culminated in C67 being permanently being excluded from her school and being placed in specialist provision. 12.3 Neither C67 or C68 disclosed any physical or sexual abuse and their parents were unable to account for their behaviour. 12.4 The children and their parents had been known to CYPS over a number of years and had been receiving support prior to being placed on a plan initially for neglect and then for emotional abuse. GSC- Official Page 43 12.5 Despite considerable intervention by Education, Health and CYPS the underlying causes of the children’s behaviour were never identified. There was an acceptance by those frontline members of staff who were working with the family that there was a great deal of activity in terms of working with the family but that this may have provided false reassurance to some professionals. 12.6 Those practitioners who have worked with the family have on reflection identified that statutory intervention could have occurred earlier and that this could have reduced the risk of ongoing harm to the children through the effective co-ordination of services. 12.7 In the absence of a disclosure by either of the two children, disguised compliance by the parents and an over optimistic view of progress within the family agencies lost sight of the fact that sexual abuse could have been occurring in the family. In this case there were risks identified which could have indicated that sexual abuse was occurring in the household and these were largely overshadowed by work to address areas of neglect, emotional abuse and C67’s complex behaviour. There was a lack of understanding of the signs of sexual abuse and the interpretation of disclosure. 12.8 Some professionals, whilst recognising the signs of abuse, still lack the confidence to deal with situations where no formal disclosure has been made and find it difficult to identify the appropriate course of action that should be taken to protect the child concerned in such circumstances. 12.9 With no formal disclosure the judgements of some individuals were clouded by the need to reach criminal burdens of proof and there is a need for all staff to acknowledge and follow the basic principles as outlined in ‘Working Together 2018’. 12.10 There were also delays in getting effective mental health advice and support for C67 and this is not an uncommon in the Local Authority area where this incident took place. A review of current pathways is therefore required. 12.11 Despite repeated attempts by those working in Education and Health there was an inability to raise this case to meet current thresholds on a number of occasions. This prevented earlier intervention by CYPS. There is there is therefore a need to review current thresholds and MASH working practices. 12.12 Multi agency working practices following C67’s admission to hospital were ineffective and failed to work in accordance with local and national child safeguarding practice in terms of information sharing and the ability to protect C67 from those that could have harmed her. The initial strategy discussion procedures at hospital need to be reviewed to ensure that they are effective. Agencies need to review current practice in these areas to ensure that they are compliant with the South West Child Protection Procedures and Working Together 2018. GSC- Official Page 44 14 Recommendation 14.1 This section of the report sets out the recommendations made in relation to this case. It is acknowledged that since the commencement of this review agencies working within the Local Authority area concerned have made considerable advancements in improving practice but accept that further work is required to reach the standards expected. 14.2 The learning and any associated changes made to policy and practice should be disseminated through a Best Practice Forum. Recommendation 1. Learning: Parents require effective education programmes that are delivered in a timely manner in order to assist them in effectively coping with family life and improve the lives of children. Recommendation: CYPS to review the current process of the allocation of parental education programmes (including Triple P) to ensure that they are delivered at the earliest opportunity. Recommendation 2. Learning: In this case practitioners felt that the Education, Health and Care Plan (ECHP) and relevant assessments including oversight from an Educational Psychologist should have been delivered earlier. Recommendation: CYPS and Education to audit and review the effectiveness of Education, Health and Care Plan (ECHP) delivery and the availability of Educational Psychologist services within the Local Authority area for children with complex needs. Recommendation 3. Learning: In this case there were delays in getting effective mental health advice and support for C67 and this is not an uncommon occurrence for children in the Local Authority area. Recommendation: CYPS and Health should review the current provision of mental health advice and support for children and young people within the Local Authority area to ensure that it is effective and delivered in a timely manner. Recommendation 4. Learning: Practitioners have stated that in complex cases like C67 there are limited options available to them for referral and support, particularly in relation to those children and young people who are violent and require anger management services. GSC- Official Page 45 Recommendation: CYPS to review and identify all available options to improve the current provision of services for adolescents with complex behavioural issues. Recommendation 5. Learning: Agencies have identified that where cases don’t reach threshold and are held by single agencies there is limited support from CYPS. Recommendation: CYPS to review current attendance practice with regards to early help/multi-agency meetings. Recommendation 6. Learning: Some professionals, whilst recognising the signs of abuse still lack the confidence to deal with situations where no formal disclosure has been made and find it difficult to identify the appropriate course of action that should be taken to protect the child concerned. Recommendation: Local Authority partnership board to review current training and guidance in respect of non-disclosure issues in sexual abuse cases. Recommendation 7. Learning: The South West Child Protection Procedures lack specific guidance for staff on dealing with non-disclosure issues. Recommendation: Local Authority Partnership to review and if appropriate amend the current South West Child Protection Procedures in relation to non-disclosure. Recommendation 8. Learning: There is a lack of confidence that decision making will be robust in similar cases where there has been a non-disclosure by a child but sexual abuse is suspected. Such cases need to be reviewed to ensure that children are not at risk. Recommendation: Undertake a thematic review of an agreed (by Partnership Board) percentage of cases across the Partnership where sexual abuse is suspected but there hasn’t been a disclosure. Recommendation 9. Learning: In this case practitioners identified that staff are unclear about the thresholds for evidence in criminal and civil proceedings in relation to child protection and safeguarding cases. Recommendation: Local Authority Partnership to develop a communications strategy to reinforce to all staff the differences between thresholds in criminal and civil cases which reflects effective practice contained within Working Together 2018. GSC- Official Page 46 Recommendation 10. Learning: Child Protection Meetings are often frustrated in delivering an effective service through time pressures, lack of attendance, poor information exchange and an inability to truly analyse the information effectively. In this case practitioners believe that there was a lack of effective information sharing at these forums. The effectiveness of these meetings needs to be reviewed. Recommendation: All agencies to review current attendance and practice in relation to core meetings and case conferences to ensure that they adhere to best practice as detailed in Working Together 2018. Recommendation 11. Learning: In this case the school felt that C67’s behaviour had reached such a point that they had no choice but to consider using permanent exclusion in order to force decisions to be made about her care and for her voice to be heard. The fact that this course of action was even considered indicates that the current system of referral and thresholds requires review. Recommendation: CYPS to review current referral and threshold criteria for children with complex behavioural issues. Recommendation 12. Learning: Within the local authority concerned there is a recognition that there is no central team which is able to collate all of the information together and provide a holistic oversight to cases. Recommendation: All agencies to review current MASH structure and practices to ensure that all available information is considered and effectively disseminated to facilitate effective decision making in terms of vulnerable children. Recommendation 13. Learning: Whilst most staff appear to be aware of the escalation and professional differences policy it should be continually circulated to ensure that all staff are aware of its contents. Recommendation: Local Authority partnership to re-circulate the escalation and professional differences policy to all relevant agencies. Recommendation 14. Learning: The review was unable to fully ascertain the effectiveness of practice in relation to the escalation and professional difference policy. GSC- Official Page 47 Recommendation: Local Authority partnership to conduct an audit to ascertain the effectiveness of the escalation and professional differences policy. Recommendation 15. Learning: Current performance process within CYPS are adversely affecting the services which they are striving to deliver. Recommendation: CYPS to undertake a review of current performance processes to ensure that are not adversely affecting caseload management. Recommendation 16. Learning: Members of staff who accompanied C67 to hospital on the 22nd January 2018 felt that the lines of communication from CYPS were poor and that they were ill-equipped to deal with the situation that they were faced with. Staff felt that CYPS should have attended the hospital earlier. Recommendation: CYPS to review current practice in relation to staff attendance at hospital where there is a suspicion that the injuries sustained by the child are non-accidental. Recommendation 17. Learning: In this case the MOC was allowed to travel and stay with C67 despite concerns about the risk that she might pose to her daughter. C67 had also stated that she didn’t want her mother present. Professionals failed to reduce risk or give C67 any opportunity to disclose what had happened to her. Recommendation: CYPS to review current advice given to agencies in situations where non accidental injury is suspected and parents are seeking to travel and stay with their children at hospital. Recommendation 18. Learning: The school had also contacted CYPS for an update and had been informed that they were unable to share any information about the welfare of C67 or circumstances due to data protection issues. Again this shows poor practice and awareness about the legislation as all agencies should have been working together at that time to deliver services in the best interests of C67 Recommendation: CYPS to ensure to increase staff awareness in relation to information sharing and data protection/GDPR. GSC- Official Page 48 Recommendation 19. Learning: In this case the strategy discussion held at the hospital was ineffective and there was a failure to effectively share information. As a result C67 could have placed at further risk through being returned home to her family. Recommendation: Police, CYPS and Health to review current strategy discussion and recording practice in relation to cases of suspected non accidental injury to ensure that it follows South West Child Protection Procedures. Recommendation 20. Learning: There was evidence that the voice of the child was not always consistently recorded in agency records. Recommendation: All agencies to review current practice to ensure that the voice and wishes of the child are accurately recorded. Recommendation 21. Learning: In this case there was a disjointed approach to the delivery of safeguarding services to C67. Agencies working within the Local Authority area accept that further work is required to develop and implement integrated care pathways. Such pathways will deliver effective services and responses in respect of child protection and safeguarding. Recommendation: CYPS to work with all agencies in the Local Authority area to review current service delivery and implement effective integrated care pathways to meet the needs of children and young people. GSC- Official Page 49 12.0 Glossary CAMHS - Child Adolescent and Mental Health Services CCG – Clinical Commissioning Group CIN – Child in Need CLA- Child Looked After CP- Child Protection CSA – Child Sexual abuse. CSE – Child Sexual Exploitation CYPS- Children and Young Person Services DSL - Dedicated Safeguarding Lead ECHP - Education, Health and Care Plan EPO – Emergency Protection Order FIT – Family Intervention Team FOC – Father of the child GSC- Government Security Classifications ICO – Interim Care Order ICPC - Initial Child Protection Conference MARAC – Multi Agency Risk Assessment Conference MASH- Multi Agency Safeguarding Hub MOC – Mother of the child NHS – National Health Service PCT- Primary Care Trust PSD - Personal, Social and Emotional Development Plan SCR – Serious Case Review SHA- Strategic Health Authority TAF- Team Around the Family TESS- [Local authority] Education Safeguarding Service YMCA - Young Men’s Christian Association GSC- Official Page 50 Bibliography Home Office, Domestic abuse and Abuse guidance; March 2016 Local Authority Professional Differences (Escalation) Policy Local Authority Serious Case Review Overview Report Child JS (2008) Local Authority Serious Case Review C18 (2010) Local Authority Serious Case Review Overview Report Child 24 (2011) Local Authority Serious Case Review Child C40 (2014) Local Authority Serious Case Review C42 (2014) Local Authority Supervision Principles Martin Kettle, Sharon Jackson, ‘Revisiting the Rule of Optimism’, The British Journal of Social Work, Volume 47, Issue 6, September 2017, Pages 1624–1640, https://doi.org/10.1093/bjsw/bcx090 Nicholas, Joanna, ‘Child Protection:”Tackling Neglect’. Special Report, Care Knowledge; September 2016. Rosaleen McElvaney, Katie Moore, Keith O’Reilly, Rhonda Turner, Betty Walsh, Suzanne Guerin, ‘Child sexual abuse disclosures: Does age make a difference? ‘Child Abuse & Neglect International Journal; 99 (2020) 104121 NSPCC Information Service (2014)Disguised compliance: learning from case reviews London: NSPCC Saheed, Fareena. ‘Engaging resistant, challenging and Complex Families’ Research in Practice (2012) South West child Protection Procedures. Widom, C S, and S Hiller-Sturmhöfel. “Alcohol abuse as a risk factor for and consequence of child abuse.” Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism vol. 25,1 (2001): 52-7. |
NC52238 | Serious persistent neglect of three siblings over a number of years by their mother. Child in need plans for Ryan and Nathan opened and then closed due to non-cooperation from the mother; all three children later had child protection plans due to neglect subsequently stepped down to child in need. Ryan and Nathan both had learning disabilities and autism. Ryan was referred to Child and Adolescent Mental Health Services (CAMHS) due to low mood and behavioural problems. Mother made several requests to have Nathan placed in residential care due to his aggressive behaviour which was later agreed. Concerns over Amelia due to developmental delay and inappropriate feeding by the mother; concerns over the home environment and safety of the children. Intensive family support provided by multiple agencies but no improvements achieved. Maternal history of: depression, sexual assault and domestic abuse; child neglect (own children). Ethnicity or nationality not stated. Learning includes: lack of access to the family home can prevent agencies fully appreciating the extent of child neglect. Recommendations include: resolve professional differences; child protection proceedings should not preclude pre-birth assessments; staff working with children with complex and additional needs should be trained and skilled; tools such as the Graded Care Profile 2 and local strategies and procedures should be followed; health, education and care plans should be robust; parenting assessments should be repeated or updated when necessary; consider filling gaps in service provision.
| Title: Local child safeguarding practice review: Ryan, Nathan and Amelia. LSCB: Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership Author: David Mellor Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership Local Child Safeguarding Practice Review Ryan, Nathan and Amelia Author: David Mellor Date: April 2021 2 Contents 1. Introduction ...................................................................................................................................... 3 2. Terms of Reference and Methodology .......................................................................................... 3 3. Brief summary of the case .............................................................................................................. 5 4. Analysis .............................................................................................................................................. 8 5. Views of mother and maternal grandmother ............................................................................. 28 List of Recommendations and Suggestions .................................................................................... 29 References ........................................................................................................................................... 32 3 1. Introduction 1.1 The purpose of this Local Child Safeguarding Practice Review (LCSPR) is to identify learning - with which to improve practice - from how partner agencies in a Council within the Children’s Safeguarding Assurance Partnership (CSAP) area worked individually and collectively to safeguard three siblings from harm over a period of several years during which there were continuing concerns about their mother’s capacity to parent them. The children will be referred to in this report as Ryan, Nathan and Amelia which are not their real names. Two of the children had substantial additional needs (Ryan and Nathan). This report is an executive summary of the full LCSPR report. 1.2 CSAP decided to review this case after concerns were raised by Ofsted following an inspection of Children’s Home 1. Ofsted expressed concern that the short breaks provided to Ryan and Nathan by Children’s Home 1 were principally to enable mother to benefit from respite rather than meet the children’s individual needs. On further examination, Ofsted expressed concern about the response of partner agencies to the risks which Nathan presented to Amelia. The Safeguarding Partners commissioned David Mellor, a retired chief officer of police with eight years’ experience of conducting statutory reviews and no connection to local services to be the lead reviewer. 2. Terms of Reference and Methodology 2.1 The period covered by the review is from April 2016, when child protection planning began for Ryan and Nathan until 31st December 2019, by which time Nathan had been accommodated by the local authority. Significant events which took place prior to April 2016 are also included. 2.2 The key lines of enquiry for the review are: How effective was Child Protection Planning (April 2016 – January 2017). Was a pre-birth assessment considered in respect of Amelia (born in August 2016)? How effective was Child in Need support? To what extent was Child Protection and Child in Need planning integrated with other plans such as Education, Health and Care plans? How effective and inclusive was multi-agency working? How holistic were assessments of the needs of the family? Were the needs of each child considered? Was the impact of the needs of each child on their siblings considered? Was mother’s parenting capacity fully considered? What action was taken when it became apparent that things were not improving for the children despite significant agency involvement? 4 How responsive were agencies when concerns in respect of the family began to escalate? To what extent did agencies involved in providing support to the family maintain a focus on safeguarding the children from abuse and/or neglect? How effectively did agencies respond to mother’s needs? How effectively did agencies respond to indications of disengagement and denial of access from mother? Did agencies gain a sufficient understanding of the ‘lived experience’ of the children. Did agencies meet the needs of the children at the appropriate level of need (the thresholds in place at the time). To what extent did agencies adopt a ‘Think Family’ or ‘Whole Family’ approach? To what extent did agencies understand the support provided by the wider family and consider the impact of the death of a key family member? 2.3 Agencies which had relevant contact with the family provided chronologies of that contact. A practitioner learning event was arranged to inform this review, which was attended by the following agencies: Teaching Hospitals NHS Foundation Trust (Health Visitor, CAMHS and School Nurse) Council Safeguarding Children with Complex Needs Team (Service Manager and Team Manager) GP Practice 2 (Practice Manager) Special School attended by Ryan and Nathan (Head Teacher) Special Educational Needs and Disability (SEND) Officer Nursery 1 (Manager) Nursery 2 (Proprietor/Manager) Children with disabilities charity (Family Support Manager) Children’s Home 1 (short breaks provider to Ryan and Nathan) was invited but did not attend. 2.4 The lead reviewer was also provided with copies of plans and key documents. 2.5 The mother and maternal grandmother of the children contributed to this review by commenting on a late draft of the report. Their views are shown in Section 5 of the report. 5 2.6 Further information on the process followed by the Children’s Safeguarding Assurance Partnership in deciding how LCSPRs should be conducted can be found at https://www.proceduresonline.com/resources/sgp/p_child_sg_review.html 3. Brief summary of the case Background 3.1 Mother, Ryan and Nathan moved to the Council area from another local authority area in 2009. The move appears to have been made to be near the support of maternal grandparents who were already resident in the Council area and because mother felt that her children’s additional needs would be met more effectively in the Council area. Ryan and Nathan had been subject of child protection planning on the ground of neglect whilst living in the original local authority. 3.2 Ryan was born in 2004 and had global development delay, moderate learning disability and autistic traits. His school regarded him as very able. Nathan was born in 2007 and was autistic, had severe learning disability and was largely non-verbal. Mother has a self-disclosed slight learning difficulty and experienced low mood. She has also disclosed sexual assault and domestic abuse which is likely to have impacted on her wellbeing. 3.3 Following their move to the Council area, children’s social care carried out three separate core assessment of Ryan and Nathan between 2010 and 2013, all of which led to Child in Need plans which were later closed due to non-engagement from mother or a retraction of consent. However, the children have been open to children’s social care on either child protection, child in need or short breaks plans since November 2013. 3.4 Amelia was born in 2016. All three children have different fathers, none of whom appear to have played a significant role in the life of their children. 3.5 When mother became pregnant with Amelia, she and the two older siblings were living in a home supplied by, and in close proximity to, a local charity which provides support to children with disabilities and their families. The charity was mother’s landlord and also provided her and the children with informal support. Mother also volunteered for the charity. In April 2016 a worker from the charity contacted the police after finding Ryan and Nathan alone in their home. They were locked in the property and had no means of contacting anyone and no access to food or drink. The kitchen was described as being in a ‘poor state’. Mother was later arrested by the police and disclosed that she was experiencing difficulties in parenting Nathan because of his violence towards her and Ryan. Ryan and Nathan were placed on child protection plans under the category of neglect. A child and family assessment (CAFA) was completed but no pre-birth assessment was carried out in respect of the unborn Amelia, who was also made subject to child protection planning when born in August 2016. 6 3.6 The children were stepped down to child in need support in January 2017. Mother was said to have engaged well with children’s social care and improvements had been made to the home with the input of intensive support from a social work assistant. 3.7 In June 2017 Ryan was referred to CAMHS by the special school he and Nathan attended. The school was concerned that there had been a decline in terms of Ryan’s mood, self-harming, anger, obsessional behaviour and a refusal to follow instructions. In addition, a key family member had died a few months earlier. 3.8 In September 2017 mother made the first of several requests for Nathan to be accommodated by the local authority. A CAFA completed at that time found that Ryan often protected mother and Amelia from what was described as Nathan’s ‘aggressive’ behaviour, which could lead to Ryan becoming frustrated, upset, anxious and engage in self-harming behaviour. In response it was decided that a provider of support to children with Autism Spectrum Disorder (ASD) would continue to provide support to both Ryan and Nathan but that this would now be provided separately. 3.9 In June 2018 Ryan disclosed to his school that he had been left on his own with his siblings and administered his own medication. However, children’s social care decided to take no further action after mother said that Ryan’s disclosures were untrue and the child declined to repeat them to a social worker. 3.10 When Amelia started at Nursery 1 in September 2018, concerns arose over an apparent development delay of 12-15 months and the fact that she was fed only pureed food by mother. A health visitor became involved but mother declined home visits from that service. 3.11 Ryan’s school expressed concerns over his behaviour following his return to school in September 2018, particularly his adoption of the persona of a man of 75. In March 2019 he was assessed by a clinical psychologist who made a number of recommendations of how best to respond to Ryan’s presentation, in particular to explore the underlying need which adopting the persona was serving. 3.12 Concerns about Amelia’s delayed development continued in early 2019, including information that the child (now approaching two and a half years of age) was spending a lot of time in a pram at home. Later in the year mother disclosed that she locked Amelia in her bedroom at night to keep her safe from Nathan. 3.13 In April 2019 the charity from which mother rented the home in which she and the children lived, used their powers as landlord to gain entry to the home after a period during which they had been denied access. The home conditions gave considerable cause for concern. 7 3.14 In June 2019 a CAFA was completed which concluded that the current high level of short breaks should continue for Ryan and Nathan and a child in need plan should be put in place to support mother’s parenting of Ryan and Nathan. 3.15 Concerns about the safety of the children within the family home began to accumulate from August 2019. Emergency respite was arranged for Nathan who was reported to be violent towards mother and Amelia. Mother moved Amelia from Nursery 1 to Nursery 2 in circumstances which raised concern that the move may have been motivated to evade scrutiny of Amelia. 3.16 From September 2019 the school became increasingly concerned about Ryan’s agitated and distressed presentation. He was excluded from school the following month after threatening a teacher with a butter knife. He continued to self-harm, including attempting to drown himself. 3.17 In November 2019 all three children were made subject to a child protection plan on the grounds of neglect. The family had been receiving intensive support from a number of agencies but no improvements had been achieved. Partner agencies expressed concern that the level of violence in the family home necessitated the children being placed in the care of the local authority. This led the Child Protection Chair to invoke the Council area’s Children’s Safeguarding Quality Review (SQR) Service Issue Resolution Procedure, the outcome of which was that assessments of mother and maternal grandmother needed to be completed thoroughly and that the Core Group needed to be promptly reconvened to develop a safety plan whilst the assessments were completed. 3.18 Also during November 2019 Ofsted inspected Children’s Home 1, which provided short breaks to Ryan and Nathan. Ofsted expressed concern that the short breaks were primarily to allow mother respite rather than to meet the individual needs of the children and when family circumstances were further enquired into, Ofsted took the view that the risks to Amelia from her siblings had not received a sufficient response. These issues were escalated to the Director of Children’s Services. 3.19 A Legal Planning meeting agreed that the legal threshold for care proceedings had been met although the outcome of the subsequent Public Law Outline meeting was unclear. 3.20 On 13th December 2019 the Assistant Director, Children’s Services and members of the Care Planning Panel agreed to issue proceedings and request accommodation of the children under Section 20 of the Children Act in the interim. After it did not prove possible to place the children with maternal grandmother, who had significant existing caring responsibilities, mother signed a Section 20 agreement for Nathan but refused to do so for Ryan and Amelia and so they remained in her care at that time. 8 4.0 Analysis Each of the key lines of enquiry are addressed in this section of the report. How effective was Child Protection Planning (April 2016 – January 2017). Was a pre-birth assessment considered in respect of Amelia (born in August 2016)? 4.1 Child protection planning was initiated after mother left Ryan and Nathan (aged 11 and 9 respectively) alone in the family’s home whilst visiting her boyfriend in a local bar. The children had been locked in their home with no means of contacting anyone and no access to food or drink. The kitchen was noted to be dirty, the home untidy and cluttered and there was excrement in Nathan’s room. 4.2 A CAFA was completed but no pre-birth assessment was conducted in respect of Amelia who was born 4 months later. The CAFA stated that it was being completed in line with a pre-birth assessment, although the impact of Amelia’s birth on the family was only briefly referred to. The Pan-Lancashire Multi-Agency Pre-Birth Protocol (1) (this current protocol differs slightly from the protocol in place at that time) sets out the following non-exhaustive list of examples of when a multi-agency pre-birth assessment, led by children’s social care, should be conducted: There are concerns that their parent, their partner or a potential carer may pose a risk to children – mother presented a risk of neglect to Amelia. There were concerns about Amelia’s father’s police record although he was later discharged by ‘probation’ who did not ‘deem him to be a risk’. However, no police checks on Amelia’s father were completed to inform the CAFA. There are concerns regarding the parent, their partner or a potential carer in terms of parenting capacity. Such concerns may include mental health problems, learning disability or inability to parent or protect children from harm – mother had neglected Ryan and Nathan and disclosed that she had experienced difficulties in parenting Ryan and particularly Nathan and was ‘extremely stressed’. She self-disclosed having a slight learning difficulty. The parent, their partner or potential carer has children that have been made subject to a Child Protection Plan, or Care or Supervision Order at any time in the past, or if proceedings are ongoing – Ryan and Nathan were subject to a child protection plan under the category of neglect from 3 months prior to the birth of Amelia until 5 months after her birth. There are concerns regarding domestic abuse. These could relate to any person who may be involved with the unborn baby – Amelia’s mother was the victim of domestic abuse from the child’s father. 9 There are concerns regarding problematic drug or alcohol misuse of the parent, their partner or a potential carer – when arrested by the police for neglect, mother was ‘under the influence of alcohol’. It is unclear whether her use of alcohol was otherwise problematic. There are significant concerns about the lifestyle of parent, their partner or a potential carer which would impact on their ability to parent or protect children – mother had planned to go out on the Saturday following the neglect incident and leave the children in the care of her sister who had mental health issues. Concealed pregnancy or delayed presentation to ante-natal services – this example did not apply to this case. 4.3 Amelia was added to the child protection plan when she was born. It is possible that children’s services took the view that this action precluded the need for a pre-birth assessment. However, application of the current Pan-Lancashire Protocol suggests that there were strong grounds for completing a pre-birth assessment. Mother was clearly struggling with the demands of parenting Ryan and Nathan. The arrival of a third child seemed likely to increase the demands upon her and impact upon the care she was able to provide to Ryan and Nathan. Arguably, the decision not to conduct a pre-birth assessment was the beginning of a pronounced tendency for Amelia’s needs to be overshadowed by the needs of her elder siblings. 4.4 Child protection planning continued until all three children were stepped down to support as children in need in January 2017. The Review Child Protection Report, which informed the decision to step down from child protection planning, concluded that mother had worked with children’s social care to improve her parenting and the family’s home conditions and there were currently no concerns about mother meeting the needs of the children. The report has been shared with this review and progress is evidenced to a degree although many concerns remained, particularly in respect of mother’s approach to boundaries and routines which she stated Ryan and Nathan were unable to adhere to because of their additional needs, Ryan’s access to inappropriate adult material from the internet and home conditions, which were said to have improved, but on the most recent home visit documented – which was six months earlier - piles of clothing had been seen on the landing, in the lounge and on mother’s bed, Nathan’s room had smelled of faeces and Ryan’s bed had lacked bedding. Nathan’s challenging presentation when agitated was said to have become more pronounced recently and although mother was said to ensure the safety of Amelia when Nathan was ‘being violent’ there was no description of how she kept Amelia safe. Mother’s cognitive abilities went largely unexplored. It was said that she had reported learning difficulties which had impacted upon her at school but that she felt that she coped well as an adult and did not feel that she required additional support. 4.5 Additionally, this review has been advised of concerns which were not referred to in the Review Child Protection Report, specifically Amelia being left alone with Ryan whilst mother answered the door, Ryan picking up Amelia when mother was not present to supervise, 10 mother’s lack of insight into Ryan’s continence issues, mother not bringing Amelia to the GP practice for her 8 week check, although this was rectified the following month and one failed visit by the health visitor. This review has been advised that the health visitor achieved only one home visit following the birth of Amelia. Recommendation 1 (Pre-Birth Assessments) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance that pre-birth assessments are conducted in compliance with the Pan-Lancashire Protocol and that the fact that elder sibling(s) are currently subject to child protection or child in need planning – which could encompass the needs of the unborn child - is not regarded as a reason for ruling out a pre-birth assessment. To what extent did agencies involved in providing support to the family maintain a focus on safeguarding the children from abuse and/or neglect? 4.6 In addressing this question it is important to recognise that in their 2018 inspection of the Council area’s children’s social care services, Ofsted found ‘longstanding and widespread failures in the quality of social work practice’ which meant that ‘many children were not having their needs responded to in the right way or at the right time’. Ofsted went on to state that ‘as a result, some children live in situations of chronic neglect for long periods of time. Their situations do not always improve and, for many, they deteriorate, resulting in poor outcomes and increased risk. For some children, the impact is serious, with children suffering additional harm that affects their health and development’. In this case, all three children experienced long periods of chronic neglect and Amelia in particular was exposed to physical abuse for a lengthy period despite substantial involvement of agencies including child protection and child in need planning. 4.7 The family dynamic of Nathan presenting a physical risk to Amelia and Ryan perceiving himself to be the ‘protector’ of his mother and sister, and Ryan suffering anxiety and engaging in self-harming behaviours as a result, was first recognised in the CAFA completed on 12th September 2017. However, the manager who endorsed the CAFA remarked that the assessment had disclosed ‘no safeguarding issues’. 4.8 The same dynamic was disclosed by mother in a child in need meeting in April 2019 and Ryan’s perceived role as his mother’s protector from Nathan was noted in the clinical psychologist’s report completed in March 2019. A CAFA completed in May 2019 noted that mother reported that Amelia’s crying upset Nathan, causing him to have a ‘melt-down’ and try to ‘get to’ Amelia, although this issue was not included in a summary of ‘needs and risks’ for each child towards the end of the CAFA. Although the focus of the assessment was primarily on Ryan and Nathan, the risk that Nathan was stated to present to Amelia could have been included in the summary of risks. Again the CAFA concluded that ‘no significant concerns were raised during this assessment period’. 11 4.9 It is unclear why the risks Nathan presented to Amelia went repeatedly unrecognised as a safeguarding concern during assessments. At the practitioner learning event it was suggested that the social workers in the children with complex needs team had a high level of expertise in assessing the additional needs of children but were less well equipped to identify safeguarding issues. Additionally, this team was managed by the Special Educational Needs and Disability (SEND) service until late 2019, at which time they were brought under the management of children’s social care, partly to ensure a stronger focus on safeguarding. However, not recognising safeguarding concerns in respect of children with additional needs appears to be a sector wide problem. A 2016 report of the National Working Group on Safeguarding Disabled Children emphasised the need to ensure that practitioners have enough of an understanding of child protection issues for disabled children, understand the increased vulnerability of disabled children and take timely and effective action (3). At the practitioner learning event it was also suggested that substantial caseloads may have been a factor in safeguarding issues being overlooked. 4.10 Safeguarding concerns began to escalate from the beginning of August 2019 when over three consecutive days mother informed Children’s Home 1 that Nathan had hit her with a paperweight and also hit his two siblings - although reference to the paperweight was omitted from the information shared with children’s social care; CAMHS informed children’s social care that Nathan was kicking and grabbing Amelia and that Ryan’s mental health had deteriorated and he was saying that he would cut himself; and mother phoned EDT in distress to express fear of Nathan for herself and her other children. On Nathan’s return from two days emergency respite at Children’s Home 1, mother phoned children’s social care to say that he was hitting her and she needed support from staff the children with disabilities charity to restrain him. 4.11 Further support was provided to mother and the children over the summer holiday period but concerns continued to be raised. On 10th September 2019 the case was discussed by the social worker and her team manager in supervision and the latter felt that the threshold for child protection planning had not been met at that time. Children’s social care has advised this review that application of the continuum of need was not consistent in this case, and that the evidence available to the above supervision meeting clearly identified that the threshold for child protection had been met at least for Amelia. 4.12 Later the same month mother reported that Nathan had struck Amelia on the head and the social worker advised her team manager that she had to physically restrain Nathan twice to protect others in the family home during a visit. Children’s Home 1 documented that the social worker told them that Nathan had pulled out a clump of Amelia’s hair. Nathan was then placed with Children’s Home 1 for 17 days to reduce the risks in the family home before matters appeared to come to a head at the 4th November 2019 ICPC at which all three children were made subject to a child protection plan on the ground of neglect. At this meeting several agencies expressed concerns that the children were no longer safe in their family home. As a result, the Child Protection Chair who had chaired the ICPC invoked the Council area’s Child Protection Quality Review Service Issue Resolution Procedure. However, although the procedure was followed, the resolution was insufficiently speedy (12 working 12 days) and the resolution was overly optimistic in that it appeared to be predicated on the assumption that maternal grandmother could care for Nathan whilst assessments were carried out (Maternal grandmother had significant caring responsibilities herself). Nor was the resolution fully actioned in that the Core Group was not brought back together by the social worker the following week to develop a safety plan. The Core Group do not appear to have met until their next scheduled meeting date over two weeks later. 4.13 Despite the serious concerns expressed at the 4th November 2019 ICPC and the invoking of the Issue Resolution Procedure, urgent action to safeguard the children was not taken and undue faith appears to have been placed in the child protection plan to keep the children safe. Although a legal planning meeting took place on 25th November 2019 at which it was decided to seek care orders, at a public law outline meeting a week later no schedule of expectations had been prepared for mother. 4.14 Ofsted escalated concerns about the children to the Director of Children’s Services following their 13th/14th November 2019 inspection of Children’s Home 1 and Nathan was accommodated under Section 20. This method of escalation – via the external regulator to senior management – appeared to be more effective at generating a decisive response than the concerns expressed by local partner agencies. 4.15 Ofsted’s 2012 thematic survey report on protecting disabled children found that disabled children who were also identified as children in need often had unidentified child protection needs. It also found that the majority of the then Local Safeguarding Children Boards (LSCBs) and local authorities were not robustly assessing the quality of work to protect disabled children. Since the publication of the report, there has been no significant change to the proportion of disabled children with a child protection plan. 4.16 In this case there was such a strong focus on the additional needs of Ryan and Nathan and the support mother needed to parent them, that Amelia’s needs were either overlooked, minimised or considered discretely from her siblings for a substantial period of time. Safeguarding concerns in respect of Ryan and Nathan were overlooked until they escalated significantly. The impact of the needs of the children on their siblings was not fully explored and the risks to the siblings from each other was explored even less fully. Additionally, there was an emphasis on preventing family breakdown at the expense of exploring and understanding the lived experience of the children, in particular Nathan who is largely unable to communicate verbally. 4.17 Whilst it is recognised that considerable change has taken place since this LCSPR was commissioned, including the transfer of the Safeguarding Children with Complex Needs team from the Special Educational Needs and Disability service to Children’s Social Care, it is recommended that the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership (CSAP) seeks assurance that the Safeguarding Children with Complex Needs team has both the skills to assess and meet the additional needs of children and has sufficient awareness of the general and particular vulnerability of children with additional needs to abuse and neglect. 13 Recommendation 2 (Safeguarding Children with Complex Needs) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtain assurance that the Safeguarding Children with Complex Needs team has both the skills to assess and meet the additional needs of children and has sufficient awareness of the general and particular vulnerability of children with additional needs to abuse and neglect. 4.18 The Panel of senior managers established to oversee this review emphasised the importance of professional challenge to the whole system for safeguarding children and felt that this had been lacking in this case and that when the challenge was made at the 4th November 2019 ICPC, the Issue Resolution Procedure did not succeed in escalating matters successfully. It was open to professionals to consider the Safeguarding Children Partnership’s ‘Resolving Professional Disagreements (Escalation and Conflict Resolution) Procedure which is a multi-agency process envisaging escalation through three stages to very senior levels of management within a maximum of 15 working days. It is unclear how frequently this Procedure is invoked. The lead reviewer has completed several reviews in which professional disagreements procedures could have been invoked but were not. The Panel felt that professionals need to have the confidence to challenge and also need to recognise that it is their personal responsibility to challenge. However, the Panel acknowledged that power was not evenly distributed within the whole system for safeguarding children and that professionals may be reticent about challenging decisions taken by children’s social care. It was felt that children’s social care needed to make it clear that they were open to challenge but also improve their explanation of the justification for their decisions so that professionals from other agencies could make a more informed decision over when a challenge was merited. Suggestion 1 (Resolving Professional Disagreements) CSAP may wish to consider how best to take the issue of resolving professional differences further. The Child Protection Issue Resolution Procedure appears to be a robust process if adhered to and has a series of steps for escalating matters although, on the evidence from this case, professionals may be reticent to push the challenge beyond the initial stages. The Partnership’s Resolving Professional Agreements Procedure appears less robust and may need to be strengthened and given greater publicity. 4.19 Until safeguarding issues began to escalate in August 2019, concerns that Amelia was experiencing parental neglect appeared to be managed on a ‘separate track’ to the ongoing involvement of agencies with Ryan and Nathan. Agencies had begun to notice that Amelia was experiencing neglect only when she started at Nursery 1 shortly after her second birthday (September 2018) although the family GP had documented ‘poor interaction’ between mother and the child a year earlier. 14 4.20 Nursery 1 and the health visitor estimated a development delay of 12-15 months, noting that she had just started to walk and her limbs appeared weak and shaky when she did so. There were also concerns about her motor skills and it was noted that she ate only pureed food. A referral to children’s social care appeared to be under consideration at this point but wasn’t made, probably because the social worker for Ryan and Nathan contacted the nursery and during that conversation concerns were shared, including those of the social worker who had noticed Amelia’s delayed development when visiting Ryan and Nathan. 4.21 Amelia was placed with nursery 1 for a year during which the nursery initiated the TAC process and made several referrals for support including Early Years SEND, speech and language therapy and the local child development centre. The nursery involved the health visitor in the case and worked hard to engage with mother, who would not allow the health visitor to visit the family home. However, concerns that Amelia was experiencing neglect increased and by January 2019 the nursery felt that her delayed development may be environmental as they understood Amelia to sleep in a pram at home and she was known to still be eating baby food at home in May 2019. The health visitor appropriately adjusted the level of service she provided to ‘Universal Plus’. The nursery became aware of the risk of physical abuse to Amelia by July 2019 when mother disclosed that she locked her daughter in her bedroom at night to keep her safe from her siblings. 4.22 At this point a safeguarding referral could have been considered although the nursery did contact children’s social care to share their concerns and were advised that Amelia was now subject to a child in need plan. However, the child in need plan initiated in July 2019 related only to Ryan and Nathan and no CAFA was carried out in respect of Amelia until 23rd August 2019. After concerns arose over the reasons why mother had decided to move Amelia to a different nursery (Nursery 2), extra time at nursery was authorised for Amelia at a child in need on 12th September 2019. 4.23 It is concerning that there appeared to be some reticence in formally escalating concerns that Amelia was being neglected. Appropriate referrals to support Amelia in overcoming her considerable developmental delay were made and discussions with children’s social care took place, but concerns had been steadily accumulating about Amelia for over a year and a safeguarding referral could have been made at various points. The Council area’s Neglect Strategy states that neglect is ‘notoriously difficult to define’ but in this case there seemed to be a reticence about naming ‘neglect’ as opposed to the use of less loaded terms such as ‘delayed development.’ 4.24 CSAP has adopted neglect as one of its three priority areas, although there remain three separate neglect strategies for each of the predecessor Local Safeguarding Children Board (LSCB) areas. This level of priority recognises that despite the potential level of harm for children who are neglected being well known, concerns about neglect do not always attract the same level of response as concerns about sexual and physical abuse. In practice neglect can be notoriously difficult to define and research shows that it often co-exists with other forms of abuse and adversity. Of particular relevance to this review, the identification of neglect, and the response to it, becomes harder where children with disabilities and/or 15 learning difficulties are involved due to the additional needs and risks associated with the disability/difficulty the child lives with. All three strategies include elements to develop the ability of practitioners to identify to, respond to and prevent neglect; with an emphasis on the need for early intervention before a time at which statutory safeguarding processes become necessary. This review has been advised that a significant ongoing training programme has been implemented in support of the strategies, including training in the use of the Graded Care Profile 2 which could help practitioners to ‘name’ neglect more objectively whilst also supporting families addressing the elements of neglect more readily. Recommendation 3 (Neglect) That when the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership disseminates the learning from this review, the opportunity is taken to highlight the response to neglect in this case and further embed the Council area’s Neglect Strategy and the use of the Graded Care Profile 2 in order to improve safeguarding practice around the identification and management of neglect. How holistic were assessments of the needs of the family? Were the needs of each child considered? Was the impact of the needs of each child on their siblings considered? Did agencies meet the needs of the children when they met the threshold for the appropriate level of need. 4.25 In Ofsted’s 2012 thematic survey report on protecting disabled children they stated that the best assessments provided a very clear picture of the child, the family and the child’s place within the family. The impact of the child’s disabilities on the child, siblings and parents was described and assessed in detail, with good use of information and assessments from other involved professionals (3). 4.26 Assessments in this case largely focussed on the additional needs of Ryan and Nathan and the support mother needed to address those needs. The impact of the additional needs of Ryan and Nathan on each other, and in particular on Amelia, was largely overlooked for some considerable time. Assessments were also insufficiently informed by updated assessments of mother’s parenting capacity which, had they been completed, would almost certainly have disclosed that concerns about her parenting remained largely unaddressed, leaving the children exposed to long term parental neglect. The Panel noted that assessments made no use of the Neglect Graded Care Profile – which is an evidence-based assessment tool that helps professionals measure the quality of care provided by a parent or carer in meeting their child’s needs, particularly where there are concerns about neglect. How effective was Child in Need support? 4.27 All three children were stepped down to child in need support from child protection planning in January 2017. Child in need support in respect of the concerns about parental neglect ended in April 2017 and thereafter Ryan and Nathan were subject to child in need 16 planning in respect of their additional needs until safeguarding concerns began to escalate in the summer of 2019. 4.28 The child in need support to Ryan and Nathan was fairly narrow in both focus and engagement of partner agencies and a manager from the children with complex needs service who has reviewed the child in need plans for Ryan, Nathan and other children with additional needs, expressed the view that the child in need review meetings were akin to ‘little chats’ between the social worker and mother and home visits amounted to a ‘tick in the box’ rather than a meaningful event. At the practitioner learning event, professionals from agencies such as the children’s school and CAMHS stated that they had not been invited to participate in child in need planning. The Panel was advised that improving the professional support to children on child in need plans was a key priority in the Council area’s Social Work Improvement Plan. To what extent was Child Protection and Child in Need planning integrated with other plans such as Education, Health and Care plans? 4.29 The purpose of an education, health and care (EHC) plan is to identify educational, health and social needs and set out the additional support required to meet those needs (4). 4.30 The most recent EHC plan for Ryan was completed on 12th July 2016. Nathan’s EHCP was completed on 3rd August 2017. Although the plans have been reviewed by their school on an annual basis, they have not been amended since that time. Therefore the plans do not reflect the substantial adversity both children experienced in the intervening years which affected their needs and the additional support required to meet those needs. 4.31 The SEND Code of Practice (2015), which provides statutory guidance for organisations which work with and support children and young people who have special educational needs or disabilities, states that EHC plans are not expected to be amended on a very frequent basis (5). However, the guidance goes on to state that an EHC plan may need to be amended at other times where, for example, there are changes in health or social care provision resulting from minor or specific changes in the child or young person’s circumstances, but where a full review or re-assessment is not necessary (6). This review has been advised that complete re-assessments are rarely required. 4.32 However, Ryan’s EHC plan should have been amended. In the reviews of Ryan’s EHC plan carried out by his school in December 2018, November 2019 and January 2020, it was recommended that his EHC plan be amended but this did not happen. Although the question of whether Ryan’s needs had changed went unanswered in the December 2018 review, the November 2019 review stated that his needs had changed, specifically his mental health which was described as ‘severe’, his toilet training and escalation of his behaviour. The November 2019 review also noted that Ryan’s provision had changed to what was described as 1:1 support on an individualised timetable. Arguably, the need to update Ryan’s EHC plan could have been identified earlier as his March 2018 EHC plan review noted that he had 17 begun self-harming at home and school when ‘frustrated and cross’ for approximately a year. 4.33 As stated, Nathan’s EHC plan was written on 3rd August 2017. It was reviewed by Nathan’s school in 2018, 2019 and January 2020. Both the 2019 and 2020 reviews recommended that his EHC plan should be amended but this did not happen. 4.34 The responsibility for considering the school’s recommendations that Ryan and Nathan’s EHC plans should be amended rests with the Council area’s Special Educational Needs and Disability (SEND) service. The service decided to action the November 2019 recommendation to amend Ryan’s EHC plan but at the time of writing this LCSPR report, this had not been accomplished. Where it is decided not to follow the recommendation to amend an EHC plan, it appears that the rationale for such a decision is not routinely documented by the local Council. The Head of the Council area’s SEND service has advised this review that his service has experienced difficulties in completing and updating EHC plans due to staffing and recruitment issues, although he advised this review that the situation is now improving. The Panel which oversaw this review expressed surprise the review of the EHC plan of a child such as Ryan, whose needs had changed so significantly and whose case had been subject to such a degree of scrutiny during the past year, had not been prioritised. 4.35 Ryan’s EHC plan made no reference to the child protection planning he had been subject to since 12th May 2016 (two months prior to the date on which the plan was written), although information gathering for the report appears to have primarily taken place during March 2016. The list of contributors to the EHC plan included Ryan’s Children’s Home 1 key worker but did not include his social worker from the children with complex needs team. Whilst the EHC plan template asks if the child is ‘Looked After’ it doesn’t ask if the child is subject to a child protection plan. In Ryan’s case, the plan inaccurately stated that there was ‘no other social care support’ for Ryan. Child in Need plans were appended to both Ryan and Nathan’s EHC plans. 4.36 The Head of the Council area’s SEND service has advised this review that they are not allowed to include the child’s social care status in the EHC plan, other than recording that they are a looked after child, without the consent of the parent. The aforementioned SEND Code of Practice confirms this position by stating that the local authority may choose to specify other social care needs which are not linked to the child or young person’s SEN or to a disability, which could include reference to any child in need or child protection plan which a child may have relating to other family issues such as neglect. The Code of Practice recognises that such an approach could help the child and their parents manage the different plans and bring greater co-ordination of services. Inclusion must (bold font used in Code of Practice) only be with the consent of the child and their parents (7). Elsewhere, the Code of Practice states that the EHC plan reviews should be synchronised with social care plan reviews, and must (bold font used in Code of Practice) always meet the needs of the individual child (8). 18 4.37 Therefore the Code of Practice emphasis on parental consent is not aligned with the accepted approach to consent in safeguarding children policy. CSAP guidance states that where a child is subject to statutory child protection, best practice is for information to be shared with informed and explicit consent (9). However, the guidance goes on to state that to overrule this requires a judgement by the practitioner (with appropriate managerial oversight) that seeking consent may place the child at risk or further risk of harm, prejudice the detection of crime, or lead to an unjustified delay in making enquiries. This lack of alignment of statutory processes is not in the best interests of the child and it would be helpful for those involved in writing EHC plans to be advised of the action to consider should a parent withhold consent to any reference to a child protection plan in an EHC plan. This issue is not addressed in the SEND Code of Practice. 4.38 In the case of Ryan’s EHC plan, his social worker was not a contributor and so the opportunity to document that he was subject to child protection planning may have been missed as a result. However, the school appears to have been involved in the child protection plan, at least as a consultee. Generally, engagement of relevant professionals in the EHC plan and review process for both Ryan and Nathan does not appear to have been sufficiently comprehensive. Social workers and health practitioners from a range of disciples were involved only intermittently - either as attendees or as the providers of reports. The LCSPR Panel felt that the involvement of the specialist school nurse in the EHC planning process would be particularly beneficial as they could act as a ‘bridge’ between the EHC plan and any child protection or child in need plan. However, the Panel acknowledged that the school nurse service currently lacks the capacity to discharge all responsibilities which would benefit from school nurse involvement. 4.39 Additionally, the EHC plans and reviews placed responsibility on Ryan to address issues in respect of which he was experiencing parental neglect. For example, Ryan’s 2016 EHC plan described very encouraging progress in his physical health, emotional wellbeing, positive behaviours, effort and achievement in class, creativity and literacy and relationships with other pupils, but went on to state that he was as yet unable to alert his mother to his toilet needs and wore nappies overnight. However, the plan noted that he was able to use the toilet at Children’s Home 1 with the assistance of verbal prompts. Mother was stated to hope that the success in his toileting routine to transfer from school and Children’s Home 1 to the home environment and later in the EHC plan it is stated that Ryan ‘needs to establish a routine in relation to his personal care for when he is at home, as he does when he is in school or at Children’s Home 1’. 4.40 The EHC plan did not appear to include any exploration of why toileting at home remained problematic or envisage that there might be a role for mother in making progress in this area. In the 2014 parenting assessment carried out by the Children with Complex Needs Team, mother contended that both Ryan and Nathan were unable to attempt toilet training ‘due to their needs’, despite the fact that, at that time, Ryan was sometimes able to use the toilet at school (Paragraph 4.45). It is also worthy of note that, in the year after the EHC plan was written, Ryan was discharged by the continence service because of the difficulty the service experienced in contacting mother to arrange appointments. The local 19 teaching hospital, which is the provider of the continence services intends to examine the process for discharging children from the service who have not been brought by their parent(s). 4.41 The EHC plan also stated that Ryan was to be responsible for ‘establishing a healthy sleeping habit in order to remain as alert as he can during the day’. The aforementioned 2014 parenting assessment identified a clear lack of routines in the family home, including a lack of bed time routines which led to Ryan staying up late which affected the following day at school. He was also noted to watch unsuitable late night TV. When challenged about the lack of routines, mother said that she ‘does not believe in routines; she does what makes her children happy’ (Paragraph 4.45). 4.42 Ryan’s EHC plans do not appear to have adopted a child-centric approach to a child aged 11 who was considered to be 3-5 years behind his chronological age in relation to his functioning. On the basis of this review, it would appear that where a child is suffering entrenched parental neglect, there is a substantial risk that his or her EHC plan may inadvertently reinforce, rather than alleviate that neglect. 4.43 The EHC plan for Nathan generally does not place responsibility on him to address issues in which parental neglect may have been a factor, possibly because his needs were greater than those of Ryan and therefore he needed higher levels of support to achieve outcomes. 4.44 Plans sometimes included important errors. Nathan’s EHC plan, and subsequent reviews of the plan, frequently refer incorrectly to Nathan’s parents in the plural and the 2017 EHC plan also incorrectly identified a key family member who had died earlier in the year. The special educational provision Nathan needed to achieve desired outcomes included nominating a named member of staff to establish strong functioning links with his family so that his learning could be supported consistently at home. It does not appear that these ‘strong functioning links’ included any home visits. 4.45 Ofsted’s 2018/19 annual report commented that area SEND inspections showed a ‘decidedly mixed picture’, in which the most successful areas identified needs effectively, leaders had a strong understanding of the effectiveness of SEND arrangements, co-production was working well and area leaders jointly plan, commission and provide services that are responsive to the needs of children and young people with SEND and their families, and education, health and care professionals worked together in a joined-up way to improve outcomes for children with SEND. Ofsted’s annual report went on to say, that in too many geographic areas, leaders did not understand children’s education, health and care needs in enough depth and did not have sufficient insight into children’s lived experiences (10). Those involved in writing Ryan and Nathan’s EHC plans clearly did not have sufficient insight into the entrenched parental neglect they were experiencing. 4.46 The Head of the Council area’s SEND service has advised this review that in addition to tacking delays in actioning amendments to EHC plans, a new EHC plan Quality Framework 20 has been introduced, at the heart of which is a comprehensive programme for the auditing of plans. This is a very welcome development as is the plan to involve the Council for Disabled Children in providing training in the writing of EHC plan outcomes. Additionally, this review has been advised that Child Protection Chairs now have access to the SEND system and that there is a record of every child with an EHC plan on the children’s social care system. Recommendation 4 (Education, Health and Care Plans) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance in respect of the following education, health and care plan issues, in order to improve safeguarding practice: when a review of a child’s EHC plan recommends amendment of the plan; decisions to amend the plan or not, the recording of the rationale for the decision and any amendments to the plan, are all completed within statutory timescales, that there is guidance on the process to follow if consent to include reference to a child protection plan in the EHC plan is refused by the parent or child, that there is a process for escalating concerns that relevant professionals are not engaging with the EHC planning and review processes, that EHC plans are written in a child-centric manner and professionals writing the plans fully explore the lived experience of the child, and that Child Protection Chairs routinely check whether the child has an EHC plan. Was mother’s parenting capacity fully considered? 4.47 One parenting assessment of mother was carried out. It was completed in 2014 at a time when she was parenting Ryan and Nathan who were aged 9 and 7 respectively. The 2014 parenting assessment – which was completed with very few sessions due to mother cancelling them - informed several subsequent assessments and plans and was not repeated or updated. CSAP’s policy on social care assessments states that they should be seen as a continuing process rather than a single event. 4.48 The parenting assessment had been commissioned to gain more of an understanding of mother’s parenting methods and the reasons why, historically she had not taken on board the support, advice and strategies suggested to her. The assessment was more successful in answering the first question, but less so the second question. 4.49 Mother was observed to show Ryan and Nathan care and attention and it was concluded that she clearly had a lot of love for them. She was said to have many strengths as a parent and very much valued her children as individuals, allowing them to make their own choices regularly. 4.50 However, the assessment identified a clear lack of routines in the family home which could impact on the children at times. For example a lack of bed time routines led to Ryan staying up late which affected the following day at school. He was also noted to watch 21 unsuitable late night TV. When challenged about the lack of routines, mother said that she ‘does not believe in routines; she does what makes her children happy’. She also contended that Ryan and Nathan were unable to attempt toilet training ‘due to their needs’, despite the fact that Ryan was sometimes able to use the toilet at school. Nathan was noted to use a dummy and mother made no attempt to reduce his use of the dummy despite being advised of the potentially adverse impact on his speech and teeth. In not attempting to reduce Nathan’s dummy use, there are similarities with the manner in which mother later parented Amelia, although it is accepted that Nathan had substantial additional needs. 4.51 At the time of the parenting assessment, Ryan and Nathan were noted to have separate bedrooms but slept on mattresses on the floor. Mother explained this by saying that the boys had broken numerous beds or destroyed them with smearing and she believed that it was better that they only sleep on mattresses ‘for their own safety’. 4.52 Mother was said to have been reluctant to accept support from services in the past and talked very negatively about prior social care involvement. The assessment noted that this could suggest her previous experiences were preventing her from engaging with the current support being offered by the then children with disabilities team (CWDT) and the assessment recommended continuing to build a relationship with mother in order to encourage engagement in the future. Perhaps building a relationship assumed more importance than challenging unsatisfactory parenting and ‘naming’ neglect. 4.53 The parenting assessment concluded that further work needed to be offered to mother: to recognise the positives in her parenting. Once this had been effective, further support could be offered to build upon those positive foundations. to support her to develop and maintain routines around suitability of what Ryan and Nathan watched on TV and the internet 4.54 The extent to which these recommendations were actioned and what might have been the outcomes, is unclear. A key question is - what, if anything, changed in mother’s parenting methods over the subsequent five years. Recommendation 5 (Parenting Assessments) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance that practitioners update or repeat parenting assessments when circumstances change which should reflect the evidence of improvements or continuing or heightened concerns. 22 How effectively did agencies respond to mother’s needs? 4.55 It needs to be acknowledged that parenting three children - two of whom had significant additional needs - as a single parent, was a hugely demanding task which would have dominated her life. Although mother had moved to the Council Area with Ryan and Nathan partly to be near her parents, the extent to which they could support her was affected by their own caring responsibilities. However, she did benefit from renting a home near the children with disabilities charity’s premises and their staff often were her ‘first port of call’ when she needed support. Mother also benefitted from the support provided to Ryan and Nathan from Children’s Home 1, the provider of support to children with ASD and the nursery provision for Amelia from her second birthday, which gradually increased to five days per week. 4.56 However, mother was noted by practitioners from a range of agencies to be struggling to cope with parenting the children. She disclosed she was ‘extremely stressed’ when seen by the Criminal Justice and Liaison Service following her arrest for neglecting Ryan and Nathan in April 2016. She was noted to be fatigued from caring for Ryan and Nathan by her GP in July 2017. She repeatedly began to request that Nathan be accommodated by the local authority from July 2017 and from the summer of 2019 frequently said that she was unable to cope or was at ‘crisis point’. 4.57 Agencies provided mother with considerable support but sought to adopt a balanced approach which promoted resilience as opposed to encouraging dependence. However, mother appeared to be selective about the type of support she accepted or engaged with, persistently declining support to help her develop her parenting skills or try different parenting strategies for example. 4.58 Mother self-disclosed a slight learning difficulty and there were times when practitioners noted that she appeared to lack insight into the needs of her children and sometimes struggled to appreciate the variation between her perception of her child’s abilities and what assessments disclosed. However, the 2014 parenting assessment did not consider mother’s learning needs it was not until October 2019 that the social worker decided to seek advice about mother’s cognitive ability and her capacity to change. It would have been of value to have explored this issue, had mother been willing to do so, at an earlier stage. How effectively did agencies respond to indications of disengagement and denial of access from mother? 4.59 There is substantial evidence of a lack of co-operation with services by mother. She declined home visits by the health visitor when concerns arose about Amelia’s delayed development in September 2018 and Amelia’s health visitor from the postnatal period was able to gain access to the family home only on one occasion. The children with disabilities charity has advised this review that in April 2019 they were left with no alternative to using their powers as landlord to gain access to the home mother rented from them. It is unclear 23 for how long mother had been declining visits from workers from the charity. Mother declined an Early Help Assessment and initially refused to consent to a referral to the local child development centre for Amelia, although she later relented. Mother moved Amelia from nursery 1 to nursery 2 in August 2019. She gave different reasons for making this choice but her failure to disclose that agencies other than children with disabilities charity was involved with the family when she applied for a place at nursery 2, suggested that Amelia’s best interests were not at the heart of her decision to change nursery provision. 4.60 Apart from the periods when her children were subject to child protection planning – May 2016 until January 2017 and from 4th November 2019 onwards, agencies were working with mother at level 2 or 3 on the continuum of need which required her consent. In these circumstances it was possible for mother to ‘pick and choose’ when to engage and with whom to engage. There is evidence that practitioners adopted a professionally assertive approach with mother at times. However, the strong emphasis on preventing family breakdown apparent in this case may have influenced practitioners to place a greater emphasis on support rather than challenge. 4.61 The Panel which oversaw this review expressed concern over the general lack of access to the family home by the health visitor following Amelia’s birth and following the concerns raised by Nursery 1 two years later. The Panel emphasised the importance of health visitors needing to see where a child is sleeping. Whilst it was recognised that health visitors do not have a right of access, mother’s persistent reluctance to admit the health visitor could have been escalated. Dissemination of learning Lack of access to the family home was an issue for a number of agencies including the children with complex needs team and the children with disabilities charity which prevented agencies fully appreciating the extent of the neglect the children were experiencing. When learning is disseminated from this review, this would be an appropriate message to highlight. What action was taken when it became apparent that things were not improving for the children despite significant agency involvement? 4.62 The overriding emphasis in assessments and plans over the years was on ‘preventing family breakdown’. The focus was therefore on providing sufficient support to enable the family unit to stay together even when it became apparent that not only were things not improving for the children but that there was a marked deterioration in their lived experience. 24 Did agencies gain a sufficient understanding of the ‘lived experience’ of the children. 4.63 The ‘lived experience’ is what a child sees, hears, thinks and experiences on a daily basis which impacts on their development and welfare. Practitioners need to actively hear what the child has to communicate, observe what they do in different contexts, hear what family members, significant adults/carers and professionals have said about the child, and think about history and context. Ultimately practitioners need to put themselves in that child’s shoes and think ‘what is life like for this child right now?’ 4.64 Agencies did not gain sufficient insight into, and understanding of the ‘lived experience’ of the children. There was a strong emphasis on the needs of mother and providing her with support. Overall, there was a stronger focus on the additional needs of Ryan and Nathan whilst the needs of Amelia which were either overlooked or looked at discretely. Overall, the lived experience of the children was insufficiently explored and articulated. 4.65 All three children experienced chronic neglect over a prolonged period, which was periodically mitigated when agencies intervened and mother was supported to improve the children’s living conditions for a time. For example the children with disabilities charity gained entry to the family’s home in April 2019 and found it to be in an ‘untidy and unclean’ state, with a strong smell of urine and piles of rubbish, dirty laundry and general clutter throughout the property. Intense intervention was provided at that time to clean and clear the property involving several tip runs, the use of a skip and hours of cleaning and sorting. However, when supporting mother to clear Amelia’s bedroom in October 2019 (six months after the first intervention), the charity found several bags of old, used and mouldy nappies. 4.66 The family’s home had no access to an outdoor space and was close to a busy road which the children would have required adult supervision to negotiate. The children appear to have spent much of their non-school/nursery/short breaks time ‘cooped up’ in this home where there was a lack of stimulation and where they may also have become isolated. 4.67 A decline in Ryan’s mood led to a referral to CAMHS by his school in June 2017. Self-harming behaviours including scratching his face and his arms and banging his head were noted by his school. He was also noted to be angry, presenting with obsessive behaviours and routines, disengaging in class and refusing to follow instructions. Concerns also began to emerge about his relationship with Nathan who he began referring to as ‘Satan’. 4.68 From September 2017, Ryan appears to have begun perceiving himself as the ‘protector’ of his mother and Amelia – with whom he was noted to have a positive relationship - from Nathan’s aggressive behaviour when agitated. 4.69 There is evidence that by June 2018, Ryan was being left to care for his siblings and administer his own medication whilst his mother was out of the home. 25 4.70 Ryan’s continence needs were not consistently addressed and in October 2017 he was discharged from the continence service as a result of difficulty in contacting mother to arrange appointments. 4.71 Ryan was allowed to watch age inappropriate horror material. From September 2018 he began adopting the persona of an old man with cancer which led to a psychological assessment. 4.72 Ryan and Nathan began to access support from the provider of support to children with ASD separately from September 2017 which may have helped to reduce the tension between them. 4.73 Nathan has significantly greater additional needs than either of his siblings but it is difficult to gain insight into his lived experience from agency records. It is clear that mother increasingly struggled to cope with his presentation and the children with disabilities charity documented concerns that she had ‘given up’ on him. There may have been a tendency to over-focus on Nathan as the principle source of difficulty within the family leading to actions such as increasing use of Children’s Home 1 for short breaks and eventually his accommodation by the local authority. The focus on Nathan’s presentation may have distracted professionals from fully appreciating the chronic long term neglect experienced by all the children. 4.74 It is striking how often Nathan’s presentation is described in terms of behaviour which professionals experienced difficulty in managing, rather than attempting to understand why he was presenting as he was. Additionally, in Nathan’s EHCP and subsequent reviews, the ‘child’s perspective’ appear to be limited to the teacher’s observations of him in the school environment and the ‘family’s perspective’ appears to be provided by mother and not always reflect the reality of his lived experience at that time. For example in the February 2019 EHCP review he was stated to be building better relationships with his siblings by mother, yet only two months later she advised a child in need meeting that she was unable to cope with Nathan’s unpredictable behaviour towards herself and Amelia. 4.75 Nathan’s tendency to try and ‘lash out’ at Amelia when she was crying may have arisen in part from his sensitivity to noise as he often wore ear defenders. 4.76 Amelia was left unsupervised, or supervised by Ryan from an early age. She entered the office of the children with disabilities charity alone on several occasions, requiring staff to return her to her home. In September 2016 concerns were expressed about Ryan being left alone to supervise his one month old sister. 4.77 Amelia experienced severe developmental delay, undeveloped motor skills and was fed mainly pureed food at home. Mother continued to have a large stock of baby food jars in the kitchen of their home for Amelia as late as October 2019 when she was over three years old. She appears to have continued to sleep in a pram long after this was appropriate and was locked in her bedroom by mother apparently to protect her from her 26 siblings. The children with disabilities charity noted that mother told them that she had put Amelia to bed at 3pm, 4pm or 5pm on a regular basis. Amelia appears to have experienced a distinct lack of stimulation and interaction within her home environment. 4.78 Amelia was clearly at risk from Nathan. Several incidents of violence from Nathan are noted in the chronology, including pulling out clumps of her hair on several occasions. The children with disabilities charity witnessed Amelia ‘cowering, shaking and clinging on to mother’s side’ when Nathan was present. 4.79 There was a marked deterioration in Ryan’s mental health over the two years prior to his brother being accommodated in December 2019 which was not fully documented in CAFAs and child in need plans for some of that time. As previously stated, it appears that CAMHS, who were providing support to Ryan are not normally contributors to child in need planning. At the learning event arranged to inform this review it was stated that, locally, there was a gap in services for children with a learning disability who experience mental health issues such as Ryan. Suggestion 2 - Learning Disability Services for Children As stated, at the learning event arranged to inform this review it was stated that, locally, there was a gap in services for children with a learning disability who experience mental health issues such as Ryan. It was not possible to explore this issue through this LCSPR but CSAP may wish to raise this with the commissioners of learning disability services. To what extent did agencies understand the support provided by the wider family and consider the impact of the death of a key family member? 4.80 Generally, there appeared to be a good understanding of the support available to mother and her children from the maternal grandparents – and the limits on that support as a result of the maternal grandparent’s caring responsibilities. The impact of the death of a key family member in early 2017 was considered by agencies, particularly the impact of bereavement on Ryan. However, as previously stated there appeared to be an assumption that maternal grandmother could care for Nathan whilst assessments were carried out following the invoking of the Issue Resolution Procedure in November 2019, which appears to have been overly optimistic. 4.81 There is no indication that agencies explored the potential for the involvement of the children’s fathers in supporting the family until late in 2019. The fathers of Ryan and Nathan were believed to reside in the previous local authority area and Amelia’s father appears to have been perceived as a risk to mother and the children for a time. How effective and inclusive was multi-agency working? 4.82 This question has largely been addressed in answering earlier key lines of enquiry questions. The children with complex needs team were the lead service throughout and 27 their overriding priority of keeping the family together and their lack of focus on safeguarding concerns set an example which partner agencies did not begin to challenge until November 2019. The role of the children with disabilities charity 4.83 A manager from the charity which provided support to mother and the children attended the practitioner learning event and made a helpful contribution. However, this review was only provided with a chronology by the charity as the LSCPR report was being finalised. The chronology provided much additional detail and further insight into the lived experience of the children. 4.84 The manager who attended that practitioner learning event felt that the charity was not commissioned, funded or equipped to provide the level of support that mother and the children needed. From the point at which mother first rented the home near the charity’s premises, they effectively became ‘first port of call’ for mother. At that time the charity employed only two support workers on the premises who had limited capacity to respond to the family’s needs. 4.85 Subsequently the charity was able to fund three family support workers and a manager from Big Lottery funding and thereafter were better equipped to offer support to mother and the children although, as before, they were not commissioned to do this. It is noticeable that the charity gradually became more active partners in working with agencies to support the family; they advocated for support for the family, prompted informal multi-agency discussions at times, and as concerns escalated from the summer of 2019, played a key role in attempts to prevent family breakdown. 4.86 However, relations between mother and the charity appear to have become strained for a time and workers from the charity were unable to gain access to the home. As stated earlier, the charity was forced to use its powers as a landlord to gain entry and the manager who attended the practitioner learning event described the home conditions she found when the charity was eventually able to gain entry as ‘horrendous’. Although the charity provided mother with intense practical support to improve home conditions, there is no indication that they explicitly alerted partner agencies to this situation. 4.87 Looking back, the manager from the charity felt that it had never been appropriate for mother and the children to live near their premises. She added that the family’s needs were ‘way above’ their remit, that all they were doing was ‘firefighting’ and that the charity’s proximity to the family may have masked their true level of need from partner agencies for a time. 4.88 There would therefore be benefit in CSAP writing to the Chair of the charity to request that he reviews the support being provided to families to ensure that their safeguarding children policy and practice is robust, in particular partnership working and information 28 sharing with partner agencies. CSAP may also wish to consider how to gain similar assurance in respect of other local charities providing support to children and families. Recommendation 6 (Role of the Children with Disabilities Charity) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership writes to the Chair of the children with disabilities charity to request that he reviews the support being provided to children and their families to ensure that the charity’s safeguarding children policy and practice is robust, in particular partnership working and information sharing with partner agencies. The Partnership may also wish to consider how to gain similar assurance in respect of other local charities providing support to children and families. Good Practice 4.85 The following good practice is noted in this case: Both Nursery 1 and Nursery 2 documented concerns in respect of Amelia and made many appropriate referrals to specialist services. Nursery 1 and Nursery 2 worked well together when mother initiated the transfer of Amelia from one nursery to another. The clinical psychology report on Ryan made several constructive recommendations to help practitioners respond to and seek to understand his adoption of the persona of an old man. Ofsted appropriately escalated concerns about the children to the Director of Children’s Services following their November 2019 inspection of Children’s Home 1. 5.0 Views of mother and maternal grandmother 5.1 Mother disagreed with much of the information agencies had recorded and shared with this review about her parenting. She also rejected the criticisms of her approach to parenting, stating that she did believe in boundaries and routines and that she implemented these consistently, citing the fact that the she always ensured the children were dressed and ready to go to school or nursery in the morning as an example. She said that it was untrue to say that Ryan stayed up late. She added that she couldn’t recall the parenting assessment taking place. 5.2 It was clear that mother had read the CSPR report carefully and had made a note of all the issues with which she disagreed. The lead reviewer subsequently checked the various agency chronologies, minutes and assessments which he relied upon to draft the report and found that the points which mother disputed were clearly recorded in agency records. 29 5.3 Mother said that she was ‘fed up’ with the ‘neglect’ word being applied to her parenting. She said that she had told professionals that they wouldn’t last ten minutes ‘in her shoes’, looking after her children. She added that lots of families struggle with a single child with additional needs, whereas she parented two. Looking back, she felt that she should have received more support particularly in parenting Nathan, adding that agencies were well aware of the difficulties she was experiencing in this regard but were slow to act. 5.4 Maternal grandmother also commented on the CSPR report. She said that her daughter had repeatedly begged the children with complex needs team for help which had been refused and that her daughter had been told that she should seek support from family and friends. Overall, she felt that if the right support had been provided earlier, then things would not have deteriorated so much. She felt that a key priority for her daughter had been keeping Amelia safe from Nathan for the first three years of her life, which had proved extremely challenging. She felt that her daughter had not been listened to and had not been given sufficient opportunity to demonstrate positive change. 5.5 Maternal grandmother also felt that the local authority’s approach for her to look after Ryan and Amelia in December 2019 (Paragraph 3.20) had not been handled competently, with plans chopping and changing. She also said that she had been unaware of the proposal for her to care for Nathan whilst assessments were carried out in November 2019 (Paragraph 4.12). List of Recommendations and Suggestions Recommendation 1 (Pre-Birth Assessments) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance that pre-birth assessments are conducted in compliance with the Pan-Lancashire Protocol and that the fact that elder sibling(s) are currently subject to child protection or child in need planning – which could encompass the needs of the unborn child - is not regarded as a reason for ruling out a pre-birth assessment. Recommendation 2 (Safeguarding Children with Complex Needs) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtain assurance that the Safeguarding Children with Complex Needs team has both the skills to assess and meet the additional needs of children and has sufficient awareness of the general and particular vulnerability of children with additional needs to abuse and neglect. Recommendation 3 (Neglect) That when the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership disseminates the learning from this review, the opportunity is taken 30 to highlight the response to neglect in this case and further embed the Council area’s Neglect Strategy and the use of the Graded Care Profile 2 in order to improve safeguarding practice around the identification and management of neglect. Recommendation 4 (Education, Health and Care Plans) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance in respect of the following education, health and care plan issues, in order to improve safeguarding practice: when a review of a child’s EHC plan recommends amendment of the plan; decisions to amend the plan or not, the recording of the rationale for the decision and any amendments to the plan, are all completed within statutory timescales, that there is guidance on the process to follow if consent to include reference to a child protection plan in the EHC plan is refused by the parent or child, that there is a process for escalating concerns that relevant professionals are not engaging with the EHC planning and review processes, that EHC plans are written in a child-centric manner and professionals writing the plans fully explore the lived experience of the child, and that Child Protection Chairs routinely check whether the child has an EHC plan. Recommendation 5 (Parenting Assessments) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership obtains assurance that practitioners update or repeat parenting assessments when circumstances change which should reflect the evidence of improvements or continuing or heightened concerns. Recommendation 6 (Role of the Children with Disabilities Charity) That the Blackburn with Darwen, Blackpool and Lancashire Children’s Safeguarding Assurance Partnership writes to the Chair of the children with disabilities charity to request that he reviews the support being provided to children and their families to ensure that the charity’s safeguarding children policy and practice is robust, in particular partnership working and information sharing with partner agencies. The Partnership may also wish to consider how to gain similar assurance in respect of other local charities providing support to children and families. Suggestion 1 CSAP may wish to consider how best to take the issue of resolving professional disagreements further. The Child Protection Issue Resolution Procedure appears to be a robust process if adhered to and has a series of steps for escalating matters although, on the evidence from this case, professionals may be reticent to push the challenge beyond the initial stages. The Partnership’s Resolving Professional Agreements Procedure appears less robust and may need to be strengthened and given greater publicity. 31 Suggestion 2 At the learning event arranged to inform this review it was stated that, locally, there was a gap in services for children with a learning disability who experience mental health issues such as Ryan. It was not possible to explore this issue through this LCSPR but CSAP may wish to raise this with the commissioners of learning disability services. Dissemination of learning Lack of access to the family home was an issue for a number of agencies including the children with complex needs team and the children with disabilities charity which prevented agencies fully appreciating the extent of the neglect the children were experiencing. When learning is disseminated from this review, this would be an appropriate message to highlight. 32 References (1) Retrieved from https://panlancashirescb.proceduresonline.com/pdfs/multi-agency_prebirth_protocol.pdf (2) Retrieved from https://councilfordisabledchildren.org.uk/sites/default/files/field/attachemnt/safeguarding-disabled-children-england.pdf (3) Retrieved from https://www.gov.uk/government/publications/protecting-disabled-children-thematic-inspection (4) Retrieved from https://www.gov.uk/children-with-special-educational-needs/extra-SEN-help (5) Retrieved from https://www.gov.uk/government/publications/send-code-of-practice-0-to-25 (6) ibid (7) ibid (8) ibid (9) Retrieved from https://panlancashirescb.proceduresonline.com/chapters/p_info_share_confident.html (10) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859422/Annual_Report_of_Her_Majesty_s_Chief_Inspector_of_Education__Children_s_Services_and_Skills_201819.pdf |
NC52251 | Life-changing injuries to a 17-year-old boy who was the victim of a shooting in March 2020. Daniel was a child in care at the time of the incident. Learning includes: where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child's safety or long term outcomes should be formally scrutinised by safeguarding partners; unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement; early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people. Recommendations include: safeguarding partnership should urge the Department of Education to to set out a strategy for how it intends to improve residential care for looked after children in England; explore how schools and academies can be supported and challenged, but also held to account, by partner agencies when there is evidence that school exclusions or non-attendance is placing, or would place, a vulnerable child at greater risk.
| Title: Child safeguarding practice report: Daniel. LSCB: South Tees Safeguarding Children Partnership Author: South Tees Safeguarding Children Partnership Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT/LR/May 2021 Child Safeguarding Practice Report DANIEL FINAL 17 May 2021 This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT/LR/May 2021 Key Family Pseudonyms Daniel not his real name Daniels’ mother DM Daniels’s father DF Partner of mother PDM Half sister of Daniel HSE born to DDM Maternal Grandmother MGM Maternal Grandfather MGF Agencies involved and abbreviations *Redcar and Cleveland (R&C) Children’s Services RCCS *Cleveland Police Complex Exploitation team CPCE *Tees, Esk and Wear Valleys NHS Foundation Trust TEWV *South Tees Hospitals, NHS Foundation Trust STHFT *Youth Offending Service YOS *R&C Health Visiitng and School Nursing Service SN *R&C Education Department Vulnerable, Exploited, Missing, Trafficked VEMT (Strategic Group) *VEMT Practitioners Group VPG Child and Adolescent Mental Health Service CAMHS Primary School SCH1 *Secondary School SCH2 Education Other Than At School; EOTAS SCH3 Education provision SCH4 Education Service Provider (Fairfeld ) ESP1 Drug and Alchol Service (CREST) SP1 - Support service for young people (Junction) SP2 - Service (Care) Provider SP3 Service (Care) Provider SP4 Please note: : The agencies marked with * were represented on the Review Team The shaded text provides brief comments which are addressed in more detail later in the report The text in boxes provides brief details on current policy and practice in Redcar and Cleveland. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 3 Contents 1. Child Safeguarding Practice Reviews 2. The approach used 3. Daniel as a young child 4. Daniel in the care of the local authority 5. The views of Daniel and his family 6. Summary of Agency interventions 7. Key Lines of Enquiry KLE1: To what extent was there a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed. KLE2: To what extent were interventions and plans effective in meeting Daniel’s needs and keeping him safe? KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered? KLE4: How well did agencies collaborate and work together? KLE5: To what extent were locally agreed pathways effective in providing support and protection to Daniel? 8. Appraisal of Practice and Safeguarding Systems 9. Concluding Comments 10. Summary of Learning Points 11. Recommendations This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 4 This page is blankThis document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 5 Daniel Daniel was a child in the care of Redcar and Cleveland Borough Council when, aged 17 years old, he was the victim of a shooting, believed to have been made in retaliation for an assault committed by Daniel a few days earlier. Daniel was taken to hospital where, as a result of his injuries, his left leg was amputated below the knee. Between 2016, when Daniel was accommodated by the local authority and March 2020, when he sustained his life-changing injuries, interventions by key agencies were not able to keep Daniel safe; professionals struggled to engage Daniel and he persistently rejected services aimed at reducing the risks to which he was very clearly exposed. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 61. Child Safeguarding Practice Reviews 1.1. A Child Safeguarding Practice Review (CSPR) is undertaken when a child dies or has been seriously harmed and there is cause for concern as to the way organisations worked together.1 The purpose of a CSPR, undertaken locally, is for agencies and individuals to learn lessons that improve the way, in which they work, both individually and collectively, to safeguard and promote the welfare of children. 1.2. Local safeguarding children partnerships have a responsibility to ensure that within 15 days of being notified about what has happened to a child, a local panel must hold a Rapid Review involving partner agencies: local authority, Police, Health, Education and Social Care. This review is to ascertain whether a CSPR is appropriate, or whether the case raises issues, which are complex or of national importance such that a national review is more appropriate. 1.3. South Tees Safeguarding Children Partnership (STSCP) held a rapid review meeting in April 2020 and a decision was taken that the involvement of key agencies in at certain points in Daniel’s life should be subject to a CSPR. An independent reviewer was commissioned to lead the review which was to focus on agency interventions between June 2016 when Daniel he became a Looked After Child and July 2020 when he reached his 18th birthday. 2. The approach used 2.1. Following the appointment of the independent reviewer, the Business Manager for STSCP established a review team to support the review process. This team comprised of senior professionals, representing the agencies that had been involved with Daniel and family members. Their role was to provide strategic information about their agencies’ involvement; to identify learning for their agency and to assist the independent reviewer’s understanding of agency involvement, what happened and why. 2.2. Members of the review team identified frontline practitioners and first line managers who had been in contact or had worked with Daniel and his family. These professionals were invited to contribute to three practitioner events so more detail could be provided about their involvement and help the review team understand how key decisions were made and why professionals acted as they did or why they might not have acted at all. Some practitioners also met with the independent reviewer on a one to one basis. Importantly, professionals were asked to consider what safeguarding systems were in place both locally and nationally which supported their practice or made it harder to do their job well. 2.3. In the early stages of the review, a timeline of agency interventions was collated to illustrate multi-agency activity and who knew what and when. Each member of the review team completed an Agency Learning Report, the aim of which was to provide a description and analysis of practice within their own agency and to identify where changes for improvement were needed or where system changes had already been put in place to improve practice. Additional information was accessed through scrutiny of various documents and agency records. 1 Working Together to Safeguarding Children (2018) This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 72.4. Given the country was in the midst of the COVID 19 pandemic, throughout the review process, all meetings with key individuals and groups were conducted remotely using various communication platforms which allowed the review to continue, albeit at a much slower pace that was originally anticipated. 2.5. This report has been produced in consultation and collaboration with the review team. The independent reviewer had oversight of the process and identified areas to support multi-agency learning as well as offering commentary upon single agency practice. This report includes detailed findings from the review and includes recommendations agreed by the review team for consideration by STSCP. 3. Family Involvement 3.1. Daniel was contacted directly and indirectly on four occasions by the independent reviewer and offered opportunities to contribute to this review. MGM also agreed to pass on contact details but sadly, Daniel did not respond to any overtures aimed at trying to ensure his voice and lived experiences were reflected in this report. 3.2. Daniel’s parents were also contacted and invited to speak with the independent reviewer but they also did not respond and the review team was left to progress the review without their input. 3.3. The independent reviewer was however able to speak with MGM whose insights and reflections were immensely helpful and are referenced at various points throughout this report. MGM was grateful for the support she had received from services during what she described as tough times trying to keep her grandson safe. She continues to be in touch with Daniel. The review team extend their thanks to MGM for her contributions to the review process. 4. Daniel as a young child Daniel’s family and early years 4.1. According to agency records, Daniel’s parents were about 16 years old when he was born in 2002 and it would seem they did not provide him with a secure and nurturing base as he grew up; he was, the review team was told, never allowed to express himself verbally or emotionally and was frequently given messages by DM that he was a ‘bad person’ who would never achieve anything. The relationship between DM and DF ended when Daniel was a young child and according to agency records, DF had intermittent contact with his son during his childhood years. Daniel’s maternal grandmother (MGM) frequently stepped in to care for her grandson and continued to do so as he was growing up and throughout his teenage years. 4.2. There are some references in agency records, which suggest that the family were reluctant to share any detailed information about Daniel’s childhood history and there are also references in agency records linking both Daniel’s parents to drug misuse and that Daniel witnessed domestic violence in the home as he was growing up. DM appears to have struggled not only to cope with Daniel’s angry and challenging behaviours, as he grew older, but also to display any empathy or affection towards him, which according to professionals left Daniel with feelings of rejection and low self-esteem. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 84.3. At some point, a partner of DM (PDM) moved in with the family and Daniel’s half sister was born when Daniel was about 3 years old. According to agency records, PDM remained a significant adult in Daniel’s life until his death in May 2019, from a drug-related overdose. 4.4. Primary school reports indicate that Daniel was a pupil who met all of his milestones and achieved well. He was reported to be generally a quiet child and followed school rules throughout his primary education, until Year 6 when he started to display some challenging behaviours. At the start of that school year, Daniel had only just turned 11 and was described by staff in SCH1 as being generally engaged and eager to please but, as the year progressed he was noted to becoming more disruptive, especially at unstructured times such as breaks and lunch breaks. However, school reports indicate that these behaviours were manageable and were never such as to warrant referrals to other agencies. Daniel as a young adolescent 4.5. MGM recalls there were no significant worries about Daniel until he began secondary school in September 2013, when he had just turned 11 years old. As the school year progressed, concerns began to emerge about Daniel’s difficult behaviours at school and at home, which DM found difficult to manage. MGM recalls that at the time, SCH2 worked closely with the family to offer Daniel support, providing time-out and access to pastoral support. Daniel began to go missing from home around this time. 4.6. By the time Daniel was 12 years old, Daniel’s missing episodes and anti-social and offending behaviours had come to the attention of police and he was at risk of being excluded from school. The family sought help from Early Help services in April 2015 and targeted time limited intervention was provided to help Daniel manage his behaviour at school. Agency records suggest involvement of Early Help services ended when there was some improvement, although MGM recalls the intervention was largely ineffective and the family saw very little change. MGM was of the view that Daniel’s ‘real problems’ began when SCH2 became an Academy in September 2015 and he was permanently excluded, under ‘new’ behaviour management procedures, in March 2016. According to MGM, Daniel was transferred to EOTAS, a Pupil Referral Unit 2 but would not always attend as some young people from ‘rival gangs’ were also there. 4.7. In January 2016, DM contacted RCCS asking Daniel to be removed from her care because he was beyond parental control, going missing and was thought to be experimenting with drugs. Early Help services were again provided. Records suggest that Early Help professionals struggled to engage with Daniel or to sustain a positive or effective working relationship with DM, whose fractured relationship with Daniel continued. Daniel’s father at this time appears to have been an inconsistent and unpredictable presence in his son’s life. Daniel’s behaviour, described as aggressive and unpredictable at times, continued to cause concern for the family. 2 Education Otherwise. Pupil Referral Unit (PRs) are PRUs types of school that caters for children who aren't able to attend a mainstream school. Pupils are often referred there if they need greater care and support than their school can provide. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 95. Daniel in the care of the local authority 5.1. In May 2016, just before his 14th birthday, Daniel was accommodated3 by the local authority on a s204 having allegedly been assaulted by DM, who told professionals she had been trying to restrain her son, who was beyond her control and she could no longer care for him. Records indicate that no other family members were able or willing to care for Daniel as they had all expressed concerns about his aggressive behaviours, use of drugs and involvement with local street gangs. Daniel was placed with foster carers, but went missing for several days soon after being placed and was then placed in a residential children’s home (RCH) over 100 miles away from his hometown. 5.2. Agency records from RCH indicate that after a troubled start, Daniel made good progress; he accessed education and there were improvements in his behaviour, although Daniel refused to engage with CAMHS to help with his angry feelings. Daniel maintained contact with DM and MGM who visited usually every two weeks and as the placement progressed there were occasional overnight stays with his family. After several months, according to MGM, plans were made to move Daniel to a residential children’s home nearer to his hometown, MGM recalls this was a ‘halfway’ move back to live with DM. When this placement fell through, MGM described this yet another rejection for Daniel and remembers him being upset that he was not moving as planned. According to MGM, DM was not willing to ‘suddenly’ have Daniel returned to her care, so MGM agreed with social workers that Daniel could live with her. This decision apparently caused a deep rift between MGM and DM, which lasted for several months. 5.3. In June 2017, Daniel moved to live with MGM and she recalled that for a short period life was relatively calm until Daniel’s relationship with his girlfriend ended and he began to go missing again. It then became apparent that Daniel was in touch with ‘old’ contacts. According to records, Daniel became more aggressive towards MGM and other family members; his missing periods escalated and there was clear evidence that he was misusing substances and offending. Professionals also observed Daniel with various injuries at times and following arrests for various offences, he was found, on occasions, to be in possession of knives and had access to unexplained funds. Police records indicate that Daniel was tagged as being involved with local criminals groups. Daniel was not accessing any education provision. In January 2019, Daniel was charged with a number of offences to which he pleaded guilty. He was made subject to a 12 month Referral Order5 and was referred to YOS. 5.4. Daniel’s placement with MGM broke down in May 2019 when MGM again reported her concern about Daniel’s aggressive and volatile behaviours and said she could not keep him safe. MGM was also concerned for her own safety. There being no other residential placement available which could safely 4 Section 20 of the Children Act 1989 sets out how a Local Authority can provide accommodation for a child within their area if that child is in need of it, due to the child being lost/abandoned or there is no person with parental responsibility for that child. 5 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 10 accommodate him, Daniel, not yet 17, was moved into semi-independent accommodation with a support package which included access to staff support and supervision during the night. 5.5. In July 2019, Daniel was referred to the VEMT Practitioners Group (VPG)6 where he was assessed as being a ‘very high risk’ child. According to agency records, social workers and other professionals were still unable to engage with Daniel; he declined referrals to access support for his substance misuse, and resisted attempts by professionals to address the risks he posed to others and the risks to which he himself was continually exposed. Agency records refer to Daniel insisting that he was ‘in charge’ and that he ‘knew’ what he was doing. Daniel, then experienced a further seven placement moves before March 2020, all of which were in response to the need to manage risks from known, and unnamed, individuals. 5.6. Daniel was suspected by police of being involved in a number of offences including assaults on others with weapons and firearms just prior to him being shot in March 2020. Daniel later described his shooting as ‘warning’ and following a threat to life 7 notice. He was consequently, safeguarded through the use of Deprivation of Liberty safeguards (DoLS) and was moved by social workers to a confidential location upon his discharge from hospital. These restrictions remained in place until his 18th birthday and were overseen by the High Court. 5.7. After Daniel was injured, he informed family members and his social workers that all he wanted was a ‘quiet life’, to repair his relationships with family members and live in safely in accommodation near them. Adult services were contacted and discussions were held with Daniel, DM, and MGM regarding what support would be provided and the gradual transition of support to adult services. However, once Daniel knew that rehabilitation services would be deferred due to COVID-19 and he did not have a date for this support to commence, he ‘shut down’ again and a ‘reachable moment’ was lost. His relationships with family members quickly deteriorated with only MGM maintaining contact. 5.8. Daniel’s behaviours escalated and he reportedly made threats to his care team staff and they eventually gave notice. This resulted in the LA commissioning a bespoke package of support from an organisation highly experienced at working with young people with complex needs. The risk management plan was extended to include external sanctions agreed by Court to restrict his liberties in terms of not having a mobile phone or use social media devices as the concerns were gang members were attempting to locate him. 5.9. Despite Daniel having limited access to phone and Internet services, he was able to re-establish contact with some associates and information came to light which suggested he was planning retaliation against his perpetrators. Daniel left the accommodation of his own accord and was picked up in a vehicle and driven away. 5.10. Daniel was transferred to Adult services in July 2020. 6 The VEMT Practitioner Group (VPG) provides support for practitioners who work with children who are or believed to be ‘Vulnerable, Exploited, Missing or Trafficked ‘ 7 Osman warnings are issued if police have intelligence of a real and immediate threat to the life of an individual. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 11 6. Summary of agency interventions 6.1. Agencies provided this information from their own records and chronologies and were asked to include any relevant background information which might help the review team understand some of Daniel’s past history. Cleveland Police 6.2. Daniel first came to the attention of police in 2013, when he was 11 years old and was reported missing from home. Police records indicate that soon after this Daniel was linked to ‘anti-social behaviour’ and ‘low level’ criminal offences. At 13, police records refer to Daniel’s ongoing drug use, an increase in missing from home episodes and an escalation of offending behaviours, including violent offences. Daniel received a Youth Conditional Caution (YCC).8 In April 2016, for an offence of Criminal Damage and was referred to South Tees Youth Offending Services. 6.3. According to agency records, Daniel’s offending behaviours and missing episodes then increased steadily and significantly over a 2 year period and by the age of 15, police intelligence indicated he had links with known crime groups in his community. Police records also refer to Daniel not being willing to engage with professionals and using intimidation techniques with witnesses to ensure that prosecutions could not be followed through. 6.4. During the period under review, Daniel was involved in a number of police investigations including alleged stabbings, drug possession and criminal damage and was listed in police records at various times as being ‘wanted’ and a ‘person of interest’, rather than as a missing looked after child. Following the death of PDM in early 2019, Daniel was suspected of stabbing the individual who he believed had supplied the drugs, which led to PDM’s death. 6.5. The first police record of Daniel using a firearm was in December 2019. Three days prior to Daniel’s injury, he was involved in a firearms shooting but this information was not shared with Children’s Services. A threat to life notice was given to Daniel whilst he was in hospital but this information was also not shared with social workers as would be expected. Comment: Intelligence about Daniel’s contacts and associates in the community and his links with known criminals in the area was not shared with safeguarding partners and this, together with him being viewed through the lens of an offender/suspect made plans for keeping Daniel safe less effective. Youth Offending Service (YOS) 6.6. South Tees Youth Offending Service became involved with Daniel in April 2016. When Daniel was moved to PL1, his YCC was managed by the YOS in that area on behalf of STYOS. This was in line with usual practice and there is evidence of continued liaison between the services until Daniel returned to live with MGM. 8 Children aged 10 – 17 years old can be given a Youth Conditional Caution if they admit a criminal offence. Youth conditional cautions are a caution with one or more conditions attached. If a child does not keep to the conditions they could be prosecuted for the original offence. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 12 6.7. STYOS became involve again in January 2019, when Daniel was sentenced to a 12 month Referral Order9for offences of Robbery and Possession of a Bladed Article. At the time of his initial assessment, YOS records indicate there was no concern that Daniel was a victim of exploitation or was involved in drug dealing activity. There were concerns however about the males, known to YOS, with whom he was spending his time but Daniel told YOS1 that he made his own decisions and was not influenced by others. According to agency records Daniel initially engaged well with YOS1 and complied with the requirements of his order. 6.8. Following further arrests for violent incidents, Daniel’s initial YOS assessment was reviewed and he was re-assessed at being at ‘High Risk of Serious Harm’ and ‘High Risk to his Safety and Wellbeing’. As a consequence, and in line with YOS case management guidance, responsibility for working with Daniel was, appropriately, transferred from YOS1, to YOS2, a more experienced case manager. 6.9. According to agency records, Daniel’s level of risk both to himself and to others significantly and steadily increased during 2019. In December 2019, YOS2 referred Daniel to MAPPA10 following police information that he had been involved in stabbings in the community. This referral was declined given there was already a ‘significant level of multi-agency involvement’ but this decision was challenged and following further arrests, YOS2 submitted a second referral over a week later. This time the referral was accepted and a meeting was scheduled for late January 2020. 6.10. Daniel at this point began to disengage from YOS and the requirements of his court order, he missed key appointments, and when contacts did happen, records suggest Daniel was often volatile and verbally aggressive. As Daniel was breaching his order, he was required to attend a court hearing in January 2020 but he failed to attend and a Warrant was issued for his arrest. Daniel was subsequently subject to bail supervision and support and was required to contact his YOS worker, 3 times per week, but at this point Daniel began to disengage with YOT2. Comment: Daniel’s working relationship with his YOS worker appears to have worked at times. Analysing why this was the case would have been a useful topic for professionals to explore. VEMT Practitioner Group (VPG) 6.11. The VPG is a multi-agency operational group in Redcar and Cleveland, which supports frontline practitioners who work with children and young people who may be at risk of exploitation or have been groomed and ‘captured’ through that process. 6.12. Daniel was first referred to VPG in July 2019. Records from the first VPG meeting in September 2019 note that Daniel had again begun to engage with YOS, his missing episodes were decreasing and risks appeared to be reducing. However by November 2019, minutes of the VPG meeting that month acknowledged that risks were ‘escalating rapidly’ and in December notes refer to Daniel not having a ‘sufficient realisation’ of what he was involved in and that ‘dealing drugs and stabbing people’ would 9 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months. 10 MAPPA stands for Multi-Agency Public Protection Arrangements and is a process through which various agencies such as the Police, the Prison Service and Probation work together to protect the public by managing the risks posed by violent and sexual offenders living in the community This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 13 ‘have consequences’. Concerns were raised about Daniel’s safety and his involvement with different criminal groups and plans for the local authority to make an application for a secure accommodation order11 in late December 2019 were noted and supported. The application for this Order was however refused due to no secure placement being available. 6.13. Between January 2020 and March 2020, Daniel’s whereabouts been largely unknown. Intelligence linking Daniel to carrying and possession of knives and firearms, drug dealing, drug use and multiple feuds in several local areas were increasing. Following the second referral to MAPPA in December 2019, Daniel registered as ‘Very High Risk’. Notes from the VPG meeting around the same time, state ‘there are concerns that [Daniel] is involved in criminality; possession of weapons and drug dealing’, and he was ‘vulnerable to Child Criminal Exploitation’ so ‘multi-agency support’ would continue. Comment: There needs to be clarity about what additionality the rating of ‘Very High Risk’ brings or can bring. Daniel was subject to VEMT and was registered as a very high-risk offender with MAPPA. Neither of these forums brought about any increase in safety for Daniel. Both forums have a high level of multi-agency input, but they did not have any impact on either securing placement stability for Daniel nor provide access to a secure bed, although they did ensure that the search for secure accommodation continued. Education 6.14. Daniel moved from his primary school, SCH1 to a secondary school (SCH2) in September 2013, by which time SCH1 had already noticed a change in his behaviour and he began about that time to be known to police. In 2013/2014, an Ofsted inspection placed SCH2 in special measures12 and this resulted SCH2 becoming an Academy in September 2015. (ACD1) 6.15. The review team have not been able to access any records from SCH2 including any which provide detail of concerns about Daniel and how or if these were reported or managed at the time. It would appear that Daniel’s school attendance at SCH2 gradually and significantly declined during his first two years; arrangements for him to attend EOTAS, were unsuccessful as was the managed transfer to another mainstream school which, after two weeks, Daniel refused to attend, because rival gang members attended that school. 6.16. There are no records of Daniel’s time in EOTAS. It has not been possible to ascertain whether this is due to loss of records, ineffective recording systems or poor record keeping by staff. In October 2016, an investigation, not related to safeguarding, was instigated in relation to leadership and management of EOTAS and this resulted in a number of staff leaving their employment. It has therefore not been possible to follow up this line of enquiry with any staff. 11 Secure accommodation orders are used in cases where a child or young person who is looked after by the local authority is assessed as needing to be accommodated in a placement, provided for the purpose of restricting their liberty 12 The term 'Special measures' is a term used by Ofsted following inspections and refers to the need for the school to receive additional, external support in order to secure required improvements. 12 Every child who is accommodated by the local authority and has a Care Plan must also have Personal Education Plan (PEP). This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 14 6.17. Personal Education Plan (PEP)13 for Daniel was completed by the Virtual School Head 14in early May 2018. The plan was discussed with professionals in order to progress the education offer being arranged in order to enable Daniel to access a level of education. MGM recalls that after Daniel had been placed with her in June 2017, she was told by a tutor that the education sessions he was delivering to Daniel each week were ending as he had been informed that Daniel was unlikely to pass his exams so the sessions were not required. This information is contained in LAC review minutes in October 2018. Comment: The impact of exclusions and the increased risk they place on vulnerable young people are well documented. The risks for Daniel were not explored in multi-agency meetings. Daniel’s Education needs as a Looked after Child were neglected. Redcar and Cleveland School Nursing and Health Visiting Service 6.18. Daniel was referred to the School Nursing service in July 2019. SN1 initially spoke with MGM who indicated that Daniel had no specific health needs. Although active in seeking information to support a looked after child health review, SN1 had no documented contact with Daniel. Comment: Although there is evidence that concerns about Daniel were evident by the time he was referred to SN1, there should have been direct contact with Daniel rather than accepting an assurance from MGM that he had no specific health needs. Redcar and Cleveland Children’s Services: Early Help Services 6.19. Daniel first came to the attention of Redcar and Cleveland Children’s Services in April 2015 when he was 12 years old. According to agency records, an Early Years practitioner (EH1) undertook eight short sessions with Daniel, which were deemed successful as the threat of exclusion then diminished. 6.20. In January 2016, agency records indicate that DM again contacted children’s services to advise she was struggling with Daniel’s behaviour and considered him to be beyond parental control. By this time Daniel had been excluded from mainstream school and was meant to be attending EOTAS. Early Help services were again put in place and although records refer to limited engagement from DM or Daniel, there are no detailed accounts to indicate exactly what work was undertaken with the family. 6.21. Three separate referrals were received from police during March 2016 requesting a child and family assessment but decisions were taken to continue to work with the family through the provision of Early Help services. Daniel continued to go missing but records suggest that he and DM refused to engage in return (from missing) interviews and in April 2016, DM, is recorded as being unwilling to undertake any further work with Early Help, which she believed was ineffective. Comment: Whilst the first intervention with Early Help may have been appropriate, the second request for help with Daniel should have led to Child and Family assessment. As concerns continued to be reported, CSC should have intervened much earlier. Redcar and Cleveland Children’s Services: Children’s Social Care 14 Virtual school heads (VSHs) are in charge of promoting the educational achievement of all the children looked after by the local authority in which they work. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 15 6.22. Following another missing from home episode in May 2016, DM refused to allow her son to return to her care and Daniel was accommodated by the local authority under s20 15. A child and family assessment undertaken during this time highlighted concerns regarding Daniel’s welfare, there were concerns about his missing episodes and his involvement with criminal groups and peers known to CSC and police. 6.23. As no family members were able to care for Daniel, coming into care was considered the only option for him. Daniel was initially placed, with foster carers outside of Area1 but went missing. Believing him to be at risk within his community, Daniel and DM were accommodated in a Premier Inn for several days whilst another more suitable placement was found. Daniel was then 13 years old. Daniel was moved to a residential provision in Area2 where he remained for almost 12 months. Daniel made sufficiently good progress for key professionals to be optimistic about his return to live with MGM, where he stayed for almost two years. 6.24. In January 2018, Daniel was made subject to a Care Order s31 16 in response to escalating concerns by professionals and family members about Daniel’s safety, his involvement with known criminals, and his offending behaviours involving knives and weapons. LAC reviews and multi-agency meetings to progress Daniel’s care plans took place within required timescales. Daniel’s social worker was unable to engage Daniel to offer support and to discuss the risk to which he was exposed and how he could be kept safe. 6.25. In May 2019, just before his 17th birthday, Daniel was moved into semi-independent accommodation in response to family concerns about his violent and aggressive behaviours. From that point, concerns about Daniel and how to manage these were discussed with safeguarding partners almost on a weekly basis. Daniel appears to have stayed only for limited periods in the supported accommodation placements provided by the local authority, and for much of the time his whereabouts were unknown and he was frequently sought after by police. According to agency records, professionals could not engage with Daniel and he was particularly hostile and verbally aggressive to his social worker. 6.26. In December 2019, professionals concerns continue to increase when it became apparent that Daniel was not only using weapons but was also using firearms. The local authority made an application to the Court for a Secure Accommodation Order but whilst the threshold for this was met, the order could not be granted because a secure placement was not available anywhere in the UK at the time. The local authority continued to search for a secure placement up until, and after, the assault on Daniel in March 2020. Comment: Daniel, unusually, moved from being a child in receipt of Early Help services to being accommodated, suggesting that statutory interventions should have happened much earlier. The challenges of finding secure accommodation for a 17 year old are well known; when the child concerned 15 Section 20 of the Children Act 1989 sets out how a Local Authority can provide accommodation for a child within their area if that child is in need of it, due to the child being lost/abandoned or there is no person with parental responsibility for that child 16Section 31 of the Children Act 1989 – Care Order. The court can create a care order under Section 31(1) (a) of the Children Act, placing a child in the care of a designated local authority, with parental responsibility being shared between the parents and the local authority. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 16 is known to use weapons and firearms and is suspected of having links with OCGs, that challenge is even greater. TEWV Child and Adolescent Mental Health Services (CAMHS) 17 6.27. Tees, Esk and Wear Valley (TEWV) CAMHS provides assessment and appropriate treatment or intervention for children and young people who are experiencing mental health problems up to their 18th birthday. Daniel was referred to CAMHS by his GP when he was around 11 years old following concerns by his mother about his aggressive and out of control behaviours at home and his pending school exclusion. According to agency records, Daniel was not taken to any of the appointments offered and was discharged from the service. 6.28. In early 2016, Daniel was referred on three occasions to CAMHS Liaison and Diversion team 18 in response to his offending behaviours. The initial screening processes following all three referrals established that Daniel did not have any mental health needs and no additional assessments were undertaken. 6.29. In early summer 2018, Daniel was referred by his social worker19 to the CAMHS LAC team as the placement with MGM was on the verge of breakdown. Daniel refused to engage but an initial consultation was carried out with MGM, which offered some insights into Daniel’s early life experiences. MGM shared with the independent reviewer that Daniel had experienced a number of rejections emerging from family relationships as he was growing up and this impacted upon his self -esteem and his need to ‘be recognised and belong’. Attempts to then meet with Daniel and DM were unsuccessful, so he was closed to the CAMHS LAC team. 6.30. Between November 2018 and February 2020, referrals continued to be made to the Liaison and Diversion team following further arrests. Although screened face to face, Daniel consistently refused assessments and any support offered. On each occasion there were no indications from mental health clinicians that Daniel suffered from any mental health condition. Following his injury, Daniel did consent to be seen by a Forensic Psychiatrist, which led to an assessment and recommendations for intervention, but Daniel did not wish to engage and no work was undertaken. Comment: Daniel was clearly seen on several occasions by mental health practitioners, but notwithstanding his refusal to engage with any assessments, agency records state there were no indications of any identifiable mental health issues. Clinical Commissioning Group (Primary Care) 6.31. Daniel attended only one GP appointment during the review period. Although medical records refer to Daniel’s ‘self-reported trauma and aggressive behaviours’, no further information was available. South Tees Hospital NHS Foundation Trust (STSFT) 17 Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) 18 The Liaison and Diversion team offers assessment and advice for people who are in police custody and who may present with mental-ill health or other vulnerabilities. 19 At this point, Daniel was a Looked After Child (LAC) This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 17 6.32. STSFT had minimal contact with Daniel prior to him being shot in March 2020. In early December 2019, Daniel was taken to the hospital by police. Whilst attempting to evade officers, he jumped from the second floor of a building, he was brought back into the hospital and treated but was later discharged. 6.33. Daniel was taken to hospital when found by police with a gunshot wound and was later advised there was no possibility of saving his fractured leg. Daniel was noted, to be ‘devastated’, but nevertheless refused to cooperate with children’s services or police and offered no information about the shooting or the individuals involved. 7. Appraisal of practice and safeguarding systems 7.1. The purpose of CSPRs is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems, if any, were in place to support professional activity and decision-making at key points in work with the family and what systems may have made it difficult for them to do so. 7.2. It is also important to be aware how much hindsight can distort judgement about the predictability of an adverse outcome. Once a serious incident to a child or young person is known it can become easy to look back and conclude that certain actions or the absence of these, were critical in leading to that outcome. The review team was mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then, might still be impacting upon practice in Redcar and Cleveland in 2021. 7.3. The challenge of reviewing what happened to Daniel over a 4 year period is that, not only do organisational structures change during that time, so do safeguarding systems as they respond to emerging knowledge and evidence about the harms children can face and from whom. Agencies across the UK now understand much more about the risks that children and young people can face from peers and groups outside the influence or protection from their families and in response have begun to develop and embed services that address those risks. 7.4. Towards the end of the period under review, namely from 2019, Redcar and Cleveland had already begun to consider how they could develop services and different ways of working with children who were being criminally exploited, or who were suspected of being exploited by criminal groups outside of the family environment. Managing change in organisations is complex and very rarely straightforward, requiring review at key steps along the way and going back to adjust when there is evidence of any less than-intended results. The review team is aware than much has changed in Redcar and Cleveland since 2016 and developments are ongoing; the findings contained in this report nevertheless remain relevant. 7.5. The review team identified five lines of enquiry, which provided a framework around which the review team could appraise practice and safeguarding systems. The recommendations listed at the end of this report emerge from learning points discussed and debated within the review team and with key practitioners. The KLEs are listed below and an appraisal of practice under each key line of enquiry follows. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 18 KLE1: How well did agency assessments contribute to a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed. KLE2: To what extent were interventions and plans effective in meeting Daniel’s needs and keeping him safe? KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered? KLE4: How well did agencies collaborate and work together? KLE 5: To what extent were national and locally agreed pathways effective in keeping Daniel safe? 7.6. KLE1: To what extent was there a collective understanding of Daniel’s needs and vulnerabilities and the risks to which was exposed. 7.6.1. There is currently no straightforward way to clearly define vulnerable children. Adversity, risk, and vulnerability are terms that have a long and significant history in child protection. ‘Adversity’ is often defined as those life events and circumstances which can combine to threaten or challenge healthy development in children such as experience of abuse, neglect rejection; loss and bereavement, living with domestic abuse or with a parent or adult who misuses drugs and alcohol. The term ‘risk’ denotes the chance of these adverse factors leading to actual negative outcomes for children whilst the concept of ‘vulnerability’ generally refers to the environmental or contextual factors that increase a child’s susceptibility to an adverse event. The importance of family history 7.6.2. Various agency reports refer to how quickly Daniel’s criminal activities and violent behaviours appear to have escalated between end of 2019 and March 2020. Viewing the chronology of agency interventions, there is some evidence to suggest that Daniel was struggling with anger, rejection, and isolation when he was as young as 11 and these factors, combined with continued unstable family relationships, may have made him more vulnerable to adverse influences outside of his family. 7.6.3. What emerges from documents seen by the independent reviewer is that some of the concerns about Daniel at the age of 13, going missing, drug use, offending behaviours and connections with individuals well-known to police and CSC, were the same concerns, albeit of a more serious nature, noted in agency records in 2020, as Daniel was approaching his 18th birthday. Whist, there were references in various agency records to Daniel’s ‘adverse childhood experiences’20, there was actually very little information contained in any agency assessments about Daniel’s childhood other than that provided by MGM and this left professionals with limited understanding about the extent of Daniel’s vulnerabilities. 7.6.4. At the point at which Daniel came to the attention of Early Help, expected practice would have been for a detailed assessment to determine Daniel’s needs and this should have included gathering 20 Adverse childhood experiences range from experiences that directly harm a child (such as suffering physical, verbal or sexual abuse and physical or emotional neglect), to those that affect the environment in which a child grows up (including parental separation, domestic violence, mental illness, problematic alcohol or drug use, and a family member being in prison). This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 19 information about Daniel’s childhood and family experiences, but this information is not available on records seen by the review team. The assessment did not explore the impact of DF’s inconsistent involvement in his life, his attachment to DM, or her parental capacity to protect Daniel and in this respect it would have been difficult to understand Daniel’s lived experiences. Consequently, Daniel was perceived to be the problem and services were provided to address his behaviours. 7.6.5. Neither is there evidence of that a robust assessment was undertaken when the family were again provided with Early Help services in early 2016, when Daniel was 13 and DM requested that he be ‘taken into care’. Good assessments matter; they are key to effective intervention and to improving outcomes for children as significant decisions are made on the basis of these assessments which affect outcomes for children in both the short and the long term. 7.6.6. Whilst, agency records indicate that DM was resistant to working with EH1, and placed the responsibility for change on Daniel and the agencies supporting him, the implications of this for Daniel were not explored as well as they might have might been. Given the known concerns about Daniel and the risk of family breakdown, expected practice would have been for CSC to have undertaken a Child and Family Assessment in January but the focus remained on Daniel’s presenting behaviours and Early Help continued to try and engage Daniel and his family to little effect. There is no evidence that a referral was made by Early Help to CSC, highlighting concerns or the escalating risk of family breakdown and consequently Daniel’s pathway into becoming a looked after child in May 2016, bypassing the child in need and child protection processes was sudden, and not foreseen by Early Help professionals and their managers. 7.6.7. The Child and Family assessment undertaken in June 2016 when Daniel became a looked after child still did not explore Daniel’s family history and background in any detail and this left professionals focusing only on Daniel’s behaviour rather than exploring the family and environmental factors which may have contributed to it. The review team had a sense that Daniel was seen at that time as a troublesome adolescent rather than as a troubled child. 7.6.8. Daniel’s Care Plan outlined the changes that Daniel was expected to make and the support he would receive from social care, education health and youth justice professionals to help him in this task but there were no actions for DM or any family members. More might have been achieved with Daniel had professionals been more curious and sought to learn more about his early life and how the impact of any childhood experiences influenced and continued to influence the core beliefs he held about himself and the world around him. It is important that professionals explore these childhood experiences so they can ensure that work focuses not only on presenting issues but also addresses the visible and hidden complexities of any childhood traumas. Learning Point 1: The connection between the past, present and the likelihood of future risk for children is about understanding the patterns of problems and needs in families that require something to change. Unless assessments are robust in exploring a child’s history, their needs may not be as well understood as they could be and this may leave some children vulnerable. Understanding complex behaviours in adolescents 7.6.9. Adolescence encompasses elements of biological growth and major social role transitions, both of which have changed significantly in the last few decades. The ‘adolescent’ period is now understood This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 20 to span ages 10 – 19 years, with the age 10- 13 years being commonly referred to as ‘early adolescence’.21 7.6.10. ‘Risk-taking is a normal part of adolescent development and most young people experiment with the increased opportunities for risk that their growing independence allows’22. For some young people, this includes experimenting with drugs and alcohol, testing out their independence or perhaps mixing with older peers who appear more ‘streetwise’ than them. It is not known whether Daniel was testing out boundaries when his first missing periods began but MGM recalled that in her view Daniel was highly susceptible to influences outside his family and enjoyed being seen as part of a group or gang. MGM recalled that as a young adolescent, Daniel would have wanted to have to ‘fit in’ and could have been easily influenced by others. 7.6.11. Numerous serious case review reports have highlighted the importance of professionals in all agencies understanding the complex behaviour of adolescents and the notion of adolescent choice. There is wealth of information, which suggests that too often professionals assume that some of the risks encountered by adolescents are a result of choices that are ‘freely made, informed and adult-equivalent’.’ 23 Professionals can also compound misconceptions through their attitudes and inappropriate language, the phrase ‘lifestyle choice’ was common parlance a few years ago and sadly, there is still evidence of its use today highlighting that members of the general public and some professionals can hold views that the harms young people experience are self-determined and self-inflicted. 7.6.12. Research and practice experience now clearly demonstrates that the pathways leading to the harms that adolescents experience are complex, not least because they often appear to involve choices which are assumed to be rational and akin to adult decision-making. Experimentation and impulsive behaviour are part of normal teenage experience and with support; most young people navigate these challenges and emerge as healthily functioning adults. However, the interaction of individual, family, and environmental factors can greatly increase a young person’s vulnerability to risk and the potentially adverse consequences of risk-taking.24 7.6.13. The review team was interested to note the occasional reference in records to Daniel needing to ‘understand the risks he was taking’ in ‘associating with inappropriate [people]’. Using this language was very probably not helpful as it presented a view that Daniel was indeed making deliberate rational choices about his behavior which, would change if he was indeed educated about the risks. Language provides a medium for describing perceptual experiences and views and therefore has an extraordinary capacity to influence the way professionals think and consequently the way they act.25 Hence the plans made for Daniel charged only him with the responsibility for changing his behavior. 7.6.14. Adolescence is a time of changing social relationships and there is a plethora of research, which highlights that peers become increasingly important to young people in a number of ways – as 21 The World Health Organisation defines 'Adolescents' as individuals in the 10-19 years age group and 'Youth' as the 15-24 year age group. 22 Risk taking adolescents and child protection Research in Practice (2014) 23 That Difficult Age: Developing a more effective response to risks in adolescence. Research in Practice November 14 24 Risk -taking adolescents – A strategic briefing Research in Practice 2014 25 This is called the Sapir-Whorf hypothesis. ‘Language may indeed influence thought’ Jordan Slatev and Johann Blomberg. Phil Papers October 2015 This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 21 friends, protectors, confidants and consequently they have an enormous capacity to influence. Daniel’s contacts in the community were clearly important to him and became increasingly so as he grew older and sought to achieve status within those groups. Despite being helped to ‘engage in more positive experiences’ and ‘understand the danger of mixing with certain peers,’ whatever it was that Daniel gained from these relationships, clearly significantly outweighed any perceived risks and known dangers. 7.6.15. The review team considered that at that time the extent to which Daniel was influenced by peer pressure was not well understood by professionals who at that time were of the view that Daniel could be supported and ‘educated’ from engaging in such ‘risky’ behaviours. The ‘risk-based’ terminology used to describe Daniel’s behaviours were not helpful as they initially implied that he was, even as a young adolescent, making unconstrained ‘choices’ when, in fact, his ‘choices’ and behaviours were underpinned by complex interacting developmental, social and psychological drivers, which professionals never got close enough to Daniel to explore in any depth. 7.6.16. There was a recognition that Daniel was significantly influenced by, and attracted to, the older peers and status-driven lifestyle he experienced outside his family but the nature of his ‘friendships’ and the links he had with groups of offending peers and adults were not built into assessments, so work focused primarily on Daniel and only to a very limited extent, on DM and MGM and their ability to keep him safe. 7.6.17. Although, some of the individuals with whom Daniel was associating were subject of interventions in their own right and actions were later taken to try and disrupt contact between them and Daniel, the plans formulated to keep Daniel safe were based on risks assumed to be in the family, i.e. DM and MGM not able to keep Daniel safe keeping or with Daniel keeping himself safe, rather than with individuals in localities with whom he was spending most of his time. 7.6.18. There was no assessment or intervention in relation to Daniel’s self-harm and records do not refer to any triggers, which led to him cutting himself or for how long this behaviour continued. Daniel’s relationships with different females was concerning, so too was his violence and aggression within these relationships which was likely indicative of his own adverse childhood experiences where he was exposed to violence within the context of his mother’s relationships. Although Daniel became looked after in 2016, there is no evidence of work being undertaken to help him address any trauma or indeed no recognition that this work would be of any value. It was not until the CAMHS LAC assessment in 2018, that this work was considered. Daniel’s childhood experiences but Daniel’s vulnerabilities to adverse influences outside his family were not recognised at that time. Current Situation: STYOS has invested significantly in better understanding the Trauma Informed Pathway. This has been an area of development for the service since 2019. 7.6.19. Recent developments about understanding harms, which happen to children outside the family environment, have led to an approach developed at the University of Bedfordshire called Contextual Safeguarding. This approach attempts to address the contextual dynamics of peer to peer abuse by acknowledging the ‘weight of influence’ that different contexts have and suggests that professionals working in the field of child exploitation need to understand that for adolescents ‘peer influence appears to outweigh that of parents/carers in the escalation towards an abusive incident, and; risks This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 22 within extra-familial settings appeared to outweigh the relative safety within families when motivating young people’s actions’. 26 . 7.6.20. Local authorities in the UK have, over the past decade; developed responsive services to meet the needs of children who were being groomed and sexually exploited or who were at risk of becoming so. By 2017, there were national calls for agencies to learn from the lessons of the past and develop services which acknowledged that children could not only be sexually exploited, they could also be criminally exploited (CCE) and pressured into committing crimes including transporting illegal drugs around the county, a practice known as County Lines. 7.6.21. Understanding CCE was, in 2018/2019 still emerging in agencies across the UK. The remit of the Tees wide VEMT arrangements in July 2019, had only just been extended to include consideration of children who were at risk of, or who were being, criminally exploited. Information-sharing and multi-agency arrangements for responding to concerns about CCE were for the most of the time under review not well established. Consequently, the very real risks to Daniel from outside influences beyond the family were not considered and the focus remained on helping Daniel adjust his behaviour and thinking and in so doing repair damaged family relationships. Current Situation: RCCS is currently working with The Children’s Society and have set up a working group with nominated champions from early help, safeguarding, the review unit, children in care and health teams to focus on best practice working with children who have been sexually or criminally exploited. This work also involves collaboration with the regional National Crime Agency exploring agency responses to CCE and County lines activity. Education: Exclusions and managed moves 7.6.22. Children excluded from school are often amongst the most vulnerable in our society. Any child can be at risk of exploitation but some vulnerabilities place children at greater risk, such as being excluded from school or being a looked after child, and Daniel was both of these. MGM expressed her views that Daniel’s exclusion from SCH 2, his transfer to EOTAS, A pupil Referral Unit, and then the attempted placement with another school at which young people from rival street gangs attended, significantly impacted on Daniel’s willingness and ability to engage with education. 7.6.23. According to research27, there is, despite the government’s cautioning against presuming links and causation, a ‘clear and near-universally acknowledged statistical link between exclusions and children and young people becoming involved in violent crime as either victim or perpetrator’’. To the review team it makes sense to presume that if children are missing from home, school or care, they are more, not less, likely to come across or be introduced to, individuals involved in criminal activities. 7.6.24. In its report ‘Back to School? Breaking the link between school exclusions and knife crime’ released in Autumn 2019, an All-Party Parliamentary Group on Knife Crime called for an end to part-time education for excluded pupils, and for mainstream schools to be more accountable for the children they exclude. Although CCE may not have been well understood when Daniel was permanently excluded from SCH2 in November 2015, the risks for children being out of school were well known and his exclusion should have prompted a Child and Family Assessment by CSC. 26 Contextual Safeguarding. University of Bedfordshire November 2017 27 https://www.justforkidslaw.org This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 23 7.6.25. Education is a key area for consideration in social work assessments and where there are concerns about a child’s safety and welfare, any significant changes to a child’s education should be discussed and, where possible, agreed within a multi-agency setting. Although there are references to Daniel’s education in his Care Plans and in LAC reviews, the review team had a sense that Daniel’s education was ‘left’ to education professionals and plans and decisions around his education were not questioned. 7.6.26. Schools should be expected to take meaningful action to put in place support to keep a child in school where they can, and equally they should be supported to do so by meaningful partnership working with other services. Shaun Sawyer, national police lead for modern slavery and human trafficking (2020) writes ‘We are seeing more exploitation than before in modern times. For understandable reasons of austerity, state youth services have been vacated. This gap of youth provision between the school and family is the void that the exploiters are filling. Youth diversion services need to be hard wired in. Child criminal exploitation, it’s all about family, creating feelings of security, self-worth and power. This gap between the school gate and the front door is where the exploiters are attractive to youngsters.’ Learning Point 2: Where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child’s immediate safety or long-term outcomes, should be formally scrutinised by safeguarding partners so that decisions can be taken about the need to re-evaluate any risks to the child and/or escalate concerns. KLE2: To what extent were interventions and services effective in meeting Daniel’s needs and keeping him safe? Daniel’s placement in June 2016 7.6.27. The pathways to critical interventions for Daniel in 2016 were determined by concerns that neither DM nor any other family member was able to care for Daniel and keep him safe and he was at risk of significant harm. Daniel was therefore accommodated by the local authority and initially placed in a foster home. After a few days, agency records indicate that Daniel was reported missing, apparently after verbally and physically assaulting the foster carers. RCCS acted swiftly and provided DM and Daniel with hotel accommodation until another placement was found. It is not unknown how this placement impacted on DM and Daniel’s relationship or whether they did indeed end up staying there for almost a week. 7.6.28. The decision to accommodate Daniel in a placement (PL1) 100 miles from his hometown was based on an assessment, which indicated that his education and safety needs could best be met within an out-of- area residential setting with 24/7 supervision. Despite Daniel not wanting to be move from his family, he was placed in PL1 alongside one other young person. Whilst, this intervention removed Daniel from adverse influences in the community, it also reduced his contact with his family, but it did keep him safe. Contact with his family was maintained and was, it would seem, well supported and as the placement progressed. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 24 7.6.29. CSC records indicate that Daniel had support from PL1 including sessions about emotional regulation, drug misuse and anger management and that he had an assessment completed by the local CAMHS service which identified he needed additional support with anger management. However, there are conflicting reports in this respect, as according to PL1, Daniel refused to engage with CAMHS so no actual assessment was ever completed. 7.6.30. Daniel’s Care Plan, monitored through LAC reviews under Looked after Child procedures, clearly stated what was expected of him during his placement in PL1; Daniel was to work alongside youth offending and drug and alcohol services, engage with therapeutic services and his education and partake in leisure activities. There were, however no references in the plan as to what changes might be required of DM, DF and other family members and this left the onus only on Daniel to change his behaviours so he could return home. Living so far from home at 13 years old must have been difficult however ‘street-wise’ Daniel may have appeared, there is little in records or reports, which acknowledges this. 7.6.31. There is evidence that whilst Daniel was in PL1, social workers attempted to work with DM. This was good practice and although DM engaged in the early days of Daniel’s placement, as plans were made towards Daniel’s rehabilitation back home, records suggest that DM began to disengage with professionals who then struggled to make contact so plans could be progressed. The future risk and implications of this for Daniel and the rejection he might have felt, do not seem to have been well considered in part, professionals said, because MGM stepped forward to agree that Daniel could return to her care. This decision caused a rift in the family and meant that for some time after his return home, DM and MGM were not on speaking terms. This would have left MGM and Daniel isolated at a time when the need for wrap around family support was critical. 7.6.32. This decision to rehabilitate Daniel back to the care of his family was by virtue of a placement MGM. There were however some notable missing incidents when Daniel did not return to PL1 and this could have been an indication that more worrying patterns of behaviour were starting to re- emerge. When formulating the plan to return Daniel to MGM, the risk of Daniel re-establishing old contacts and reverting to previous patterns of behaviour was not assessed and he was in effect placed back into the same environment amid the same family tensions that had led him previously to being accommodated. 7.6.33. Daniel’s Care Plan focused from the outset on helping Daniel change his behaviours and ‘understand’ the risks to which he could be exposed if his behaviour did not change, but the plan did not, as would be expected, evolve during his time in PL1 and the wording and goals of his plan in June 2017 were almost identical to those captured in the LAC review on year later. 7.6.34. Making plans to support individuals and families is an essential component of social work activity. Like many plans seen elsewhere by the independent reviewer, Daniel’s plans contained goals to be achieved but did not contain the means by which progress could be measured, making difficult the task of monitoring progress and reviewing outcomes and, leaving professionals unable to easily identify what was working or not working, and why. In the plans seen by the review team, there were no references to any extra-familial harm to Daniel which, given what was known about his activities in the community, was a significant omission. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 25 7.6.35. There is a distinction in care planning between ‘goals’ and ‘objectives’, the former being continuous and longer term and the latter generally being more short-term and practical but still needing to evidence a credible link to the achievement of the longer-term goals. Daniel’s plans contained laudable goals, but without any functional, practical or SMART objectives, it was difficult to clearly identify exactly what had been achieved and what changes were evident to support Daniel’s return home to the care of his family. Learning Point 3: Children’s plans should always include targets/objectives that are SMART, so work with families can be easily monitored and the effectiveness of key interventions and outcomes measured. Current Situation: RCCS have begun to utilise and embed the Signs of Safety approach and this will support improvements in practice especially in relation to drawing up plans for work with children and their families. Care should be taken however to ensure that plans for children include goals and objectives which are specific, measurable, achievable and realistic; without these, progress cannot be measured and work with children will be less effective. Working with Parents 7.6.36. Developing a clear understanding of what is happening to a child within their family and community is vital to any assessment and the most usual and most effective way to achieve this is by engaging parents and children in that process, reaching a shared view of what needs to change, what support is needed, and jointly planning the next steps. A joint approach between families and practitioners is essential but there is no evidence of such a relationship between any professionals and DM or DF, although MGM was clearly willing and motivated to do what was best for Daniel. 7.6.37. Professionals clearly found it difficult to engage with DM, and DF as he worked offshore and was therefore not always contactable. DM’s apparent resistance to fully engage with professionals should have prompted further exploration about to what extent DM was willing and motivated to do some things differently in Daniel’s best interests and how she might best be supported to do this. Whilst cooperation and partnership working is not possible in all cases and parents may respond to professional concerns with denial, resistance and outright hostility, the review team felt that MGM’s willingness to step forward and care for Daniel overshadowed the need for professionals to purse work with Daniel’s parents. Learning Point 4: Unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement and this is likely to limit the effectiveness of any family work. The Care Order 2018 7.6.38. A Child and Family assessment was undertaken just prior to Daniel’s return home. Again this was good practice, although there is little to evidence the assessment changes Daniel’s Care Plan. It did however highlight the progress that Daniel had made in PL1, and acknowledged DM’s negativity towards Daniel and that her resistance to working with professionals had significant implications for Daniel. It did not however lead to a change in Daniel’s Care Plan, address how MGM would be helped to prevent Daniel reverting to past behaviours or identified the need for a robust safety plan. The assessment carried a note of optimism, which was not tempered by managerial oversight or the This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 26 Independent Reviewing Officer (IRO). MGM was assessed28 and Daniel returned to live with her and a support package was put in place. The nature of this package was not clear to the review team. 7.6.39. However, the lack of engagement with MS, together with continued concerns about Daniel led CSC to seek legal advice and in January 2018, DM or DF made Daniel subject to a Care Order, which was not contested. This intervention was believed to be in Daniel’s best interest. 2018 - 2019 7.6.40. Between January 2018 and early 2019, Daniel had occasional contact with DM and DF but remained living with MGM. LAC reviews took place within expected timescales with each noting the same issues: Daniel’s education supported through, what seems to be rather ad hoc arrangements, involving one to one tuition, Daniel’s continued drug use and missing episodes and Daniel’s continuing involvement in criminal activities. Records refer to Daniel consistently refusing to engage in any support or therapeutic services and MGM recalls that as time went by Daniel’s aggressive behaviours, occasional demands for money and involvement in what she described as ‘local gangs and turf wars ‘ escalated. 7.6.41. ‘Gangs’ is a broad term and it is important to recognise and not conflate, ‘street gangs’ operating in a locality and which seek to cause harm to others from different areas, with organised criminal [gangs] groups, referred to now as (OCGs) 29. It is not known exactly when Daniel’s involvement with street gangs (social media sites confirmed his involvement in ‘turf wars’) shifted to an involvement with OCGs as information was not shared as might have been expected by police but by December 2019, there were evidence that Daniel was using firearms and was possibly offending to order.30 At this point, VPG sought to establish links between Daniel and OCGs in Area3. Records suggest that professionals by this time were at a loss as to how to work with Daniel and keep him safe. 7.6.42. During this period, the review team was unable to determine exactly what pro-active interventions, if any, were in place to work with DM or Daniel. It would have been difficult to embark on any work without the cooperation and motivation of Daniel, but even so plans did not change to reassess risks, which were in fact steadily growing. Unknown to CSC, at that time, Daniel was in fact becoming embroiled in organised criminal activity, he had no supportive networks and family relationships, already strained because of safety fears, were at risk of breakdown. Agency records refer to Daniel being dismissive of anything social workers could offer and frequently expressed the view that he knew what he was doing and didn’t require any help. Referral to VPG 7.6.43. By early 2019, professionals had begun to recognise that some of Daniel’s behaviours were indicative of him being criminally exploited; injuries, substance misuse, missing episodes, aggression towards professionals, possession of weapons and unexplained funds. It was however, not until May 2019 that Daniel was referred to VPG so data and intelligence about Daniel’s activities and the individuals with whom he was associating could be shared and plans formulated accordingly. From agency 28 If the child is Looked After by the Local Authority they can be placed with connected persons such as relatives and friends. These relatives or friends must undertake a Friends and Family assessment and approved as local authority foster carers and to meet the required standards and responsibilities of foster carers. 29 Hidden in Plain Sight Gangs and Exploitation National Youth Agency (2020) 30 See RCCS Agency Learning Report This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 27 records, it would seem that by this time, Daniel may well have been involved in organised criminal activities for at least 18 months at the time he was referred to VPG, this information had not been shared by police with other agencies. 7.6.44. At the point of Daniel’s referral to VPG, the remit of the Tees VEMT arrangements had only just been extended to include consideration of children who were at risk of or who known to be criminally exploited. The detail of the strategy was however not to be finalised until the end of that year. Nevertheless, VPG acted swiftly in response to concerns and Daniel was listed as Very High Risk. Social workers were tasked with providing VPG with regular risk assessments and were challenged when these were not forthcoming. 7.6.45. The review team was told that whist work promptly commenced to map associates, given that Daniel refused to talk about people or places and important police information, at that time, had not been shared, it was difficult to properly understand the extent of these risk factors at that time. VPG meetings were held monthly, although as concerns escalated about Daniel, meetings tended are held almost on a weekly basis, so agencies could keep abreast of his placement moves and share information about his whereabouts. The review team had a sense that whilst VPG was effectively driving forward work with Daniel, it remained difficult to put any measures in place that would demonstrate safety due to Daniel’s lack of willingness to engage with professionals and this left effectively left him vulnerable and at risk. Current situation: VPG. VPG arrangements have been revised and weekly meetings now take place to consider all new referrals and share information about missing children and young people. For every child that is now subject to VEMT there is now an established professional email exchange so the information can be shared, assessed and responded to as it arises. Children’s services now work closely with police colleagues in the Complex Exploitation Team (formerly police VEMT team) to consider how children’s plans can properly encompass all known information to better contribute to safety planning for children. VPG chairs now attend police meetings where intelligence relating to OCG activity across South Tees is shared and analysed. Placement sufficiency and the impact on planning and decisions 7.6.46. Once it became evident that Daniel could no longer live with MGM, Daniel was provided with semi-independent accommodation in his hometown and a support package was initially put in place, provided by SP3. Daniel at this time was almost 17 years old. It is of course, in the best interests of most young people of Daniel’s age to live in the family home, or, where this is not safe or appropriate, with responsible adults in their wider family and friend’s network. There is clear evidence that professionals working with Daniel recognised this and tried hard to identify and resolve the breakdown in family relationships. By this point, MGM had had her home windows broken and her car vandalised three times and she suspected these were ‘threats’ or ‘messages’ to Daniel; she feared for her own safety from others and also from Daniel, who she described as becoming more violent and aggressive towards her. 7.6.47. Daniel was referred to MAPPA following a Section 18 wounding and a series of significant offences including robbery and kidnap. He persistently, and perhaps not unexpectedly, failed to comply with his placement agreement and threatened staff in SP3 if they reported him missing which they were required to do. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 28 7.6.48. A number of placements move in various settings followed in response to concerns about Daniel’s safety and the possibilities of retaliation due to him being involved in violent crimes. For much of the time, Daniel’s whereabouts were unknown, sometimes for days at a time. In December 2019, the local authority was granted permission to seek a Secure Welfare Order believing this was the only way that Daniel could be kept safe. Despite daily searches no suitable accommodation could be found. The possibility of placing Daniel in an unregulated placement and securing authorisation for a DoLS31 was discussed, but this option was dismissed as it was recognised that any staff ‘supervising’ Daniel would be at significant risk if they tried to curtail his liberty. By this time information had come to light that Daniel was using firearms. Whilst the search for secure accommodation for Daniel continued, risk assessments were undertaken in respect of the staff that were offering support and supervision and safety measures were put in place to ensure their protection. A note from a VPG minute in January 2020 states that [unless Daniel can be securely accommodated] he is likely to be seriously harmed or will seriously harm someone else. 7.6.49. The briefing by the Office of the Children’s Commissioner in November 2020 ‘The Children no-one knows What to Do With’ outlines that for children in residential care, ‘the standard of care is variable, there are not enough places; children are left at huge risk waiting for suitable accommodation, and the problem is getting worse’. The briefing further outlines the risks for children associated with unregulated placements and the acute lack of capacity in children’s secure accommodation settings. Searches for a secure bed for Daniel were made on a daily basis. 7.6.50. In January 2021, the government announced an independent review to address poor outcomes for children in care as well as looking to strengthen families to improve the lives of vulnerable children. The briefing and government action demonstrates that some of the challenges highlighted in this review have a national context that is, reportedly, high on the government’s agenda. 7.6.51. Each Local Authority/Children’s Trust has a ‘sufficiency duty’ 32 to ensure there is suitable accommodation to meet the needs of children that they are looking after. They have to demonstrate that they are doing all that is ‘reasonably practicable’ on a strategic level to meet the sufficiency duty. Meeting the placement needs of Daniel proved to be consistently problematic in that none of the placements were secure and Daniel could come and go as he pleased, and there was clear evidence that staff in SP3 colluded with Daniel and did not reporting him missing when they were required to do so. 7.6.52. Placing a child in an unregulated placement is a not a choice that any council would want to make, but it has become an increasing occurrence due to the national shortage of regulated settings able to meet the needs of children, like Daniel. Unregulated homes are not registered or inspected by the regulator Ofsted and as such are not required to meet any specific standards. They are often created in response to a crisis need and when there is no other option, it then falls to the local authority to conduct due diligence checks to be satisfied that all statutory requirements are met and that the care provided is lawful. In 2020, there were a number of High Court judgments involving young people for 31 32The "sufficiency duty" was introduced by the Children Act 1989 and requires local authorities to take steps that secure, so far as reasonably practicable, sufficient accommodation within the authority's area which meets the needs of its looked-after children and those who would benefit from being accommodated. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 29 whom no suitable care home place could be found anywhere in England, even when the Court was advised that the lives of those children would be endangered if a home could not be found. 7.6.53. The background to this matter is one that is now depressingly familiar to the Family Division of the High Court 33and replicates the challenges faced by RCCS in finding a suitable, safe, and secure placement for Daniel. 7.6.54. A report from the National Audit Office – ‘Pressures on Children’s Social Care, 2019 states that demand for residential placements, including the need for secure accommodation has outstripped capacity. The [increase] in the use of residential care has exposed the lack of suitable placement capacity available to local authorities: only 32% of local authorities report that they have access to enough residential homes for children aged 14 to 15 years, and 41% for those aged 16 to 17. The lack of secure accommodation for children with complex needs compounds this challenge even further. Learning Point 5: Unless the lack of secure accommodation is addressed nationally, children like Daniel with complex needs and behaviours will continue to fall through the gaps that exist between secure accommodation, regulated accommodation and detention under the mental health legislation. 7.7. KLE3: How did professionals manage and respond to Daniel’s refusal to engage with them and the services they offered. 7.7.1. From talking to practitioners, a complex picture emerges of a young person who everyone felt was at the most serious end of the risk spectrum but with whom no individual could effectively engage. It is clear that professionals tried hard to communicate with Daniel about the risks he was facing and the consequences of his behavior and also tried to encourage him to seek help to mitigate those risks. There is however much to evidence that Daniel remained adept at resisting any meaningful involvement with professionals and although there were times when professionals thought they might be ‘getting through’, later events suggested that Daniel was equally adept at displaying disguised compliance and giving the appearance of cooperation whilst his risky behaviours not only continued, but were seen to escalate. 7.7.2. Even without a thorough understanding of Daniel’s early childhood, it might have been helpful if professionals had developed and worked from a hypothesis that Daniel was highly likely to have attachment issues and therefore did not trust or feel the world was a safe place. Whilst there are many records describing the difficulties professionals faced in trying to engage him, there were far fewer reports analysing why this might be so and how professionals might forward in trying to work with him. 7.7.3. Hard to reach behaviours in adolescents with associated behaviours such as drug misuse, aggression and criminal acting-out are well researched. 34 Some research is found under the heading of 33 See Z (A Child-DoLS Lack of secure placements [2020] EWHC 1827 34 That Difficult Age: Developing a more effective response to risks in adolescence Research in Practice (2015) This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 30 adolescent psychopathology and anti-social behaviour, but other studies focus on the strong links between adolescent mental health states and early relational factors and parenting styles. Mental states, beliefs, wishes, feelings and thoughts, whether conscious or unconscious, are known to determine actions and behaviours and Daniel’s determination to acquire status and show people he was in charge and needed no-one, were likely indicators of Daniel’s core beliefs about himself and the unsafe world in which he lived. According to MGM and professionals who knew him, Daniel’s behaviours actually belied a vulnerability that he was careful not to expose. There were however small glimpses of Daniel’s inner turmoil, evidenced by references to him cutting himself and the ways in which he responded to disappointment, challenge, and rejection. 7.7.4. Although professionals struggled to find ways to engage Daniel there is little to indicate, the need to do so was identified as an essential and purposeful intervention in its own right. Work with Daniel was undertaken at a later stage by YOS1 on knife crime, which apparently grasped his attention and led him to produce a PowerPoint presentation on the topic. Whist the appropriateness of the subject matter was questioned, it nevertheless indicated there were ways to communicate with Daniel albeit on his terms, but the need for focused relationship-building opportunities was not well recognised. 7.7.5. The review team was of the view that the continued focus on Daniel’s behavioural symptoms and the view that he needed to ‘understand the risks and the consequence of his behaviour’ was not helpful and a more nuanced approach to his world might have achieved more. The experience of living in an environment of heightened tension, violence or anxiety as Daniel did, seemingly from a relatively young age, would have had a direct impact on his brain development and neurochemical pathways. Alertness and responsiveness to threats and perceived threats were no doubt hard wired into his neurological systems and the primitive flight/fight responses would have left him on continual alert. 7.7.6. This aspect of Daniel’s functioning could have been better explored; it was a fundamental part of who he was. Professionals suggesting that Daniel did not understand the dangers of his world were, it might be argued, naïve, given that Daniel carried weapons and wore a stab vest – he knew the dangers and prepared himself for those risks accordingly. The reality was that professionals could not actually keep Daniel safe and it is likely that Daniel was acutely aware of this even if he had wanted it to be so. There is evidence Daniel believed that being part of a gang was actually a safety measure for Daniel and this was perhaps not fully recognised by professionals, young people often report that the criminal group provides them with relational support, comradery, a family (which may otherwise be absent) and importantly for Daniel, a sense of identity and belonging. 7.7.7. This begs the question of how professionals can be better supported to understand in much greater depth a young person’s experience of gangs and violence and the ‘codes’ and ‘rules’ they need to adopt in order to survive; how do young people relax and know who they can trust living in a community that is violent and safe and importantly, how can professionals work effectively with young people, when it becomes apparent, as it clearly did with Daniel, that they are excited and hyper- aroused by that violence? 7.7.8. The challenge for professionals was of course the balance between taking critical actions to keep him safe, offering support which he refused to accept and then also taking time to learn more about his life and coping mechanisms. These areas of work were vastly important but they were not fully reflected in the multi-agency plans drawn up for work with Daniel. Research tells us that the highest This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 31 rates of success with young people come from relationship-based practice with long-term support from a worker whose sole purpose is to build that relationship and, if that professional is in a young person’s life for a significant amount of time, they are more likely to drop barriers and begin to trust and that is where true engagement begins. 7.7.9. Some of the challenges in securing Daniel’s engagement were certainly compounded by changes in the allocated social workers (4) and team mangers (2). Daniel appeared to engage more readily with the youth offending service and was particularly interested when completing work with them about gangs and the associated risks, which some professionals thought may have further developed his interest in organised crime. It is far more likely that Daniel took pleasure in talking about his life and demonstrating his knowledge about street life and such engagement was therefore still useful. Learning Point 6: Early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people as part of their professional role. These professionals need to be well supported to develop specialised skills and the right mind-sets so they can develop relationships with young people that are able to withstand resistance and disengagement, but continue nevertheless to support effective change. Current Situation: RCCS is working with a Tackling Child Exploitation (TCS) programme to develop a more preventative strategy aimed at early recognition, engagement, and prevention for children who are at risk of exploitation. This is a partnership between Children’s Services, Early Help, the Police, the Community Safety partnership, YOS and Education. Consideration is also being given to recruiting specialist adolescent social workers to work with children and young people who are or are at risk of being exploited. Learning Point 7: There are critical moments in children’s lives when a decisive response is necessary to make a difference to their long terms outcomes. These ‘critical or reachable moments’ are likely to include, the point at which they are excluded from school, when they are arrested, when they are physically injured. There would be benefit in ensuring that services and systems are in place to ensure that these ‘key’ moments are anticipated and individual practitioners can step in and capitalise on the receptiveness of children at these times. 7.8. KLE4: How well did agencies collaborate and work together 7.8.1. According to agency records, Looked After Child reviews took place in line with required timescales. Care meetings to progress Daniel’s Care Plans took place regularly, although minutes from these meetings suggest they were used more for information-sharing and allocation of tasks than analysing what was working for Daniel and his family and why. 7.8.2. The LAC review held in March 2017 referred to occasions when Daniel had not been returning to his placement after visits home was not engaging with education, and DM was refusing to have him home at that time. The review team could not evidence a support package in place, which recognised that in effect very little had changed for Daniel and the chances of him reverting to his previous behaviours were high. Neither did the LAC review held in June just prior to Daniel going to live with MGM address this issue. The contents of the June LAC review are cut and pasted almost in their entirety from the meeting three months earlier and again there was no challenge by the IRO as might This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 32 be expected as to what measures would be put in place to support Daniel and how would these be measured. 7.8.3. It is difficult to determine how effective multi-agency working was in June 2017 and 2018, although it is clear that professionals communicated with each other during this time. From mid-2018, concerns began to escalate about Daniel’s involvement in stabbings, violent assaults, and aggravated burglaries. Daniel was sentenced to a 12 month Referral Order35 in January 2019 for an offence of robbery but it was not until July 2019, that Daniel was referred to VPG by a social worker newly assigned to work with him to whom Daniel admitted that his observed injuries were a result of him being tied up to a chair and beaten. 7.8.4. Professionals told the review team that knowledge about CCE was only just emerging and prior to that time, the possibility of criminal exploitation had not been considered. Following the referral to VPG, there is evidence that agencies began to work more closely collaborate and share information. Professionals remained vigilant in their attempts to engage and support Daniel but this did not bring about any increase in safety for him. 7.8.5. According to the chronologies provided to the review team, there would appear to have been at the very least, around 45 multi-agency meetings held about Daniel, during the 4-year period under review and about half of these took place between May 2019 and March 2020. Most of these meetings included all or most of the agencies/services referred to in previous sections and most meetings had at least 3 or more professionals, and sometimes as many as 12 – 14 individuals in attendance. Practitioners involved in the review said that supervision sessions generally took place regularly and these were both supportive and challenging. 7.8.6. Risk management meetings took place but it was clear that until late 2019, agencies did not have a comprehensive understanding of the extent of Daniel’s involvement with criminal communities across South Tees and therefore, notwithstanding a lack of cooperation from Daniel, agreed strategies were not effective in keeping him safe. 7.8.7. The Police Agency Learning Report states that Daniel was ‘opened to ‘our’ VEMT team in 2015’ implying that Daniel’s contacts and activities were even then being monitored by police colleagues. However, there is little to suggest that this information was purposefully shared with colleagues. Certainly, by 2017 police were fully aware of Daniel’s involvement with adult criminals who were known to police and suspected of committing violent offences and being involved in the use and supply of illegal drugs. This information, and the extent and nature of Daniel’s contacts with these individuals or the possibility that Daniel could be involved with organised criminal groups (OCGS36) was never shared with partner agencies. 7.8.8. Police told the review team that information they held at the time was highly sensitive and related to ongoing police operations and there were limits to what could be shared. This clearly left other 35 A referral order is an order available for young offenders who plead guilty to an offence whereby the young offender is referred to a panel of two trained community volunteers and a member of the youth offending team. It can be for a minimum of three months and a maximum of twelve months. 36 An OCG is defined as a group which: has at its purpose, or one of its purposes, the carrying on of criminal activities, and. consists of three or more people who agree to act together to further that purpose. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 33 professionals trying to protect Daniel; unaware of the risks he was facing from influences outside of his family and from whom. Significantly, social workers were not informed that Daniel had been involved in a firearms incident three days before he was shot and it was only at the point that Daniel was due for discharge after he had been shot that social workers were made aware that police had issued a ‘threat to life’ notice two week earlier. As Daniel’s corporate parent, the local authority should not only have been informed of the intention to issue this notice, they should have been present when it was delivered and would certainly not have agreed to Daniel being informed when he was still heavily sedated with pain relief. 7.8.9. It was clear to the review team that important information was not shared by police with partner agencies at times when it was necessary and appropriate to do so. Views were expressed that, at that time, the force’s safeguarding arrangements and partnerships were not as robust as they should have been, a view highlighted in the HMICFRS 37 Inspection report following an inspection in December 2018. The review team was informed that information-sharing procedures between agencies have during the past 12 months been reviewed and revised. Learning Point 8: Agencies need to be able to confidently share information in various ways across force and partnership areas so plans to protect children are based on up to date and relevant information. There is a need to ensure that the revised information-sharing agreement is fit for purpose and is working well, taking into account emerging challenges but remaining focused on the need to safeguarding and protect children and young people. 7.8.10. The use of integrated approaches to respond to sexual exploitation of children through multi-agency cooperation is well recognised and has been for several years.38 During the period of this review, the need to establish similar arrangements for children who were at risk of criminal exploitation was only just emerging and procedures and protocols in South Tees had not yet been formalised at a strategic level and were not yet embedded into operational practice. Current Practice: Police: Cleveland Police have now established a Complex Exploitation Team to ensure a wider focus and a more targeted approach to respond to the sexual and criminal exploitation of children and adults, modern slavery and county lines operations. Chairs of VPG across South Tees now attend these meetings where intelligence about OCGs is analysed so implications for children and young people can be better understood from a multi-agency perspective. 7.8.11. The application for a secure order discussed in the December multi-agency risk management meeting was discussed as being the only way in which Daniel’s safety could be secured, but the absence of a bed within the secure estate, or a refusal to accept him, meant this could not be accessed. There were outstanding arrest warrants during December and Daniel seemed to go ‘underground.’ Despite challenges from the VPG chair, there were occasions when police continued to view Daniel through the lens of an offender and tagged him as ‘wanted’ rather than as a missing, looked after child. Referrals reporting Daniel as missing were therefore not always accepted at a local level by police and although this was raised by the VEMT DCI, it appears that the practice continued. There were at 37 Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services 38 Working Effectively to Address Child Sexual Exploitation. Research in Practice Revised 2017. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 34 least 4 missing episodes when police refused to accept the missing reports in relation and the search for Daniel was not therefore prioritised as well as it might have been, leaving him at great risk. 7.8.12. As evidence continued to emerge of Daniel’s violent offences and intimidation of others Daniel was referred to MAPPA in February 2020 and was registered as VERY HIGH RISK and was to be managed under level 2.39 The review team did not have sight of any multi-agency management plan in respect of the risks identified and neither was there any evidence that Daniel’s’ Pathways Plans40 were amended in line with the risks identified. 7.8.13. Despite a high level of multi-agency input, neither VPG nor MAPPA brought about any increase in safety for Daniel, his risk status never reduced and it is unclear what else could have been done, without provision of a bed in a secure setting. The use of DoLs at that time, was thought to be too great a risk for any staff supervising him as attempts to impose the authorised restrictions by staff gave rise to threats and intimidation by Daniel which left them at a loss as to how they could keep him safe. 7.8.14. Whilst, his referral to MAPPA and his assessment of ‘Very High Risk’ had limited impact for the safety and support for Daniel, it did support agencies to make key decisions about what they had to do to keep him safe and how to keep others including staff and the general public as safe as possible from potential harm by harm Daniel. This included making decisions around 2:1 staffing, ensuring NHS and other agencies were aware of the risks should he attend their agencies and ensuring staff had access to safety alerts if needed. The assessment also supported the local authority in taking the very unusual steps of moving a 17 + young person out of area, securing a DoLS and maintaining this until his 18th birthday. Without the assessments, these actions would not have been taken. 7.8.15. Professionals in multi-agency meetings were concerned that Daniel would either seriously injure someone or be injured him. Risk assessments were undertaken in relation to the staff working in the various settings where Daniel was placed, although the possibility of staff being threatened and frightened into ‘overlooking’ Daniel going missing or having prohibited visitors was not understood nor well recognised. There were indicators that he was involved with OCGs but this intelligence was never confirmed and therefore it remained difficult to assess and to militate against these risk factors, especially given Daniel did want the help or services offered. 7.8.16. Tackling violence and exploitation requires a multiple strand approach involving a range of partners across different sectors and communities. Local Community Safety Partnerships (CSP) need to be central to these approaches, so that issues are understood and owned locally and all relevant partners can play their part, this means focusing not only on crime reduction and reducing harms but including also child welfare and perhaps a greater alignment with child protection systems. It can be argued that extra-familial harm cannot be addressed without the involvement of CSPs and the services they oversee. Current Situation: Links with the community safety partnerships and the neighbourhood policing teams have now been strengthened. Mapping meetings take place which focus on 3P model of peers, 39 Level 2 – A local multi-agency management for offenders where the ongoing involvement of several agencies is needed to manage the offender. Once at level 2 there will be regular multi-agency public protection (MAPPA) meetings about the offender to develop a coordinated plan. 40 The name of ‘Care Plans’ was changed to Pathway Plans sometime in 2019. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 35 perpetrators and places and information sharing across particular cohorts of children to deepen understanding of risk, to consider safety planning and ensure that all lead professionals are sufficiently alert to the breadth of concerns about groups of children and perpetrators, as opposed to just the child. These meetings are attended by all relevant partners and include police analysts. 7.8.17. It was not clear to the review team to what extent senior managers were informed about and aware of, the risks that staff working with Daniel were carrying throughout 2019. A discussion did take place between the Director of Children’s Services and the Assistant Chief Constable in December 2019 which highlighted the challenges and frustrations agencies were experiencing in trying to keep Daniel safe. 7.8.18. The independent reviewer was advised that ‘Line of Sight’ meetings do take place in Redcar and Cleveland when complex decisions are needed. It is vitally important that senior leaders have a clear line of sight about the most vulnerable children and young people in addition to a clear understanding of the scale of child exploitation across Redcar and Cleveland so commissioning, policy changes and resource pressures can be addressed. Senior managers also need to be able to review and prioritise resources or specific activities for some individual children at high risk, and of course hold decision-makers to account. 7.8.19. It is important to recognise and acknowledge that the complexities of working with some young people means positive outcomes are not always achievable and some young people do remain at risk, despite the attention of services. The conclusions of Munro (2011) are pertinent here; she argues that what is required ‘is for all to have realistic expectations of how well professionals can protect children and young people [and remember that] this work involves uncertainty.’ Such challenges and uncertainties should not, of course, preclude continued efforts to protect children and young people from harm but the impact on professionals of working directly with complex young people, like Daniel, when the necessary resources are non-existent, should not be underestimated Transition to Adult services 7.8.20. The VPG members discussed whether Daniel would remain subject to VEMT after turning eighteen. Professionals did not feel they had been able to provide an intervention that effectively safeguarded Daniel. However, the group had remained vigilant; had always acknowledged that Daniel’s case was complex but attempts had continued to be made to offer intervention and support. The VPG members did not feel there was any benefit to keeping Daniel subject to VEMT. Daniel had decided that he was not going to engage with the services offered, it was felt that VEMT has no further service to offer him. Daniel’s case would transfer to the Leaving Care Team, but the primary lead would be MAPPA. It was agreed that VEMT should hand over their role to MAPPA, once Daniel turns eighteen years. 7.8.21. It was noted that there were concerns arising in respect of transfer to adult services given the significant efforts that had been made while Daniel was in hospital and following his discharge to try and secure a smooth transition for him. Although Daniel was a looked after child with RCCS, he was going to be living with MGM in a neighbouring authority and therefore would access adult services from the LA area in which he was residing. A hand-over meeting between key agencies was convened and it was agreed that an assessment would be undertaken by adult’s services in Redcar and This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 36 Cleveland. It subsequently transpired that Daniel would not, however, engage in the assessment. Daniel’s Personal Advisor from Leaving Care team continued to try and meet with Daniel but Daniel resisted attempts to make contact. 7.8.22. Although outside of the scoping period, concerns were raised by some professionals about the transition process from children to adult services. Examples were given of a number conversations held with, for example, homeless services and health (around Daniel’s physical rehabilitation) which reflected increased expectations of Daniel now he was an adult. It was queried whether more could have been done by the Leaving Care team to ensure that Daniel’s Pathway Plan addressed his support needs during a crucial and critical point of transition, but it was acknowledged that without Daniel’s cooperation nothing else could have been done at that point. 7.9. KLE5: To what extent were locally agreed pathways effective in providing support and protection to Daniel. 7.9.1. Some of the issues raised in this review are complex and require action from central and local government, police and other agencies, but this review has highlighted the difficulties for Redcar & Cleveland, and other authorities, in trying to safeguard and protect Daniel, as a young adolescent whose needs and vulnerabilities had clearly been exploited. The child protection system 7.9.2. The child protection framework is clearly set out in Working Together 2018 and is embedded in local practice. The association between abuse/significant harm and parenting and the grounds upon which the local authority should intervene is evident and well known. The framework benefits from independent chairing, clearly set out decision-making responsibilities, regular and timely reviews, and partner agencies that are familiar with and committed to the process. It also has associated statutory data collection, which allows the system to be held to account. Statutory guidance is followed and decision-making responsibilities are clear. 7.9.3. From the point at which Daniel became a looked after child in 2016, professionals recognised that he was beyond the control of his family and that in order to prevent him from ‘placing himself at risk’, he needed to be moved to a safer place. In this respect the child protection system was used effectively and as intended, with social workers trying to work with family members so they would be better able to meet Daniel’s needs and would at a future date protect Daniel from adverse external influences. 7.9.4. Once it became apparent, as it clearly did, that these adverse external influences held far greater sway than family or professionals and Daniel’s involvement in, and exploitation by, factors outside his family was putting him danger, professionals sought safety through other means. Placements in regulated and unregulated settings. 7.9.5. There can be no doubt that the local authority was focused on trying to meet Daniel’s needs. Resources were clearly not an issue, the main challenge described by those involved in finding and managing placements for Daniel was finding a specialist resource that could and would hold him and manage his challenging and violent behaviours. Moving Daniel to semi-independent placements brought their own challenges with risks to staff and limited if any oversight of his day to day activities and whereabouts. Daniel went missing from these placements on a regular basis, had taxis pick him This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 37 and drop him off whenever he chose. Seeking a DoLSs at this stage was considered not wise, given the risk involved to others. 7.9.6. Over the last decade, the challenge of providing capacity to care for the most vulnerable children has increasingly fallen to the private sector as the demand for care has grown and local authority provision has not kept pace, or even shrunk in some areas. There were over 11,000 more children in care in 2019 than there were in 2011 – 73% of those additional children were cared for by private organisations. Over the last decade, there has been expansion from both smaller providers (who might own one or two homes) and major private equity investment. Furthermore, there is a clear lack of planning and oversight for the market as a whole, leading to an increasingly fragmented, uncoordinated, and irrational market that ultimately does not meet the needs of children. 7.9.7. Using the additional information set out above, local authorities should make better use of their power as purchasers – through for example greater use of regional commissioning and frameworks – to increase the extent to which they can shape the market and their own provision. In doing so, they would be able to exert more market power, share more risk with other local authorities, and benefit from more of the kinds of economies of scale that have allowed large private providers to grow and succeed. Application for a Secure Accommodation Order 7.9.8. Professionals consequently sought support from the judicial process. Daniel clearly met the criteria for a Secure Accommodation Order under s 25 of the Children Act which states that such an order can be made if a young person is likely to run away and suffer significant harm or, if secure accommodation is not provided then the young person is likely to injure themselves or others. This order can only be granted if there is already a secure bed available and despite, the review team was told, daily searches, none could be found. 7.9.9. The Department of Education urgently needs to set out a strategy for how it will improve the sufficiency, quality, and costs of residential care in England. The strategy must prioritise ensuring the adequacy of placements, in order to address chronic lack of capacity highlighted by the thousands of children in the care system who are currently experiencing high levels of instability including frequent placement moves. The Criminal Justice System 7.9.10. Daniel seemed to deliberately go underground when he was aware that there were warrants out for his arrest and actively avoided criminal justice processes; he was often subject to warrants without bail. The evidence available suggests that Daniel had committed a series of serious offences but due to a lack of willingness from victims to make statements, the matters that were put to the Court were often low-level and therefore only invited low-level disposals. Although orders and conditions were imposed, Daniel breached these, seemingly without consequence, so restrictions on his liberty were lessened as opposed to increasing. Agency records indicate that this left Daniel with a view that he was ‘untouchable’. 7.9.11. Professionals told the review team that paradoxically, there were times, when they believed the only way Daniel might have been kept safe was if he had been charged and given a custodial sentence. Under the Bail Act 1976, the courts can also remand a child for their own ‘welfare’, without the young person being convicted or sentenced and, when the criminal charge they face is unlikely to, or will This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 38 not, result in a prison sentence. This is a significant indictment on our safeguarding system if we have to resort to the most punitive sanction available, imprisonment, to make up for failings in care and child protection systems in the community. Contextual safeguarding 7.9.12. It might be suggested if his Daniel’s childhood experiences had been more nurturing and had there been different professional interventions at key points in Daniel’s life, the outcomes for Daniel might have been more positive. These are important considerations and for many young people they provide some explanation for the difficulties they face in adolescence and provide and often provide the evidence to build safety plans and reduce risk.41 Research reminds us however, that these are not the only routes to harm facing young people, there can be traumatic consequences of victimisation and exploitation through for example peer relationships, grooming online and by criminal groups operating in the community. 7.9.13. Staff who contributed to the review were clearly far more knowledgeable about extra familial harms than they were even in 2020 and the review team were advised of several training programmes which have been delivered to staff in respect of CCE and referrals into the National Referral Mechanism (NRM)42 7.9.14. Local authorities need to respond to the abuse of children in all its forms. According to Firmin, (2020), Contextual Safeguarding offers ‘a lens through which extra familial harms can be recognised as abuse and responded to accordingly. This means not pushing the responsibility for protecting children solely onto parents but recognising that the state also has a duty of care and there are other ways of tackling this issue that vex traditional child protection approaches’. 7.9.15. It is clear from conversations held within the review team and with practitioners that even prior to this review being concluded, changes have been introduced in Redcar and Cleveland to strengthen and revise responses to adolescent risks and to develop services which offer a different way of safeguarding children abused outside of their homes. These changes are to be welcomed. Current Situation: Redcar and Cleveland are involved in a pioneering programme to support to young people who are in care, or on the edge of care. No Wrong Door – Strengthening Families Protecting Children programme; which was devised by North Yorkshire County Council, is one of three innovative models selected by the Department for Education as part of an £84 million investment to support eighteen local authorities across the country to improve work with families and safely reduce the number of children entering care. 41 Contextual Safeguarding and Child Protection. Rewriting The Rules Firmin ((2020) 42 The National Referral Mechanism (NRM) is a framework for identifying victims of human trafficking and ensuring they receive the appropriate protection and support. The NRM is also the mechanism through which the Government collects data about victims This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 39 8. Concluding Comments 8.1. Experimentation and impulsive behaviour are part of normal teenage experience and most young people navigate their adolescent years without long-term negative impacts. We now know however, perhaps more so than in the past two decades, how the interaction of individual, family and environmental factors can greatly increase a young person’s vulnerability to risk and the potentially adverse consequences of risk-taking. 8.2. Working with adolescents in harm’s way, requires confident professionals in all agencies. Professionals need to fully understand the complexities of working with children and young people who are vulnerable to the grooming tactics and behaviours of skilled adults, intent on exploiting those vulnerabilities outside their family environment. Whilst our collective response to the challenge must be to recognise and respond to the complexity of these risks and work together to protect children from what are often unimaginably dangerous circumstances, it must also be acknowledged that without increased resources at regional and national levels, children like Daniel will inevitably fall through gaps in provision. 8.3. The significant shortfall in the availability of approved secure accommodation causes considerable problems for local authorities and courts across the country. It continues to be the subject of expressions of judicial concern in a number of cases by judges dealing with cases on a regular basis. Whilst, it cannot be said with any certainty that had there been a secure bed for Daniel, he might never have sustained such injuries, it is possible that he may well have been kept safe for longer and much might have been achieved in that window of opportunity. 8.4. This review found evidence of some good practice by persistent practitioners who worked hard to find a way to engage with Daniel and keep him safe. The review has highlighted the importance of multi-agency working and will hopefully remind professionals working with young people to be aware that the pathways leading to harms that adolescents face are complex, not least because they often involve what appear to be adolescent choices and behaviours which can mask, rather than expose hidden vulnerabilities. 9. Summary of Learning Points: Learning Point 1: The connection between the past, present and the likelihood of future risk for children is about understanding the patterns of problems and needs in families that require something to change. Unless assessments are robust in exploring a child’s history, their needs may not be as well understood as they could be and this may leave some children vulnerable. This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 40 Learning Point 2: Where concerns about a child have been identified and statutory agencies are involved, any significant changes in education that could have an impact on a child’s immediate safety or long-term outcomes, should be formally scrutinised by safeguarding partners so that decisions can be taken about the need to re-evaluate any risks to the child and/or escalate concerns. Learning Point 3: Children’s plans should always include targets/objectives that are SMART, so work with families can be easily monitored and the effectiveness of key interventions and outcomes measured. Learning Point 4: Unless professionals are skilled in building relationships, being directive, supportive and non-judgemental in their work with parents, they are more likely to face resistance, ambivalence and disengagement and this is likely to limit the effectiveness of any family work. Learning Point 5: Unless the lack of secure accommodation is addressed nationally, children like Daniel with complex needs and behaviours will continue to fall through the gaps that exist between secure accommodation, regulated accommodation and detention under the mental health legislation. Learning Point 6: Early intervention to prevent or disrupt involvement in street gangs, offending behaviours and youth violence needs to involve skilled and trained facilitators to work with young people as part of their professional role. These professionals need to be well supported to develop specialised skills and the right mind-sets so they can develop relationships with young people that are able to withstand resistance and disengagement, but continue nevertheless to support effective change. Learning Point 7: There are critical moments in children’s lives when a decisive response is necessary to make a difference to their long terms outcomes. These ‘critical or reachable moments’ are likely to include, the point at which they are excluded from school, when they are arrested, when they are physically injured. There would be benefit in ensuring that services and systems are in place to ensure that these ‘key’ moments are anticipated and individual practitioners can step in and capitalise on the receptiveness of children at these times. Learning Point 8: Agencies need to be able to confidently share information in various ways across force and partnership areas so plans to protect children are based on up to date and relevant information. There is a need to ensure that the revised information-sharing agreement is fit for purpose and is working well, taking into account emerging challenges but remaining focused on the need to safeguarding and protect children and young people. 10. Recommendations Recommendation 1: (Learning Point 5) South Tees Safeguarding Partnership (STSCP) should urge the Department of Education to urgently to set out a strategy for how it intends to improve residential care for looked after children in England. This strategy needs to show how the DoE will ensure the adequacy of placements for children, to address the chronic shortage of placements, including those, which provide secure accommodation. STSCP should also press the DoE to respond to the recommendations regarding This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 41 residential care made recently by the National Audit Office; the Housing, Communities and Local Government Select Committee; the Public Accounts Committee and the Children’s Commissioner. Recommendation 2: (All Learning Points) STSCP should use the findings from this review to support the development of a multi-agency, strategy aimed at addressing the risks faced by vulnerable adolescents susceptible to abuse and exploitation in South Tees. STSCP should ensure that the strategy, whether it is named ‘Vulnerable Adolescents ‘or Adolescents at Risk’ should include: Partnership aspirations and overarching goals for effective and ongoing work with vulnerable adolescents A roadmap for how agencies across South Tees will work together to: prevent vulnerable adolescent abuse and exploitation identify vulnerable adolescent abuse and exploitation engage and support vulnerable adolescents disrupt vulnerable adolescent abuse and exploitation enforce/ prosecute vulnerable adolescent abuse and exploitation The means by which professionals will be supported to develop and refine specialised skills to build and maintain relationships with adolescents and especially with those for whom contact with statutory services is not working The process for ensuring there is improved connectivity between key multi- agency risk assessments, for example VPG, MAPPA and MARAC there are systems in place to ensure these are used to inform a child’s Pathway Plan Recommendation 3: (Learning Points 2) STSCP should explore, with key stakeholders, how schools and academies can be supported and challenged, but also held to account, by partner -agencies when there is evidence that school exclusions or non –attendance is placing, or would place, a vulnerable child at greater risk. Recommendation 4: (Learning Points 3) The use of tools, such as chronologies, varied assessments, children’s plans etc, to aid professional judgment and decision-making is well researched. The review team was of the view, however, that more could be done to educate and support practitioners know what tools are available, how best to use them and when, tools such as: better use of chronologies to support multi-agency decision-making assessments which purposefully explore early childhood experiences assessment tools which measure parental capacity to change (as opposed to quality of care) production of plans which include SMART targets so progress, or the lack of, can be measured This document is confidential to South Tees Safeguarding Children Partnership and must not be shared or copied without permission CSPR/Daniel/FINAL REPORT /MAY 2021/LR 42 Recommendation 5 (Learning Point 8) STSCP should seek assurance from partner agencies that the revised information-sharing protocol between police and key agencies is working well and that professionals in all agencies are kept well-informed and regularly updated as to what information can be shared, with whom and when. This is especially important when concerns about child criminal exploitation arise. Recommendation 6 Whilst, STSCP should seek assurance that the learning from this review will be widely disseminated by partners agencies, the partnership should also consider how it can be confident, and evidence, that learning from this and other similar reviews make a difference to professionals practice and contributes to improved outcomes for children, young people and their families. END/ |
NC047219 | Suicide of a 14-year-old Black British girl in the Summer of 2014 while living in foster care in Kent. Child J had a history of suspected emotional, physical, sexual abuse and neglect and complex mental health needs including suicide ideation, self harm and an eating disorder. Child J suffered acute and chronic bereavement after her mother's death from a long term illness and a series of other losses, including a breakdown in her relationship with her older half-brother and changes in foster carers. Child J was supported as a Child in Need before being looked after by the local authority when her family were unable to care for her. She also received adolescent acute and community mental health services. Issues for learning include: the significant impact of bereavement, transitions and loss on Child J; the need for J's history and the impact of her experiences to be taken into consideration in risk assessments and continuity of planning and treatment arrangements; the need for agencies to be clear about their understanding of the legal concept of parental responsibility and when young people can make decisions; care planning for looked after children in receipt of mental health services; the importance of Child J's diaries and whether practitioners had sufficient professional curiosity about their content and how this could have been raised with her; and social media and pro-anorexia or 'Pro-Ana' websites. Poses a series of questions for consideration by Lambeth Safeguarding Children Board based on the findings of the review.
| Title: Serious case review: Child J: overview report. LSCB: Lambeth Safeguarding Children Board with Islington and Kent LSCBs Author: Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Lambeth Safeguarding Children Board with Islington and Kent LSCBs Serious Case Review Child J Agreed February 2016 Following endorsement at a Joint LSCB in December 2015 Contents Page Statement by the Chair of Lambeth Safeguarding Children Board Introduction Executive Summary Key Lessons: Headlines Family details J’s profile Timeline and analysis of agency and multi-agency assessments and support J’s voice – including the diary, Facebook and issues of hindsight Family and Carers’ Voices Learning and Conclusions – including learning from the NHS Health Overview Report Appendices 1 2 4 5 11 12 13 48 48 54 70 Lambeth Safeguarding Children Board Olive Morris House, 18 Brixton Hill, Brixton, London SW2 1RD Statement by the Chair of Lambeth Safeguarding Children Board I welcome this report into the tragic death of this young person. The SCR was commissioned by my predecessor in conjunction with the Chairs of Islington, Kent, Southwark and Wandsworth Local Safeguarding Children Boards. We extend our condolences to J’s family, friends and carers and to those practitioners who worked closely with her to help and support her and who developed trusting relationships and affection for her. The purpose of an SCR is to seek to understand what happened and why it happened in the context of local safeguarding systems rather than solely the actions of individuals. It is to ensure that agencies are held accountable for their services and their systems and processes in safeguarding children and how they work together as a multi-disciplinary system. An SCR also aims to enable LSCBs, through a single case, to test the effectiveness of local and national safeguarding children procedures, protocols and working arrangements. Lessons from the review will be used to improve workers’ and agencies’ understanding of self-harm by young people and support improved co-ordination across mental health and social care services. This report was endorsed at a joint LSCB Meeting in December 2015. A separate Action Plan will be required by each LSCB in response to the questions raised by the Review. Lambeth LSCB will publish its Action Plan in early 2016 alongside the SCR. At the time of endorsing the SCR it is noted that the Inquest into J’s death has not yet been completed. Lambeth SCB will publish any learning from the Inquest alongside the SCR and the Action Plan. Paul Curran Independent Chair Lambeth Safeguarding Children Board February 2016 Page 2 Introduction J was 14 years old when she took her own life in the summer of 2014. At that time, she was looked after by Lambeth Children and Young People’s Services and had recently moved to live in a new foster home in Kent. Immediately prior to the move to the foster home J had spent four months as a voluntary in- patient in an adolescent psychiatric unit, as a result of a crisis in early 2014 when it was assessed that there was a high risk that she would seek to seriously harm herself or take her own life. The Lambeth Safeguarding Children Board (LSCB) convened a meeting of relevant agencies and recommended that in the circumstances of J’s death an SCR was required. The Independent Chair of Lambeth SCB endorsed this. The Terms of Reference were negotiated with other LSCBs which had an interest in the review. It was agreed to focus the review on agency and multi-agency assessments and interventions to support J and her family from the time of the referral as a child in need in November 2011, when J’s mother was dying, to July 2014 when J herself died. Agencies in undertaking their own Internal Management Reviews were asked also to review the background of J’s care up to October 2011 in order to understand her history, life experience and resilience. The key LSCBs were Lambeth, Kent and Islington, where J had lived; and Southwark and Wandsworth, where J was temporarily placed while in the care of Lambeth Council (Sec 20 Children Act 1989). Some health services had also been provided in Camden for her mother – but these had been commissioned as part of her residency in Islington. This report sets out a brief summary of priority lessons, describes the key phases of J’s life through a timeline and analyses the multi-disciplinary and single agency responses to J during these phases, as a child in need, and the challenges of working with a young person who has chronic and acute emotional health problems with developing suicidal ideation. Alongside the timeline a commentary is provided which also includes some lessons which derive from a specific event or issue and which do not necessarily form a part of the overall priority lessons. The key lessons and the thinking behind them are then discussed in more detail. The SCR Panel has raised some questions for LSCBs to think about in relation to the lessons and to consider in formulating an Action Plan. The analysis of the work undertaken to support J and her family and carers seeks to understand what the practitioners working alone or together at the time can have known, or could be reasonably expected to know, at the time that the decisions and actions for her care were taken. As part of this SCR, and in parallel, NHS England commissioned a Serious Incident Review, co-ordinated by the Lambeth Clinical Commissioning Group to cover all the health agencies which were involved. Its findings are included in this review. Information for the report was provided from a chronology of agency contacts with J and her family or between agencies by the key agencies involved. This was used to create the Timeline for analysis. Stakeholder agencies provided Independent Management Reviews (IMRs) describing and analysing their agency involvement and work in a systemic way. The Terms of Reference for those IMRs is included in the Appendices. A Serious Case Review Panel with two Independent Reviewers and representatives from the key agencies who had not been part of the service delivery or direct management of the case reviewed all the material. Where necessary the Panel sought clarification about information or actions. Page 3 When the priority lessons had been identified these were shared with the practitioners and immediate managers who had worked with j and who had been responsible for the case through a Practitioners’ Learning Workshop. This was to ensure that the Panel’s thinking reflected the practitioners’ experience, understood the context in which they were working, was proportionate and not over influenced by hindsight. Interviews with the two Independent Reviewers were held with J’s Aunt and J’s foster carers in order to understand their perspective. The attempt to contact J’s half-Brother was unsuccessful. These interviews and the Practitioners’ Learning Workshop enabled corrections and changes to be made to the final draft of the report and the correction of some misunderstandings or gaps. J’s Aunt also made some comments on seeing the final report as it was about to be published and it was agreed to amend some information and to include additional comments about her perspective. The Independent Reviewers would like to thank J’s Aunt, foster carers and the practitioners for taking part, sharing their views, and contributing to the learning in a non-defensive and helpful way. Bridget Griffin and Malcolm Ward Independent Reviewer and Independent Chair SCR Panel February 2016 Page 4 Executive Summary J had challenging experiences as a child in a family where there was a history of complex relationships and emotions, separations, parental mental and physical ill-health; and alleged abuse. She experienced acute loss (age 12) through the illness and death of her single-parent mother who was in hospital for six months, before being discharged home to die. J entered a period of acute and then chronic bereavement and further losses as she moved from care by one relative by running away to another relative; and then was accommodated by the local authority. Throughout the period from before her mother’s death to her time in foster care there was evidence in her writings of suicidal thinking, examples of these writings first became known to professionals after her Mother’s death. In January 2014 J was admitted as a voluntary patient to psychiatric hospital care in an adolescent unit, as a result of what was assessed to be active planning to take her own life. A few months later, when she was assessed to be safe to be discharged she transferred to a different long-term foster home outside London. These transitions from autumn 2011 to summer 2014 are characterised by moves across service-delivery boundaries, adding to the difficulty of meeting her emotional needs at a key stage in her development as an adolescent. She began to show increasing signs of pre-occupation with weight and eating control, self-harm, and suicidal ideation and suicide attempts. J’s Aunt sought help from services with these matters. J was of concern to universal agencies (schools and GPs) and specialist services as a child in need, a child in need of protection, and finally as a looked after child and as a child in need of specialised adolescent acute and community-based mental health services. Multi-disciplinary services co-ordination and case planning were essential to her support and care as a child with highly complex needs. This was complicated by moves across local authority and health provision boundaries. J was a seen as a bright, articulate and seemingly resilient child; at times appearing to cope, at times avoidant of help. She was able to express her thoughts and feelings clearly, but did not always choose to do so. At times she made statements which were not true and at times she deliberately masked her thinking and behaviours. At times J wrote down her thoughts in ‘diary’ notes. These were not in formal printed diaries and were initially sporadic; not all are dated. At times they were in books, such as a birthday book, or in notebooks or on single sheets of paper. J’s Aunt has stated that she shared the content of one of the books with practitioners in Islington and Lambeth; the writing pre-dated J’s mother’s death. Later some single pages of J’s writings were shared with staff in Lambeth. It was known that J used writing and drawing a lot and she was encouraged to do this. However, the full detail of the volume of writing, the content and the possible significance as an aid to understanding J was not known at the time. The concerns raised in the pages that were known about were not shared across services at the time, or over time as teams of workers changed. Nor were their contents considered as part of key mental health risk assessments or referred to specialists for consideration. Some practitioners were aware that J was writing in notebooks but felt that they could not look at these as a parent might because of her right to privacy. After her tragic death it came to light that J had committed a great deal of her thoughts, feelings, hopes and desperation to notebooks over many months, while she was experiencing acute emotional difficulties. J’s diaries have given this review what may be a unique hindsight into a young person’s thinking and voice, but which were not available to the practitioners who sought to help and protect her at the time. If the writings are an accurate reflection of J’s thoughts rather than fantasy they show a young person of extremely low self-esteem, feeling alone, rejected and unloved, pre-occupied with her body image and the need to lose weight; and experimenting more and more with suicidal thinking and behaviour. They also show what appears to be influence by specialist websites for people with pre-occupation with anorexia. It is not clear if J, herself, accessed such websites or whether she learned of these through peers, possibly in the adolescent in-patient unit. Page 5 A serious case review should avoid hindsight and seek to learn from what information was available and known or what could have been known to practitioners at the time that they made their assessments and plans. Some analysis and discussion of J’s diaries is included in this report as they raise important questions about helping young people who are troubled with thoughts about eating, weight loss, anorexia, self-harm and suicide for front line practitioners for whom these areas are less familiar. Key lessons: Headlines The sections in these headlines are discussed more fully in the body of the report. Bereavement, Transitions and Losses The eco-map in the appendix illustrates the number of losses experienced by J over 2 years and 7 months. Losses included in this map include losses of attachment figures or key people all-be-they a family member, a peer group, a carer, or a professional with whom J had a relationship; as can be seen these are significant. During this time J was entering adolescence, transitioning to secondary school, and moving home across administrative boundaries. The significance of these compounded losses and transitions were not held in mind by the multi-agency professional group at the time they were working with J, it was only when this review brought together the information that the significance of these losses and transitions was thought about. These were important factors that impacted both on the services that were provided and most importantly on J’s emotional world. It was the view of the Panel that this warranted greater thought and consideration in understanding J and planning for her needs; especially when that planning itself included further losses of significant relationships as she moved. Questions for Safeguarding Children Boards: How is attachment theory and how are transitions and losses understood by those agencies responsible for the assessment of a child’s needs across a range of service provision and how might improvements be realised? How can Boards work with all relevant agencies in order to improve transitional arrangements for children moving across geographic boundaries? What are the particular challenges and how might these be addressed? How does the system ensure that practitioners can hold these things in mind and translate them into practice? For Looked After Children how would foster carers be supported in understanding and supporting patterns of loss? Page 6 Assessments and Treatment (including risk assessments and continuity of planning and treatment arrangements) Over time it was established that J had a very ‘poor psycho-social history’, even in the early days of planning, this psycho-social history was recorded across agencies and professionals but did not appear to adequately feature in treatment or assessments. A picture of poor and ambivalent emotional attachments and possible emotional abuse and sexual abuse as a child even before her mother’s death. She was in grief and experiencing complex bereavement, the continued losses of significant people, including family, carer, friends and professionals after her mother’s death probably compounded this. However, J appeared as a bright, articulate and resilient child, possibly masking her emotional need; she was seen in the in-patient unit as guarded and intensively private not trusting staff and being more open until towards the end of her stay. In assessing the care and support arrangements for J it is not clear her history and the impact of her experiences were fully taken into consideration or the abilities required in those who may have to care for her. In a period of neglect after her Mother’s death this was not assessed as a child protection matter. Allegations of sexual abuse were not followed up, using the agreed procedures. When it was feared that J may self-harm or take her own life while in her first foster placement good risk assessments were undertaken and reviewed to mitigate against dangers of hanging, cutting or ingestion. For the second foster placement such written risk assessments of the environment were not put in place by the placing authority on the un-checked assumption that the independent fostering agency would do this. At the time of that transition from the in-patient unit to the second foster home it was understood by non- health professionals that the risk of suicide or self-harm had greatly diminished. It was known that some risk remained but the significance of this was not fully understood by the second foster carers. They had some experience of working with young people with mental health difficulties but this was beyond their experience. The risks should have been clearly spelled out and a check done to ensure that they were properly understood by carers and non-health workers. Discharge Planning from the Adolescent In-Patient Unit J was an in-patient in a specialist adolescent psychiatric unit for several months where she had intensive supervision and support and was at times, in the initial period, on close watch for self-harm. She appeared better on discharge but there was no smooth transition of treatment plans for her. She was moving from a total care and support environment to a new family, and to a different set of community services which had not been consulted about local provision and were not aware that she was transferring to their care or of the level of her need until some time after she had arrived. The agreed plan was that, until local community mental health services were in place in her new community, J would receive services from Lambeth mental health services after discharge from the in-patient unit. No direct service was offered. Non-health workers looked to the mental health specialists to guide them in seeking appropriate arrangements for J’s care and were re-assured that the risk of self-harm or suicide had lessened. For tier 3 community CAMHS and tier 4 inpatient CAMHS with knowledge of assessing suicide and self-harm J was not an unusual child in terms of the population of patients that they see. For non-health workers J was a complex and needy child and outside their usual experience. In communication between these two systems it is important to ensure that there is understanding in the use of language and perception, especially in relation to risk. Health workers must understand their responsibilities for ensuring that non-health workers and carers (or family) understand levels of risk and how they may Page 7 be mitigated. Where there has been risk but it is assessed to have gone or receded there must be a clear contingency plan put in place, to support the identification of any relapse. All agencies must understand the additional duties to support and safeguard looked after children. Understanding the legal concept of Parental Responsibility and when young people can make decisions At times there was confusion in understanding about J’s legal status after her Mother’s death, what the role and responsibility of a testamentary guardian1 is, the responsibility and rights of someone with parental responsibility, and whether J should be subject of a care order or not. J was thought to have been ‘Gillick’ competent based on her age but no assessment was done of her actual competency to make important decisions given her life-experience and vulnerability. The Children in Need processes or Looked After Children processes should have established these as early as possible. 1 A testamentary guardian is appointed by a parent, who holds parental responsibility, to assume parental responsibility for a child on that parent’s death. It is usually done through a will. It is governed by section 5 of the Children Act 1989. Questions for Safeguarding Children Boards: Relevant boards should ensure a clear understanding from commissioners and providers of mental health services (including CAMHS tier 3 & 4 provision) in relation to the range of therapeutic interventions for children with complex needs such as J’s in order to effectively plan for future provision. LSCBs should consider what generic training and support should be in place for practitioners and managers outside child and adolescent mental health services in understanding self-harm and suicidal ideation and behaviour in order to strengthen them in offering support to family and carers or workers in universal services. Questions for Safeguarding Children Boards: LSCBs should seek assurance that staff, including those in universal services, are aware of the legal aspects of parental responsibility and the significance of knowing who can make decisions for a child and when young people may be able to make decisions for themselves. Page 8 Care Planning (Child in Need, Looked After Reviews, Care Programme Approach & Multi-Disciplinary Work) J was a child who, by the very nature of being a Looked After Child within tier 3 and tier 4 mental health provision, was extremely vulnerable, with complex emotional social, physical and mental health needs. There was a need for all professionals to work together to share information and bring together multi-disciplinary expertise in order to plan for J whilst an inpatient, and in planning for her future care and discharge. The statutory processes that are in place were not robust enough and did not achieve successful co-ordination, and this mitigated against achieving an overall care planning approach that met J’s complex needs. Positive attempts were made to co-ordinate the two formal planning and review processes for Looked After Children and children in receipt of mental health services through the Care Programme Approach (CPA) – this review questions whether more should be done to bring these two systems closer together more formally and to ensure that professionals across disciplines have greater understanding of each other’s cultures and perspectives. A question has also been raised about the need for community based CAMHS psychiatry to be more directly involved with in-patient psychiatry as part of the CPA. Management Overview & Leadership J was a child with complex, Tier 4 mental health, needs who by the nature of her Looked After Child (LAC) status and her acute and chronic mental health needs, required the provision of a range of multi-agency services and specialist resources. This presented challenges both to the practitioners and carers working closely with J. Her needs resulted in the provision of expensive specialist resources. The SCR Panel expected that a child with such needs who presented such challenges to services would have been the subject of higher management scrutiny and monitoring and that practitioners would have received equally close supervision and reflective challenge. Initially the SCR Panel found evidence of reflective supervision, which it thought to be essential in this case, to be sketchy. However, feedback from practitioners and managers showed this to have been more robust and responsive. Some of the reflective supervisory thinking about J to support some of the frontline practitioners was undertaken within agencies rather than conjointly across agencies in a Team Around the Child Approach. A question arose about the reflective supervision for Independent Reviewing Officers how are the IROs supported in analysing and escalating complex cases which cross services? Questions for Safeguarding Children Boards: Relevant boards should review how care planning for a child who is LAC and an in-patient of a Tier 4 establishment can be achieved to ensure a joint multi-disciplinary approach where the child’s holistic needs both whilst an in-patient and when planning for discharge can be effectively realized; and examine how, in circumstances when there are gaps in discharge planning arrangements/transition, these concerns can be successfully escalated to senior management and resolved prior to discharge. It is recommended that a joint multi-disciplinary working group is established to progress and it is further recommended that the work of this group is shared more widely to enhance national learning on this issue. Page 9 J’s Diaries A question which the Panel has raised and believes is important for learning to prevent serious self-harm in future similar cases is whether J’s diaries became a place for J to rehearse and acclimatise herself to self-harming and suicidal thoughts. J appears to have become de-sensitized to normal psychologically healthy barriers to survive, which may have counter-acted thoughts to harm herself or take her own life. It is clear that J thought about ending her life on repeated occasions over a protracted period. The continual detailed mental pre-occupation about anorexia, self-harm and ending her life through her writing, without supportive challenge from carers or practitioners, appears to have psychologically prepared her for the final event. The Panel questioned whether more could have been done to work with J to help her share her diaries and her thinking. Not all staff were aware that J kept diaries or journals. Some staff did hold back from looking at them or discussing them with her for fear of breaching her rights. The Panel considered whether practitioners had sufficient professional curiosity about what J was writing and how this could have been raised with her. Consulting with J and establishing her views This lesson links to and further develops those above. Whilst J was consulted with about her views on a number of occasions, in respect to making key decisions about her care the ‘Gillick competency’ test was applied. Gillick competency applies only to the issue of young people being competent to make a decision, without parental consent, about medical treatment. It was the view of the Panel and the Lead Reviewers that the application of this as a blanket approach to Questions for Safeguarding Children Boards: LSCBs should be aware of what the current arrangements for supervision (reflective management) within agencies are; and what the joint-arrangements are when a child is receiving services across agencies? Are these the subject of regular quality assurance audit and challenge? Is reflective supervision currently being provided within agencies and how are outcomes being evaluated? Are current training programmes sufficiently promoting the knowledge base and skills of practitioners in understanding the impact of a child’s psychosocial history and in providing services to children with such complex needs? Are Agencies aware of which cases should be the subject of senior management scrutiny and review, and where needed, intervention in order to resolve any barriers to joint working? Questions for Safeguarding Children Boards: Given the learning in the case how will relevant Safeguarding Boards seek to address the importance of holding a child’s writings such as diaries in mind when working with children and young people such as J. Do current professional training programmes address how this might be done? Is there a need to issue specific guidance in this area/amend existing policy/procedure to reflect the importance of this issue? How can professional curiosity be encouraged in a way to engage and work in counselling young people? Page 10 assessing J’s ability to make informed decisions about her care was misleading. It was their view that J’s competency to give agreement was variable - as it depended both on the question being asked and J’s needs at that time. Overall, it was felt that undue weight was placed on J’s ‘Gillick competency’ and that there were times when decisions needed to be made by someone who acted with parental responsibility (as a ‘reasonable parent’ would) and, as a result, on occasions make decisions that did not concede to J’s wishes. It is clear in hindsight from her diaries that J’s competency to make important decisions was often compromised. Social Media/Internet Access From J’s diaries and from agency records it appears probable that J used the internet or was aware of the content of ‘Pro-Ana’ anorexia web sites; she also used Facebook. Information from J’s diaries and from agency records, some of which was known to those seeking to support her at the time, raises questions about how professionals understand young people’s use of social media and possible negative but powerful influences, such as the ‘Pro-Ana’ websites. Given local safeguarding children policies about safe use of the internet a question arises as to how J was being guided on the appropriate use of the web in order to help her make more informed sense of the information that she was accessing and in her safe use of social media sites. Questions for Safeguarding Children Boards: How widespread is the use of the ‘Gillick Competency Test’ used in relation to assessing a child’s ability to make informed decisions that have a fundamental impact on the care the child receives/how decisions are influenced/made? How will this be addressed so that the question of a child’s competency to make decisions is based on a solid understanding and appreciation of a child’s individual needs and informed capability? Could the assessment of capability used within the adult Mental Capacity Act be a useful way to inform LSCBs how this issue might be successfully addressed? Questions for Safeguarding Children Boards: What knowledge and training do staff in different services have about the use of the internet to access websites and their risks, and how are staff equipped in understanding the use of social media sites to inform assessments and to safeguard children from harm? How are LSCB e-safety policies and procedures being applied? Page 11 Family details Maternal Grandmother Maternal Grandfather Maternal J’s Aunt (1) Maternal J’s Aunt (2) DOB: June’58 DOB: Sept ‘65 Mother’s boyfriend Mother’s Partner Mother Mother’s Partner Father of J DOB: Sept ‘59 DOD: NOV ‘11 Father of Brother DOB: Jan ‘61 DOB: NK DOB: NK J J’s half Brother DOB: Sept ‘99 DOB: Oct ‘91 DOD: July 2014 Page 12 J’s profile Who was J? J was a Black British young woman of African Caribbean heritage, her mother was Black British and her father was thought to be Nigerian. She was born in north London and spent her early years at home with her older half-Brother in the care of their mother. When J was 12 months old the Mother and children moved to the Midlands, returning to north London a year later where the family remained for J’s childhood until her mother’s death. In her early years J attended a childminder and local nursery, and later a nearby primary and secondary school. Whilst at school J was observed to be a bright child who did well, in her first secondary school she exceeded expected grades, she was noticed to be an avid reader. From her diary entries, and from observations made by various professionals, it was clear that J was creative with a particular flair for, and enjoyment of, art and fashion design. She was noticed to take pride in her appearance and many of her drawings were of fashionable items of clothing and accessories. In November 2013, when J was thirteen, her diaries reveal her hopes for the future and show she had an interest in photography, in learning a musical instrument and attending Art College. She enjoyed a number of peer relationships with both boys and girls although appeared to have had no close long term friendships. J was articulate and was thought to be resilient, she engaged well in meetings and in conversations with professionals. However, those that knew her well also felt she was ‘closed’ and did not often reveal her inner world. She was reluctant to talk about her experiences in depth and although she attended various therapeutic sessions was reluctant to engage and was clear that she did not want bereavement counselling. At times she made statements about her experiences which were known to be untrue. J’s life and events, her family care and services provided to support her The Timeline presented below has been compiled from confidential chronologies provided by the agencies involved in J’s and her family’s support. They comprised universal services (health and education), local authority children in need and looked after children services, community child and adolescent mental health services, a hospital emergency service, police, in-patient adolescent mental health services and an independent fostering. The table concentrates and comments on the information that was available at the time to the agencies which provided the relevant services, or information that could have been available. The SCR Panel in reviewing J’s history analysed the information and identified key phases and transitions. Some general comments are made on J’s needs, assessment, support and intervention, use of procedures and available research and best practice. The most important over-arching lessons and themes are identified separately in the Learning and Conclusions section of the report. Page 13 Time Line J’s Journey Phase Event / Actions Implications and Analysis Phase 1 Background and early history J: Birth to 11 years Sept 1999 J’s Birth J born to in Islington, N London. It is understood her mother was a single parent. She had an older half-Brother. Later (for a few years) there was said to be a step-father. The Aunt said he was only a boyfriend. In late 2000 Mother was diagnosed with myasthenia The family history, reviewed in retrospect and hindsight from the point of J’s death suggests there was a problematic bonding and attachment between Mother and J, from an early age. A family history was taken by workers in the first core assessment. Early child hood and parental care April 2002 J 2 years 7 months Records document J’s mother struggling to meet the emotional needs of her two children when J was 2 years old. During a home visit the health visitor noted Mother presenting as “extremely stressed”, she had difficulty managing both children’s behaviour – particularly J, and was worried that she could not meet J’s emotional needs. There was concern that Mother was experiencing a “manic episode”, Agency records state that she was distressed by the break-up of her relationship with J’s father (but it was not reported if he had been resident in the home). It is J’s Aunt’s view that this is incorrect. An application was made for a nursery place for J, Mother was referred for counselling services and a referral was made to Children’s Social Care. The Health Visitor made an urgent referral to the GP for who saw Mother the following day. The GP referred Mother to a psychiatrist. Within weeks the psychiatric view was that Mother was more stable, she had placed J with a childminder 5 days per week and was appropriately responsive to J’s needs. Children’s Social Care undertook an assessment but decided that no services were needed. This brief psychiatric involvement, including medication, ended in summer 2002. Mother had clear mental health needs. History of maternal mental health difficulties from Mother’s own adolescence. The multi-agency response to the mental health episode in 2002 was appropriate by health visitor, GP, mental health services and social care. There was no clear picture of Mother’s partners – it is understood that she may have had three different partners – the fathers to her two children and a boyfriend - but this is not clear. J herself later made a historic allegation of sexual abuse by her mother’s boyfriend which would have taken place in this period. J also alleged later that in this period her Mother had told J to kill herself. Page 14 Phase Event / Actions Implications and Analysis 2003 – 2007 J 4 – 7 years Mother later described variable moods and depression throughout this period – see next entry. Little is known of J’s primary school years and her educational or social progress. Summer 2007 J Almost 7 years In summer 2007 Mother was re-referred to psychiatric services by the GP after concern by Mother’s employers about her health. Mother described variable moods, listlessness, and depression, thoughts of dying, periods of low energy and periods of energetic mood over the previous three to four years. This resulted in various possible diagnoses, including: manic depressive illness, hypomania, bi-polar disorder and cyclothymia. Mother reported symptoms worsening after the birth of J, and psychiatrists noted mother identified a clear link between her relationship with her own mother and her relationship with daughter, J. J’s Mother was described as angry with her mother and of “not having a relationship with her”. Mother later associated an increase in her own depressive symptoms when J reached 4 years old; which was the age Mother told professionals of having been separated from her mother and placed in (private) care. There is no record of J’s or her half-Brother’s needs being considered as part of the assessment of this episode. This memory is probably incorrect as Mother was placed in a residential nursery at six months. Her older sisters were in a neighbouring and linked children’s home and had regular contact with her. J’s Aunt believes this to have been a private arrangement made by their mother. It is possible that J’s Mother’s first ‘memories’ would be from the age of three or four years hence her association of this with J at three or four years. Towards the end of this period J was preparing to transfer to Secondary School - her Mother’s physical health was deteriorating. Phase 2 Recognition of J as a child in need, Early Assessment and Support J aged 11 years 10 months to -12 years April 2011 to early November 2011 Mother was diagnosed with pancreatic cancer and admitted to hospital in April. She transferred hospital for specialist care in the summer. Additional health concerns were myasthenia gravis, pernicious anaemia, asthma and hypertension. J visited her regularly in hospital. J and her half-Brother were The SCR Panel’s view was that this period was critical. It was an opportunity for Partner Agencies to come together, to share information and plan together for J’s needs. Page 15 Phase Event / Actions Implications and Analysis Mother’s illness, decline and death supported in the family home by relatives. J’s Aunt visited the Mother daily in the hospital, supported J in her visits to the hospital and after the Mother’s return to the family home. J transferred to secondary school in September. Mother returned home in October with support from family and the Palliative Care Team. The Palliative Care Team visited Mother at home, in order to complete an assessment to determine the services to be provided. A number of concerns were identified. These led to a referral to Children’s Social Care: Mother’s diagnosis of pancreatic cancer Differences of opinion between various family members about Mother’s needs and J and her half-Brother’s needs Concerns, expressed by relatives about the half-brother’s ability to care for J and concerns about J’s future guardianship. Mother’s relationship with J which was noted to be tense. Referrals to children’s services and to the GP for the half-Brother were appropriate and timely. 12 years 1 month A parallel letter was sent to the GP, from the Palliative Care Team, outlining the referral to Children’s Services and the need for J’s half-brother to be provided with counselling therapy/ bereavement support ‘particularly in taking on a caring role for J so soon after mother’s death’. The Palliative Care Team understood that Mother refused to allow J to be told of her impending death. The Palliative Care Team visited regularly Eight days after the initial visit by the Palliative Care Team Mother died at home. J was aware that her Mother was acutely ill but professionals believed that J was not told that her Mother was likely to die as her Mother did not want this. This prevented pro-active work to support J with her mother’s impending death. J’s Aunt’s view is that J was aware that her Mother was dying at the time and confirmed this after her Mother’s death. Page 16 Phase Event / Actions Implications and Analysis Phase 3 Recognition of J as a child in need, Early Assessment and Support J aged 11 years 10 months to -12 years November 2011 to May 2012 J’s school informed Children’s Social Care that J was posting messages on Facebook saying she was alone at home crying. The school worked sensitively with J to help share the news with other pupils about her mother’s death. A social worker discussed this with J on the phone and was re-assured that J was managing the loss. J returned to school (her new school) in late November. A social worker was appointed to support J and her half-Brother. J was recognised as a child in need and the primary task was to support the half- Brother in securing the tenancy to the Mother’s home and in claiming benefits. A Family Support Worker was appointed to assist with this alongside the social worker. Acute bereavement, loss, poverty – neglect In December a Children in Need Meeting summarised the recent history and noted that the half-Brother (18) – now J’s carer was ‘experiencing a lot of problems (financial)” and “seemed quite depressed”. Add: J’s Aunt has stated that she visited the home regularly throughout the period of the Mother’s illness and after her death. Visiting at least three times per week and often daily. She also cared for J in her own home in S London at weekends and in school holidays. A further Children in Need Meeting in mid-January identified as positive that J and her half-Brother had returned to live in the family home. However, basic furniture, an oven and household equipment was needed and it was “unclear how half-Brother will adapt to role of guardian and manage the care of J”. J’s Aunt has stated that J and her half-Brother never lived in his accommodation but both remained resident at the Mother’s There were a number of CIN meetings in this period. J’s emotional difficulties were becoming clearer, her eating difficulties were identified. “The amount of tasks which were undertaken during the core assessment prevented or distracted (the SW) from carrying out a detailed assessment of J’s needs” (Islington IMR) There were questions about the ability of J’s half-Brother to care for her and meet her needs; and there were concerns about the home environment. As the half-Brother did not claim the necessary benefits, they were living in poverty; there was a lack of food, warmth and a shortage of essential furniture and equipment in the home, including no oven and for a period only one bed. The half-Brother had some of these items but there were delays in arranging their transfer to the family home. The Core Assessment did not explore in depth whether the half-Brother had the capacity to take on the role of caring for J, as her guardian; “Tasks are completed efficiently by social workers but the wider question of the capacity of ** (J’s brother) to care for J is lost” (Islington IMR). It was questionable to leave some of the tasks to J’s half- Page 17 Phase Event / Actions Implications and Analysis address throughout her illness and death. It was noted in social care supervision in early April that the half-Brother was finding it hard to cope consistently, as a result it was planned to convene a Family Group Conference to see if any other family members might be able to Care for J. The referral for a Family Group Conference was made in early May; attempts to hold the Family Group Conference were unsuccessful as Family Members, except J’s Aunt, did not wish to attend. It was also noted in this supervision that it would have been punitive to use safeguarding / neglect procedures to tackle the apparent neglect and that moving from the half-Brother would be a further loss for J. It was noted that progress was slow. School referred J to the ‘Friendship Group’, a CAMHS support service in February. However, when J met with the psychologist from the Friendship Group in mid-May she declined to talk about her Mother’s death and the social worker agreed to refer J to a CAMHS Tier 3 service. J attended a number of Anxiety Group sessions run by CAMHS at the school, initially she engaged but then disengaged from these sessions. Later, after this period, it was alleged that the half-Brother may have been abusing J during this time; this was not alleged to or known by workers in this period. Nor has subsequent evidence been found to substantiate it. J herself later said to staff that her half-brother had not abused her. It was J’s Aunt’s view that J had later said that the half-Brother had looked at J oddly and made her feel uncomfortable. Brother who was not coping and at times reluctant to engage with the workers: “J’s basic needs were not being met”. When it became clear that the half-Brother lacked the capacity to care for J, the social work team did not look at alternatives. “(The SW) was tenacious in her attempts to contact him (half-Brother) …. However, in focusing on (half- Brother) and the urgency of the situation with regard to finances and accommodation, the full extent of J’s needs was overlooked…..These concerns were never put to (half-Brother) as they might have been if he were her parent. They were not considered at a strategy discussion where one might reasonably conclude that there may have been a possibility that she would be assessed as suffering significant harm. The involvement of mental health practitioners/services commenced. J was referred to CAMHS Tier 2 and accessed this support through school. This was the first time her mother’s death was formally raised by professionals with J (some 5 months after Mother’s death). J was reported as reluctant to talk about her mother’s death. She was later referred to Tier 3 CAMHS. Summary and Comment: There was a lack of focus on J herself in both phases 2 and 3 and on the cumulative effect of neglect of her emotional needs. “There was an assumption that she was in a supportive loving family with good attachments. However, J’s early life was without sufficient support and attachment and what was there fell away after the death of her mother. The thinking that her half-brother would be able to meet her needs was flawed. As a result, there was no one who truly understood J’s inner world and no one who tried to do this.” (Islington IMR). There was little direct therapeutic work with J - although she did have the Support Group at school, but its primary focus was not for work with young people with such complex emotional problems. It has been noted that minutes of CIN Meetings were not circulated. Page 18 Phase Event / Actions Implications and Analysis Phase 4 A period of transitions J aged 12 years (almost 13 years) Mid-June 2012 to end of August 2012 Late one evening J ran away to her Aunt in Lambeth following an argument with her half-Brother. J’s Aunt agreed to take her in. All the services required for J had to be re-assessed and re-initiated in south London. “The SW referred the case to Lambeth and carried out some excellent work …to ensure that J received the support services which had started to be put in place in Lambeth” (Islington IMR). Change of carer, home, transfer from Islington, disengaging with talking support, concern about J’s emotional well-being J told the support Group at school (Islington) that she was worried about having to move schools, but remained at the Islington school until the end of term. A few weeks later she was noted to be low in mood and disengaged and told the group that she was having flashbacks and stated: “someone might find out my secrets”. End of July Referral from Islington Children’s Social Care to Lambeth Children’s Social Care. The Core Assessment noted the history and J’s low self-esteem, “caused by her relationship with mother”, which was described as “temperamental”, and identified Mother speaking to J in an abusive manner. J was reported to be “crying all the time” and writing on Facebook saying she was alone. The half-Brother was described as not being emotionally available to J. The unstable caring arrangements were noted. The referral noted concerns about J’s emotional wellbeing, eating difficulties, low mood and challenging behaviour at school. Lambeth Children’s Social Care did not accept the case and so no services were offered. Islington Children’s Social Care closed the case in August as there was no further role for them. Islington also advised J’s Aunt where she should seek assistance in caring for J, if needed. J continued to be offered the support of the CAMHS Friendship Group at school. She was observed to be low in mood and starting to disengage from the group. She was worried about the impending change of schools. (J’s Aunt had not told J at that time that she may change school) The clinical appointment for a CAMHS Tier 3 service was made for the end of August in Islington, after she had already moved to south London. J did not attend the appointment with Islington CAMHS in late August. Islington CAMHS initiated the transfer of J’s case. The Islington referral and core assessment provided to Lambeth Social Care seen as part of this Review described the loss, that J’s half-Brother had not been managing well and that there had been financial problems. It was made because of concerns about whether the new arrangement with J’s Aunt was viable, given her previous reluctance to care for J. It raised concerns about J’s Aunt being able to manage J’s behaviour, which she found difficult at times. Questions were raised about J’s emotional stability and behaviour at school and J’s reluctance to accept therapeutic support. There were no safeguarding concerns and no mention of risk of self-harm. The key areas where it was thought that J needed continued support as a Child in Need were the possible unstable care arrangement and J’s emotional well-being. The referral was received by Lambeth but no services were offered, the reason for this is unclear: “The referral of J as a CIN with unstable care arrangements, recent loss and bereavement issues should have triggered an Initial Assessment ……..this would have been expected Page 19 Phase Event / Actions Implications and Analysis practice…there is no rationale recorded on the system as to why this did not meet the CIN threshold” (Lambeth IMR). clinical appointment for a CAMHS Tier 3 service was made for the end of August in Islington, after she had already moved to south London. J did not attend the appointment with Islington CAMHS in late August. Islington CAMHS initiated the transfer of J’s case. The Islington referral and core assessment provided to Lambeth Social Care seen as part of this Review described the loss, that J’s half-Brother had not been managing well and that there had been financial problems. It was made because of concerns about whether the new arrangement with J’s Aunt was viable, given her previous reluctance to care for J. It raised concerns about J’s Aunt being able to manage J’s behaviour, which she found difficult at times. Questions were raised about J’s emotional stability and behaviour at school and J’s reluctance to accept therapeutic support. There were no safeguarding concerns and no mention of risk of self-harm. The key areas where it was thought that J needed continued support as a Child in Need were the possible unstable care arrangement and J’s emotional well-being. The referral was received by Lambeth but no services were offered, the reason for this is unclear: “The referral of J as a CIN with unstable care arrangements, recent loss and bereavement issues should have triggered an Initial Assessment ……..this would have been expected practice…there is no rationale recorded on the system as to why this did not meet the CIN threshold” (Lambeth IMR). Summary and Comment on Phase 4: Despite J’s high level of needs there was no continuity of support or care. J had now lost her mother, her home and the professional support services with which she was familiar. Page 20 Phase Event / Actions Implications and Analysis Phase 5 CIN Assessment and Planning (Lambeth) J aged 13 years Sept 2012 to March 2013 Transfer from Islington to Lambeth CAMHS Disclosures of alleged historic & recent sexual and emotional abuse J’s Aunt enrolled J in a summer play scheme over the summer holidays so that she would meet local young people. J started at a new school in Lambeth In early September Islington CAMHS sent a summary to the GP, suggesting referral to CAMHS in Southwark. (This should have been Lambeth) In mid-September Islington CAMHS contacted J’s new school – J was reported to be on the waiting list to see a counsellor but consent was required from J’s Aunt to refer to Lambeth CAMHS. The same day Islington CAMHS contacted J’s Aunt by phone to gain consent to refer to Lambeth CAMHS – during that conversation J’s Aunt alleged to Islington CAMHS that: J was sexually abused by Mother’s ex-boyfriend J had described emotional abuse by her Mother including being given a plastic bag and told to put it over her head to kill herself. J’s half-Brother and J were observed to be on the same bed and half- Brother was masturbating next to J whilst she was sleeping. (J’s Aunt has said that she did not report that he was abusing J or that he was masturbating but that he should not have been on the bed with J and was behaving oddly. It was not clear that J was asleep. J designed a thank you card for her Aunt referring to saving J. J was reported to have described her half-Brother as viewing her in a sexual way and of being ‘emotionally unkind to her’. The SCR Panel’s view is that this is as an important phase as J was experiencing a number of transitions and her significant emotional needs were becoming clearer. Insufficient information about J was transferred from J’s school in N London to her new school, this was despite a wealth of information being held by the school and a considerable amount of work and commitment to J: “(There was) ….no transition planning with the receiving school. This is remarkable poor practice and would be likely to contribute to the vulnerability of a child moving to a new borough to a new school at a time in her life when she was bereaved and disadvantaged”. (Education IMR). The Islington School Nurse Service was informed of J’s needs a few days prior to her move (this was a 7-month delay). No handover with the School Nurse in Lambeth took place. During this period the following emerge: o Historic and recent allegations of sexual abuse o J’s level of emotional suffering/risk was clearer. Risk of suicide identified by CAMHS / Aunt had raised a number of concerns o J’s previous history becomes clearer, indicating early trauma: including possible child sexual abuse as a young child and emotional abuse. o The extent of self-harm was emerging. o J’ voice is noted but - she does not want to talk about her past as it is “too painful”. o J said that she felt like an “empty box”, “feels nothing”. Page 21 Phase Event / Actions Implications and Analysis Islington CAMHS advised J’s Aunt to contact Lambeth Social Care and also referred this to Lambeth Social Care by email the same day, recommending a police investigation. This was good practice Lambeth Core Assessment as a child in need started J’s Aunt rang Lambeth social care and left a message, Lambeth social care returned her call and left a message. Two days later J’s Aunt attended the Lambeth Social Care office and repeated her concerns. Lambeth Social Care noted the concerns and directed that a social worker should gather information and speak to J, no timescales were agreed. There was no Strategy Discussion or sharing of information with the police. J’s Aunt stated that she showed J’s birthday book, containing wishes to self-harm, to a Duty Worker in this meeting, but there is no record of this. One of the allegations of sexual abuse/sexually inappropriate behaviour towards J was recent: There should have been sharing of information with the Police Child Abuse Investigation Team in a strategy discussion to agree a section 47 enquiry and how J would be interviewed. “It would have been expected practice to initiate a Sc47 enquiry…. there is no rationale recorded as to why the procedures were not followed” (Lambeth IMR) Achieving Best Evidence procedures should have been considered. None of which happened and no consideration was given as to whether either of the two men alleged to have abused J may be a risk to other children. This was a failure to follow the agreed London Child Protection Procedures. First anniversary of Mother’s death Islington CAMHS referred J to Southwark CAMHS which decided to screen for psychosis and Post Traumatic Stress Disorder. However, J and her Aunt wished to be seen by Lambeth CAMHS not Southwark. A week after the allegation of sexual and emotional abuse a Lambeth social worker visited J and her Aunt at home. J repeated her allegations about sexual abuse. J’s Aunt queried why the half-Brother had been allowed to care for J. J’s Aunt gave social care the identifying details of the mother’s ex-boyfriend. J showed pictures she had drawn of her Mother depicted as a devil, of being inappropriately touched by mother’s ex-partner, J putting a plastic bag on her head (with her mother standing beside her smiling), of self-harm (cutting and pills), of how she wanted to kill herself, and of her mother’s funeral when J is smiling (she is happy that her mother has died). The social worker concluded that J had suffered significant harm in her mother’s care and was concerned “that she is withholding This was a second occasion in which consideration should have been given to gathering information with the police under a section 47 child abuse investigation, but it did not happen: “There was considerable delay in speaking to J and there is no reason given for this delay…. this would have impacted on J negatively as having disclosed she would need reassurance people were taking it seriously and the disclosures about **** (mother’s boyfriend) have been lost” (Lambeth IMR). Page 22 Phase Event / Actions Implications and Analysis all that may have happened to her”. A core assessment was recommended by the social worker and agreed by the Team Manager. Lambeth CAMHS involvement January 2013 Joint work CAMHS / children’s social care In November Islington CAMHS referred J to Lambeth CAMHS, noting a history of the death of J’s mother, “emotional and sexual abuse”, and “unusual experiences of having thoughts in her head that are not coming from her …. has described events that are not real and like a dream”. Lambeth CAMHS appointed a CACS co-ordinator, with a view to refer to a psychiatrist. J did not keep the first appointment, was seen at the end of November, but was reluctant to talk. Appointments were offered to J’s Aunt and J to complete an assessment. In a CAMHS session, in November 2012, involving the CAMHS CACS coordinator and J’s Aunt, reference was made to mother’s death, but J was said to report that she does not want to talk about her Mother’s death. In mid-January The CAMHS CACS Care Co-ordinator contacted the social worker who shared the history of maternal mental health and concerns about J’s Aunt’s current stress. J’s Aunt had described disagreements with J and J “not wanting to talk about the past as it is too painful”. J was described as “depressed sad/low in mood”. The need for a referral to psychiatrist is noted but no immediate psychiatric input or oversight is recorded. J made regular visits to see the CAMHS CACS Coordinator with her Aunt. However: “there was an incomplete CAMHS assessment and a Child and Adolescent Brief Risk Assessment which was also acknowledged as incomplete…. this resulted in unclear management plans throughout Child J’s contact with Lambeth CAMHS” (CAMHS IMR). J’s Aunt stated that she asked for bereavement counselling for J. J’s Aunt disagrees with this statement, saying that she was committed to J and wanted help for her. The first joint work in Lambeth – information sharing between Lambeth CAMHS and Lambeth children’s social care. Relationship between J and her Aunt deteriorating Lambeth Children’s social care noted that the relationship between J and her Aunt was deteriorating. The social care record noted that J’s Aunt described J as “unhappy/having thoughts of self-harming” “and has self-harmed in the past”. The record noted that J’s Aunt had stated that J kept a diary “that is full of negative thoughts”. J’s Aunt disagrees with this statement, saying that she was committed to J and wanted help for her. There was a delay in completion of the Core Assessment which was out of timescale. J was a child in need – there was not yet a clear assessment of her needs or how to respond to them. Page 23 Phase Event / Actions Implications and Analysis Decisions were made by social care: ‘to complete Core Assessment, the social worker to take J to CAMHS appointment, the possibility of a family group conference to be explored, case to be transferred to Family Support Social Work Team’. The alleged sexual abuse was not included in these decisions. There was increasing evidence that the family care arrangement was under great strain and was fragile. Complex grief reaction In mid- February in a joint meeting with the CAMHS worker and her social worker J said she was not going to share all her thoughts and feelings. She did raise concern about own mental health (hearing voices, talking about having psychic powers, seeing auras, feeling worried that she may have bi-polar or be schizophrenic).” Feels like an empty box, feels nothing, difficulties sleeping, low mood, self-harm, feels aggressive/angry towards others”. There were no reported manic or hypomanic episodes and no current evidence of intent or plans to self-harm. It was decided to discuss the concerns with a psychiatrist and consider a meeting with J, J’s Aunt, social worker, CAMHS Coordinator and the psychiatrist. The complexity of J’s emotional needs and the fragility of her situation were not being fully recognised by staff; compared to other children her needs were not seen to stand out. The alleged sexual abuse was not being dealt with and the ability of J’s Aunt to meet J’s complex emotional needs was questioned by social care but not discussed with J’s Aunt. J’s Aunt felt that the depth of her commitment to J was not fully taken into account. It is the view of the SCR Panel that J was suffering from a complex grief reaction to her mother’s death, coupled with possible early childhood trauma, J’s bereavement was not included in the treatment provided. Psychological input recommended At the end of February in a CAMHS review (J not present) A psychiatrist noted “2+ years of low mood worsening over the last year. Complicated grief reaction, irritability, mood swings, suicidal ideas and plans, impulsivity, and difficult interpersonal relationships. Low mood for most of each day over the previous two weeks. Occasional death wishes and suicidal plans”. Psychiatrist recommended: psychological treatment; but medication was not required at that time. J was seen by a psychiatrist in late February and towards the end of March. Whilst under the care of Lambeth CAMHS J reported perceptual disturbances such as hearing voices and seeing images for a number of years, alongside odd feelings. She also described occasional suicidal ideas or plans – but at the time of the psychiatric review she denied any thoughts of harming herself or ending her life. She did not meet the criteria for diagnosis of depressive or anxiety disorder, bipolar affective disorder or psychosis. February 2013 Throughout February both Children’s Social Care and CAMHS noted that J’s Aunt was struggling to care for J, J’s Aunt was anxious about her own complex and deteriorating health – a view was formed that Social Care noted: The relationship with J’s Aunt was deteriorating. J’s Aunt was associating her own poor and deteriorating physical health with J’s behaviour and it was thought that there may be some risk to J Page 24 Phase Event / Actions Implications and Analysis J may be at risk of physical harm. as a result of this. …. the response lacks some urgency Re: risk assessment, care planning/ contingency planning, given the possibility of imminent placement breakdown, ” (Lambeth IMR). J’s Aunt has stated to this review that she wanted more support for J as time went on and that she felt undermined in her caring role. She has stated categorically that the risk of physical harm to J was never raised by her or discussed with her. March 2013 J’s writings / diary entries In early March three separate pages of J’s writings/diary were scanned into the Children’s Social Care record – Lambeth Children’s Social Care chronology summarises them: “Nov 2012: J feeling unwanted, low self-esteem. (Dated the day before the anniversary of Mother’s death). Mid Feb 2013: feeling rejected by mother, hearing voices after mother’s death, physical abuse by mother in the past, seeing no point in living, unable to be happy. Not mattering to many people. J reported attempts to poison herself by inhaling fumes/drinking nail polish. Late Feb 2013: feeling unwanted, feeling there is no future”. It is not stated how or when these separate diary pages came into children’s social care’s possession, they are not referred to in the running case notes, but stored in a document storage section of the electronic record as scanned copies. There is no indication how their contents were used, the contents were later shared with CAMHS but advice was not sought through clinical supervision in relation to risk assessments. “The diary notes seen on 4/3/13 indicate how damaged J is and the level of risk to self……some of these entries re attempts to kill herself/self-harm are concerning and it is unclear how they were followed up” (Lambeth IMR). Staff who worked with J and her carers later were unaware of the existence of these writings. Phase 6 Planning for J as a child in care J aged 13 years March 2013 Breakdown of care arrangement with At the end of the first week of March it was agreed by Social Care that J should be accommodated (section 20 Children Act 1989); Social Care noted that J’s Aunt had said that she could no longer manage J. The search for a foster carer was started. J was looking forward to moving to a foster placement but had idealized expectations of her future placement. The family finding J’s Aunt has stated to this Review that J coming in to care was a shock to her, she disputes that she requested this. But she has said that it was possibly a time for J to make a fresh start and possibly be adopted and get away from her troubled feelings. She thought that J had an idealized view of foster care and that J’s wishing to be in care was not challenged. Page 25 Phase Event / Actions Implications and Analysis J’s Aunt Planning Sc20 Care referral noted a history of “moderate mental ill health” and recent self-harming. The need for planned placement/not an emergency placement, due to risk of feelings of rejection. A week later J met prospective carers and felt very positive about moving to them. However, the placement did not go ahead; the reasons were unclear. The Placement with J’s Aunt was becoming increasingly difficult. There was concern about J’s Aunt not being able to meet J’s needs and the possible impact of another change of carer on J’s emotional health. J’s Aunt said that she had felt rejected and undermined by J being taken into care and subsequently she stood back as she was hurt. This period of time offered an early opportunity to plan for J’s complex needs in care. J had a complex life story. The pieces/chapters needed to be held in mind to understand her needs and make effective plans. There were apparent aspects of resilience, although the notes from the diaries that were seen indicated that J’s inner world was characterised by thoughts of self-harm and suicidal ideation. It was not clear, given J’s history, that there had been an assessment of her ability to form and manage emotional attachments, such as those that a foster home may require. J had idealised expectations; careful placement planning needed to avoid future disruption (if possible) and offer security but this did not happen. CAMHS assessment The following week in a medical review at CAMHS. J’s was described as anxious and upset, although not meeting the criteria for major depression/anxiety. “J has clear idealised expectations of foster care which may pose hurdles and hurt”. J met her prospective carer and felt positive about moving to her. The incomplete assessments in CAMHS “…… resulted in unclear management plans throughout J’s contact with Lambeth CAMHS. In addition, gaps in assessment and formulation were not recognised or remedied. And so as J moved into LAC and then the private service her needs as an adolescent LAC with emotional and mental health vulnerability were not explicitly assessed and met in a coherent care plan.” (CAMHS IMR). Phase 7 J became a Looked After Child (CIC) Age 13 years and 6 months March – April 2013 J moved from her Aunt to foster care under section 20 Children Act in the third week of March J was noted to have felt rejected and hurt on moving from her Aunt although putting on an ‘upbeat face’. J’s Aunt said that she learned of the planned move by text and This period offered the next opportunity to plan for J’s complex needs as a child in care. There was confusion about the status and role of testamentary guardians. It seems that no formal care agreement was signed with the testamentary guardians. It is not clear why not, although this did not invalidate the care arrangement. It is unclear to the SCR Panel how J was matched to this carer and Page 26 Phase Event / Actions Implications and Analysis Planning change of key workers packed J’s belongings for the same evening. J did not say goodbye to her. She was also hurt by what had happened and how it had happened. The Aunt states that she was not asked to sign any papers and did not receive copies of care plans, reports or reviews for J. She felt that it was all taken out of her hands and that she was not kept informed. Although invited she did not go to the first LAC Review (or subsequent) as a result of the way she felt she had been treated. As a result of becoming looked after her CAMHS care was due to transfer to the Children Looked After Mental Health Service (CLAMHS). Her social work responsibility was also due to transfer to a different team. what planning took place to prepare J for the move, however this placement proved to meet her needs well. J J’s change of status from child in need to becoming a ‘looked after child’ meant that she would require a change of social worker (& supervisor) and from CAMHS to CLAHMS workers. The SCR Panel questioned whether these were systemic losses for a child who had already lost several key relationships. (See section on transitions and eco-map of losses). Looked After Review J’s first statutory Looked After Child Review was held in mid-April. An improvement in mood (although variable) was noted in the new foster placement (‘very happy and very sad’), “low self-worth, struggling with low mood for a long period of time, struggles with her identity and reported as pleased her mother died, reported variable relationship with peers at school”. Care Plan: legal team to be contacted to resolve issue of no-one acting with Parental Responsibility for J. It was expected that J would remain in care long term. J’s Aunt did not respond to requests to have face to face contact with J. She has stated that this was because she was feeling hurt and rejected. This period offered the next opportunity to plan for J’s complex needs as a child in care. There was confusion about the status and role of testamentary guardians. It seems that no formal care agreement was signed with the testamentary guardians. It is not clear why not, although this did not invalidate the care arrangement. It was being recognised that J had acute needs. J’s future care would require effective inter-agency partnerships; particularly between social care, foster care, CLAMHs and school. The IRO appropriately recommended legal advice should be sought with the view to initiating Care proceedings. The social worker recognised that J could seem resilient, but importantly noted that this may mask her internal world. This was a good observation by the SW but without a complete CAMHS assessment or input by a psychological/psychiatric it was difficult for the SW to conclude what J’s inner world was like. Page 27 Phase Event / Actions Implications and Analysis Phase 8 Transfer of services between services / teams J 13 years and 7 months April - May 2013 Looking after J in placement Towards the end of April, a month after J moved to the foster home, the foster carer reported concern about J’s emotional wellbeing, J was at times “very low” and “not seeing the point in living”. The carer requested counselling for J. She was advised to contact CAMHS. The social worker noted that the Foster Carer may need additional support in caring for J. The Carer was advised to continue to risk assess the environment to safeguard J. The Social worker informed CAMHS of the Carer’s concerns and requested support for the Carer. In these early weeks of placement, vital information was coming together to inform partners of J’s needs and future plans. There were significant concerns about J’s emotional wellbeing. There was good information sharing and a recognition that the Carer needed specialist advice and support to care for J. Risk Management A few days later the CAMHS worker advised the social worker of a conversation with the Carer about the Carer’s concern about J’s low mood, negativity, difficulty in functioning, and wanting to die. A Risk management plan for J in placement was agreed (including removing tablets, ligatures etc.) The CAMHS worker suggested J is “at high risk”. Discussion within CAMHS resulted in advice that “this is a pattern that is not inconsistent with previous episodes of low mood”. Close support was offered to the Carer and she was linked to a Mentor (Carer) and given numbers to contact her own social worker or other workers out of hours. The fostering service undertook detailed risk assessments and supported the Carer in securing items which J might use to harm herself by hanging, cutting or ingestion. This was good practice. Therapeutic Support At the beginning of May, the CYPS Core Assessment was concluded. It provided comprehensive information and noted J’s early years and poor attachments. The allegations of historic child sexual abuse were noted. Transfer of case from CAMHS to CLAMHS (Child Looked After Mental Health Service). Plan: ‘J to continue to receive art psychotherapy’. In these early weeks of placement, vital information was coming together to inform partners of J’s needs and future plans. There were significant concerns about J’s emotional wellbeing. There was good information sharing and a recognition that the Carer needed specialist advice and support to care for J. The risk of suicide was felt to be high, and some discussion with the carer took place in terms of risk management by CAMHS and by CSC (This was good). However, the CAMHS risk management plan was incomplete. Risks were discussed at an internal CAMHS meeting but it was advised that this current period of low mood was consistent with previous Page 28 Phase Event / Actions Implications and Analysis episodes of low mood: “her needs as an adolescent looked after child with emotional and mental health vulnerability were not explicitly assessed and met in a coherent care plan” (CAMHS IMR). It was not clear why there was no psychiatric input / advice to this case at this stage. It is noted that the CAMHS IMR identifies difficulty in the provision of psychiatric cover due to staffing gaps. Whist J engaged well with the art psychotherapy there is no evidence that any other therapeutic support was offered. The services provided were of a high standard but J had complex needs, she was regarded as high risk of suicide by those that knew her best (FC/SW/CAMHS). Overall, the service response to J by CAMHS did not appear to meet her needs May 2013 Referral to the Police of the alleged sexual abuse The Social Worker contacted the Police Child Abuse Investigation Team (CAIT) about one of the allegations of Child Sexual Abuse made against mother’s ex- partner (Previously recorded in entries in Sept 2012) CAIT advised that there was no role for CAIT “as no disclosure by J”. Advised contact with the safer neighbourhood team. Within days, following a decision in supervision the social worker talked direct to J about the allegations. J confirmed the details of her Aunt’s report and that she wanted to make a statement to police about her mother’s ex-boyfriend having sexually abused her, when she was a young child. This additional information was provided to the Police including details of the alleged abuser. The Police Child Abuse Investigation Team concluded that the allegation constituted a possible sexual offence but there was insufficient information to take the matter further. This referral to CAIT was eight months overdue: “There are no explanations for the reasons for the delay recorded on file or acknowledged by the manager, it is clearly out of timescales” (Lambeth IMR). The referral did not include the allegations against J’s half-Brother this was a significant omission. A discussion between the police and the SW took place. “This discussion did not meet the criterion set out in the London Child Protection Procedures and decision was reached that this was a single agency (CSC) matter. J was a Lambeth LAC and her allegation was one of sexual abuse therefore the police should have initiated and led a criminal investigation in parallel with an LCS(CSC) initiated and led Sec 47 Children Act 1989 enquiry.” (Police IMR). This did not happen. J was spoken to directly by the social worker, she said she had been affected by what had happened and was keen to make a statement, this was passed on to the police but this was not progressed by CAIT: “This was a lost chance to develop the limited disclosure made a referral. The decision to proceed by means of a single agency investigation directly impacted on J’s opportunity to make and evidential statement” (Police Page 29 Phase Event / Actions Implications and Analysis IMR). J was disappointed by this lack of progress of her allegations and the SCR Panel’s view was that the likely impact was that J felt she was not believed. There was no consideration as to whether either of the alleged perpetrator may have previously been or continued to be a risk to other children. The allegations against J’s half-Brother remained unknown to the police until after J’s death. J’s low mood By mid-May, eight weeks into the placement, the Carer was struggling to cope with J’s low mood and the impact on her own two children. The new CLAMHS worker met with the Carer’s supervising social worker and agreed to offer support to the Carer when needed. Looked After Child medical. J’s ongoing emotional and psychological problems noted. Case responsibility transferred to the LAC SW Team This was appropriate and shows good linking between the Carer’s support social worker and the CLAMHS worker although the treatment plan remains unclear and there was still no psychiatric input / oversight. This medical was robust and appropriate although health recommendations outlined in the IHA health plan were completed, this was not communicated to parties and there was a: “lack of formal assessment of risk of suicidal intent as part of the health assessment process” (Health IMR). A new social worker and supervisor were allocated. Phase 9 Early parenting of J by the Local Authority / partnership responsibilities J aged 13 years and 9 months Mid-June to Early July 2013 Awareness of suicidal thinking The Carer reported concern about J having suicidal thoughts. The School described J as exhibiting behaviour that is manic and irrational. CLAMHS advised attendance at Accident & Emergency for a mental health assessment. The Psychiatric assessment at A&E resulted in a diagnosis of depression (long term) and noted: “she was clearly depressed and had very little insight into triggers as well as what relieving factors are there to help and seems to be in a state of continuous helplessness”. The risk to self was concluded as moderate; medication/hospital admission possibly being required in the future. J’s risk of suicide heightened. Appropriate contact was made with the on duty A&E psychiatrist which dealt with the immediate risk. It is the view of the Lead Reviewers that this visit to yet another professional in an unfamiliar environment potentially could have been avoided if a community psychiatrist had been seeing J. The assessment completed by the on duty psychiatrist was of a high standard, clearly outlined J’s needs and how to manage risks at home and for the first a clear management plan is recorded on multi-agency files. There was a recommendation for J to be offered Cognitive Behavioural Therapy (CBT) Page 30 Phase Event / Actions Implications and Analysis J at high risk A 3 step management plan was given to J and the Carer. Art therapy was noted and Cognitive Behavioural Therapy (CBT) was recommended due to the severity and long standing nature of the depression, ongoing community management. On seeing this comment the Aunt stated that this is how J had been before coming into care. The Carer continued to report continuing difficulties in caring for J. CLAMHS placed J on ‘high risk’ case list and set up weekly appointments for J with the CLAMHS Care Coordinator. Over the next two weeks J attended these with her Carer. Supplementary information provided to this review states that the taking therapy subsequently undertaken by the CLAMHS Care Coordinator with J was within a framework of CBT; alongside group sessions for young people who hear voices, attendance at a local art project, and an offer of a referral to a bereavement project. “(There was) a view that J’s difficulties and risk factors were related to psychosocial stressors rather than mental health risk. (There was) a greater need to understand the impact of both on this young woman” (CAMHS IMR). Phase 10 Care Planning / Corporate and Partnership Support J aged 13 – 14 years July to November 2013 Long-term Care Planning The second Looked After Review was held in early July. The need to progress legal proceedings to gain a Care Order so that the Local Authority could hold Parental Responsibility was recommended (this had not progressed since the first LAC review) and the need for J to be seen by a psychiatrist in the community was also noted. The long term care plan was confirmed as long term fostering in the current placement. The recommendations to pursue care proceedings and for psychiatric overview whilst appropriate lacked follow up. The IRO engaged J well and sought to understand J and to establish her views. The involvement of the IRO service and the impact of the LAR process is detailed at the end of this report. Responding to risks The Art Therapist highlighted two additional areas of concern in regard to two incidents shared by J in the art therapy group, both related to J reporting that she may seek to harm others. In one J claimed to keep scissors for protection (alleging that she was ‘almost sexually assaulted on the street’ and managed to avert assault by holding the scissors to the man’s throat’). J’s school the school had no knowledge of incidents described by J. This information was shared with CLAMHS, this constituted good information sharing. However, these statements were not followed up/investigated. Good inter-agency communication. The GP received a letter from paediatrician requesting blood tests to explore J’s tiredness and to test for ‘haemoglobinopathies’, symptoms noted of myasthenia gravis and requests neurology These medical checks were progressed but the results were not communicated to professionals involved in J’s day to day Page 31 Phase Event / Actions Implications and Analysis Risk assessed as reduced referral, ophthalmology review, audiology check(tinnitus) and ENT assessment (recurrent nose bleeds). In early August J and her Carer attended two further appointments with the social worker and CLAMHS co-ordinator. J was noted to be brighter in mood, looking forward to the summer holidays and no concerns were identified. The risk assessment plan was reviewed and confirmed and the carer was advised to take J to A&E to see a psychiatrist if she was concerned. care. The foster carer engaged very well with CLAMHS and followed through on the advice she was provided. She showed ongoing commitment to J despite the obvious challenges. “It was unclear where the clinical senior oversight was in this case” (CAMHS IMR). Planning for J’s Long Term care Responding to allegations At a social work visit, J was advised of care proceedings and became visibly distressed about the thought of possibly having to return to the care of her family. She spoke about her low moods/difficulty in sleeping and mood swings, that she was unable to control. J was sorry for her Carer ‘who is finding J’s moods difficult’, and said; ‘on two occasions her Carer broke down and started crying because she did not know what to do about J’s low moods’. J continued to express the need for her previous allegations to be investigated. At the end of August J raised concern that an old friend was in contact with her mother’s ex-boyfriend and was concerned for her friend’s safety (she was also upset that her own allegations about sexual abuse had not been followed up). J’s disclosures still had not been the subject of investigation, this was now almost a year after she first made her allegations. This was significant for J. The SW followed up these statements with J but there was a confusion about the information held on file about the alleged perpetrator, and there was no further follow up. J reluctant to continue in therapeutic work Matching J to long term carers In early September J did not want to continue attending meetings with the CLAMHS Care Coordinator as she felt she did not have a good relationship with co-ordinator, and did not find sessions helpful. J was referred to the bereavement project, ‘voice collective group’, art project as alternatives. At the end of September, the Local Authority Placement Panel confirmed that a permanent long term foster placement should be sought for J. J was able to express her views about continuing to attend CAMHS however her views were not explored and so remained unheard “(There was) …no evidence of exploration with J about why she did not want to engage in one to one work” (CAMHS IMR). Attempts to identify an appropriate permanent placement and to match J to carers took place 6 months later. J was just 14 and it was important that some form of permanency was arranged for her – there had not been an assessment of J’s attachment and her ability to form emotional attachments within a family. Hence plans for J’s Page 32 Phase Event / Actions Implications and Analysis future remained unclear. Therapeutic support Low mood, fragile behaviour – stress on the Carer At the beginning of October J started the ‘Voice Collective Group (a therapy project)’. Over the next three weeks J spoke about how to manage her voices/coping strategies. In early October J’s bouts of low mood and fragility of behaviour are discussed with J and her Carer during a home visit; although overall the placement is reported to be going well. The significance of J possibly hearing voices was appropriately shared with CAMHS, but there remained no psychiatric overview. Information available suggested the foster carer was providing a good level of care to J and was committed to her. However, she was struggling with J’s care. J is aware of this and the inference that her behaviour impacted on adult’s health/wellbeing (her Mother had blamed her for this in the past). J’s legal status Legal advice was received that the Local Authority did not require Parental Responsibility as J was seen to be ‘Gillick competent’. It was suggested that J’s half-Brother and J’s Aunt should be asked ‘to renounce their Parental Responsibility’. It is not clear how this competency was assessed or whether it was based on age alone or whether her vulnerability and actions were taken into account. Gillick competency is not a relevant test to apply in these circumstances. The Looked After Review had made recommendations about care proceedings but this was not pursued, the reason is not clear. Poor food intake At the end of October beginning of November: There were concerns about J’s poor food intake and vomiting/gastroenteritis diagnosed at A&E (although there was some confusion over whether this was a physical illness or a symptom of J’s emotional difficulties). Family Group Conference and long term planning J was told by her social worker that family members had pulled out of a planned Family Group Conference (FGC) to explore if any member of the family could offer a home to J. (J’s Aunt has stated that she was unaware of this). The decision to proceed with a FGC was questionable. It is unclear why return to family care was being considered, it was assessed that J’s testamentary guardians were unable to meet her needs and the previous LAR had confirmed J’s care plan to be long term fostering. It is unclear why a FGC was being pursued. It does not appear that consideration was given to whether sharing this information with J would be harmful to her in compounding existing feelings of rejection/being unloved. Staff advised the Independent Reviewers that the advice they were given was that the FGC must be undertaken as a precursor to Care Proceedings as the Court would require this. Page 33 Phase Event / Actions Implications and Analysis The view taken here is that the Local Authority should have been prepared to demonstrate to the Court why this was not in J’s best interests, rather than slavishly follow procedure. In mid-November the Local Authority confirmed J’s care plan to be long term fostering. In the same meeting J’s social worker raised a question with J about her low food/liquid intake. J talked about wanting to lose weight. J showed the social worker her Facebook and pictures of her family. J asked about future placement plans. She spoke about the current placement being “boring” and requested a placement change. The social worker noted on file “I have the feeling that J’s cultural needs are not being fully met. J is a very creative young person and likes to be stimulated”. A previous review had confirmed the care plan to be long term fostering in the Care of FC1. The comments on file about the placement not matching her cultural needs/not providing sufficient stimulation were simplistic, this was a good placement where J’s most pressing needs in relation to stability and safety were being met. Response to therapeutic support The CLAMHS co-ordinator continued to meet the Carer and J, there were further concerns about J’s eating. In a meeting at the end of November J was seen to be low in mood and did not want to attend talking therapy as “no-one understands” and “she does not find this helpful”. This was the third time J expressed her views on her meetings with CLAMHS. “(There was) …no evidence of exploration with J about why she did not want to engage in one to one work” (CAMHS IMR). Phase 11 Planning for J’s care as a long term child in care J aged 14 years 3 months December2013 – early January 2014 Concerns about eating In early December J’s third Looked after Review took place. The possibility of J having an eating disorder was raised. A recent 3-day fast was described. J was also described as eating continuously and then making herself sick; she was described as “closed” and of recently feeling down. A possible referral to a psychiatrist recommended and care proceedings recommended. The recommendations to pursue with Care proceedings and for psychiatric overview whilst appropriate, lacked follow up. The IRO engaged J well and sought to understand J and to establish her views. The involvement of the IRO service and the impact of the LAR process is detailed at the end of this report. J’s family confirms that none of them can care for her J attended the Family Group Conference and heard her family members stating they could not look after her, although promises were made by some family members to have contact with her. Given that the plan has already been confirmed as long term fostering the value of this meeting is questionable and the impact on J hearing this in the FGC was not considered. It is the view of the Panel that this increased J’s sense of being alone. Page 34 Phase Event / Actions Implications and Analysis J’s Aunt described holding back as she felt inhibited by the circumstances and had had no indication that J may wish to return to her. Adoption is ruled out. Response to growing concerns In Art Therapy, J’s mood was very flat; she spoke about the need to lose weight/to exercise and spoke about “wanting to go up for adoption”. J discussed adoption with her social worker and she was told this was unlikely given her age. The CLAMHS coordinator continued to meet with J and her Carer up to Christmas and in one session focused on J’s eating. J “wants to be a size 6 and will not eat until she has achieved this”. The Carer expressed serious concerned about J’s low mood and J’s eating, the Carer was advised by CLAMHS “to take a step back”, as there were no immediate concerns about J’s health. Just before Christmas J avoided a meeting with the CLAMHS Coordinator as she did not want to talk. She was reported as being teased at school by peers as she had a crush on a girl. The art therapy provided was of a good quality it was consistent and J engaged well communication by the Art Therapist with the multi- agency group was excellent. J faced final rejection from her family and her hopes of a substitute family (through adoption) were challenged. The impact on J of these two issues coming together were not considered. The Designated Nurse for looked after children contacted the social worker concerned about the pattern of J “binge eating and starvation”. J spent Christmas Day with a cousin and family. A few days later J’s Carer reported J was eating more sensibly, contact with maternal family had been positive; and J was “in a better mood. J also spent New Year’s Eve night with wider family. Response to growing concerns At the end of the first week of January the Carer reported that J was “very low in mood”; she was concerned about J’s emotional welfare. The social worker spoke with J who ‘had nothing to live for, no family, and no friends and could not see past the day’. The social worker contacted CLAMHS for advice. Page 35 Phase Event / Actions Implications and Analysis The CLAMHS coordinator proposed to seek advice from the psychiatrist on “whether further intervention is required”. The school expressed concern about J’s behaviour and her low presentation, J was unable to make plans or see past the end of the day. CLAMHS informed the social worker that the risk was “not regarded as high enough to warrant urgent discussion with psychiatrist”. Discussion with a psychiatrist was planned for the following week. “There was poor team discussion on high risk cases”. Formulation and risk assessment plan remained incomplete and the lack of psychiatric overview and management in the community remained ongoing: “It was unclear where the clinical senior oversight was in this case” (CAMHS IMR). Phase 12 J’s first (known) active suicidal intention / behaviour and admission to in-Patient Unit J aged 14 years and 4 moths Early January 2014 The following day the Carer found J in her bedroom with the window open and dressing gown cord tied like a noose. J was taken by the Carer and social worker to A&E and was seen by the on duty psychiatrist. J was angry she had been found out. She confirmed she had been planning suicide for some time and had self-harmed by using the blade of a pencil sharpener. J spoke about having researched various methods of suicide, on the internet. She spoke of her plan to go out with her friends on the Saturday evening for dinner (“last supper”), before committing suicide. She spoke about a previous attempt in Feb ’13, and of self-harming in October ’13. She had feelings of hopelessness about the future and worthlessness, reported feeling secluded and cut off from her family. It was concluded that J was at high risk of suicide. She was admitted to a paediatric ward overnight, 1:1 supervision provided. The A&E psychiatric assessment noted deliberate self-harm from the age of 6/7 years, a history of emotional abuse and sexual abuse by mother’s boyfriend. J’s first (known) active suicidal intention/behaviour and admission to In- Patient Unit. This was the second time J was seen by a psychiatrist on an emergency basis, it is a good assessment and clear. “There was a poor handover from consultant psychiatrist to successor (Inpatient unit) and there was a confusion about responsibilities” (CAMHS IMR). J’s Aunt states that she was not informed until late evening of the concern. Page 36 Phase Event / Actions Implications and Analysis Clinical observation was “severe depressive episode with psychotic features, suicidal ideation, strong and ongoing (chronic background of severe abuse and traumas)”. Medication, CBT and group therapy recommended. Phase 13 J’s early weeks in the In-Patient Unit J aged 14 years and 4 moths Mid-January – Mid March 2014 Children’s social care agreed to retain the foster placement for six weeks, while J was in hospital On being informed that J was in hospital J’s Aunt indicated that she wished to exercise her role as Guardian; as a result, the Local Authority decided to initiate care proceedings. This was appropriate. This was appropriate (albeit delayed) The In-Patient Unit noted that J reported possible auditory and visual symptoms and likely symptoms of Post-Traumatic Stress Disorder. She also reported previous bulimic behaviour. She had previously had thoughts of drowning herself or taking overdoses. Initial presentation was severe depressive episode with psychotic feature, in addition strong suicidal ideation (chronic) – with no current urge - a background of severe abuse and traumas; and low self-worth. The aim of the admission was to clarify diagnosis; to manage current levels of risk; to stabilise her mental state and ensure appropriate follow up and community support. She was seen for individual therapy on a weekly basis. J thought that talking was pointless and planned to kill herself by any means possible. Safety measures were put in place. Page 37 Phase Event / Actions Implications and Analysis She was diagnosed with severe depressive episode without psychotic symptoms and Post-Traumatic Stress Disorder. J agreed to receive medication in discussion with the psychiatrist. At the end of January, it was noted that after a long period of low mood and suicidal thoughts, J’s mood had improved, J had started to talk of past traumas/flashbacks. She was not taking offered medication (to assist sleep) but was attending Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) sessions. The Care Programme Approach Meeting due at the end of January was cancelled (as the psychiatrist was on sick leave). It is not clear what alternative arrangements were for CPA Meetings in the absence of the Psychiatrist. February 2014 By mid- February J was engaging in therapy sessions, although engagement was noted to fluctuate. Her feelings were predominately of shame, guilt, anxiety and sadness. She was frequently observed to react negatively when her Foster Carer or J’s Aunt did not visit as frequently as she would like, although both maintained phone contact with J and visited J on the ward. Regular risk assessments were undertaken and J systematically attended ward rounds and weekly reviews with her key worker was prescribed medication for depression and mood disorder (to reduce her risk of impulsive behaviour). J did not engage well with therapeutic work offered. “There was no in-depth understanding of J’s history…and there was no attempt to undertake a full family assessment”. J was found to engage “only minimally in key work sessions and groups and was found to be “guarded throughout her admission” (Inpatient Unit IMR). J’s Aunt stated that she was unable to care for J long term and agreed to the Local Authority taking legal proceedings. J’s Aunt spoke of her own emotional health problems and of J’s mother “starving J, then force feeding her”- as reported by J. A ‘Looked after progress meeting’ took place in mid-February where it was confirmed that a Foster Placement would be sought for J. LAR progress meetings have no formal status or authority. Given that the decision was to look for an alternative foster placement, this constituted a change in care plan, procedures dictate that this should have led to a formal LAR. There were no minutes of this meeting and community CAMHS were not in attendance. This is not good practice. Page 38 Phase Event / Actions Implications and Analysis J’s Aunt stated that she was unable to care for J long term and agreed to the Local Authority taking legal proceedings. J’s Aunt spoke of her own emotional health problems and of J’s mother “starving J, then force feeding her”. The SW visited regularly, this was good practice. The Local Authority commenced seeking a new long term foster placement on the understanding from advice by the in-patient unit that this was the most appropriate form of care for J. March 2014 At the beginning of March J went on day leave to her Foster Home but returned in low mood feeling “unwanted”. When talking about a new foster family J was optimistic but also spoke about feeling that “she avoids getting attached to people as she predicts they will just leave”. Throughout March 2014: J’s mood was changeable on the ward, she spoke about wanting to kill herself and hearing ‘a voice’. Her relationship with food was variable; she had very low goals, she felt unwanted by her foster Carer (‘she thought she would be there until 18 years’). J was taking prescribed anti- depressant and sleeping medication. J’s mood temporarily improved after two male patients were admitted; she had emotional feelings for one of the young men. But her mood quickly deteriorated and attempts at self-harm were identified. Phase 14 Planning for J’s discharge from the In-Patient Unit to long term care 14 years 6 months Mid-March to Mid-May 2014 Children’s social care commenced the search for a suitable long term foster placement. J had requested to be placed “with a lesbian couple preferably with pets”. J was placed on red risk due to staff finding that J had attempted to drink cleaning fluid and staff had found a knife in J has lost another attachment with a significant adult (foster carer 1) and at this point no future placement has been identified. She had packed her belongings and these had been moved into storage. J was in limbo, the impact of this on J did not appear to be given the required attention. J’s Aunt stated that she was not informed about this. Page 39 Phase Event / Actions Implications and Analysis her room. March 2014 During March a Looked After Child Health Review Assessment (RHA) was completed. A number of the recommendations, from previous assessment were believed to be outstanding, including the CLAMHS assessment, blood tests, ophthalmology, neurology, and ENT appointment and dental reviews. This RHA identified that a significant number of recommendations from the HA a year previously were outstanding, as it was believed no action had been taken by GP/LAC Nurse/ LAC Doctor to progress. The recommendations were reassigned to the SW, this was inappropriate. In fact, the recommendations had been progressed by the GP, but there had been no communication about this with key professionals. Planning for J’s future At a second “LAR progress meeting” J’s recent self-harm of cutting and drinking shampoo was identified Scored ‘abnormal’ in all domains of emotional and behavioural development in Strengths and Development Questionnaire (SDQ). It noted that a careful discharge plan was required. The meeting noted that J was “sad that placement with her Carer was coming to an end” and noted “J does not want to go into residential care, insisted on placement with a single female carer”. J was noted on ward to be very sad and low, about the change of foster placement, showing anxious and volatile behaviour, “hiding in corners”, not attending DBT or CBT. The meeting noted the need for a careful discharge plan; this was appropriate. However, the meeting had no formal status or authority and it did not link with the CPA, this was a missed opportunity to achieve robust integrated planning. The decision to pursue another foster placement appears to have been taken in discussion with a number of professionals however there was a lack of sufficient consideration of J’s attachment profile/psychosocial history in making this decision: “No one professional sought to gain in depth information relating to child J’s early childhood experiences” (In-patient IMR). April 2014 Care Programme Approach Meeting at the beginning of April. J had very low self-esteem and depressive episodes. The Consultant felt that the current volatile behaviour was linked to anxieties about her future placement. Medication was not having an impact. Consultant was recorded as saying DBT may be of benefit in the future. J was reported as handing a note to nursing staff about “things they do not know about her past…the friend, the drug phase, the actions and the plans” (details unclear). J was reported as not feeling suicidal at present, but she continued to ‘disassociate’ when distressed. Later in April the social worker visited potential foster carers but – neither set was deemed suitable as a result of the needs of other children in placement. It is noted that medication was not having an impact and that J had not fully engaged with therapies offered. J’s current difficulties were being linked to social anxieties. The note J passed to staff was concerning, but was not the subject of further investigation. It is not clear how this competency was assessed or whether it was Page 40 Phase Event / Actions Implications and Analysis Final Legal Advice was that Care Proceedings were not required for J as she was “Gillick competent”. based on age alone or whether her vulnerability and actions were taken into account. Gillick competency is not a relevant test to apply in these circumstances. The LAR had made recommendations about care proceedings but this had not yet been achieved, as a result of the social worker’s workload. Planning for J’s future At the end of April, the Care Programme Approach Meeting noted J’s mood fluctuated. At times, she was tearful and angry; at other times, bright and engaging. There were periods of distress, making self-degrading comments about herself; she had been overheard planning to abscond. A risk management plan was put in place. J was no longer reporting feeling suicidal, she continued to disassociate when distressed, and appeared confused as to her whereabouts. She was said to be internalising her feelings. Medication was not effective. Going to visit a FC placement, confused about what she wants’. J was thought to be going through a dip due to high anxiety about a new placement, feelings of hopelessness and abandonment. J had spoken to staff ‘about being in a cult/gang, when she saw some horrible things and that they tried to make her jump in front of a train’. This was not the subject of curiosity or investigation Residential care was considered at the meeting but was felt to be a last resort, only if a foster placement could not be found. Residential care was felt ‘not to be ideal for J’ and that ‘any residential placement would need to ensure it met J’s emotional health needs’. J was noted to be have frequent phone contact with her half-Brother and her Aunt. Her Aunt also visited regularly, but a fraught relationship between J and her Aunt was noted by staff. The Aunt has stated that this was on one occasion only as J was cross with her for telling staff that J had been bullying other residents. J was told of the Foster placements which were not going ahead, The quality of professional discussion and decision making on this issue is questionable. The question about J’s attachment profile (her ability to form appropriate relationships and manage in a family) and the risks of a future family placement breakdown do not appear to have been considered. The primary issue at this point was the need to manage the risks in a placement. There does not appear to have been a discussion about a hierarchy of needs and there was no consideration about whether a secure order might be required. Page 41 Phase Event / Actions Implications and Analysis she appeared ‘visibly upset almost demoralised’, and then disengaged from communication. May 2014 Identification of new foster home and risk assessment At the beginning of May, a prospective independent foster home in Kent was visited by the social worker, only the foster father was at home. The following day the Independent Fostering agency confirmed that both Foster parents were agreeable to J’s placement. The Foster Agency noted the need for a thorough risk assessment given J’s history. This was appropriate but was not provided or, later, effectively chased / escalated. May 2014 In Mid-May the Ward Round noted J was anxious about the new placement. Her mood was changeable, she was ‘chaotic’, ingesting soap, dismissive when asked about feelings; had erratic eating (purging /binging); and had a dissociative episode in a CBT session (‘incoherent, speaks about seeing images of a group doing things to children and fears the group will come to get her. Feeling unwanted’). Her observation level was increased to every 30 minutes. Risk stated; ‘as in previous meetings’. At the same time The Social Care Supervisory Decisions were: care proceedings to be initiated. It was noted that there was no current contact with J’s Aunt or half-Brother. J’s Aunt says that this was not correct as she was visiting J two to three times per week at this time. Plans for J to be introduced to the Kent foster family were confirmed. Notes from The In-Patient Unit indicate that J was not responding to therapy, medication appeared to be the only consistent treatment. At this time, it was felt that the medication was not effective. Both the implications of this and the treatment plan were unclear. J’s worrying statements about seeing images were not the subject of curiosity or investigation. Risk assessment/discharge/ transfer of care/ consideration of alternative placements (such as secure/residential) were not discussed. There was no written risk assessment in relation to this overnight stay. J went to stay in the foster home for two nights. On return to the In-Patient Unit J told the staff that the ‘leave had gone really well’. The Fostering Agency requested a risk assessment from the In-Patient Unit and was advised that ‘a verbal (oral) risk assessment had been provided to the foster carers’. Whilst it is understood the Foster Mother was told of the risks she did not understand the seriousness of these risks and the risks were not sufficiently articulated in a risk management plan. The lack of a risk assessment was critical. It is unclear how decisions could be made, in relation to whether carers are able to keep J safe, Page 42 Phase Event / Actions Implications and Analysis A few days later the Ward round noted ‘Risk details as before….. J has told a peer she will kill herself on discharge…. No concerns from nursing team, observation every 30 mins. Nursing staff report mood fluctuation ‘from extremely low to excitable within a short space of time. J denied suicidal thoughts; has the appearance of anxiety but does not identify with this’. Two days later J went to the new foster placement in Kent, for a period of extended leave without this risk assessment. The significance of J informing a peer she will kill herself on discharge is noted in records held at the in-patient unit, this is not the subject of interrogation and does not impact on discharge planning. The statement of ‘risks as before’ is ambiguous: this is a critical time in planning for J’s safety on discharge. There was no viable risk assessment completed in relation to this extended leave. The In-Patent Unit requested that Lambeth CLAMHS referred J to the local CAMHS team in Kent, where J would be placed and J’s discharge from the In- Patient Unit was planned for six days later. Given that it was planned that J is to be discharged 6 days later, this request to transfer care back into the community was late, The Panel’s view is that Kent CAMHS should have been consulted as part of the planning as soon as the Kent foster home was identified, Kent CAMHS should have been invited to the planning meetings. It is also noted that Kent County Council was not consulted about this placement as it should have been. The In-Patient Unit was concerned that throughout J’s placement there had been no direct community psychiatrist involvement from Lambeth CAMHS. Phase 15 Transfer of J’s care to a new foster placement and community J 14 years and 8 – 10 months End of May to July 2014 J is discharged J returned to the In-Patient Unit for the Care Programme Approach Meeting which was also the discharge meeting and was discharged to the new foster placement the same day. The Unit noted: J has not self-harmed for several weeks. Been quite guarded since admission and not wanted to talk about her previous traumatic experiences, therefore this is still a need for this to be addressed in the community. This was a critical period involving the transfer of care/risk into the community and the transfer of day to day care to new carers/new agency: “At no time either at admission or discharge was there a consultant psychiatrist psychiatric discussion/liaison” (In-patient IMR). Although towards the end of her stay in the in-patient unit J was thought to be more trusting of staff she had not fully engaged in therapy to address underlying trauma. This coupled with a previous Page 43 Phase Event / Actions Implications and Analysis The Plan was for the Foster Carers to contact CAMHS if concerned. Early warning signs /relapse indicators discussed were discussed with the Foster Mother (Foster Father did not attend the discharge meeting) but were not put in writing. entry stating that medication was no longer effective suggests that J was being discharged with no effective treatment in place to address her long standing depression and no follow up secured. No check had been done that the Kent CAMHS had been notified of J’s placement or needs or the risk. This was contrary to NICE Guidance on transfer of cases. It would have been good practice for the Kent CAMHS to have been invited to and attended the CPA Meeting. This was not appropriate – the risk assessment and actions to be taken should have been put in writing in a risk assessment (such as the one used with the first foster carer) and a check that the Carer/s fully understood what was being asked. No written plan or actions were passed to the Fostering Agency. There was no contingency or relapse plan in place. Although the Carers had some previous experience of young people with emotional health issues it was not clear that they had experience of this kind of behaviour or understood what to look out for or how to handle J’s moods or behaviour. They did not understand that there was still a risk of suicidal behaviour. J’s early days of placement and transfer of care and services The Lambeth Social worker visited the following day. The Foster Carer said the move had gone well; she noticed days when J’s mood had been low, relationships with the other foster children were noted to be good. J was on anti- depressant and anti-anxiety medication and reported as compliant with taking medication. J requested her belongings, which were in storage, from the previous foster home. The social worker understood that Kent CAMHS had been notified of J’s placement although application for funding from Lambeth CLAMHS to Kent CAMHS had not been made and still required progression before treatment in the community could start. It was good practice for the SW to visit so soon. J had been placed with no local CAMHS provision, no school place and inadequate risk assessment/risk management plans. “There was an unreasonable delay in making a referral to (the local) CAMHS and barriers to the referral were not escalated through senior clinical management lines…. her needs as an adolescent Looked after child with emotional and mental health vulnerability were not explicitly assessed in a coherent care plan” (CAMHS IMR). “The foster family had no direct experience or training that covered working with inpatient mental health services or in caring for young people who had a recent history of depression/suicidal ideation and Page 44 Phase Event / Actions Implications and Analysis self- harm. This should have prompted a greater degree of support and guidance” (Fostering agency IMR). There was an assumption in this IMR that this guidance should have been provided through the in-patient unit, this did not happen and the support provided to the foster carers by the fostering agency was inadequate. There should have been a follow up visit by the ‘host’ CAMHS to J 7 days after discharge, this did not happen and was unacceptable. First week of June The Foster Mother registered J with the GP immediately and went, without J, after a few days to ask for repeat medication as J had been discharged with only 5 days’ medication. She handed over a handwritten pro-forma discharge note from the In-Patient Unit, which had minimal information. The GP gave two weeks’ medicine and insisted on seeing J before prescribing more. This was good practice The In-Patient Unit Care Programme Approach Review/Discharge planning notes (from the meeting at the end of May) were faxed to the social worker a week later. They reported ‘J brighter in mood since new placement found, engagement in groups superficial since admission, not discussed previous traumatic experiences, needs community follow up support, had suicidal thoughts previous week but did not act on these. Unclear if improvements due to medication or environmental factors. Contingency plan: warning signs noted. Particular risks identified as self-harm suicide ligatures self-neglect (restricting diet/purging)’. The Social Care Deputy Practice Manager visited the placement and observed the placement to be ‘going well’. Social work supervision – noted that the referral to Kent CAMHS should be completed by the end of June; J was noted to be settling well. This delay was not acceptable and the risk management plan was insufficient in managing the risks and in guiding the foster carers. Practitioners in Kent were being asked to take important clinical decisions without sufficient background or a true understanding of risk. There was too much reliance on the foster carers to hold the risk. The absence of a robust risk management plan was not identified and the lack of continuity of mental health services was not recognised as a potential area of concern. Mid-June 2014 The Foster Mother returned with J to the GP. J’s recent in-patient care was noted, she was reported as settling in well after two The GP acted appropriately and supportively – but the 6-day delay in faxing the referral to Kent CAMHS was not acceptable. However, it Page 45 Phase Event / Actions Implications and Analysis weeks and to be taking her medication regularly. The GP noted a positive relationship between the Foster Carer and J. No concerns were reported, although occasional bingeing and fasting were mentioned. J was chatty and seen to be open. She reported no suicidal ideation or self-harm since the move to the foster home. The GP agreed to follow up the referral to Kent CAMHS (although this was not in fact done until six days later). He offered ‘open door’ to return for support if necessary. was not the GP’s responsibility to make this referral as the GP did not have all the required information. Mid-June 2014 Three days later the social worker visited the placement and noted that the placement was going well. The need for a school place was identified, the local school had said the Local Authority (Lambeth) needed to complete the application for a school place. It was noted that there was currently no support social worker from the Fostering Agency. The same day the LAC Review was held and noted: ‘J remains concerned about body image. Settled in well, and relates appropriately in the household’, noted not to be in school, ‘appeared happy in placement’. The Health needs previously identified by Designated Nurse for Looked After Children was not discussed. The Care plan recommended was: ‘J to remain in LA care under Sc31 at current placement’, care proceedings recommended. Diagnosis of clinical depression noted. ‘CLAMHS to start work with J on 31/7/14’. It was noted that no placement agreement was in existence as meeting has not been held. J had been in Kent for three weeks and was not in school. A school placement would have added additional support, structure and safeguarding for her. The LAR was again recommending Care proceedings, this has been repeated from J’s first review, contrary to the IRO regulations there has been no escalation of this delay to senior managers. Despite the previous meeting stating the need for robust discharge planning, the absence of such planning was not the subject if escalation by the IRO. The sense of urgency of a young person being discharged from four months as a psychiatric in-patient was lost. This referral was urgent and should have been given much higher priority, there was an 8-day delay in sending the appointment letter. The SCR Panel’s view is that the referral to Kent CAMHS should have been completed before J’s discharge from the In-Patient Unit and Kent CAMHS should have been invited to the discharge meeting. Part of the reason for the delay was awaiting receipt of discharge reports from the In-Patient Unit and consulting with J. These delays were unacceptable. In mid-June Kent CAMHS received the referral letter from GP and screened the request as a non-urgent referral. Three days later they accepted the referral and offered a routine appointment. In the third week of June the Fostering Agency visited to support Page 46 Phase Event / Actions Implications and Analysis the Carers and noted that a risk assessment had still not been completed. The same day the Local Authority social worker and Fostering Agency met to complete the Placement Agreement. It was noted that it ‘should have taken place prior to Looked After Review to determine delegated authority and remit of placement’. It was also noted that a new Agency Supervising social worker had not yet been allocated. The Local Authority social worker was to visit every 4 weeks. The purpose of Placement Planning meetings is to identify the needs of the child and the action that needs to be taken, in the immediate future, about these needs by carers, support workers and others. These delays were unacceptable and compounded the lack of support/ guidance provided to these carers. The Agency should have escalated the issue of the lack of a written risk assessment. The gap and change in support workers possibly impacted on this. Delay in local CAMHS support Four weeks after the start of the placement the Lambeth social worker received the CLAMHS referral from Lambeth to the Kent CLAMHS with the required history, discharge summary and documentation and forwarded it the same day. The CLAMHS Co-ordinator had first contacted Kent CAMHS before J left the In-Patient Unit. Kent CAMHS provided a referral form and requested details of the GP and a discharge summary from the in- patient unit. The day after J’s [permanent move to Kent Lambeth CLAMHS asked the Lambeth CCG Commissioner to ensure that funding would be provided for J as a non-Kent child. The required information was emailed in the last week of June but not accepted by email – hence it was sent by the social worker by fax. July 2014 At the beginning of July, the Fostering Agency visited the Carers. This delay in providing routine support to the foster carers was not acceptable. Mid-July 2014 A few days before her death J telephoned her first foster carer in the evening. During the conversation J said that everything was ‘fine’. She thanked the carer for looking after her and said ‘if not for you I would not be alive’. The Aunt reported that J had also said this to her. The day before J’s death The newly appointed independent fostering agency supervising social worker visited J and the Carers in order to support them. The Lambeth social worker visited the same day. J was seen to be in a positive mood and talking about her future education. It was learned after J’s death from J’s Aunt that on this same day there was a telephone conversation between J and her Aunt in the This is hindsight and was not known until after J’s death. Page 47 Phase Event / Actions Implications and Analysis late afternoon, they had spoken for an hour. J had been animated, was positive about visiting her new school that day, there was nothing in the conversation that suggested that J was planning to take her life. J offered to send her Aunt a wool or rag doll that she had made or to send her rock candy, but J’s Aunt declined this. That evening the Foster Carers went out for the evening for a family celebration leaving their adult daughter (an approved carer) to care for J and the younger foster children. It is understood there was a minor disagreement between J and the adult in the household. J’s death The following day J was found in the early afternoon, hanging by a belt from a pole which was fixed into her bedroom wall as a clothing rail. Resuscitation was not attempted; it was concluded J has been dead for some time. She was not discovered earlier as her Carer was allowing her to sleep in. The risk assessment had not identified the risk of hanging, hence the presence of a fixed solid clothing rail (a scaffold pole) in J’s bedroom had not been identified as a risk. It remains unclear whether J had been taking her prescribed medication. Page 48 J’s Voice J’s diaries After J died her diaries were discovered. During the course of this Serious Case Review these diaries were made available to the Lead Reviewers. The diaries that have been seen start in September 2012, and end just before J died in July 2014. An earlier diary was made available to the Independent Reviewers by J’s Aunt which has entries which pre-date J’s Mother’s death. There are references to J’s ‘dairies’ in agency records. J’s Aunt gave J a number of large notebooks to use as diaries in which to write down her thoughts. J’s first foster carer was aware that J was writing in a ‘notebook’. J’s Aunt and the first foster carer expressed concern about the content. Staff at the In-Patient Unit were also aware that J wrote in notebooks and also encouraged her to keep a diary – although the Review has been advised that the books recovered after J’s death were not part of any therapeutic work at the Unit. The full significance of these diaries was only fully realised after J’s death. The pages reveal neatly written accounts of J’s inner world and include many sketches, lyrics from songs or lines from poems. They provide a moving account of a child’s inner world, a world that was increasingly marked by hopes and struggles of finding love; and meticulous recordings detailing food and fluid intake, plans of weight loss, and relentless self-denigration. On many occasions J clearly stated that she wanted to be anorexic, and there are a number of references to ‘Pro-Ana’ (assumed to be Pro- Anorexic websites - see below). There are many references to suicidal ideation, and to self-harm. Whist J was living with her foster carer (foster carer 1) in Lambeth these references are not significant but it is acknowledged that not all diaries covering this period were available to the Lead Reviewers. The entries relating to anorexia ‘Pro Ana’ and self-harm increase in intensity over her period as an in-patient. Whilst in her foster placement in Kent (foster carers 2) J’s diary entries reveal that her thoughts of self-harm and suicide were ongoing. Family and Carers’ Views J’s Aunt and half-Brother and her Foster Carers were invited to meet the Independent Reviewers to share their perspectives on the support that J was offered and that they were offered to assist them in caring for J. The invitation to the half-Brother was returned from the address where he had been living and he was not seen. The summaries provided here are taken at face value. J’s Aunt was seen with a friend who also knew J. The Carers were seen with their support social workers. Page 49 J’s Aunt J’s Aunt described a background where she and J’s Mother had grown up in ‘private’ care themselves as children, resulting in complex family dynamics. Until her Mother’s illness and death J had been more distant from the wider family in south London. J’s Aunt became more involved when J’s Mother was dying. She had been unaware that she was to be designated as Guardian alongside J’s half-Brother. She was not advised of the legal implications of this or of the responsibilities and rights it involved in carrying Parental Responsibility. She thought that she had 50% guardianship only and she remained unclear about her status as a testamentary guardian until she met with the lead reviewers as part of this review. J’s Aunt described being fully involved on a daily basis when her sister, J’s Mother, went into hospital in April 2011. She visited the hospital daily and then called in each evening to check on the well-being of J and her half-Brother, returning on the night bus to south London in the early hours. She told the lead reviewers that she did not initially want to care for J after J’s Mother’s death as she had observed J’s behaviour which was difficult; but she but supported J and her brother by visiting them frequently to offer practical support and provide resources. She had J to stay with her in south London for weekends and half-term. She was aware that J’s half- Brother was finding it hard to cope and although she attended child in need meetings she did not understand the plans of the school or children’s social care, she felt excluded and like an onlooker at the meetings that she attended. She had sight of some diary entries that pre-dated J’s Mother’s death which were worrying and contained suicidal thoughts. She said that she passed this to the social worker at a meeting at the school (Islington social care has no record of this but states that J’s Aunt told them of the concerns). When J was living with her she gave J some notebooks to write down her thoughts and J would sometimes leave them open for her to see, J also gave her notes or hand-made cards; examples were to apologise to or thank her Aunt. When J ran away to her Aunt’s home J’s Aunt took her in, but she was not sure if she would be able to cope with J’s behaviour. However, she made a bedroom for J and supported her in moving to a school nearer to her home, and communicated with the school about J’s background and circumstances. She spoke about outings they would have together and how her adult sons and their families would occasionally entertain J for the day, weekends and half-terms. J’s Aunt had no financial support for J for the first few months whilst she was living in her care. When the lead reviewers asked whether J would accept affection she replied saying J could accept cuddles or would want to hold her Aunt’s hand at times; but she would often regress and J was often clingy and anxious when they were out of the home together. Increasingly J would also ‘explode’ at home and her J Aunt would talk with her. J was self-denigratory, describing herself as ugly, saying she wished to be dead and that no-one loved her; she described her mother as evil and of abusing her. J’s Aunt encouraged her to talk but the explosions continued from time to time – occasionally J would ‘glaze over’ and when asked what the matter was would say ‘nothing’. J would often write things down on sheets of paper or in books and leave them out for her Aunt to read. J’s Aunt continued to be worried about what J wrote and about J’s behaviour, on one particularly memorable occasion she recalled that one morning, the day after a CAMHS session, she asked J if there was anything wrong; J spoke about trying to kill her Mother with bleach, and being glad that her Mother was dead, wishing that she was herself dead, and saying that she hated her Aunt and would kill herself - before running out of the house. J’s Aunt sought help from Lambeth social care duty service that day by going in to the office. She said that she showed a manager J’s diary; J’s Aunt was concerned about what J was writing, she was worried that J would harm herself or kill herself or would run away. Page 50 J’s Aunt felt that when the social worker started working with J, J started to shut her Aunt out; and that J wishing to go into foster care came from the conversations between the social worker and J. J’s Aunt had not wanted J to be accommodated but it seemed J increasingly wanted this and so her behaviour became more difficult, making it harder for J’s Auntie to manage. She had not wanted J to be accommodated and so did not co- operate with the family finding and described being hurt that J was going in to foster care. She said she learned about the planned move to the foster home by text, which made her angry. When J moved - there were no goodbyes. Thereafter, she remembered being invited to the first Looked After Review meeting but not to subsequent meetings. She said she felt shut off, ‘left high and dry’, treated as if she was a ‘criminal’, and was angry about this. There was no contact between J’s Aunt and J whilst J was in foster placement 1; she thought that J would contact her when she was ready. She attended meetings at the In-Patient Unit and visited J regularly but felt that J had put barriers up to people and the staff could not push past those barriers. ‘J shut down and would have none of it.’ In her view Staff would deal with the new issues and current behaviour but did not seem to get to the underlying problems. J’s Aunt did not feel that she could say that she would take J back as J had not asked to go back to her. She did not feel as if she was being consulted, she had to remind staff that she had ‘part-guardianship’. She was concerned that J was to be placed in the country away from London on discharge but felt re-assured that the foster carers had previous specialist experience in dealing with mental health problems. She had no face to face contact with J after J moved to Kent, support for this was being arranged, but she did have phone contact with J. The day before J’s death she rang J. J talked about wanting to buy some turquoise steps that she had seen for her room and a scarf. J wanted her Aunt to have some knitted toys that J had made or some rock candy. In retrospect J’s Aunt wondered if J was bequeathing her things. Foster Carer 1 J’s first foster carer was a single parent of African heritage, with several years’ experience of fostering for the Local Authority. She described J as very intelligent, attractive, artistic, clever with crafts; and smart dressing, with an eye for design and colour. J had had emotional problems from when she was little. J had described feeling unloved by her mother; and that her half-Brother could not cope with her. During the placement J had wanted contacted with her Aunt but felt that this was not reciprocated. (J’s Aunt, on learning this as part of the review said that she was not told this at the time.) The Grandmother occasionally telephoned the foster carer and J spoke to her on the phone. J had contact with her wider family in the summer for a family event including the foster carer and spent Christmas Day with her family but did not feel part of the family. She also went out for the night with family members at New Year, which J found a better experience. J found the Family Group Conference traumatic. She felt that no-one wanted her. She was increasingly unhappy after New Year 2014. Her mood changed frequently. Page 51 The Carer felt very well supported by her fostering-support social worker who she could contact in emergencies. She also had a very good link and felt well-supported by J’s social worker, who she thought was a very good social worker for J. The Carer was well-supported by the CLAMHS Co-ordinator and was able to ring her between the weekly sessions which the Carer attended with J. When J moved to the In-Patient Unit she continued to visit J – initially five days a week and later three days per week and occasionally took J out. There were good risk assessments and reviews by the fostering support social worker (instigated by the Head of Service) looking into J’s self- harming behaviour and what actions were required to prevent her harming herself. Sharp items and the washing-line were removed and chemicals were locked away. J’s mood swings were extreme one minute up and the next down. J had said to the Carer –‘one day I will do myself in’ and ‘there is no point being alive; ‘I have no dad, no mum and no family’’. The Carer felt that J trusted her and talked to her easily. The school was helpful and made allowances for J’s behaviour; the Carer could talk with them as needed. J could be panicky in crowded places, and around her peers and had few friends. She became close to the Foster Carer’s daughter. Caring for J was full-time - she had never had a child like J before but hoped that by encouraging J and talking to J about her own (at times adverse) experiences that she would be able to help J. There were times when J was pretending. J would say ‘everything is okay’ when it was not and would say that there are things that the In-Patient Unit did not know. J would draw on paper. One example was an A3 sheet of paper which she discussed with the Carer where J drew pictures and talked about having no-one and suicide. J drew pictures of people with tears and said that that was how she felt. That is when she went to the hospital for the first A&E psychiatric assessment. J did not use the computer much but did use Facebook to keep in touch with her half-Brother and old friends. J would sleep early but slept poorly. J ate well, was tall and slim, ran and jogged; and had a good body but was worried about her weight. After J had been in the In-Patient Unit for several weeks this foster placement came to an end J cried and was screaming about losing her place in the foster home. But the Carer was clear that she could not offer all that J needed through one to one surveillance, as she had been asked to do on a possible home visit, as she had her own children to care for. She was also worried that J would hang herself in the foster home. The Carer felt that she had all the help she needed, including mentoring from a more experienced Foster Carer, and could not have asked for more. She undertook additional training in suicide and loss which she found helpful. The fact that the CLAMHS Coordinator was based in the same building as the social work services was also helpful. Her own older daughter was a great help. The Independent Reviewers were impressed by this Carer and what she offered J and believed that what was described by the Carer and by the social workers was a developing attachment between J and the Carer. Page 52 Foster Carers 2 The Carers have over 11 years’ experience of fostering 37 children. In their view J was the most intellectual and creative child they have ever fostered. They believed (in retrospect) that they had not been given enough information about J. They understood at the time that she had depression, which they thought from previous experience that they would be able to deal with. Their initial concern when they first learned about her was rather that she was a young black girl being placed in an area where there are few black children. When they were first sent information about J they spoke with their link-worker and then the Lambeth social worker met with them and the Foster Mother also spoke with the keyworker at the In-Patient Unit a couple of times. They asked questions about J and as a result thought that they could try to meet her needs. They learned that J had been ‘cutting her arm’ and that her depression was linked to her body image. From the Discharge Meeting at the hospital the Foster Mother understood that there had been no new incidents – but later has wondered if the hospital held things back. She would have liked a one to one with the Psychiatrist to learn more about J. They were both clear that they did not understand at all that there was a risk of suicide. Both Carers were shocked on learning from the Independent Reviewers that the reason for J’s admission to the In-Patient in January had been what was seen as a serious risk of suicide. They said that they had not known this. They thought that J’s behaviour had been assessed as a ‘cry for help’ not as a concern that J would seek to take her own life. If they had known that they would not have offered the placement as they would have been concerned about the possible impact on their two foster children. They were clear that they would have put the other children’s needs first. The first contacts with J in Kent and in London went well before J moved to their home permanently. No specific risk assessment was done for the foster home specifically for J. The Carers had removed razor blades from the bathroom as they knew J had cut herself; they thought to do that from previous experience that they had had. They had not been asked to do so or think about other areas of possible harm, such as rope or chemicals or medicines. J was concerned about her weight and dieting but she was not starving herself and ate well. J had no access to the internet at home – except on her phone, to use the internet on the computer she had to go to the library. When the Foster Mother went to the GP to get the repeat prescription the script had not been sent through by the In-Patient Unit and so she had to contact the Unit to ask them to send it to the GP. When she took J to see the GP for more medication, J was more concerned about her height, she wanted to grow taller, like her Mother, and she was worried about a curve in her back; the GP re-assured her. The Foster Carer did not remember if the GP asked specifically about self-harming thoughts or behaviour. J took the medication twice a day. The Foster Mother kept the medication and gave it to J to take, watching her most of the time; it did not occur to her to Page 53 check that J was swallowing it, as she was not advised to check that J had actually swallowed it. J did not like the medication as she thought it affected her sleeping. J ‘clicked’ with the other two foster children quickly, especially the older one who was nearer her age. They bought her a bike so that she could go out with the other girls and J decorated it in a very colourful way. J was not in school and so J and the Foster Mother spent the days together while the other children were at school. J would write stories, poems and songs, and draw. The three children played together and got on well. J was very creative and would make things – especially rag dolls. She played the guitar, liked to paint old furniture, and was interested in clothes and trinkets from second hand shops. J chose colourful clothes or materials which she would use for her handicrafts or accessorising. They never went to furniture shops with J and had no knowledge of the ‘steps’ which J had referred to in her phone conversation with J’s Aunt. They believed J to be settling in well. J described it as a ‘fresh start’. J kept in contact with old friends through her phone, she liked YouTube and used FaceBook to speak to her half-Brother, who, J said, was unhappy that she was in foster care as he should have been looking after her. The Carers felt well-supported. They had fostered for eleven years and know a number of staff in the Independent Agency – as some of them have previously been their link-workers. Although they did not feel that they needed it, the Agency rang every Monday to check how the weekend and previous week had gone for all the children. When their link-worker left suddenly they did not feel worried as they did not think there were any difficulties and they could contact the Agency if they needed to, with confidence. There was always someone they could talk to, if needed. They were visited by one of the Agency’s staff before the new link- worker was appointed. The Lambeth social worker visited each week after J was placed, except for one week when a different Lambeth worker visited. The Carers thought this was helpful. They could also have called her if they needed to. The day before J died, the Lambeth social worker met J and the Foster Mother at the prospective school which J would start in September. The meeting went well. J was very pleased that she would not have to repeat a year, having missed so much school. J described this as her ‘happiest day’. J declined a visit back to London the following week with her social worker. That evening she wished to make cakes for the Foster Father as it was his birthday. They were unaware that J had rung her previous Carer or her Aunt in the few days before she died. They did not know that J had kept diaries until after her death when the diaries were found among her belongings; although she shared her other story writing, pictures and songs with them. When asked what they thought Agencies could learn from J’s tragic death the Foster Carers (2) said: ‘Give full information – all the information you have got. Don’t put roses on things.’ ‘Do what you say you will do and get things done.’ Page 54 ‘Did they think about the other children? When placing a child, like J, think about the other children who are already in the home.’ Learning and Conclusions – including learning from the NHS Health Overview Report The purpose of a serious case review is not to blame but to seek to understand ‘what happened, and why, and what action will be taken to learn from the review findings’2. The review should also be proportionate. Such understanding must review the actions undertaken by agencies within the agency context, the systems, knowledge and skills that were in place to inform the assessments made, and the actions taken, including any systemic dynamics which were not intrinsic to the case management but which may have impacted on it. Where responsibility is shared across agencies Local Safeguarding Children Boards and their Member Agencies will want to know how effective the multi-agency information sharing, joint assessments and co-working have been and whether agreed local policies and protocols have been used and are fit for purpose. In the analysis above the table of commentary has evaluated the work done at the different stages of J’s journey from both individual and multi-agency perspectives. Those lessons do not need to be repeated here. J was in a unique position. She had lost her mother in tragic circumstances and her family was unable to care for her. Her needs were complex and, over time, became more compounded. The moves across administrative boundaries complicated this and increased difficulties in understanding her needs and responding to them. She was also entering adolescence. For staff in Tier 3 and 4 mental health services she was not unusual, for staff in non-health services she was a complex child. Her ‘journey’ through the child in need and safeguarding systems was mixed. She was identified as a child in need prior to her mother’s death and received support. Assessments of her family’s ability to meet her needs were insufficient and did not recognise when she had become a child in need of protection as a result of acute physical neglect, which she concealed. Although her emotional needs were being seen, the depth of those needs does not appear to have been fully recognised, nor that they were not being met (and possibly could not be met) through her wider birth family. She was experiencing emotional neglect, requiring protection services. Transition from one geographical area to another was not well-managed or co-ordinated across services between Islington and Lambeth – perhaps because it was thought her family would manage this. She continued to be a child in need but was not, initially, accepted as such by Lambeth Children’s Services – a transitional child in need meeting covering health, CAMHS and schools would have been beneficial to ensure that J’s history and unusual needs were known and well understood and that there was a smooth transfer of co-ordination of the help she needed. When both historic and current allegations of possible sexual abuse were made, a formal section 47 child protection assessment led by a strategy discussion or strategy meeting should have taken place and information should have been shared and sought from key agencies who were supporting J. This was delayed and did not follow national or local guidance. 2 Working Together to Safeguard Children, 2015 page 72 Page 55 When it was clear that J’s Aunt could not continue to care for J and concerns were noted that J may be self-harming, there was information sharing across services but a lack of co-ordination. There was also confusion about her legal situation and whether she was ‘competent’ to make decisions for herself, simply because of her age – regardless of an assessment of her capability or the impact of her continual experiences of loss and feelings of rejection. When J showed the need for more specialised child and adolescent mental health services these were provided but there was a lack of co- ordination. She was offered different forms of therapy and the opportunity to speak about her losses but declined this. Workers who were not from specialised mental health services looked to the specialists to work with J and advise them. Other processes such as Looked After Review processes appear to have become compromised by deference to CAMHS. As a looked after child there was drift in planning and lack of a timely needs assessment to secure J’s future and appropriate care arrangements. When J needed fourth tier specialist and in-patient mental health input other systems recognising her status as having no parent and needing longer term planning had a lower status. More was needed to ensure that the systems worked closely together. J’s behaviour was increasingly risky – but much was hidden from those seeking to protect her; and when glimpses of J’ self-denigrating, self-harming and suicidal thinking did emerge her denials were readily accepted. Risks were considered when J was being prepared for discharge from the in-patient unit the transfer to a new family in a new area. Risk of relapse was not spelled out. The SCR Panel’s view is that the transfer was too speedy. J required a whole new range of service providers and these were not in place or coming in to place when she moved. Staff had known that there needed to be a risk management plan in place and that J would require local mental health services. Actions should have been taken to put these in place before her move and to involve those services in the discharge planning and preparation for her care. She was moving to an area where she was unknown. Such lessons as these are not new, there is no new or magic solution. Appropriate policies and procedures are already in place but pressures, lack of co- ordination and information sharing impacted by other non-case related agency dynamics distracted from J’s needs. Although unique in many ways J was like many other children in need. The Review Panel questioned whether the severity and uniqueness of her losses and her situation were missed as she seemed, on the surface, like many other children in the looked after system. J’s Aunt had mixed feelings about offering to care for J but supported her extensively in the period before J’s Mother’s death and after when J was in the care of her half-Brother. When J ran away to her Aunt, her Aunt took her in and intended to offer J a home for life; but wanted more specialist help for J from psychological services as she thought that J was very troubled. She loved J, provided a home, sought services for her, supported her in change of school and attending CAMHS. However, J’s Aunt felt rejected by J when J went into care and so stood back; becoming involved again when J was admitted to the in-patient unit. J ’s Aunt did not feel listened to or supported by services in her concerns about J. The foster carers in Lambeth and Kent offered J affection and good family care, and made good quality relationships with her. But it was asking a great deal of such families to manage the potential risks that J posed to herself without greater understanding and training or experience of self-harming behaviour or an understanding of eating disorders and poor self-image. J’s diaries, with the benefit of hindsight, show that she was probably more troubled and self-denigrating than could have been known by those working with her at the time. Page 56 Over-arching themes and lessons A range of lessons have been identified during the process of this SCR. The methodology used to conduct this review has allowed senior agency representatives to take lessons back into their respective agencies as they have emerged, and to implement action plans in response to these service/agency/team specific findings. Some of the lower priority lessons are included in the Timeline. In line with relevant SCR guidance in relation to proportionality, key priority lessons for relevant Safeguarding Children Boards are detailed below. They represent the most important overarching lessons for LSCBs and multi-agency partners. Bereavement, Transitions and Losses The eco-map in the appendices depicts J’s significant losses, estrangement, or the ending of a relationship (denoted in white); as can been seen these are significant. The number of times J moved home is not included in this eco-map. J moved home several times between the ages of 12 and 14 years. She moved from her home with her mother and half-Brother to the home of her maternal Aunt; and then moved to the home of foster carer 1; from there she moved to the in-patient unit. Whilst there she lost her home with foster carer 1 and her belongings were put into storage. Her final move was to the foster placement in Kent. Overall J’s transitions across service boundaries were poorly managed by the services involved; the transfer of information was either consistently delayed or not transferred at all, communication between professionals was fragmented and this led to gaps in service provision and further delays. All of J’s moves were characterised by a change in the professional network; each new encounter with professionals invariably led to J telling the story of her life again. During this time J was moving into early adolescence, the particular social and emotional challenges of adolescence do not have to be repeated here. There was no comment on the impact on J of these multiple losses and transitions during this critical developmental period, and there did not appear to be an understanding of their possible impact. This included an apparent difficulty in understanding dynamics of attachment and loss, and how these would affect her ability to make future relationships, such as in a future (foster) family. Attempts were made to discuss her losses and bereavement, in particular the death of her Mother, but J was reluctant to engage in these. Questions for Safeguarding Children Boards: How is attachment theory and how are transitions and losses understood by those agencies responsible for the assessment of a child’s needs across a range of service provision and how might improvements be realised? How can Boards work with all relevant agencies in order to improve transitional arrangements for children moving across geographic boundaries? What are the particular challenges and how might these be addressed? Page 57 Assessments and Treatment J’s psychosocial history included complex bereavement, possible physical emotional and sexual abuse, significant losses, possible attachment disorder and multiple transitions. She was a child who had no significant attachment figure, her behaviour revealed the depth of her sadness and her diaries recorded her relentless self-loathing. Many professionals spoke to J and heard her life story, her behaviour including self-harm and suicidal ideation were known about, the recordings in her diaries, whilst largely unknown, were ‘unsurprising for a child with such a past’. J was clear that the joint sessions she had at CAMHS with her carers were not helpful; ‘talking did not help’. Whilst she engaged in the art psychotherapy that was provided, this was not sufficient to address her significant mental health needs Whilst J was an in-patient, medication was regarded as the most effective consistent treatment she received. Despite this being the only form of treatment at discharge, during the latter part of her stay, there was confusion over whether medication was effective. When J went to live in Kent, in the absence of CAMHS provision, medication was the only treatment received for her mental health difficulties. There was confusion over how her medication was supervised by the foster carers in Kent, poor record keeping at the placement. There was poor communication from the in-patient unit at discharge. Understanding the legal concept of Parental Responsibility and when young people can make decisions J was unusual to services as she became an orphan and by her late Mother’s will was placed under the guardianship of her half-Brother and an Aunt. J’s Aunt did not understand the significance of this role, that it carried legal Parental Responsibility (PR) and what rights and responsibilities are inherent in that role, notably that she had the right to act independently of her nephew who also had PR. She states that she was not advised what being a Testamentary Guardian meant. Practitioners also seemed to be unclear about J’s legal status. This confused thinking about who could make decisions for her and whether she should have been made the subject of Care Proceedings. J became a Looked After Child under section 20 of the Children Act. J’s Aunt and half-Brother continued to hold Parental Responsibility for her until her death. In terms of treatment options, it is not clear if agencies other than the Local Authority understood the significance of this. J was thought to have been ‘Gillick’ competent based on her age but no assessment was done of her actual competency to make important decisions given her life-experience and vulnerability. The Children in Need processes or Looked After Children processes should have established these as early as possible. Questions for Safeguarding Children Boards: Relevant boards should ensure a clear understanding from commissioners and providers of mental health services (including CAMHS tier 3 & 4 provision) in relation to the range of therapeutic interventions for children with complex needs such as J’s in order to effectively plan for future provision. LSCBs should consider what generic training and support should be in place for practitioners and managers outside child and adolescent mental health services in understanding self-harm and suicidal ideation and behaviour in order to strengthen them in offering support to family and carers or workers in universal services. Page 58 Care Planning (Child in Need, Looked After Reviews, Care Programme Approach & Multi-Disciplinary Work) The reasons for J coming into care are not fully clear. J’s Aunt has stated that she had not. felt able to care for J initially following the Mother’s death because of her own health and J’s behaviour; but had been actively involved in supporting the half-Brother as J’s carer in practical and emotional ways. and had been concerned about his maturity, his ability to care for J practically and emotionally and his own needs and bereavement. She was in contact with and went to CIN meetings with Islington staff. When the arrangement with J’s half-Brother broke down, J ran away to her Aunt, who accepted the task and sought to care for J and make arrangements for her education, health and emotional needs – including seeking appropriate psychological help for J for bereavement. She had planned to offer J a home to adulthood and considered that she might adopt J (although this was not discussed with social care staff). However, she found J increasingly hard to manage and sought additional help, as well as raising concerns about alleged sexual abuse. She was concerned about the content of J’s writings, which J regularly left out for her to read. J’s Aunt wanted psychologists to get to the bottom of J’s problems but increasingly found J’s behaviour at home hard to deal with and felt that over time J became alienated from her, becoming increasingly attracted to the idea of foster care. It is J’s Aunt’s view that she did not ask for J to go into care but she allowed J to go into care as that is what J wanted and that J pushed for this. J’s Aunt felt rejected by J. Children’s social care believed J’s Aunt to be at the end of her tether and wishing J to be accommodated. It is not clear to the Review Authors that diversion from care and supporting the family was fully explored. There were a number of meetings where J’s needs were discussed and plans were made for these needs to be met. The most critical of these care planning forums were J’s Looked after Reviews (LAR’s), and whilst an in-patient the Care Programme Approach meetings (CPAs). Looked after Reviews In testing how the care system worked to support and plan for J statutory Looked after Reviews played a key role. The IRO Handbook provides statutory guidance for Independent Reviewing Officer’s (IRO) and local authorities on their functions, in relation to case management and review of the care provided to Looked after Children. There are two clear and separate aspects to the function of the IRO: chairing the child’s review; and monitoring the child’s case on an ongoing basis. In exercising both parts of this role the IRO handbook outlines the responsibilities of the IRO in relation to a wide range of areas focusing on the inclusive nature of reviews, including but not exclusive to; “facilitating consultation with a wide range of parties, promoting the voice of the child; ensuring that plans for looked after children are based on a detailed and informed assessment, are up to date, effective and provide a real and genuine response to each Questions for Safeguarding Children Boards: LSCBs should seek assurance that staff, including those in universal services, are aware of the legal aspects of parental responsibility and the significance of knowing who can make decisions for a child and when young people may be able to make decisions for themselves. Page 59 child’s needs.” J was the subject of 4 Looked after Reviews and had the same Independent Reviewing Officer throughout; this was good practice and allowed J to have a consistent figure in her life who was able to hold her history in mind. It is clear that J engaged with her IRO, and that the IRO was committed to understanding J and to establishing her views. This review found that whilst the IRO made important recommendations in relation to care planning, when these recommendations were not implemented there was no effective response, this is not an unusual finding and has been the subject of government attention and research. Escalation and challenge are clearly important tenets of the LAC system, the absence of which compromises effective care planning for children (see below). Care Programme Approach The Care Programme Approach (CPA) was introduced in 1990 to provide a framework for effective mental health care for people with severe mental health problems. Its four main elements are to put in place systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services, the formation of a care plan which identifies the health and social care required from a variety of providers, the appointment of a care co-ordinator to keep in close touch with the service user, and to monitor and to co-ordinate care, to provide regular review and, where necessary, to agree changes to the care plan. Whilst J was an inpatient she was the subject of three CPA meetings attended by the Lead Psychiatrist, CAMHS and key workers within the in-patient unit. The first scheduled meeting was cancelled and for the second there were no minutes. Joint planning The most critical care planning period was when J was an in-patient, and whilst an in-patient two LAR Progress meetings were held chaired by the IRO and three CPA Meetings chaired by the Lead Psychiatrist. Despite the key principles of these statutory planning forums being very similar these meetings were held in parallel and key players were not present and it was the absence of robust, timely, integrated care planning between the statutory planning forums that had the most significant impact on how effective planning was not achieved. Research of available government guidance, research and literature looking at how the CPA and LAR processes integrate in order to form a coherent planning approach to the care and discharge of a child from a Tier 4 in-patient establishment revealed nothing of significance. The IRO handbook makes brief reference: ‘In relation to children admitted to a psychiatric unit, whether as a voluntary patient or as a result of a compulsory admission under the Mental Health Act 1983 the IRO will need to be satisfied that the local authority is fulfilling its responsibilities and that appropriate plans to meet the child’s needs and planned outcomes are in place before discharge’. In relation to CPA guidance: ‘Ensuring effective communication between service users (including families), health providers and other involved agencies using the Care Planning Approach so that families and professionals are fully involved in the treatment and discharge process and that timely and appropriate community services are available upon discharge’. So whilst these references are remarkably similar there is no specific guidance in relation to ensuring an integrated approach to a child who is the subject of both statutory processes. In a sense it could be argued that the separate guidance sits in its own furrow and application of the guidance in practice mirrors this silo approach, as seen in this case. Roles and responsibilities of the multi-disciplinary group The separate nature of the planning meetings affected how the different roles and responsibilities of the multi-disciplinary group and services were understood, this led to assumptions being made characterised in two important ways. From the perspective of staff at the in-patient unit, whose expertise Page 60 was in mental health not in working with a looked after child, the unique position of a child looked after by the local authority did not seem to be fully understood (ref: In-Patient IMR) and so the unique challenges of J’s care status were not appreciated. Equally for Children’s Social Care staff, whose expertise is in looked after children not mental health, the purpose of J’s admission to the in-patient unit was not understood. There was a sense that J ‘was admitted for treatment in a highly specialist residential unit and when the time came for discharge she would have received the appropriate treatment’. These assumptions had a direct impact on planning for J’s future placement. On advice from the in-patient unit it was understood that J would be best placed in a foster family rather than a residential unit. The first foster placement had been a good one and there was evidence of attachment behaviour and good management of risk but it was seen as short term only and was not seen as suitable for J’s long term needs. The carer who was committed to J also felt that she could not manage the level of risk that she had experienced previously in caring for J and that it would not be right for her family. J was deemed well enough for discharge and was described as wanting to go as well as becoming anxious about where she would be discharged to. Unlike other young people she had no family to return to. In seeking a new foster family for J it seems her complex attachment history and needs and the possibility of a continued or reversion to a level of high risk of self-harm and suicidal thinking were not fully considered or included in the family finding. It was good practice that the in-patient unit and social care discussed the suitability of possible families that were put forward. However, there was a lack of robust, informed professional debate and challenge about the type of specialist placement J might require, and what was realistic in a foster family. The transition arrangements were poor and the risk management plans were inadequate. Management Overview and Leadership J was a child with a complicated psycho-social history, with a history of possible emotional, physical, sexual abuse and neglect, complex mental health needs, and was a looked after child. In Lambeth initially there was no multi-disciplinary co-ordination or management overview to support front line practitioners in understanding the complex needs of a child such as J. Case recordings in Children’s social care reveal a ‘surface deep’ level of supervision and guidance. Initially from Lambeth Children’s Social Care perspective J was not a remarkable child, there were many other children catching the attention of senior management, and J was seen as being cared for by her family, which could be argued to be sufficient. The referral from Islington did not trigger that J was a Questions for Safeguarding Children Boards : Relevant boards should review how joint-care planning for a child who is LAC and an in-patient of a Tier 4 establishment can be achieved to ensure a joint multi-disciplinary approach where the child’s holistic needs both whilst an in-patient and when planning for discharge can be effectively realized; and examine how, in circumstances when there are gaps in discharge planning arrangements/ transition, these concerns can be successfully escalated to senior management and resolved prior to discharge. It is recommended that a joint multi- disciplinary working group is established to progress and it is further recommended that the work of this group is shared more widely to enhance national learning on this issue. Page 61 priority Child in Need. From the perspective of CAMHS; case recordings reveal that equally J was not a child whose presentation was remarkable. This suggested to the SCR Panel that the significance of J’s history and the seriousness of her presentation was not understood in a reflective way. There also appeared to be some drift and delay in the early management of the case within Lambeth. J was in an establishment that was an exceptionally high cost resource equally independent fostering provision is a high cost resource, this in itself suggested that J’s case warranted the attention of senior management. Instead the front line practitioners were largely left to go it alone and this resulted in assessments, care planning and decision making that in the absence of close reflective supervision, and senior management guidance failed to comprehend the complexities of J’s needs. It has been noted that in Lambeth children’s social care at the time that this case was being managed there were several changes in senior management and leadership. Systems to monitor high priority cases were not as effective as previously or as now. Teams were under pressure and there were changes in staff. The Looked After Team which took over responsibility for J’s care after she was accommodated was better staffed with a strong team identity but had to take on work for other services such as the court team. J’s Diaries A number of professionals perceived J to be a resilient child whilst others correctly identified that J was reticent and avoidant about expressing her thoughts and feelings; she appeared at times to be ‘coping well’, but this was sometimes thought only to be ‘surface deep’. On occasions when J was asked about her feelings she gave positive views, denying suicidal thinking, even in the final weeks up to her death. Some practitioners were aware that J wrote a diary or wrote in notebooks. The content of a few pages had been seen and were worrying. Carers expressed concern about some of the entries which indicated risk and suicidal or self-harming ideation. Other practitioners working with J later were unaware of the worrying content of the earlier pages which had been shared. Some knew that she was often writing in books but felt inhibited from discussing her writings and diaries with her. Questions for Safeguarding Children Boards: LSCBs should be aware of what the current arrangements for supervision (reflective management) within agencies are; and what the joint-arrangements are when a child is receiving services across agencies? Are these the subject of regular quality assurance audit and challenge? Is reflective supervision currently being provided within agencies and how are outcomes being evaluated? Are current training programmes sufficiently promoting the knowledge base and skills of practitioners in understanding the impact of a child’s psychosocial history and in providing services to children with such complex needs? Are Agencies aware of which cases should be the subject of senior management scrutiny and review, and where needed, intervention in order to resolve any barriers to joint working? Page 62 The question asked by this SCR Panel was whether it would have been appropriate or ethical for practitioners to have read these diaries at the time (one practitioner told us that they saw such a notebook but held back from looking at it on grounds that it would have breached J’s rights, even though as a parent herself she may well have done so). J was in care; the Local Authority was acting as her parent. Given the acute nature of J’s mental health concerns would it have been appropriate to have read J’s diary, if it had been accessible– what would a reasonable parent have done? Legal advice to this SCR is that it would not have been legal to have accessed J’s diaries without her permission. J’s permission was not sought and this becomes the central issue as, despite a number of professionals knowing about her dairies or writings, there was little thought or reflection about their significance as an important part of understanding J’s inner world - their possible significance in assessing her mental state, and the risk of self-harm, and suicidal thinking was not fully available. J’s Voice: Establishing J’s wishes and feelings through consultation Multi-agency case recordings, and Independent Management Reports completed as part of this Review, showed that J was consulted fully and that her wishes and feelings were ascertained in a number of different areas. In line with requirements J’s views were regularly ascertained as part of her Looked After Reviews. Areas included, but were not exclusive to, her wishes and feelings in relation to her current and future placements and her views in relation to CAMHS support. When decisions were being made about whether to pursue a Care Order, legal advice was that J was ‘Gillick’ competent – ‘Gillick Competence’ now more usually referred to as ‘Fraser Guidelines’ - applies to contraceptive advice. 3J was felt to be ‘Gillick competent’ and this appeared to be an important consideration in deciding that the Local Authority did not need to secure parental responsibility for J. This view of J being ‘Gillick competent’ appeared as a feature throughout the involvement of the multi-agency group and appeared to be applied in relation to all decisions upon which J was consulted. There was no test of J’s ability, such as there might have been under the Mental Capacity Act if she had been over 16 years of age. The advice that she was Gillick competent seems to have been based solely on her age rather than an assessment of her mental and emotional capacity, the impact of what had happened to her, her developmental experiences, and her losses. 3 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/legal-definition-child-rights-law/gillick-competency-fraser-guidelines/ Questions for Safeguarding Children Boards: Given the learning in the case how will relevant Safeguarding Boards seek to address the importance of holding a child’s writings such as diaries in mind when working with children and young people such as J. Do current professional training programmes address how this might be done? Is there a need to issue specific guidance in this area/amend existing policy/procedure to reflect the importance of this issue? How can professional curiosity be encouraged in a way to engage and work in counselling young people? Page 63 Social Media/Internet Access Between November 2011 and January 2014 a number of references can be found in case records relating to J’s use of Facebook. J talked to her social worker about communicating with friends/family members on Facebook. Her use of Facebook was rightly the subject of concern when pupils raised concern about her wellbeing with members of school staff as J was expressing suicidal thoughts and intentions shortly after her Mother’s death. Later J’s Aunt raised concerns about J communicating with an older man and posting a photograph of herself in what was felt to be inappropriate clothing. On these occasions professionals correctly reported their concerns for J’s safety and wellbeing. However, apart from recording the information within the case narrative, there appeared to be no further curiosity or management overview of the possible significance of J’s use of social media or of the potential safeguarding action that may have been needed. J’s diaries reveal she was aware of the content of Pro-anorexic – ‘Ana’ web sites with some regularity. It is not known if J accessed these sites herself or whether she gained the information from peers who had eating disorders in the in-patient unit. Whilst this was not known to professionals at the time, it is the view of the panel that given J’s known preoccupation with her food and fluid intake and with her body image, knowledge of these websites and the dangers they pose would have provided the opportunity to have explored these issues with J more fully and to put in place clear advice and safeguarding measures to protect her from the risks these sites pose. Useful research into the use and risk of such websites is: Virtually anorexic: Where’s the harm by Dr E Bond, University Campus Suffolk4 4 www.ucs.ac.uk/virtuallyanorexic Questions for Safeguarding Children Boards: How widespread is the use of the ‘Gillick Competency Test’ used in relation to assessing a child’s ability to make informed decisions that have a fundamental impact on the care the child receives/how decisions are influenced/made? How will this be addressed so that the question of a child’s competency to make decisions is based on a solid understanding and appreciation of a child’s individual needs and informed capability? Could the assessment of capability used within the adult Mental Capacity Act be a useful way to inform LSCBs how this issue might be successfully addressed? Questions for Safeguarding Children Boards: What knowledge and training do staff in different services have about the use of the internet to access websites and their risks, and how are staff equipped in understanding the use of social media sites to inform assessments and to safeguard children from harm? How are LSCB e-safety policies and procedures being applied? Page 64 Additional Findings There are a number of findings relevant to single agencies. These issues are covered in corresponding IMR’s and the expectation is that these issues are the subject of further exploration and action by the relevant agencies responsible. The additional findings mentioned in this section have been selected for attention by relevant safeguarding boards either because of their particular significance or because they affect more than one safeguarding partner. Investigation of sexual abuse allegations J made a disclosure about sexual abuse; she was consistent in making this disclosure and was keen for it to be the subject of investigation. A concern about possible inappropriate sexualised behaviour towards j had also been reported. There was delay in progressing these enquiries and when the police were contacted a decision was made not to progress to a joint investigation. As noted in the timeline this was not appropriate practice; the disclosure and allegation were left unexplored and unresolved and it was only after J died that these were the subject of investigation. This was poor practice and in all likelihood left J feeling she was not believed or heard Discharge arrangements (including risk assessments) Lead responsibility for overseeing these arrangements was held jointly by the in-patient unit and CAMHS. The In-Patient Unit held a particular responsibility for ensuring risk assessments were well documented, robust and clearly articulated and understood. This did not happen and was poor practice. Whist the unit also held lead responsibility for the transfer of J’s general care, within this role they were reliant on other professionals fulfilling their responsibilities. This included responsibility held by CSC to arrange for J’s schooling, responsibility by CAMHS to visit J 7 days after discharge and to transfer care to the local CAMHS team to ensure J was provided with a timely appropriate response, and responsibility by the fostering agency to ensure the carers were appropriately trained and supported. Given J’s history the Panel believes that the arrangements should have been in place before J moved or very soon after. Questions for Safeguarding Children Boards: It is understood that in response to findings from recent serious case reviews action has been taken to improve the practice in this area. Relevant Boards are recommended to request an update on the progress in this matter and keep under review. Questions for Safeguarding Children Boards: Relevant Boards should request a progress report from the in-patient unit detailing how these lessons will be taken forward in the future and maintain an overview of progress. Relevant Boards, with Commissioners, should examine how in the future the duties of multi-agency partners in this area will be scrutinised and challenged to enable these arrangements to be satisfactorily fulfilled. Page 65 Looked after Reviews and the role of the IRO As part of this review the minutes of J’s looked after reviews were scrutinised. As previously identified, there were a number of recommendations made by the IRO that were not taken forward by the Social Work team. The recommendations that were taken forward related only to those that have a performance indicator attached (e.g. Personal Education Plan, dental and health checks). The LAR’s consistently made a recommendation that a Care Order should be pursued, this was started but not achieved. There was no escalation or challenge to the Local Authority when this did not happen and this is contrary to statutory guidelines. In addition, the LAR documents, that include the minutes of the meeting and the Social Work report, were c o n f u s i n g . Outdated information had been cut and pasted from previous reviews, and there were large sections of the form that were left blank. This meant that the document as a whole did not provide a comprehensive picture of J and her needs and had implications both in terms of planning and meeting J’s needs. Community Psychiatric Management and Leadership (CAMHS) There was no consistent community psychiatrist taking an active role in the care and treatment of J whilst she was living in the community, on admission to the in-patient unit, and on discharge. The lack of management overview and leadership in a number of agencies is identified above and does not need repeating here. It is understood that there were a number of staffing problems in the community CAMHS team and it was the view of the Panel that this contributory factor, whilst understandable, from the perspective of J was not acceptable; the absence of a community psychiatrist had a significant impact on the way J’s mental health needs were assessed and her care managed. Questions for Safeguarding Children Boards: Relevant Boards are recommended to audit Looked After Review Arrangements to identify whether this is a common feature of LAR’s. Firstly, in relation to the possible barriers that may exist in IROs fulfilling their statutory responsibilities in challenge and escalation and secondly in relation to the quality of LAR documentation. Questions for Safeguarding Children Boards: Relevant boards should challenge the agencies responsible for the commissioning and provision of this service on this matter and receive regular updates on how changes will be made and sustained. Page 66 Matching J’s needs to carers During J’s life as a child in care J was matched and placed with two foster families. It was not possible to identify the practice based decision making process showing how J was matched to carers as no documentation could be found that showed adequately how these decisions were reached. Neither of these placements was made in an emergency, and so there was time to consider J’s needs and follow a practice based process of matching her needs to carers. That said, J’s placement with her first foster carer was a good placement where it seemed that J’s emotional needs were understood, and from her diary entries J felt settled and able to plan for her future. J’s second placement after discharge was secured through an independent fostering agency. Whilst it is understood there is a process in place that was followed in respect to the identification of such placements, it was the view of the Panel that whilst the carers were well meaning and provided a comfortable family home for J it was not possible to understand how the match had been made. J was a black child, these carers were white and lived in a predominately white area. It is understood that current guidance on matching no longer emphasises the need to provide a racial or cultural match. However, given this placement was likely to become J’s long term placement it was the view of the panel that the lack of regard for J’s racial and cultural identity in making this match was poor practice. J did not have regular contact with birth family members and had no contact with members of her community in a way that would enable her racial and cultural identity to be promoted. It was understood that the family were chosen partly on the basis that they had experience in caring for children of J’s age who were emotionally troubled. This was naïve; J required a placement with carers who were trained and experienced in caring for children who have significant mental health needs and in providing care to children who self- harm and have suicidal ideation. As identified in the relevant Independent Fostering Agency IMR, the carers did not have this experience or training. As raised earlier in this report the original question of what type of placement J required was not the subject of satisfactory interrogation and so the decision to pursue a fostering placement was questionable. It may be that there are foster placements available that are able to provide care to children in such difficult circumstances, but in this case failure to match J with carers in this way placed both J and the carers in a difficult and arguably untenable situation. Lessons from the NHS Health Agencies Overview As part of the SCR process NHS England undertook a parallel review from a health perspective. Each Agency which provided services to J completed an Independent Review using Root Cause Analysis; those reports were also made available to the SCR Panel. The NHS appointed two Independent Psychiatrists to advise that review, which was led by the Designated Doctor and Designated Nurse of the Lambeth CCG. The review analysed the Agency Reviews and interviewed some of the key practitioners. Questions for Safeguarding Children Boards: How will relevant Safeguarding Boards review how current matching processes are completed both with internal fostering placements and with placements made through independent providers in circumstances such as J? What possible steps can be taken to assist those responsible for making these critical matching decisions? Page 67 The Findings from the Health Overview Report are summarised here: Good Practice Points The Palliative care team delivered end-of life care in challenging circumstances; they made a holistic evaluation of the material and emotional needs of J and her brother after mother’s death and rapidly sought to involve appropriate agencies. There was good handover of care between Islington and Lambeth CAMHS services There was appropriate provision of Tier 3 community CAMHS service, in which J. actively engaged. The art therapy offered was clearly planned and adequately supervised and appropriate recommendations for future work were made. There was good transition to the CLAMHS service once she became looked after. LAC Health assessments were holistic and of high quality and an outreach service was provided when J was an inpatient in hospital. Child J had skilled and comprehensive medical assessments when she presented at both acute hospitals emergency departments. The Priory hospital provided appropriate individual and group work. They had good awareness of child J’s traumatic background, and her reluctance to talk about this. Regular risk assessments were conducted, and CPA meetings, chaired by a consultant, took place at appropriate intervals. J. formed a good relationship with her key nurse, who worked closely with the SW and foster carer in planning J’s discharge, including the provision of a safety plan. The Kent GP responded quickly arranging follow up mental health care and medication for J when she was brought to the practice. Care and Service Delivery Problems 1. Clinical leadership Although individual practitioners worked hard to address J’s needs, effective clinical leadership was not established within all of the community mental health services who worked directly with child J. There was an absence of consistent case management oversight and supervision by a consultant psychiatrist or other senior clinician, despite J. being identified as a high risk case and having known safeguarding concerns. This resulted in no clear care plan being in place for J prior to her hospital admission. There was little evidence of a coordinated and integrated approach to the delivery of her care, including the monitoring of her medication and no regular review of her mental state or risk level. The care co-ordinator in CLAMHS appeared to be working largely in isolation. Page 68 1.1 There was no senior community CLAMHS clinician/consultant psychiatric liaison with the inpatient team whilst J was an inpatient. This was particularly significant as J. posed a significant risk and was on psychopharmacological treatment. It contributed to the lack of effective discharge planning and missing responsibility for who was going to see J for her 7-day post discharge review. This lack of involvement was not effectively challenged or escalated by the clinical lead of the inpatient unit. 2. Discharge planning The professional responsible for J’s care in hospital and discharge was the inpatient consultant psychiatrist (known as the Responsible Clinician). The time after discharge would be stressful and difficult for Child J. Child J had been in hospital for a significant length of time and was going to be discharged home to a new geographical area and to a new foster placement. Before discharge, a care plan should be made under the Care Programme Approach (CPA) which will look at how to meet her needs. Given J‘s level of complexity and risk, the agreed discharge plan was insufficient and fell below expected standards. The discharge appeared to take place very rapidly once a foster placement had been identified which may have affected the ability to recognise or resolve some important issues. There were no clear arrangements put in place for the 7-day post discharge follow up for J. There was no confirmation of allocation and transfer of her care and management to a community CAMHS consultant. There were plans for Child J’s social worker to see her weekly after discharge. However, it was inappropriate for her social worker alone to review her considering her significant psychiatric diagnosis, on-going medication and assessed risk of self-harm. Additionally, there was no clear timescale to register J with a Kent GP (which was essential before her care could be transferred to Kent CAMHS), or specifically allocate this important task to a member of the professional network. It is unclear why the referral by Lambeth CAMHS to Kent was significantly delayed. However, Lambeth CAMHS agreed to be available for consultation until the Kent CAMHS transfer. It is noteworthy that J did not have any contact with a CAMHS clinician following her discharge from hospital in the 8 weeks before her death. 3. Communication - Co-ordination and Communication 3.1 Communication between adult and children’s services Adult services (e.g. palliative care team, district nursing) could have made links with children’s service providers (e.g. school nursing) to support child J. There is a lack of easy lines of communication between adult and children’s services working in the same community. 3.2 Communication between community health providers There was an absence of communication and discussion between the community clinicians who provided first line support to child J (GP, school nurse, community child mental health services, and LAC Health services), so a holistic view of her needs was not formulated or shared. High quality LAC health assessments were undertaken, with clear recommendations, but responsibility for following up on health tasks (e.g. between paediatrician and GP) was unclear. Page 69 4. Supervision The need for effective supervision is a key lesson from this review. Staff who are in the front line of practice must be well supported by effective supervision. Supervision of workers carrying out child and family assessment is essential, as the assessment can have far reaching effects on the planning of care and the assessment of need and/or risks. Children at high risk of adverse outcomes require especially robust supervisory and management support in order to ensure: reflective practice, challenge, adequate recording, prevention of drift, timely caseload transfer, and effective communication between health agencies and other agencies. However, the purpose of supervision is ultimately to ensure that the child’s safety and welfare is given paramount consideration at all time. 5. The Voice of Child J The health professionals who worked with Child J (universal services, LAC Health, A&E, Tier 3 & 4 mental health services) were sensitive and supportive of her needs. Her views and wishes were well captured in the clinical notes; these generally informed the work that was undertaken with her. However, when she voiced her impression that the anti-depressant medication was not being effective, there is no evidence of this having been taken into consideration. 6. Commissioning of Child and Adolescent Mental Health Services NHS England Case Managers maintain an overview of patient pathways and are responsible for quality monitoring of contracted and hosted providers (i.e. the specialised commissioning contract is held by one NHS England region but the service is located elsewhere) NHS England Case Managers are not usually directly involved in decision-making for the majority of discharges but may be involved if the issues are particularly complex or there are difficulties in making progress. The difficulties in effectively managing J’s discharge were not highlighted to the NHS England case manager and they were not approached to support her discharge directly. This was a missed opportunity. Additionally, NHS Lambeth CCG was not approached by the local CAMHs service seeking funding authorisation. Lambeth Safeguarding Children Board February 2016 Page 70 Foster carer Lambeth Appendices Foster Carer’s Daughter CAMHS Coordinator Mental health professional Islington (FG) A&E Psychiatrist Foster siblings GPs School Teacher/staff Lambeth Mental health practitioner Lambeth (VC) Maternal Cousin and Family KCH Psychiatrist LAC Doctor Independent Fostering Agency SW Supervising SW (FC) Lambeth Peers Islington In-Patient Therapists LAC Nurse CLAMS Coordinator In-Patient Psychiatrist Art Therapist Islington Art Therapist Lambeth SW 1 (CIN) Islington SW 2 (CIN) Lambeth Independent Reviewing Officer (IRO) Foster Carers Kent Half Brother J SW 3 (LAC) Lambeth Peers: In-Patient Unit Peers Lambeth School Teacher/Staff Islington In-Patient Key Worker & Nurses Foster siblings Lambeth osfot Maternal Grandmother Maternal Aunt Wider family members Mother (Deceased) Page 71 Appendix 2 Terms of Reference and Methodology The Terms of Reference for the SCR were agreed between the Independent Chairs of Lambeth, Islington and Kent LSCBs – in discussion with the Chairs of Southwark and Wandsworth LSCBs (as some of the services provided were in their areas). Terms of Reference of the Review - All agencies involved with J across Islington, Lambeth, Southwark, Wandsworth and Kent LSCB areas are asked to check if they offered services to J in the period January 1999 to July 2014 and, if so, to secure their records and undertake an Independent Management Review (IMR) of their assessments of J’s needs and the services offered. - The local LSCBs are asked to liaise with their local Partners on this. - Agencies should notify the Lambeth Safeguarding Children Board of their involvement with J and her family, compile a summary chronology of those key contacts, including relevant inter-agency contacts and note, in summary, the content and outcomes of those key contacts. Chronologies – Scope: For the period January 1999 to November 2011 only significant events (i.e. not all events) or information should be noted about J’s development and care and any concerns about her welfare or behaviour, including from antenatal services, primary care, community health, early years services, schools, social care or housing. Other agencies may become identified in this process and the Lambeth SCB should be notified. For the period from October 2011 a more detailed chronology should be compiled indicating key contacts with J, her family members or carers or inter-agency communications, summarising the content and outcome of the contact or communication and who was involved from the agency by role e.g. SW1, HV1, GP2, etc. The chronology should be confidential and should not identify an individual by name – only role. Independent Management Reviews (IMR) Using the agency chronology, agency records and conversations with relevant practitioners, each agency which had contact with J or her family is asked to compile an IMR. This should be undertaken by a suitably qualified and independent practitioner who is able to analyse the agency involvement and provide a review which comments on the agency practice and any lessons arising from the review. The review should be endorsed by a senior manager of the agency who did not have direct involvement in the management of the case. Page 72 The Agency IMRs should note and review: - the key and priority practice episodes (these will be drawn from the agency chronology); - the agency’s involvement, commenting on the work undertaken and use of LSCB and agency policy and procedures, or accepted best clinical/professional practice, in use at the time; - the agency’s and inter-agency assessment of J’s needs, including her developmental needs, her emotional needs, and ethnic and cultural needs; and any risk identified, including signs or disclosures of neglect or abuse; - analysis of the planning and management of transitions for J, including specialist advice/support; - the direct work undertaken with J and her family members – how J’s views and wishes were ascertained and how her family’s views and wishes were ascertained; - inter-agency information sharing and co-operation to meet J’s identified needs; - the decisions, actions taken and timescales, noting any gaps, errors and successes and why these occurred; - the views of the practitioners involved and any management or supervisory oversight of the work, seeking to understand the work undertaken by what was known at the time, not through hindsight, but noting any gaps; - the agency systemic context in which the work was undertaken and any factors intrinsic to the agency, or external to the case, which may have impacted on the work. - The IMR should note the key lessons, including concerns and good practice, which have been learned as a result of the agency independent review and any recommendations to be taken as a result within the agency, or by the home LSCB or by other bodies; and whether the agency has accepted such internal recommendations as formal actions. - Non-health agencies should compile their IMR using the principles above. SCR Panel - Lambeth SCB appointed a panel of senior and experienced practitioners, with experience in safeguarding, to draw together the learning from the IMRs and Health Overview and to comment on the work undertaken. - The SCR Panel members were independent of the line-management for this case. - Two independent lead reviewers were appointed to support the process and author the final report. - The Panel was commissioned by the Lambeth SCB Chair. - None of the Panel Members had direct involvement in the management of the case up to the point of J’s death. - The Panel are able to co-opt specialist advice, as needed. - The Panel had the authority to invite the agency IMR authors to further discuss their IMRs and findings. Participation by family members and carers - J’s Aunt and brother will be advised at an early stage of the review, its purpose, how it will be conducted and how they may be involved; including by direct conversation with agreed SCR Panel members, probably the independent lead reviewers. - Consideration should be given to seeking early clarification of the allegations made by J’s Aunt of possible neglect and abuse. Page 73 - Consent is not required for access to agency records about J or her mother, who are both deceased. There should be no need for access to records about her J’s Aunt or brother, but if it is decided that this may be needed consent will be sought. - Both sets of foster carers will be advised of the review and should be consulted as part of their agency IMRs, but they will also be invited to make direct representation to the SCR Panel, should they wish to do so in writing or in a meeting with the Lead Reviewers. Governance The SCR Panel Chair will hold responsibility for informing the LSCB Chair/s of any emerging findings which require attention before the SCR is completed. Governance meetings will be convened twice during the course of the Review to inform the LSCB Chairs and DCSs of the emerging findings and to present the draft review before its completion. 3. Membership of SCR Panel Malcolm Ward, Independent Chair / Reviewer Bridget Griffin, Independent Reviewer Dr Alison Barnwell, Designated Doctor, Lambeth CCG Dr Sarah Bernard, Consultant Child and Adolescent Psychiatrist, Named Doctor for Safeguarding Children, South London & Maudsley NHS Foundation Trust Patricia Denney, Asst Director, Safeguarding Children and Quality Assurance, Kent County Council Lisa Humphreys, Asst Director, Lambeth Children’s Social Care Russel Pearson, Specialist Crime Review Group, Metropolitan Police Service Lesley Ward, Manager, Next Steps Fostering Avis Williams-McKoy, Designated Nurse, Lambeth CCG Lara Wood, Islington Children’s Services Vanessa Wright, Quality Improvement Lead, Priory Healthcare Paul Maddocks, Specialist Crime Review Group, Metropolitan Police Service stepped down from the Panel for personal reasons. None of the Panel Members had had any direct involvement in the case. The Panel was supported by Rupinder Virdee, Sandra Fernandes, Andrea Watkins and Maria Burton of the Lambeth SCB. Page 74 4. Independent Management Reports Received Central and NW London NHS Foundation Trust Guy’s and St Thomas NHS Foundation Trust – Lambeth Community Health Services and Looked After Children Health Services Islington Council – Children’s Social Care Islington Council – Early Years’ Services Islington Council – Schools and Young People’s Services Islington GP Service Kent GP Service Lambeth Clinical Commissioning Group Lambeth Council – Children’s Social Care Lambeth Council – Education Services Metropolitan Police Next Steps Fostering NHS England OFSTED South London and Maudsley NHS Foundation Trust (Mental Health/CAMHS) Sussex Partnership Foundation Trust (Kent CAMHS) The Priory Group (Independent Mental Health Provider) Kent Community Health NHS Trust, Kent County Council – Children’s Services and Kent Police confirmed to the SCR Panel that they had had no involvement with J prior to her death. 5. Bibliography Bond; Virtually Anorexic – Where’s the harm? A research study on the risks of pro-anorexia websites; University Campus Suffolk; 2012 Meltzer, Lader, Corbin, Goodman and Ford; The mental health of young people looked after by local authorities in wales: Summary Report Welsh Assembly/Office of National Statistics; 2004 Ougrin, Tranah, Stahl, Moran and Asarnow: Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta- Analysis; Journal of the American Academy of Child and Adolescent Psychiatry, Vol 54 Numb 2 February 2015 Self-harm and suicide in children and young people – Reconstruct Research Service (www.reconstrict.co.uk) Undated Page 75 Suicide: Learning from serious case reviews, NSPCC 2014 Independent Reviewing Officers’ Handbook, DfE, 2010 https://www.gov.uk/government/publications/independent-reviewing-officers-handbook Young Minds - has a range of useful leaflets, articles and information about childhood and adolescent suicide and self-harm http://www.youngminds.org.uk Published by Lambeth Safeguarding Children Board February 2016 |
NC52433 | Death of a 4-month-old child in October 2019. Child K was found dead in the family home, after having been asleep on the sofa. Learning includes: need for greater focus on children's lived experiences and the emotional impact of substance misuse; need to develop practice of 'respectful uncertainty' as a means to combatting disguised compliance, particularly where substance misuse is a concern; risk to children was increased by parental drug misuse going undetected; need for consideration of reasons for grandparent's caring role as this can help professionals with their work with the family and the plans they develop; need for multi-agency approach to assessment of risk. Recommendations include: safeguarding children partnership to ensure all agencies are using age appropriate tools in all assessments to understand children's lived experience, and incorporating children's lived experiences into all plans; to ensure all partners incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers; seek assurance from children's social care and local drug services that changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances; ensure that, where grandparents are playing a significant caring role, this is fully explored as part of assessments and contained within all action plans; explore ways of ensuring information about risk is provided by all relevant services and incorporated into safeguarding assessments and plans. Please note that this report was written in May/2021 but was published in 2022.
| Title: Child K: local child safeguarding practice review. LSCB: Kirklees Safeguarding Children Partnership Author: Nicki Walker-Hall Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. THIS REPORT IS STRICTLY CONFIDENTIAL AND MUST NOT BE DISCLOSED TO THIRD PARTIES WITHOUT DISCUSSION AND AGREEMENT WITH THE KSCP PRIOR TO PUBLICATION. THE DISCLOSURE OF INFORMATION BEYOND THAT WHICH IS AGREED, WILL BE CONSIDERED AS A BREACH OF CONFIDENTIALITY FOR THE SUBJECT AND A BREACH OF CONFIDENTIALITY OF ALL THE AGENCIES INVOLVED. Kirklees Safeguarding Children Partnership Child K LOCAL CHILD SAFEGUARDING PRACTICE REVIEW Safeguarding Adults Review Month 2020 Nicki Walker-Hall Version 2, May 2021 2 | P a g e Table of Contents 1. Introduction 3 2. Summary of learning themes 3 3. Context of Child Safeguarding Practice Review 3 4. Succinct summary of case 4 5. Methodology 5 6. Terms of Reference 6 7. Engagement with family 7 8. Review timeline 7 9. Analysis of the Key Lines of Enquiry 7 10. Conclusion 14 Appendix i – Key to acronyms/ abbreviations 15 Version 2, May 2021 3 | P a g e 1. Introduction 1.1 This case was referred to Kirklees Safeguarding Children Partnership following the death of Child K aged 4 months. Child K was one of three siblings. Sibling 1 was 3 years old and sibling 2 (Child K’s half-brother) was 10 years old when Child K died. At that time all three children were subject to Child Protection Plans under the category of neglect; both parents were known to be misusing substances. Mother and father were both arrested for causing or allowing the death of a child. Father was further arrested for possession of heroin. 1.2 This case was referred for Rapid Review in accordance with Working Together 20181. The Rapid Review Group concluded that this case met the criteria for a Child Safeguarding Practice Review (CSPR) as abuse or neglect was suspected. 1.3 The Chair of Kirklees Safeguarding Children Partnership (KSCP) endorsed this decision and the Review was commissioned. 1.4 This CSPR will take into account the guidance in Working Together and the principles of the systems methodology recommended by the Munro review.2 1.5 The review covers the period from 26.10.18 to 27.10.19. This period encompassed the start of Child in Need for siblings to the date of Child K’s death. 2. Summary of Learning Themes 2.1 The following are the main learning themes. • Greater focus on children’s lived experiences • Develop tools and skills in the practice of ‘respectful uncertainty/healthy scepticism’ as a means to combatting disguised compliance – increase professional curiosity • Develop a joint approach to drug using parents • Recognise, assess and support family members in caring roles • Develop comprehensive joint risk assessments 3. Context of Child Safeguarding Practice Reviews 3.1 The responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Child Safeguarding Practice Review Panel and at local level with the safeguarding partners. Working Together to Safeguard Children 2018 contains the statutory guidance for undertaking Child Safeguarding Practice Reviews (CSPRs) when a serious child safeguarding case has been reported. These are cases in which: 1 HM Government (2018) Working Together to Safeguard Children https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agency_guidance.pdf 2 The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011). Version 2, May 2021 4 | P a g e • abuse or neglect of a child is known or suspected and • the child has died or been seriously harmed 3.2 Meeting the criteria does not mean that safeguarding partners must automatically carry out a local Child Safeguarding Practice Review. It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice. 3.3 This review will be cognisant of the following requirements: • recognise the complex circumstances in which professionals work together to safeguard children; • seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • be transparent about the way data is collected and analysed; • make use of relevant research and case evidence to inform the findings. • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike; and • be suitable for publication without needing to be amended or redacted, ensuring that the subject child and/or family cannot be identified. 4. Succinct summary of case 4.1 The family had a long history of involvement with statutory services in relation to parental substance misuse, offending behaviour and child protection concerns. Both father and mother were class A substance misusers, primarily crack cocaine and prescription drugs for both, and additionally heroin for father. From 2008 – 2014, mother attended Children’s Centre Activities and, for a time, was allocated a family support worker. Further support was sought during mother’s pregnancy with sibling 1 in recognition of previous alcohol issues, mental health issues, and to work on routines for sibling 1. The case was closed in October 2015. Further support was provided around toileting for sibling 1 and sibling 2 in 2017; closing in September 2017. 4.2 Immediately prior to the review period (Oct 2018) mother had been charged, and was on bail, for an offence of robbery and was due to go to trial a month after the birth of Child K. Maternal grandmother had raised concerns regarding who would care for the children if mother received a custodial sentence, which was thought likely. Partner agencies started to work together to explore the options in the event mother was incarcerated; the children were placed on Child in Need (CIN) plans. Version 2, May 2021 5 | P a g e 4.3 Mother was referred to Support for Women and Antenatal Service (SWANS) during all three of her pregnancies. Mother indicated she had last used substances in October 2018 and maintained she was not using substances throughout the pregnancy. Mother expressed concern that she may relapse after Child K was born. Mother was not accessing the support offered for her substance misuse and did not engage well with services, including specialised antenatal care, provided by SWANS, throughout her pregnancy. She did though give some negative drug tests during pregnancy, she also lied about her drug misuse despite evidence suggestive of continued drug use e.g. unclear drug test results, financial difficulties and third party information. 4.4 Father was accessing support for his substance misuse through the local drugs agency, CHART. Father indicated he was not injecting substances; this was untrue as he was a regular attender at the needle exchange service. Father’s significance was not realised by professionals; father was not residing in the family home. It was thought sibling 1 did not have a relationship with father; this perception was later challenged when father was excluded from the family home and sibling 1’s behaviours deteriorated. 4.5 Consideration was being given to alternative care arrangements for all 3 children. Maternal Grandmother, who had provided considerable support to the whole family had said she would take the older siblings but would be unable to care for a new born baby. Alternate carers within the family were explored via family group conferences. 4.6 The case changed from one of considering alternative placements if mother received a jail sentence when Child K tested positive for crack cocaine and opiates at birth and was treated for drug withdrawal. An Initial Child Protection Conference (ICPC) was held and all 3 children were made subject to a Child Protection Plan under the category of Neglect. 4.7 Siblings were noted to have injuries just prior to this incident that raised concerns, however, the paediatric medical assessments subsequently found no sign of non-accidental injury or neglect. 4.8 The children’s father’s role within their lives were latterly explored and contact arrangements agreed. There had been previous domestic violence incidents between parents and in former relationships which was of concern. 4.9 Child K had a bottle of milk around 9.00pm and fell asleep on the sofa. Mum advised that she had used crack cocaine between the hours of 8.00 and 9.00pm. Child K was left to sleep on the sofa. It would appear that mum also slept on the sofa and she had noticed that the other child in the family had come down from their room and was asleep on the living room floor. When mum woke around 7.00am she noticed that Child K felt cold and that she was not responding. Mum called for an ambulance and through their instruction dad attempted to give CPR. Child K was taken to hospital where she was declared dead. Mother later informed the police she and father had been drinking and had misused substances the previous night. Child K was found to have bruising to her back; following the post mortem the cause of death had been recorded as “Unascertained (history of co-sleeping). Version 2, May 2021 6 | P a g e 5. Methodology 5.1 A group representing partner agencies of the Kirklees Safeguarding Children Partnership developed the terms of reference in line with Working Together to Safeguard Children (2018), and West Yorkshire Safeguarding Children Procedures, Chapter 10.1 (8.20). The following agencies were identified as having been involved with Child K and Child K’s family. • Kirklees Children’s Social Care • Police • Calderdale and Huddersfield Foundation Trust • Locala: Health Visitor Service / School Nurse • Education • Support for Women and Antenatal Service (SWANS) • CHART • Greater Huddersfield CCG 5.2 Agencies provided a chronology with analysis of significant events between these dates and a summary of significant interventions prior to 26.10.18. Agencies provided a list of practitioners and managers involved in the family’s care. Nicki Walker-Hall, an experienced Serious Case and Learning Lessons Review author from a health background, was commissioned to undertake the review. 5.3 A narrative of events was developed by the reviewer. Two separate practitioner and two separate manager learning events were held in January and March 2020 in order to understand the single and inter-agency practice in this case. The reviewer has only been able to gain limited insight into the perceptions of the family and how the different agencies related to them through discussion with practitioners. 5.4 A draft report was produced for consideration by the KSCP sub-group. 5.5 Further Terms of reference were agreed, and a more concise and focused report produced. 6. Terms of Reference 6.1 Originally, the terms of reference and Key Lines of Enquiry provided to the reviewer for this review were as follows: Sustaining services and support: • The rule of optimism • Child-centred practice • Supervision Assessment of risk: Version 2, May 2021 7 | P a g e • Quality and timeliness of assessments (inc. Pre-birth Assessments and Child Protection Plans) • Analysis in assessment and risk • Quality and timeliness of decision-making • Contingency planning 6.2 Following submission of the first draft report and a change in personnel, the following Key Lines of Enquiry were agreed: • Listening to children’s lived experience • Working with families with disguised compliance • Substance misuse • The role of extended families • Professional curiosity • Multi-agency working and managing risk 7. Engagement with family 7.1 The reviewer would have liked an opportunity to speak with the family to gain an understanding of their experience of the services offered. To date this has not been possible. This case was subject to a number of parallel processes (coroners inquiry and police investigation) which have inhibited the reviewer’s ability to speak with the family. 8. Review timeline 8.1 Working Together 2018 suggests that Child Safeguarding Practice Reviews should be completed within 6 months of initiating it, unless there are good reasons for a longer period being required. This review has not met the expected timeframe. Illness, bereavement, change of personnel, and Covid-19 have all added to significant delay. 9. Analysis of the Key Lines of Enquiry Listening to children’s lived experience 9.1 There is limited information regarding the children’s lived experiences. Assessments provide a real opportunity for practitioners to understand a child’s lived experience. In this case, sibling 1 was thought too young to be spoken to alone. When sibling 2 was spoken to alone, he spoke of being bullied at school but mentioned nothing about mother or his home life. Assessment tools, devised to elicit the voice of either child, were used on one occasion within school; however, the environment was not conducive for the child to talk. These tools were not used within the Child and Family Assessment. 9.2 Practitioners were able to describe the children but there was no clear understanding of their lived experiences. Practitioners talked about aspects of the children, for example, Sibling 1 was reported to be chatty, and would show his toys, Sibling 2 was reported to have a close relationship with mother, grandmother and siblings, but did not have a positive relationship with father who was not his biological father. Practitioners could identify Version 2, May 2021 8 | P a g e changes in sibling 2’s behaviours; these were reported to be dependent on the level of contact he was having with grandmother; grandmother was viewed by professionals as a positive, stable influence. Sibling 2 spent a lot of time with grandmother; practitioners were not sufficiently curious as to the reasons behind this arrangement. Practitioners had not had any concerns regarding the care of the children until grandmother raised her concerns. 9.3 In this case, sibling 2 was of an age where he was able to articulate concerns. When he did so, these concerns were not ignored but nor were they proactively responded to within assessments and investigations. At the practitioner’s event, a discussion was had around gaining information from children. Discussions with the children were too often focussed on the concern and were not widened to explore their lived experience. 9.4 There is evidence of professionals striving to maintain focus on the child. This is particularly evident within the school and nursery and during each Child In Need meeting. The children’s health and emotional wellbeing were discussed and plans made to address their needs progressed. However, as a result of the practitioners not understanding the children’s lived experience, the focus was on the minutiae and not the bigger picture. Sibling 2 was displaying behaviours suggesting his emotional health was being impacted, and both siblings were displaying behaviours that suggested they were witnessing behaviours in adults likely to cause them harm. It is imperative that when professionals are identifying indicators that children are being exposed to harmful behaviours, they maintain a healthy scepticism, explore the origins of the behaviours, and consider the risk to the child and what actions may be required to keep them safe? 9.5 Children may speak to a number of professionals during the course of an assessment or investigation. If the alleged perpetrator or someone supporting the alleged perpetrator continues to have access to the child during this time, the child may be unduly influenced to change their story. The lack of understanding of the couple’s relationship meant professionals did not give sufficient thought as to whether mother or father might exert pressure on sibling 2 to change or retract his allegation. Mother’s lack of response to attempts by the police to speak with sibling 2 during the investigation should have given rise to heightened concern for the children but didn’t. Learning point 1: There is a need for greater focus on children’s daily lives, their lived experiences, and the emotional impact of substance misuse. Meetings need to maintain focus on the child whilst considering the adults’ issues and the impact the adults’ behaviours were having on the children. Recommendation 1: KSCP to seek assurance from all agencies that: • age appropriate tools are being used with all children within assessments and on-going work, to understand the children’s lived experiences and • that all plans are child focussed with evidence of consideration of the impact of adult behaviours on the child Professional curiosity and working with families with disguised compliance Version 2, May 2021 9 | P a g e 9.6 Disguised compliance describes the process of parents hiding dangerous or poor parenting practice by actively working to deceive and undermine professional involvement. There is evidence of disguised compliance on behalf of both parents. Throughout her pregnancy, mother did not disclose substance misuse to any professionals. Indeed, any tests that indicated she had, were met with denial; she openly lied. Father was not truthful about the mode of his drug misuse, always indicating he was not injecting, but making frequent use of the needle exchange service. Professionals were presented with situations where they could have been more curious. A number of referrals/third party intelligence were received indicating mother was misusing drugs. These occasions all provided opportunities for further in-depth assessment. Previously, Serious Case Reviews (SCR’s)3 have found children would be better protected by agencies being receptive to information being plausible, either until it is proved to be unfounded or where good assessment finds no substantiation. This process requires critical thinking and professional curiosity to reach a confident judgement. 9.7 In this case, the couple’s parenting capacity was not assessed, and this allowed them to hide or down play the negatives from statutory agencies. They exhibited tokenistic engagement by presenting themselves when they were well on several occasions. Professionals maintaining a culture of ‘healthy scepticism’ and practising to embed this as a cultural norm is essential to practitioners recognising and tackling this subversive behaviour. This review has enabled multi-agency professionals to reflect on how mother and father managed to mislead professionals with apparent ease. The review has also shown, more disturbingly, however, that, despite the significant history known to various agencies, no single practitioner or service knew what life was like for these children. 9.8 It is not unusual for clients to present themselves in a more favourable light. The challenge when working with families who on the surface appear to cooperate but are not, is identifying this so it can be challenged. Lack of inclusion of all local drug services within multi-agency meetings allowed mother’s protestations that she hadn’t misused drugs to remain unclear. 9.9 Father was not known to school, nursery or the SWANS service and his role within the family was not fully recognised whilst the case was being managed as Child in Need. Successive biennial analyses and more recent Serious Case Reviews4 warn that professionals too often overlook the presence of males in families. 9.10 Father was spoken to as part of the Child and Family Assessment. However, the concentration was on mother and father’s drug and offending behaviours which they placed in the past. This had an effect of lowering practitioners’ perceptions of the risks. 9.11 It is essential that systems are set up in ways that make it easy for professionals to identify non-compliance. It is only by identifying deception and naming it, that those who are not being truthful and are saying what professionals want to hear, can be challenged. 3 Serious case review report: Child T (2017) North East Lincolnshire NSPCC SCR Repository 4 Hidden men: learning from case reviews: Summary of risk factors and learning for improved practice around ‘hidden’ men NSPCC 2015 Version 2, May 2021 10 | P a g e This couple were missing medical appointments, asking for needle provision without undergoing tests, not providing adequate explanations, all behaviours heavily suggestive of non-compliance. Often it is difficult for a lone professional or single agency to identify disguised compliance. Sharing information with, gathering information from, and making best use of partner agencies’ expertise, is essential to uncovering non-compliance; professionals were deceived. 9.12 Providing practitioners opportunities for reflection and consideration of whether a family are being compliant, through supervision and managerial oversight, can aid detection of disguised compliance. Learning Point 2: Multi-agency professionals need to develop tools and skills in the practice of ‘respectful uncertainty/healthy scepticism’ as a means to combatting disguised compliance, particularly in safeguarding children where parental substance misuse is a cause for concern. Recommendation 2: KSCP and its partners to incorporate disguised compliance into all safeguarding training, supervision and managerial sessions with frontline workers. Substance misuse 9.13 Whilst parental substance misuse does not automatically indicate child abuse or neglect, it can have an impact on children in a number of ways, which includes impairment on the development of an unborn child. A parent's practical caring skills may be diminished by substance misuse and withdrawal from substance misuse may give rise to mental states or behaviour that put children at risk of injury, psychological or emotional distress or neglect. Children of parents experiencing withdrawal are known to be at increased risk of significant harm5 . Substance-misusing parents may find it difficult to prioritise the needs of the children over their own, and money available to the household to meet basic needs may be reduced. Children may be at risk of physical harm, or death, if drugs and drug paraphernalia are not stored safely and children have access to them. 9.14 Drug and alcohol services were working with both mother and father and mother was receiving midwifery care, including care via the specialist midwifery service for drug and alcohol users. They missed many appointments with these practitioners and failed to cooperate in what was asked of them. Drug and alcohol service practitioners were not invited to take part in CIN meetings, thus an opportunity for them to share information and their expertise was missed. 9.15 CHART and the needle exchange service, whilst based in the same building, used separate entrances and separate recording systems. This allowed the situation of father indicating he was not injecting to the recovery co-ordinator and then obtaining a significant amount of needles and syringes, demonstrating very regular injecting, to go undetected. 5 Altobelli & Payne, 2014 https://www.bacp.co.uk/bacp-journals/bacp-children-young-people-and-families-journal/march-2014/noticing-the-hidden-harm/ Version 2, May 2021 11 | P a g e There has since been changes to the way the two parts of the service work and record that should prevent this situation arising again. 9.16 Roles, responsibilities and the way services were configured were confused and, as a result of commissioning arrangements and a failure to resolve funding arrangements, social workers were undertaking drug testing without the training and expertise to understand the results. Drug testing equipment was not being stored and monitored safely. This presented significant risks and, in this case, masked evidence that mother was using illicit substances. Learning point 3: The way drug and alcohol services were configured and the interface between drug and alcohol services and CSC heightened the risk that problematic drug use would go undetected and unaddressed in such a way as to increase risks to children. Recommendation 3: KSCP to seek assurance from CSC and local drug services that agreements regarding funding, changes to service design, and ways of working have improved the reliability of testing, communication, information sharing and risk assessing of parents who are misusing substances. The role of extended families 9.17 Grandmother volunteered information to practitioners and discussed her concerns. Grandmother was upfront about mother’s drug use and made a number of referrals. Referrals from family members should be deemed as significant events. Relatives making referrals is particularly difficult where, as in this case, the family were also involved in offering ongoing support. 9.18 Initially, practitioners wondered whether there might be a malicious element to grandmother’s referrals and considered these referrals in the context of motivation and the credibility of the referral. The thinking was, “Is this a concerned grandparent or is she just frustrated and exasperated with mother?”. 9.19 Grandmother was quickly viewed by professionals as very significant within the family although her role was not entirely clear. Grandmother was reported by practitioners to be very caring and protective of the children; she was said to have a particularly strong bond with sibling 2, for whom she acted as an advocate. Grandmother was articulate, intelligent and an ex-teacher. Grandmother indicated she was torn with regards to her relationship with mother. 9.20 Grandmother took on a carer role and was supporting mother and the children financially, emotionally, and physically. Often involvement of extended families is viewed as positive, however it can also be a negative and have the impact of leaving a parent impotent. 9.21 Professionals needed to explore the reasons for grandmother taking on her caring role. Was this at the behest of mother? Instigated by grandmother? Why did mother require such assistance to care for her children? 9.22 The unintended consequence of grandmother’s care of the children was to obscure professionals’ view, leading to an underestimation of the magnitude of all the issues. Version 2, May 2021 12 | P a g e Learning point 4: Grandparents who take on a caring role for their grandchildren do so for a variety of reasons. Some because of a shortfall in parents’ capacity to care for the children, some because of their own controlling behaviours, and some for purely practical reasons. Understanding the reasons helps professionals within their work with families and in the plans they develop. Recommendation 4: KSCP and its partners to articulate and ensure that, where grandparents are playing a significant role in the care of their grandchildren, this needs to be fully explored as part of assessments and contained within action plans, and ensure this is embedded in practice. Multi agency working and managing risk 9.23 Research highlights the importance of professionals from all agencies working collaboratively, sharing knowledge and expertise6. There were a number of different meetings being held by and between different agencies and different disciplines within agencies. The interface between all these different meetings (CP, CIN, SWANS risk assessment meetings, FGC, etc.) was not clear. 9.24 In this case, key professionals from key agencies were not invited and/or not in attendance at key meetings. Lack of inclusion of CHART/SWANS within CIN and CP meetings lost opportunities for experienced drug and alcohol professionals to provide partner agencies with clarity on the meaning of the drug test results and, ultimately, mother’s drug use. This is particularly relevant when, on occasions, there were queries regarding the validity of results, and when a drug was found on testing which counteracts the effect of other drugs. When hair strand testing was discussed at meetings, mother would cut her hair. This behaviour was suggestive of on-going drug use and potential increased risk; this needed greater challenge. 9.25 Assessment of risk in safeguarding is complex and requires the assessor to be objective and analytically skilful. There are a number of factors that had the potential to impact the assessment of risk in this case. The initial referral to CSC, during the review period, was made by grandmother. There was scepticism regarding the validity and motivation for the referral. Munro found that there was a striking difference between the response of CSC when referrals were made by relatives or neighbours to those made by professionals. Those made by professionals were treated much more seriously and with an initial expectation that it might be true, leading more often to a thorough investigation7. Robust assessment requires practitioners to: • Be open minded and take an independent approach to the evidence • Reflect and critically analyse all of the information 6 Social work assessment of children in need: what do we know? Messages from research DFE March 2011 7 Munro, E. (1996) Avoidable and unavoidable mistakes in child protection work. London: LSE Research Articles Online. Available at: http://eprints.lse.ac.uk/archive/00000348/ Version 2, May 2021 13 | P a g e • Collate and coordinate large amounts of information to extract key findings • Deploy knowledge and expertise in child protection and social work theory • Be given and to take the time and opportunity for rigorous critical thinking 9.26 Lack of full understanding of mother and father’s drug taking was a significant factor that affected the assessment of risk. Both mother and father were not honest with professionals. 9.27 With hindsight, it is clear mother was a largely functioning drug user. Professionals, although aware of mother’s offending, didn’t consider this sufficiently in context of her drug use. There was a lack of focus on finances; this could have provided professionals with a clearer understanding as to whether financial difficulties were due to a lack of money coming into the household or because of drug use. The significant financial support mother was receiving from grandmother also masked the extent of the problem. 9.28 After Child K was born, mother’s drug use could no longer be denied, and practitioners became more aware of her deception. The relationship between mother and father remained unclear. The fact that father was not residing in the family home appeared to skew professionals’ view. Father was not considered fully in the analysis of assessments and when considering risk. 9.29 Latterly Sibling 2 made a comment around father injecting in his groin; this was a clear indicator that father was injecting illicit substances and a key point where parents should have been robustly challenged. 9.30 None drug and alcohol practitioners had a perception that, as father was attending the drug and alcohol service, this meant he wished to become abstinent; this was erroneous. Father never indicated or behaved in a way that led drug and alcohol workers to conclude he wished to achieve abstinence. Father was clear he enjoyed and wished to continue his drug use. Had drug and alcohol practitioners been aware of this, they would have been better placed to make more accurate risk assessments. 9.31 Mother, as a self-confessed addict, would always be at increased risk of using illicit substances whilst she maintained the relationship with father. Mother was skilled in hiding her lifestyle from those around her. 9.32 The reviewer learned that risk was considered by all professionals attending review conferences. Each element of the plan was discussed, and consideration given as to whether the risk was reducing or changing. Whilst that is positive, it was felt that whilst there was some challenge in ICPC meetings, done in a restorative way, there needed to be more challenge in all meetings. A barrier to this was the perceived negative impact it might have on building relationships with families, and practitioners not wanting this to break down. When working with families, professionals need to provide both high support and high challenge to be effective. Learning point 5: Accurate assessment of risk is dependent on the assessor being in receipt of all the information available across agencies and services, and on having the skills and Version 2, May 2021 14 | P a g e input from those with additional knowledge. Currently some services are not included in requests to provide information when there are safeguarding concerns. Different agencies and services are carrying out single-agency assessments of risk. It is not clear how these separate assessments of risk are being brought together to provide a clear multi-agency assessment of risk on which plans of action are based. Recommendation 5: KSCP and its partners to explore ways of ensuring information pertaining to risk is provided by all relevant services and incorporated into safeguarding assessments and plans. Examples of Good Practice: The section 47 enquiry in June 2019, following the birth of Chid K, was of a good quality. It provided much greater clarity regarding disguised compliance and recognised that the couple’s drug usage was unknown, that mother was regularly borrowing money for her own needs, and that mother was dishonest with professionals. Within this assessment, there was a greater sense of the children and the children’s relationships with mother and father and there was clear analysis. This assessment led to a decision to escalate the case to CP. School and nursery staff demonstrated good knowledge and safeguarding practice in relation to referring concerns and following MASH advice. 10. Conclusion 10.1 The death of Child K was unexpected by the professionals involved. There is evidence that many of the professionals involved had worked hard to support the children and family. However, opportunities to increase professionals understanding of the children’s lived experiences were not always taken. 10.2 Professionals were not sufficiently curious, and did not routinely challenge mother when they had evidence to support their concerns; they were too accepting of mothers explanations. 10.3 Issues in the way services were configured, allowed father to report no IV drug use whilst obtaining needles, and professionals without sufficient knowledge and expertise to interpret drug test results; this impacted on professionals ability to challenge both parents. 10.4 The children’s grandmother was extremely supportive of the children and unwittingly masked some of the evidence that would have helped professionals recognise the level of risk to the children. The difficult position grandmother found herself in was not fully acknowledged. Grandmother was not sufficiently supported and was relied on by professionals. 10.5 Development of a comprehensive joint risk assessment would have helped partners to identify the full risks in this case. Version 2, May 2021 15 | P a g e Appendix i – key to acronyms/ abbreviations CIN Child in Need CP Child Protection CSC Children’s Social Care CSPR Children’s Safeguarding Practice Review FGC Family Group Conference ICPC Initial Child Protection Conference KSCP Kirklees Safeguarding Children Partnership SCR Serious Case Review SWANS Support For Women and Antenatal Service |
NC049031 | Concerns about child sexual exploitation (CSE) of a 16-year-old girl. Child GG was known to a number of services and several assessments of her psychological and physical needs were undertaken. She was excluded from school on a number of occasions. Concerns around Child GG being sexually exploited were formally discussed at six multi-agency meetings in the six months preceding Child GG being taken into police protection in December 2015. Learning issues identified include: lack of recognition among professionals of the risk of CSE as well as 'drift'; lack of coordination of services, especially around referrals and thresholds; the importance of relationship-based practice with children who have been involved in CSE, including the recognition that some children involved in CSE find it difficult to accept that they are being exploited and consequently do not engage fully with agencies; the need to avoid blaming or holding children responsible for the abuse and CSE; the importance of information sharing and of professionals proactively seeking information when there are concerns. Recommendations include: increase knowledge about CSE and the features and manifestations of adolescent behaviour, ADHD and ASD so that professionals can distinguish between these; review the skills of professionals in building positive relationship with children; audit the extent to which children involved in or at risk of CSE are no longer blamed or held responsible and that records are respectful about the child and their family; raise awareness of CSE with taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs.
| Title: Overview report: serious case review: Child GG. LSCB: Surrey Safeguarding Children Board Author: Glenys Johnston Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 K Overview report SERIOUS CASE REVIEW Child GG Author Glenys Johnston OBE Director Octavia Associates Limited November 2016 2 1. INTRODUCTION Background to the review This report of a Serious Case Review (SCR), examines the responses, support and services provided to a child referred to as Child GG and her family, from January to December 2015 when Child GG was in her mid-teenage years. 2. THE REVIEW 2.1 Elaine Coleridge-Smith, the Surrey Safeguarding Children Board (SSCB) Independent Chair agreed to commission an SCR on the 30th March 2016, because of concerns that Child GG had been the subject of child sexual exploitation (CSE) and there was learning to be derived, as to the effectiveness of services to support her. 2.2 A Serious Incident Notification was sent to OfSTED on the 19th May 2016, in accordance with statutory procedures. 2.3 The review was conducted under the statutory guidance of ‘Working Together 2015’ and applied the principles of learning and improvement from that guidance which states: “SCRs and other case reviews should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at that time rather than using hindsight; Is transparent about the way data is collected and analysed and; Makes use of relevant research and case evidence to inform findings” 2.4 All the agencies that had been involved with Child GG and her family were asked to complete a record of their involvement, with comments and this was collated into a combined chronology. A list of these agencies is attached at Appendix 1. The information used to undertake this analysis was derived from a combined chronology, two learning events with practitioners and managers, telephone interviews with professionals who were unable to attend the practitioner events or from whom more information was needed, meetings with Child GG and her mother and a review of key documents. 2.5 The SSCB SCR subgroup approved a methodology that included agencies adding comments to their chronologies, this worked well in some aspects, although some professionals interviewed found that this did not easily enable them to answer the key issues identified in the terms of reference. Any areas they could not address were explored in interviews by the Lead Reviewer and at the practitioner and manager’s events. 2.6 I was asked to undertake the SCR as the Lead Reviewer, produce an Overview Report, facilitate events to gather the views of managers and practitioners who were involved with Child GG or the services delivered at the time and individual, follow up interviews. 3 2.7 I am independent of the local authority and all the agencies involved in this review, having not had any previous involvement with them, apart from undertaking a SCR in respect of another case. I have extensive experience of undertaking SCRs, chairing LSCBs and inspecting and reviewing local authority services to children and young people. 2.8 The review was overseen by a SSCB SCR Review Panel chaired by Amanda Boodhoo the designated safeguarding nurse who was not involved in the case. Excellent support has been provided to the review by members of the board’s staff team. 2.9 The terms of reference for the review are attached at Appendix 1. In line with Government advice it seeks to evaluate why things happened rather than focussing on what happened. The involvement of the family 2.10 I met Child GG and her mother and am very grateful for their contribution to the review and their reflections on what had worked well and what had not. Some of these views are incorporated into the report. 3. CONTEXT 3.1 Surrey is a large county council in the south of England in which approximately 256,400 children and young people under the age of 18 years live. This is 22% of the total population in the area. It is a relatively affluent area, approximately 10% of the local authority’s children are living in poverty. The proportion of children entitled to free school meals in primary schools is 8% (the national average is 15%) and in secondary schools it is 7% (the national average is 14%). There are comparatively lower numbers of children from minority ethnic groups (13% of all children living in the area), compared with 22% in the country as a whole. 3.2 On 31st March 2015, 5735 children had been identified, through assessment as being formally in need of a specialist children’s service i.e. they were children in need of support or protection, this is an increase from 4,538 on 31st March 2014. 3.3 On 31st March 2014, 925 children and young people were the subject of a child protection plan. This is an increase from 925 on 31st March 2014. 3.4 On 31st March 2015, 995 children were being ‘looked after’ by the local authority (a rate of 31 per 10,000 children). This is a reduction from 925 (33 per 10,000 children) on 31st March 2013. 3.5 The local authority operates nine children’s homes. Seven were judged to be ‘good’ or ‘outstanding’ in their most recent Ofsted inspection and two were judged to be ‘adequate’. The previous inspections of services for ‘looked after’ children in September 2010 judged services to be ‘adequate’. The Ofsted inspection of the local authorities (Children’s Services) child protection arrangements, in September 2012, judged services as ‘adequate’ and the Ofsted report, published in 2015, regarding the inspection of services for children in need of help and protection, children ‘looked after’ and care leavers, judged the service to be ‘inadequate’. The local authority is subject to regular monitoring by Ofsted, of the improvements made. 4 3.6 Surrey Police were the subject of an HMIC vulnerability inspection in July 2015 and were graded as ‘inadequate’. A subsequent review of progress, by HMIC in April 2016, identified that: there had been significant improvement in all areas although progress in developing and embedding the MASH was slow; the inspectorate advised that the progress needed to continue in order to embed all the improvements. 4. CHILD SEXUAL EXPLOITATION 4.1 Ten years ago, very little was known or understood about CSE. Over the last eight years it has been the subject of much debate and improvements in practice, particularly since statutory guidance was issued in 2009 and it became an area to be reported on by Ofsted and the high-profile cases in Derby, Peterborough, Rotherham and Oxfordshire, raised the extent of the problem. 4.2 CSE is a form of child sexual abuse but it differs in an important respect which is that grooming is involved, in person or via the internet and social media; it results in children being inappropriately influenced to perform sexual acts in return/exchange for something-praise, gifts, drugs etc. and the perpetrators to also receive the sexual gratification they want. Children under 16 years of age are not legally able to consent to sexual intercourse; sexual activity with a child or causing, inciting a child to engage in sexual activity or meeting a child following sexual grooming and exploiting children are criminal offences; children who are the subject of CSE are completely innocent of any involvement and are not in any way responsible, despite what may be perceived as a transactional arrangement. Children do not always perceive CSE as a crime and can feel that they are in control of what happens to them. 4.3 Definitions of CSE vary across the UK and N Ireland and, informed by a growing understanding of the subject have led to the DfE consulting on a new definition for England. 5. NARRATIVE OF KEY EVENTS 5.1 This section does not list all the events and interactions that took place, it highlights significant events, examples of interactions and opinions drawn from an integrated multi-agency chronology. 5.2 Although the review covers the services that were provided in 2015, previous events that are relevant are included as they evidence early concerns in relation to Child GG’s difficulties in engaging with professionals, school attendance problems, aggressive behaviour, self-harm, drug use and sexual activity with older males. 5.2.1 Child GG was referred to Child and Adolescent Mental Health Services (CAMHS) in 2012 and was intermittently involved in services until April 2014. She had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), oppositional behaviour and Autistic Spectrum Disorder (ASD). She was aggressive towards her mother and her peers and sometimes harmed herself by cutting and scratching her body. She was described as non-compliant with her medication and assessment and did not agree with the diagnosis, she did not want to attend CAMHS and therefore did not engage with the service offered. 5 5.2.2 In 2013, there were concerns that Child GG was not attending school regularly, and she experienced difficulties with another child at school, which was reported to the police by her mother. 5.2.3 In April 2014 School 1 completed a Common Assessment Framework (CAF) which sought to address Child GG’s self-esteem by a referral to an Attendance and Engagement programme and providing support to Child GG and her mother to support Child GG to take her medication and understand the risks of self-harm and how to reduce this. 5.2.4 In the same month, Child GG’s mother reported that her daughter wanted to meet a 16-year-old boy who she had met on Instagram. Her mother had refused as Child GG was only 13 years old and she had become verbally abusive to her mother and had assaulted her. The police visited the family and supported Child GG’s mother’s view and identified the potential risk of CSE, they did not undertake research on the 16-year-old boy to ascertain his vulnerability, or the extent of his contact with other children. 5.2.5 Concerns increased in 2014 about Child GG engaging in sexual activity with the 16-year-old boy and on 16th May 2014, information was appropriately shared with Children’s Services and health. 5.2.6 In July 2014 Child GG was referred to the Alternative Learning provision at a short stay school, this application was not successful however. The same month an application to another Short Stay School (School 2) was made, agreed in November, and was planned to continue until March 2015. 5.2.7 In December 2014, Child GG was fitted with a contraceptive implant. The file records of the GP and the local provider of community health services do not indicate that consideration was given to the fact that Child GG was only just 14 years old. 5.2.8 On 27th December 2014, following a fight at home, evidence of Child GG using cannabis extensively and associating with older people was identified, a referral was made to the Multi-Agency Safeguarding Hub (MASH) highlighting the risks of CSE and the potential impact on Child GG’s half-brother Child H; a child and family assessment was agreed, but no information was gathered by the police, in relation to the people with whom Child GG was associating or who were supplying her with drugs. 5.2.9 On 28th December 2014, the case was allocated to a social worker who had been qualified for one year. Key events covered by the period under review All the following dates occurred in 2015. 5.2.10 On 2nd January, a police report was shared with the school nurse at School 2 concerning Child GG’s physically aggressive behaviour to her mother, the school nurse did not contact Child GG, as she was only on the mainstream school role to secure her education, whilst she was at the Short Stay School and was not under the care of the school nurse. 5.2.11 On 4th January, Child GG’s mother informed the school that her daughter was living with her aunt, there was no information as to the reason or the 6 length of time this arrangement would last, this information was reported to Children’s Services but not placed on the school’s child protection file. 5.2.12 On 6th January, the social worker and a family support worker visited the family home to begin the child and family assessment. Child GG was seen alone by the family support worker who felt there was a risk of family breakdown and a referral to the Extended Hours Service (EHS) and the Youth Support Service (YSS) was planned. 5.2.13 On 7th January, the social worker consulted CAMHS who had discharged Child GG in April 2014 when she had not engaged in their service, CAMHS did not offer a service following the consultation with the social worker, despite the concerns expressed about Child GG’s difficulties but they recommended a referral to a drug use agency to address her cannabis use. 5.2.14 On 9th January, Chid GG’s mother contacted a local Hospital saying her daughter was out of control and was smoking cannabis. 5.2.15 On 15th January Child GG was excluded from school. 5.2.16 On 16th January, a multi-agency meeting was held including the social worker and Child GG, it was agreed she would be referred to the YSS and her placement at the short stay school would be extended on a permanent basis. 5.2.17 On 19th January, in supervision between the social worker and her manager, issues of Child GG’s violence and engaging in under-age sex were identified and a referral to EHS was agreed but it was felt that the concerns did not meet the threshold for child protection enquiries or intervention. On the same day, the police visited the family, due to reports of aggression by Child GG towards her cousin; Child GG’s mother again reported her drug use and sexual activity. No information was subsequently gathered in relation to the risks of CSE and Children’s Services have no record of this visit or the incident referred to. 5.2.18 On 22nd January, the social worker referred Child GG to YSS for Child in Need support. 5.2.19 On 23rd January, Child GG was excluded from school for one day. 5.2.20 On 26th January, the police visited the home as Child GG was reported to be out of control, she was taken into custody but not prosecuted as this was not considered to be in the public interest, Child GG was seen as the cause of the problems without consideration of the wider vulnerabilities in relation to CSE. The same day, the Criminal Justice Psychiatric Liaison Service (CJPLS) reported that Child GG was compliant with medication (information held by Children’s Services does not support this view), was living at home and did not need further support from their service. 5.2.21 On 27th January, the social worker was informed of the above aggressive incident but not of the arrest or the involvement of CJPLS, there is no evidence that this was discussed with a manager to consider a strategy meeting to assess the risk to Child GG and Child H. This was contrary to procedures but appears to have been decided as a child and family 7 assessment was being undertaken. The same day the family support worker visited Child H, the records do not indicate whether the violence towards him by his half-sister was addressed or his needs assessed and planned for. 5.2.22 On 28th January, the local hospital undertook a health assessment as part of the statutory assessment process for a statement of special educational needs, a copy of the letter of assessment was sent to the school, the GP, and Child GG’s parents but not to Children’s Services. 5.2.23 On 30th January, Child GG was excluded from school. 5.2.24 On 2nd February, Child GG’s mother informed the social worker of the school exclusion the previous week and that she was not coping with her daughter. The social worker does not appear to have discussed this with her manager or reviewed the increasing risks to Child GG and Child H. The situation was not discussed with Dr 2 in relation to Child GG’s ADHD and ADD and how Child GG could be encouraged to take her medication and so reduce the aggressive aspects of her behaviour and the attendant risks to her mother and half-brother. 5.2.25 On 3rd February, Child GG was excluded from school. 5.2.26 On 4th February, School 2 informed the Children’s Services duty social worker that Child GG had made explicit statements about how many men she was having sex with, who she wanted to have sex with and her use of cocaine and LSD. Later the same day, School 3 contacted the same duty worker to say they were concerned about the pressure that Child H was under due to his half-sister’s behaviour. There is no evidence that these issues were discussed with a manger or a strategy meeting was considered. 5.2.27 On 5th February, Child GG was excluded from school. 5.2.28 On 9th/10th/11th February Child GG was excluded for three half days. 5.2.29 On 11th February, a meeting was held between School 1 and School 2 due to Child GG’s behaviour, lack of engagement in education and her vulnerability when she was not in school. 5.2.30 On 12th February, Child GG’s mother reported to the family support worker and the police that her daughter was missing from home and had been arrested for shop lifting. A strategy meeting was requested by the police although Children’s Services have no record of this request. On the same day, School 1 contacted School 2 due to the number of exclusions (12) at the centre and concerns about Child GG having inappropriate sexual images, smoking in school and leaving school without permission. There is no evidence that safeguarding actions were taken about the sexual images. 5.2.31 On 13th February, Child GG was involved with YSS due to the shop lifting offence and the subsequent Youth Restorative Intervention Order, however, CAMHS were not involved, due to Child GG’s previous attitude and lack of engagement. 8 5.2.32 On 21st February, the police informed the social worker that Child GG had thrown a knife at her mother. This was not raised with a manager and a strategy meeting was not convened. The chronology also highlights the lack of direct work with Child GG or Child H by Children’s Services. 5.2.33 The EHS, received a referral and asked for further information which was not received within timescales. There was a view that EHS would not work with families where YSS was involved. 5.2.34 On 22nd February, a referral had been made to YSS. However, at the initial handover meeting the YSS social worker was informed that the case was going to an Initial Child Protection Conference (ICPC) and YSS would not be required to provide Child In Need support. Child GG was not made the subject of a child protection plan at the conference but the Child in Need work did not go back to YSS. This would appear to be because the social worker was considering referring to the EHS and the young people’s substance misuse service and could not refer to EHS if Child in Need support was being provided by the YSS. 5.2.35 On 26th February, Child GG was excluded from school. 5.2.36 On 2nd March, Child GG was excluded from school. 5.2.37 There is no record of the strategy meeting referred to in the police entry in the chronology (as above) in the Children’s Services entry for 12th February or of it taking place within statutory timescales. 5.2.38 On 4th March, Child GG’s mother informed the family support worker that her daughter had assaulted her, was receiving gifts and had been visiting Nottingham and London to meet older men. This information was passed to the social worker and the Assistant Team Manager (ATM) but the records are not clear whether the ATM reviewed the incident. There is no record that a strategy meeting was convened or consideration given to receiving Child GG into care, with the agreement of her mother. 5.2.39 On 4th March, Child GG was excluded from school. 5.2.40 On 5th March, the social worker and family support worker witnessed Child GG assaulting her mother in front of Child H. A strategy meeting had already been agreed but did not take place until five days later. 5.2.41 On 9th March, a strategy meeting was held and included a representative from the local health provider of community services. It was agreed a joint section 47 enquiry would be carried out by Children’s Services and the police. Child GG would be referred to the mental health preventative day service and the young people’s substance misuse service. The CSE register would be checked to ensure Child GG’s name was included and support would be provided for Child H. 5.2.42 On 11th March, Child GG was excluded from school. 5.2.43 On 12th March, the mental health preventative day service did not accept the referral, as in their view Child GG’s school placement was not in jeopardy and they thought other services including EHS, could provide support. The same day, Child GG was admitted to Accident and 9 Emergency at the local hospital after she had sent a text to her mother to say she wanted to harm herself and had been taking drugs. Following an assessment by CAMHS Child GG was discharged the following day with her agreement to being referred to the young people’s substance misuse service. 5.2.44 On 17th March Child GG was excluded from school. 5.2.45 On 23rd March Child GG was excluded from school. 5.2.46 On 30th March, an ICPC was held. School 2 and Children’s Services attended. The GP was unable to attend the meeting but he provided a report, although this did not include information about Child GG’s sexual history. Relevant health information was not shared with the ICPC Chair and the school nurse was unable to attend. The report from the social worker highlighted the full range of Child GG’s difficulties and recommended that she and Child H should be made the subject of Child Protection plans however, at the meeting the social worker changed her opinion as she was advised at the meeting that the involvement of the mental health preventative day service would reduce risks to Child GG and the family. Following a split decision, it was agreed that a Child in Need plan would be agreed and referrals to the mental health preventative day service, EHS and YSS would be explored again. 5.2.47 On 31st March, the social worker referred Child GG to the young people’s substance misuse service who requested confirmation of Child GG’s consent to this. 5.2.48 On 8th April, the social worker completed a child and family assessment, it had been due to be completed on the 28th January 2015. 5.2.49 On 13th April, Child GG was excluded from school. It was also decided that Child GG would not be allowed to continue attending School 2 after the Easter holidays, due to her behaviour. 5.2.50 On 14th April, Child GG’s mother informed the social worker that her daughter was frightened, as a friend has discovered she was not 17 years of age. The social worker was also told that Child GG continued to self-harm; this information was not uploaded onto the central recording system until 17th June so it could not be accessed by other staff. 5.2.51 On 15th April, EHS requested further information, following their receipt of a second referral. The same day, a crisis call was received from Child GG’s mother who said her daughter was receiving threatening texts, it was decided she would go and live with her aunt again; this information was also received from the police who visited but there is no evidence of a response by Children’s Services and there was a delay in uploading the reported concerns until 22nd July 2015.The police did not seek further information on the person Child GG said was providing her with drugs. 5.2.52 On 20th April, a Team around the Family meeting was held in school, it was agreed that concerns would be shared with Special Educational Needs managers to determine whether an education assessment was required. 10 5.2.53 On 21st April, the social worker referred Child GG to the mental health preventative day service as agreed at the ICPC on 31st March and discussed with the ASD worker about whether she could offer Child GG support, the ASD worker stated that Child GG’s needs were beyond her expertise and as Child GG was living with her grandparents in another local authority area it would not be appropriate anyway. 5.2.54 On 23rd April, the first Child in Need meeting was held, the social worker inappropriately chaired it, instead of an ATM. There was no review of the recommendations made at the ICPC. 5.2.55 On 24th April 2015, the police identified that the above joint visit had not taken place and recorded this again on 14th May, adding that it would appear a single agency visit had been made by Children’s Services and they had decided that Child GG was not ‘at risk’. It was agreed that the police should undertake their own interview, on 17th June 2015 the police identified that they had not done so and a visit was made the same day. 5.2.56 On 27th April, the young people’s substance misuse service responded, within timescales, to the referral they had received. 5.2.57 On 5th May, an Education, Health and Care Needs Assessment (EHCN) was requested by a paediatrician. 5.2.58 On 8th May, School 1 informed School 2 that the mental health preventative day service had not accepted the referral for their involvement. 5.2.59 On 14th May, the social worker made the third referral to EHS as the mental health preventative day service had not accepted the referral to them. 5.2.60 On the 21st May, EHS advised the social worker that they would close the referral to them so that the social worker could pursue a referral to the mental health preventative day service which was more likely to be accepted if they did not attend discussions. 5.2.61 By the 27th May, Child GG returned home and was saying she did not want to be involved with the mental health preventative day service, as she had previously agreed, as she would know people who also attended. Child H was reported to be more subdued following his half-sister’s return home. 5.2.62 On 3rd June, Child GG and her mother were seen at a doctor’s clinic in the local hospital and follow up appointments was made for Child GG to be seen at the ADHD clinic. 5.2.63 On 4th June, the YSS worker informed the family support worker that Child GG had been visiting people in Nottingham, Leeds, Manchester and Ireland. No consideration of a strategy meeting appears to have taken place. The same day, a meeting at School 1 discussed whether Child GG could attend the mental health preventative day service. The mental health preventative day service appeared unclear as to whether she would meet their criteria and said they would require a referral from EHS so it was agreed Child GG would first be referred to EHS. 11 5.2.64 On 5th June, the family support worker saw Child GG with her aunt but the records make no reference as to the appropriateness of this arrangement, how the parenting role was shared with Child GG’s mother and how safe she was. 5.2.65 On 8th June, the young people’s substance misuse service made significant efforts to contact Child GG. 5.2.66 On 10th June, Child GG’s mother informed the GP that her daughter wanted her contraceptive device removed and she was worried that this would increase her daughter’s vulnerability. Child GG was seen by the GP and stated she could manage any risk to her as she” always asks partners whether they have been tested first”. This surprising statement by a 14-year-old does not appear to have been explored by the GP. 5.2.67 On 15th June, the ATM requested that a Child in Need meeting was recorded as having been held on 4th June, there is no evidence that this meeting had taken place in Children’s Services’ records but other agencies record in their chronology that a “multi-agency meeting” had taken place (which was probably the Child in Need meeting) but there were no actions for their service. The meeting discussed Child GG’s difficulties and noted that an Education, Health and Care Plan (EHCP) had started and would be completed by September. 5.2.68 On 15th June, Child GG was discussed at a Missing and Exploited Children Conference (MAECC). Three actions were agreed (including a referral to Sliding Doors) but not allocated to a named professional and the records of the meeting do not include the discussions or an analysis of risk. On the same day, Child GG informed the young people’s substance misuse service that she did not want their support. The meeting was not used to address and resolve the number of referrals to a range of different support services. 5.2.69 On 17th June, police records evidence that CSE risk assessments/safeguarding, action and trigger plans and system markers to highlight high risk cases were added to their information systems. 5.2.70 On 18th June, Child GG’s mother informed the family support worker and the police that she had again been assaulted by her daughter who was continuing to visit a 17-year-old male in Nottingham and on occasions drinking alcohol heavily when in a public place. The records do not indicate that a strategy meeting was considered and the risks to Child H do not appear to have been assessed. On the same day EHS accepted the referral made by Children’s Services. 5.2.71 On 24th June, the police appointed a single point of contact (SPOC) in relation to the CSE risks, to facilitate information and provide a consistent response. 5.2.72 On 26th June, Child GG was reported missing from her aunt’s house having gone out to meet a man she had met on the internet. There was no consideration of a strategy meeting and Children’s Services records do not evidence that the missing children procedures were followed, for example by meeting Child GG on her return, to gather information and ensure she was safe. 12 5.2.73 On 2nd July, Child GG was allocated to the EHS service. 5.2.74 On 9th July, concerns about Child GG’s risky behaviour were shared with the local health provider of community services but not responded to by a triage assessment, in accordance with organisational guidelines. 5.2.75 On 20th July, the second MAECC was held, the records note the involvement of EHS and that Child GG had again been referred to the mental health preventative day service, even though this had been done on a previous occasion, the records do not include the difficulties of engaging Child GG in services and how this could be resolved. But it agreed that a Safeguarding Advisor should provide advice to Child GG’s parents. 5.2.76 On 24th July, the EHS service was again unable to engage Child GG, this difficulty does not appear to have been reviewed. 5.2.77 During August, there was a continued lack of engagement by Child GG and concerns about her behaviour and the risks to her continued to increase however, the records indicate that Child GG had not been seen by the EHS social worker since June 5th. 5.2.78 On 10th September, the referral to the mental health preventative day service remained pending. Alternative education provision was arranged and on-line learning was identified as a possibility. 7.2.79 On 24th September, a locum social worker requested a strategy meeting, the manager of EHS advised that this request may not be accepted as Child GG’s mother was fully engaged in supporting her daughter. 7.2.80 On 25th September, the third MAECC was held and recognised that the safeguarding plans were not working and a strategy meeting should be convened as Child GG was at high risk of CSE. Other than this action, it is unclear what the MAECC plans were. On the same day, Child GG refused to attend Sliding Doors as she thought she would be embarrassed by other young people who she knew, being there. 5.2.81 On 5th October, Child GG was reported missing and found intoxicated in London. No consideration was given to convening a strategy meeting or liaising with Surrey Police. On the same day, the alternative education provision worker had a good meeting with Child GG and following the meeting she appropriately reported her concerns about Child GG’s involvement in sexual activity, with inappropriate people. 5.2.82 On 14th October approval was given to produce an EHCP. 5.2.83 On 19th October, the EHS manager identified that agreed actions had not been completed by EHS and should be considered by a strategy meeting. On the same day, a MAECC was held and it agreed that a strategy meeting should be convened to review the plans for Child GG. 5.2.84 On 26th October, a strategy meeting was held but the minutes were not agreed until 25th November which was considerably outside timescales. A decision was made for Children’s Services to instigate section 47 enquiries 13 as a single agency i.e. not including the police, and if Children’s Services thought the thresholds were met, to convene an ICPC. It was also noted that Child GG and her mother were unwilling to engage with the EHS, YSS and the mental health preventative day service and adult mental health services were unwilling to offer support to the family as EHS has been unsuccessful in engaging the family. 5.2.85 On 29th October, management of the case was transferred to a different ATM. 5.2.86 On 2nd November, the case was transferred to new social worker within the Referral, Assessment and Intervention Team (RAIS). A robust assessment was recorded highlighting the significant risks of CSE, Child GG’s lack of engagement in services and her mother’s difficulties in managing her daughter’s behaviour. 5.2.87 On 4th November, Child GG was seen by her new social worker, following initial hostility, she engaged well with the worker and talked about her life and her wishes. 5.2.88 On 9th November, School 1 informed the social worker that Child GG was not accessing her Special educational needs (SEND) provision and asked the social worker for advice about how this could be improved. 5.2.89 On 18th November, a MAECC was held, records show that the number of missing episodes had reduced but Child GG was continuing not to engage with the police. It was agreed the police should pro-actively identify the adults involved with Child GG, through social media. 5.2.90 On 23rd November, Child GG assaulted her mother. 5.2.91 On 25th November, section 47 inquiries were completed 23 days outside timescales. On the same day, Child GG assaulted her mother and the police undertook a second Domestic Abuse, Stalking and Harassment (DASH) assessment (to identify the level of domestic abuse risk to Child GG’s mother and to child H). 5.2.92 On 28th November, Child GG was arrested for the third time, following the assault on her mother on the 23rd November. Following her arrest, her mobile phone was examined and a number of sexual messages from a male were identified. 5.2.93 On 3rd December, a second referral to the young people’s substance misuse service was received and responded to within timescales. 5.2.94 On 3rd December, a strategy discussion was held with the RAIS ATM and a single agency section 47 enquiry was agreed, to be undertaken by the police. 5.2.95 On 4th December, the police arrested an adult male on suspicion of grooming with a view to CSE, following examination of electronic equipment no evidence of inappropriate or illegal activities were found. 5.2.96 On 7th December, a MAECC was held, a summary of concerns and Child GG’s lack of engagement with services was recorded. Child GG was 14 identified as at continuing high risk of CSE and it was agreed that YSS and Sliding Doors would be offered to her. 5.2.97 On 9th December, Child GG was placed in police protection and a foster care placement was requested from Children’s Services. The police also informed Children’s Services of the extensive number of inappropriate images, texts, information about drug use, attendance at sex clubs, pictures of Child GG with large amounts of cash, countless references to drugs and the identification of 24 adult males with whom Child GG had had contact. The police also stated they were taking action against Child GG’s mother for wilful neglect, although it was subsequently decided that she had not committed an offence and her bail conditions were cancelled. Children’s Services decided a legal planning meeting would be held, to consider whether the thresholds for a Secure Accommodation Order were met for Child GG, it was also agreed that the case would be managed under the LSCB’s Complex Abuse Process and a meeting on the 10th December would be chaired by a Senior Manager. 5.2.98 On 10th December, a complex abuse strategy meeting was convened which identified a considerable number of concerns and actions to address these, including seeking consent from Child GG’s mother for her daughter to be voluntarily accommodated i.e. placed in ‘care’ and if this agreement was not obtained, consideration being given to an Emergency Protection Order and the removal of Child GG from home. The same day, with her mother’s consent, Child GG was placed in a foster home and a place in a children’s home in another local authority area was sought to move Child GG out of the area as soon as possible. 5.2.99 On 17th December, the police visited Child GG at her residential placement, she disclosed that she had been raped by an 18-year-old man and she agreed to an Achieving Best Evidence (ABE) interview, but in March 2016 it was decided that the evidence she gave did not meet evidential thresholds. 5.2.100 On 22nd December, an ICPC was held, Child GG was not placed on a child protection plan as she was a ‘looked after child’ and the subject of statutory LAC planning arrangements. 5.2.101 On 23rd December, a senior manager agreed that Child GG’s care should be managed through a Care Order and the Public Law Outline process should be used to apply for this. 5.2.102 On 19th January 2016, Child GG’s name was removed from the list of children discussed at the MAECC. 5.2.103 In January 2016, disclosures by Child GG led to the arrest of a number of adults, both male and female, due to concerns about them sexually exploiting children. It was subsequently decided that in none of the cases was there insufficient evidence to support prosecutions for criminal offences. 15 6. ANALYSIS 6.1 This section considers the quality of practice, actions, decisions, missed opportunities and improvements referenced in the terms of reference. Risk assessment and decision making What were the key points for assessment, decision making and effective intervention in this case and what was the quality and timeliness of decision-making? 6.2 Overall, the quality and timeliness of assessments (including strategy meetings to assess new information and emerging risks) was poor. 6.3 During 2014, there were clear issues of concern in relation to Child GG’s non-school attendance, aggression, self-harm, under-age sexual activity with an older boy, drug use and lack of engagement with services and taking her medication. Although individual agencies, school, CAMHS, health and the police responded and a CAF was completed, there should have been an earlier referral to Children’s Services, so that a multi-agency approach could have reviewed the information and agreed an integrated approach to support Child GG and her family and explore the risks presented by a named male. 6.4 Throughout 2015, there were several opportunities to assess and re-assess the situation and plan effective interventions but several of these were missed. The children and family assessment which commenced in January 2015, took four months to complete, well outside the 2013 statutory guidance, “Working Together to Safeguard Children” timescale of 45 days. I have reviewed the assessment and am satisfied with the content and exploration of risk and identification of need. 6.5 On 21st February, 4th March, 18th June, 26th June, 19th August, 25th September and 5th October new information and increasing concerns should have led to the consideration of strategy meetings with partner agencies, to identify the level of risks to Child GG. There appears to have been a lack of compliance and understanding about strategy meetings and when they should be convened. On 24th September, an inappropriate decision was made not to convene a strategy meeting because Child GG’s mother was fully co-operating with the plans for her daughter. On another occasion, in January 2015, it was decided not to convene a strategy meeting as a child and family assessment was being undertaken. This was not in accordance with statutory guidance which states “A strategy discussion can take place following a referral or at any other time, including during the assessment process”. On some occasions, when strategy meetings were held, they were outside SSCB timescales, the agreed actions were not appropriate and the record of decisions and actions were not completed for some time, which meant there was a lack of clarity as to what actions agencies should take and some actions were not implemented. In April 2015, the police noticed that a joint visit with Children’s Services, agreed at a strategy meeting in February, had not taken place and it appeared Children’s Services had made the visit on their own. It took until 17th June for the police to carry out their visit. On 7th December, a strategy meeting decided that section 47 enquiries should be made only by Children’s Services, which given the extensive involvement of the police, was not appropriate. 6.6 When strategy meetings were held, the children were not always seen and information as to the plan was not shared with Child GG’s mother. 16 6.7 In terms of other assessments, a paediatric assessment in 2012 diagnosed ADHD, oppositional behaviour and ASD. Child GG did not agree with the diagnoses and did not engage with support or take her medication. In March 2015, Child GG was assessed in hospital and the chronology indicates that a thorough assessment was completed and identified the complex issues and Child GG’s resistance to co-operating; an appropriate plan was also completed and included an offer of a further assessment, when and if, Child GG felt able to engage. During the review, comments were made that, following the diagnosis of ADHD, Child GG looked for information about the medication she had been prescribed on the internet. Having seen the possible side effects, she became anxious and did not want to take it, there seems to have been little exploration of the reasons for her decision. 6.8 There was some understanding of Child H’s needs and of the impact his sister’s difficulties had on him, but it was the view of RAIS at the time that he was receiving services from other agencies. A lack of exploration and oversight of what these services were, contributed to the lack of consistently effective planning until late in 2015, when he became the subject of a Child in Need plan. 6.9 It is not known whether an assessment of Child GG’s mother was made as part of the child and family assessment which, given her pivotal role in safeguarding her daughter, would have been appropriate. In December 2015, it was agreed that a parenting assessment should be undertaken through the Public Law Outline process, the purpose of this was to determine whether Child GG could safely return to live with her mother. The chronology ends before information as to whether this assessment took place could be recorded. 6.10 The decision not to make Child GG the subject of a child protection plan was based on the fact that Child GGs mother was fully cooperative and doing all she could to protect her daughter, whilst that decision was not inappropriate it was not reviewed in light of the fact that the Child in Need planning arrangements were ineffective in co-ordinating and delivering an integrated plan. At the time, there was a lack of clarity about the arrangements for children in need of statutory support with several services undertaking this work. This was identified as a failing by Ofsted in August 2015. Were the risks of sexual abuse and/or sexual exploitation to Child GG while missing from home and school, effectively considered and responded to appropriately? 6.11 Agencies were aware of the risks to Child GG of CSE from an early stage, however, as the above section states, new information was not always responded to appropriately with strategy meetings and assessments but services, particularly the police who frequently visited the family, were responsive, particularly to Child GG’s mother’s concerns. 6.12 Child GG spent a lot of time out of education, despite the efforts of schools to provide her with appropriate education. There were many occasions when Child GG was excluded from school, due to her behaviour, although she was never permanently excluded, but is not clear that an assessment of her vulnerability or the risks presented by being excluded was considered in relation to the exclusions although there was recognition of the fact that when not in school or at home she may be at risk of CSE. 6.13 There is less evidence that when Child GG was living with her aunt any assessment of her care or the management of risks was thoroughly evaluated, Child GG was not the subject of a child protection plan nor was she a ‘looked after child’ so the local authority had little authority to impose a plan however, in late 2015 a written agreement was produced to clarify the arrangements. 17 6.14 The chronology provides very little evidence that when Child GG was staying with her aunt, steps were taken to ensure she was in receipt of education, apart from a visit by the family support worker on 4th June 2015. The chronology evidences that this took place but not whether education was discussed. Resources to support Child GG, who was identified as a child with social, emotional, and mental health difficulties were agreed on the 19th August 2015. On the 10th September the chronology identifies that the EHCP to address these needs was still awaited and on the 14th October, the chronology notes that the draft plan was waiting to be written but approval had been given for the EHCP to be written by the panel. In December 2015, the SEND Team Manager was seeking for an improved SEND plan to be completed as Child GG was not accessing this provision. Child GG’s mother found the lack of consistent education very frustrating. 6.15 Children who are not in school are entitled to up to 25 hours a week of education. This is dependent on their circumstances. In February 2015, in recognition of the fact that Child GG had already had 12 fixed term exclusions School 1 contacted School 2 to suggest that Child GG should access education via virtual learning environment (VLE). In May 2015 School 1 again contacted School 2 to say that the referral to the mental health preventative day service had been turned down and as Child GG was not attending School 2 she was not receiving any education and due to her inappropriate use of the internet Child GG’s mother would not support her receiving education via a home computer; in June 2015, the school instructed staff to send work to Child GG’s home and to do so in paper versions as she had no access to a computer; in September as part of alternative education provision, support on-line learning was again considered a possibility but was subsequently provided in person. What was the quality of multi-agency risk assessments and were Child GG’s mental health needs assessed and treated appropriately? See above. Was the level of vulnerability and risk to Child GG fully understood by the different services within an organisation and effectively communicated between different services and partner agencies? 6.16 Most agencies understood Child GG’s vulnerability and risk in terms of social, physical, mental, emotional, and sexual issues and inter-agency communication by telephone and email was good. There were some occasions when health information was only shared with health agencies and some inter-agency communication was not evidenced in the records, although it may have happened. There was less use of multi-agency meetings where professionals met face to face; as previously stated, strategy meetings were not effectively managed and the Child in Need plan was not managed well. At the first ICPC there were differences of opinion about whether the children were at risk of significant harm and required a child protection plan and MAECC did not, until late in 2015, provide an effective forum for multi-agency information sharing, assessment, and planning. 6.17 The YSS social worker took the opportunity presented by the SCR to reflect on her practice; whilst she was confident that she had supported Child GG effectively, establishing a good rapport and encouraging and supporting better engagement with the social worker, she is of the view that, with the benefit of hindsight, she could have contributed more to the CSE risk assessment and could have requested that she was invited to meetings with other agencies such as the education planning meetings, this reflection is commendable professional practice. 18 Is there any evidence that a focus on other risks impacted negatively on the identification of possible child sexual exploitation? 6.18 The records do not indicate that a focus on other risks had a negative impact on the possibility of CSE. Although the understanding of CSE was at a low level early in 2015, it increased during the year. The challenges inherent in the case; Child GG’s difficulty in engaging with services and taking her medication; her frequent absences from home and school and; spending time living with her aunt, faced agencies with frequently changing demands which they had difficulty keeping up with. How effective was the Missing and Exploited Children (MAECC) procedure and its implementation in this case? What was known about child sexual exploitation at the time? 6.19 There were seven MAECC meetings that discussed Child GG’s situation between July 2015 and January 2016. MAECC was at a very early stage of development in early 2015 and there was a lack of distinction between child protection and CSE issues with professionals insufficiently informed to make the distinction. 6.20 At the practitioner’s SCR event, professionals commented that some agencies such as health, including the GP, were not informed that a child was being considered at MAECC but this has considerably improved with lead CSE nurses in Safeguarding Teams attending MAECC and triage meetings or contributing by sending reports (however, GPs are still not informed when children go missing or are excluded from education). 6.21 There was also a lack of understanding about what agencies could do, individually or collectively. This led to ineffective risk assessments and plans, there are comments in the chronology that indicate MAECC was not making any difference. 6.22 There was no separate consideration of the risks presented by alleged perpetrators and what actions could be taken to gather information and deploy effective disruptive approaches. 6.23 There have been improvements, MAECC is now more effectively chaired with Children’s Services and the police chairing separate sections to focus separately on the victim and the perpetrator however, the decision not to continue considering Child GG at MAECC when she became a ‘looked after child’ was, in my view premature. 6.24 There is also a greater focus on CSE by the police and Children’s Services, local triage panels have been introduced to discuss victims and perpetrators at an early stage, share information and put early support in place. The police Safeguarding Investigation Units (SIU) now include a specialist CSE team that focusses on medium and high risk cases and a CSE Single Point of Contact (SPOC) carries out extensive research on any adult suspects and pro-actively address any concerning behaviour by warning them, disrupting their activities and where appropriate, arresting them. Practitioners and managers who attended the SCR event commented very positively on these new arrangements. 6.25 In addition, education now contribute to MAECC meetings through the attendance of the Education Welfare Officer, education have also put additional resources into CSE and have improved multi-agency communication which has led to the earlier recognition of CSE and referrals to Children’s Services and the triage process. 19 However, there is still the need to improve the knowledge and understanding of professionals in relation to what constitutes CSE. 6.26 Some professionals I interviewed, commented on the huge increase in resources deployed in relation to CSE, the considerable increase in specialist staffing roles and the amount of time that is devoted to CSE each week, they wondered whether this is always proportionate to the scale of the problem and the impact on other types of child abuse for example physical abuse. One professional said that attending MAECC takes too much time, too many cases are discussed and the fact that not all attendees have prepared for the meeting means they take too long. In their view the same children are repeatedly discussed because the outcomes have not been positive and the same things are repeatedly tried with a lack of evaluation of the plans; they felt the discussions and plans should be more outcome focussed to make a more efficient use of the time. Were there any issues in communication, information sharing or service delivery, within, between or across localities and services, including services commissioned jointly by the agencies? Agencies should make particular reference to the arrangement for escalation of concerns within and between agencies to more senior officers. 6.27 One of the key features of this case was the difficulties experienced by agencies in co-ordinating integrated support services particularly with the mental health preventative day service, the EHS and CAMHS. There was a lack of understanding about what services each could offer and under what circumstances they would accept referrals, which wasted the social worker’s time and led to delays in effective arrangements being put in place. For example, at the practitioner’s event it was commented that Children’s Services and education had held the view that Child GG should be offered support from the mental health preventative day service but they were told that if a child is the subject of a child protection plan they would not be eligible, they therefore decided that she should be assisted as a Child in Need so that EHS could become involved and then she could access the mental health preventative service, however EHS would not accept her as she was engaged with YSS. Given the positive relationship the YSS worker established with Child GG there would have been benefit in the case continuing to be held by the service under child in need and challenging other agencies regarding the coordination of services. 6.28 Professionals who attended the SCR events commented that there needs to be a review of specialist and support services in Surrey to identify gaps and duplications and ensure that together they provide services that can meet the needs of all children at risk of CSE. 6.29 In completing the chronologies, agencies made no reference to opportunities to escalate concerns or use the SSCB escalation policy; a procedure that was agreed in 2014. When different services within agencies became involved with Child GG, was her family history sufficiently explored and understood to enable these services to fully understand the vulnerabilities and risks? 6.30 The assessments completed by social workers in April and November were good and considered the history of the family, but in respect of other agencies, there was insufficient information in the comments attached to the chronologies, to evaluate whether they all shared an understanding of the history however, this does not mean it had not been considered. Education identified that it had been difficult to work out what 20 had happened in this case, due to the lack of recording of child protection concerns by their staff, this has been addressed and decisions and actions are now recorded and designated Safeguarding Leads meet to discuss cases of concern and identify individual risks and annual audits in schools now include record keeping as part of their evaluation. When Child GG and her mother failed to engage fully with services provided, were services sufficiently persistent in promoting engagement or were there missed opportunities? Did the services within agencies have effective procedures to deal with non-engagement or non-attendance and were these procedures followed 6.31 There is evidence that services tried hard to engage Child GG but this proved difficult. Many children involved in CSE do not recognise that they are at risk and are reluctant to engage with services although non-statutory services are sometimes more attractive to them. An added difficulty was that Child GG did not accept that she needed to take her medication for her difficulties, had she been able to, her behaviour and attitude may have been different. 6.32 The information available does not enable me to address the issue of procedures to deal with non-engagement or non-attendance and I cannot see that these are addressed in the SSCB procedures. Did the services effectively communicate with Child GG in a way that she could fully understand? Were there any missed opportunities to communicate more effectively, particularly in respect of her Special Educational Needs? 6.33 The records evidence that some people were able to engage well with Child GG. For example on the 8th October 2015 the alternative education provision professional was able to enable her to share her difficulties and concerns and to divulge significant information, the chronology also comments that the police SPOC established a good relationship with Child GG and the young people’s substance misuse service used different approaches to communicate with her. When she was involved with YSS, in addressing the offence of theft through the Youth Restorative Intervention Order, she did engage well and although the consequences of not doing so may have been a factor in her engagement, she was more fully involved with the YSS workers than with some others and this was due to the structured way the worker dealt with her, the regularity and frequency of contact and the worker’s ability to communicate effectively; this view was supported by Child GG when I met her. Management oversight/supervision and accountability Was there sufficient management accountability for decision-making? What was the quality of supervision? Were senior managers or other organisations and professionals appropriately involved in the case particularly in responding to the impact of parental views? 6.34 The quality of management oversight in Children’s Services was ineffective until October 2015 when a new social worker and manager were appointed, the case should not initially have been allocated to a social worker who had only been qualified for a year and had no experience of working with children affected by CSE, she received little management advice, direction or supervision that enabled her to reflect and adapt her practice; and she carried a large caseload, as a consequence, she was not able to visit Child GG for inappropriately long periods. 21 6.35 The records evidence a lack of formal and informal supervision for the first social worker and the family support worker and there were gaps in recording when supervision took place and what was discussed. The service was under considerable pressure during the period covered by the review and management posts were covered by temporary locum staff or supported managers in other teams, the restructuring of the Child in Need team and pressure on RAIS increased the level of demand and led to a focus on progressing work through the team rather than ensuring effective practice. 6.36 The co-working of the case between the social worker and the family support worker lacked clarity as to their respective roles and there is no record of joint supervision taking place. 6.37 There was a lack of management ‘grip’ and recognition of the drift and delay in the case management and planning processes, difficulties in providing co-ordinated services both statutory and specialist were not resolved sufficiently quickly and led to frustration and increased work for the social worker. 6.38 When new Children’s Services’ management arrangements were put in place for this case in October 2015 there was a marked improvement in the effectiveness of decision making, practice and planning with good examples of senior managers over-ruling previous decisions and clearly recording their views and the reasons for them. The chronology also states that new arrangements have been put in place to ensure that strategy meetings are now better managed, recorded and the actions are implemented. 6.39 The police records indicate an example of effective management oversight when in April 2015, it was identified that an agreed action at a strategy meeting held some months earlier had not been completed, however it still took until mid-June to do so. 6.40 In education, additional safeguarding support has been increased for professional colleagues who seek advice, it is not clear whether this extends to regular case management supervision. 6.41 The chronology makes no reference to the issue of management oversight or supervision in other agencies as required by the terms of reference so I cannot comment on their effectiveness. Knowledge and understanding of CSE across agencies Consider whether all agencies when exercising its statutory and non-statutory responsibility could have done more to protect young people from child sexual exploitation and whether the range of options available was in any way limited by the actions of other agencies. What was the understanding of agencies’ roles and responsibilities in relation to perpetrators of CSE? 6.42 The police recognise that insufficient pro-active action was taken in relation to perpetrators and they have positively addressed this in several ways, see above. 22 How did agencies respond to the growing awareness of CSE? 6.43 Agencies have introduced stronger CSE arrangements, including the introduction of CSE champions in Children’s Services, more effective ways of monitoring CSE risk, the use of a CSE risk assessment tool, training, MAECC and triage arrangements. 6.44 Following a recent peer review and subsequent audit, the local authority recognises there is a need for stronger oversight, by MAECC, of children at risk of, or subject to CSE and work on this is being taken forward. 7. PRACTITIONERS/MANAGERS’ EVENT 7.1 In July 2016 two events were held to hear from practitioners and managers, their views of the quality of care and support given to Child GG, whether practice had been poor or good why this was; and what improvements had been implemented and what remained to be done. These events were attended by 19 professionals from across agencies. Their views are included throughout this report. 8. RESEARCH 8.1 Research in recent years has identified several challenges; and learning points for all agencies in relation to CSE. 8.1.1 In Ofsted’s Thematic Review of SCR’s (2011) involving teenagers who were being sexually exploited, they note ‘there was a failure to understand the impact of coercion by the abusers on their (young people) behaviours and to assess their capacity to make informed choices’ and it also identified criminalization of their behaviour rather than the identification of their victim status. In many of the reviews, the problems of drift, lack of collaboration and coordination, assuming others were managing welfare, and lack of inter-agency challenge were present. 8.1.2 S Hullitt (2016) notes the complex issues involved with caring for young people who are victims of CSE, in that the young person often does not differentiate adults and may perceive the care as negative surveillance. Young people who have fragmented experiences, because of fragility in their families, bereavement and their own cognitive functioning, may have a relationship to power and authority, and adults around them that lead them towards exploitative relationships. She goes on to suggest that CSE is a complex issue, beyond the narrow practice of child protection responses. 8.1.3 The NSPCC Review (2013) notes that CSE can be particularly hard for professionals to recognise and respond to. Confusion around young people’s rights and their capacity to consent to sexual activity, means both young people and professionals often wrongly view exploitative relationships as consensual. This means that sexual exploitation often goes unidentified and young people can be reluctant to engage with services. Practitioners need to persevere to engage young people and need to be aware of the child protection implications of sexual activity. The focus should be on ensuring young people’s safety, protection, and 23 wellbeing rather than managing their challenging or risk taking behaviours. This review also notes the need to recognise the child’s vulnerability and not criminalize their behaviour and in addition the importance of early and comprehensive assessment. Assessing the capacity to consent must include the consideration of the coercive nature of grooming. The review also notes the vulnerabilities of children involved in CSE. So, whilst there was the opportunity to learn from the Thematic Ofsted (2011) review and information coming out of the reviews in Derby and Rochdale many services were only getting to grips with the impact of grooming and CSE at the end of 2013. 8.1.4 The question for SSCB is whether changes in the meantime would alter the outcome for Child GG if she presented to the system today. Several professionals who participated in this review said they felt the knowledge and management of CSE had improved in the last year and today a child would be more effectively supported. 9. EMERGING THEMES 9.1 During the review some learning themes that were identified included: The importance of the skills and time to build effective relationships with children who find it difficult to engage; recognition that some children involved in CSE find it difficult to accept they are being exploited and that some respond well to consistent, clear and structured relationships. It is interesting that Child GG said the reason she got on with some professionals was that they always ‘turned up’ took ‘no nonsense’ and she knew they would never ‘give up’ on her. She said that others did not visit her due to absences from work that were not addressed by management action, that they spoke ‘down’ to her and treated her like ‘a little kid’ and she resented both their caring but patronising tone and the fact they said they knew how she felt and what she had been through, when in her view, they could not. The importance of professionals understanding the impact of conditions such as ADHD, oppositional behaviour and ASD and the typical features of these in terms of the child’s behaviour and understanding. These features can include impulsivity, difficulties in understanding the impact of their behaviour on others and the consequences of their actions. Child GG naturally wanted to be seen as a normal child and was at pains to point out to me that she was ‘not stupid or sick’. I was told by some professionals that they knew that, following her diagnosis, she looked up the side effects of her medication and this was the reason she did not want to take it. There were at times difficulties in professionals deciding what was normal adolescent behaviour and what was due to her conditions but there was less understanding of the impact of CSE on her behaviour. The importance of skilled, informed supervision and management oversight and the benefits of securing professional expertise such as CAMHS in supporting the understanding of professionals and how best to manage challenging behaviour. The need to consider and minimise the impact of a challenging child, especially one who was suffering from the control, fear and influence of external perpetrators, on the family, including the impact on her younger brother and her 24 mother who was herself the victim of domestic abuse, however unintentional. Child GG’s mother describes this summer as the worst they had ever experienced, unable to leave Child GG unattended at any time she has been unable to ensure her son also enjoyed his school summer holidays. Child GG’s mother undoubtedly did all she could to control and support her daughter when professionals were struggling to do so too. Arresting her for neglect was a particularly inappropriate thing to do. The need to avoid ‘blaming’ or holding children suffering from CSE as somehow responsible for the abuse; it was very saddening to hear from Child GG that she knew she had done ‘bad things’ and it was all her fault. As identified consistently in SCRs nationally, the importance of professionals sharing information, pro-actively seeking information and clarification and not assuming that they will be told if there is something they need to know. Equally important in terms of sharing information is the need to invite the right people to meetings, during the review some professionals commented that; GPs are not informed if a child is being considered at MAECC nor when a child is missing or excluded from school, until recently health and schools were not asked for information by MAECC and now they are only asked about high risk cases, some agencies said they were not aware of all the activity around Child GG because information was not always shared in referrals to their services, some said they had experienced difficulties in knowing which professionals were already involved. 10. CONCLUSION 10.1 This review examines practice, processes and services during 2015, at the beginning of which, knowledge of CSE in all services was at a low base and agencies did not have effective arrangements in place to identify and address it. There was poor practice, management oversight, supervision and decision making in Children’s Services; although practitioners were committed to Child GG they were not able with others to prevent the abuse due to a lack of knowledge, skills, capacity and a co-ordinated approach within which to work, however, the improved management oversight in October 2015 marked a turning point in the case with significant improvements evident across services. 10.2 The police recognise that their knowledge of CSE, absence of designated specialist officers and a lack of focus on perpetrators and the measures the police could take to divert and gather information on them, were key factors until late in 2015, the introduction of MAECC was a positive development but it took time to work effectively and a recent review has identified further improvements to be made. 10.3 Although Child GG received significant support and commitment from one school she did not have a statement of Special Educational Needs. Her mother feels this is the thing that could have helped most; that had her daughter had additional support she would have been able to remain involved in school, had fewer behavioural difficulties and exclusions and ultimately being sent to what were in her view ‘unsuitable schools’. The SEN was first suggested when Child GG was in year 7 but her mother feels there was resistance to the forms being completed as it was believed there was nothing wrong with her daughter and the problem was the relationship between them. It was not until earlier this year (2016) that the SEN plan was completed, well outside expected timescales. Child GG received very little education during 2015, despite the 25 statutory amount to be provided is 25 hours per week, this could have had a detrimental impact on her education and her future outcomes unless they are being addressed. 10.4 The level of confusion about what specialist and support services could deliver and what their criteria were, led to wasted time and effort and from comments made at the practitioner’s event appears to remain. There appeared to be a lack of flexibility about services to meet the needs of the child. 10.5 During 2015, significant parallel improvements were taking place, awareness of CSE was raised considerably, additional services were being put in place, MAECC and triage arrangements became established and management oversight and supervision improved in Children’s Services health and education. 10.6 This report sets out the improvements that have been put in place and the commitment, increasing knowledge and confidence of practitioners in identifying and addressing CSE. However, two peer reviews, of CSE including one by the Local Government Association and one of MAECC by an Independent Consultant, have made a substantial number of recommendations. It is for agencies and the SSCB to determine the extent to which improvements have been made and the recommendations from the external reviews have been implemented and are making a real difference and what improvements still need to be developed and delivered. 11. RECOMMENDATIONS The SSCB should: 1. Assess and if necessary, improve the extent of current knowledge about CSE and the features and manifestations of adolescent behaviour, ADHD and ASD so that professionals can distinguish between these. 2. Review the skills of professionals in building positive relationship with children particularly those who professionals find it challenging to engage and the extent to which professionals are knowledgeable about what assists in building relationships - honesty, trust, time persistence structure and consistency. If this is found to be inconsistent or staff lack confidence, the SSCB should provide multi-agency training to address this. 3. Audit the extent to which effective, reflective supervision and management oversight and decision making is implemented across agencies, acknowledging that supervision means different things in different agencies. 4. Audit the extent to which children involved in or at risk of CSE are no longer blamed or held responsible and that records are respectful about the child and their family. 5. Ensure that the significant improvements across all services and arrangements such as triaging and MAECC are embedded. 6. Raise awareness of CSE with taxi drivers, hotels, after school clubs, youth groups, park wardens and sports clubs. 26 7. Satisfy itself that professionals understand that information sharing involves joint responsibilities for providing and seeking information and that the Board’s escalation policy is understood and effectively used. 8. Map the range of specialist and voluntary services that are provided and commissioned to assist children, not just those involved in CSE and where necessary re-commission or commission services to fill the gaps. Whilst this work is being undertaken, knowledge about what services provide, their thresholds and the referral pathways should be widely shared. 27 Appendix 1 Scope and Terms of Reference for the Serious Case Review (SCR) in relation to Child GG Elaine Coleridge-Smith Surrey Safeguarding Children Board (SSCB) Independent Chair agreed to hold a Serious Case Review on 30/03/2016. A Serious Incident Notification to Ofsted was made on 19/05/2016. 1. The events leading to the decision to conduct a SCR and scope of the review The SSCB is undertaking a SCR as a result of a referral by Surrey Police. A request for information was sent to all partner agencies that are members to the SCRG for information and upon consideration of the submitted information it was agreed that the criteria were met for a SCR. The SSCB will review the management of involvement by all agencies with Child GG and her family in line with the requirements in chapter four of Working Together 2015. The review seeks to explore how agencies worked together in identifying and managing risks, especially around child sexual exploitation. The review will identify strengths and improvements in the safeguarding system, especially in relation to child sexual exploitation, as well as potential learning for the LSCB and partner agencies 2. Methodology of the SCR This Serious Case Review is going to be carried out using some of the principles embedded within the SCIE approach. This methodological approach has been selected to enhance the understanding as to why decisions were made and services delivered in a particular way and to assist the benchmarking of the impact of recent changes to the multi-agency approach to CSE. It is really important that agencies and individuals involved in providing services to Child GG and her family recognise that the purpose of this process is to identify learning and not to apportion blame. Agencies will be asked to provide a chronology detailing their involvement with Child GG and any relevant data with other family members, namely her mother and sibling (Child H). As part of the chronology, agencies are requested to include comments against entries where appropriate to enhance the understanding of the context of their involvement. Practitioners that have been involved in providing services to the family will be invited to attend a facilitated event, where the key terms of reference will be explored. Following this event, individuals and managers, where relevant, may be contacted by the overview author to provide further clarification. The independent author will compile a report based on information from chronologies, the practitioners’ event and individual consultations with practitioners and managers. This report will be shared in a follow-up event with practitioners who participated in the earlier facilitated event and managers who might have been consulted. 28 At the start of the process, a briefing event will be held for the professionals that will be involved in writing the chronology or attending the facilitated events and individual consultations. Managers are also welcome to the briefing event as they may be consulted on a one-to-one basis. 3. Terms of reference of the SCR The purposes of this review are to: establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra- and inter-agency working and better safeguard and promote the welfare of children. The experiences of Child GG and how well services responded to her needs will be explored through the facilitated event and individual follow-up consultations (if required), by considering the following broad themes: 1. Risk assessment and decision making What were the key points for assessment, decision making and effective intervention in this case and what was the quality and timeliness of decision-making? Were the risks of sexual abuse and/or sexual exploitation to Child GG while missing from home and school effectively considered and responded to appropriately? What was the quality of multi-agency risk assessments and were Child GG’s mental health needs assessed and treated appropriately? Was the level of vulnerability and risk to Child GG fully understood by the different services within an organisation and effectively communicated between different services and partner agencies? Is there any evidence that a focus on other risks impacted negatively on the identification of possible child sexual exploitation? 2. Intervention and aligned processes How effective was the Missing and Exploited Children (MAECC) procedure and its implementation in this case? What was known about child sexual exploitation at the time? Were there any issues in communication, information sharing or service delivery, within, between or across localities and services, including services commissioned jointly by the agencies? Agencies should make 29 particular reference to the arrangement for escalation of concerns within and between agencies to more senior officers. When different services within agencies became involved with Child GG, was her family history sufficiently explored and understood to enable these services to fully understand the vulnerabilities and risks? When Child GG and her mother failed to engage fully with services provided, were services sufficiently persistent in promoting engagement or were there missed opportunities? Did the services within agencies have effective procedures to deal with non-engagement or non-attendance and were these procedures folllowed? Did the services effectively communicate with Child GG in a way that she could fully understand? Were there any missed opportunities to communicate more effectively, particularly in respect of her Special Educational Needs? 3. Management oversight/supervision and accountability Was there sufficient management accountability for decision-making? What was the quality of supervision? Were senior managers or other organisations and professionals appropriately involved in the case particularly in responding to the impact of parental views? 4. Knowledge and understanding of CSE across agencies Consider whether all agencies when exercising its statutory and non-statutory responsibility could have done more to protect young people from child sexual exploitation and whether the range of options available was in any way limited by the actions of other agencies. What was the understanding of agencies’ roles and responsibilities in relation to perpetrators of CSE? How did agencies respond to the growing awareness of CSE? 4. Time period for review The principal focus of the serious case review will be from 01.01.2015 until 31.12.2015. The review will invite all agencies to provide a summary of all significant events and relevant family history outside the specific scope and timescale, where this will help to inform the overall analysis. 5. SCR panel membership The SCR group will be formed from the following agencies: Surrey Children’s Service, Surrey Youth Service, Surrey Schools and Learning, Surrey Police, Local Clinical Commissioning Group, National Probation Service and Kent Surrey Sussex Community Rehabilitation Company. 30 The SCR group is chaired by Amanda Boodhoo, Designated Nurse for Safeguarding. The SCR overview author will be Glenys Johnston Independent Safeguarding Consultant. Additional members will be co-opted if specialist knowledge is required. 6. Surrey agencies currently believed to be involved The following agencies are known to have been involved at this point: SCC Children’s Services SCC Youth Support Service SCC Schools and Learning Surrey Police CAMHS Local health provider of community services Local hospital Mental health preventative day service Young people’s substance misuse service Local Clinical Commissioning Group (Surrey General Practitioners) If other agencies are identified they will be asked to contribute as appropriate. 7. External agencies currently believed to be involved No agency external to Surrey identified as being involved in this case. 8. Managing public, family and media interest Family interest in the review will be considered by the SCR and the panel chair. Child GG and members of her family will be invited to contribute to the review by meeting with the overview author towards the end of the process. Media and other public interest in the review will be managed in line with the agreed SSCB press / media strategy. The subjects and other family members will not be identified by the SSCB and all agencies will take whatever steps are appropriate to reduce the likelihood of identification in criminal proceedings if these occur. 9. Legal advice to the SCR The Principal Solicitor Surrey County Council is an adviser to the SSCB and will advise the SCR panel, SCR panel chair and chair of LSCB as required. |
NC047420 | Death of E, a 17-year-old boy, from injuries sustained by hanging in December 2014. Coroner returned an open conclusion on whether E's death had been an accident or suicide. The local authority looked after E from when he was 3-years-old in a 'Family and Friends' placement with his maternal aunt and her partner. He spent time in respite foster care and before his death, moved to the same area as his birth father. Family history includes: mother's mental health and substance misuse difficulties; mother's death from an overdose when E was 8-years old and the absence of E's birth father for much of his childhood. E faced difficulties including: emotional distress; challenging behaviour at home; being known to the police and alcohol and substance misuse. Findings include: there is a tension between the roles of the local authority as corporate parent and 'Family and Friends' carers who can be seen as 'parents', this can result in blurred boundaries and difficulties asserting the local authority's statutory responsibility for a child when this is needed; due to inconsistent standards in transfer summaries and chronologies, new social workers do not always receive enough background information to gain an holistic understanding of the needs and risks facing young people and their carers. Uses the Social Care Institute for Excellence (SCIE) learning together systems model and poses questions for the local safeguarding children board based on the findings.
| Title: Serious case review: Child E. LSCB: Brighton and Hove Safeguarding Children Board Author: Sally Trench and Leighe Rogers Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child E Serious Case Review – Brighton & Hove LSCB Page 1 Brighton & Hove Safeguarding Children Board Serious Case Review: Child E Lead Reviewers: Sally Trench Leighe Rogers April 2016 Child E Serious Case Review – Brighton & Hove LSCB Page 2 CONTENTS Title Page A Introduction 3 1. Why this case is being reviewed 3 2. Succinct summary of case 3 3. Time frame 4 4. Family composition 4 5. Research questions 5 6. Methodology 5 7. Methodological comment and limitations 6 B Findings 8 8. Introduction 8 9. Appraisal of professional practice in this case: a synopsis 8 10. What is it about this cases that makes it act as a window on practice more widely? 24 11. Findings list 25 12. Findings in detail 26 Finding 1 26 Finding 2 29 Finding 3 32 Finding 4 34 Finding 5 39 Finding 6 41 Finding 7 43 Finding 8 46 13. Additional learning 49 14. Conclusion 51 Glossary: terms and acronyms 52 References 53 Appendix 1: Learning Together methodology and process 55 Child E Serious Case Review – Brighton & Hove LSCB Page 3 A. INTRODUCTION 1. Why this case is being reviewed 1.1 Brighton & Hove Safeguarding Children Board (BHSCB) agreed to conduct a Serious Case Review (SCR) regarding E, a child in care who was seriously injured by hanging on 1st December 2014, and who died in hospital the following day, 2nd December 2014. 1.2 1.2 The Case Review Subcommittee considered E’s death at their meeting of 13th January 2015, and recommended the commissioning of an SCR to the Independent Board Chairperson. This decision was supported by the Chairperson, subject to a peer review from another Independent Chairperson. Once the decision was endorsed, Lead Reviewers were appointed and planning for the SCR began in March 2015. 1.3 The decision was in line with the following guidance for undertaking an SCR: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died [of suspected suicide] and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.1 1.4 The parallel process of the inquest did not affect the commencement of the SCR, especially as the Coroner’s Court can sometimes be considerably delayed. The Board Chairperson was in correspondence with the Coroner to confirm the Board’s decision-making. 2. Succinct summary of case 2.1 E was a 17 year old boy, approaching his 18th birthday, when he died. He had been looked after by Brighton & Hove Council (via a Full Care Order2, conferring Parental Responsibility on the local authority) from the age of 3 years, in a ‘Family and Friends’ placement with his maternal aunt and her partner3. His mother, who had mental health and substance misuse problems, was unable to care for him, and died of a drugs overdose when E was 8 years old. Her own mother and brother committed suicide, and it appears that she also intentionally took her own life. Before her death, she had continued for several years to have inconsistent contact with E, who was clearly distressed by her absence. His parents had split up when he was a baby, and E’s father was absent, and his whereabouts unknown, throughout his childhood. 2.2 In these circumstances, his placement with his close maternal relatives was extremely fortunate. The family regarded E as their son, and were committed to giving him a secure and loving family life. Although Adoption and a Residence Order were both considered by the family, neither was proceeded with, on the grounds that they believed extra support for E from the local authority (LA) would be needed as he grew up and especially in adolescence. 2.3 E liked school and did reasonably well in his studies. He was charming, polite and willing – thus popular with school staff as well as pupils. Elsewhere, however, his behaviour, especially as he reached adolescence, became increasingly challenging at home, and risk-taking elsewhere; he began to come to the notice of the police, sometimes in association with other 1 Working Together to Safeguard Children, 2013 (since revised in 2015), and Local Safeguarding Children Boards Regulations, 2006 (Regulation 5) 2 Children Act 1989, S31 3 E’s maternal aunt is referred to throughout this report as ‘Foster Mother’ (FM) and her partner as ‘Foster Father’ (FF). Child E Serious Case Review – Brighton & Hove LSCB Page 4 young people, and there were concerns that he was experimenting with alcohol and drugs. There were also signs that he was very anxious at times, and troubled about his identity and his past, about which he wanted to know more. 2.4 Just before his 16th birthday, E’s birth father (BF) telephoned B&H Children’s Social Work Services and expressed his wish to know about and have contact with his son. E was told about this a few months later, after his GCSEs had been completed. Initially, he wanted only ‘online’ contact with his father, and this remained the situation until shortly before his death. 2.5 During E’s first year of college, his anti-social behaviour outside the home, and anger and sometimes violence within it, increased. The placement was for many months at severe risk of disruption, and this eventually happened in October 2014. At this point, E went into respite foster care in a nearby town. 2.6 E returned home after about 5 weeks, following a burglary in FM and FF’s house, for which he blamed a friend and his ‘associates’. E’s subsequent assault on this boy led swiftly to an exchange of social media threats which apparently terrified E and prompted his desire to leave Brighton immediately. Under extreme pressure from E, a temporary plan was agreed by his carers and Children’s Social Work Services for him to stay ‘under the wing’ of his father in the Home Counties, while an urgent foster placement was sought in that area. 2.7 Five days after this move, E was discovered to have hanged himself in his father’s friend’s house, and died in hospital shortly after. 2.8 The Coroner’s judgement about causation was as follows: ‘I am going to return an open conclusion. There is insufficient evidence to conclude that this was either an accident or suicide.’ 3. Time frame 3.1 The Learning Together4model of case reviews focuses on a recent period of time, so that current multi-agency systems can be examined, and staff who have been involved with the child and family are more likely to be available to contribute to the review. In this case, we aimed to capture the major changes for E as he turned 16, and in his last year of school. We therefore chose the period: January 2013 to date of death, 2nd December 2014 3.2 As part of the process of the review, E’s earlier history was considered as a backdrop to the events of this period, but not analysed in detail. It was fortunate that many of those involved in the review had known E and his family for many years, and could comment on their story over time. This added perspective and context about how the placement had been managed prior to the period under review. 4. Family Composition 4.1 E lived with his maternal aunt and her partner, and his younger cousin. His birth father has a wife and two children, all of whom live in another part of the country. The family are all White British. 4 Social Care Institute for Excellence (SCIE) systems model, developed by Fish, Munro and Bairstow, and now used for learning reviews and Serious Case Reviews. Please see Appendix 2 for details. Child E Serious Case Review – Brighton & Hove LSCB Page 5 4.2 As a very small child, E began to spend periods of time in the care of his aunt and her partner, because his mother was sometimes unable to look after him. From the age of 3 onwards, he lived full-time with this family, in a ‘Family and Friends’ fostering arrangement. This report has highlighted the complexity of such an arrangement, especially where it is very longstanding, and where the family members are both relatives (aunt and uncle) and foster carers, and in addition have come to regard themselves as ‘parents’ of the child. 5. Research questions 5.1 The research questions which underpin a Learning Together review represent the areas of learning which are expected from a particular case. They do not constrain other potential areas of learning. In this case, Brighton & Hove LSCB set the following questions: What can we learn about the challenges of working together with looked-after children (and their families) when they reach adolescence, especially for those children where… there has been a long-term placement with kinship carers; there is a risk of placement breakdown; there is a family history of suicide; and there may be a vulnerability to group activity. 6. Methodology 6.1 The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – what happened and why in that particular context – to identify what may be the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ and which constitute the wider learning which local authorities and LSCBs are expected to pursue. Details of the Learning Together model and the process of this review are in Appendix 1 of this report. 6.2 Review expertise and independence The review was led by two independent professionals: Sally Trench is an accredited SCIE reviewer with extensive experience of writing SCRs, using both traditional Part 8 methodology, as well as more recent systems models. She is also an SCR Panel Chair, with a lengthy background in local authority social work (adult mental health, children and families/child protection, and quality assurance). Leighe Rogers was Director of Operations and former Interim Chief Executive with Kent Surrey and Sussex Community Rehabilitation Company and Surrey and Sussex Probation Trust. In both these capacities Leighe was organisational lead for Child Protection. She has been a member of several Local Safeguarding Children Boards and recent Chair of the Brighton & Hove Case Review Subcommittee. Leighe has experience as Chair of SCRs and author of Individual Management Reviews (IMRs). She has completed SCIE training and is working towards accreditation as a SCIE reviewer. Child E Serious Case Review – Brighton & Hove LSCB Page 6 7. Methodological comment and limitations 7.1 In this case, all the elements of a full SCR using the Learning Together systems approach were adopted. Review Team membership was at a senior level with representation from Children’s Services (including Social Work, Education and Youth Services), Health, Education and Police. There was a large Case Group (the professionals who worked with the child/family), with similar agency representation made up of front-line staff, and middle and senior managers. 7.2 There were challenges for how the Review Team operated, which affected both the process of the review and the stages of agreeing a final report. The following factors proved to be constraints: Appropriate Children’s Social Work Services representation was not established until after the review process was well underway, and their nominated member of the group was replaced at the last meeting by someone who had not previously been part of the review. The changes were particularly unfortunate because of the central role of this agency, given E’s status as a looked-after child. Membership of Review Team meetings was affected by a number of absences. Contextual information about agencies, and previous LSCB learning which might help underpin this review, were not consistently flagged up and made available during the analysis of the material and formulation of findings. Hard evidence, requested from Review Team members, was not always provided in a timely or reliable way. 7.3 Membership and attendance 7.3.1 The Review Team and Case Group 7.3.1.1 The Review Team met 10 times (more than is usual, given the complexity of the case). Four of these meetings included the Case Group, for one introductory half day and three extended ‘feedback’ half-days. Whilst the Lead Reviewers feel the commitment to the review process was strong, this was not always reflected in attendance at meetings, for both the Review Team and the Case Group. The initial Children’s Social Work Services representative on the Review Team was replaced once his involvement in the case became clear and he then participated as a member of the Case Group. 7.3.2 Limitations on the Review Process 7.3.2.1 Some absences from meetings were unavoidable because of illness, leave or other work pressures. In other instances, the distress felt in relation to E’s death was a factor, and we were aware how difficult it was at times for some people to take part. However, we (the Review Team) were also conscious that some practitioners, including those under extreme stress, were nonetheless committed to participating as fully as possible, managed to do so, and made important contributions to the learning. 7.3.2.2 The review ran in parallel with E’s inquest and this had a significant emotional effect for all those involved, first and foremost members of his family. The impact on professionals, many of whom had been working with E over a number of years or for shorter periods before his death, was a palpable and consistent feature within the Case Group. 7.3.2.3 Several of the initial meetings for this SCR coincided with the first stages of a major reorganisation in Children’s Social Work Services. This meant that, for many staff who were being asked to participate in the SCR, there was at that same time uncertainty in relation to Child E Serious Case Review – Brighton & Hove LSCB Page 7 their jobs and their futures. This was thus not an ideal context for taking part in another stressful process in a positive way. 7.3.2.4 Alongside anxiety and sadness within the Case Group, there were some tensions across different parts of Children’s Social Work Services, which appeared to affect people’s openness to taking part in a collaborative learning process. These appeared to relate to the different approach of workers with responsibility for the child (the ‘looked-after’ team) and those who supported the carers. 7.3.2.5 More widely, conflicting views remained within the Case Group as to the validity of the emerging findings and about the appraisal of certain areas of practice. An additional meeting was used to address these, but did not entirely resolve them. This can occur in case reviews when a number of people are involved, and is a reminder that absolute unanimity on conclusions is not always achievable. 7.4 Family participation 7.4.1 Involving family members is an expected and important part of a Learning Together review. The adults in this case (FM and FF, and BF and his wife) were invited to meet with the Lead Reviewers and to contribute their views in relation to services provided to E and to them. Several efforts were made in order to achieve this, and a meeting between the Lead Reviewers and BF and his wife was held. This enabled us to share their input with the Review Team at an early stage. Until later in the review, FM was unwilling to meet anyone in person, and instead provided a long written statement giving her views. 7.4.2 After the draft report was completed, all family members were invited and accepted our offer to read it through and give their feedback directly to the Lead Reviewers. As a result, some errors of fact were corrected in the final version, and their views have been inserted at appropriate points in the text of the review. 7.4.3 It was clearly very difficult and distressing for the family members to undertake this work with us. Not only was it time-consuming for them but they had also to make arrangements to miss work and for child care. The process required them to think back in detail about all that had happened for E and for themselves. As might be expected this was a painful process for them. We are very grateful that they have been prepared to participate and help us think about how services might be improved for other young people. 7.4.4 A summary of the views of BF and FM: BF and FM expressed a very strong sense of anger at the actions of agencies, Children’s Social Work Services in particular. They believed that E would not have died had he not been allowed to go to the local authority area of BF. They felt that there had been ‘a total lack of preparation, a failure to follow protocols, and, more generally, a lack of resources offered to E’ (an example given was the over-use of agency workers in 2013/14, and E’s loss, when he moved teams at age 16, of the Social Work Resource Officer, whom he had known for many years and to whom he was attached). 7.5 Gathering data 7.5.1 Members of the Review Team conducted a total of 24 individual conversations with members of the Case Group. These included contributions from staff from all the services named above, as well as a conversation with E’s GP and the Foster Parents responsible for a brief period of respite care. Overall the Review Team was impressed by the quality of the information gained Child E Serious Case Review – Brighton & Hove LSCB Page 8 from individual conversations and the commitment of those concerned to the review process. With large numbers of potential conversations and the time available, there was a need to prioritise. We did not interview Child and Adolescent Mental Health Services (CAMHS) practitioners, who were not involved during the time scale reviewed, although there had been brief contact with E and FM in late 2012. A query about E’s mental health needs and his reluctance to use CAMH services will be picked up in a later section of this report (Additional Learning: para 13.1), rather than in a substantive finding. The named nurse for CAMHS took part in the initial Review Team meeting, and later gave feedback on the final report, which has been incorporated. The RUOK worker (who did not know E) was not seen for a conversation, but was a member of the Case Group, and was able to offer advice from the perspective of her specialist agency. 7.5.2 The establishment of a consistent evidenced narrative about E, his family history and the involvement of professionals over many years, was hampered by some difficulties in gaining timely access to records and the sometimes conflicting information held by contributors. However, a large amount of useful documentation was reviewed (a list is included in Appendix 1, Para 10.4). B. REVIEW FINDINGS What light has this case review shed on the reliability of our systems to keep children safe? 8. Introduction 8.1 The Findings – the main body of the report – begin with a synopsis of the appraisal of practice. This sets out the views of the Review Team about how timely and effective the interventions with E and his family were, including good practice but also identifying where practice fell below expected standards. Where possible, it provides explanations for this practice, or indicates where these will be discussed more fully in the detailed findings. 8.2 There is then a section to help the reader move from the case-specific detail to its more general relevance: this section explains the ways in which features of this case are common to other work that professionals conduct with children and families, and therefore how they can provide useful organisational learning to underpin improvement (‘a window on the system’5). 8.3 Finally, the report discusses in detail the 8 priority findings that have emerged from the review. The findings explore how well local safeguarding systems are supporting individuals, teams and whole services to offer effective help to children and families. They also outline the evidence that indicates that these are not one-off issues, but underlying patterns – which have the potential to influence future practice in similar cases. 9. Appraisal of professional practice in this case – a synopsis 9.1 Introduction 9.1.1 This appraisal section is set out in chronological order, and briefly makes reference to when E first became a looked-after child. E was subject to a Full Care Order for almost all of his childhood, with the LA acting as his Corporate Parent. As a consequence, it is inevitable that 5 Vincent, 2004 Child E Serious Case Review – Brighton & Hove LSCB Page 9 much of the practice analysed in this report, and most of the findings, relate to Children’s Social Work Services 9. 1.2 The Review Team are aware that some of the practice and systems identified as problematic are already being addressed strategically within and across agencies. In the relevant findings, we give an account of some of the changes that have happened or are underway. The Board’s response to this report will have a fuller description of these developments and improvements. 9.1.3 The most comprehensive change, since the period covered by the review, has been that within Children’s Social Work Services, where their structure and ethos have been redesigned to respond to difficulties identified in recent times. These related to problems of staff retention, and recruitment of managers; of weak management and non-reflective supervision; and of large teams which meant that children and families as service users experienced too many transitions/changes of workers. It is fair to say that most of these featured, in one way or another, in E’s case. 9.1.4 The new structure has smaller teams (pods) which are aimed at providing continuity of social workers for the service users, the restoral of relationship-based work, and the collaboration of the whole team in cases via weekly group supervision. The aim is to work effectively with individual children and parents, and to promote safe and stable families. Staff support will be provided by developing their skills and through the use of better models of supervision and management. 9.2 Overall, E’s story highlights many of the complex issues faced by LA Children’s Social Work Services in discharging their responsibilities as the Corporate Parent of a child in the long-term care of family members. His placement with his maternal aunt and uncle afforded him the opportunity for permanence and a sense of belonging. Almost everyone we spoke with described close and loving relationships between these family members and saw that E regarded his foster parents as his mum and dad. The foster parents similarly regarded E as their son. 9.3 However, we heard from some of those who were closest to him that there were times during his childhood, and especially as E grew older and began to have renewed questions about his past and familial relationships, that his status as a child in care increasingly troubled him. To him, this made him feel different from his foster parents’ biological son, E’s first cousin and also his ‘brother’. (FM has stated that this was not the case. She believes that E was not treated differently within the family, nor did he feel that he was.) 9.4 The early involvement of agencies with E and his family – prior to the period under review, January 2013 until December 2014 – is critical to gaining an understanding of how professionals over time approached and understood their roles in managing the case. When appraising the practice of these professionals, we have seen how the more recent context was affected by FM and FF’s initial approval as F&F carers, at a time when statutory guidance about their assessment and approval, and the requirements for working with such placements, were very different from current practice. At that time, there were far fewer formal expectations of F&F carers, and the rigorous requirements which are now in place for all foster carers did not apply (e.g., levels of annual training, unannounced visits, etc.) Thus, there was an ‘inherited’ pattern for the LA of working with this family, formed by earlier decisions and relationships with the carers. Child E Serious Case Review – Brighton & Hove LSCB Page 10 9.5 Until early 2013, there was a largely consistent group of Children’s Social Work Services workers and managers, as well as the Designated Teacher for Looked-after Children at his secondary school, all of whom had known E for several years. This was positive for all concerned, in that relationships could be sustained, and the professionals’ understanding of E’s needs was well developed and solid. The social work professionals regarded him and his carers as a family who were generally functioning and looking after E well. There was a strong commitment on both sides to maintaining the placement long-term. This meant that they expected that the family could be allowed to get on with their life and make all day-to-day decisions with minimal intrusion from the LA. This was appropriate to the nature of the placement (F&F) and the known circumstances at the time. 9.6 This approach is re-enforced in the recently issued guidance on permanence and long-term placements.6 In the new guidance, however, there is the clear expectation that a ‘lighter touch’ by the LA must be accompanied by a comprehensive and ongoing assessment that the child’s needs are being met in an adequate way, which is known about and approved by the Corporate Parent/LA. 9.7 In the review period, the Review Team were told of a number of examples of significant actions (or inactions) by FM which were taken without consultation with the LA – something which will be referred to in more detail in sections below. She had historically been given considerable responsibilities through what in time (from mid-2014) became a fully recorded process of ‘delegated authority’. In this case the formal record of delegated authority extended to all aspects of parental care, to a point where it was unclear what responsibilities remained to the LA as Corporate Parent. This approach in the end made it complicated and difficult for Children’s Social Work Services to take the lead and intervene at points of family crisis and finally placement breakdown. The role of the LA as Corporate Parent and the challenges of holding this in balance with F&F carers is the subject of Finding 1. Just prior to the review period 9.8 In the second half of 2012, E’s Social Work Resource Officer (SWRO2 – his longstanding worker from the Children in Care Team), his equally longstanding Independent Reviewing Officer (IRO) and his FM observed that he was distressed and sad. Children’s Social Work Services made an appropriate referral to the local Child and Adolescent Mental Health Services (CAMHS) and an assessment appointment in October was attended by FM and SWRO1. In preparing for this meeting (filling in a form), FM described a boy who was showing signs of extreme vulnerability and emotional distress, and at the consultation reported that E had made one mention of feeling suicidal in the past year, reportedly ‘in the context of not getting his own way’.7 9.9 E himself attended one CAMHS appointment in November 2012, but declined any further input. As a result, the case was closed by CAMHS. This is routine practice. Given that many (if not most) adolescents are reluctant to engage with a psychiatric service, there is an argument for a more flexible and creative means of reaching young people in need of a CAMH service. Whilst locally we understand that CAMHS do have an outreach service for older teens8, there was no evidence that this approach was used in this instance. (There is further information about local CAMHS developments and other suggestions in Para 13.1 below) 6 Permanence, long-term foster placements and ceasing to look after a child: Statutory guidance for local authorities, DfE, March 2015 7 From the notes taken by the CAMHS worker at the assessment interview. FM has told the Lead Reviewers that ‘E never mentioned suicide to her’. 8 This is the ‘Teen to Adult Personal Advisor Service’ which is an ‘outreach rather than clinic-based service’. Child E Serious Case Review – Brighton & Hove LSCB Page 11 Start of Review Period: First half of 2013 9.10 This was a period of major transition for E, who was preparing to move on from his secondary school, which he had attended since the age of 11, and where he had been a popular pupil, having good relationships with staff and other pupils alike. 9.11 In early 2013, E was working hard in preparation for his GCSEs. His SWRO2, who knew him extremely well and had developed a good relationship with him, transferred his case to the 16+ Team. The move was required because of his age (at the time Children’s Social Work Services had a separate 16+ Team, although this is no longer the case), and also because of a mandated requirement made by OFSTED that only qualified social workers could be ‘allocated’ for a child in care. Coincidentally there was an unexpected change in the IRO who had chaired E’s reviews over the past five years. This meant that some of the organisation’s continuity of knowledge and understanding of E and his foster family was broken. 9.12 Findings 2 and 3 consider the risks of loss of continuity and understanding of a child when a case is transferred to a new worker, something which was happening frequently at the time in the 16+ Team. The other automatic change which E experienced when he turned 16 no longer applies, as the 16+ Team was merged into the Support Through Care (STC) Team which kept responsibility for children throughout their time in care – regardless of their age.9 9.13 SWRO2 made the necessary arrangements to ensure a good handover to the new social worker, including a detailed Transfer Summary, and continued to work with the family until E’s last LAC review in February 2013. E urgently needed a Personal Education Plan (PEP) meeting, and SWRO2 arranged for this to happen shortly thereafter. 9.14 It is not clear from records or discussions with the Case Group how the impact on E of the change of SWRO2 and the appointment of a new IRO was considered. Both had been involved with the family for a large part of his childhood, and SWRO2 in particular was fond of E and had been able to establish a good working relationship with him. In our view, an assessment of the likely impact on E of these changes should have been undertaken with E and his carers, with consideration given to how the consequences of these changes might have been formally acknowledged and if possible mitigated. Lack of detail in records also makes it difficult to know what was addressed in E’s last LAC review (February 2013). This review did not, according to its record, address some important aspects of transition for E, nor mention preparation for the Pathway Plan10 process, which would then take over from his LAC Reviews – including the requirement for an assessment11 to be undertaken as the starting point for Pathway Planning. In E’s case this could have included the extra support for E and the family. 9.15 The B&H format for the Social Worker’s report for LAC reviews (and, later, for PPRs) covers all the required headings, with a dedicated space for the child/YP’s views under each area for discussion. This makes it a useful tool, only let down if the information shared in the review is 9 In late 2015, after the events covered by this review, Children’s Social Work Services underwent a major reorganisation into a new structure, shifting from large teams into far smaller practice groupings (‘Pods’), a change described in detail above, in Para 9.1. One of the key drivers for this change was to support relationship-based social work with the child and family, team supervision and an ‘ownership’ of the work by all members of the team. The elimination of ‘artificial’ case transfer points was just one way of supporting this. 10 ‘The assessment and pathway planning process for a care leaver must include a measured evidence-based analysis of the young person’s continuing need for care, accommodation and support…’, Children Act Regulations, Volume 3, Para 3.8 11 The Children (Leaving Care) Act 2000 Child E Serious Case Review – Brighton & Hove LSCB Page 12 not full and accurate enough, as was the case with some of the reviews conducted during the period under review. First contact from E’s birth father 9.16 Before that review, E’s birth father (BF) made his first contact with the LA, with a view to meeting him. Children’s Social Work Services had made many previous attempts to reach BF, but never with any success. E knew very little about him, and SWRO2 was aware that BF’s emergence would be ‘huge’ for him, given his desire to know more about his parents, including BF who had disappeared from his life when he was a baby. She completed the necessary identity and police checks and shortly after met with BF to confirm these with him. This was expected practice. 9.17 The foster carers were consulted and agreement was reached on a decision to delay informing E about his father’s reappearance, given that E was at this point preparing for his GCSEs. The decision to delay telling E before his exams was on balance a reasonable one, as there clearly were risks attached to sharing this information with E at a critical phase in his education. However, there were also risks in withholding the information, as became apparent later when e-communication was established between E and BF, without the knowledge of Children’s Social Work Services. A formal record of decision-making regarding BF’s approach, and evidence of any related risk assessment would have been appropriate and might also have alerted practitioners to the absence of up to date ‘Life Story’ work, and the complexities arising from different narratives, from the two sides of the family. 9.18 There was nothing recorded in relation to planning and preparing for managing the contact (whether direct or indirect) between E and his BF. Given the potential emotional impact of the initial contact, whenever it came, and that the LA ran the risk of not being able to manage when this happened, there should have been a structured process of planning together (the Corporate Parent, the foster carers and BF) – not only for E, but for BF (and his family). This should have included consideration of the risks attached to free access to communication via social media. This work could have commenced among the adults before E’s GCSEs, in the period when he did not yet know about BF. 9.19 With insufficient planning, and the apparent drift in thinking about this complex/anticipated relationship, E’s eventual meeting with BF was unprepared for. 9.20 How E would eventually be told about the contact from his BF was not clear within Children’s Social Work Services’ records, although the review was told that there was social work agreement that FM and FF should undertake this after his exams were over. Afterwards, they were told that e’s initial response was that he did not want face-to-face contact with BF at that point. Finding 1 considers how and why the LA’s and the carers’ different roles and responsibilities were not always clear and agreed. 9.21 It was important for E to be supported to develop his own understanding of why he was in care, and to be enabled to place his past into context and to gain a perspective to assist him with establishing his own identity. Key to this was the completion of ‘Life Story’ work appropriate to his age and understanding. The gathering of this information and discussion with E should have been a continuous process and would have assisted him to build resilience. It seems highly likely that staff initially working with him may have relied on E’s carers to share the details of his early life with him, and thus undertake the very important ‘Life Story’ work throughout his childhood. Records are unclear on this point and our conversations with staff shed insufficient light on the plans in this respect. There is very little Child E Serious Case Review – Brighton & Hove LSCB Page 13 evidence of sustained ‘Life Story’ work being undertaken with E (either immediately prior to or during the period under review), which would have helped him to prepare to meet the emotional challenges of his teenage years. There was limited ‘Life Story’ work done with him when he was very young (before his mother’s death), and a record of further intensive work being undertaken between the ages of 11-12. Some of his later PPR Meetings commented on the need for this work to be resumed. 9.22 This review has found that, although sources of information about E’s history were available in records, including some contained in Transfer Summaries, there was inconsistent use of these records. During the time scale of this review, it was not clear that all his workers or managers themselves had an adequate understanding and knowledge of his history – without which it would be difficult to undertake Life Story work, or to have an adequate understanding of E’s overall needs and vulnerability. Whatever the circumstances of a placement, there is a clear expectation that Children’s Social Work Services workers will read and digest the history of a child in care. In this case, this was an area of practice which we found to be poor, and in need of improvement. Findings 2 and 3 explore some of the barriers to this good practice, including difficulties in accessing the full range of records, and (for some workers and managers) insufficient time to explore these. Changing workers for E 9.23 E continued to work hard towards his GCSEs, but nonetheless his behaviour at home/outside school was increasingly troubled, and included experimenting with drugs, coming to the notice of the Police, and defiance and anger towards his carers and cousin. His FM was well supported by her SWRO1 (what is often, elsewhere, called the Supervising Social Worker), who had known the whole family for several years. SWRO1 understood E’s past and his current difficulties, and was in many ways the lynch pin for communicating about these to the new SWs who followed on from March 2013. SWRO1 ensured that there were useful joint visits to the home, and made appropriate referrals to other services (such as RUOK), which was good practice. 9.24 During the period under review there were four changes of social worker, and in the last 22 months of his life, the records indicate that no social worker saw E more than five times. Inevitably this led to difficulties for each social worker in being able to establish a relationship with him, with E becoming increasingly elusive. BF described E, when they were together, as bitterly complaining about his changes in SWs: ‘Why am I going to confide in someone I have only known for 5 minutes?’. E also spoke to his BF about the earlier loss of SWRO2. We know that children in care can feel particularly let down and alienated when they experience repeated changes of social worker, and the loss of a familiar relationship seems to have affected E, his family, and co-workers in the F&F Team. 9.25 Some workers were involved for a very brief time (one, SW2, never meeting E), and held varying degrees of understanding about E’s personal and family history. SW4 (see below), who was allocated the case in May 2014, was given a verbal handover that E’s case was stable and without problems, and the transfer summary she received, unlike previous ones, had very little in the way of case history included. 9.26 The disadvantages of using a succession of agency workers for a child in care are well understood by Children’s Social Work Services. Unfortunately for E, the 16+ Team, at the time when he transferred into its care, was struggling with an absent manager and a far higher than usual number of agency staff (this was in contrast to the rest of the service). He thus Child E Serious Case Review – Brighton & Hove LSCB Page 14 experienced 4 social workers in a period of 18 months, and this lack of continuity inevitably affected the ability of both sides to work effectively together. 9.26.1 A new manager for the STC Team (which had subsumed the 16+ Team) had arrived in early 2014, and by the end of that year had successfully reduced the use of agency staff. 9.26.2 The reliance on a proportion of agency staff, in all agencies, will vary over time, with many factors affecting this, some of which may not be quickly remedied by the organisation. It is therefore important that plans are in place for the best use of these staff. The risks of lack of continuity for a child like E need to be carefully considered, and plans made with clear reasons for choosing to use a temporary or permanent member of staff. 9.27 During the spring of 2013, although E was working towards his exams, he was also demonstrating increasing levels of anxiety and ‘outbursts’ at home. In response to a worrying situation, SWRO1 and SW1 carried out a joint visit on 2nd April 2013 – a useful step, as it involved teams across the service. However, 3 days later, matters had escalated to the point where there was police involvement, and E was removed from home overnight. FM did not inform the LA about this incident for 3 days (nor did the Police send the required notification to alert Children’s Social Work Services for their attention), and then only reported that E had been violent, not that he had been removed. Finding 8 addresses the inconsistent notification of police-recorded incidents to Children’s Social Work Services. 9.28 There was no plan in place which enabled all concerned to focus on the growing concerns of the FM or on E’s deteriorating behaviour, and there is no record of E being seen in response to this incident. This was an insufficient response to a serious and risky event. A strategy meeting or professionals meeting would have been an appropriate means to bring together all of the agencies who were providing interventions to E and his foster family, even after the delayed reporting of the most recent violent incident. It would have enabled knowledge of the deteriorating situation to have been shared, along with FM’s worries about E’s potential mental health difficulties. Again, the role of the Corporate Parent should have come to the fore at this point. 9.29 E’s social workers (between April 2013 and May 2014) met the requirements of statutory visits to E, in line with Children Act regulations. It is not always clear what their purpose or focus was or whether E was seen alone or in the company of his FM. There was no chronology attached to the case which might have alerted practitioners to repeated patterns of behaviour. This resulted in successive practitioners responding to the immediate issues, for the most part presented by FM, and failing to deal with them in a coherent and planned way. The overall Finding 3 comments on the inconsistent use of chronologies in B&H Children’s Social Work Services and the effect on practice. Finding 7 addresses issues related to poor recording. 9.30 The lack of a chronology became increasingly important throughout the remaining period as opportunities to identify patterns of behaviour and their meaning, including extreme examples of risk-taking, self-medication with drink/drugs, and signs of depression or anxiety were lost. One exception to this observation was the RUOK worker, who recognised a pattern of escalation in E’s drug-taking and other risky behaviour, and who therefore took up the referral regarding E (which he refused to accept) in order to give advice to the professionals working with him. Child E Serious Case Review – Brighton & Hove LSCB Page 15 9.31 One of the most notable features of this case was E’s presentation at school (and later college), as a ‘model pupil’ and a hard working, ‘cheeky cheerful chappie’, which was in stark contrast to the angry and potentially self destructive behaviour acted out elsewhere. Whilst it was important for workers to be able to recognise and praise E’s many positive attributes, it was noticeable (from records seen) that at that time, they were less likely to reflect on aspects of his behaviour and activities which told a different story and indeed suggested an underlying emotional struggle. Much of what was going on for E was seen as ‘typical adolescent behaviour’, including cannabis use and coming to the attention of the Police. Summer 2013: Leaving school and E’s first Pathway Plan Review 9.32 By the summer of 2013 E had secured sufficient passes at GCSE to gain a place on his chosen course at college, several miles from his home town. Both he and his foster parents were pleased with his results and they helped him buy a motorbike – a real reward for his hard work, and one which enabled him to travel to undertake a part-time job. The summer months passed without further known incidents. 9.33 Children’s Social Work Services’ records are unclear about the level of contact with the family and E during this summer. The departure of SW1 is given different dates (in May and June) on the e-system, and there was no clear record of a formal handover of the case – although a Transfer Summary usefully included case history sections copied from a previous summary. Transfer of E’s case, consecutively, to two agency social workers took place through July and August. E never met the first of these (SW2), although she prepared a records-based report for his Pathway Plan Review (PPR) meeting in August. 9.34 There is a general sense of drift and loss of momentum in this period. The requirement for ‘an assessment of E’s needs for advice, assistance and support’12, as a 16-year old ‘eligible’ young person13 is not mentioned, and appears not to have been undertaken by the succession of SWs in 2013. By the time the first PPR meeting was held, FM and FF had told E about the approach from his BF. E was reported as not wanting to have face-to-face contact with his BF yet. This was seemingly not questioned by the professionals involved and we found no evidence that recorded plans were put in place to support E with his decision-making or to prepare BF and his new family for a meeting, should E change his mind. There followed e-contact between E and BF, which could be presumed to affect E considerably. In the view of the Review Team, this was a further missed opportunity to take responsibility for a key element of preparing this young person for eventual contact with BF and his family. 9.35 The PPR meeting in August, looking back at the past 6 months, presented an occasion and setting to explore important issues with E in a supportive structured setting. However, the review was of limited value, for reasons which will become clear, because it did not address the key issues with which E was grappling. (see Finding 4, for details of what was missing (also ref Care Planning and Case Review Regulations 2010). 9.36 It was a small meeting, with only E, his FM, SWRO1 and new Social Worker SW3 present. The FF was not present at this review or indeed at any of the reviews in the timescale of this review. The Review Team understand that the absence of a carer is not unusual because of 12 Children Act Regulations and Guidance, Volume 3: Planning transitions to adulthood for care leavers, DfE, revised January 2015, p10. 13 Defined as a child who is a) looked-after, b) aged 16 or 17, and c) has been looked after by a local authority for a period of 13 weeks, or periods amounting to 13 weeks, which began after he reached 14 and ended after he reached 16 (Para 19B of Schedule 2 to the 1989 Act and regulation 40 of the Care Planning Regulations). Child E Serious Case Review – Brighton & Hove LSCB Page 16 the work commitments of some foster parents, particularly foster fathers (not just in B&H, but around the country). There is a very real difficulty in ensuring formal attendance when a foster parent is working, and this was particularly the case for E’s FF who worked away from home very regularly. But there are no records to suggest that efforts were made to solicit FF’s views – for example by meeting with him beforehand. The widespread absence of many male carers from planning meetings and reviews for children in care is discussed in Finding 6. 9.37 The PPR meeting (and the process) had no input from education providers. This was a case where involvement from the LAC lead at E’s school had been very active in supporting E over many years. She had attended all his LAC Reviews and had developed a good understanding of his educational needs – and was still involved with him during the past 6 months under review. This was also a potential opportunity for E’s new college to be represented and to be part of future planning. We understand that this did not happen because E had to agree membership and he did not want his new college to be represented at the review. The purpose of the PPR meeting and the enhanced role of the young person in its conduct are explored in Finding 4. 9.38 The limitations of such a small PPR can be got round by the use of other forums, such as a professionals meeting, when the LAC Review or the PPR has not included all the relevant people or has not talked about what was needed to be done. During the 2 years before E’s death, there were strong reasons to be concerned about aspects of his behaviour. One consistent professional, SWRO1 from the F&F Team, requested a professionals meeting on two occasions (November 2013 and in late summer 2014). This was sensible and good practice, but did not result in a meeting happening. The limited use of professionals meetings is discussed in Finding 5. 9.39 Had the professionals from all settings been able to share their knowledge of E, this might have resulted in a more comprehensive assessment of his relationships, his levels of anxiety and general emotional wellbeing. It is not clear what understanding professionals had about differing presentations of people with mental health problems, particularly depression. Whilst we found no evidence to suggest a formal diagnosis of depression for E, there were recorded concerns about anxiety and low mood from FM, and some from E himself. Given his family history we would have expected that professionals would have considered this aspect of his health more closely. 9.40 E was at times offered services (persistently so, in relation to drug use, by SW3) but, like many adolescents, he was not willing to accept these. This is a well-known challenge to services tasked with engaging with adolescents in different ways. A recent Brighton & Hove LSCB Learning Review (J)14 commented on the difference in services which are ‘…established in a way that enables a more flexible approach to the young person and are able to be more responsive to individual need and those that are office or clinic-based and are less able to provide a customised approach. CAMHS generally has a clinic based service delivery that is less flexible although the doctors do attempt to provide an individual service as was shown by the last doctor from CAMHS who worked with J. The nature of the Youth Service is that it is most able to provide an intuitive service that is driven by the young person. RUOK attempts to straddle the divide between these two approaches and was very successful at engaging J in productive work’. (Para 4.6.4) Please see Para 13.1, under ‘Additional Learning’, for further comment. 14 Brighton & Hove LSCB Learning Review J, F. Johnson and A. Gianfranco, August 2014 Child E Serious Case Review – Brighton & Hove LSCB Page 17 First year of college 9.41 In autumn 2013 E began the college course in aeronautical engineering which he had hoped to do. Aside from some reportedly ‘silly’ behaviour at the start, he quickly settled down and progressed well with his course. His attendance through that academic year was very good, with only two absences recorded over the entire period. However, the pattern of concerning behaviour outside college continued; in his first term he was found unconscious and admitted to A&E following excessive use of alcohol and drugs, and subsequently told his FM about experimenting with cocaine. The carers were informed and on this occasion Police completed the required notification to Children’s Social Work Services (MOGP/1). Finding 8 discusses the inconsistent use of this notification in relation to children allocated to Children’s Social Work Services, including children in the LA’s care. 9.42 This was an example of risk-taking behaviour by E, which, in the Review Team’s view, should have prompted a strategy meeting or professionals meeting to include all agencies involved with him. 9.43 SWRO1 continued to support FM in trying to manage and help E, but this was becoming increasingly difficult for all parties. She suggested to SW3 that this case needed more input from him, and towards the end of the calendar year, SW3 increased his visits to E to monthly, rather than the statutory three months. SW3 said in conversation that he had reviewed E’s records, which suggested that he did not know, and ‘was not meant to be told’, about the details of his mother’s death. 9.44 SW3 made regular attempts to engage E with discussing his cannabis use and encouraging him to meet with the appointed RUOK worker, which was good practice. It is an ongoing and wider practice challenge about how to engage meaningfully with young people around substance misuse, particularly if the young people see this as unproblematic. First half of 2014 9.45 The next PPR meeting was held in February 2014, and E’s good work at college was noted. As before, membership was limited, and FF again was not present. College personnel who had direct contact with E were not invited and in accordance with E’s expressed wishes did not know that E was in care, nor about his reported behavioural difficulties outside college. As with all his reviews, E participated in the whole process – a circumstance that was reported by his IRO as ‘rare’ among young people. The placement was again described as stable. Concerns about drug taking, and the serious incident that led to E being hospitalised were not discussed in the meeting (again at E’s request). Contact with the BF was again confirmed as a matter to be dealt with by E and his carers. 9.46 In the following months, E’s presentation and behaviour at college was in marked contrast to a deteriorating situation at home, where he was increasingly out of the control of FM and FF. He began to be missing more frequently, to come to the attention of police, and to be defiant and aggressive towards family members, as well as stealing from them. In June 2014, he was arrested, with others, for burglary and theft. FM was informed of this incident, but it was not reported by Police to Children’s Services. Police should have completed a MOGP/1 referral to Children’s Social Work Services. E also told FM about breaking into a Children’s Centre and letting off fire extinguishers. As the frequency of his going missing from home increased, the family’s anxiety and exhaustion increased. SWRO1 continued to support FM and to give clear messages about the need to inform Police when E was missing (something that FM did not do consistently). Child E Serious Case Review – Brighton & Hove LSCB Page 18 9.47 A further change of social worker took place in May (SW4, another agency worker), without any handover by SW3 – whose departure was reportedly unknown to the family. On allocation, SW4 recalls being told by the previous Practice Manager that E is a ‘nice lad, settled, there are no problems’. (The manager concerned has no recollection of this description, and refutes the words as coming from him.) Within two weeks, however, a very upset FM informed both her and SWRO1 (via emails) that respite care was needed for E, who would not be allowed to go on holiday with the family because of his increasingly defiant behaviour. In the end, the matter was resolved within the family, all of whom had a harmonious holiday together. 9.48 Perhaps because of the increasing stresses in their family life, and the absence for over a year of a consistent SW for E, it was likely that the family would struggle to engage with another new SW. For SW4, it was thus a challenge to make a positive and trusting relationship with E and his carers. Both she and her Practice Manager (PM2) identified this as an essential part of the social work task. This was made more difficult as during this period the FM was often unavailable, and at times refusing to meet with SW4 or SWRO1, or to agree to a Placement Stability Meeting, as proposed by SWRO1 and her manager in the F&F Team. 9.49 In the midst of this very difficult situation, the F&F Team requested a meeting with the STC team, with a view to agreeing a joint way forward. This did not happen, though the reasons are not recorded. It is not clear whether escalation to a team manager was considered, as a means to achieving joint discussion. (Lack of recording is discussed in Finding 7.) 9.50 E’s college studies went well and he successfully completed his first year. Although a second year was an option, E made a decision, supported by FM and FF, not to return to college. The next course would be harder and E had achieved enough to pursue a career with the RAF when he was ready. He still needed to pass his English GCSE and plans were in place for him to resit this exam. SW4 made, and pursued, a referral for E to be seen by the Youth Employability Service Worker for the Virtual School. As already noted, this was a period when it was hard for professionals to reach E or FM, but the meeting eventually happened, and E confirmed that he was working in a variety of part-time jobs (thus, not NEET15). 9.50.1 The Review Team felt that this decision to leave full-time education should have been discussed more thoroughly, including at the next PPR meeting (see below). 9.51 In 2014, professionals were concerned about how FM was dealing with E’s challenging behaviour. SWRO1 in particular worked hard to offer support to FM, who regularly shared with her many of the difficulties attached to this behaviour. However, FM was reluctant to accept professional support and advice which challenged how she managed E. Late summer/autumn 2014 9.52 The summer months were regarded by SWRO1 and SW4 as a time of almost complete family breakdown. FM continually requested respite care (though there was no clear plan about its purpose), while E would not agree to this. The idea of a referral to Functional Family Therapy was also discussed on a number of occasions (see below). 9.53 A further PPR meeting took place in August 2014. Shortly before this meeting, E had a serious accident with his motorbike which ‘wrote off’ the bike and meant he lost his part-time job. 15 Not in education, employment or training Child E Serious Case Review – Brighton & Hove LSCB Page 19 He felt upset that this experience was not properly appreciated by his FM, and this added to the bitterness and anger in the family relationships. 9.54 The PPR meeting: membership remained limited to a small core group in accordance with E’s wishes. The IRO recognised that the family was under immense stress because of E’s behaviour and deteriorating relationships in the household. She also noted that E was sad and upset about how (he felt) he was treated differently from his cousin/’brother’. 9.55 E’s decision not to return to college could have featured more prominently in the review and been explored with him in detail, and the involvement of education would have assisted this process. However, a useful plan was made for him to retake his English GCSE – something he needed in order to join the RAF, which remained a goal for E. 9.56 For a very long time, email had been FM’s preferred means of communication with social workers. During these summer months, she was letting workers know in her emails how badly things were going downhill in the family. At the same time, it was becoming very difficult to arrange other forms of direct contact, especially for the workers and manager in the STC Team. FM was not available for arranged visits, or did not agree to these. At a point of crisis, when communicating and working well together were needed more than ever, those jointly responsible for E were struggling to work together effectively. 9.57 A few days after the PPR meeting, recognising that the placement was at risk of collapse, SW4 and SWRO1 were proactive in trying to seek out both E and his carers. An unannounced home visit was finally successful, which enabled them to meet with FM, and then to have a detailed discussion with E on his own. This was good joint work and demonstrated both persistence and assertiveness on their part. 9.58 SWRO1 and SW4 urged that a referral to Functional Family Therapy (FFT), previously discussed, was needed if the placement was to continue. This was agreed by FM, but not by E – and thus, it could not be accepted by FFT, as their model relies on the participation of all family members. 9.59 The specialist health nurse also saw E during this period (just after the PPR meeting). In preparation for the visit she reviewed the previous year’s health report and consulted with her colleague. This was good practice. 9.60 E’s annual health check was reported as largely ‘unremarkable’. E’s emotional wellbeing was covered in this and the previous annual health check, and he did not disclose anything of concern in relation to mental health or emotional difficulties. However, the nurse recognised that E was in distress, apparently because he was struggling to deal with the practical consequences of his bike accident, mainly dealing with insurance matters. E was clear with her that he did not want these feelings to be shared with the social worker. The nurse persisted and was able to get E’s permission to share some of her concerns with SW4, specifically about his needing help with insurance as a means of supporting him. 9.60.1 The health action plan which the SW is sent a copy of covered all the issues discussed at both reviews, which is helpful in ensuring that the SW remains aware of the process. 9.61 The managers of both SWRO1 and SW4 were both now involved in addressing the serious breakdown of the placement. FM had notified professionals (via email) that E was out of their control, and she had renewed concerns that he might be using cocaine, as well as cannabis; Child E Serious Case Review – Brighton & Hove LSCB Page 20 she again mentioned his ‘mental health’ history – something which was only infrequently raised with professionals. The need for a different kind of meeting (and a different strategy) was acknowledged, and at SWRO1’s instigation, a professionals meeting was agreed across their two teams. Unfortunately, this had to be delayed because of SW4’s annual leave (mid-September). 9.62 As the placement problems escalated, the difficulty for workers in communicating directly with FM became critical, as she was refusing visits or meetings entirely in the second half of September – communicating only by email. There was no clear joint strategic response to this from the professionals involved, when a more robust insistence on partnership with the Corporate Parent was needed (Finding 1). 9.63 A move to respite care had been offered from July onwards, but was repeatedly resisted by E, who at times resorted to breaking into his own home in order to remain there. In October, a move to alternative foster carers was finally brokered, in response to FM’s persistent requests. She was struggling to deal with E’s increasingly aggressive behaviour, as well as his further lengthy periods outside the home. The foster home was at some distance from E’s home area, but the move, to experienced foster carers, was appropriate. 9.64 The status of this move was not understood in the same way by all concerned. Was it ‘respite’ or an open-ended/permanent move? The new foster carers and FM believed it to be permanent, while most professionals (as reported in conversations) saw it as respite (although at the beginning, likely to be of uncertain length). It is not known what E understood about the nature of the placement. The ambiguity was increased by FM’s packing up all E’s belongings into bags to be removed by SW4. What was clear was that the SW team wished to preserve and support E’s links to his family whilst away from home. Despite the anger at this point for both E and his family, their ongoing attachment was never in doubt. 9.65 E’s BF has said in conversation with the Lead Reviewers that he feels professionals in Children’s Social Work Services should have contacted him at this point, about E’s need for care. It seems unlikely that this would have been thought of, given the fact that E’s relationship with his BF had been left to E, and had received little professional attention for some time. The nature of the growing relationship and its impact on E should have been the subject of an ongoing assessment process. 9.66 Shortly before E’s move to the new foster carers, Children’s Social Work Services staff (PM2 and SW4) visited the home, met with FM, and as a result were concerned about her wellbeing. They wondered whether she had problematic alcohol use, and a discussion with SWRO1 afterwards suggested that there had been ‘issues’ about excess drinking in the past (this is denied by FM). 9.67 On the day that he moved, in response to a question from SW4, E made allegations about his foster parents’ excessive use of alcohol. As a result, a ‘Standards of Care’ investigation16 took place. Local procedure suggests that this should commence with a joint visit by the SWRO for the carers and the SW for the child, and that the outcome should be determined across both parts of the service. However, neither team appeared to recognise what needed to happen, and the F&F Team undertook and completed the investigation alone. The Team have 16 Standards of Care investigations are carried out in relation to foster carers where there are allegations or concerns about how they are caring for the child in their care. This process covers the kind of concerns which are not deemed to need a child protection, or S47, investigation. Child E Serious Case Review – Brighton & Hove LSCB Page 21 acknowledged that this was an oversight on their part, regardless of whether E was to return to FM and FF or not. 9.67.1 The outcome of the investigation was a request for FF to seek advice from his GP about his alcohol consumption. 9.68 E was reported not to be entirely happy with the arrangement, as he saw it, of becoming a ‘foster child’ and being looked after by professional foster carers. However, he was active in finding work (at a local locksmith), and was pleased to have an income of his own. He spent time with his girlfriend and remained in some contact with FM and FF, via a wider family gathering to which they invited him. 9.69 E initiated more Facebook/email contact with BF during this period, and was upset and angry after learning from him a different description of some of the events of his very early years: a reminder of the complexity of identity and Life Story work. Had there been planned work with both E, his BF and BF’s immediate family prior to their contact, the impact on E might have been altered. 9.70 Whilst away from home, E also attended a GP appointment at which he sought help for feeling anxious and depressed. The GP offered a follow-up appointment to continue assessing E’s needs, but the date for this was after E had left Brighton. Neither Children’s Social Work Services, nor FM and FF, were aware of this consultation. 9.71 In late November, E was in the vicinity of his old home, when he discovered a burglary had just taken place there. He let FM and FF know that he wanted to move back home immediately. They agreed, and collected him from his new foster carers’ home without initially approving this with the LA (the foster carers challenged FM about this, but she removed E without official sanction). The decision between E and FM was checked with Children’s Social Work Services after the fact. In response, SW4 and PM2 insisted that this return home had to be with input from Functional Family Therapy, and SW4 and a worker from FFT visited to outline how this would be taken forward. This was an appropriate condition to be given to E and the family. 9.72 E was convinced he knew who had committed the burglary. He visited and confronted the alleged perpetrator (a close friend), and in doing so unintentionally assaulted the young man’s carer. E was aware that his friend was associated with a particular group, and had been the victim of a stabbing in the recent past. Now, E became extremely fearful that he too would be harmed because of what he had done – possibly by the young man’s associates (the reasoning is not entirely clear). What was apparent was that E became utterly determined to leave Brighton in order to escape harm. 9.73 This crisis coincided with the ongoing e-communication with BF, and E now had the idea that he could move away from the area, to BF, to ensure his own protection. BF had been told about this by FM, and they had discussed the need to keep E safe. All this occurred immediately prior to the PPR Meeting on 27th November. PPR Meeting 27th November 2014 and following events 9.74 The PPR Meeting on 27th November had been brought forward because of E’s move into respite care. After his unexpected move home, PM2 proposed a professionals meeting outside the PPR, and this was sensible and good practice. It appears time ran out for this to Child E Serious Case Review – Brighton & Hove LSCB Page 22 happen, as events unfolded. A visit to the family between SW4 and FFT was also reported to have been made in the week before the PPR Meeting (but not recorded – see Finding 7).17 9.75 The meeting had the usual attendees, but this time, prompted by recent events and E’s precipitate return home, it sought to address concerns and put a plan in place to support E and the family. SWRO1’s manager was present and this was a clear indication of the seriousness with which the F&F team regarded the situation. The preparatory report for the PPR dealt with some underlying issues, and the IRO spoke about E’s anxiety and reinforced the need for Life Story work about his past and identity. The idea of input from FFT to support his principal placement with FM and FF was confirmed. This was good practice. 9.76 However, E’s level of fear about his personal safety, and his insistence on leaving Brighton immediately, overshadowed all the other discussions. The professionals present saw that he was genuinely in fear for his life, and that he would not consider any option short of going right away from Brighton, and to stay in BF’s care. E was now 17 years and 10 months old, almost an adult, and would clearly be able to ‘vote with his feet’. A decision had to be made about his immediate future, and there were attendant risks attached to each potential course of action as well as to inaction. 9.77 The decision-making after this point has had to be pieced together to a large degree from the recollections of people involved at the time, because the records in Children’s Social Work Services relating to particular decisions and the rationale for them are poor. Adequate recording has been an issue throughout the case (see Finding 7) and it is particularly unfortunate that it was not more carefully attended to at the time, given the influence hindsight will now have, in light of the known and tragic outcome. 9.78 What is clear is that the Children’s Social Work Services’ position moved in a short space of time. It started at the point of the PPR Meeting as one that acknowledged E’s perception that he was in danger, but which saw his desire to go to his BF as potentially risky and inadvisable, given that the two had never met. Attempts were initially made to find an alternative foster placement that he could move to as soon as practically possible, while involving the police in a risk assessment. Police who spoke with us were clear that they saw the risk to E as low (but see following paragraph). 9.79 Children’s Social Work Services’ initial reservations about E going to the local authority where his birth father lived were shared by FM, but she was seen to be in support of the plan, if it was the only way to protect him. In the afternoon, the police visited E and FM to advise on personal safety and appropriate protection measures18. E’s apparent unwillingness to comply with these, together with his refusal to stay with FM or to use any other offered local placement, made it difficult, if not impossible in the view of Children’s Social Work Services, to keep him safe while he remained in Brighton. They now accepted that a) E was determined to leave Brighton, and b) that he could not be kept safe by the Police while remaining in Brighton (this ‘view’ has been denied by Police with whom we have spoken, and it remains unattributable). 9.80 By the end of the day, after a number of earlier telephone calls between E, FM and BF (although accounts differ on this), and a critical afternoon conversation between PM2 and BF, stressing the apparent high risks in Brighton, the move to BF had been agreed, as it was seen 17 FM says that this meeting was cancelled. 18 FM states that the visit was mainly about mediation between E and the young man he had assaulted. She also states that the police officer did not say E could not be kept safe in Brighton. Child E Serious Case Review – Brighton & Hove LSCB Page 23 by Children’s Social Work Services to be the ‘least worst’ option in circumstances where E reportedly refused to consider any alternatives. By this stage it was also known that BF, although willing to help, could not have E to stay in his home as he had not had time to prepare his family for E’s existence. E was to stay with BF’s friend/neighbour, allowing him time to do this. The move of E was made by FM taking him to meet BF at a designated place, so that he could be driven to the local authority where BF lived. 9.81 Efforts to find an alternative arrangement continued. In fact, by the following day, a potential foster placement in Bedford had been identified, to be explored the following week. 9.82 Whether the situation was as grave as E perceived it to be will never be known. What does seem to be clear is that the social work response became reactive; rather than seek to slow things down in order assure themselves of E’s safety in an unknown placement and in line with regulations, their responses reflected that they had become convinced that he was in immediate danger. The degree to which this reaction was driven by E’s age – almost 18 and old enough to make his own decisions – is a matter for debate. Notwithstanding his age, the regulations regarding placement of a looked-after child still applied, and still required the LA to act as his Corporate Parent, in line with these regulations. 9.83 The approval of a senior manager, as a final gate keeping safeguard, is necessary for any ‘unregulated’ placement even in an emergency. This was not sought, as it procedurally should have been, although the service manager was later that day informed of the decision to move E and saw this as a fait accompli – and one made by managers whose judgement he trusted. The events, as described to the Review Team, suggest that the significance of an ‘unregulated’ placement and therefore the need for senior management approval were not clearly apprehended and considered by any of the managers during this process. This should be a matter of concern for the department, given that these regulations are there for the safety of all concerned – both officers and service-users alike. 9.84 As already noted, the decision-making in this crisis was poorly recorded, including the rationale for it. It is likely that at the time the move was judged to be a pragmatic, temporary solution in line with what E wanted. Our conversations with the staff involved support this assessment, but the lack of records gives us no firm evidence for this. FM’s and BF’s views 9.85.1 Both FM and BF dispute the account outlined above. BF believes he was pressurised into providing a solution to an immediate crisis. He only agreed because he was convinced of the reality of the risk to E, and because of his desire to help his son in these circumstances. He was reluctant on the grounds of meeting his child for the first time in this way, and also because his other children did not know of E’s existence. 9.85.2 FM states that she never agreed to E’s move, and in fact says that by the end of the afternoon, he had calmed down and agreed to remain at home with her and FF. This was not communicated to Children’s Social Work Services. She feels the decision was taken out of her hands by PM2 negotiating the plan directly with BF. 9.85.3 Both FM and BF believe that Children’s Social Work Services exaggerated the risk to E and were determined to move him away. They find it hard to understand how the decision in the morning (that he should not be moved to BF) was changed in the afternoon. Child E Serious Case Review – Brighton & Hove LSCB Page 24 9.86 B&H Children’s Services remained in phone contact with BF and E on 28th November (Friday). His SW4, in her own time, kept in touch with him by telephone over the week-end. However, there was no contact with BF’s friend/neighbour with whom E was staying, and no checks were carried out regarding him. The minimum of a Police check was agreed, but not carried out due to a misunderstanding about who would do this. Having made the arrangement, there should have been immediate follow up to risk assess, including a home visit to both BF and his friend/neighbour before the weekend (possibly by local Children’s Services). 9.87 A foster placement in/near the area that BF lived had been identified for discussion on the Monday. E died as a result of self-strangulation (by hanging) on the following day. Conclusion 9.88 The Review Team have given much thought to the events immediately preceding E’s death and have scrutinised the decision-making by all parties. After a tragedy such as this, it is natural to seek explanations and sometimes to want to blame an individual or an organisation; this is not the position of this review. It is the case that practice could and should have been better at different times and in ways that the Findings (below) consider in broader terms. It is also the case that there were examples of good individual practice in what we have seen. It is our view that there is no justification for making a causal link between practice, even poor practice, and E’s death. 10. What is it about this case that makes it act as a window on practice more widely? 10.1 The initial research questions for this SCR (Para 4.1 above) suggested that this individual case might identify general findings about working with young people and their families in long-term kinship placements, including those where the turbulence of adolescence brings greater challenges for carers and young persons alike. This has proved to be true, and these patterns are ones which affect the work of agencies (especially Children’s Social Work Services) far beyond this LA. 10.2 We found a number of additional local challenges, in the inconsistent use of case history, record-keeping, and, in one team, a period of over-reliance on agency staff. There were recognised problems in the number of electronic record systems (3 separate ones, at the time; now reduced to 2). There were also some familiar ‘attitudinal’ patterns, in relation to male carers and connecting with young people who do not easily share their underlying distress or vulnerabilities. 10.3 The research question relating to ‘vulnerability to group activity’ has not proved fruitful, in that we have found no information to suggest that E was linked to any anti-social or criminal ‘group’, nor involved in any identifiable activity by such a group (bar a peripheral friendship with one other young person). 10.4 Similarly, it was difficult to reach any broader conclusions about working with a young person where there is a family history of suicide, save to say that this is a relevant factor in any assessment of emotional vulnerability. Child E Serious Case Review – Brighton & Hove LSCB Page 25 11. Findings list 11.1 A list of the findings follows below, each matched with a category, which names the type of systems finding it is, according to the SCIE list of categories (Appendix 2, Para. 5). 1. There is an inherent tension regarding the respective roles of the local authority as Corporate Parent, and Family and Friends Carers who are seen as ‘parents’ or ‘family’. This can result in unhelpfully blurred boundaries and a difficulty in asserting the LA’s statutory responsibility for a child or young person when this is required. Communication and collaboration in longer term work 2. In Children’s Social Work Services, it is difficult to access the various sources of a looked-after child’s past records, leading to an associated response of not prioritising this essential preparation; the result in many cases is that the Corporate Parent does not easily know the life story of its children. Tools 3. The tools for transmitting background information about a child or YP (transfer summaries and chronologies) are not produced to a consistent standard, meaning that a new SW may not have the background and qualitative information which would support a holistic understanding of the child/YP and family and their needs and risks. Communication and collaboration in longer term work 4. Is there a risk for professionals, in following Care Planning, Placement and Case Review Regulations, to give too much responsibility to young people over their Pathway Plan Reviews, with the result that difficult subjects are not raised if the young person objects? Communication and collaboration in longer term work 5. Nationally, there is no routine framework for multi-agency professionals to meet outside of Pathway Plan reviews, leaving the responsibility with an individual practitioner to convene such a forum. The result is that planning and decision-making for a child often proceed without the benefit of a joined-up discussion of others’ perspectives and concerns about a child. Management systems 6. There is a pattern of focusing only on the primary (usually female) carer for a child in care, and not giving sufficient attention to the role of the non-primary carer (usually male). This can result in professionals’ lack of awareness of both positives and negatives that the other carer may bring to his/her role. Human biases 7. In B&H Children’s Social Work Services, there is inconsistent recording. Without a complete and accurate record, it is difficult for practitioners and their managers to analyse the facts and context of a child’s situation, and to make appropriate decisions and plans. Management systems 8. Sussex Police do not always act in accordance with their own guidelines by informing Children’s Social Work Services about their observations of, contact or interventions with young people. This means that opportunities for joint thinking, decision-making and interventions may be lost. Communication and collaboration in longer term work Child E Serious Case Review – Brighton & Hove LSCB Page 26 12. Findings in Detail 12.1 Finding 1. There is an inherent tension regarding the respective roles of the local authority as Corporate Parent, and Family and Friends Carers who may be seen as ‘parents’ or ‘family’. This can result in unhelpfully blurred boundaries and a difficulty in asserting the LA’s statutory responsibility for a child or young person when this is required. (Communication and collaboration in longer term work) 12.1.1 F&F carers are rightly regarded differently from other foster carers. Their motivation to care for a member of their family is unlike that of professional foster carers who wish to undertake this role as a job. The expectations placed on F&F carers are defined differently, and they are paid at a lower rate. However, in choosing to be F&F carers, family members are electing a formal, supervised arrangement over a private one – one for which they get an allowance and within which they can expect support and supervision for themselves, and appropriate services for the child in their care. These formal expectations should be agreed on both sides, including the minimum standards of care which are the legal responsibility of the LA as Corporate Parent. National statutory guidance outlines these as follows: ‘Whilst many of the issues that go with being a family and friends carer are likely to be the same whether or not the carers are approved as foster carers, being a foster carer brings with it additional responsibilities and obligations which have to be met. The local authority will be responsible for the child’s care plan and for supervising the family and friends foster carer, whilst the family and friends foster carer will exercise delegated authority within the overall framework of the care plan and the placement plan and will be expected to demonstrate they are meeting the child’s needs as set out in the care plan and engage in appropriate learning and development’.19 12.1.2 B&H’s F&F policy20 outlines these expectations and gives descriptions of what is on offer to carers locally, how they will be treated, and the commitment to the child in placement. 12.1.3 Neither national nor B&H local guidance and policy documents address the issues highlighted in this finding, nor do they refer to the extra complexity and stresses that many F&F placements experience. In other words, the nature of the partnership required between LA and carers, and potential difficulties in this, are not included in guidance and policy documents – thus leaving individual services to work this out for themselves. This finding suggests that where longstanding F&F carers have virtually all authority delegated to them, the LA may find it difficult to intervene when needed to ensure a child’s needs are being met. How did the issue feature in this case? 12.1.4 FM and FF were approved to care for their nephew at a time when this agreement was not required to be ratified by a Fostering Panel or Agency Decision Maker, as has been the case now for several years. A relationship with the LA developed over time which saw them as the ‘parents’ of E, who were well able to get on with his care and their family life with minimal input from the LA. FM and FF loved E and were seen by professionals as highly committed to ensuring he would grow up safely in their care. This was true of the workers from both teams (F&F fostering team and Children in Care Team) and E’s Independent Reviewing Officer (IRO), 19Family and Friends Care – Statutory Guidance for Local Authorities, DfE, 2010, Para 5.2 (http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.uk/publications/eOrderingDownload/Family%20and%20Friends%20Care.pdf) 20 Family and Friends Policy, Brighton & Hove City Council, July 2014 Child E Serious Case Review – Brighton & Hove LSCB Page 27 all of whom knew the child and family for a very long time (up until age 16, when there were several changes of workers). 12.1.5 However, E was a child with a complex and sad history of repeated separation and loss, which extended until the death of his mother when he was 8 years old. Thus, he had very complex needs, and the placement was not always straightforward, including in its early years. The difficulties for E and his carers were to be expected, given his early experiences of abuse and neglect, and then a protracted period of uncertainty about what would happen to his mother and who would care for him in the long-term. 12.1.6 This review has focused on the two years of E’s ‘transition’ from adolescence to adulthood, a period which often brings real distress for young people who are unsure about many aspects of their lives, including the distant loss of parents and their own identity. In the turmoil of E’s mid-teens, there were important aspects of the LA’s role which were not sufficiently dealt with on both sides. The delegation of decision-making to FM and FF exposed areas where the Corporate Parent needed to be more assertive in order to ensure that E’s complex needs were being met. For example: The re-surfacing of E’s need for Life Story work – in particular, explanations about his mother’s death and what had happened to his father – were not agreed by FM and therefore not addressed in his Care Plan. The LA and the carers did not work together to prepare E for contact with his birth father, but rather let this be handled by E and the family, in a way which did not prepare E for meeting him. The responsibility of the carers to inform the LA and Police about all missing episodes was not well established or consistently adhered to – although they were reminded of this by SWRO1. Important decisions (e.g., dealing with E’s contact with his BF, and about E’s return home from respite care) were taken by his carers, without input from Children’s Social Work Services. Face-to-face meetings between the carers and Children’s Social Work Services (SW4 and SWRO1) were eventually declined by FM, in a period of serious crisis in the placement, when there needed to be a strong partnership with the LA. There was a pattern of FM’s seeking help from Children’s Social Work Services when things were going wrong with E, but, once things were ‘right’ again, of her unwillingness to work together to try to prevent future problems or crises. 12.1.7 FM had consistently been given considerable responsibilities through what in time (from mid-2014) became a fully recorded process of ‘delegated authority’. In this case the formal record of delegated authority extended to all aspects of parental care, to a point where it was unclear what responsibilities remained to the LA as Corporate Parent. This approach in the end made it complicated and more difficult for Children’s Services to work in partnership and to intervene at points of family crisis and finally placement breakdown. 12.1.8 As the placement was under such very great strain in 2014, a stronger intervention by the LA could have been considered – e.g., developing an action plan with E that included steps to address behavioural and relationship issues. What makes this an underlying issue? 12.1.9 There is nothing to suggest that practice in this case was fundamentally different from other cases of F&F or network care in B&H (although the length of this fostering arrangement may Child E Serious Case Review – Brighton & Hove LSCB Page 28 have been unusual). The F&F Team are clear that the way of working with F&F Carers is very different from the relationship with professional foster carers. National minimum fostering standards are maintained, but in most other respects, F&F carers have delegated authority which covers virtually all aspects of the child’s care. 12.1.10 In many if not most cases, this does not cause problems. But in some circumstances, the rights of the carers/’parents’ to make decisions for the child and to deal with matters of all kinds can become overriding, and may not be challenged when it is needed to do so. 12.1.11 The current B&H Delegated Authority form does not adequately spell out and distinguish the respective roles and responsibilities of the LA as Corporate Parent and of the carers, thus leaving room for confusion and disagreement. What is known about how widespread or prevalent the issue is? 12.1.12 This is not just a local issue. Nationally, F&F Carers (often termed ‘Connected Persons’ carers) are appropriately regarded as the first alternative placement for a child who cannot be cared for by birth parents. They make up 11% of placements for all LAC children and 15% of all LAC children in foster care (Figures for end March 2015: 7,910). 12.1.13 The importance of family links for looked-after children is universally acknowledged, both in terms of research evidence about outcomes, and in the statutory framework for looked-after children. As a consequence, there is a different kind of approach to how such placements operate. Many, if not most, children in F&F placements would rather be there than anywhere else (this was definitely true for E), so removal by the LA is something to be avoided wherever possible. 12.1.14 For long-term placements, new statutory guidance21 regarding permanence and long-term foster placements confirms a ‘lighter touch’ approach, albeit one which must be carefully assessed in each case. This is likely to push practice in the direction of giving more responsibility and independence to the carers, in a way which this finding might wish to challenge – or at least provide a cautionary note. 12.1.15 Alongside all the positives for a child, it is also the case that many F&F placements are very emotionally complex, with carers often distressed about the family member (mother or father) who has not been able to care for their child. The demands on F&F carers are increasingly being recognised, so that specialist support groups and separate training to support them are being developed in many places. B&H has a comprehensive set of workshops and training packages to meet the needs of F&F carers. These are not compulsory, but carers are encouraged to use them. Why does it matter? 12.1.16 The LA retains Parental Responsibility for children under Full Care Orders, although as in this case considerable responsibility for day-to-day decision-making is delegated to carers. The LA are required to follow the legal procedures for promoting the wellbeing and safety of a looked-after child, and providing a dedicated social worker who is responsible for ongoing assessment of the child’s needs and for making and reviewing plans to meet these. 12.1.17 In order to carry out this responsibility, both the LA and carers need to be clear from the outset about what their respective roles and responsibilities are in implementing the child’s 21 Permanence, long-term foster placements and ceasing to look after a child: Statutory guidance for local authorities, DfE, March 2015 Child E Serious Case Review – Brighton & Hove LSCB Page 29 Care Plan/Placement Plan. Thus, it is essential that the LA’s complex relationship with F&F carers is better defined and agreed, so that the needs of the child for safety, stability and healthy development can be met as well as possible – including at times of conflict and vulnerabilities in the placement. Finding 1: There is an inherent tension regarding the respective roles of the local authority as Corporate Parent, and Family and Friends Carers who are seen as ‘parents’ or ‘family’. This can result in unhelpfully blurred boundaries and a difficulty in asserting the LA’s statutory responsibility for a child or young person when this is required. The lack of clarity about the respective roles of the Corporate Parent and F&F carers for a child in care means that when the Corporate Parent needs to assert its authority to ensure the wellbeing and safety of a young person, they may be severely compromised. This is because the LA as the Corporate Parent has not found a way to properly distinguish between: 1. Delegation with its obligation to oversee the decisions of the F&F Carers whilst retaining ultimate responsibility and 2. Effectively relinquishing decision-making to F&F Carers whilst calling it “delegation”. Considerations for the Board and member agencies How can the Board satisfy itself that B&H Children’s Social Work Services retains the necessary authority invested in it as Corporate Parent to ensure the best possible outcomes for a child or young person? How can the Board satisfy itself that F&F carers are provided with specialist support groups and training, which meets their particular needs? How can the Board ensure that Children’s Social Work Services staff and F&F carers are unambiguously clear about each other’s roles, rights and responsibilities – including when there are disagreements or problems in the placement? Would it be helpful to review the local policies and procedures for F&F carers, in line with the issues raised by this finding? 12.2 Finding 2. In Children’s Social Work Services, it is difficult to access the various sources of a looked-after child’s past records, leading to an associated response of not prioritising this essential preparation; the result in many cases is that the Corporate Parent does not easily know the life story of its children. (Tools) 12.2.1 There is not a routine habit by new workers (Social Workers/SWROs/Practice Managers) to review a child/family’s history when picking up a case; indeed, to achieve this is regarded as extremely difficult. Reasons given are: not enough time, combined with inaccessibility of old files, and profusion of records in different formats which do not join up to make a comprehensible whole. 12.2.2 This situation acts as a detriment for planning, decision-making, and working directly with the child, as well as inhibiting the Corporate Parent’s responsibility to record and maintain an account of the child’s story and experiences – for the child and workers alike. Child E Serious Case Review – Brighton & Hove LSCB Page 30 How did the issue feature in this case? 12.2.3 E’s changing social workers in 2013 and 2014 had a weak understanding of his history (although one, SW3, said he knew about the ‘secret’ kept regarding his mother’s death). They had not read old records, and did not have access to a complete chronology for E and his family. This inevitably affected how they saw some of his risk-taking behaviour, his relationship with his carers, and his questions about his parents and his past. For example, the history of multiple suicides in his close family was not part of his ‘story’, nor the several years of dysfunctional contact (on/off) with his birth mother. A link between a pattern of familial suicides and the vulnerability of a young person22 or adult was therefore not explored in relation to E. 12.2.4 The Practice Manager/supervisor (2013 and part of 2014) equally had limited information about E’s history, and was thus unable to fill in any gaps for his workers. What makes this an underlying issue? 12.2.5 Members of the Case Group were adamant about the general difficulty in accessing previous Children’s Social Work Services records. This is because they are held in different forms (paper and electronic) and in many different places, and more than one electronic system is in place (previously 3; now 2). The Review Team were told that piecing the jigsaw together is daunting, and requires more time than most workers or their managers have. (This fits with the description of agency workers being required to ‘hit the ground running’.) 12.2.6 It does not help that chronologies are inconsistently used in B&H Children’s Social Work Services, making it more difficult to see patterns in behaviour, clusters of incidents, and thus to be alerted to worrying cycles or repeated signs (see the next Finding 3). 12.2.7 But: a member of the Review Team managed fairly quickly and easily to access social work records for E from several years ago. Even E’s earliest history is available to be read in legal files, offering a coherent account of essential background material, especially about his experiences with his mother and the decisions made regarding his long-term care. It is the responsibility of managers and front-line staff to prioritise the time for such reading. Similarly, managers and staff are responsible for maintaining an awareness of relevant research relating to vulnerable young people and areas of particular risk. What is known about how widespread or prevalent the issue is? 12.2.8 This is a national issue, given that all the barriers described above are complaints familiar in Children’s Social Work Services departments around the country: a mixture of old paper records, sometimes in archives some distance away, and newer/mixed or incompatible electronic systems which are not easy to navigate and rarely have a section which provides a full and coherent history of the case, or the child/family. A recent SCR23 suggested that ‘cut and paste’ functions used for updating documents in some systems do not allow for ‘old’ material to be sifted, resulting in a confused account, not useful to anyone. 12.2.9 A number of SCRs nationally have confirmed the poor attention and time given to reading historical records, in whatever form they are. 22 Research findings relating to greater vulnerability to suicide, across countries and internationally (e.g., the World Health Organisation), consistently cite a family history of suicide as ‘a predisposing factor’. Please see References for examples of such research. 23 SCR regarding Child B, Kingston LSCB, 2015 Child E Serious Case Review – Brighton & Hove LSCB Page 31 Why does it matter? 12.2.10 There are two critical reasons to know about and reflect on a child’s (child in care) story. The LA, as Corporate Parent, has the same responsibilities of a ‘natural’ parent, who must try to understand their child and to keep him safe and developing well, in the context of his individual experiences and needs. For the LA, this must underpin the ongoing process of care planning and review. 12.2.11 Secondly, the current Social Worker for the child needs to be able to use the same historical picture to guide their understanding of the child, and to gauge the effectiveness and suitability of plans and interventions – especially in the tumult of adolescence. 12.2.12 Despite a sense of ‘something missing’, there does not appear to be a robust debate about the risks of undertaking complex work with the child/YP without a proper understanding of his or her psycho-social history. It is vital that the organisation and the worker who represents it at the front line must feel that this is their child, and behave accordingly. Without this level of knowledge, understanding, and informed involvement, the child will not feel (nor be) held safely and securely. Finding 2: In Children’s Services, it is difficult to access the various sources of a child’s past records, leading to an associated response of not prioritising this essential preparation; the result in many cases is that the Corporate Parent does not easily know the life story of its children. Typically social work staff taking on a new case do not undertake a review of a child’s history. This seems to be due to a combination of believing there is not enough time and that the task is too complex with records being difficult to access. There is also a lack of awareness of the dangers in failing to do so. This results in a failure to see patterns of behaviour indicating a change in risk. The absence of an effective tool for chronologies makes it difficult to maintain ‘life story’ work. Considerations for the Board and partner agencies What is the LA’s expectation in relation to workers’ knowledge and understanding of an individual case at the point of transfer? What is the current policy for guiding staff to appropriate source material? What review systems are there in place to ensure ‘life story’ work is maintained for children in care? What is Children’s Social Work Services’ expectation in relation to staff recording new information from whatever source? What kind of training is needed, and for which groups of staff? Is the Board aware of the limitations of Children’s Services’ IT systems? Child E Serious Case Review – Brighton & Hove LSCB Page 32 12.3 Finding 3. The tools for transmitting background information about a child or YP (transfer summaries and chronologies) are not produced to a consistent standard, meaning that a new SW may not have the background and qualitative information which would support a holistic understanding of the child/YP and family and their needs and risks. (Communication and collaboration in longer term work) 24 12.3.1 The idea that ‘background’ information is necessary in order to provide an effective and appropriate service to a child/family is a familiar one, but one which is often overlooked when workers can find no readily accessible sources for that information. Transfer summaries (and, where possible, face-to-face handover meetings) and chronologies are essential tools for workers and their supervisors to rely on. Where these are not consistently available and well used, the work with children will be of a lesser quality, and may not be safe. How did the issue feature in this case? 12.3.2 E’s SWRO2 provided both a Transfer Summary and a face-to-face handover meeting when E moved to the 16+ Team and a new Social Worker – excellent practice. After that change of workers, there were no further handover meetings, so the function of the Transfer Summary became extremely important. 12.3.3 SWs (1 and 2) both created Transfer Summaries, cutting and pasting the useful history which had been included by SWRO2. Some, but not all, current issues were ‘flagged’ by SW1, but the next worker was unfamiliar with the case and had nothing else to add. SW3’s Transfer Summary had lost all the ‘history’ material, leaving SW4 with little to go on, apart from an inaccurate description (at that point) of the placement as ‘stable’. 12.3.4 Chronologies were not available for E’s recent (or more distant) history, and this meant that, e.g., patterns of ‘incidents’ and crises in the placement, as well as clusters of offending, were not able to be identified as a build-up of troubling signs. What makes this an underlying issue? 12.3.5 The Review Team were told that Transfer Summaries do not consistently provide the right kind of in-depth information and analysis which would support a new worker’s understanding of the child/family. A different problem, of accessing them electronically, was identified in the recent Baby Liam SCR, but the report responds that this is ‘… not a problem within Brighton & Hove because the CareFirst IT system has a specific, standalone case transfer record that requires management sign-off.25 This suggests that it should be possible to use this tool more effectively. 12.3.6 There is no evidence of chronologies being used consistently across the teams in Children’s Social Work Services. It is not clear whether this is because the electronic system(s) doesn’t offer an appropriate tool, or whether there is not ‘custom and practice’ of ensuring a chronology is maintained and used in the work. 12.3.7 ‘Not enough time’ to attend to these essential tools has also been mentioned in this case review, as being a common context for the work in Children’s Social Work Services. This challenge, linked with the fact of a churning staff group, almost inevitably results in a weaker understanding of a child or YP and their needs. It also means that these useful structures are 24 This finding links closely to the one above, as they have similar results: the reduced understanding of the child/young person 25 SCR Baby Liam, Brighton & Hove LSCB, 2015, Para 4.7.4 Child E Serious Case Review – Brighton & Hove LSCB Page 33 unavailable for reflecting on and analysing information in assessment, planning and supervision. What is known about how widespread or prevalent the issue is? 12.3.8 The Review Team has been unable to find wider information about the production and use of good Transfer Summaries, around the country. 12.3.9 In relation to chronologies, there is more evidence. After the Victoria Climbie Enquiry promoted the idea of a composite chronology at the front of every Children’s Services file, there was evidence nationally of improvement of practice, but this did not persist. The introduction of the Integrated Children’s System (and its translation into many varieties of electronic systems) failed to deliver an effective tool for chronologies, nor a single, easily accessible system to view a child’s long-term story. 12.3.10 The other constraint is ‘not enough time available’, and that too is a widely shared context in services which are undergoing significant changes, including cuts and staffing constraints. With fewer workers, and fewer permanent workers, the pressure of workloads becomes greater. Another recent SCR26 describes a situation in which pressed workers in a busy team ‘were not encouraged to undertake chronologies’. The author comments on how this can lead to a failure to ‘build up a more coherent and clear pattern of family functioning’. Why does it matter? 12.3.11 In Beyond Blame, Peter Reder et al’s analytic review of 35 child death inquiries27, the value of information from the past is underlined – as a means by which to understand and respond appropriately to current behaviour: ‘The importance of history cannot be overemphasised’ (p124). The power of chronologies is also illustrated dramatically in the text, showing how patterns and signs of risk are highlighted when (even a skeleton) chronology is maintained as an active tool for working a case. Guidelines for good practice include allowing time to review the background of a case when staff take it on (p122). 12.3.12 Given the pressure of complex and challenging workloads, the help that is available from transfer summaries, chronologies, and other key documents (such as specialist assessments, court judgements) should be used in all cases. Without this, workers will struggle fully to understand what is going on for a complex or troubled young person. Finding 3: The tools for transmitting background information about a child or YP (transfer summaries and chronologies) are not produced to a consistent standard, meaning that a new SW may not have the background and qualitative information which would support a holistic understanding of the child/YP and family and their needs and risks. Where full and accurate sources of the history of a looked-after child are not reliably available, there is the obvious risk that this history will be poorly understood by workers, and equally importantly that the child will not be given his own ‘life story’ by his Corporate Parent. The issues of identity and personal history are highly significant to children who have lost a parent or parents, and should be at the top of the Corporate Parent’s list of responsibilities. 26 SCR anonymised (2015 – C5641), NSPCC archive, Para 11.4 27 Reder et al, 1993 Child E Serious Case Review – Brighton & Hove LSCB Page 34 Considerations for the Board and member agencies: What is the current policy regarding the production of chronologies – in B&H Children’s Services? In partner agencies? How are handovers of cases generally handled? Apart from transfer summaries and chronologies, are there other ‘key documents’ which could be signposted? What is the LA’s expectation in relation to workers’ knowledge and understanding of an individual case at the point of transfer? Is there a commitment by managers to prioritising the time needed by staff for reading key case material? What are the most important tools to underpin the work? What are the changes in ‘culture’ which would be required in order to prioritise a) the production of chronologies and effective transfer summaries, and b) the time to read these. See recommendation from SCR28: ‘The Boards should look to establish a Practice Working Group to look at creation of a Simple Chronology Tool that could be completed across agencies’. What would signify improved practice for children if these tools were well produced and well used? 12.4 Finding 4. Is there a risk for professionals, in following Care Planning, Placement and Case Review Regulations, to give too much responsibility to young people over their Pathway Plan Reviews, with the result that difficult subjects are not raised if the young person objects? (Communication and collaboration in longer term work) 12.4.1 Care Planning, Placement and Case Review Regulations (2010) require young people who are in care to be at the centre of decisions that are made about their life, and for older young people to be given more responsibility regarding their PPR meetings. While this is right and proper, the professional responsibility remains to assess their needs in the round, so that these can be met insofar as possible. In order to do this effectively requires that PPR meetings do include significant information about a young person’s level of risks and needs, so that he/she can be helped to think through things that are difficult, as well as the things they feel more comfortable about discussing with the range of professionals who know them and who are present in a review meeting. 12.4.2 There is evidence in this case that difficult matters, and sometimes essential information, were not raised or addressed directly with the young person in their PPR meetings. We have 28 SCR Child CH, Enfield and Haringey LSCBs, 2015 (Para 61) Child E Serious Case Review – Brighton & Hove LSCB Page 35 made this an indicative finding only, as further investigation is required by the Brighton & Hove LSCB in order to demonstrate whether this is commonplace. 12.4.3 Where there is no other meeting to discuss such matters, this can result in important issues and concerns getting lost and not shared throughout the network around the young person (see link to Finding 5, below, which considers how additional multi-agency meetings are not routinely convened for children in care). 12.4.4 The Children Act Guidance and Regulations, Volume 3: planning transitions to adulthood for care leavers (revised 2015) makes it clear that, for 16-17 year olds (‘eligible young people’), the LA retains all its responsibilities of care planning and review, which are now folded into the Pathway Plan Review process.29 12.4.5 The regulations also outline the function of the PPR meetings, and what should be addressed, to include: Health and development Education, training and employment Family and friends social network Financial capability 12.4.6. In all of these areas, it is clear that the LA has responsibility for maintaining a plan which will meet the young person’s assessed needs, and include ‘who, what, how, when’ in the plan. To be meaningful, the PPR meeting will need to consider what has happened since the last review and how this has affected the plan, taking into account the views and wishes of the young person, whilst also balancing these with the known facts and opinions of key professionals – for example, from health, education and related services. 12.4.7 A number of Pathway Plans have been criticised in the courts30 for not meeting this responsibility, and for not carrying out the required assessment (described above). (Studdert, p2) Case law has clarified that a Pathway Plan ‘must clearly identify a child’s needs, and what is to be done about them, by whom and when’, and that it ought to be a ‘detailed operational plan’ so that it can be used ‘as a means of checking whether or not [the] objectives are being met’. 12.4.8 It is clear from all the guidance that the young person’s full involvement and participation are at the heart of the Pathway Planning process, but that this does not diminish the responsibility of the LA (Corporate Parent) and that of other agencies for contributing to the plan. How did the issue feature in this case? 12.4.9 During the period under review there were four PPR meetings each chaired by an IRO. In accordance with E’s wishes these meetings were limited to a small core group involving E and his FM, together with the SW at the time, and SWRO1. E was able to determine both the membership and overall content of the meeting. This meant that, in accordance with his wishes, several key pieces of information and significant events were not shared. This significantly compromised the review and planning process, and meant that at different 29 Para 2.9. ‘At the point at which a young person becomes an eligible child and it is envisaged that s/he will be leaving care, the pathway plan must be prepared which must include the child’s care plan. This is in order to capture the actions which will be necessary from the responsible authority, the young person’s carer, young person, parent, and other identified parties in order for the young person to make a successful transition from care.’ 30 Studdert, O. Child E Serious Case Review – Brighton & Hove LSCB Page 36 times there was a lack of clarity as to who had knowledge of events and where responsibility lay. With so much of what was actually happening to E not being discussed, it is reasonable to speculate that this may have undermined E’s confidence in professionals involved, and their ability to plan for his safety and wellbeing. 12.4.10 The way in which this meeting was constituted meant that at a time when the people working with E needed all the relevant information about him to be shared as part of the assessment and planning process, there were significant gaps. Information was not routinely sought or shared for planning purposes. This resulted in fragmented multi-agency involvement. Individuals could try to address and minimise the risky behaviour known to them, whilst unaware of a wider and more concerning pattern. 12.4.11 For example, at PPR1 (August 2013), key events, including contact with E’s birth father and episodes of disruptive /violent behaviour were not discussed, and there was an absence of reflection on significant events. Accordingly, no realistic plans and contingency arrangements could be put in place to deal with either. Instead, the PPR record states that E’s relationship with his foster carers ‘continues to be up and down but no more than most adolescents’. The placement is described as stable. The Review Team found this surprising given the turbulence described by FM and the involvement of police in this period, alongside FM’s ongoing concerns about E’s drug-taking. 12.4.12 PPR2 (February 2014) noted E’s good progress at college, and again described the placement as stable. E’s admission to hospital having been found unconscious as a result of excessive drink was not mentioned, and other Police concerns (e.g., about E’s ‘doing drugs’ with a mate) were not known to those at the meeting. SWRO1’s concern about the fragility of the placement was not shared (this links to Finding 5, below). What makes this an underlying issue? 12.4.13 The LA as Corporate Parent, and those to whom it delegates authority, hold ultimate responsibility for the care and wellbeing of children in their care. In order to fully exercise this role it needs (particularly within the forum of PPR meetings) to: 1) understand and review what has happened with the delivery of the care plan, and 2) assign responsibilities and develop decision-making protocols in a way that is clear to all concerned. These responsibilities need to be balanced with the imperative to place the young person at the centre of care planning and to enable them to take an increased share in decision-making commensurate with their chronological age, emotional wellbeing and level of maturity. Relationships and attitudes established early on in the management of a case will in most instances influence the success of later work. 12.4.14 Conversations and discussions with the Case Group confirmed that older children/YP in care are given a leading role in how their reviews are conducted. A member of the Review Team, the Head of Service for youth offending and drugs services (RUOK), commented that it was routine for workers from these critical areas to be told they were not invited to a LAC Review or a PPR meeting. Their absence could be mitigated by the inclusion of written factual reports to inform the planning process. Their exclusion makes it likely that important issues for the young person may not be discussed or recorded (and see Finding 5, below, which suggests that alternative forums for discussion are not routinely used). What is known about how widespread or prevalent the issue is? 12.4.15 There have been a number of legal cases which have challenged the inadequacy of Pathway Plans. Oliver Studdert (Partner Maxwell Gillott Solicitors), writing an article for Family Law Child E Serious Case Review – Brighton & Hove LSCB Page 37 Week, (www.familylawweek.co.uk/site.aspx) entitled ‘The importance of pathway plans and Local Authorities Duties to Care Leavers ’, argues that they are frequently limited to a short narrative which fails to meet the Regulation 8(2) of the Children (Leaving Care) (England) Regulations 2001 which provides: "The pathway plan must, in relation to each of the matters referred to in the Schedule, set out – (a) The manner in which the responsible authority proposes to meet the needs of the child; and (b) The date by which, and by whom, any action required to implement any aspect of the plan will be carried out." The Schedule identifies these matters to be dealt with in the pathway plan and review as being: 1 The nature and level of contact and personal support to be provided, and by whom, to the child or young person. 2 Details of the accommodation the child or young person is to occupy. 3 A detailed plan for the education or training of the child or young person. 4 How the responsible authority will assist the child or young person in relation to employment or other purposeful activity or occupation. 5 The support to be provided to enable the child or young person to develop and sustain appropriate family and social relationships. 6 A programme to develop the practical and other skills necessary for the child or young person to live independently. 7 The financial support to be provided to the child or young person, in particular where it is to be provided to meet his accommodation and maintenance needs. 8 The health needs, including any mental health needs, of the child or young person and how they are to be met. 9 Contingency plans for action to be taken by the responsible authority should the pathway plan for any reason cease to be effective.” 12.4.16 Studdert cites recent cases where a challenge to the inadequacies of Pathway Plans has been made and judges have commented upon the legal expectations placed upon LA staff in this respect. 12.4.17 ([1] R (J) v Caerphilly County Borough Council [2005[] EWHC 586 (Admin); [2005] 2 FLR 860 In the Caerphilly case Mr. Justice Munby stated that "a care plan is – or ought to be – a detailed operational plan. … but whatever the level of detail which the individual case may call for, any care plan worth its name ought to set out the operational objectives with sufficient detail – including detail of the "how, who, what and when" – to enable the care plan itself to be used as a means of checking whether or not those objectives are being met. Nothing less is called for in a pathway plan” 12.4.18 The Caerphilly finding is supported by several other cases notably (R (A) v LB of Lambeth [2010] EWHC 1652 (Admin); [2010] 2 FCR 539; R (G) v Nottingham City Council and Nottingham University Hospital [2008] EWHC 400 (Admin); 11 CCLR 280, 290; R (Birara) v London Borough of Hounslow [2010] EWHC 2113 (admin). Together these judgements reiterate that an assessment must determine a child’s needs, how those needs are met and evaluate the progress made. In this way anyone examining the plan would be able to ascertain the progress made and the areas which remain to be addressed. Child E Serious Case Review – Brighton & Hove LSCB Page 38 Why does it matter? 12.4.19 The PPR process is designed to ensure that the goals and milestones for a child in care are set out, agreed and met, in a plan which covers all aspects of wellbeing including emotional, educational and social development and issues related to identity. The views of the child or young person are central to the PPR process, and it is right that the active participation of the young person in their review is encouraged – especially as they enter the transition period of leaving care and becoming an adult. However, a balance must be struck in relation to their wishes, and the need for input from professionals and family members, especially where there are risks and problems which need to be addressed together. Finding 4: Is there a risk for professionals, in following Care Planning, Placement and Case Review Regulations, to give too much responsibility to young people over their Pathway Planning Reviews, with the result that difficult subjects are not raised if the young person objects? There is a tension between giving older young people greater responsibility for their own 6-monthly reviews, as part of an appropriate preparation for independence, and ensuring that the Corporate Parent remains able to address areas of serious concern for the young person in the care planning process. Where these areas are ‘vetoed’ by the young person, and vital information is not shared, then areas of risk and need may not be addressed, leaving the YP without appropriate help and support. Considerations for the Board and member agencies: What does the Board think about the ‘balance’ that is described above? Does it need to be re-examined? Can IROs as a group assist in thinking about what makes for a helpful/unhelpful balance? Is there an agreed approach locally for older YP in relation to the content of their PPR meetings? Is there a regular review of the quality of Pathway Plans? If so, what are the lessons learned from this? What ideas do the Board and member agencies have about supporting better uptake by YP of services that they more than often decline, but which they need? What would provide evidence that the balance in PPR meetings was working well, both for the YP and for the Corporate Parent? Child E Serious Case Review – Brighton & Hove LSCB Page 39 12.5 Finding 5. Nationally, there is no routine framework for multi-agency professionals to meet outside of Pathway Plan reviews, leaving the responsibility with an individual practitioner to convene such a forum. The result is that planning and decision-making for a child often proceed without the benefit of a joined-up discussion of their perspectives and concerns about a child. (Management Systems) 12.5.1 Unlike the formal Child Protection system of planning and review, 6-monthly LAC review meetings do not involve all the professionals who are working with or involved with the YP. Nor is there anything equivalent to Core Groups which meet every 6 weeks to share information about progress, shifting circumstances/events, and difficulties. If an ‘extra’ meeting is needed to discuss a child in care and the concerns of professionals, this has to be specially requested. How did the issue feature in this case? 12.5.2 The Key Dates chronology for this case conveys a powerful picture of ongoing difficulties, leading to the breakdown in E’s relationship with his carers. These were not adequately addressed in his LAC Reviews and his PPR Meetings in 2013/14 (see Finding 4 above), and there were no other meetings where the professionals met to discuss E’s and the family’s situation, and consider what better strategy there might be to help them. 12.5.3 SWRO1 was the worker with greatest awareness of the stresses and strains in the placement, and received the most communication from FM about when and why the relationships in the family were at breaking point. Partly because new SWs knew less about E and his carers, a professionals/briefing meeting would have been extremely helpful, to bring people together to share both information and views about E and the family. For example, PM2 was shocked to read in parts of the chronology prepared for this review about E’s historic mention of suicidal thoughts (2012). The degree of conflict in the placement was shared less over time by FM, as workers continued to change. 12.5.4 There were two times when SWRO1 requested an ‘extra’ professionals meeting (2013 and 2014, both at a low point in the placement), but neither of these happened. It is important to understand why they didn’t: was it because of staff not having enough time, especially for workers with what were deemed higher priority duties and tasks? This is something which the service needs to explore. What makes this an underlying issue? and What is known about how widespread or prevalent the issue is? 12.5.5 This is a national issue, based on different procedures and structures for the work of Children’s Services and fellow agencies. The LAC Review/Pathway Plan Review process does not offer a regular and inclusive forum for the ‘team around the child/YP’ to meet to discuss him/her, how well their interventions are working to meet the child’s needs, and indeed how well they are functioning as a professional network. 12.5.6 In contrast, CAF, Child in Need and Child Protection work is carried forward by means of such regular multi-agency meetings and reviews, with contributions via reports when professionals cannot attend. 12.5.7 The ease and confidence with which fellow professionals in other areas can convene ‘extra’ meetings regarding a child in care (or any other child being worked with by Children’s Social Work Services) is not known to the Review Team. We suspect that the pressures of work and the view of Children’s Social Work Services as holding lead responsibility may leave the Child E Serious Case Review – Brighton & Hove LSCB Page 40 wider network out of the loop, and possibly unaware of when things are going wrong. In some areas, the idea of having a meeting without a child, especially an older child, or parents/carers present is resisted, making another reason why professionals may not ask for a professionals-only meeting. Why does it matter? 12.5.8 There are many reasons why extra meetings might be required, given how much can transpire in the 6-months time frame between LAC reviews and PPR meetings. Where things are going badly wrong for a young person, or where the plans and partnership work of professionals are ineffective – for whatever reason – it is vital that any member of the professional network can confidently request a professionals meeting, or simply for an extra review meeting to be called forward. We have seen in this case that professionals can be left with appropriately rising concerns but still struggling to pull together a professionals meeting to share these with colleagues and make effective plans. This can leave the young person without the timely care and attention that may be needed in response to serious problems. Finding 5: There is no routine framework for multi-agency professionals to meet outside of Pathway Plan reviews, leaving the responsibility with an individual practitioner to convene such a forum. The result is that planning and decision-making for a child often proceed without the benefit of a joined-up discussion of their perspectives and concerns about a child. The lack of any formal or regular meeting which includes the full range of professionals involved with a looked-after child, or other children in need, tends to weaken partnership working and information-sharing. Professionals are less likely to recognise concerning patterns which need to be addressed. The result is a loss of effectiveness and a potential for drift in dealing with the child/young person’s problems. This problem is exacerbated when the young person’s PPR Meeting (see Finding 4, above) does not have key professionals present. Considerations for the Board and member agencies: Does the Board regard this as a problem? Are there any perceived barriers to the use of professionals meetings for a child in care? For other children? If so, what might these be? Would it be helpful to formulate agreed criteria, which agencies could use to support the request for a professionals meeting? Is there an escalation policy for use when it is difficult to set up a professionals meeting? Would it be helpful for a multi-agency meeting to be held as a ‘preparatory meeting’ in advance of the PPR Meeting or LAC Review? How would the Board know if this situation was improved? Child E Serious Case Review – Brighton & Hove LSCB Page 41 12.6 Finding 6. There is a pattern of focusing only on the primary (usually female) carer for a child in care, and not giving sufficient attention to the role of the non-primary carer (usually male). This can result in professionals’ lack of awareness of both positives and negatives that the other carer may bring to his/her role. (Human biases) 12.6.1 Fostering gender roles are often no different from those in many typical families in this country, where the male partner is less involved in child care than the female. For fostering families, this may be reflected in how communications are managed, and in minimal expectations about input from the male carer, including attendance at key meetings. However, a lack of partnership with both carers risks ignoring the significance of the man in family life – for good or ill. This may include how he is a role model for the child (in this case, a boy – almost a young man), the nature and quality of their time together, and the support he can offer to his partner when, again, in this case, there are major problems with the young person’s behaviour. How did the issue feature in this case? 12.6.2 Like FM, FF was approved as a foster carer and there were formal requirements attached to this status. But he was rarely seen by workers, on visits, at meetings, and even at the annual Fostering Reviews. Efforts to include him were not successful. 12.6.3 FF’s views about E and his wishes and feelings in relation to the deteriorating situation of the family during 2014, were not ascertained in advance of E’s PPR meetings, which meant that he had no input into professionals’ understanding E’s lived experience for the previous 6 months under review. 12.6.4 One result of this lack of contact with FF was that SWRO1 and E’s social workers remained unaware of his heavy drinking, which was considerably above the recommended level for a man. This was in the context of FM’s concerns about E’s drinking and drug use. 12.6.5 The Review Team heard repeatedly, and read in case records, that E saw FF as his ‘father’. He wanted to have the same surname as his cousin/’brother’. This fact makes it even more significant that FF’s absence was, over time, accepted and he was routinely left out of any dealings with the LA. What makes this an underlying issue? 12.6.6 All the professionals involved in this case took the view that this was widespread and ‘normal’ practice in B&H – and could be explained largely in terms of the working life of the male carer and hence their ‘unavailability’. The idea of arranging meetings to be able to include male carers was not deemed generally practicable, although meetings with parents/carers and family will frequently be scheduled to take place outside of core hours. 12.6.7 The recently published Brighton & Hove Serious Case Review regarding Baby Liam pointed to a different way in which a male carer may be ignored (in that case, within the Midwifery Booking Form), and noted that ‘many agency procedures are insufficiently robust in their approach to men’31. The common feature in these (and instances given below) is an underestimation of the significance of the role played by men in the lives of their children. 31 SCR Baby Liam, Brighton & Hove LSCB, 2015, Para 4.2.1 Child E Serious Case Review – Brighton & Hove LSCB Page 42 What is known about how widespread or prevalent the issue is? 12.6.8 This is a national issue. It is not confined to foster carers, but is regularly reflected in services’ dealings with fathers and male carers generally. For example, it is commonplace for fathers not to be present at key health events, such as the New Birth Visit, when vital information about infant care is provided (such as advice about shaking babies and co-sleeping). There are exceptions, illustrated by a growing commitment in some services to the inclusion of fathers/male carers (e.g., in commissioning Children’s Centre services to provide programmes for fathers). 12.6.9 This pattern of insufficient attention to fathers or male partners is starker in relation to what are regarded as ‘absent men’, as described in Brandon et al’s review of SCRs (2009). They found that men who are deemed (perhaps incorrectly – cf the case of Peter Connelly) to be absent, are often ignored within the professionals’ work with the mother and children, and not included in assessments. This has two very different consequences: children might not be adequately protected from poorly understood risks, but children might equally be denied potentially positive contact with fathers and their extended family. Brandon writes: Our approach to making sense of men in households is taken primarily from the child’s perspective. We work from the premise that men who are regularly part of a family are likely to have a high level of day to day contact with the child. Even if this is not the case, their presence will have a crucial impact on the care giving environment generated for the child.32 12.6.10 Scourfield (2001, 2006) reminds us of common ways in which men are not included in the work of agencies – e.g., ‘the failure to take men into account in an assessment’, and even ‘the dearth of information about men in most SCRs’. Why does it matter? 12.6.11 Children who live with two foster carers have relationships with both and are inevitably affected by them both. So female and male carers are and should be seen as critical resources for the child, whatever the allocation of family roles and relative levels of time spent in the home. Where the local authority (the Corporate Parent) has very little idea about how the male carer relates to the child, what role he has, and what more he might have to offer, they are in danger of ignoring and under-using this resource, including the knowledge and insights they have about the child. Finding 6: There is a pattern of focusing only on the primary (usually female) carer for a child in care, and not giving sufficient attention to the role of the non-primary carer (usually male). This can result in professionals’ lack of awareness of both positives and negatives that the other carer may bring to his/her role. Children who live with two carers almost inevitably have a relationship with both, and are therefore affected by both in different ways. The risks of not involving the second (usually male) carer in assessing the child’s needs and making plans are plain to see. A young person may be at some risk from that carer, or (conversely), missing out on positive contributions that could be strengthened and supported – e.g., from a male role model. 32 Brandon et al, 2009, p51 Child E Serious Case Review – Brighton & Hove LSCB Page 43 Considerations for the Board and member agencies: Is this an area which has come to the attention of the Board? Has the Board considered the evidence (noted in many SCRs) about how the roles of males with children are ignored? Is there a culture that values the primary carer (usually female) to the exclusion of the non-primary carer? Is there a local ‘custom and practice’ about this in the fostering service? Or in other services? Are men expected to take part in key processes, such as LAC reviews, New Birth Visits, Midwifery Booking appointments? In relation to looked-after children in placement, are non-primary carers clear about the expectations of them and their role? What do services think would be the benefit to children to include both carers more fully? What might be significant barriers to doing this (apart from people’s working hours – something which should be able to be dealt with)? What do the S11 reports say about how practitioners in agencies consider ‘fathers, male partners and other significant adult males in the family when gathering family information as well as in all assessments addressing the needs and welfare of children and young people’? How would the Board and constituent services be able to measure any difference for children of involving both carers more fully? 12.7 Finding 7. In B&H Children’s Social Work Services, there is inconsistent recording. Without a complete and accurate record, it is difficult for practitioners and their managers to analyse the facts and context of a child’s situation, and to make the most appropriate decisions and plans. (Management Systems) 12.7.1 Complete and accurate record keeping is integral to the social work task (Swain; Kagle, 1991). This is acknowledged within B&H practice guidelines, which require that practitioners’ records: ‘should be contemporaneous notes and should be recorded at the time wherever possible. This is especially important if there is a particular crisis/high risk issue. If there is unavoidable delay on recording, the expectation is that case notes should be no longer than 3 weeks behind.’ 12.7.2 Qualification and subsequent related training make clear the expectations of staff in relation to the recording of all communications, whether it be a face-to-face contact, e-mail exchange, or professional conversation. Clear, timely unambiguous case records aid both decision-making and report writing. Records are the means by which staff are able to evidence their work and be held to account for what they do. It follows that the poor maintenance of appropriate records undermines the quality of the service being provided Child E Serious Case Review – Brighton & Hove LSCB Page 44 and renders the service provider open to criticism. A movement towards simpler, less detailed recording does not affect the requirement for completeness and accuracy. How did the issue feature in this case? 12.7.3 The SCR was hampered at a number of points by Children’s Social Work Services records that were slim or non-existent. The Review Team was told that some visits and meetings had happened but were not recorded (examples are cited in the Appraisal section of this report). This leaves the service in a very vulnerable position, if records cannot be relied on to be complete and accurate. This is especially true in relation to recording about evidence and rationale for decision-making. 12.7.4 The most striking specific example of this deficit was the ‘muddle’ of what happened in relation to E’s sudden move to be near his BF. Our understanding of who was involved with this and how the decision was reached was limited by the absence of detailed recording of events over the course of that afternoon and by the absence of a recorded rationale for the decision itself. This applied to workers and managers at all levels of those involved. 12.7.5 More generally, gaps in recording have a particular impact when workers change frequently. In this case, there were several changes of staff in the STC team (where E’s case was held), and we were told they had to ‘hit the ground running’. An understanding of the case could only come from records and summaries. This meant that each practitioner taking on the case could potentially be relying on incomplete records, and a lack of time to search for a case history. This would inevitably reduce the effectiveness and the quality of their work with the child and family, and limit their understanding of the complex nature of E and his family and the issues with which they were all grappling. What makes this an underlying issue? 12.7.6 There were several examples where social work practitioners have said that a visit had taken place or a professionals meeting was held for which we could find no written record. Similarly there were occasions where important decisions have been made (e.g. regarding contact with BF; the move to permanent/respite care; the move to stay close to BF) with no accompanying record to show how the decision was made, what factors were taken into account and how these were balanced with other factors. 12.7.7 Managers during this review have acknowledged that this is an area where improvement is needed. A recent Ofsted report in B&H commented that ‘The rationale for decisions is rarely recorded’. What is known about how widespread or prevalent the issue is? 12.7.8 Deficits in recording practice are well known in social work practice and have featured in a number of SCRs. Communication and recording errors were noted by Lord Laming in his report into the death of 7 year old Victoria Climbie: In some cases nothing more than a manager reading a file, or asking a straightforward question about whether standard practice had been followed, may have changed the course of these terrible events. (para 1.17) Resolving this conflict of evidence has not been helped by Ms K’s poor note taking. There is certainly no record of a telephone conversation between Ms A and Ms K in Ms A’s contact notes on Victoria's case file. (para 6.284) Child E Serious Case Review – Brighton & Hove LSCB Page 45 12.7.9 In publishing his progress report on the protection of children in England following the Baby P case, Lord Laming wrote of… ‘the vital role good record-keeping plays in underpinning supervision and sharing of information. Local leaders must ensure that children’s and young people’s information is managed and recorded effectively to reduce their risk of harm. ‘ Why does this matter? 12.7.10 The coherence of social work, clarity of goals and how decisions are made are all dependent on the maintenance and accessibility of accurate written case records. The importance that an individual agency attaches to recording and the reading of files is of equal importance to that of the professional who has the responsibility to both read and add to case records and to ensure that they have a detailed understanding of their cases. Where either of these is compromised, good practice is undermined, decisions may be taken without a full understanding of or recognition of the facts, and it is then difficult for those not previously involved with the case to understand how these were reached. Good recording, the retrieval of and reading of case records support good decision-making and support effective organisational lines of accountability. Finding 7. In B&H Children’s Social Work Services, there is inconsistent recording. Without a complete and accurate record, it is difficult for practitioners and their managers to analyse the facts and context of a child’s situation, and to make the most appropriate decisions and plans. Inconsistent and incomplete recording presents a challenge to effective multi-agency work and to the professionals’ ability to analyse the facts and the context of a child’s situation and the interventions that are necessary to safeguard and promote a child’s welfare. Good case records should contain relevant and accurate information about a child, which can be relied upon to inform reviews, analysis and decision-making. When these records are not maintained, a sound understanding of the case is harder to achieve, and this makes it particularly difficult for a new worker to understand the child/family and the immediate circumstances, concerns and issues. Considerations for the Board and Other Member Agencies How can the Board satisfy itself that case records are being appropriately maintained? In individual agencies, what are the expectations by senior managers regarding good quality and accurate recording by staff? Are they confident that staff have time to carry out this area of their responsibilities? Are there perceived barriers – cultural and/or administrative – to the maintenance of timely records? What kind of training is needed, and for which groups of staff? Is the import of maintaining records fully understood by all staff – i.e., if it is not recorded, ‘it did not happen’? Do staff recognise what needs to be recorded and how to record it? Is the import of maintaining records fully understood by all staff i.e. If it is not recorded it did not happen? Do managers make use of case notes in staff supervision? What kind of measures would support improved record-keeping? Child E Serious Case Review – Brighton & Hove LSCB Page 46 12.8 Finding 8: Sussex Police do not always act in accordance with their own guidelines by informing Children’s Social Work Services about their observations of, contact or interventions with young people. This means that opportunities for joint thinking, decision-making and interventions may be lost. (Communication and collaboration in longer term work) 12.8.1 In Sussex Police any direct contact by police with a child should be recorded on a SCARF (previously MOGP/1 form) and forwarded to the relevant Child Protection Team before the relevant officer goes off duty. These forms should then be shared with Children’s Social Work Services. In this case these forms were not completed on all relevant occasions, and therefore information was known to police that was not shared with other parties. How did the issue feature in this case? 12.8.2 During 2013 there were 10 incidents recorded on police computer systems that related to E: One incident related to police officers attending his home address in response to a call from FM, who stated he was ‘smashing up his room’. It records that E was removed from home. Three of the incidents involved his FM reporting him absent/missing. Another three incidents all related to the same occurrence on 02/10/13, where E was found slumped on the pavement, and was taken to hospital, where it was believed that he had taken controlled drugs. The remaining three incidents related to intelligence reports regarding E being seen with other associates who were known to the police. 12.8.3 Only one of these incidents was shared by the attending police officers with the Child Protection Team. This was the only one where an MOGP/1 was created and it relates to the suspected drug use linked to Es admission to hospital. This incident was shared with Children’s Social Work Services. 12.8.4 Between January and November 2014 there were twenty-five incidents recorded on police computer systems. Of those incidents: Only two were shared with the Police Child Protection Team. One was shared with Children’s Social Work Services. Nine of these recorded incidents were when E was reported as absent by his FM. There were also incidents that involved him coming to the attention of police and his arrest in relation to an alleged burglary. The remaining records concerned the alleged burglary at E’s home address and the subsequent threats made towards him and his family prior to his move from the area in late November. 12.8.5 Not all the recorded incidents were of a nature which would have required for notification to be sent to the Child Protection Team. However, some were and the failure to submit a SCARF/MOGP/1 meant that information known to the police was not shared with other agencies. 12.8.6 Throughout the period of their involvement, police were unaware of E’s status as a Looked-after Child. In responding to reports of E being absent/missing from his home, they engaged with his FM who they understood to be his legal parent. In common with other police forces, their response to young people reported as missing from home by their parent will vary according to categorization. The categories are: Child E Serious Case Review – Brighton & Hove LSCB Page 47 Missing: Anyone whose whereabouts cannot be established and where the circumstances are out of character, or the context suggests the person may be subject of a crime or at risk of harm to themselves or another. Absent: A person not at a place where they are expected or required to be. 12.8.7 In this case from the information available to the police and taking into account E’s age and the views of the FM whom they understood to be his legal parent, officers were satisfied that E was ‘Absent’ from home. This seems to be a reasonable decision given the facts known to police at the time. At the same time this does raise a question about thresholds for sharing information about repeated absences of a young person particularly in the context of other police-recorded incidents. 12.8.8 There were several instances during the period under review where E came to the attention of police in circumstances where the sharing of information through a SCARF/MOGP1 was warranted and did not happen. Examples where it would have been appropriate to complete the required notification include their attendance at his home address and removal from the family home following an incident where he is reported to have been ‘smashing up his room’, and his arrest and detention in connection with an alleged burglary. Although in each instance E’s FM did inform Children’s Social Work Services of this (and some of the other recorded incidents), this was not always the case and in some instances (particularly where notification was about the absences from home) did not happen at all. 12.8.9 In any event police were unaware of E’s status as a child in care and so would not have been aware that any information known to the FM would be shared with Children’s Social Work Services. Had the police routinely shared all their knowledge in relation to all recorded incidents, this would have presented a further opportunity for Children’s Social Work Services to review risks connected to the management of the case, and arguably might have acted as a trigger for a professionals meeting and with that a more joined-up approach to his care. What makes this an underlying issue? 12.8.10 The Police response to a child or young person being categorized as ‘absent’ from home differs to that of one being reported as ‘missing’. A person designated as missing will be recorded on COMPACT the Sussex Police Missing Persons database, with the Police making enquiries to trace them. The investigation into the missing person will be regularly reviewed by the duty Sergeant and duty Inspector with a Detective Inspector carrying out a review if the person is still missing after 48 hours or they are regarded as being at high risk. A person designated as absent will not be entered onto COMPACT and the expectation is on the person reporting to make enquiries to trace the person, albeit the Police will carry out some basic enquiries such as address checks. The designation is periodically reviewed. Audits undertaken by the police have consistently shown that MOGP/1s are not always completed for every contact with a child. What is known about how widespread or prevalent the issue is? 12.8.11 The failure to share information with other agencies is a common finding in many Serious Case Reviews frequently resulting in missed opportunities for multi-agency action to help families and protect children. Information sharing is crucial if children are to be effectively safeguarded and protected. 12.8.12 The MOGP1 and its replacement SCARF are the formal written means through which police information is shared by police officers following a recorded incident in which a child is Child E Serious Case Review – Brighton & Hove LSCB Page 48 involved. Since the MOGP/1s were first introduced (over 20 years ago), the dynamics of police contact with children has changed. There is now far less casual contact with children, and any interventions are now more likely to arise from police responding to incidents, such as domestic abuse. This has resulted in a significant increase in the numbers of MOGP/1s completed, and the request from Children's Social Work Services in one area for the police to reduce the number of MOGP/1s forwarded to them. 12.8.13 Police recognize that there is now a need for more specific guidance on when a SCARF, which replaced MOGP/1s, should be submitted. Given the rise in incidents, specifically domestic abuse, that police are now attending there is an argument which says that it may be unrealistic to expect a SCARF to be completed for every contact with a child, when the significance of any contact may vary significantly. 12.8.14 We understand that a further audit of SCARFs is now being considered by police to review their number and content, and consideration being given to adding to the current risk indicators on the SCARF and giving officers further guidance in order that there is more consistency in when SCARFs are completed/shared, and more assessment of the risk any child may be facing. It is further understood that the completion of SCARFs will be the subject of a routine audit through the introduction of new audit measures for the Safeguarding Investigation Units. This development is welcomed by the review team. Why does it matter? 12.8.15 The sharing of relevant, evidenced and accurate information in accordance with agency guidelines is inextricably linked to good joint decision making and coordinated interventions. These are the foundations upon which good practice in child safeguarding is built. 33 Finding 8. Sussex Police do not always act in accordance with their own guidelines by informing Children’s Services about their observations of, contact or interventions with young people. This means that opportunities for joint thinking, decision-making and interventions may be lost Sussex Police do not always follow procedure for the sharing of information using a MOGP1 (now SCARF). This means that information only known to themselves is not always shared with Child Protection/Children’s Social Care. In this case the child in question was a Looked After Child (LAC) and the police were unaware of his LAC status. Irrespective of his status as a LAC there were numerous police recorded incidents over a 24-month period some of which should have been the subject of a MOGP1 referral. This finding raises questions for police and Children’s Social Work Services about current guidelines about the circumstances that should lead to a MOGP1/SCARF being raised. As with all procedures /guidelines there will remain some judgement/discretion about their use which balances the need to share the information with the risk identified by both agencies of system overload. Considerations for the Board and partner agencies Is the Board aware of the current mis-match between guidelines for police staff with respect to initiation of a SCARF referral and current practice? How can the Board satisfy itself that SCARFs being completed and shared in accordance with the law and police policy and guidance? Do the Board think there should be a threshold for raising a SCARF in circumstances where a child has been reported as multiply absent from home? 33 Brandon M et al (2011) A Study of Recommendations Arising from Serious Case Reviews 2009-2010, London, Department for Education Child E Serious Case Review – Brighton & Hove LSCB Page 49 13. Additional learning 13.1 Accessing CAMHS 13.1.1 E was a boy whose early experiences of parental care could be predicted to result in his needing help from therapeutic services. He had some counselling input as a younger child, and again, just before the time scale of this review, he was referred to CAMHS because of persistent distress and low mood. E himself, while he was in respite foster care (October 2014) approached his GP asking for anti-depressant medication for anxiety and depression. 13.1.2 At other times, E was adept at covering these feelings, and was seen by many as a cheerful, cheeky lad who got on with adults and children alike. 13.1.3 E declined to use the CAMH service to which he was referred in autumn 2012. He went for one appointment, and decided it wasn’t for him. The case was closed by CAMHS shortly after E’s decision. 13.1.4 E’s reluctance to engage with CAMHS echoes the findings in two recent Learning Reviews in Brighton & Hove, both in relation to the deaths of vulnerable adolescents. These have highlighted what is a local and national issue: the need to create different, ‘young-people friendly’ ways of improving access to CAMHS for adolescents. In the second of these reviews, which also used the Learning Together model, its Finding 4 asserted that: ‘There is inadequate choice in mental health service provision to meet the preferences of many young people, leaving them with the option of attending, or not, the available medically-focused option.’ The associated action point for Brighton & Hove LSCB was that it needed… ‘to be assured that mental health and emotional wellbeing services for adolescents are receptive, responsive and attractive to the needs of young people’. 13.1.5 The idea of ‘assertive outreach’ is not accepted as critical, in order to create services which ‘reach out to where children and young people are within the community, not just receiving support in clinical areas’. In this spirit, B&H CCG have reviewed their CAMH Services in the past 12 months, and have developed a Local Transformation Plan for Children and Young People’s Mental Health Services, as part of a 5-year Strategy of Change and Development across the whole system. 13.1.6 There is increasing recognition that the work to support children and young people may sometimes of necessity be carried out via CAMHS’ input to their parents/carers, to enable them to understand and help their child/young person with their emotional distress. And parents/carers may themselves benefit in a number of ways from such support, to help them cope better with the demands on them of helping their child. 13.1.7 Finally, the introduction of materials to raise awareness about adolescent mental health for all those working with young people (not just mental health practitioners): in February 2016, the Government issued a newly developed resource, MindEd, in association with the Royal College of Paediatricians and Child Health which offers free educational resources on Child E Serious Case Review – Brighton & Hove LSCB Page 50 children and young people’s mental health.34 It would be helpful if this could be promoted as part of the toolkit for staff in all agencies who work directly with vulnerable adolescents. 13.2 Support for staff 13.2.1 The Review Team were told that the introductory meeting for the Case Group was for many people the first time they had had a chance with others to speak about what had happened to E, and their responses to this. We know that some services/agencies routinely convene some kind of debrief/support meeting for staff involved very shortly after such an incident, and it is expected that they will attend. We felt this was a good model. 13.2.2 We were also informed that staff in need of counselling after E’s death were offered telephone counselling only (or possibly face-to-face counselling after a telephone ‘triage’ assessment). This was not acceptable to some members of the Case Group, and it seems appropriate to use this report to give feedback to the local authority, in relation to their responsibility towards staff. 13.2.3 Generally, we felt that all services needed to adhere to a principle of being ‘pro-active’ in relationship to the needs of staff in such circumstances. Experience tells us that it is not only those involved with a child for a long time who may need sensitive support. 13.3 Timing of the SCR 13.3.1 E was a young person who had been known to some members of the Case Group for most of his childhood, and there was a great deal of warmth and fondness towards him. The grief that followed from his death was profound for many, and they found taking part in the Serious Case Review extremely distressing. 13.3.2 The Review Team suggest that such circumstances need to be thought about very carefully when planning to commence an SCR. It may or may not be possible or helpful to postpone its beginning, but this should be given some thought. In the event that the SCR does need to proceed quickly, then the support needs of the professionals who knew and worked with a child or young person should be assessed and given as much attention as possible. 13.3.3 In many regards, the same factors should apply when thinking about the ability of family members to take part in the SCR. 13.3.4 The Review Team are aware of the expectations within Working Together (2015) regarding timeliness of SCRs35, so that lessons are learned and implemented as swiftly as possible. There is clearly a tension between this and any consideration for delaying the commencement of an SCR. 34 www.gov.uk/government/speeches/childrens-mental-health-new-online-resources-for-adults 35 Chapter 4 (Learning and Improvement Framework) sets out expectations for timeliness: that the LSCB should notify any incident to the DfE within 5 working days; that a decision about carrying out a SCR should be made within 1 month; and that the SCR should be completed within 6 months. Child E Serious Case Review – Brighton & Hove LSCB Page 51 14. Conclusion 14.1 This systems review has had two principal aims: to report and learn from what happened, and why, in a particular child or family’s story; and to consider what this tells us about the wider safeguarding of children in Brighton & Hove, and how this might be improved. 14.2 Overall, the review has highlighted the complexity of working long-term with a child/young person in the care of family members (but who remained under a Full Care Order to the local authority), whose early experiences were extremely sad and distressing, and not fully resolved for him. 14.3 It explored the initial “research questions” in relation to multi-agency working, and identified findings which related to the first three of these (see Para 4.1). The question about ‘vulnerability to group activity’ was not answered, given the evidence that E was not involved in this area. 14.4 The findings have focused on the learning for Brighton & Hove which will improve agencies’ response to all children in care, and to their relationship with Family and Friends carers. The involvement of all services, as part of a team around a child in care, is seen as valuable and important. 14.5 There were no findings, nor any data captured in the review process, that suggested that any agency’s actions (by commission or omission) could have predicted or prevented E’s death. The Coroner’s judgement supported this conclusion, as the inquest determined that there was no sign that E might harm himself when he made the decision that he would stay with his BF, nor was there any current or past suggestion of suicidal thoughts.36 As a result, the Coroner concluded that although E had died by strangulation, having hanged himself, there was not sufficient evidence that he intended to take his own life (required for a verdict of suicide). 14.6 The contents of this report have been the product of the Review Team and Case Group, who contributed their knowledge and experience in relation to this case, as well as their wider understanding of how safeguarding systems operate in Brighton & Hove and elsewhere. The process has been extremely demanding for staff, given their various relationships with E and the shock and sadness at his death. 14.7 The report’s findings were enhanced by additional information provided by E’s BF and his wife, and a written contribution from his FM. 14.8 It is hoped that this review will support learning and improvement across the safeguarding network, and will lead to better outcomes for children and young people as they move through care and into young adulthood. 36 The Coroner presumably had no knowledge of the CAMHS records (November 2012) which refer to E’s speaking about suicide. Child E Serious Case Review – Brighton & Hove LSCB Page 52 GLOSSARY: TERMS AND ACRONYMS BF Birth father B&H Brighton & Hove City Council BHSCB Brighton & Hove Local Safeguarding Children Board CAMHS Child and Adolescent Mental Health Services Case Group The group of professionals involved, from all agencies, with the child/family FF Foster Father (for E) – married to E’s maternal aunt FFT Functional Family Therapy (an intensive/specialist service used with families who are at risk of breakdown) FM Foster Mother (for E) – E’s maternal aunt FTE Full Time Equivalent (in staffing statistics) F&F Family and Friends Fostering Team GCSE General Certificate of Secondary Education HMCI Her Majesty’s Chief Inspector (in this case, of Education, Children’s Services and Skills) IMR Individual Management Review (single agency reports which form part of some Serious Case Reviews) IRO Independent Reviewing Officer (chair of required 6-monthly reviews of a child/YP’s care plan/Pathway Plan) LA Local authority LAC Looked-after child (child in the care of the local authority) Learning Together The systems model of case reviews developed by SCIE (fully described in Appendix 2) MOGP1 Memorandum of Good Practice1: Notification from Police to partner agencies, regarding a child who has come to their notice (now incorporated into the SCARF – see below) OFSTED Office for Standards in Education, Children's Services and Skills PEP Personal Education Plan (required for all children in care) PM Practice Manager (Children’s Services) – first line manager/supervisor of social workers PPR Pathway Planning Review Review Team Senior manager representatives from all the agencies involved with the child/family RUOK Drugs misuse service for adolescents SCARF Single Combined Assessment Report Form. This incorporates the MOGP1 form for children and includes vulnerable adults as well. SCIE Social Care Institute of Excellence – developers of a systems model of case review, ‘Learning Together’. This model was used for this SCR. SCR Serious Case Review SW Social Worker SWRO Social Work Resource Officer, used in the Friends and Family Fostering Team and (previously) in the Looked-after Children Team YP Young person (a term sometimes used for 16-17 year olds, who are not yet adult, but who legally remain a child) Child E Serious Case Review – Brighton & Hove LSCB Page 53 REFERENCES Brandon, M., Bailey, S., Beldersone, P., 2009, Gardner, R., Sidebotham, P., Dodsworth, J. Warren, C. and Black, J. Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005–2007, DCSF, 2009 Care Planning, Placement and Case Review Regulations, 2010 The Children Act 1989 The Children (Leaving Care) Act 2000 The Children Act Guidance and Regulations, Volume 3: planning transitions to adulthood for care leavers, DfE, revised January 2015 Family and Friends Care – Statutory Guidance for Local Authorities, DfE, 2010, Para 5.2 http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.uk/publications/eOrderingDownload/Family%20and%20Friends%20Care.pdf Fish, S., Munro, E., and Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Fostering Service Regulations and National Minimum Standards for Fostering Services, DfE, 2011 Learning Review J, Brighton & Hove LSCB, August 2014 Pathway Plans, Chapter 5, www.dhsspsni.gov.uk/leaving-after-care-ch5.pdf Permanence, long-term foster placements and ceasing to look after a child: Statutory guidance for local authorities, DfE, March 2015 Reder, P., Duncan, S., and Gray, M., Beyond Blame: Child Abuse Tragedies Revisited, Routledge, 1993 SCR C5641 (NSPCC archive), 2015 SCR Baby Liam, Brighton & Hove LSCB, October 2015 SCR Child CH, Enfield and Haringey Safeguarding Children Boards, 2015 Studdert, O., The Importance of Pathway Plans and Local Authorities’ Duties to Care Leavers Vincent, C., ‘Analysis of clinical incidents: a window on the system not a search for root causes’, Quality and Safety in Health Care, vol 13, pp 242–3, 2004 Working Together to Safeguard Children, 2013, and Local Safeguarding Children Boards Regulations, 2006 (Regulation 5) Child E Serious Case Review – Brighton & Hove LSCB Page 54 A sample of research findings relating to patterns of familial suicide The following studies reflect a much wider number (references in the WHO document below) of studies which identify a close familial history of suicide as a ‘predisposing factor’ for a child or young person who has emotional difficulties. Ferguson, D.M., Beatrais, A.L., Horwood, L.J., ‘Vulnerability and resiliency to suicide behaviours in young people’, Psychological Medicine, 2003, Jan; 33(1) 61-73 Sarchiapone, M., Carli, V., Cuomo, C., Balore, A., ‘Vulnerability to Suicidal Behaviours: Risk and Protective Factors’, Department of Health Services, University of Molise, Campobasso, Italy (no date given) Public Health Action for the Prevention of Suicide – A Framework, World Health Organisation, 2012 Child E Serious Case Review – Brighton & Hove LSCB Page 55 APPENDIX 1 Learning Together Methodology and Process 1. This review has used the SCIE Learning Together model – a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2013 revision of WT 2013 now requires all SCRs to adopt a systems methodology. 2. The Learning Together model is distinctive in its approach to understanding professional practice in context; it does this by identifying how systems influence the nature and quality of work with families. Solutions then focus on redesigning systems to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3. Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4. The basic principles – the ‘methodological heart’ of the Learning Together model – are in line with the systems principles outlined in Working Together (WT) 2013: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5. Typology of underlying patterns: Findings are described using the categories developed by SCIE to provide a means of grouping together the kinds of systems issues which are found. There are six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Child E Serious Case Review – Brighton & Hove LSCB Page 56 Each finding is assigned its appropriate category, although some could potentially fit under more than one category. 6. Anatomy of a finding: For each finding, the report is structured to present a clear account of: How did the issue feature in the particular case? How do we know it is not peculiar to this case (not a quirk of the particular individuals involved this time and in the particular constellation of the case)? What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? What are the implications for the reliability of the multi-agency child protection system? These ‘layers’ of each finding are illustrated in the Anatomy of a Learning Together Finding (below). Child E Serious Case Review – Brighton & Hove LSCB Page 57 7. Review Team and Case Group 7. 1 Review Team The Review Team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by at least one and often two independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, and so on. The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review. Name Agency Mia Brown Brighton & Hove LSCB Manager(Champion) Sally Trench SCIE Independent Lead Reviewer Leighe Rogers SCIE Independent Lead Reviewer Sue Donald Nurse Consultant for Children In Care, Sussex Community NHS Trust Anna Gianfrancesco Head of Service: YOS & RUOK, Brighton & Hove City Council 1.Andy Whippey 2. Richard Hakin 3. Helen Gulvin Service Manager, Children’s Social Work Services, Brighton & Hove City Council Child Protection Reviewing Officer Manager, Brighton & Hove City Council Assistant Director, Children’s Social Work Services, Brighton & Hove City Council Chris Parfitt Head of Service, Youth Service, Brighton & Hove City Council Mark Storey Head of Virtual School for Children in Care, Brighton & Hove City Council Natasha Watson Principal Lawyer, Brighton & Hove City Council DS Jane Wooderson Review Team, Sussex Police Throughout the review process, the Lead Reviewers and the Review Team have been fully supported by the Brighton & Hove LSCB Business Manager and Senior Administrative Officer. Their efficiency and professionalism in arranging meetings, obtaining copies of documents, and generally enabling effective communication throughout the review, have contributed considerably to the process and to the production of this report. 7.2 Case Group The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 22 Case Group professionals, and two family members. Case Group members were invited to an Introduction Meeting (to explain the Learning Together model and the SCR process) and later to three feedback meetings. Attendance was generally good, although a couple of absences were caused by the distress of the member of staff. Child E Serious Case Review – Brighton & Hove LSCB Page 58 Health: GP LAC Nurse Specialist Nurse for YP in Brighton CHILDREN’S SERVICES: IROs (2 – previous and current) Practice Managers (3) – Family & Friends Fostering Team, and Children in Care Team Team Managers (1) – Children in Care Team Social Workers (3) – Children in Care Team Social Work Resource Officers (2) – F&F Fostering Team and Children in Care Team Head of Service – Looked after Children Foster carers Education: Designated Teacher for Looked-after Children 16+ Advisor for the Virtual School College Tutor College Pastoral and Learning Mentor Police: DS, Safeguarding Investigation Unit Police Officer, Integrated Offender Management scheme in YOS 8. Structure of the review process: A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The Review Team form the ‘engine’ of the process, working in collaboration with Case Group members. The Review Team held an introductory meeting for the Case Group at the beginning of the process, to explain the Learning Together model and the process they would be part of. Case Group members were then involved via individual conversations, and in three multi-agency meetings/Workshops, where they were asked to give feedback on interim/draft reports. There was a considerable amount of helpful feedback received from the Case Group in response to different parts of the emerging report/findings, not only in meetings, but in ongoing correspondence, and production of relevant records for the Review Team to consider. The Review Team were involved in collecting and reading data, including a multi-agency chronology and key documents. Together with the Lead Reviewers, they met to analyse the material and contribute to the findings (9 meetings). 9. Scope and terms of reference Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. In this review, we noted and explored the questions (Para 4 of the main report) which the Brighton & Hove LSCB had posed as of particular interest. Child E Serious Case Review – Brighton & Hove LSCB Page 59 10. Sources of data 10.1 Data from practitioners Workshop Days were held at which members of the Case Group responded to the analysis of the case and gave feedback about accuracy and fair representation of the material presented. In relation to the emerging findings, the Case Group were asked to comment on whether these were underlying and widespread/prevalent. In other words, could we draw conclusions about whether, and in what way, this case provided a ‘window on the system’? 10.2 Key Practice Episodes and Contributory Factors Following on from individual conversations, the first two Workshop Days aimed to piece together the practitioners’ ‘view from the tunnel’ and a selection of Key Practice Episodes (KPEs). These KPEs are significant points or periods in relation to how the case was handled or how it developed. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decision-making at the time. 10.3 Participation The Learning Together model relies on professionals contributing very actively to the review and the resultant learning, as it is their unique experiences which help us understand what happened and why. We know that participation in a case review can raise anxieties and distress about what has happened to children, and this was especially so in this sad case, not least because some members of the Case Group had known E over most of his childhood, and were very fond of him. In addition, there was a parallel process (the inquest) underway, and this added to the anxiety of some witnesses. The lead Reviewers and the Review Team are grateful for the willingness of the professionals to attend difficult meetings and to engage actively in the review. 10.4 Data from documentation The Lead Reviewers and members of the Review Team were given access to the following documentation: Documentation Agency source LAC Reviews (report and record of review): February 2013 Children’s Services Pathway Plan Reviews (report and record of review): August 2013, February 2014, August 2014, November 2014 Children’s Services Records of Statutory SW visits to E, throughout review period Children’s Services Transfer summaries Children’s Services Email correspondence SWRO1 and FM, throughout review period Children’s Services Email correspondence between FM and various social workers, throughout the review period Children’s Services Email correspondence between professionals in Children’s Services, throughout review period Children’s Services Standards of Care letter Children’s Services Standards of Care guidance Children’s Services Pathway Plan Reviews guidance Children’s Services Police IMR Police Facebook records E and Child X Police Fostering Service Regulations and National Minimum Standards for Fostering Services (2011) DfE Child E Serious Case Review – Brighton & Hove LSCB Page 60 10.5 Data from family, friends and community The Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. In this review, E’s BF and his wife met with the two Lead Reviewers during the review and gave helpful information. E’s FM initially did not wish to take part in a face-to-face meeting, but provided a detailed statement for the SCR. Both sides of the family were involved in giving helpful feedback after their opportunity to read the draft report (including FF). Child E SCR: Learning & Improvement Report Page 1 Learning & Improvement Report Brighton & Hove Local Safeguarding Children Board Response to Child E Serious Case Review E was a looked after child, living long-term with his maternal aunt and her partner (Family & Friends carers) and their son. In his mid-teens, E became unsettled and at times distressed, and the placement came under increasing pressure, related to his angry defiance at home and risk-taking behaviour elsewhere. At school he continued to achieve well as a compliant and popular pupil. When E’s placement broke down in early autumn 2014 he went into foster care with Brighton & Hove carers in another village. It seemed that E ‘engineered’ a return home after a few weeks, and at this time was involved in an attack on a friend whom he suspected, with associates, of being involved in a burglary at his family home. E then became very frightened about the danger of reprisals, and insisted that he must be moved out of Brighton immediately. E was determined to go to stay with his birth father, who at this point was only known to him via social media (though the local authority had met him). The local authority was called upon to approve an emergency, unregulated placement, which involved E going to stay with a close friend and neighbour of his birth father over a week-end, while a foster placement in that area could be found. It was at this person’s home, four days later, that he was found to have hanged himself. As a result of E’s death I requested the Board undertake a Serious Case Review (SCR) to ascertain lessons from the ways in which agencies had worked singly and together with E and his family. Throughout this review professionals who had worked with E and his family spoke of a ‘cheeky cheerful chappie’ and a ‘lovely boy’. It was clear that E was much cared for by his family and those supporting him. Working Together 2015 allows LSCBs to use any learning model consistent with the principles in the guidance. This review was conducted using the Social Care Institute for Excellence (SCIE) Learning Together systems methodology. Sally Trench, an independent person with experience in conducting reviews arising from safeguarding concerns, was commissioned as the lead reviewer. She was supported by a consultant and former member of the Brighton & Hove LSCB, Leighe Rogers. Both have considerable safeguarding experience. To support the process, a review team consisting of senior managers from involved agencies met 10 times with lead reviewers and were a sounding board, providing necessary context on organisational policies and practice. Frontline staff who worked with E and his family were heavily involved in the review, talking about their experiences and safeguarding practices. Some family members also contributed to the review, sharing their experiences of receiving services during the period focused on in this review. A full evaluation of the process will be undertaken to learn from the experiences of all those involved with this methodology. The review found that there was learning for agencies involved but that the tragic incident was neither predictable nor preventable. The Brighton & Hove LSCB has reflected on the lessons arising from this tragedy and will use its’ authority and statutory role to make sure these are shared throughout all agencies working with children and young people in the city. This work has already started through a series of learning events and the extensive circulation of a briefing for professionals working with children and families. Actions necessitated from this review will be monitored by the Brighton & Hove LSCB’s Case Review Subcommittee with progress reported to the Board. Graham Bartlett Independent Chair Brighton & Hove Local Safeguarding Children Board Child E SCR: Learning & Improvement Report Page 2 Finding 1. There is an inherent tension regarding the respective roles of the local authority as Corporate Parent, and Family and Friends Carers who may be seen as ‘parents’ or ‘family’. This can result in unhelpfully blurred boundaries and a difficulty in asserting the LA’s statutory responsibility for a child or young person when this is required Board Response The Board would like to make clear that it understands that Family & Friends (F&F) Carers are rightly regarded differently to other foster carers. We acknowledge that in this case there appears to have been some blurring of boundaries between the responsibilities of the Corporate Parent and Family & Friends Carers. This ambiguity may have compromised the Corporate Parent’s ability to assert its authority to ensure the wellbeing and safety of E. The Board accept that it is difficult to remove all ambiguity and tension about respective roles, rights and responsibilities in Family & Friends care. This is because regulations governing the approval process require fitting family members into a legal framework and allocating them a professional role. This doesn’t reflect their familial relationship, the nature of that relationship and the inevitable emotional context of the care being provided. This finding shows us the nature of the partnership required between the local authority, as the Corporate Parent, and Family & Friends Carers, and potential difficulties in this, as already outlined, are not included either in national or Brighton & Hove local guidance and policy documents. It is our view that such placements as these may benefit from more specific guidance addressing the extra complexity and stresses of such arrangements. This finding also suggests that where longstanding Family & Friends Carers have virtually all authority delegated to them, the local authority may then find it difficult to intervene when needed to ensure a child’s needs are being met1. We know that when a placement starts a Placement Planning Meeting takes place and delegated authority agreements are agreed which set out the roles/ responsibilities of carers, parents, social worker. An issue may be that for longstanding placements the delegated authority agreement is not routinely updated, although it is subject to review by the Independent Reviewing Officer, as appropriate. The Board would recommend a more formalised arrangement to strengthen this system. We must also be mindful that young people, particularly those aged 16 plus who are legally Gillick competent to make some decisions, should be consulted in decisions made about their care. In support of compiling this Board response, Brighton & Hove City Council’s Families, Children & Learning Directorate, have clarified that if a child is placed under Fostering Regulations with Family & Friends carers a qualified social worker is allocated to supervise the placement in accordance with Fostering Regulations. It has been confirmed that the Family & Friends Team run a monthly Support Group for Family & Friends Carers, and special guardians, and that Family & Friends Carers access the same training programme as unrelated foster carers. In addition to this they can also access, and are actively encouraged to do so, a rolling program of Friends & Family workshops. The expectation is that all foster carers should attend. Ofsted, as noted in its 2015 inspection, commented, ‘Foster carers receive good quality preparation and are well supported’. The Board have been assured that there is an appropriate level of training and support for Family & Friends Carers, but at this stage it is not clear what engagement with these offers look like and how non-engagement is monitored and scrutinised to ensure the best outcome for the child. This will require further exploration in order for the Board to be satisfied that Family & Friends carers receive specialist support groups and training, for their particular needs. Since this serious case review there has been an Ofsted inspection of services for children in need of help and protection, children looked after and care leavers (14 April – 8 May 2015). This inspection rated services for Children Looked After & achieving permanence as Good. Whilst this is re-assuring the Board needs to now be further satisfied that the Families, Children & Learning Directorate retain the 1 Delegated authority is the process that enables foster carers to make common sense, everyday decisions about the children and young people they care for, such as allowing them to go to friends’ houses for sleepovers, signing consent forms for school trips and even arranging hair cuts.Holders of parental responsibility can delegate authority to foster carers to undertake such tasks and decisions. Foster carers never have parental responsibility for a fostered child, so they can only take decisions about the fostered child where that authority has been delegated to them by the local authority and/or the parents. Child E SCR: Learning & Improvement Report Page 3 necessary authority invested in it as Corporate Parent to ensure the best possible outcomes for a child or young person. Ofsted’s Review of the Brighton & Hove LSCB also recommended that we improve our links with the with the Corporate Parenting Board to provide a greater focus to looked after children living outside the authority area and to better understand why thresholds for care or accommodation are reached. This finding supports our need to tighten our links as a priority. Proposals 1.1 Board make a recommendation to the Families, Children & Learning Directorate that delegated authority arrangements are reviewed at every Looked After Child and Pathway Plan Review by Independent Reviewing Officers. 1.2 Board make a recommendation to the Families, Children & Learning Directorate that the Family & Friends Carers policy and procedures are reviewed to ensure they incorporate learning from this SCR. 1.3 The Board will contact the Corporate Parenting Board to ensure they are advised of findings from this serious case review. 1.4 Children’s Social Work service provide an update to Board on how Family & Friends parenting capacity is assessed in relation to the changing needs of the child. 1.5 Children Social Work service to provide a report to Board on the attendance at Friends & Family Carers training take up and scrutiny of non-engagement. Finding 2: In Children’s Social Work Services, it is difficult to access the various sources of a looked-after child’s past records, leading to an associated response of not prioritising this essential preparation; the result in many cases is that the Corporate Parent does not easily know the life story of its children. Board Response Findings 2 and 3 are linked, but have slightly different nuances. Finding 2 is concerned with the accessibility of past information and its impact on the Corporate Parenting fulfilling their responsibilities. Both findings reinforce issues of identity and personal history being highly significant to children who have lost a parent or parents. It is our view that this should be high up on the Corporate Parent’s list of responsibilities. This review has led us to question how social work staff taking on a new case undertake a review of a child’s history and access relevant information held about the child. Frontline staff who contributed to this review cited such difficulties as: not enough time, combined with inaccessibility of old files, and profusion of records in different formats which do not join up to make a comprehensible whole. This is not the first time difficulties accessing historical records/ source material has been highlighted to the Board. We fully accept that the situation can be to the detriment of planning and decision-making. Over the past year the Board have been regularly updated on the extensive work that the Families, Children & Learning Directorate have been undertaking to overhaul disparate information systems and have been advised that at this point in time information is properly indexed and easily accessible to staff. The Board recognises that a failure to take into account relevant information about the child could inhibit the Corporate Parent’s responsibility to record and maintain an account of the child’s story. This review has urged the Board to consider what review systems are currently in place to ensure ‘life story’ work is maintained for children in care. We are advised that the six monthly social work report compiled for Looked After Children Reviews, overseen by the child’s Independent Review Officer, includes a question, under the heading Identity, which asks for a summary of what support has been provided to the child to help them understand their life story. It has since been recognised that the current life story Child E SCR: Learning & Improvement Report Page 4 work policy on Operational Procedures relates only to children who have a care plan for adoption, although the guidance remains relevant, this needs to be updated to include all looked after children. Issues of identity and personal history are looked at again in Finding 3. Since this review the Local Authority have clarified to the Board their expectations with regards workers’ knowledge and understanding of an individual case at the point of transfer. The Board are advised there is an expectation that there is a face to face handover between workers, or their manager if the worker is absent, that case records, or at very least key documents such as reviews, health assessments, education plans, family history and chronology, are read. A discussion with the Independent Reviewing Officer should be take place and a meeting with young person/carer and family, if appropriate. The Board needs to assure itself that this expectation is clear, and fulfilled across social work teams, this action links with an action in Finding 3. Proposals 2.2 The Board recommend that the Families, Children & Learning Directorate update their Life Story Work Policy to include all looked after children. 2.3 Children’s Social Work to provide an update to Board regarding the systems in place that ensure life story work is maintained for children in care. Finding 3: The tools for transmitting background information about a child or YP (transfer summaries and chronologies) are not produced to a consistent standard, meaning that a new SW may not have the background and qualitative information which would support a holistic understanding of the child/YP and family and their needs and risks. Board Response As per Finding 2, the Board accept that where full and accurate sources of the history of a looked after child are not reliably available, there is the clear risk that this history will be poorly understood by workers. We agree with the report that transfer summaries (and, where possible, face-to-face handover meetings) and chronologies are essential tools for workers and their supervisors to rely on. We acknowledge that frontline staff participating in the review advised that transfer summaries do not consistently provide adequate in-depth information and analysis. All our partner agencies, in fulfilling their safeguarding duties, must remain focussed on the child and understand the importance of their history in relation to assessing and planning for future functioning. The review could find no evidence of chronologies being used consistently across the teams in Children’s Social Work Services. It is the Board’s view that the current chronology format has limitations. We are told that skeleton chronologies of key events in the life of a child are available on all case records. There is an expectation that social workers familiarise themselves with these and plan time with their managers to read and digest this information, and are provided adequate time to do so. The One Story model will be introduced in October 2016, and up to date chronologies are a key part of this model and will be monitored by managers and quality assurance. The Board will want to hear progress updates on this. The Board have been advised that the implementation of the Pod model 2has resulted in a reduced number of case transfers across teams. However, the consistency of keyworkers has been affected by having to have a number of agency social workers to ensure statutory duties are complied with. Brighton & Hove City Council have recruited a number of new permanent staff and it is anticipated that the 2 In October 2015, Brighton & Hove’s Social Work services adopted a new model of practice which moved away from separate assessment, child in need and child protection teams to a “Pod” structure. There are now 16 pods, each with around 8 social workers, and a child will be allocated to a specific worker in a particular pod upon assessment and then remain with this team throughout the time they require this intervention. This has removed the risks associated with the introduction of a new social worker at transition points between services, for example when a child goes into care, and also allows for stronger relationship-based practice. A Group Supervision model ensures that the Manager and other members of the Pod are aware of the cases, and are thus able to better cover for the allocated worker during absences than the previous system of duty cover. Child E SCR: Learning & Improvement Report Page 5 number of agency staff will have radically reduced by Autumn 2016. The Board will want to receive an update on this matter to satisfy itself that consistency of keyworkers has improved. Proposals 3.1 The Board recommend that Children‘s Social Work remind practitioners that chronologies should be available on all cases and be regularly updated. 3.2 Children‘s Social Work to report to Board on social work staff turnover rates. Finding 4: Is there a risk for professionals, in following Care Planning, Placement and Case Review Regulations, to give too much responsibility to young people over their Pathway Plan Reviews, with the result that difficult subjects are not raised if the young person objects? Board Response Findings 4 and 5 both concern the Pathway Planning Review (PPR) process. Finding 4 is concerned with the contents of the PPR meeting and the professionals present, both determined by the young person at the centre of the review. The Board would like to make clear it supports the views of the child or young person being central to the PPR process, and agree that the active participation of the young person in their review should always be encouraged – especially as they enter the transition period of leaving care and becoming an adult. What finding 4 asks us to consider is if the Corporate Parent has struck the right balance with regards to keeping the young person’s wishes central to the care planning process and it remaining able to address any areas of serious concern for the young person. The Board consider that the young person’s need, and right, to privacy should be respected, and that there may well be valid reasons that any young person approaching adulthood would not want to discuss sensitive personal matters in front of their teachers or youth worker, or their parent/carer if they are present. That said, the Corporate Parent needs to make certain that if discussions are not taking place within the PPR, that there is a forum, as part of the wider care planning process, to discuss any sensitive or contentious issues, and that the Corporate Parent, or those to whom it delegates authority, remain sighted on these issues. The Board are advised that in such instances a separate discussion or series of discussions or separate meetings are had with the young person or carer. The review acknowledges that a professional meeting outside of the PPR, at least on two documented occasions, was proposed. Finding 5 discusses alternative forums for such discussions in more detail. Proposals 4.1 Board recommend that the Pathway Plan Review and Looked After Children Review paperwork is updated to include recording of issues that need discussion outside of review process 4.2 Board request that Children’s Social Work undertake audit on quality of Pathway Plan Reviews and report findings to the LSCB (to include the views of young people). Finding 5: Nationally, there is no routine framework for multi-agency professionals to meet outside of Pathway Plan reviews, leaving the responsibility with an individual practitioner to convene such a forum. The result is that planning and decision-making for a child often proceed without the benefit of a joined-up discussion of others’ perspectives and concerns about a child Child E SCR: Learning & Improvement Report Page 6 Board Response This finding highlights the lack of any formal or regular meeting which includes the full range of professionals involved with a looked after child, or other children in need, which subsequently implies a weakness in partnership working and information sharing. The Board understand there are a multitude of reasons why extra meetings might be required, given how much can transpire in the time frame of 6-months between Looked After Children Reviews and PPR meetings. We are of the view that it is vital that any member of the professional network can confidently request a professionals meeting, or call forward an extra review meeting. The Board believe this should be the accepted norm, supporting both the worker with the rising concerns and the young person to receive the timely care and attention that may be needed in response to serious problems. Since this review the Board are advised that such arrangements are in place currently, in the form of Placement Stability Meetings; Strategy Meetings, Network Meetings (for CIN & LAC). However, the finding from this serious case review may be indicative that not all frontline staff are aware that these alternative forums can be utilised alongside the PPR. Proposals 5.1 The Board recommend that a reminder of practice highlighting the purpose and function of Placement Stability Meetings for looked after children should be circulated to front line managers and staff. 5.1 The Board request that all partner agencies remind staff of the need to request professionals meetings when required. Finding 6: There is a pattern of focusing only on the primary (usually female) carer for a child in care, and not giving sufficient attention to the role of the non-primary carer (usually male). This can result in professionals’ lack of awareness of both positives and negatives that the other carer may bring to his role. Board Response From this review we recognise that there may be a tendency to focus on the primary carer when engaging with families. This is a matter which has been identified in a previous Brighton & Hove Serious Case Review (Baby Liam, October 2015) which found that the booking form used by midwives is mainly sought from the expectant mother rather than both parents, meaning that important information relating to the assessment of risk may not be obtained. We recognised that it was an issue across a number of agencies hence we added a standard, Consideration of fathers and other significant adult males, to the Section 11 audit3. The standard asks partner agencies to evidence that there is guidance in place for practitioners to consider fathers, male partners and other significant adult males in the family when gathering family information as well as in all assessments addressing the needs and welfare of the child. In the case subject to this SCR we see that communication between the Corporate Parent and the primary carer broke down so much that communication was only carried out by email and engagement with the non-primary carer was sporadic. The Board believes that the perspective of both care givers will provide professionals with a richer understanding of what life is like for the child. It will enable the partnership between local authority (and in this case, therefore Corporate Parent) and the carers to be stronger. It will empower both carers to be heard and to regard themselves as influential in the child’s life. Most of all it will allow the child to be better protected and supported as all those involved in their care will have a stake in their upbringing. After careful consideration we are not, at this point, satisfied that the expectations of foster carers are clear, less so around non-primary care givers. We have considered whether indeed such expectations are reasonable. What we do know is that good practice looks like developing and maintaining trusting, open, professional and supportive relationships between carers and the professionals they come into 3 Section 11 of the Children Act 2004 requires key persons and bodies to make arrangements to ensure that in discharging their functions they have regard to the need to safeguard and promote the welfare of children. Partner agencies are requested bi-annually to undertake a self-assessment to provide evidence of their organisational and strategic level safeguarding arrangements in response to these requirements. Child E SCR: Learning & Improvement Report Page 7 contact with. What is not clear right now is what variety of engagement strategies professionals employ to hearing the voice of the non-primary carer. Nor how professionals are trained, enabled and supported to engage with non-primary carers where there are underlying difficulties in engaging with the primary carer. There is a clear benefit in ensuring that the non-primary carer is provided with information and the opportunity to engage when the placement is in breakdown, whilst recognising that this may not always be a realistic option when the placement is settled. The Board regard it our responsibility to assure that both carers are engaged and involved in any decision making and interventions around a child, as far as is practicable. For the reasons given we feel that that is both in the interests of the child and of effective planning and practice. We feel on balance that there should be a higher expectation of engagement for foster carers levelled with a flexible range of opportunities through which each carer’s voice can be heard. The Board needs to assure itself that the default position should be to engage and hear both carers. Particularly with Family & Friends carers, the Board needs to be sure that there is an explicit expectation for both carers to engage with the Corporate Parent. To that end, and recognising that carers will have conflicting priorities (e.g. work), the Board needs to be assured that a lack of engagement by non-primary carers is identified and understood and flexible options are provided to help them engage. Proposals 6.1 The Board will strengthen its S11 audit expectations around how agencies meet the current standard applied. 6.2 The Board will seek reassurance from the relevant agencies that their supervision policies and practice (including training) address the benefits and challenges of engagement with all carers for a child Finding 7: In B&H Children’s Social Work Services, there is inconsistent recording. Without a complete and accurate record, it is difficult for practitioners and their managers to analyse the facts and context of a child’s situation, and to make appropriate decisions and plans. Board Response Accurate and timely recording of events and decision making provide for auditable and defensible practice which, too, aids forward planning and greater understanding of a child’s journey and that of their care and support. The Board acknowledges that it requires reassurance that case records across all agencies are appropriately maintained. This, and other serious case and learning reviews, have highlighted that record keeping is variable and that can lead to risks for both practice and professionals. On many levels the expectations of good quality and accurate record keeping are high, but the application of these can be frustrated by; unsuitable systems, culture, leadership, resources and time each not being conducive to efficient recording. It has been made clear through this review that time is a precious commodity. With increasing workloads and static resources the expectations on staff around contact time are given greater priority than record keeping. Recognising the reality of the availability of resources, the Board would expect to see a culture reflected across all agencies that accurate, timely and proportionate decision making, and recording thereof, is championed through the leadership and through supervision so staff understand it is as important to their practice as contact time. The Board would also expect that systems support rather than hinder efficient timely record keeping, reducing bureaucracy as far as possible, yet allowing for full and accessible records to be available for supervision, audit and inspection. Furthermore, where professionals’ knowledge and understanding of Child E SCR: Learning & Improvement Report Page 8 their responsibilities around record keeping is found to be lacking, workforce development strategies should be put in place to address this. Proposals 7.1 All agencies to provide an update to Board regarding recording practices and adherence to recording expectations. Finding 8: Sussex Police do not always act in accordance with their own guidelines by informing Children’s Social Work Services about their observations of, contact or interventions with young people. This means that opportunities for joint thinking, decision-making and interventions may be lost. Board Response In this case E was a looked after child (LAC) and the police were unaware of his LAC status. Irrespective of his status as a LAC there were numerous police recorded incidents over a 24-month period some of which should have been the subject of a referral to Children’s Social Work. This finding raises questions for police and Children’s Social Work Services about current guidelines around the circumstances in which a SCARF4 should be raised. Sussex Police have confirmed that Force Policy requires that a SCARF should be completed when police “have any involvement……. with a child”. The policy and subsequent guidance to officers has been directed towards those officers who have direct involvement with children, particularly uniformed response, neighbourhood teams and those officers working in schools. Police audits on compliance with this policy have indicated that these notifications are not always completed in these circumstances, despite regular reminders to staff. The reasons for this are not clear, but should be seen against a rise in the number of domestic abuse incidents attended by police, where a SCARF is required to be completed and compliance is high. This may have focussed officers’ attention on more serious incidents, and away from the lower level interventions officers have with children, where historically SCARFs (and the previous notification form MOGP/1s) were completed. In addition, in recent years the introduction of risk indicators within the SCARF or MOGP/1 have guided officers to focus on interventions where there are clear safeguarding issues. This may have further influenced the decision-making by staff on when a SCARF should be completed, and at a strategic level, requests by Children’s Social Work in some areas for the police to reduce the number of notifications, may also have had some impact. It is the LSCB’s view that the current uncertainty as to when a SCARF is required indicates there is a need for a fundamental review of the circumstances in which a SCARF should be completed. Proposals 8.1 The Board recommend that Sussex Police, in consultation with other agencies, to review the circumstances in which a SCARF should be completed and update Force Policy accordingly.. 8.2 Board to assure itself that, once the Force Policy is updated, operational practice regarding sharing safeguarding information through SCARF reflects the revised Force expectations. 4 Police officers are expected to complete the Single Combined Assessment of Risk Form, SCARF, in a number of circumstances that are outlined in policy, and it combines a number of previous forms and assessments that were used. In the context of children it replaces the old MOGP/1 that officers completed when they had some direct intervention with a child. However it is also used in relation other areas of police work, and has replaced the old vulnerable adult notification (VAAR) and other forms in relation to domestic abuse, stalking etc. Child E SCR: Learning & Improvement Report Page 9 Additional Learning 1: Accessing Child and Adolescent Mental Health Services (CAMHS) Like many/most young people, E declined to use the Child and Adolescent Mental Health Service (CAMHS) to which he was referred in autumn 2012. He went for one appointment, and decided it wasn’t for him. The case was closed by CAMHS shortly after E’s decision. His reluctance to engage with CAMHS echoes the findings in two recent Learning Reviews in Brighton & Hove, both in relation to the deaths of vulnerable adolescents. These have highlighted what is a local and national issue: the need to create different, ‘young-people friendly’ ways of improving access to CAMHS for adolescents. Board Response We look forward to the outcome of the Local Transformation Plan for Children and Young People’s Mental Health Services insomuch as it develops a range of routes to services who meet the emotional wellbeing and mental health needs of children and young people in Brighton & Hove. It will also support parents and carers to enable them to understand and help their child/young person with their emotional distress. Learning from this Serious Case Review and the two aforementioned learning reviews have been included in the recent Joint Strategic Needs Assessment (JSNA) and actions are being implemented through the Transformation Plan to address change and improvements. This Transformation Plan is held to account through NHS England with local co-commissioning arrangements in place across the Brighton & Hove Clinical Commissioning Group and the Local Authority. The process of assurance to the Board will be agreed with the Brighton & Hove Clinical Commissioning Group. We feel there is a place for a universal service (similar to antenatal services for first time mothers) that can be accessed by looked after children that, recognising the trauma that will have resulted in them becoming looked after, allows them to engage in services to help them while providing professional therapeutic support to identify underlying factors before they escalated into mental health problems. Young people will continue to have the right to exercise choice when accessing mental health services unless there needs are such that they require care under the Mental Health Act. Proposals: 9.1 Brighton & Hove Clinical Commissioning Group will report progress to the Board in Autumn 2016 on the following points: Re-procurement of the Wellbeing Service to include all ages Development of Primary Mental Health Worker offer within schools and colleges Improvements to mental health pathway for looked after children Development of training offers for front line staff working with children and young people to improve knowledge and understanding of mental health Development of a mental health anti-stigma campaign and a single online point for all information, help and support around mental and emotional health Development of a more consistent outreach model for delivering tier 3 CAMHS (building on the Teen to Adult Personal Advisor (TAPA) model) Development of a Sussex-wide response to children and young people in crisis (building on the Urgent Help Service) Additional Learning 2: Support for staff During the undertaking of this serious case review the Review Team were told by some frontline professionals that they had not had an opportunity, before the serious case review process, to speak with other staff from across the multi-agency network about what had happened to E. The Review Team Child E SCR: Learning & Improvement Report Page 10 were advised that telephone counselling can be accessed, (or possibly face-to-face counselling after a telephone ‘triage’ assessment). Board Response The Board were surprised that the serious case review was the first opportunity that some staff had to speak about what happened to E and their responses to that. Although it is perhaps not so surprising that this will have been the first time staff from across the safeguarding partnership would have got together to discuss what had happened. The Board needs to ensure when planning the initial meeting for staff that the possibility that this may be the first time colleagues have met is taken into consideration. On a slightly separate, but related point, the Board will want to look to all agencies to provide a flexible and accessible counselling or support service that encourages and presumes take up when required and promotes this further through supervision. Proposals: 10.1 Future learning reviews commissioned by the Board will involve consideration of impact upon staff of initial joint learning events. Additional Learning 3: Timing of the SCR The review highlighted that the grief that followed from E’s death was profound for many, and they found taking part in the serious case review extremely distressing. The Review Team suggest that such circumstances need to be thought about very carefully when planning to commence a serious case review. Board Response In combination with the response outlined under the Support for Staff learning above, the Board has to balance identifying and rolling out learning from reviews in a timely way with the ability of family members and professionals to be ready and able to contribute meaningfully to this process. The statutory expectation is reviews will be carried out swiftly, but that there should be a balance. The Board does not consider that any delay should be lengthy. That said, there may be times when a short period of time is necessary to allow family members and staff to be able to be in a place where they are able to contribute to what is always a difficult and emotional process. In terms of staff it is unlikely that such a delay would be authorised unless effective support measures are in place within the respective agencies. 18 SCR Quality Markers have been produced as part of the Learning into Practice Project, a one-year DfE-funded project conducted by NSPCC and SCIE between April 2015 and March 2016. Quality Marker 8 is concerned with the management of the serious case review, including timeliness. Since this serious case review Brighton & Hove LSCB have self-assessed ourselves against these quality markers, reflecting on the challenges of balancing the need to put into practice the learning from the case with the need to allow staff and family members the space to grieve. |
NC047765 | Sexual exploitation of a girl when she was aged between 13 and 15 by a large number of British Asian men of Pakistani heritage. Jeanette had to care for her mother from a young age; she was neglected and physically abused by her father; her mother died when she was 13 and she subsequently lived without parental supervision. She spent time outside the family home in the company of older men who gave her cigarettes, alcohol and drugs. Following disclosure to the police, 54 suspects were arrested, and 25 were charged. Issues identified include: failure to allocate a consistent children's social care worker; lack of suitable forums to discuss children at risk; lack of action to 'disrupt' the activities of men who abuse children; a lack of systems, practices and procedures in services to children in need and children at risk of sexual exploitation. Recommendations include: that police and the LSCB ensure that regional statistics relating to perpetrators of child sexual abuse are accurate; that professionals working with children and young people are able to identify and act upon drug and/or alcohol use; to ensure that perseverance is still a key component of any training on child exploitation; to ensure that escalation procedures are fit for purpose and that all professionals are aware of their existence and are confident in using them; a version of this report to be commissioned by the LSCB to use with young teenagers to make them more aware of the dangers of child sexual exploitation.
| Title: Serious case review: overview report in respect of Jeanette. LSCB: Calderdale Safeguarding Children Board Author: Barry Raynes Date of publication: 2016 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 111 Serious case review overview report in respect of Jeanette Barry Raynes Director Reconstruct October 2016 Page 2 of 111 CONTENTS Introduction Page 3 Methodology Page 4 Terms of reference Page 4 Independence Page 5 Serious case review panel Page 6 Family involvement Page 6 The consultation process Page 6 Timescale Page 11 Dissemination of learning Page 11 Summary of events Page 12 From birth to 10 Page 12 Age 11 Page 12 Age 12 Page 12 Age 13 Page 13 Age 14 Page 14 Age 15 Page 15 Age 16 Page 22 Analysis Page 25 Introduction Page 25 Analysis of events Page 26 What Happens Now Page 30 The relevance of cultural issues in relation to the perpetrators Page 35 Conclusion Page 44 Findings Page 45 Bibliography Page 49 Appendices Page 50 Terms of Reference Child sexual exploitation action plan Continuum of need Early intervention single assessment Practice standards Risk assessment form Page 3 of 111 1. INTRODUCTION 1.1 This report is about a remarkable young woman, who will be referred to as Jeanette. With the help of a kindly and persistent police officer, a caring, competent and confident social worker and a patient and non-judgmental foster family, Jeanette came through a life full of difficulty, upset, neglect and sexual exploitation to arrive at a point in her life where she was able to assist the police in bringing 17 successful prosecutions for a variety of trafficking and sexual offences including rape. She went through the trauma of hours of police interviews, examination and cross examination because she wanted to ensure that other young people did not go through the same humiliation and sexual abuse that she experienced. 1.2 The report will demonstrate how a lack of co-ordination amongst professionals - between 2009 and 2011 - failed to protect Jeanette despite the best efforts of practitioners from, in particular, Jeanette’s school, police and the youth offending team. The report will then go on to explain how well her present social worker and foster family cared for her, the professionalism of the police in collecting evidence for a major prosecution and describe how Calderdale now deals with victims of child sexual exploitation. 1.3 Calderdale is a small Metropolitan Borough of West Yorkshire. Its main area of population is Halifax. This report refers to Calderdale when describing services and Halifax when discussing the geographical area where Jeanette and her abusers lived. 1.4 A number of reports have recently been written into child sexual exploitation involving Asian men and white girls1 and this report builds upon the learning that those reports provided. Everyone involved in the production of this report shares Jeanette’s wish that other young people will be spared the trauma that she has suffered. They hope that this report will: a) contribute to the rising awareness throughout the U.K. about child sexual exploitation, b) explain why Jeanette was particularly vulnerable to this abuse, c) consider whether there is a cultural link explaining why the men who abused Jeanette were almost all British Asian men of a Pakistani heritage, d) identify learning and contribute ideas to help better protect children in the future. 1.5 Jeanette is a white British woman. Between 2008-2011 (when she was 12 – 15 years old) Jeanette was abused by a large number of men, she suggested over 100; 54 were arrested, 25 of whom were charged. 1.6 Throughout this report I refer to Jeanette as a “child”, not a “young person”: not because I believe her to be childish or immature but to stress the fact that abusers are exploiting the emotional and sexual immaturity of children. As far as issues of sex and sexuality are concerned, young teenagers are still “children” and it is now generally accepted that the professional response to the protection of children from sexual exploitation is taken more seriously when they are referred to as “children” rather than “young people”. 1.7 Often when British Asian men of a Pakistani heritage are convicted the word Muslim is used to describe them. This is the only part of this report where religion is referred to. This is because Islam does not preach that women should be abused and I have found no evidence that religion had a part to play in the events that will be described later in this report. 1 Rochdale, Bristol, Rotherham and Oxford Page 4 of 111 2. METHODOLOGY 2.1 Serious case reviews are commissioned by local safeguarding children boards when a child has died through abuse or neglect or been seriously harmed and it is believed lessons can be learned from the way in which the local authority, their board partners or other relevant persons have worked together to protect the child. Boards are now able to design the way in which they carry out these reviews. Calderdale Safeguarding Children Board decided that this review would have a panel of senior managers (independent from Jeanette’s case) from local agencies who work with children, written reports from each agency written by managers who were independent of Jeanette’s case and two people independent of both the case and Calderdale agencies: one of whom would chair the panel and one of whom would lead the review and produce this report. 2.2 There is debate amongst professionals in the safeguarding arena about the need for analysis rather than description of events. This report contains a detailed summary of events, in a style more personal than most serious case reviews. The reason for this is to explain: why and how Jeanette became ensnared in this abuse, demonstrate that individual professionals were aware of the danger that Jeanette was in, describe how the lack of systems and procedures hampered those professionals, and provide a learning tool (via narrative) for professionals and the public alike. The summary of events in this report has been read and approved by Jeanette herself. 2.3 The report describes events in the recent past, (mainly between 2009 and 2012), but the reader should be reassured that practice around child sexual exploitation in Calderdale had improved, largely because of Jeanette’s assistance, before this review started. These changes are described later in this report in a section entitled “What Happens Now”. Terms of reference 2.4 I was guided by terms of reference2 completed by the Panel, (copy included as appendix 1). Those terms contained some questions (listed below) set by the Local Safeguarding Children Board (LSCB) at the beginning of the review process. These questions were addressed by each agency report author and assisted me in understanding what had happened and why. 1. Determine whether the National, Regional and Local policies, procedures, thresholds and practice expectations of the agencies in use at the time were followed during this period. How would this be different now? 2. The vast majority of people who were questioned in regard to sexual offences against Jeanette are British Asian men of a Pakistani heritage. What, if any, are the gender, race and culture issues that are relevant to this case? 3. Were single and multi-agency communications and information sharing appropriate, accurate and acted upon? 4. Were single and multi-agency assessments and interventions child-focussed, appropriate, accurate, acted upon and complete? 5. Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of agency’s actions in relation to these. 6. Identify learning that will help partners and the LSCB to strengthen understanding of and response to Jeanette and to all vulnerable children and young people. 7. Did agencies understand and implement policy and practice in relation to CSE in their contact with Jeanette. If not, why was this? 8. Were any of the professionals or organisations involved with Jeanette working in isolation? 2 A series of statements and questions relating to the quality of this report and the way in which the review should be conducted. Page 5 of 111 9. What can we learn from the engagement with the young person, parents and extended family in fully understanding vulnerability, harm, risk and effective interventions? 10. Was professional practice informed by appropriate and effective supervision? 11. Were there examples of challenge by the LSCB into systems and processes of identification and monitoring of victims of CSE, and were there occasions when challenge might have made a difference? Independence 2.5 The independent chair was Maureen Noble. Maureen works as an independent consultant following a career of more than thirty years in a range of senior roles in public sector agencies. Maureen has a background in public protection and community safety and has worked with government at ministerial level in relation to national policy and transformation of public sector services. Maureen is a member of the NICE3 national working group on domestic abuse and acts as a volunteer strategic advisor to a national charity. Maureen has previously worked as an author and chair of numerous serious case reviews for Local Safeguarding Children and Adults Boards. She has also chaired and authored several domestic homicide reviews. She has not worked for any of the agencies involved in this review. Maureen is white British. 2.6 The lead reviewer was Barry Raynes. Barry is a non-executive director of Signis, a company which owns Reconstruct - which provides child care training and consultancy to managers and staff throughout the United Kingdom. Reconstruct also supplies advocacy, independent visiting and participation services to children. 2.7 Barry has thirty-five years’ experience of child protection social work. He has been involved in over 30 serious case reviews since 2007 – either overseeing the work of Reconstruct’s consultants or producing overview reports. He has written web-based child protection and child care procedures for more than 50 LSCBs and local authorities in England, Wales and Scotland. Barry has a Masters degree in public sector management and has studied to doctorate level. Barry is also white British. 3 National Institute for Health and Care Excellence Page 6 of 111 Serious Case Review Panel 2.8 The serious case review panel met on nine occasions between January 2015 and May 2016. The overview report was ratified at the local safeguarding children board meeting on 29th July 2016. 2.9 The panel comprised of: Name Designation Organisation Jamiila Sims Service Manager Children’s Social Care Steve Woodhead Service Manager Early Intervention Janet Youd Nurse Consultant Emergency Care, Acting Head of Safeguarding Calderdale and Huddersfield NHS Foundation Trust Jeff Rafter Service Manager Youth Offending Team Tom Taylor Assistant Principal Jeanette’s school Donna Green Programme Manager, Public Health Branching Out Darren Minton Detective Chief Inspector West Yorkshire Police Ed Chesters Detective Chief Inspector West Yorkshire Police Julia Kirkbright Team Manager, Child and Adult Services, Legal Calderdale Council Gill Poyser Young, Designated Nurse for Safeguarding Children NHS Commissioners, CCG Richard Haigh National lead tackling CSE Children’s Society Maggie Smallridge Head of West Yorkshire National Probation Service (Bradford & Calderdale) National Probation Service Julia Caldwell, Calderdale’s Board manager was present at all meetings acting as an advisor. None of the Panel were from an Asian background. Family involvement 2.10 This report is about Jeanette, who is now an adult, and she has been involved throughout the process of the review. The Panel contacted her father and let him know that the review was taking place and he was invited to read the report before publication. The consultation process 2.11 The review involved consultation with a high number of staff and members of the public: Jeanette practitioners who had worked with Jeanette and their managers discussion with senior managers of children’s services in Calderdale, (via the Panel) focus groups with members of Halifax’s British Asian community Jeanette’s current social worker the senior police officer leading the enquiry experts in child sexual exploitation and race issues, (from universities and The Children’s Society) Jeanette’s foster carers. I found all these people to be reflective, open and frank and thank them for their contribution to this report. Details of the consultation process are as follows: Page 7 of 111 Jeanette 2.12 Calderdale’s business manager and I met with Jeanette and her current social worker on three occasions. The first time we explained the serious case review process and asked Jeanette whether there were any areas that she particularly wanted us to explore. She said there weren’t but that she would be interested to hear what we thought at the end of the process. 2.13 I had, by this first meeting, read the joint chronology and I mentioned to Jeanette that some of the staff members who had been involved in her case had been trying hard to protect her, in particular a school nurse. Jeanette had no recollection of this professional and was surprised to learn that she had had so many children’s social care workers allocated to her. It therefore occurred to me that Jeanette’s “story” – if written only from the perspective of professionals’ case records – would not reflect Jeanette’s life as she had lived it. 2.14 We asked Jeanette if she would be happy with me viewing the recordings that the police had made of her interviews for the prosecution case and she agreed that I could. This provided me with material that I have used within the summary of events section of this report and it gave me a better understanding of the crimes committed against Jeanette and the reasons for her vulnerability. 2.15 We met Jeanette a second time nine months later. The long gap had been agreed because Jeanette was, during that time, involved in the trial of her abusers and had experienced the trauma of being examined and cross-examined by both the prosecution and defence lawyers (this was video recorded for the trial). By the time we met I had formulated the “narrative” section of this report (Part 3) and I read it out to her whilst her social worker listened and asked Jeanette questions checking that she understood what I had written. Jeanette was indeed surprised by the amount of activity that had been occurring between professionals. She said she could only remember three of her ten workers from children’s social care. In all Jeanette had eight social workers and two outreach workers. To avoid confusion for the reader I describe these generically as children’s social care workers and refer to them individually as CSC(1) through to CSC(9). 2.16 On the third occasion we discussed the whole report and Jeanette told us she was satisfied with the findings. Practitioners who had worked with Jeanette and their managers 2.17 I met on five occasions with the practitioners mentioned in the report and their managers. On the first four occasions I met separately with practitioners, and then their managers, and I met with them all together on the last occasion, along with the authors of the agency reports. 2.18 The main purpose of these meetings was to discuss the particular issues pertaining to child sexual exploitation work in Calderdale and their memories of Jeanette. They told me that there were now many systems in place which directed their work better, not only in terms of child sexual exploitation but younger children “in need”4 and vulnerable teenagers. It was clear they had already reflected on Jeanette’s case and they were saddened by her experience. Though they thought her case to be extreme, they thought there were other children in the area who were also vulnerable to exploitation. They were confident that they were better able to protect these children but not naïve enough to believe that all children were safe from this type of abuse. 4 As defined by The Children Act 1989 (children who need services from the local authority) Page 8 of 111 2.19 I came to this piece of work fresh from reading the Jay report (2014) into child sexual exploitation in Rotherham5 which described professionals who were reluctant to speak out for fear of being called “racist”. I determined therefore that I would discuss the fact that most of Jeanette’s abusers were British Asian men and challenge practitioners to consider why this may be. My experience was that, whilst there was some understandable reticence to discuss these issues, professionals were able to examine race and culture, consider a range of explanations (which this report will cover) and be reflective about their own practice. The “understandable reticence” was simply that we were a group of white professionals discussing the culture of British Asians (if there is such a homogenous thing) – inevitably we were generalising, always we were talking from a standpoint of ignorance. No-one spoke of pressure from senior managers or politicians to not mention race and culture (as was identified in the Rotherham report) and I concluded that I was not dealing with professionals or organisations who were seeking to limit such discussion. The professionals pointed out to me that, though the men all came from a similar culture in terms of racial identity, they also all lived in the same area as Jeanette and many had some contact with an illegal drug culture operating in the area. I concluded therefore that there were three issues of culture to be considered: the cultural heritage of the British Asian men involved, the small area where Jeanette and her abusers lived (described as a “post code” issue by professionals), the subculture caused by illegal drug activity. Discussion with senior managers of children’s services in Calderdale, (via the Panel) 2.20 The panel consisted of senior managers from agencies working with children in Calderdale. The purpose of the Panel was to plan the process of the review and quality assure this report. The issues we were discussing - race, culture, racism, sexuality and sexual abuse - were contentious and, at times, fraught. There was a healthy range of views expressed and I am grateful to the Panel members for their suggestions as they have improved the quality of this report. Focus groups with members of Halifax’s British Asian community 2.21 I decided at the beginning of this process that I needed to have some interaction with members of the British Asian community living in Halifax if I was going to be able to explore the issues around race and culture and hear an Asian perspective of life in Halifax. 2.22 Calderdale Council employs a range of community workers and I liaised with two in particular. I decided that I did not want to meet with “community leaders”, who are often from a religious background and predominately men. This view is supported by Barnardo’s (2016)6 who suggested that “access to communities should be via a broad range of stakeholders, rather than solely through male religious leaders, and particularly through those with child-centred perspectives” (page 22). The community workers identified a number of British Asian men and women who would be happy to meet with me. Both groups were a mixture of invitees who the community workers work with on a regular basis, some of whom already knew each other, either through the Council of Mosques or a community group. 5 Independent Inquiry into Child Sexual Exploitation in Rotherham (1997 – 2013) 6 “It’s not on the radar: The hidden diversity of children and young people at risk of child sexual exploitation in England” Page 9 of 111 2.23 It was decided by the men and women themselves that it would be easier for them to speak openly about issues about sex, sexuality and culture if I met with them in separate gender groups. This I did on seven occasions. I made it clear at the beginning of each of the first meetings that I did not see the individuals in the groups as representing their “community”. With hindsight this was a very important statement to make as it freed up the participants to say what they thought. At the beginning, talking with and listening to the men’s group was difficult as the men were more defensive than the women. I did not think this was unusual because we were not only discussing issues of race and culture but gender and, in particular, male violence over women. I believe I established good relationships with both groups who spoke openly to me about their own views, their heritage, their experience of living in Halifax, how sexual relationships are discussed in their families and their thoughts about the events that had led to this review. 2.24 This was an essential and helpful part of the review process. There was a mixture of opinions (as there was in professional groups and the Panel). Some of the women in particular were clear that there were issues of gender imbalance and power within the area. Many people from both groups thought that the cultural impact of illegal drug use was at least as important an issue as race and culture and all agreed that the men involved in the abuse would be under no illusions that what they have done was wrong. 2.25 A lot of discussion focused upon the general experience of living as British Asians in Halifax, an acceptance that there was a separation between communities along with an acknowledgement that the separation was changing. Both men and women told me that the British Asian community in Halifax were much more open about discussing issues such as domestic abuse, child sexual abuse and child sexual exploitation now than recently, and that much work was being done by members of the community themselves in opening up discussion about these issues. Consequently, the belief was that children were safer now than they had been before. I will elaborate upon this later in this report under the section entitled “community engagement”. Jeanette’s current social worker 2.26 Jeanette’s current social worker (known as CSC(9) in the narrative section of this report) and I have worked closely together throughout the process of this review. As well as being Jeanette’s social worker she is an experienced practitioner. The senior police officer leading the enquiry 2.27 A recent report by the Association of Chief Police Officers and the Crown Prosecution Service7 indicates that people working on serious case reviews and the prosecution of offenders relating to the review should share information and co-operate. Although he retired towards the end of the process of this review, I worked closely with the senior investigating officer. Much of the material in this report relating to the perpetrators comes from him, and I found our discussions extremely helpful in compiling information about the offenders for this report. 7 “Liaison and information exchange when criminal proceedings coincide with Chapter Four serious case reviews or Welsh child practice reviews” Page 10 of 111 Experts in child sexual exploitation and race issues 2.28 It has become clear to me during the process of compiling this report that knowledge and understanding about child sexual exploitation historically and nationally has been much greater in the voluntary than the public sector. To assist me in understanding the general issues about child sexual exploitation I met with an experienced manager from Calderdale’s women’s centre. I was interested in exploring how to help children who don’t know they are being exploited and abused, and I found the manager’s suggestion, that there is a similarity to working with people who are victims of domestic abuse, and the importance of professional perseverance along with a belief that the person will eventually leave their abuser, very helpful. 2.29 I had one meeting with two Asian academics who have been studying race, culture and child sexual exploitation. This was helpful in confirming for me that research is limited in this area but that the academic world is taking the issue seriously. They confirmed that I would be unlikely to be able to come to a firm conclusion about issues of race and culture, but I should aim for the report to be helpful in elaborating the factors and pointing the way for future research in this area. Jeanette’s foster carers 2.30 I met on two occasions with Jeanette’s previous foster carers: once to hear their experience and once to inform them of the conclusions of the report. I found them to be caring, considerate and professional, and I have included a lot of what they said to me in the narrative section of this report. They described well how they helped Jeanette move on from her abuse and have therefore provided information that could be useful for other carers in this situation. Interviewing the perpetrators 2.31 There was discussion at Panel about the appropriateness of offering to interview the (then) alleged perpetrators for the benefit of this review: the majority opinion was that this would not be useful whilst the prosecutions were in process and therefore I have not attempted to have conversations with the offenders. This issue will be reconsidered now that the trial is over. Agency reports 2.32 The following organisations produced reports detailing their involvement with Jeanette, critiquing the practice of the professionals involved whilst considering broader contextual issues relating to guidance, systems and processes. Children’s social care Independent reviewing service West Yorkshire police Youth offending service General practitioner’s service Calderdale and Huddersfield NHS Foundation Trust Education Sure Start (Parent Support Worker in School) National probation service Page 11 of 111 2.33 The Probation Service had no involvement with Jeanette. However, it was noted by the Panel that five of the men charged with offences against Jeanette were known to the West Yorkshire Probation Trust at the time of the offences. The agency report produced by the probation service identified that only one of these five men had any history of sex offending, and his offences were not similar to these offences in that the sexual offence was against an adult female in the context of a relationship. Although there was some general local learning for the probation service, the Panel were agreed that it was not possible for probation officers to predict that those five men would be involved in these types of offences. 2.34 The agency reports produced for this review were thorough and unstinting in their criticism of the work undertaken in Jeanette’s case, and provided evidence about how things had improved in the Calderdale area in the last three years. Timescales 2.35 The criminal prosecution of this number of offenders was complex and took two years to piece together and resulted in three separate trials spread between February and June 2016. There has been considerable delay between starting the review in January 2015 and finalising the report in November 2016. This is because it is not possible to publish a serious case review report until the trials associated with the case have been completed, as the content of the review report may prejudice the trial. This means that the review has taken 21 months. Dissemination of learning 2.36 A culture of continuous learning and improvement in Calderdale across the organisations that work together is complemented by regular monitoring and review. This is outlined in the Calderdale SCB Learning and Improvement Framework. However, some examples of how the learning from this review will be promoted and embedded are: a) Training and briefings to professionals and young people b) Newsletters, briefing papers and learning lessons for front line practitioners c) Quality assurance through audit d) Performance management of indicators outlining practice improvements or need for development e) The production of a version of this report suitable for use with 14 year olds f) Publication on website g) Policy and procedure updates h) Action plans: translation of recommendations into SMART programme of action that lead to sustainable improvements in practice which have been monitored, implemented and updated through the Calderdale LSCB Case Review Sub Group and Business Group i) Challenge events for front line practitioners to ensure the learning has been absorbed Page 12 of 111 3. SUMMARY OF EVENTS (Jeanette’s story) 3.1 This part of the report quotes from information that Jeanette gave to the police when she helped them put together the prosecution case. The quotes are displayed in italics and are used to explain Jeanette’s story in her own words in order to help the reader understand how Jeanette became victimised by her abusers. It is important that the reader realises that the professionals working with Jeanette did not have access to all of this information at the time they were trying to help her. From birth – ten years old (1995-2005) 3.2 Jeanette was the youngest member of her family, she has two siblings who are considerably older than her. 3.3 When Jeanette was a year old her mother was diagnosed with a life-threatening and life-changing disease and she was told that she had approximately 15 years left to live. Jeanette’s mother’s illness and short life expectancy was therefore ever present in Jeanette’s life. This disease causes a disorder in movement and Jeanette remembered being bullied at school at the age of five because of the way her mother walked. Jeanette recalled that her father wanted her to walk home alone but her mother refused to allow this. 3.4 From the age of eight, Jeanette’s mother’s health deteriorated and Jeanette remembers that she and her sisters did most of the caring for her mother. Jeanette said that her father was often away from the family home. Jeanette’s primary school attendance was 84%, and in addition she was late on average once every fortnight. Age 11 (2006-2007) 3.5 By the time she was 11 years old, Jeanette’s life at home was unhappy: her mother was ill, her father often absent and, when at home, there were lots of arguments. She was caring for her mother and was receiving little attention from her father. She started at secondary school, a transition that many young people find difficult at the best of times. There are no records to indicate that anyone had identified Jeanette as a young carer. Had she been, she would have been seen as a “child in need8” and offered some support. 3.6 She told her present social worker (in 2015) that this was the time that she started to go out late at night to a local park, often with older young people, and she started to meet some of the men who would later go on to abuse her. Age 12 (2007-2008) 3.7 When Jeanette was 12, her mother went into a care home full time and her eldest sister left home, leaving Jeanette with her father and her other sister (then aged 18). She described how her father was often away living at his girlfriend’s house, meaning that there was often no gas, electricity or food at home. As a contrast to life at home, Jeanette enjoyed the attention that she was getting from men in the park and felt liked and accepted by them. There are no records to indicate that any professionals knew that she was spending her time in this way. 8 A definition from the Children Act 1989 which means a local authority (not necessarily children’s social care) should provide services Page 13 of 111 3.8 In police interviews for the criminal proceedings associated with this case, Jeanette described how her father left the family home (this description was not known to professionals at the time they were trying to help her). “My dad didn’t live there for about a year. I was there with my sister. There was nothing to eat or anything like that. I started drinking, 11 or 12. I just went out and had a drink with friends from school. I drank to forget about things”. 3.9 She also described how she became friendly with another girl, then aged 15, and how she began to be “groomed9” by men for abuse. “I’d go out, hang out with friends I used to go with a particular girl. I’d hang around with her, she was 15, I was 12. We’d go out and meet random people, stay out all night. I thought she was alright but my mum never liked her. I felt sorry for her, she didn’t get on with her mum. We’d get drunk, get high. Sometimes we met people in the park. We’d get someone to buy us vodka. I started drinking at 11, smoked cannabis before cigarettes. We’d sunbathe, listen to music. People would talk to us. Men would stop and we’d get into cars. I started off with cannabis just before I was 13 then I got into heavy drugs as it went on. I didn’t know anyone who wasn’t taking drugs”. 3.10 Jeanette described an early incident when one of the men and two of his friends had keys to a house, and she went in with them and another girl. She was 12, and the other girl 16. They had some drinks, a bottle of vodka that was mostly drunk by the girls. Soon afterwards, the police came and said they suspected a burglary. The men were arrested and the police took Jeanette home. The other girl was left to make her own way home. Age 13 (2008-2009) 3.11 Jeanette’s mother died soon after Jeanette’s 13th birthday and, three months afterwards, her father moved out of the property permanently - leaving Jeanette with her 19-year-old sister. 3.12 On 9th February 2009 CSC(1) was allocated to Jeanette because the Family Court had asked for a s(7) report10, but records offer no indication why. The children’s social care worker filed a report for court on 13th March, in which he was positive about Jeanette’s wellbeing and a recommendation was made that her father be granted parental responsibility as, presumably following the death of her mother, no-one had parental responsibility for her. 3.13 On 4th April Jeanette’s school reported to the police, but not to children’s social care, that she had brought cannabis belonging to her father into school and had distributed it to fellow students. On 5th June children’s social care received a referral from a youth worker, who knew Jeanette because an education welfare officer had asked that he work with her. He said that he was worried about Jeanette as he thought she may be involved in child sexual exploitation. The referral contained direct quotes from Jeanette which included reference to ‘cruising with older males’ and how her father never cooked for her and was never in. Apparently, Jeanette had said that her father was violent towards her after her mother had died and she had said: “if I start talking I won’t be able to stop and my dad would end up in prison”. Children’s social care case files indicate that the referral was ‘refused’ because it contained no new information since the Section 7 report for court had been completed. 9 The process by which the men “befriended” Jeanette and won her trust in order to abuse her. 10 A report for court to consider the child’s welfare Page 14 of 111 Age 14 (2009 – 2010) 3.14 On 5th August 2009 police officers went to a house because they had been informed by the mother of a friend of Jeanette’s that her daughter, a third young woman and Jeanette were missing. Jeanette was found with the two other girls, in the company of two British Asian men. The girls did not make any complaints and the police officers took them home having warned the men about their behaviour. Once home, one of the girls said that she had been subjected to unwanted sexual advances from one of the men - who she said had tried to grab and kiss her. However, no further action was taken against the perpetrators because the young woman was not prepared to be interviewed and examined further. The police records show a referral was made to children’s social care but there is no record of that referral being received. The allegation of sexual assault was not recorded as a crime, though it should have been. 3.15 On 1st November the school made a referral to Sure Start, who allocated a Parent Support Worker in School (PSWiS) to the family. 3.16 An Ofsted inspection into safeguarding arrangements in Calderdale took place between 18th- 29th January 2010, which found safeguarding arrangements to be “inadequate”. 3.17 On 12th February 2010 the PSWiS visited Jeanette, and then telephoned the police and children’s social care because Jeanette said that she had been hit by her father because she was “out of control”. The police visited with a children’s social care worker who recorded that Jeanette had marks on her neck. Jeanette said that she did not want any further help. Jeanette was now living with her sister and said she didn’t want to go home because her father hit her, was never at home, was a gambler and took drugs. Her sister told the children’s social care worker and police officer that she was concerned because Jeanette was getting gifts and presents from Asian men. Later that same day CSC(2) was allocated to Jeanette. “Guys would offer you drugs if you would sleep with them. They pull up in a car and ask where are you going they say why don’t we go out for a drink. They’re nice to you, they buy you a drink, I’d have vodka. Once you’ve had a drink they offer you drugs. You smoke cannabis anyway but heavier drugs when you’ve had a drink, you don’t think about it. You just take it. You go to a hotel. Most of the time you don’t remember because you’re off your head. They all tell you fake names, obviously… I can’t remember the first time I had sex, I’ve never had sex sober”. 3.18 On 16th February CSC(2) recorded that Jeanette was a “child at risk and returning at 6am in the morning” and living with her sister was “not in the best circumstances”. Shortly after this date Jeanette went to live with her aunt. There are no records of an assessment being completed until 8th April when CSC(3) was allocated to Jeanette. An assessment was started following a strategy meeting11 called because of allegations of an assault on Jeanette by her father. The assessment was completed on 13th April. Jeanette continued to allege that her father had physically assaulted her. Prior to living with her aunt, Jeanette’s school attendance had only been 37%. The assessment recorded that Jeanette was no longer receiving presents from Asian men. 3.19 The PSWiS closed the case on 6th April because Jeanette was now living at her aunt’s and her school attendance had improved. 11 A meeting between police officers and social workers to consider whether an investigation into child abuse should take place. Page 15 of 111 3.20 On 28th April an education welfare officer (EWO) contacted children’s social care and the children’s social care worker recorded the EWO: “has been aware that Jeanette had been getting into cars with Asian males and drinking alcohol when she was not in school, however said he felt this is no longer the case and that she is safer at her Aunt’s” 3.21 On 3rd June someone from Jeanette’s school made a referral for Outreach services12 and eleven days later an outreach worker was allocated to Jeanette. The work to be completed was listed as “relationships, parenting work with dad, awareness regarding bereavement”. Two weeks later children’s social care recorded that Jeanette was again living with her father. 3.22 On 25th June Jeanette said at her outreach session (with her father and aunt) that she knew some of her friends were at risk of child sexual exploitation by getting cannabis from Asian men but that she no longer had any involvement. It was noted that Jeanette’s school attendance had fallen since she had returned home to live with her father. 3.23 On 1st July CSC(4) was allocated to Jeanette and over the next eight days this worker carried out three sessions with Jeanette or her father. On 9th July 2010 CSC(5) took over from the outreach worker appointed on 3rd June. She remained involved with Jeanette until May 2012. Age 15 (2010-2011) 3.24 On 16th September 2010 CSC(6) was allocated to Jeanette, (records do not indicate why a change of social worker was needed). It is unclear why this happened, (because the records do not state a reason) but it may be that Jeanette was denying that she was being sexually exploited. The outreach workers had offered 15 sessions and Jeanette had attended for most of them whilst her father had missed most. 3.25 On 23rd November 2010 Jeanette was arrested for shoplifting. She was tested for drugs and was found to have taken cocaine. She received a Juvenile Reprimand13 for the shoplifting offence. Later that same day, staff from Jeanette’s school discussed how worried they were about her and made a referral to children’s social care which included Jeanette’s comments that her father could turn violent when he was in a bad mood, and the fact that she regularly went out late at night and associated with older males. Jeanette’s school attendance was 70%. 3.26 On 1st February 2011 a professionals’ meeting was held following concerns expressed by the school nurse to CSC(6). Jeanette had told her outreach worker that she was going in cars with older males, but that nothing was happening, and that she was only going to look after the younger girls. She also stated that she was going out in the early hours of the morning without her father’s knowledge. CSC(6) said that she would discuss the case with her manager about whether Jeanette could come into care voluntarily. The conversation took place on 7th February 2011 but no action was taken because of a reorganisation in the department. A further meeting was booked for 7th March 2011. 3.27 On 4th February Jeanette’s father’s partner rang children’s social care to say Jeanette had was missing. The children’s social care worker telephoned the missing person co-ordinator for the police, who added a ‘flag’ to Jeanette’s name (on the police computer) to indicate that she was at high risk. This police officer remained working with Jeanette until August 2012. Because of the importance of his involvement this report will refer to him by the pseudonym “Robert”. It is unclear exactly when Jeanette returned but she was back in the family home by 8th February. 12 Unqualified workers who work with people in the community. 13 These replaced “cautions” and are issued for a minor first offence Page 16 of 111 3.28 On 7th February the school contacted CSC(6), who said she had discussed Jeanette with her manager, as agreed at the meeting held on 1st February, and the case was due to be transferred to another team because of a departmental reorganisation. There was no further comment made about the possibility of Jeanette going into care. CSC(6) said she had spoken to Jeanette’s father's partner and advised her to report Jeanette to the police when she went missing. 3.29 On 8th February children’s social care received a referral from an ambulance crew to say that Jeanette was not coping with her situation, running away, going missing for two days and her father had slapped her for refusing to say where she’d been. 3.30 The next day Jeanette went to school with a bruised lip. The school phoned the police, who noted that her father had hit her as a result of non-school attendance. A child protection referral was made to social care. That same day Jeanette told a teacher at the school that she had been pushed down the stairs at home by her father and that she stayed with a friend for two days. She would not say who the friend was. The school called children’s social care and passed on this information. 3.31 The following day (10th February) the school phoned children’s social care for an update but were unable to get any information. They then rang the police, who said a child protection investigation had been undertaken by children’s social care (despite the fact that this now warranted a joint investigation between police and social care) and the case was now closed. There are no records of this investigation. Later that day CSC(7) was allocated to Jeanette. 3.32 On 16th February 2011 the school telephoned the police to raise concerns because Jeanette had left for school in the morning but had not arrived, they recorded her as “temporary absent”. The next day the case was passed to Robert who, the following morning at 3:45 a.m. contacted Jeanette who stated that she was safe and well at a friend’s house and would not be returning home until 9pm. 3.33 On 23rd February 2011 police officers went to Jeanette’s sister’s address to see if they could find her but there was no one in. Enquiries were made at the home of a friend of Jeanette and the friend said she had not seen Jeanette for a few days. Jeanette returned home later that night, stating she had been at the house of a 19-year-old male friend drinking vodka. Whilst away from home she had met up with her sister, who had brought her home. 3.34 On 7th March 2011 a meeting was held at the school, as Jeanette’s school attendance was now 60%. The meeting discussed Jeanette’s alcohol misuse, child sexual exploitation and physical abuse. Jeanette had been telling professionals that she was staying in hotels in Leeds, Manchester and Huddersfield. Professionals at the meeting expressed their dissatisfaction over the lack of involvement from children’s social care. Concerns were also raised by school staff over the fact that a part-time children’s social care worker was leading this case. The duty social worker present said that she would look into the case being transferred to a full time social worker. 3.35 Three days later Robert and a children’s social care worker went to Jeanette’s address to conduct a risk assessment but she was not present. Her father said she was spending time with a 19-year-old male, and that Jeanette had been found in possession of sums of money and vodka. The two professionals then went to Jeanette’s school, saw her and completed a child sexual exploitation risk assessment form. She was assessed as medium to high risk. She said she was in a relationship with a 21-year-old man, she drank four bottles of vodka per week and used drugs. Throughout the meeting Jeanette constantly received calls to her mobile phone. Page 17 of 111 3.36 On 18th March 2011 CSC(8) was allocated and Jeanette told her that “everything was ok”. However, she also gave a clue about what was happening to her as she also said she’d been “out in a taxi last night”. 3.37 On 30th March 2011 police visited Jeanette at her home following a report from her father that she had returned home drunk. She was arrested in order to prevent a breach of the peace and taken to the police station. Whilst there, one of her friends came in claiming that, the night before, Jeanette had tricked her into getting into a car with two unknown Asian men. The friend stated she was taken to a restaurant in Huddersfield where she was sexually assaulted before being taken home. This event did not trigger a strategy meeting or a child protection inquiry for Jeanette – this may be because a professionals meeting was due to take place the following day. She was returned to her father’s care with no risk assessment or contingency planning. 3.38 The following day a further meeting of professionals took place. The minutes state that a girl claimed that Jeanette had enticed her into the car of an Asian male, where the doors were locked and the girl was touched inappropriately by two men. Jeanette was going out at night while the family were asleep. Her father’s girlfriend and her son had moved into the family home. Apparently Jeanette’s friend said that this was not the first time that Jeanette had tried to get her into a car. The police stated that Jeanette had been arrested and interviewed on suspicion of facilitating a child sexual offence, and at the conclusion of the enquiries she was not charged with any offences. Both the police and school made it clear at the meeting that they felt this case should be moved up to child protection from child in need – something that had been expressed at previous meetings. The children’s social care worker again said that the case would be discussed with her manager and the police were unable to take any disruptive action against the offenders, because neither Jeanette nor her friend had been able to identify the offenders. 3.39 On 6th April 2011 Jeanette’s father found explicit sexual messages on her phone suggesting sexual activity in exchange for money with five men. He banned her from leaving the house except to go to school. Robert took the phone for “evidential purposes” and tried, but failed, to identify who the holders of the numbers were. Jeanette was seen at school by CSC(8), regarding the concerns surrounding her mobile phone, sexually transmitted diseases and risk of pregnancy. This resulted in a child sexual exploitation meeting taking place the next day. 3.40 On 13th April 2011 Jeanette sent a text message to Robert asking him to ring her because she was out of credit. When he phoned she said she was in a hotel but she didn’t know where. Robert helped her to find out (she was in Bradford) and then collected her and took her to the police station where MCAT was found in her possession. She was arrested for possession of controlled drugs14 and a referral was made to the Youth Offending Team. It was established that Jeanette had been taken to the hotel by a British Asian man. This man was arrested on suspicion of rape and interviewed. He stated that he had seen Jeanette in Bradford on a few occasions in cars ‘chilling’ with other men. He said she had told him she was 19 years old. On 11th April 2011 he had seen her getting out of a black Mercedes. He asked Jeanette if she wanted to drive around and she agreed. They went to a hotel in Bradford where Jeanette had sex with him and some other men. Whilst in the room Jeanette had taken MCAT and cocaine. 14 This later became a “final warning” Page 18 of 111 3.41 In her video interviews with the police (this description was not known to professionals at the time they were trying to help her) Jeanette said: “I drank to forget about things. I drank lots so I couldn’t feel the sex and I’ve never had sex sober. They always offered me the alcohol. It was always hard stuff, I never poured my drinks. If I hadn’t been drinking I would have seen it in a different light. I wouldn’t have agreed to have sex if I hadn’t had drink. It’s not like I enjoyed the sex. If I got a text I thought I’d have a drink or a smoke. I was drinking every night, bottle of vodka every night. The men supplied me with the vodka, they just bought it anyway, I didn’t have to ask for it. They’d sometimes get more people. I wanted someone to talk to, have a drink with, smoke and company. It wasn’t about the sex”. 3.42 The police records show that Jeanette told them she had had sex with three men but she was extremely vague about the details. She said that at least one of them knew that she was 15 years old. She denied being involved in prostitution15. The crime was reviewed by a Detective Inspector and finalised as a no crime with regard to the rape allegation. A Final Harbourer’s Warning16 was administered to one of the men. 3.43 Robert challenged the decision to prosecute Jeanette because he felt that she was a victim of child sexual exploitation and should have been dealt with as such and not be criminalised. Jeanette was bailed for a Final Warning for possession of a class A drug and was then taken to a Children’s Home for one night, she then went to stay with her aunt. An appropriate adult17 from the Youth Offending Team (YOT) sat in with Jeanette during the interview. She passed information onto the YOT prevention co-ordinator for child sexual exploitation who agreed that a strategy meeting needed to be held (set for 20th April 2011) and allocated a YOT worker to Jeanette. 3.44 On 14th April 2011 Robert’s manager sent the following email to CSC(8): “I understand your team currently manage Jeanette aged 15 years. It is the view of West Yorkshire Police that she is currently leading a lifestyle that puts her at serious risk of significant sexual, physical and emotional harm. For some time now intelligence received by Social Care, Education and the Police has identified Jeanette as being at risk of Child Sexual Exploitation. Recent events have seen her arrested for facilitating a child sexual act upon fellow CSE victim and more recently a victim of rape by an adult male from Bradford who is currently under police investigation. Evidence gathering by the Operation Handle Team at the Safeguarding Unit has established that Jeanette was subject of sexual acts by at least a further four adult males at the hotel, Bradford on Monday 11th April 2011. Despite the best efforts of investigating staff, Jeanette has refused all cooperation with the Police and continues to act in a manner that puts her in great danger. We cannot clearly manage this risk as a single agency and it is my view that this case merits further assessment by Social Care and I would like you to consider bringing all professionals around Jeanette together in a child protection conference. Can you please give this case further consideration and update the Safeguarding Unit with any decisions made.” 15 Earlier Government guidance (2000) has used the term “child prostitution” as opposed to “child sexual exploitation”. This phrase is now no longer used because it implies a level of consent from the child. 16 Now known as “Child Abduction Warning Notices”. Warnings are issued to people who are believed to have placed a child or young person at risk of offences being committed against them. 17 An adult who accompanies vulnerable people and adults who are being interviewed by the police. Page 19 of 111 3.45 On 18th April 2011 a YOT assessment was completed regarding the offence. The assessment concluded that Jeanette’s vulnerability scored as Very High. It said: “Jeanette is heavily involved in CSE and has been for a number of years, therefore she cannot see the risks she is placing herself in. It is also believed Jeanette has tried to entice other young girls into CSE and in some cases she has been successful. She admits to using class A mainly substances, (sic) MCAT and cocaine which she states are given to her by her older male friends. She frequently goes missing from home, often frequenting hotels with a number of different males, which places her in an extremely vulnerable and risky situation. There are also concerns that Jeanette will disappear once she has left school and she has indicated to me once she turns 16 she will leave home and obtain her own flat. There are a number of professionals currently working with Jeanette and her family, but from the information I have gathered from other agencies involved suggest that a number of professionals have been involved for at least two years, but no improvements seem to have materialised. In fact, things have probably got worse”. 3.46 A week later YOT worker(1) met with Jeanette. They talked about her offence and how she found herself in the situation she did. Though Jeanette was quite open about what had happened she referred to these older males as friends of hers and she kept some details to herself. 3.47 On 12th May 2011 a meeting of professionals was held. The recent events were discussed and concerns were expressed that Jeanette was being sexually exploited. Education, social care, YOT, CSE worker, and Lifeline18 were present. Professionals requested that Jeanette be subject to a child protection plan. CSC(8) agreed to discuss this and a referral to the Family First Panel19 with her line manager. It was agreed that Lifeline would carry out an assessment to see whether they could work with Jeanette, and the outreach worker would have weekly sessions with Jeanette and separate meetings with Jeanette’s father. The next day CSC(8) made a referral to the Family First Panel. 3.48 A week later a telephone call was received by CSC(8) from Jeanette's father’s partner. She said that Jeanette had stormed out of the house because her dad had grounded her and also removed her mobile phone. She said there were disgusting text messages on the phone which she had given to Robert. She stated that she couldn’t cope with Jeanette's behaviour any more, as it was making her ill, and that she and Jeanette's father didn’t want her to return home as they could not keep her safe. Despite this, Jeanette returned home the next day. The police visited and Jeanette said she had been stopping with a friend who lived around the corner. 3.49 On 23rd May 2011 Jeanette’s case was discussed at the Family First Panel. The outreach worker was asked to pick up extra parenting work. 18 A voluntary organisation that works with individuals, families and communities both to prevent and reduce harm, to promote recovery, and to challenge the inequalities linked to alcohol and drug misuse. 19 A committee of senior managers who agree the allocation of resources to families. Page 20 of 111 3.50 Three days later, YOT Worker(1) met Jeanette, her father and her father’s partner and introduced them to Jeanette’s mentor, YOT Worker(2) who happened to be the appropriate adult who Jeanette had previously met. Jeanette’s father said that things had settled down since last week. Later that day a further professionals’ meeting took place. Present were CSC(8), her manager, Robert and YOT worker(1). They discussed ongoing concerns regarding the risk to Jeanette. Robert explained that once Jeanette was 16 years old the police would have difficulty protecting her in her current situation. However, if she was looked after by the local authority the police would have better opportunity to safeguard her as a child at risk of child sexual exploitation until she was an adult20. 3.51 At the end of May YOT worker(2) met with Jeanette after which she sent the following email to the YOT prevention co-ordinator for CSE: “Jeanette mentioned meeting a guy called (NAME)21 who is 27… who drives a (CAR) (no colour given). Jeanette says she has known him for a few years. He has a girlfriend who she hasn’t met. Jeanette says they go to places where the Police can’t pick them up, but did not mention where? Jeanette said (NAME) owed her a bottle of vodka but wouldn’t say why. Jeanette also said that when she is 16 she can do what she wants.” 3.52 On 2nd June children’s social care held a Gateway Panel meeting22 and a recommendation was made to ask Jeanette’s father to agree to her being placed voluntarily in care,23 even though it was recognised that this may be difficult to put into practice if Jeanette herself was not in agreement. 3.53 A week later Jeanette arrived at school by taxi for an exam. She said she had come from Manchester and she had been assaulted by a male who she then hit with a hammer. She was under the influence of drugs. She had a broken tooth and a split lip. Later that day Jeanette taken to the hospital by police and children’s social care workers. Whilst there she said to the police that she wanted to get out of what she was involved in and she was placed in police protection24. She became accommodated25 and she was moved to a local foster placement. Because she was unable to give the police more information they were unable to take any action against the alleged offender. 3.54 Jeanette’s story, as told to the police during a video interview was as follows, (this description was not known to professionals at the time they were trying to help her): “When we got to the hotel one of the men would always go into the hotel first to check that the same male receptionist was on duty. He would then get money from the other males in the car to pay for the room. I had sex with one of the men, his brother and three other men in the same room. At this point the other males returned and had sex with me. I was not happy having sex but I did not actually say “no”. I was very drunk having taken drugs and drunk vodka.” 20 This is presumably a reference to the age of consent rather than the duties and responsibility of the local authority. 21 All names, phone numbers and car registration numbers have been deleted from the text but “CAR” etc. left to demonstrate the detail of this professional’s work. 22 These meetings are chaired by senior children’s social care managers who make decisions about whether or not to a child should be accommodated into local authority care provisions either under S20 or under an Interim Care Order via court proceedings. 23 Children Act 1989 s20 24 Police can ask a local authority to look after a child for up to 72 hours. 25 This means it was with the agreement of her father and done under s20 of the Children Act 1989. Page 21 of 111 3.55 On 15th June 2011 Jeanette was reported missing by her foster carer. Officers contacted Jeanette on her mobile. She was drunk and would not say where she was. Male voices could be heard in the background. She was found the next day at her father’s house. Later that day YOT worker(2) arrived at Jeanette’s house for her session, but was told by Jeanette’s father’s partner that Jeanette was now in care. 3.56 The next day Jeanette told Robert she had been in Rochdale with a friend and had become involved in a fight. She had bruises and her ribs were sore. She refused any medical treatment. 3.57 The following day YOT worker(2) visited the foster carers, who were unaware that she was involved with YOT. 3.58 On 20th June YOT worker(2) met Jeanette at college to help her enrol on a child care course. She later sent an email to the YOT prevention co-ordinator for child sexual exploitation saying “Jeanette was picked up after the meeting by an Asian male in his 30s who was driving a (CAR), (COLOUR) (REGISTRATION PLATE). Jeanette has a further new mobile number – (NUMBER)” 3.59 The next day Jeanette went missing again. She was found the following day at her sister’s house by Robert. She stated that she had been walking the streets all night as she did not want to go home to the foster carers. She had been drinking vodka and taken cannabis. Two days later YOT worker(2) sent the following email to the YOT prevention co-ordinator for child sexual exploitation: “Jeanette asked if she could use NAME’s (YOT worker(2)) phone to make a call. The numbers rang off the phone were – (TEL. NUMBER) & (TEL. NUMBER). Jeanette said that the person she was ringing was known to her as (NAME), whom she had met up with last night at 19.50pm outside KFC. YOT worker(2) said that she had been with Jeanette prior to her meeting with this male so she waited around a while and noted down the details of the vehicle Jeanette got into – a taxi registration (REG NUMBER) (COLOUR) (CAR). She also told YOT worker(2) that the male who picked her up from college yesterday was known to her as (NAME).” 3.60 On 24th June 2011 Jeanette was again missing. YOT worker(2) contacted Jeanette on her mobile phone during the evening and Jeanette said she was out in Halifax with friends. She said that she did not want to return to her foster carers, as they refused to let her stay out for the night. YOT worker(2) tried to talk her into going back and Jeanette returned to the foster carers the next day. 3.61 On 1st July Jeanette went missing. She returned on 4th July. On 7th July 2011 Jeanette’s first Looked After Child26 review took place. It was noted that she had been missing nine times since being placed in foster care on 10th June, just 27 days earlier. The decisions made at the review were: 1) Jeanette to remain accommodated. Father was present and agreed. 2) Move Jeanette to a foster placement outside of the district to afford her some protection. 3) Establish a clear plan of intervention to assist in breaking the cycle of abuse. Where possible current support to continue into new placement. 26 These are meetings that take place to make sure that children in care are being looked after properly. Page 22 of 111 3.62 On 8th July 2011 Jeanette met her Lifeline worker for the first time (to start the assessment agreed at the meeting on 12th May) but she was under the influence of drink and drugs so an assessment was difficult. Three days later Jeanette told her LifeLine worker that she had been raped approximately six months ago. This information was passed to children’s social care but Jeanette refused to make a statement to police. 3.63 In her police interview (this description was not known to professionals at the time they were trying to help her) Jeanette said: “I had sex with one man. When he’d finished he went and got another man saying that I had to have sex with this man because he owned the house we were in. I refused. The first man became violent, pinning me to the wall. He said if I didn’t have sex with the second man I’d have to walk home from Bradford. The other man stood there smiling. We had sex in a locked room with my arms pinned above my head27”. Age 16 (2011-2012) 3.64 On 22nd July 2011, two weeks after the LAC review first made the recommendation, Jeanette moved to a new foster placement, one that was a considerable distance from Calderdale. Robert and CSC(8) drove her there. When they arrived Robert took all of Jeanette’s phones off her, he said for evidence but it was also to help end the contact that she had with her abusers. The foster carers told me the following during my meeting with them in May 2015: “Jeanette was standing on our door step with a black eye, smudged make-up, wearing low cut trousers and a low cut top with her fake tan running off her. She came in, sat down and said “you seem like a nice family but I won’t be staying here for more than two hours”. We were told that she was addicted to drugs and alcohol but that turned out to not be true. We showed her the room that she would have, and the foster father walked to the shop with Jeanette because she wanted a tuna and cucumber sandwich. We unpacked her bag noticing that all her belongings were in that one bag. We threw away two empty bottles of vodka but found one that was half-empty. We put it in our medicine cabinet and told Jeanette that she could have some when she wanted it. She only ever asked for one measure and eventually she threw it away saying “it probably wasn’t any good any more”. 3.65 The existence of the vodka put the foster carers in a difficult position as Jeanette was too young to have this in their house. However, they were at an early stage of forming a relationship with her and their judgment was that throwing the vodka away would be too confrontational. She was the carers’ first full-time foster child, and their only previous experience had been to look after a young person for a week-end. 3.66 On 1st August 2011 the second Looked After Child Review took place. The decisions were as follows: 1) Jeanette to remain with her present foster carers. 2) to maintain the out of district placement whilst the plan of work outlined in this review is carried out. 3) Jeanette to attend a course on child care. 4) Social worker and carers to decide when a home visit is right for Jeanette to see her family. 5) Jeanette to receive self protection work. 3.67 On 12th August CSC(8) visited Jeanette and recorded that: “Jeanette is making good progress in new placement, does not wish to return to Halifax, talks of having no childhood or family life”. 27 This information was not known by professionals at the time. Page 23 of 111 3.68 The foster carers told me that they noticed that Jeanette didn’t know any TV programmes and took a while to relax. They described her as having a “disrupted socialisation” – by which they meant she hadn’t been “taught” to act “normally”. They had to encourage her to just sit and relax; they told her that she didn’t need to come down in the evening in full make up, that it was OK to sit in a dressing gown and watch television. 3.69 They told me about the importance of believing her story and listening properly to what she was saying without pushing her to talk. They asked open questions when she brought up the subject about what had happened to her. At one time Jeanette read an article in a newspaper about child sexual exploitation and said that this had been what had happened to her. They encouraged her to believe that she had done nothing wrong and, in time, they noticed she placed the responsibility for the abuse with her abusers and not herself. 3.70 They noted that for many months Jeanette asked permission for things like having a biscuit or using the toilet. She explained that this was how she was expected to behave whilst at home. She said that if she just took something her father would hit her. 3.71 They encouraged her to believe in herself, and encouraged her to go to college - pointing out that she knew a lot about Health and Social Care because of the care she had given to her mother when her mother was ill. 3.72 The foster carers had two daughters, one a similar age to Jeanette and one younger, and they thought that this helped Jeanette because she could see how they dressed and behaved. 3.73 The foster father talked about the importance of keeping himself safe by staying downstairs if only he and Jeanette were in the house, not hugging her, being careful about telling her how good she looked because this would have been what her abusers would have told her. He movingly described to me the first hug that Jeanette had given him when she was 18 saying: “I’m an adult now, so I can”. 3.74 They described how the men who she had been mixing with retained a great emotional hold over her for a long while because they had been meeting a need that Jeanette had for company, love and approval. 3.75 On 5th September 2011 CSC(8) was allocated to Jeanette. 3.76 On 17th November 2011 Jeanette told her foster carer that she had once been raped by 19 men in one night. The foster carers passed this information onto CSC(8). This disclosure was the beginning of the process whereby Jeanette, with help from her social worker and foster carers, understood that she was not responsible for the abuse that she had suffered. This resulted in her making a full disclosure to the police regarding the sexual abuse she had suffered. She told her foster carers that she had thought about her niece and wanted to protect her and other children in Calderdale. She said that she wanted to talk to Robert and he conducted most of the initial interviews which took place between 1st February 2012 and 22nd March 2012. 3.77 Jeanette was surprised at her first Christmas with the foster carers because of the amount of presents that they and their family had bought for her. She said her previous Christmas had been celebrated by a McDonalds meal and a bottle of vodka. Jeanette drank a glass of wine with her meal and said it was the first time she had drunk alcohol out of a glass. Page 24 of 111 3.78 In February 2012 Jeanette was video interviewed for the first time. Her willingness to talk to the police and the evidence she provided resulted in eleven interviews being conducted. The extent of the enquiry was reported to West Yorkshire Police Gold Group and the case was subsequently transferred to the Homicide and Major Enquiry Team in August 2012. 3.79 She provided the police with further interviews between 6th November 2012 and 16th September 2014. In total 53 interviews were conducted, amounting to 44 hours of video evidence. This resulted in: 5,900 lines of enquiry being pursued 733 interviews (both complainants and suspects) 1,754 statements being taken 2,812 exhibits being seized 90 premises and 21 vehicles searched 413 Phones and SIM cards taken and examined 156 Computers and peripherals taken and examined 3.80 As a result of the disclosures made to the police by Jeanette, 54 suspects were eventually identified, arrested and interviewed between May and September 2013. Their home addresses were searched and, where appropriate, forensic examinations were undertaken. Crime scenes were identified in some hotels which underwent forensic examination. Identification procedures took place resulting in 20 positive identifications. 3.81 Of the 54 men identified and questioned, 25 were charged. All but one of the men were British Asians, the other was White British. 3.82 On 18th June 2012 CSC(9) was allocated to Jeanette’s case. At the time of writing this report (October 2016) she is still Jeanette’s social worker and has been instrumental in helping Jeanette put her life back together. 3.83 Jeanette’s foster carers remained in contact with her for some considerable time after she was placed in their care. Page 25 of 111 4. ANALYSIS Introduction 4.1 Jeanette’s story describes an inadequate system. This inadequacy had already been identified by Ofsted. The three main agencies, police, health and children’s social care initially failed to protect Jeanette, despite attempts made by individual professionals, until she realised she had been abused and actively sought out help. This happened after she’d been living in foster care. The terms of reference produced at the beginning of this process in January 2015 contained a number of questions based upon practice in Calderdale before 2012. The agency report authors have addressed those questions and I cover their answers in the analysis of events below. There have been many changes within the agencies that protect children in Calderdale since the summary of events described in this report; listed under the sub-heading “What Happens Now”. 4.2 There was considerable contact between Jeanette and health professionals (both primary and specialist), and the review identified that communication between these professionals, particularly between the GP and the local Accident and Emergency Department could have been better. There were missed opportunities for these professionals to find out more from Jeanette about what was happening to her. There were aspects of Jeanette's experience that she found too difficult to discuss with me and which she did not want to appear in a public report. The Review Panel concurred with Jeanette's wish on the basis that the publication of the report should do no harm. The review has observed that the provision of health services to Jeanette was reactive and not based upon the risks inherent in a young person who was being sexually exploited. Opportunities to enquire about these risks were missed, which left Jeanette vulnerable in terms of her sexual health. As part of this exercise health colleagues conducted an internal review which identified some relevant learning which has already been implemented locally. As a result of this review health agencies can now be assured that the following are in place, which should reassure the local safeguarding children board that children and young people who are at risk of child sexual exploitation can be identified and appropriate actions taken: All children and young people who attend A&E, where there are causes for concern regarding behaviours including alcohol/substance misuse or sexualised behaviours, have a report shared with the acute hospital safeguarding team highlighting the concerns which are then reviewed and information shared to health agencies or children’s social care and appropriate referrals made. Information with regard to spotting the signs of child sexual exploitation have been shared with all health agencies and is available on the clinical commissioning group’s website and Intranet site which is accessed by GPs. Mandatory safeguarding training within all health agencies now includes ‘spotting the signs of child sexual exploitation’. Health services contribute to the weekly child sexual exploitation hub and share. information/actions with health partners including contraception and sexual health services. Safeguarding supervision is mandatory for all front line health practitioners, including A&E staff. Contraception and sexual health services have reviewed the proforma for use with children under 18 years of age, and now include questions relating to behaviours which could identify them to be at risk of child sexual exploitation. Page 26 of 111 The GP in this case did not review A&E attendances by children and young people. The GPs now review all A&E attendances by children – this was implemented immediately it was highlighted during the writing of the IMR by the Named GP in Calderdale. 4.3 Jeanette’s school found the situation difficult to deal with. When she was at school she rarely behaved badly – a fact acknowledged by all the professionals who worked with her. School professionals called and attended many meetings, and made referrals to children’s social care. They were dissatisfied with the responses and made this clear at some of the professionals’ meetings, yet they never escalated their concerns to social care or police managers. Analysis of events 4.4 The summary of events makes depressing reading and it is clear that children’s social care and the police failed to co-ordinate the professionals involved. The police’s missing person’s co-ordinator Robert’s own supervision, in this case, failed to support him in his attempts to help Jeanette. Calderdale’s children’s social care department had been inspected in December 2012 and June 2013 by Ofsted and was both times found to be “inadequate”. In January 2015 Ofsted declared Calderdale to be “much improved”, especially with regard to child sexual exploitation. 4.5 My analysis of the summary of events falls into three phases: 1. Jeanette’s pre-teenage years (1995-2009), 2. The period of time when Jeanette’s sexual exploitation was at its worst (2009-2011), 3. Jeanette working with professionals to build a prosecution case (2011-2016) Page 27 of 111 Jeanette’s pre-teenage years (1995-2009) 4.6 Social workers first became involved in Jeanette’s life in February 2009, when she was 13 years old. CSC(1) completed a s7 report for court recommending that Jeanette’s father be given parental responsibility (presumably he was not married to Jeanette’s mother). Between April – June 2009 police and social care received two referrals: one from Jeanette’s school to the police (April) to say that Jeanette had brought cannabis, grown by her father, into school and was distributing it to other pupils; and one from a youth worker to children’s social care (June) who believed that Jeanette was being exploited sexually, her father was violent towards her and never cooked for her. The police investigated the first referral as a criminal offence but could find no evidence to support further action, whereas children’s social care did not take any action on their referral because they believed it offered no new information. 4.7 These two incidents contained clear evidence of a child (Jeanette was then aged 13) being at risk of significant harm, even without the allegation of child sexual exploitation, and it is difficult to understand how the referral from the youth worker could be dismissed as “no new information” by children’s social care. Neither social care nor the police knew about both events. The only agency who did was the school, but because neither the police nor social care took the referrals any further there was no assessment which meant that the information was not shared appropriately. The period of Jeanette’s sexual exploitation (2009-2011) 4.8 There were many professionals trying to help Jeanette during this time including the police officer Robert, school professionals, children’s social care workers and YOT members. This period of time is characterised by their own lack of co-ordination, and Jeanette being unable to recognise that she was being abused - which meant that she didn’t provide information to help children’s social care and the police to identify the men who were abusing her. Lack of co-ordination 4.9 Ten children’s social care workers were allocated to Jeanette between 2009 and 2011 but, aside from CSC(8) who took Jeanette into care, their intervention was ineffective. They were not helped by the constant reorganisation of the department, and their work is characterised by: lack of action, reluctance to take decisions, lack of clarity about the status of Jeanette’s case and repeated reference to “checking with their manager”. 4.10 On 10th February 2011 a teacher from Jeanette’s school telephoned the police to make a referral. She was told that children’s social care had completed a child protection investigation and there was to be no further action. Neither children’s social care nor the police have any record of a child protection investigation. Professionals from the school should not have been satisfied by the word of a third party about another organisation – they should have followed up their concern with children’s social care. The point about escalation could therefore also be made about the staff in Jeanette’s school. They remained concerned for a number of years, and they were demanding children’s social care workers at meetings, for example stating at the meeting held on 7th March 2011 that a part-time worker wasn’t good enough (paragraph 3.34), yet they too failed to follow escalation procedures and discuss the situation with senior managers in children’s social care. Page 28 of 111 4.11 The email from the police to children’s social care of 14th April 2011 (paragraph 3.44) reveals the concern that the police had that Jeanette’s case wasn’t being taken seriously enough. They asked the children’s social care worker to bring “all professionals around Jeanette together in a child protection conference”. There is no record to confirm that the sender of the email received a reply. It is curious that the police did not follow this up and “escalate” their concerns to higher management in both the police service and children’s social care. Police lack of support for Robert 4.12 I met with Robert and he told me of the problems that he had faced when working with Jeanette. He explained that some of his seniors saw Jeanette as a “missing person” without realising that this was a sign of possible sexual exploitation which resulted in the risks being minimised. There were even times when Jeanette was recorded as an “unauthorised absence” – a less significant category. 4.13 As a missing person co-ordinator it was not unusual for Robert to be left to deal with very high risk situations around missing people, (both children and adults). This meant that he would often be required to deal with Jeanette’s ongoing chronic risk whilst dealing with emergencies. Robert said that there was a lack of interest from senior officers because Jeanette was not saying that she welcomed help from the police. Jeanette’s inability to recognise the abuse 4.14 Jeanette was co-operative, up to a point, with professionals. She kept appointments but denied she was at risk even though she talked openly about being with men who were older than her. The fact that she didn’t recognise she was being abused undoubtedly made the professionals’ task of protecting her difficult. Therapeutic intervention (of whatever type) is largely predicated upon the willingness of the service user to admit to having a problem. Child protection practice overrides this in cases of younger children but struggles with older, more capable young people – simply because young people can’t be forced into accepting help that they don’t want – even when they need it. Jeanette was open about some of the things that were happening to her and the signs of child sexual exploitation were clear and were being picked up by the professionals around her. Her unwillingness to accept that she was being abused is not unusual in these situations, indeed it is to be expected. Protective action in Calderdale (as will be explained later) no longer relies upon an admission from the child. Jeanette’s vulnerability 4.15 The summary of events describes a child who had lived a difficult life before she came to the attention of the men who would go onto abuse her. A life characterised by: caring for her mother from a young age, her description of neglect and physical abuse from her father, the loss of her mother when she was thirteen, living without parental supervision. 4.16 It isn’t surprising that Jeanette chose to leave what appears to have been a cold and neglectful household and seek company and adventure in the park - mixing first with older girls and then enjoying the attention she was getting. Page 29 of 111 4.17 In that latter regard she is unlikely to be different from many young teenage girls. All young people take time to understand their sexuality. Risk taking (sometimes involving alcohol and illegal drugs) is often a part of the journey into a mature outlook on life, relationships and sex. Most young teenagers share these experiences with people of their own age. It is unlikely that every experience they have will be positive but, for many, the positive outweigh the negative and the negative experiences do not cause dysfunction and trauma. 4.18 Jeanette’s life was not like this. She didn’t spend her formative years in the company of boys and girls of a similar age but older men who were using their significant difference in age to take advantage of her naïvety. They flattered her, offered her rides in cars, treated her - she thought - like a grown up by inviting her into their world and allowing her to smoke, drink and take drugs – an adventure with lots of associated risks. 4.19 As the abuse increased the less Jeanette was able to take part in her other life: her schoolwork suffered, her friendships ended, her estrangement from her family grew. She got sucked in to the point that the only thing that would stop the abuse was to move her a long way away, to remove all contact with her abusers, to let her spend time in a non-judgmental, secure, nurturing environment where she was loved for who she was, given time to reflect upon her experiences and move the blame away from herself onto the men who abused her. Her foster carers allowed her to live a normal life – for the first time for many years: watch TV in a dressing gown without make-up on, go shopping, go to the gym and attend college. 4.20 Many members of the public, and according to other reports some professionals, ask why young people allow this to happen to them - describe them disparagingly, place the responsibility for the abuse on their shoulders. But Jeanette’s story is salutary. A young teenage girl like many others- unsure of who she is, confused by the feelings inside of her - is easy prey to men who are able to use their maturity and relative wealth to prey on her vulnerability. Consent 4.21 This report is being written because of the abuse that Jeanette suffered. However, one of the aims of serious case reviews is to learn broader lessons. Some of the men prosecuted for Jeanette’s abuse admitted they had sex with her but suggested in their defence that she “consented” to the sex and, they thought, was over the age of 16. They may, or may not, really believe this but it does highlight broader issues about the nature of “consent”. Irrespective of age, a person cannot be said to have consented to sex if their decision-making is adversely affected by drink or drugs28. 4.22 Did Jeanette consent? She herself, in a police interview, said she “didn’t say no” which, at the time of the interview (2012) implied that she was still confused about consent and she believed she had some of the responsibility. But it’s not an informed consent, it is compromised decision-making because she’s not being given a proper and a fair choice. Sex happens when she is so intoxicated and drugged that saying “no” is not an option. 4.23 Despite the importance of considering the complex nature of consent, there were times when there was no ambiguity. For example, Jeanette described the following in this report (paragraph 3.63): “the first man became violent, pinning me to the wall. He said if I didn’t have sex with the second man I’d have to walk home from Bradford”. 28 R v Bree [2007] EWCA 256 Page 30 of 111 Jeanette working with professionals to build a prosecution case (2011-2016) 4.24 Jeanette’s move to her second set of foster carers in July 2011 was a life-changing event. Their care for her and the fact that she was now far away from her abusers meant that she had the space to reflect upon her life. She decided in December 2011 that she wanted to talk to Robert about the abuse that she had suffered and, in contrast to the second phase of the summary of events, the work of the police and CSC(9) was excellent - resulting in a huge collection of evidence whilst ensuring that Jeanette’s welfare was looked after. This third phase was the opposite of the second phase: work was co-ordinated, people understood their roles and Jeanette accepted that she was abused and responded positively to the guidance that she was offered. Conclusion to this analysis of events 4.25 The summary of events in this report demonstrates that individual professionals were aware of the danger that Jeanette was in and were trying to take appropriate action. These included: staff at the school who were making referrals to children’s social care and attending professionals’ meetings, Robert, the police missing person co-ordinator, YOT worker(2) who collected evidence against Jeanette’s abusers, Jeanette’s present social worker and CSC(8) Jeanette’s previous foster carers. 4.26 Nevertheless, during 2009-2011 these committed individual professionals (and others) were unable to protect Jeanette because professionals in Calderdale did not, at that time, have an effective system for assessing and planning intervention for children at risk from sexual exploitation. 4.27 In practice, professionals had no system to support them beyond making referrals to children’s social care - culminating in a series of meetings which did little more than allow professionals to express their concerns. The continual change of children’s social care worker (ten in all) meant that no plan, even if formulated, could be implemented properly. 5. WHAT HAPPENS NOW IN CALDERDALE 5.1 The summary of events described: the failure to allocate a consistent children’s social care worker, lack of suitable forums to discuss children at risk, lack of action to “disrupt” the abusers a police service that did not adequately support Robert in his dealing with Jeanette during her sexual exploitation. 5.2 I am an experienced author of serious case reviews and have often heard the phrase: “but it’s different now” when I ask professionals about poor practice in the past. Sometimes they are correct, sometimes things aren’t very different. Hearing and reading about the experiences of Jeanette, meeting her and listening to her speak on her video interviews has been a harrowing experience, but it has been mitigated by me meeting many of the professionals who were involved with her between 2010 and 2012 who describe very different working practices. In addition, I have: interviewed staff and managers, viewed minutes of meetings, read strategic plans, seen new training materials, Page 31 of 111 obtained statistics, and I am confident that practices, systems and processes have improved both the services to children in need and children at risk from significant harm and sexual exploitation in Calderdale. These changes have come about because of Jeanette’s case. Professionals and managers in Calderdale realised long before this report was written that they had failed Jeanette and it is largely because of her situation that the changes described in this section have been implemented. That practices have improved has been confirmed by Ofsted, who noted that by January 2015 Calderdale children’s social care was “Much Improved”: “CSE is given a high priority in Calderdale. Well-developed structures, systems and procedures, underpinned by a clear strategy and coherent action plan, are evidence of a collective determination to tackle child sexual exploitation.” Ofsted inspection of Calderdale 2015 (page 44). 5.3 These changes and many more are now co-ordinated through the “Child Sexual Exploitation Action Plan” which is led by the safeguarding children board. This plan includes objectives designed to: 1. Identify locations and individuals or groups who sexually exploit. 2. Inform, engage, empower and protect children, young people, families and communities from being at risk or experiencing sexual exploitation by understanding the nature and impact of sexual exploitation. 3. Prevent children and young people experiencing or continuing to experience sexual exploitation. 4. Provide appropriate support, protection, intervention, information and services to children, young people, parents, carers, friends and communities. 5. Divert, disrupt and actively pursue those individuals and groups intent on exploiting children and young people. 6. Successfully prosecute those who perpetrate or facilitate the exploitation of children & young people. 5.4 The child sexual exploitation action plan describes strategic changes but there have also been specific process changes which ensure the objectives above are achieved. These include, but are not limited to: Systems a multi-agency screening team (MAST). a joint police and social worker child sexual exploitation team, which includes a virtual team of partner agencies that meet on a weekly formal case monitoring basis. new panels to discuss children in need (Early Intervention Panel, Vulnerable Young Person Panel). Practice a practice standards document. better definition of thresholds. new “missing” procedures. social worker re-allocation measurements. Revised CSE risk assessment that is completed by any agency involved with the child. Page 32 of 111 Multi-agency screening team (MAST) 5.5 A MAST has been implemented in Calderdale, which acts as a ‘first port of call’ advice service for professionals and members of the public who are concerned about children and young people. This team is multi-agency and shares all relevant information on a child and their family. The multi-agency nature of the team improves decision making. Thresholds 5.6 A Calderdale continuum of need and response document, (copy included as appendix 2) has been implemented across all agencies. It provides clearly defined thresholds to ensure appropriate support services are identified via the Early Intervention panels when the social care threshold for intervention is not met. This better ensures that children and families get the right help at the right time. Joint forums exist with police, schools and health to ensure this document is purposeful, updated and is being adhered to in assisting all professionals who work with children and young people to jointly identify risk. Multi-agency child sexual exploitation team/hub 5.7 This team is made up of two social workers and three police officers, all highly experienced in working with perpetrators and victims of child sexual exploitation. They are managed by a police sergeant and a social work team manager. The team meets three times per week with representatives from Youth Offending, Health, Family Intervention Teams and Safe Hands29 to discuss new referrals and new information relating to children known to be at risk. An urgent meeting will be convened between police and social care if required on the other two days if new information cannot wait until the next scheduled meeting. 5.8 Children who have been sexually exploited or are thought to be at risk of sexual exploitation have their names added to a child sexual exploitation “matrix”30 and are classified as red (high), amber (medium) or green (low) depending on how at risk they are considered to be. All children on the matrix are discussed weekly, new information is shared and actions are planned and reviewed. The names are added to the Police National Computer and they are also considered for a referral to the Calderdale Safeguarding Slavery Lead for the National Referral Mechanism31. Children on the matrix are allocated to a lead worker who keeps contact with them even if there isn’t an incident and whether the young person wants it or not. A child’s name is not removed from the matrix until there is clear evidence the child is no longer at risk due to successful interventions, a change in circumstances or when there has been no intelligence of concern received for a period of time. This process is not dependent on disclosures from young people. Some children are discussed but thought not to be at risk of child sexual exploitation - in these circumstances their names are not added to the matrix but a member of the team ensures that other professionals are able to take responsibility for their ongoing needs and welfare. The child sexual exploitation weekly hub consists of the child sexual exploitation team, health, CAMHS32, education, youth services, drug services and other partner agencies. 5.9 In addition to individual casework, professionals in the child sexual exploitation team: determine whether criminal offences have been committed, 29 A specialist resource commissioned by Calderdale Council and managed by the Children’s Society working with children who have been sexually exploited or are at risk of exploitation. 30 A system that grades their risk as green (low), amber or red (high). 31 A framework for identifying victims of human trafficking. 32 Children and mental health services Page 33 of 111 secure evidence from victims and suspects, provide guidance to other professionals, provide awareness raising and preventative education for children who are at risk of being sexually exploited, and take action against people intent on abusing and exploiting children. 5.10 Key operational members of this hub and other partner agencies are also part of an operational group which meets monthly to feed back to senior managers the “on the ground” issues that their staff are facing, and contribute detail to the child sexual exploitation action plan. New panels 5.11 Jeanette should have been defined as a child in need from a very early age. Later in life, but before she was sexually exploited, she was at risk of significant harm. Two panels have since been created in Calderdale, (“Early Intervention” and “Vulnerable Young People”) to ensure that cases like Jeanette’s can be properly assessed and discussed in a multi-agency forum. These panels are assisted by an early intervention single assessment system (known in other parts of the country as a common assessment), (copy included as appendix 3). 5.12 The early intervention panel meets fortnightly whilst the vulnerable young people’s panel meets weekly to support professionals who are concerned about children and young people. Discussion at panel enables professionals to provide a tailored and multi-professional service for children and young people. 5.13 A teacher from Jeanette’s school said she remembered going home “crying with frustration”, but confirmed to me that practice is much improved now as the panels, MAST and child sexual exploitation team achieve: better co-ordination, clarity of roles, allocation of lead professionals, and monitoring and review. The frustration that she felt was exacerbated by there being no procedures in place at the time for her to “escalate” her concerns to senior managers. Practice Standards Document 5.14 A practice standards document for children’s social care has been implemented and is being continually improved and updated. Currently on version 7 (December 2015), it is a quality control system covering all aspects of practice for social workers working with children and families: from referral to leaving care, (copy included as appendix 4). Page 34 of 111 Missing Procedures 5.15 The narrative of events in this report often featured times when Jeanette was noted by the police to be “missing”. At the time (2009-2011) “missing” teenagers were not always considered to be a high risk or a priority. This has now changed, and a new and revised missing procedures policy has been introduced which now defines a missing person as anyone whose whereabouts cannot be established and: 1. the circumstances are out of character, or 2. the context suggests the person may be: a. subject of crime; or b. at risk of harm to themselves or another, or 3. they are not at a place where they are expected or required to be but are not expected to suffer or cause harm. If a child is missing for: three working days; or four separate occasions in any one month; or six separate occasions in any two-month period and is a case open to children’s social care then a strategy meeting33 is held to consider: what additional measures are required to protect the child; whether there have been further missing episodes; whether to circulate the child’s details to other local authorities and agencies in the area where the child may be; notifying national agencies; appropriate legal action if there is any concern that the child may be removed from the jurisdiction. 5.16 If the case is not open to children’s social care, and the criteria of four or six episodes is met, then the team who undertake the return interviews assess whether a referral should be made to children’s social care and whether or not to hold a professionals meeting. 5.17 All young people who have been missing are risk assessed for child sexual exploitation, and if there is any concern about any aspects of the young person’s situation the police make a referral to MAST or the Emergency Duty Team EDT if out of hours, including children missing for up to three working days, if they are not an open case. If they are an open case, then this information is provided to the child sexual exploitation team who assess the concern further. These changes mean that police officers now respond much quicker to young people who are missing and have a heightened sense of risk than they did in Jeanette’s case. Social worker turnover 5.18 Jeanette has had her current social worker since 2012 but had many children’s social care workers, nine in all, between 2009-2012 during a period of high instability in the council. The children’s social care workforce in Calderdale is much more stable, with only 2% of posts filled currently by agency staff. Turnover of social work staff in 2015 was 18%. Workforce statistics (for all children’s agencies) are produced and monitored at monthly senior leadership performance meetings and by the LSCB. 33 A multi-agency meeting which plans a child protection investigation Page 35 of 111 Co-ordination across geographic boundaries and within Calderdale itself 5.19 This section of the report contains many initiatives which, taken separately, are improving the protection of children throughout Calderdale. However, the systems are also well co-ordinated. There are clear protocols for moving children’s cases from one panel to another and for ensuring that children have a lead worker who co-ordinates the services provided to them. 5.20 Abusers of children are not respecters of geographical boundaries. To combat this, Calderdale uses the same risk assessment forms (copy included as appendix 5) and shares information with Leeds, Kirklees, Bradford and Wakefield in a five authority approach -which means information about children and abusers is being shared throughout the West Yorkshire police area. Information is also shared across all other local authorities where relevant, and in all cases where children looked after are placed in other local authorities as this is a statutory requirement. Jeanette’s effect on these changes 5.21 It is worth noting that the improvements that have been brought about in Calderdale in the last four years are largely as a result of Jeanette’s case. These improvements have come through her willingness to provide the police, and through them other agencies, information pertaining to how vulnerable she was and how determined her abusers were. 6. THE RELEVANCE OF CULTURAL ISSUES IN RELATION TO THE PERPETRATORS Introduction 6.1 There was unanimous agreement amongst the Panel that issues of culture should be included in the review and general agreement about what follows. There were some differences of opinion relating to how far the analysis should move away from the case itself. Much of what follows is specific to Jeanette’s situation but I accept the valid criticism that, in places, my writing is general and speculative. However, my discussion with the focus groups and academics has suggested areas for further research and I include these because they are relevant to general learning and will aid conclusions and learning in this report. 6.2 Cultural and religious issues are usually only addressed in reporting about abuse when the perpetrators or victims come from a minority group. Media coverage of the serial offender Jimmy Savile never refers to him as “the Catholic Jimmy Savile” nor does the media feel the need to point out that Rolf Harris, Gary Glitter, Stuart Hall and Max Clifford, currently in prison because of offences committed against children and women, are all from the white majority – with no reference made to their religious persuasion. Child sexual abusers come from all nationalities, cultures and religions. 6.3 Nevertheless, 53 of the 54 men charged with offences in relation to these crimes were British Asian men of Pakistani heritage, all of whom had spent their lives living in England and this mirrors reports into child sexual exploitation in Rotherham, Rochdale, Bristol and Oxford. The similarities between the offences and the offenders described in those reports and this suggest that a consideration of culture, whilst having the danger of stereotyping, is necessary to aid further research in this area and assist in learning. This section of the report will consider whether and how cultural issues have impacted on this case and will describe the measures that the Pakistani community in Halifax have taken to protect children in their area. Page 36 of 111 6.4 To tackle the complex issue of culture I will: describe what we know about the alleged perpetrators because this will indicate that the issues to be addressed are not just about race and culture examine definitions because those used for sexual abuse and sexual exploitation are conflated meaning that statistics are not able to differentiate between different types of abuse consider the cultural implications relating to this case because the vast majority of the people prosecuted for these offences were British Asian men of a Pakistani heritage consider the issue of post code because it could be that most of the perpetrators were British Asians of a Pakistani heritage because they lived in the same area as Jeanette write about the Pakistani community in Halifax because professionals need to have some understanding of the heritage of the groups with whom they work – White or Asian. describe social capital, bonding and bridging to consider whether Pakistani communities may be more insular than other black and ethnic minority groups consider how sex and relationships are discussed consider the role played by illegal drug dealing describe what’s happening now because this may be relevant to recommendations arising from this review because many of those prosecuted were involved in this criminal activity because children are likely to be better protected by members of the public in Halifax in the future The perpetrators 6.5 In June 2013 (during the arrest phase for this case) the 25 (then) alleged perpetrators who were charged by the police and who appeared in courts in February 2015 were aged from 22 to 41 years old - ten were over the age of 30, the average age was 27. It is difficult to establish whether they knew each other because, during their police interviews, they claimed to not know each other. Although the men were not a “gang34” there were a number of distinct groups within those charged: five groups have been identified comprising of four, three, three, four and two men. Whether these groups were known to each other is still open to question - there are no obvious links between the other nine men. Nine have previous convictions for supplying controlled drugs. 6.6 Of the 25 charged six admitted to having sex but claimed they thought Jeanette was older than 16 and was consenting whilst the other 19 denied any sexual contact. Seven of the defendants lived in the Bradford area, one lived in Huddersfield and 17 lived in Halifax. 34 An organised group in a hierarchy usually associated with illegal activities Page 37 of 111 6.7 Although some of those charged were unemployed, the police recorded the following occupations for the defendants: garage mechanic taxi driver staff in take away restaurants sales assistant textile worker painter/decorator doorman warehouse operative driving instructor. The problem of definition 6.8 In considering whether there is a cultural dimension to child sexual exploitation it is necessary to turn first to definitions and consider the type of exploitation that this report is describing. Child sexual exploitation was defined as follows: ”Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. … In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources…” HM Government 200935 (page 9). 6.9 Recent reviews into child sexual exploitation involving British men of Pakistani heritage have described similar situations to this report, and a more relevant definition of this type of abuse is offered by CEOP36 who in 2011 provided the following: ‘Localised grooming’ is a form of sexual exploitation – previously referred to as ‘on street grooming’ in the media - where children have been groomed and sexually exploited by an offender, having initially met in a location outside their home. This location is usually in public, such as a park, cinema, on the street or at a friend’s house. Offenders often act together, establishing a relationship with a child or children before sexually exploiting them. Some victims of ‘street grooming’ may believe that the offender is in fact an older ‘boyfriend’; these victims introduce their peers to the offender group who might then go on to be sexually exploited as well. Abuse may occur at a number of locations within a region and on several occasions. ‘Localised grooming’ was the term used by CEOP in the intelligence requests issued to police forces and other service agencies in order to define the data we wished to receive.37” 6.10 There appears to have been many occasions where Jeanette’s details were passed on from one man to another. The pattern of abuse that she suffered, and the abuse described in other reports, fits the description of “localised grooming”. It may therefore be a better definition for researchers to use when considering whether there is a cultural element to this particular type of abuse. 35 HM Government (2009) Safeguarding children and young people from sexual exploitation HMSO 36 Child exploitation & online protection centre 37 Out of mind, out of sight Page 38 of 111 What are the cultural issues relevant to this case? 6.11 Coming to a firm conclusion about issues of race and culture is impossible, given the lack of existing data, the difficulty in agreeing definitions of child sexual exploitation and the poor recording by professionals of the cultural background of perpetrators. 6.12 Many reports into the prevalence of abuse fail to measure the ethnicity of perpetrators. An exception to this is the recent report38 by the Children’s Commissioner for England (OCCE) which gathered data from some police forces about the cultural background of perpetrators (between April 2013 – March 2014) of all forms of child sexual exploitation, (sole operators, gang and group based). The data was incomplete because 35% of forces did not contribute to the inquiry. The 25 police forces who did take part reported 3,968 perpetrators: 60% were White or White British, 10% were Asian or Asian British, 8% were Black or Black British, 2% were of another category and 20% were of unrecorded ethnicity. 6.13 If these figures are compared to the 2011 census it appears that White British were proportionately underrepresented because they make up approximately 85% of the male population, whilst British Asian and Black British men were over-represented (8% and 3.5% of the population respectively). 6.14 The differences were more pronounced when sole operators were removed from the figures. This left 1,231 perpetrators of group and gang-based child sexual exploitation reported by 19 police forces. Of these: 42% were White British, 14% Asian British and 17% were Black British, 23% were of unrecorded ethnicity and 4% were from different categories. 6.15 The following table shows the figures more clearly. Nationality England population All categories of child sexual exploitation Gang and group based child sexual exploitation White British 85% 60% 42% British Asian 8% 10% 14% Black British 3.5% 8% 17% Other 3.5% 2% 4% Unrecorded 0% 20% 23% Page 39 of 111 6.16 There are at least three problems associated with this simple comparison: 1. that of definition of child sexual exploitation which has already been described. 2. the sample: if the police forces who did return figures were those predominately in multi-cultural areas the comparison with the English population as a whole is inaccurate. 3. professionals often reported perpetrator groups as ‘Asian’ without a more detailed analysis, which, when explored further turned out to include Afghan, Kurdish and White British perpetrators. An earlier OCCE report39 was “in no doubt that data is gathered more assiduously on perpetrators identified by professionals as `Asian’, `Pakistani’ or `Kurdish’”. 6.17 This means that the figures are probably skewed by professionals only recording cultural background when the perpetrators are “Asian” or “Black British”, and suggests that a large number of the unrecorded population could well be White British. The relevance of post code 6.18 Many of the professionals involved in the case said they believed the main issue to be that of “post code” and not ethnic and cultural background because Jeanette and most of the men who abused her lived within a small area in Halifax. Although the percentage of British Asians of a Pakistani heritage in Calderdale equates to approx. 10% of the population, the Pakistani population in this area is approaching 90%. 6.19 This post code opinion is somewhat undermined by statistics produced by Calderdale’s child sexual exploitation team. Between September 2015 and February 2016 the cultural identities of men suspected of being involved in child sexual exploitation in Calderdale were as follows: 12 White British 13 British Asian of Pakistani heritage 5 were from different cultural backgrounds 6.20 This means that British Asians of Pakistani heritage are over-represented locally because they make up 43% of this sample but only 10% of Calderdale’s population as a whole. Further figures in February 2016 identified 18 perpetrators being “managed” by the child sexual exploitation team: 15 (83%) are described as “Asian”. The Pakistani community in Halifax 6.21 All seemingly similar groups of people contain individuals who are very different to one another and this community is no exception. I have been told (by the Asian men and women who I met) that the families of many of the people who now make up the community living in this area moved to England in the 1960s, mainly coming from the Mirpuri district of Pakistan. However, the majority of British Pakistanis living in Halifax now were born in Calderdale and have no direct association with Pakistan itself. I was told that many have no interest in visiting Pakistan and most feel well integrated into Halifax and see themselves as British. 39 I thought I was the only one; the only one in the world Page 40 of 111 6.22 The women and men in the focus groups described a way of life typical of any small community. People know each other’s business, they gossip and they look out for one another. The women in particular described how their lives are, to an extent, governed by the men in their families and they recognised that there were good and bad aspects to this - they were protected but also controlled. 6.23 The women in particular made distinctions between generations, believing that the older generation found it harder to believe that there may be a problem regarding the attitudes of young men in their community. They also described how it is harder for someone to talk about these issues if their only language is Mirpuri, as many of the terms needed to discuss sexual abuse are not translatable. They also acknowledged that those who don’t speak English will be less informed because so much information is made available through English media. They believed that white girls were more vulnerable than Asian girls, but didn’t necessarily think that Asian girls were not at risk. They acknowledged that some families were reluctant to call social workers or the police for help as other people in the community would soon find out about their problems. 6.24 Both men and women described the response of the community to the news of the allegations and said it caused shock and, initially, some disbelief. They said that some of those charged were respectable family men and others were already known to be involved in the illegal drug trade. They said that initially some people in the community didn’t want to talk about it, found it hard to believe and were embarrassed, but that others have appropriately used the case as an opportunity to build upon the rising awareness in the community of the dangers of male power. 6.25 There was some discussion about how family life was changing within the community with younger parents now being more reluctant to accept extended family and community advice with regard to their parenting. There were bad and good things about this: the children could become more isolated but paternalistic community control has diminished. There are difficulties for young people and families as teenagers take on more of a White British lifestyle. Although there is more awareness of the dangers of sexual abuse than there was 15 years ago, children may now be more at risk because they are less “monitored” by the family and community. 6.26 The women stated they believed that female voices don’t get heard much within the community. They believed that it was harder for British Asian girls of Pakistani heritage to come forward with disclosures about abuse because of their fear that their family’s standing in the community may be damaged. 6.27 It is tempting, having read the paragraphs above, to presume that all these issues exist because the families are from a Pakistani heritage. However, many of the descriptions could also describe families from any background: male dominance and differences in attitude between generations also exists in the majority white population in the U.K. Social bonding and bridging 6.28 The concept of social capital, bonding and bridging is helpful in considering how communities interact with one another and why they may do so in different ways. Social capital is a concept used to describe the collective benefits that a community derives from co-operation between individuals within that group. Social capital can be divided into two sub-categories, “bonding” and “bridging”. Page 41 of 111 6.29 Bonding capital describes the links between individuals within a particular group, how individuals benefit from the common heritage of that group and the values they share with each other. It is more likely that oppressed and marginalised individuals bond more within their own community. 6.30 Bridging capital describes the connections between groups rather than the individuals within a group. Bridging allows different groups to share and exchange information, ideas and innovation and builds consensus among groups who represent diverse interests. Fukuyama (2002) described the growing contact between groups as a ‘radius of trust’. Unlike “bonding”, which occupies a narrow radius of trust, “’bridging’ creates a wider radius of trust; indeed, it builds bridges between communities”. 6.31 The academics who I interviewed and the members of the focus groups with whom I spoke consider the British Pakistani community to be more “bonded” than “bridged”. Individuals stay more within their community and mix less with outsiders. Whilst the advantage is that individuals within bonded groups feel safer and are better able to protect themselves, the disadvantage is they become more isolated. 6.32 In Britain it appears there is a vicious circle affecting British Asian Pakistani communities and their willingness to “bridge”. The more society worries about, for example, radicalisation and stresses the Asian background of perpetrators of child sexual exploitation, the more the community will “bond” to better protect themselves. Talking about sex and relationships 6.33 Both the Asian men and women groups spoke about how discussions about relationships were not open and did not happen between genders; for example, one young woman said to me: “I wouldn’t watch Eastenders with my brother”. 6.34 Discussion about sex and relationships is important but it can be more difficult for young people to talk openly to their family elders if they believe that they will be judged harshly. Sex before marriage is probably a greater taboo in British Asian families compared to their White British counterparts. If so, discussion about consent will be harder. Understanding consent about sex is not easy for young people, the more the issue can be discussed safely the better. The relevance of the illegal use of substances (drugs and alcohol) 6.35 A view shared by many of the professionals who worked with Jeanette, and many of the men and women in the focus groups, was that the reason that most of the perpetrators were of Pakistani heritage was: (a) drug use was an important part of the method by which the perpetrators broke down Jeanette’s resistance; and (b) most of the drug dealers in the area of Halifax where Jeanette lived were from the Pakistani community. At the time of arrest 36% of the defendants had a history of drug offences (and a further 14% were charged with drugs offences associated with the crimes against Jeanette). 6.36 I have described (indeed generalised) about the culture of British Pakistani families in the section above. It is equally as valuable to describe (and generalise about) the sub-cultural aspects of illegal drug use and consider its relevance to this review. Page 42 of 111 6.37 Possession of illegal drugs offers excitement and risk and is an act which places the user outside the law and the conventions of their own community. The availability of illegal drugs assists in the abuse as both a bribe and an anaesthetic. 6.38 The men in the focus groups described the people involved in crime in the area they lived in as a “community within a community”. If culture and heritage is an issue in localised grooming, then the possibility that it is fuelled by illegal drug use must be taken seriously. Action being taken by the British Pakistani community in Halifax 6.39 So far this section has failed to determine whether British Pakistani men are over represented amongst perpetrators of localised grooming. The lack of national data collection and research into this subject, alongside broad definitions of abuse, along with the fact that not all abuse is recorded means that a definitive answer to this question may never be found. 6.40 The section of this report entitled “What Happens Now?” has already detailed the action that professionals have taken and the rest of this section of the report will detail the action that the British Pakistani community in Halifax have taken to better protect children in Calderdale from child sexual exploitation. 6.41 Although there is no consensus amongst the men and women in the focus groups that British Pakistani men are more likely to abuse children in the way this report describes compared to other men, they do take the protection of all children seriously and have a good understanding of the risks that children take when they are out of their homes late at night. They have told me that there is much greater awareness of the dangers of abuse of male power, and consequently a greater determination to tackle, discuss and report issues of domestic violence. 6.42 A local group “TAG” (Together Against Grooming) has been set up by local Asian people to “work with others to respond to the issue of sexual exploitation of children and vulnerable young people”. http://www.taguk.org/ Their website makes it clear that there is no Islamic or cultural justification for abuse of women or children but they have come together: “in response to a number of recent cases where the perpetrators have mainly been from an Asian/Muslim background”. This group of volunteers has written and presented many training sessions to churches, mosques and neighbourhood groups and all Calderdale’s youth workers to raise awareness of child sexual exploitation. 6.43 Between June – October 2015, more than 1,000 taxi drivers (most of whom are British Pakistani) attended compulsory training run by Calderdale council to raise awareness about child sexual exploitation and to encourage them to report suspicious activity. This has resulted in a number of referrals to police and children’s social care from taxi drivers. 6.44 A group of British Pakistani women have set up a child sexual exploitation group to offer training and information to young people about the dangers of grooming on the internet. Page 43 of 111 6.45 The local Cohesion and Equality Officer, himself a local British Pakistani, has visited all the mosques and madrassas in Calderdale to raise awareness about child sexual exploitation, furnish people with information about the danger signs to look out for, and explain how to make referrals to children’s social care and the police. His experience has been that, though people remain fearful of making referrals to organisations because of possible reprisals from the men who they refer, they are continuing to contact him and give him information about men who they suspect, and he is passing on this information to the relevant authorities. 6.46 The local Neighbourhood and Cohesion manager, along with her assistant co-ordinators have integrated awareness of child sexual exploitation into the work that they do with local women’s groups. They explained that people within the community are much more open about discussing issues of sex and relationships than they were two years ago and that this has resulted in them being better able to protect all children from harm, increased referrals to the police and encouraged women to better support each other. 6.47 The British Asian Pakistani community in Halifax increasingly accept that there are individuals within their community who pose a risk to children. British Asians are leading the way in Calderdale in raising awareness of the danger to children from child sexual exploitation amongst all members of the population. 6.48 This report has drawn from other reports into child sexual exploitation involving British Asian men from a Pakistani background. At the time of writing however there is also a focus in British society upon child sex abuse in the Christian church and amongst celebrities working in the media. We know from the past that children have been abused in boarding schools and children’s homes by the very people paid to look after them. Jeanette’s situation has many similarities with those other examples. A group of men, who have some similarity and allegiance with each other, find themselves (or put themselves) in a situation where they are given (or create) status and are able to create the opportunity to abuse children. They consider themselves to be inviolate of the law, create fear and dependency amongst their victims and use their status to silence those who may be suspicious of their activities. 6.49 Institutions, (by which I mean organisations rather than buildings) where men are able to dominate, place children at risk. The group who abused Jeanette were just such an institution: male dominated, untouchable (so they thought), some of them outside the law because of their drug dealing activities, threatening to the law abiding people around them – they created for themselves all the ingredients we know are needed to abuse children. All they then had to do was find vulnerable children to abuse. It may well be that it is this male dominance that is the real problem – not the racial and cultural background of the men involved. Page 44 of 111 7. CONCLUSION 7.1 This serious case review was commissioned by Calderdale safeguarding children board following the sexual exploitation of a single female child (Jeanette) between 2008-2011 when she was aged between twelve and fifteen by a large number of British Asian men of Pakistani heritage, 15 of whom are now serving custodial sentences (from 10 months – 25 years) for their crimes. 7.2 The review has highlighted that many individual professionals from all agencies who had contact with Jeanette realised that she was being sexually exploited from a very early point in their intervention with her. Unlike some other reviews into these matters, this review has not found any evidence of these workers being confused about issues relating to whether Jeanette was making a “lifestyle” choice, though there is some evidence to suggest that this attitude may have existed (in 2011) in higher levels of the West Yorkshire police force. 7.3 The review has found that, five years ago, those professionals were not supported by their senior managers with systems (i.e. risk assessment forms) and processes (i.e. early intervention panels) that would have helped them to collate information and draw up effective multi-agency interventions. 7.4 The review has found that the way in which children are now protected from child sexual exploitation in Calderdale bears no relation to the approach of 2011. Amongst other initiatives there is now considerable awareness in all agencies about risks, a dedicated multi-agency sexual exploitation team and considerable cross-border approach to the problem. 7.5 The review has not found that professional staff in Calderdale were fearful of discussing issues of race and culture, nor any evidence that anyone higher up in the organisations placed pressure upon professionals to cover up any discussions that could damage community cohesion. The review has found that community work is being carried out by council employees, police officers and local voluntary groups to raise awareness throughout all communities in Calderdale about the vulnerability of children and the grooming techniques of some adults. 7.6 This review has considered the relevance of race and culture and included information shared by two focus groups of Asian men and women. It has identified issues that related directly to this case and others that are broader and require further research. This review has also considered that cultural issues may not have been pre-determined by race but by illegal drug activity, the “community within a community” described earlier – or is indeed an issue of “institutional power” more to do with gender and not race. 7.7 The review found that Jeanette began to turn her life around when she was moved a considerable distance from her abusers in Halifax. Whilst this “out of borough” placement worked for Jeanette it should not be assumed that this review has concluded that this is the right answer for all children who are being sexually exploited. The importance of schooling, family and good friends should not be underestimated when considering the best way of protecting children. 7.8 The issue of consent to having sex in Jeanette’s situation was not complex. She was plied with enough drink and drugs so that she, in her own words, “didn’t say ‘no’”. As this report explains a person so intoxicated cannot give informed consent, whatever Jeanette’s abusers believed. But consent is a complicated issue and young people need assistance in understanding these complexities. Page 45 of 111 7.9 This report has been about one victim and, because of that and Jeanette’s willingness to share her experiences, the report has drawn upon a strong narrative. The point of this is to explain the following issues: Vulnerability Consent Use of drink and drugs Cultural issues The need for a co-ordinated response 7.10 The difficulty for Jeanette of bringing so many men to justice should not be underestimated; her decision to do so resulted in days of interviews with her by police officers and the stress of being cross-examined by many legal representatives. 7.11 Jeanette worked with me and her social worker to produce this report in the hope that other children would be better protected from child sexual exploitation than she was. Reports like this which highlight both poor and good practice are an important part of improving protection for children, and Jeanette can rest assured that her story has been told and will be shared to allow others to better understand this complex problem. Other reports have identified that children feel well supported during the process of prosecution but are left stranded when that support is taken away at the end of the trial. I am pleased to report that Calderdale children’s social care has committed themselves to continuing to give Jeanette the support she needs which includes regular visits from her social worker CSC(9) and counselling sessions as and when required. 8. FINDINGS 8.1 This serious case review does not lend itself to a series of simple recommendations because the events occurred over five years ago, and many improvements in practice, management and policy have already taken place throughout the agencies that make up Calderdale’s safeguarding children board. The review has, however, suggested some themes that require further exploration and these will be listed in this section of the report as “findings”. Some of these will have recommendations attached but others are listed as learning points for further consideration. 8.2 They are as follows: 1. Issues of race and culture a. The role of culture b. The role that substance misuse played c. Ethnic mix of staff in the public sector in Calderdale d. Prevention of child sexual exploitation 2. Young people’s understanding of child sexual exploitation a. How to help children who don’t know they are being exploited and abused b. Continuity of staff 3. Agency responsibility a. Escalation and supervision 4. Learning from the case Page 46 of 111 Issues of race and culture The role of culture 8.3 This review gave considerable thought to the issue of culture in child sexual exploitation cases and identified that, according to many recent reports and prosecutions, there may be a link between the cultural background of some British Asian men of Pakistani heritage and a type of child sexual exploitation known as “localised grooming”. Nevertheless, the review recognised that there were similar power dynamics in this case to other institutional abuse cases where the background of the men was not predominately Asian, and concluded that - though culture may have a part to play - gender is a consistent and predominant factor in almost all cases of child sexual exploitation and child sexual abuse. 8.4 There was debate within the panel relating to whether or not the author should limit his observations to this case or should consider wider cultural issues. Whilst this issue remained unresolved there was unanimous agreement amongst panel members that this review did not have the resources or remit to consider more general questions about the cultural identity of perpetrators of abuse in any depth. The review makes a national recommendation that there be further academic research into the cultural identity of perpetrators of localised grooming, and suggests that gender power, bridging and bonding, criminality, male attitudes towards women and openness about sex and relationships be areas that research should consider. 8.5 The lead reviewer asked the child sexual exploitation team for statistics regarding the cultural background of the perpetrators who they were tracking. British Asian men of Pakistani heritage appeared to make up a disproportionately high number of these men. This report also acknowledged that national statistics regarding the cultural background of perpetrators were often poorly collected. The review recommends that West Yorkshire Police and Calderdale safeguarding children board assures itself that regional statistics relating to perpetrators are accurate. 8.6 Although, as already noted, the cultural background of perpetrators is being collected in Calderdale, the lead reviewer was unsure how the information was being used. The review recommends that Calderdale safeguarding children board asks the child sexual exploitation operational group to produce a plan relating to how they will make use of the statistics collected relating to the cultural background of perpetrators. The role that substance misuse played 8.7 There is a common view amongst some professionals, many of the Asian men and women interviewed in the focus groups and members of the panel, that drugs were an essential aspect to the abuse of Jeanette, both in the way in which they were used along with alcohol to make her compliant and the fact that many of her abusers were involved in a “community within a community” – those using and dealing in illegal drugs. The review recommends that Calderdale’s child sexual exploitation hub collect statistics relating to the known criminality of perpetrators with the intention of further considering the role that illegal drugs play in the sexual exploitation of children. The review recommends that Calderdale safeguarding children board ensures that professionals working with children and young people are able to identify and act upon drug and/or alcohol use, including making referrals to specialist services where appropriate and Page 47 of 111 that drug and alcohol workers are fully trained in understanding issues of child sexual exploitation. The ethnic mix of staff in the public sector in Calderdale 8.8 10% of Calderdale’s population are British Asians, yet the lead reviewer met only one Asian professional throughout the course of the review: the local cohesion and equality officer. Although Children’s Social Care services employ staff who fully reflect the ethnicity of the local population this may not be true of all agencies. Understanding the community with whom agencies work is much easier if the workforce reflects that population. The review recommends that Calderdale safeguarding children board continues to support the work of community liaison officers and conducts a survey of its members to determine the ethnic mix of staff. Prevention of child sexual exploitation 8.9 The review has highlighted that the local community and the council’s community workers are developing a range of initiatives relating to raising awareness in the public throughout Calderdale about child sexual exploitation, all of which are co-ordinated and supported by the local community centre. In times of austerity it can be easy to cut these services, often viewed as peripheral to the main “business”. It is the lead reviewer’s opinion that primary prevention is being cost-effectively implemented by these community services in Calderdale. Young people’s understanding of child sexual exploitation How to help children who don’t know they’re being exploited and abused 8.10 This report has documented how hard it was for professionals to help Jeanette when she didn’t realise (or admit to the fact) that she was being abused. The report has highlighted the importance of professionals not giving up on young people, not being frightened to continue to voice their concerns to the young people themselves and to develop a “thick skin” when they are told that their advice is unwelcome. It is also a systemic issue insofar as individual professionals need to be allowed to keep open cases of child sexual exploitation where progress may seem non-existent. The report also describes how long it can take for a young person to realise they are being abused – and acknowledges that this can often be after the child has turned 18 years of age. The review recommends that Calderdale safeguarding children board assures itself that perseverance is still a key component of any training on child sexual exploitation and agencies ensure that cases of child sexual exploitation remain allocated even when progress may not appear to be evident. The review also recommends that Calderdale safeguarding children board liaises with the adult safeguarding board to: ensure all professionals who work with young adults are aware of the issues relating to child sexual exploitation; and to ensure professionals are well placed to help relevant young adults come to realise that they have been abused and are not responsible for this abuse. Continuity of staff Page 48 of 111 8.11 The panel noted how important it was for Jeanette that she had at least one professional in her life who maintained contact with her. For the summary of events described in this report that professional was Robert, since the prosecution case began that person has been CSC(9). Agency responsibilities Escalation and supervision 8.12 Although the report generally praises the perseverance of Robert and staff at Jeanette’s school, the panel were disappointed at the failure of those professionals and their managers to use “escalation” procedures – a process whereby professionals can complain to their own senior managers, and those of other agencies, about action or inaction that they perceive to be detrimental to the welfare of a child. The review recommends that Calderdale safeguarding children board is assured that its own escalation procedures are fit for purpose and that all professionals are aware of their existence and are confident in using them. Learning from the case 8.13 Most reports into child sexual exploitation analyse the situations of multiple victims. This review is unique inasmuch as only one victim has been written about. Jeanette wishes the review to be used to protect better other children from the abuse she suffered. The review recommends that Calderdale safeguarding children board, (with Jeanette’s continued permission) commission a version of this report to be used with young teenagers to make them more aware of the dangers of child sexual exploitation. Page 49 of 111 Bibliography ACPO and CPS publications (2014) Liaison and information exchange when criminal proceedings coincide with Chapter Four serious case reviews or Welsh child practice reviews HMSO Barnardo’s (2011) Puppet on a string: The urgent need to cut children free from sexual exploitation Barnardo’s Bhatti-Sinclair, Linton, Ng’andu, Singh (2015) Critical multi-culturalism and child sexual exploitation – presentation to Joint Social Work Education and Research Conference paper 2015 CEOP (2011) Out of Mind, Out of Sight: Breaking down the barriers to understanding child sexual exploitation, London, CEOP http://www.ceop.police.uk/documents/ceopdocs/ceop_thematic_assessment_executive_summary.pdf Cockbain, E., Brayley, H., & Laycock, G. (2011) Exploring internal child sex trafficking using social network analysis In Policing: A Journal of Policy and Practice, 5(2), 144_157. Cockbain E; (2013) Grooming and the ‘Asian sex gang predator’: the construction of a racial crime threat in Race & Class 54: 22 Cockbain, E., Brayley, H & Sullivan, J; (2014) Towards a common framework for assessing the activity and associations of groups who sexually abuse children Journal of Sexual Aggression: An international, interdisciplinary forum for research, theory and practice Volume 20, Issue 2, pp156-171 Fox, C. (2016) It’s not on the Radar: The hidden diversity of children and young people at risk of sexual exploitation in England Barnardo’s Fukuyama, F. (2002) Social Capital and Development: The Coming Agenda SAIS Review of International Affairs Volume 22, Number 1, pp. 23-37 Gohir (2013) Unheard voices: The Sexual Exploitation of Asian Girls and Young Women Muslim Women’s Network http://www.mwnuk.co.uk/resourcesDetail.php?id=97 Griffiths, S. The Overview Report of the Serious Case Review in respect of Young People 1,2,3,4,5 & 6 Rochdale http://www.rochdaleonline.co.uk/uploads/f1/news/document/20131220_93449.pdf HM Government (2009) Safeguarding children and young people from sexual exploitation HMSO HM Government (2015) Working Together to Safeguard Children HMSO Humphreys, S. (2015) Independent commentary: Oxfordshire Stock-Take https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448350/Independent_commentary__Oxfordshire_stock-take_2015.pdf Crown Copyright Jay (2014) Independent Inquiry into Child Sexual Exploitation in Rotherham 1997 – 2013 http://www.rotherham.gov.uk/downloads/file/1407/independent_inquiry_cse_in_rotherham Melrose, M; et al (2013) Child Sexual Exploitation in Luton: A Scoping Study Luton LSCB http://lutonlscb.org.uk/child_11_667496891.pdf Myers, J and Carmi, E (2016) The Brooke Serious Case Review into Child Sexual Exploitation Bristol Safeguarding Children Board Office of the Children’s Commissioner OCCE (2012). ‘I thought I was the only one. The only one in the world’: Interim report from enquiry into child sexual exploitation in gangs and groups http://www.childrenscommissioner.gov.uk/content/publications/content_636 Office of the Children’s Commissioner (2013) “If only someone had listened” See Me, Hear Me Pona and Baillie (2015) Old Enough to Know Better: Why sexually exploited older teenagers are being overlooked, The Children’s Society Page 50 of 111 APPENDIX ONE TERMS OF REFERENCE SERIOUS CASE REVIEW SUBJECT: Child M Page 51 of 111 STATEMENT IN RELATION TO CHILD SEXUAL EXPLOITATION (CSE)40 ‘Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, attention, gifts, money) as a result of them performing, or others performing on them, sexual acts or activities. Child sexual exploitation grooming can occur through the use of technology without the child’s immediate recognition; for example, being persuaded to post sexual images on the internet/mobile phones without immediate payment or gain. In all cases, those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and /or economic or other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social/economic and/or emotional vulnerability.’ Source: UK National Working Group for Sexually Exploited Children PURPOSE OF THE TERMS OF REFERENCE These terms of reference outline the system of accountability for the review’s work. It has been drafted taking into account the following functions: 1. To stand as part of the commissioning contract enabling Calderdale Safeguarding Children Board to determine whether the Independent Chair and Independent Lead Reviewer have satisfactorily completed the tasks required. This document outlines what responsibilities the Independent Chair and Independent Lead Reviewer have and what tasks they are expected to undertake. 2. To act as a public document so that all stakeholders can hold the review to account for any specific failures to adhere to the terms of reference 3. To provide a way for all stakeholders, including the public, to determine whether the Serious Case Review process was adequate for the task. 40 Page 52 of 111 PURPOSE OF THE REVIEW The purpose of the review is to improve services and prevent similar serious abuse or neglect. SCOPE OF THE REVIEW The time period is from 1st September 2006; when Child M commenced secondary school. The review period ends on the 31st August 2012 when the Gold Command Operation began. The SCR Review Panel will take into account relevant information from outside the time period under review, but this will not be analysed in detail. The report will focus on service engagement and response to Child M. Family members may be discussed within the review, but only in relation to information contained within Child M’s records: ISSUES TO BE EXAMINED 1. a. Look at the facts of the individual case and the young person’s story and; b. Benchmark local policy and practice against national guidance and local understanding in relation to CSE in the period under review. Serious Case Reviews should be conducted in a way in which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisation involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. (Working Together, Chapter 4 para 10, March 2013) Initial terms of reference will be submitted to the Independent Chair of the CSCB based on information known at the time. It should be noted that the terms of reference are a living document and not set in stone. They may need to be amended, in the light of new information, at any point during the course of the review. The Serious Case Review Panel will have responsibility for agreeing any variation to the terms of reference. Page 53 of 111 2. Determine whether the National, Regional and Local policies, procedures, thresholds and practice expectations of the agencies in use at the time were followed during this period. How would this be different now? 3. 51 of the 52 people who were questioned in regard to sexual offences against Child M (and 24 of 25 who are being prosecuted) are Pakistani men. What are the gender, race and culture issues that are relevant to this case? 4. Were single and multi-agency communications and information sharing appropriate, accurate and acted upon? 5. Were single and multi-agency assessments and interventions child focussed, appropriate, accurate, acted upon and complete? 6. Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of agency’s actions in relation to these. 7. Identify learning that will help partners and the LSCB to strengthen understanding of and response to Child M and to all vulnerable children and young people. 8. Did agencies understand and implement policy and practice in relation to CSE in their contact with Child M. If not, why was this?? 9. Were any of the professionals or organisations involved with Child M working in isolation? 10. What can we learn from the engagement with the young person, parents and extended family in fully understanding vulnerability, harm, risk and effective interventions? 11. Was professional practice informed by appropriate and effective supervision? 12. Were there examples of challenge by the LSCB into systems and processes of identification and monitoring of victims of CSE and were there occasions when challenge might have made a difference? METHODOLOGY Barry Raynes from Reconstruct is independently appointed as serious case lead reviewer. The review is managed by the Serious Case Review Panel and Independently Chaired by Maureen Noble. The administration process is managed by the Business and Quality Assurance Manager of the CSCB and the review is commissioned by the Independent Chair of the CSCB on the advice of the Case Review sub group and on behalf of the full Board. The LSCB Independent Chair will attend some panel meetings at the request of the Panel Chair or pursuance of his role as commissioner. Arrangements will be in place to feed back to the LSCB Independent Chair through panel minutes and the CSCB Business and Quality Assurance Manager. Page 54 of 111 Agencies providing chronologies, IMR reports and contributing to reflective events: 1. Children’s Social Care, Children and Young People’s Service 2. Youth Works, Children and Young People’s Service 3. Independent Reviewing Officer (IRO) Service, Calderdale Metropolitan Borough Council 4. Calderdale and Huddersfield NHS Foundation Trust (School Nursing, Midwifery & Accident & Emergency Services) 5. Family Support 6. GP – NHS England 7. Jeanette’s school 8. West Yorkshire Police 9. Youth Offending Team 10. Lifeline / Branching Out (Children & Young People Substance Misuse Service) 11. Others as appropriate Panel members: 1. Independent Chair 2. Independent Lead Reviewer 3. Designated Nurse, NHS Commissioners, Clinical Commissioning Group 4. Detective Chief Inspector West Yorkshire Police 5. Service Manager, Children Social Care, CYPS, CMBC 6. Nurse consultant for Emergency Care, CHFT 7. Public Health (current commissioner of children and young people substance misuse service and school nursing), CMBC 8. Head of Youth Offending Team, CMBC 9. Service Manager, Family Support, CYPS, CMBC 10. Representative from Children’s Society; Safe Hands Project 11. Education –Assistant Principal from Jeanette’s secondary school 12. Contribution of Child M through advocate Page 55 of 111 A STATEMENT OF GOOD PRACTICE The approach taken with the review should be proportionate: led by individuals who are independent of the case; professionals fully involved and able to contribute their perspectives without fear of blame; contribution of the young person and family members where applicable; publication and inclusion of the final report in the CSCB Annual Report; and improvement sustained through regular monitoring and follow up. Criminal Proceedings and Concurrent Investigations To ensure this review does not adversely affect the ongoing criminal process, it will be managed according to the arrangements which are subject to national guidance that has been agreed between chief constables (ACPO), the chairs of LSCBs and the Crown Prosecution Service (CPS) in England and the principles set out in the National Association of LSCB Chair guidance on SCRs and parallel processes. Other concurrent investigations will be monitored and any learning will feature in the SCR overview report. ETHOS OF THE REVIEW Child M will be fully involved in the review and be consulted at each major stage of the process. This will include an awareness of the process and terms of reference, contribution to the questions forming the report and agreeing publication decisions. Interviews and involvement from any other family member will only be included with specific agreement from Child M but may include other family members. An agreement on the parameters and governance of involvement with Child M will be agreed with the SCR Panel and the Senior Investigating Officer in the criminal case. The family will be kept informed of the review and its progress (subject in this instance to consideration of Child M’s views) and consulted prior to formal approval by the board and publication (This consultation may include issues regarding publication). The Calderdale Safeguarding Children Board Independent Chair will meet with Child M and family members as advised by the Panel Chair if there is a need to respond to any specific or particular concerns or issues. It is necessary to ensure that the processes of obtaining information, involving families, hearing from staff and professionals and writing the report have due regard to the matters in s149(1)(a)-(c) of the Equality Act 2010. Hindsight bias and outcome bias will be recognised and reduced by using analysis which examines how things were and perceived to be at the time, why decisions were made and actions taken at the time. Page 56 of 111 The main objectives for the SCR Panel and the Independent Lead Reviewer are to: Collate and analyse the detailed information and findings from information received from the agencies, practitioners and families involved, including the Individual Management Reviews, chronologies, practitioner learning events, interviews with family members, front line practitioners etc. In the light of this the aims are to: Confirm/agree any further Terms of Reference and time period for the SCR Identify if any further information is needed or other reports need commissioning Scrutinise and analyse to confirm learning and resolve any differences The terms of reference should be subject to regular review and additions made where appropriate. The reviewer will work with the SCR Panel in accordance with the terms of reference. The Overview Report The overview report should bring together the relevant information and analysis contained in the individual agency reports, together with any reports commissioned from other parties. The following format is suggested, although details may need to be changed depending on the nature of the case. Introduction - Summary of circumstances leading to the SCR. - Terms of reference. - List of contributors to the SCR, Panel members and Independent Lead Reviewer(s) of the report. The facts Genogram showing family membership, including extended family and index child's household unless this might lead to identification. Summary of chronology of involvement with the child and family by all relevant professionals, paying particular attention to occasions when the child was seen and the child's views or wishes sought or expressed. Summary of the relevant information known to the agencies involved about the parents/carers, and the home circumstances of the children Analysis Page 57 of 111 A consideration of how and why events occurred, judgements and decisions made and actions taken or not. There may be comment as to whether, in the Independent Lead Reviewer’s view, different decisions or actions may have led to an alternative course of events. The analysis section may also be able to highlight examples of good practice. The analysis should be structured so as to reflect these terms of reference. Conclusions and Recommendations This should include a summary of the findings of the review, lessons to be learned from the case, and the Panel's recommendations for action. Recommendations should include, but not be limited to, the recommendations made in the individual agency reports. Recommendations should be few in number, focused and specific, and capable of being implemented. The responsibility of accuracy lies with the Independent Lead Reviewer ensuring the report is structured and written so as to promote accessibility and understanding. The report must reflect the fact that it will be published with minimum redactions, so as to protect the child and to ensure that the reader can see how learning has been identified and acted upon. Page 58 of 111 APPENDIX TWO Calderdale Threshold document: The Continuum of Need and Response: The document can be found in full here: http://www.calderdale-scb.org.uk/wp-content/uploads/2016/03/Continuum-of-need-website.pdf Level 1 represents children with no identified additional needs. Their needs are met through accessing universal services. Level 2 represents children with additional needs that can be met by targeted support by a single practitioner or agency - universal services. Level 3 represents children with additional needs that can be met by targeted support by a multi-agency integrated support package - mainly universal services coordinating their approach. Level 4 represents children with significant additional needs that have not been met following a co-ordinated, multi-agency response from the Early Intervention Panel and for whom significant concerns remain. This is when Children’s Social Care may become involved. Level 5 represents children with complex needs at the highest level of vulnerability which will be met by multi-agency support from specialist services. (Social Care will always be the lead professional when a child protection enquiry is necessary, S47) Page 59 of 111 APPENDIX THREE REFERRAL TO MAST: Secure e-mail: [email protected] NB; only works when sending from another secure email address, or FAX: 01422 392875 or Telephone 01422 393336 REFERRAL TO DCT: [email protected] - 01422 394091 REFERRAL TO EIP: Upper Valley [email protected] - 01422 368279 Lower Valley [email protected] - 01422 394094 Halifax Central [email protected] - 01422 392510 North & East [email protected] - 01422 392495 Early Intervention and Safeguarding Statutory Request for Service/ Referral For Referral to an Early Intervention Panel (EIP) – All agencies please complete this form and attach a Child and Family Single Assessment, if completed. For Referral to the Disabled Children’s Team (DCT) - All agencies please complete this form and attach a Child and Family Single Assessment, if completed. For Referral to the Multi-Agency Screening Team (MAST) – For urgent Child Protection concerns, please contact MAST and complete this form within 24 hours. For all other requests for service/referrals please complete this form and attach the completed Child and Family Single Assessment. PLEASE INDICATE REQUEST FOR SERVICE / REFERRAL TO: Early Intervention Panel (EIP) Disabled Children’s Team (DCT) Multi-Agency Screening Team (MAST) Please complete this form as fully as possible, if information is unknown leave blank. Please type this form or ensure it is written legibly. If you are aware that the child has a Social Worker, go directly to the Social Worker/ Team, there is no need to use this form. (Please refer to the practice guidance). 1. REFERRAL DETAILS Date of Referral Time of Referral Name Job title Agency Address Telephone Email Secure Y / N 2. DETAILS OF CHILD / YOUNG PERSON Child’s Name DOB / EDD Age Unborn Y / N Gender M / F Disability/ learning difficulty (if known please specify) Ethnicity Page 60 of 111 Is English their first language? (Included child and parents / carer) If no, please specify preferred language Is an interpreter needed? Y/N Religion Address Postcode Tel No Early Years Provider/School/College attended: (Also please give name of any key contact person) UPN: Attendance: % Child’s GP Address/ Tel No NHS No: 3. DETAILS OF ALL SUBJECT CHILDREN If not at the same address, a separate referral needs to be made in respect of each household. (To add additional rows, right click in the final row, click ’Insert’, ‘Insert Rows Below’) Name DOB / EDD / Age Gender M/F Disability School / Nursery Relationship to the above child Child also referred Y/N FAMILY / HOUSEHOLD MEMBERS (To add additional rows, right click in the final row, click ’Insert’, ‘Insert Rows Below’) Name DOB / EDD / Age Gender M / F Ethnicity Parental Responsibility (PR) Employed Y / N Relationship to the above child OTHER SIGNIFICANT PEOPLE LIVING IN THE HOUSEHOLD (To add additional rows, right click in the final row, click ’insert’, ‘Insert Rows Below’) Page 61 of 111 Name DOB / EDD / Age Gender M / F Address/ Contact number Ethnicity Parental Responsibility (PR) Employed Y / N Relationship to the above child 4a. DETAILS OF REQUEST Please detail why you are requesting a service, clearly specifying presenting issues and areas of concern, and the evidence you have to support this, for example child’s developmental needs, parenting capacity, or family and environmental factors. Please highlight any further actions required to support the needs / concerns. 4b. Is the child at immediate significant risk of harm? (MAST REFERRAL ONLY) Is there a concern regarding an injury, if so please include details of the injury/mark and when the incident/concern occurred. Has the child seen a medical professional? 5. Include anything else that you feel might be useful to know about the family e.g. mental and physical health issues, domestic violence, substance use, or any risks for workers visiting the family etc. Page 62 of 111 6. List the actions taken, or support provided so far e.g. Early Intervention / Statutory Child and Family Single Assessment TAC Meetings, Early Intervention Plan, Child in Need Plan, Child Protection Plan. Agencies currently or previously involved, and any intervention tools you have used with the child and family. 7a. Have you attached additional information? (If so please specify, e.g. any previous assessments / plans) 7b. Has an SDQ been completed? Y / N Date: 8. Are you aware of any previous Children’s Social Care involvement? Y / N Was this in Calderdale? Y / N If no, which Local Authority? 9. CHRONOLOGY (To add additional rows, right click in the final row, click ’Insert’, ‘Insert Rows Below’) Brief chronology of relevant historical information of significant dates and events All agencies should provide a brief chronology of any relevant historical information of significant dates and events. Record clearly which child this significant event relates to. Date Significant event Child / Family Member Professional / Agency 10. PROFESSIONALS / AGENCIES INVOLVED WITH THE FAMILY (To add additional rows, right click in the final row, click ’Insert’, ‘Insert Rows Below’) Details of professionals / agencies involved with the child(ren) / family / household members. Child / Family Member Agency Agency Contact Name / Job Title Telephone Number(s) Page 63 of 111 If you are currently providing a service to the family and are actively involved, should this request commence to a Child and Family Single Assessment, then you may be asked to undertake a joint visit with the allocated worker within five days. 11. CONSENT Consent is only required to share information with other agencies, if there are no Child Protection concerns. Consent is not required to undertake an Early Intervention or Statutory Child and Family Single Assessment which will identify any outstanding needs and services the child / family requires. However, consent should be sought to share information to enhance the assessment. A. CONSENT - MULTI-AGENCY SCREENING TEAM / DISABLED CHILDREN’S TEAM ONLY Parental consent is not required to share information or inform that a request for service/referral is being made, where there is a risk of immediate significant harm to a child/young person by the parent/carer and there is a statutory responsibility to refer Child Protection concerns to Children’s Social Care. Where the above does not apply, you must ensure the parent/carer or child/young person is informed that this request for service/referral is being made and consent dependant on the request being made. Have you informed the parent / carer and child / young person, that you are making this referral? Y / N Do you have consent for this referral? Y / N Do you have consent to share information? Y / N Verbal consent Y/N Parent/carer Y/N Child/young person Y/N Written consent Y/N Parent/carer Y/N Child/young person Y/N If no, please state reason: Page 64 of 111 Views of parent / carer and child / young person: B. CONSENT - EARLY INTERVENTION PANEL ONLY I agree to the gathering and sharing of information on this form with partner agencies and representatives of the Early Intervention Panel as required so that they can help to provide the right services for my child and family. I agree that any personal information provided by me on this form will be treated in accordance with the provisions of the Data Protection Act 1998 and my family’s details will be held on the Calderdale Children’s Services databases. PARENT / CARER: (please state) Name: Signed: Date: Contact Telephone Number: YOUNG PERSON: Name: Signed: Date: If consent is not obtained, please state reason: Page 65 of 111 APPENDIX FOUR CHILDREN’S SOCIAL CARE PRACTICE STANDARDS It is anticipated that the Social Care Overarching Principles are delivered by our staff operating these standards in their day-to-day practice. CONTENTS MAST 2 Children’s Assessment Team (CAT) 3 Child and Family Single Assessment 3 CiN Planning 6 Review of CiN Plan 7 Case Recording 8 Case Supervision 9 Standards for Visiting 10 Strategy Meetings/Discussions 11 Page 66 of 111 S47 Enquiries 12 Child Subject to a Child Protection Plan 13 Children Looked After 17 Looked After Reviews 19 Adoption or Long Term Looked After 21 Leaving Care 22 Page 67 of 111 STANDARDS FOR ALL RECORDS PERSON RESPONSIBLE MULTI AGENCY SCREENING TEAM (MAST) – also see MAST practice handbook The referral records the date and time the information was received and the names and details of the person making the referral. It will also record full basic details of the child/young person, parent/carers, significant others, everyone in the household, ethnicity, nationality, first language, religion, disabilities, SEN status and school attendance data and any communication requirements, as well as if consent has been obtained from the parent/carer. Full referral information and appropriate support evidence needs to be obtained at point of referral, including service being requested and any other agency/professionals involved with the child. It is essential the referral is recorded on CASS on the date of referral. The Referral Information Coordinator (RIC) alerts the Team Manager (TM), or Practice Manager to any immediate Child Protection referrals Referral Information Coordinator The referral is finalised within 24 hours unless it is an immediate child protection referral which should be completed within 2 hours. The referral records the decision made, further action required and outlines the reason for this. Decision will be informed by historical and current information held by Children Services, as well as partner agencies in MAST and this is to be recorded on Referral Record. Team Manager/ Practice Manager The referrer is informed in writing of the outcome of the referral and a case note added in the child’s record to confirm this has taken place within 24 hours of the decision. Referral Information Coordinator If an immediate Strategy Discussion is required, this is held with the partner agencies in MAST including relevant external agencies where appropriate. This is initiated and chaired by the TM, or PM, who will immediately notify the CAT Duty Team Manager/ Practice Manager Page 68 of 111 Practice Manager (PM) and they will identify an appropriate experienced Social Worker to attend the meeting. The TM must ensure that full consultation takes place with all relevant agencies prior to the strategy meeting to ensure their information informs decision making. The TM/PM will immediately complete the CASS Strategy document recording the discussion and outcome of the meeting. The PM reviews all Contacts/Referrals and identifies and allocates any tasks to be undertaken by the Screening Social Workers, that is required to make an informed decision in respect of the referral Practice Manager Screening Social Worker completes tasks identified by PM so the referral can be Reviewed and Outcomed within 24 hours Screening Social Workers The referral is finalised by the duty manager The PM is responsible for reviewing the information recorded by the Referral Information Coordinator or MAST Screening Social Worker and quality assurance of the referral. The referrer is notified of the outcome of their referral in writing within 24 hours of the decision. Team Manager Referral Information Coordinator CHILDREN’S ASSESSMENT TEAM (CAT) MAST TM/PM will allocate on CASS cases outcomed for further assessment to the CAT Inbox Where the complexity warrants it, this will be done following a personal or a telephone discussion between the TM and Duty PM and/or the allocated social worker. MAST Team Manager /Practice Manager The case is allocated to a suitably trained and experienced worker within 24 hours. All Section 47 investigations will be allocated immediately. Duty Practice Manager A ‘face to face’ discussion should take place between the social worker and the Duty Practice Page 69 of 111 allocating Practice Manager at the point of allocation. Although allocation should take place electronically within the CASS System this should not replace the need to speak with the worker. This discussion should include: The nature of the concerns Historical facts to take into account Timescale for visit to the child/family Who the worker should speak to following the initial visit. Manager There is clear recorded instruction as to the initial work to be completed during the course of the Single Assessment. The Duty Practice Manager should clearly record in a “Case Management” case note and within the Single Assessment the tasks and targets which have been discussed with the worker. Duty Practice Manager Child and Family Single Assessment (for comprehensive guidance supporting these standards, please see the Child and Family Single Assessment Guidance document) The timeframe will be clearly identified as the standard 15 days, with a progress review by day eight, unless further time is required for completion of a more comprehensive assessment. Additional time can be 25, 35 or the maximum 45 days. The case would then be reviewed as per procedures within supervision, at additional review points, or when the assessment is completed and submitted for sign off. The assessment will be regarded as completed once it has been signed off/approved by their line manager. Where the assessment is not completed within timescales, the reason for this should be recorded. Refer Child and Family Single Assessment Guidance. Social Worker/Practice Manager Unless the visit is made under Section 47, the social worker should – where appropriate - arrange to make the initial visit jointly with the referrer within five working days of allocation. At the first home visit made for the preparation of the Social Worker and referrer where appropriate Page 70 of 111 assessment, the child/young person and his/her parent/carer is provided with a copy of: The consent to share information leaflet and signed Consent obtained The Complaints leaflet The Access to Records leaflet. The child/young person must always be seen as part of the assessment and spoken to and seen alone where age appropriate. Social Worker The assessment record clearly, explicitly and separately records all of the following: Reason for the assessment Child/young person’s developmental needs Parents capacity to respond appropriately to child/young person’s needs Family and environmental factors that impact upon the child and his/her family The child’s and parent/carer’s views An analysis of risk and protective factors in the family. Information should be gathered from a variety of sources to inform the assessment including the child, his/her family and professionals in other agencies who know and are delivering services to the child and his/her family. The assessment should cover in detail the three domains and dimensions as detailed in the Framework for the Assessment of Children in Need and their Families, alongside Working Together (2015) Guidelines. Social Worker The assessment should take into account any previous involvement with the child/young person and the current assessment is set in the context of the historical information. A chronology should be updated as part of the assessment, or commenced as this provides a summary of previous involvement with the child and the historical context for any assessment. The chronology should include events significant to the child’s journey and a brief synopsis of the event and its outcome. This should include the multi-agency chronology provided and any other significant events reported by other agencies. Previous involvement with the child and his/her family is critical information to support Social Worker Page 71 of 111 the evaluation and assessment of the current presenting needs. Any assessment of a child should be set in the context of previous involvement and concerns as this may highlight any emerging patterns or indicators of risk or harm in this family. As such, the chronology must be utilised whilst the assessment is being completed. The record should detail the date/s the child/young person and family members were seen for the purposes of preparing the assessment and clearly, explicitly and separately record: The wishes and views of the child/young person and how they have informed decision making The wishes and views of the parents/carer and how they have informed decision making. Gathering information and making sense of a family’s situation are key phases in the process of assessment. It is not possible to do this without the knowledge and involvement of family. It requires direct work with the children and their family members and the social worker will need to meet with them to complete the assessment. Social Worker The assessment records the names and designations of all agencies/professionals that contributed or were consulted in the preparation of the assessment. Details of those who contributed to the assessment should be recorded in the assessment record. If information is requested but has not been provided within timescales, then this should be noted and once received, recorded in the case notes. In order to effectively complete an assessment of a family, this should be undertaken on a multi agency basis. An assessment planning meeting may be considered at the outset of the process in complex cases which identifies what information is required and who should provide this. Social Worker The assessment analyses the needs of the child, the parents’ capacity to meet those needs and family and environmental factors impacting upon the family to inform the decision making process. There must be an analysis of the level of risk to the child. Social Worker Page 72 of 111 The most important part of the assessment process is the analysis of the information gathered and the implications of this to the protection and welfare of the child. The social worker should identify any indicators of risk or harm or impairment to child’s welfare as well as protective factors that will keep the child safe. Details of what further action is to be undertaken including the reason for this, need to be recorded within the assessment. Social Worker The outcome of the assessment is recorded and details of what further action, if any, is to be undertaken including the reason for this. The assessment record should explicitly detail: Any indicators of significant harm or impairment to the child’s welfare Protective factors What needs to change or happen What services are required to ensure that the identified needs of the child are met Where the assessment identifies the need for services to be put in place immediately, then this should be actioned and not delayed until all assessments are completed Social Worker There is documentary evidence that the child/young person and his/her parent/carer are informed of the outcome of the assessment and provided with a copy. Assessments are undertaken in partnership with families and the completed assessment should be shared with the child (dependent upon age) and his/her parent/carer and provided with a copy. This ensure that they fully understand the reasons for decisions reached by the social worker, have the opportunity to challenge the decision making process and can correct any factual inaccuracies in the record. Social Worker The assessment is authorised by the line manager It is the role of the line manager to ensure that the quality of the assessment meets the required standards and that the decisions reached are based on a sound analysis of the information gathered and will safeguard the child and promote his/her welfare. Practice Manager/Team Manager CIN PLANNING Following completion of the assessment where the outcome is this is a Child in Need, a CiN Planning Meeting should be convened within 10 working days where the plan will Social Worker Page 73 of 111 be completed. Upon completion of the assessment, the plan should be prepared outlining the outcomes to be achieved and services delivered to meet the assessed needs. This should be completed within10 days to ensure that services are co-ordinated and delivered to the child in a timely manner. The plan will be SMART and explicitly detail: The outcomes to be achieved The actions required to achieve the outcome Timescales for actions to be completed, either a target date or frequency Who is responsible for the implementation of the action The actions outlined in the plan should be specific, measurable, achievable, realistic and have set timescales. Terms like ‘ongoing’ and ASAP are not acceptable. Social Worker The plan will state the minimum visiting frequency required of the lead professional or the social worker. The plan should explicitly detail the minimum frequency that the lead professional or the social worker will visit the child and his/her family. The minimum visiting frequency should be individually determined based on the needs of the child but should not be less than four weekly. Social Worker The plan is prepared in consultation with the child/young person and his/her parent/carer and their views are recorded on the plan and agreed at the planning meeting. Social Worker The objectives of the plan and how they will be achieved are discussed with all relevant family members, agencies and professionals and their details recorded. The plan should be implemented by the team around the child led by the lead professional or the social worker and as such, it is essential for other professionals working with the child to know what services are being provided to the child and his/her family by whom and when. This ensures that there is no duplication of service delivery, that services provided are complimentary and everyone working with the child is aware of who is doing what. Social Worker Page 74 of 111 The child/young person, his/her parent/carer and all key family members and agencies are provided with a copy of the plan within five working days of the meeting. Social Worker REVIEW OF CHILD IN NEED PLAN Reviews of the plan should take place at six weekly intervals. However, the multi-agency group may decide that less frequent reviews at up to three monthly intervals are required. Disabled children who are managed at CIN level 3 will be reviewed at a minimum of 6 months. Plans should be regularly reviewed by the multi agency team around the child to ensure that the plan remains relevant, the services delivered are effective and timescales for action are being achieved. Social Worker/ Practice Manager The review monitors progress against the implementation of the plan and this is explicitly recorded with any concerns or changes to the plan. Social Worker/ Practice Manager Any new information received about the child is evaluated and responded to Through the child in need review process, the team around the child should share information about the child and this information evaluated in the context of the assessment and plan. Assessment should continue throughout the period of intervention and professionals need to keep their judgements under constant critical review being willing to respond to and challenge new information. CIN Assessments should be updated annually, in line with other assessment processes. Social Worker/ Practice Manager/Lead Professional In circumstances where there is concern about additional risk, the Practice Manager may request that a Single Assessment is carried out by the social worker. Practice Manager The child/young person and his/her parent/carer are supported to participate in the review process. The plan will clearly indicate how their wishes and feelings have informed planning and service delivery. Throughout the period of involvement with a child and his/her family, it is important to develop a cooperative working relationship so that the family feels respected, informed and listened to and that professionals are working with them in an open and honest way. Parents and children should be fully prepared for any meeting understanding who will be there, the purpose of the review and how they will participate in the process. Parents and children should be given clear feedback on how their contribution has been taken Social Worker/Lead Professional Page 75 of 111 into account and acted on. Family members and other agencies/professionals are engaged in the review process Other professionals should be fully prepared for the review meeting by being informed of the type and purpose of the meeting, who will be attending and the expectations of them in the meeting. The views of partner agencies are then reflected in the documentation. Social Worker/ Lead Professional CASE RECORDING Case recording is child focussed The child must be seen and kept in focus throughout the intervention. It is imperative that the child’s circumstances are seen through the child’s personal experience. What does it feel like to be this child living in this particular set of circumstances? The voice of the child must be listened to and social workers should ask themselves what the child is telling them. Direct work with the child is essential to achieving child focussed intervention to ascertain their views and understand the meaning of their experiences to them. Social Worker/ Lead Professional A multi-agency chronology of key events for the child is maintained up to date The chronology is a means to provide an overview of events in the child’s or young person’s life and must be used by practitioners to as an analytical tool to help them understand the impact, both immediate and cumulative, of events and changes on the child or young person’s developmental progress. An up to date and complete chronology ensures that any emerging patterns or issues within the family of a serious or deep rooted nature are identified and responded to. Social Worker/ Lead Professional Case records are up to date within 24 hours where there are child protection concerns and within a maximum of 48 hours for all cases. Social Worker/ Lead Professional Page 76 of 111 All case records reflect professional practice in particular: Use plain English rather than jargon Distinguish between fact and opinion Demonstrate a commitment to the principles of equality and valuing diversity Are respectful of the child/young person and his/her family Social Worker/ Lead Professional Case notes will detail: The date of the contact The reason for the contact Who the contact was between Details of the contact The outcome of the contact Whether the child was seen and spoken to and if seen alone An analysis of the contact Any further action to be taken arising from the contact All social care staff Professionals supporting the child and his/her family are referred to in the records by name and designation. Social Worker/ Lead Professional Case records show when information has been shared and with whom. Social Worker/ Lead Professional Case records are accurate and grammatically correct. Details of relevant agencies and family members in are updated as appropriate the maintained persons’ section Social Worker/ Lead Professional Case records are subject to review and quality assurance in both supervision and file audit. Social Worker/all Supervisors CASE SUPERVISION Each child/young person’s case is supervised on a monthly basis. Regular supervision is essential to safe social work practice. It should provide a safe but challenging space to oversee and review cases. Practice Manager/Team Manager Records of cases to be supervised should be reviewed by the manager either prior or during the case supervision In order to effectively supervise a case, managers must prepare for case supervision by reviewing the child’s record to appraise themselves of the up to date circumstances Practice Manager/Team Manager Page 77 of 111 regarding the child, to quality assure the standards of practice and be reassured that the intervention with the child is outcome focussed and complies with procedures A case supervision record is completed each time the case is supervised and explicitly details: Review of actions from the last supervision Significant events since the last supervision Any key decisions made Reflective analysis Actions to be taken by social worker with timescales The case supervision template should be fully completed and this will promote discussion, critical evaluation and ensure management oversight and decision making. More general reflection on the social worker’s practice will take place and be recorded in their personal supervision. Practice Manager/Team Manager Case supervision demonstrates evidence of robust and effective management oversight Practice Manager/Team Manager Where individual cases are discussed within group pod supervision, the same standards for review and recording apply. (See Safe Successful Families Handbook for more detail). A copy of the case supervision record is stored in the child’s electronic record. Practice Manager/Team Manager/ Pod Coordinator CIN with FIT lead (rather than social worker lead) The case is supervised by FIT on a monthly basis and management oversight by the Practice Manager is bi-monthly. FIT Practice Manager STANDARDS FOR VISITING All children should be visited by their social worker at an individually determined level agreed by the social worker and their line manager through the planning or supervision process which enables the effective delivery of services to safeguard the Social Worker/Practice Page 78 of 111 child and promote his/her welfare. The child’s plan should clearly detail the minimum frequency at which the child is visited by his/her social worker and visits carried out at least in accordance with this minimum level. It is essential that children are seen and spoken to regularly by their social worker and this will often need to be more frequently than the minimum level outlined in the plan. Good social work practice will be guided by professional judgement based on the needs of the child. In order to safeguard children and ensure that minimum standards are in place, the service has determined minimum visiting standards as follows: Children in Need – four weekly Disabled children who are managed at CIN level 3 – eight weekly Children subject to protection plans – Every 10 working days from the protection plan being put in place until the first review. Thereafter at a minimum of every 15 working days. Children Looked After – Within five working days of placement (including where there has been a placement change) and weekly until the first review, thereafter minimum of monthly until the child has been in their permanent placement for one year, thereafter three monthly. Children placed for adoption – within 5 working days of placement and weekly until the first review, thereafter minimum of monthly until adoption is finalised. Manager/Team Manager CHILD PROTECTION STANDARDS a) STRATEGY MEETINGS/DISCUSSIONS This should be timely, but take place in sufficient time to protect the child and to allow partner agencies to attend. For allegations/information indicating risk of significant harm to the child, the strategy meeting/discussion should be held on the same day as the receipt of the contact. Where additional information needs to be gathered, the relevant manager may - in consultation with the police - decide to extend the timescale to a maximum of 24 hours. For allegations against staff that may result in disciplinary procedures a LADO referral should be initiated within one working day Strategy Meetings/discussions should be led by a practitioner with line management responsibilities. Practice Manager /Team Manager Page 79 of 111 Timescales for subsequent strategy meetings should be set at the initial meeting. The strategy meeting/discussion gathers information from and consults with key professionals involved with the child. Strategy meetings/discussions must involve children’s social care, health and the police as a minimum, but other key agencies should be involved as appropriate. In particular, every effort must be made to consult with the school or nursery and the referring agency. The TM or Practice Manager must ensure that full consultation takes place with all relevant agencies prior to the strategy meeting to ensure their information informs decision making. The TM will immediately complete the CASS Strategy document recording the discussion and outcome of the meeting Practice Manager/ Team Manager The reason for the strategy meeting/discussion is recorded. Practice Manager/Team Manager The strategy record outlines information shared and an analysis of risk to the child. The tasks of the strategy meeting/discussion are to: Share available information; Determined whether the threshold has been met for a section 47 enquiry/assessment to be initiated Agree the conduct and timing of any criminal investigation, where relevant Plan how the section 47 enquiry should be undertaken including the need for medical examination and/or treatment Agree any action required to secure the immediate safety of the child Determine what information will be shared with the family Determine if legal action is required. Practice Manager/Team Manager Information shared and action agreed is considered within the context of child’s racial, cultural, religious or linguistic background This will include establishing whether an interpreter is required. Practice Manager/ Team Manager Page 80 of 111 Any need arising from a disability is taken into consideration and appropriate plans put in place. Practice Manager/Team Manager The strategy record details the decision of the discussion/meeting and reason for this. Any information shared, all decisions reached and the basis for those decisions should be clearly recorded by the chair of the strategy meeting/ discussion and circulated within one working day to all parties to the discussion. Practice Manager Team Manager/Pod Coordinator/RICS b) SECTION 47 ENQUIRIES The section 47 enquiry/assessment should be led by a qualified and experienced social worker. Newly Qualified Social Workers do not lead section 47 enquiries within the first six months of practice, but may co-work with a suitably qualified and experienced worker. The lead worker is responsible for ensuring an accurate record of the section 47 enquiry/assessment. Practice Manager/Team Manager All children in the household must be visited and spoken to during a section 47 enquiry and their views recorded. Those who are the focus of the concern should be seen alone, subject to age. Parental permission should be sought wherever possible and appropriate. Children are a key and sometimes the only, source of information about what has happened to them. Accurate and complete information is essential for taking action to promote the welfare of the child. It is important that discussions with children are conducted in a way that minimises distress; leading or suggestive communication should always be avoided. Children may need to be seen away from home in a safe environment. Children may need time and more than one opportunity to develop sufficient trust to communicate any concerns they may have. Social Worker The child’s parents/carers should be interviewed and their views recorded. The local authority has a duty to work in partnership with parents. In the great majority of cases, children remain with their families following section 47 enquiries, even where concerns about abuse or neglect are substantiated. As far as possible, enquiries should be conducted in a way that allows for constructive working relationships with families and parents/carers are given an opportunity to express their views and these are taken Social Worker Page 81 of 111 into consideration. The needs and safety of all children in the household are considered and assessed Those making enquiries about a child should always be alert to the potential needs and safety of any siblings or other children in the household of the child in question. In addition, enquiries may need to consider children in other households with whom the alleged perpetrator has contact. Social Worker Non resident parents, others with PR and significant others are appropriately involved and their views recorded. Social Worker A Child and Family Single Assessment is automatically commenced at the same time as a section 47 enquiry is initiated. This should cover all relevant dimensions in the Framework for Assessment of Children in Need and Their Families, in addition to the child protection concerns. Information should be gathered in a systematic way and should include the history of the child, family and household members including any previous specialist assessments and an analysis of risk. Social Worker At the completion of the enquiries, the line manager analyses the information and agrees the outcome of the enquiry and/or plan any further actions in consultation with any relevant professionals. Practice Manager/ Team Manager c) CHILD SUBJECT TO A PROTECTION PLAN An initial child protection conference must be convened following a section 47 enquiry that concludes that a child is suffering significant harm and remains at risk of harm or likely to suffer significant harm. This has to be agreed by the relevant line manager. Team Manager/Practice Manager The initial child protection conference (ICPC) is held within 15 working days of the strategy meeting/discussion. Team Manager/Practice Manager/Independent Reviewing Officer An ICPC must consider all children in the family or household Even where concerns are being expressed only in relation to one child, all children must be identified and the risk of harm to them assessed. Independent Reviewing Officer The social work report includes a detailed analysis of the information for the child’s future safety, health and development. Social Worker/ Independent Page 82 of 111 The social work information to the conference should include: An up-to-date chronology of significant events and agency and professional contact with the family, incorporating all historical information Information on the child’s current and historical developmental needs Risks and protective factors Information on the capacity of the parents and other family members to ensure the child is safe from harm and to respond to the child’s developmental needs within their wider family and environmental context Views, wishes and feelings of the child, parents and other significant family members An analysis of the implications of the information obtained for the child’s future safety and meeting his/her developmental milestones; Recommendations to the conference Consideration is given to how best to include partners who are known to have been violent/intimidating in the Child Protection Conference. It may be appropriate for the Social Worker to discuss an agreed strategy with the Independent Reviewing Officer when arranging the conference. Reviewing Officer The social work report is prepared and shared with the child/young person (where appropriate) and parents/carers at least five days prior to the conference. The report must be signed by the Team Manager or Practice Manager and be completed on CASS: For Initial Child Protection Conferences this should be no more than three days prior to the ICPC. For Review Child Protection Conferences this should be no more than five days prior to the RCPC. The social work report for the ICPC should include the outcome of the section 47 enquiry/assessment to date. Social Worker/Team Manager/Practice Supervisor The child (where appropriate) and parents/carers contribute meaningfully to and where possible attend the conference and their views are recorded and taken into account. Attendance at a conference must be carefully planned, the social worker should ensure that all person’s with parental responsibility and significant others are given sufficient information and support to make a meaningful contribution. The social worker must explain to child/parents/carers the purpose of the meeting, who will attend, the way in which it will operate, their right to bring a person for support or an advocate. The social worker should refer the child to the advocacy service with the child’s consent, unless this is not appropriate. Independent Reviewing Officer Page 83 of 111 Social Worker The conference minutes have sufficient detail to provide the reader with an understanding of the information shared, issues discussed and reasons for decision reached. The record of the child protection conference is a crucial document for all relevant professionals and family members and should include: The essential facts of the case A summary of the discussion which accurately reflects contributions made All decisions reached with information outlining the reasons for the decision A translation of decisions into an outline or revised child protection plan enabling everyone to be clear about their tasks The main decisions should be recorded and circulated to all those invited to conference within one working day and the full minute circulated within 15 working days. Independent Reviewing Officer The Chairs summary accurately assesses the risk and ongoing likelihood of significant harm. Independent Reviewing Officer An outline Protection Plan which is outcome focused is discussed in conference and produced within one working day of the conference. The 1st group develops the Outline Child Protection Plan into a full Child Protection Plan which is SMART at its 1st meeting within 10 working days. The Practice Supervisor or Advanced Practitioner should attend the first core group meeting to quality assure the SMART plan. Guidance for core group members is available as part of the CSCB procedures and through the conference chair. Independent Reviewing Officer Practice Supervisor/Advanced Practitioner The protection plan clearly outlines what action should be taken in the event that parents/carers do not cooperate with the protection plan. Social Worker/Independent Reviewing Officer/Team Page 84 of 111 The Team Manager or Practice Supervisor must sign off the final Child Protection Plan. The contingency plan should be realistic, specific and clear. Manager Where the initial child protection conferences decide that the child does not need to become the subject of a plan, the conference will consider whether recommendations should be made for services to be provided to the child. The conference together with the family should consider the child’s needs and what further help would assist the family in responding to them. Where appropriate, a child in need plan or CAF should be drawn up and reviewed in accordance with the standards. Independent Reviewing Officer The first core group meeting must be within 10 working days of the conference to produce an outcome focused detailed and SMART protection plan and this is distributed to family and professionals. They should be attended by the relevant Practice Supervisor or Advanced Practitioner The detailed child protection plan should: Have the child and his/her needs at the centre of the plan; Include specific, achievable, child focussed outcomes intended to safeguard and promote the welfare of the child; Include realistic strategies and specific actions to achieve the planned outcomes; Clearly identify roles and responsibilities of professionals and family members including the nature and frequency of contact by professionals with children and family members; Lay down the points at which progress will be reviewed and the means by which progress will be judged; Set out clearly the roles and responsibilities of those professionals with routine contact with the child as well as any specialist or targeted support to the child and family. Set out clearly the contingency plan Social Worker/Practice Supervisor At the first Core Group Meeting a Core Group Agreement should be drawn up which should address arrangements in respect of the work of the Core Group which should include: Chairing Minuting The same person should not be expected to both chair and minute the meeting. Social Worker/Practice Manager Page 85 of 111 Core group meetings should take place at no less than four weekly intervals. The minutes of the meeting and the updated Child Protection Plan should be circulated by the social worker to all professionals and the family within 5 working days of the core group meeting. All professionals should be made aware that they have a responsibility to ensure they have an up-to-date copy of the Child Protection Plan. Social Worker Independent Reviewing Officer The core group meetings are attended by key family members, including the child where appropriate and professionals and these are recorded accurately to reflect what information has been exchanged, the progress against the child protection plan and future action attributed to different members of the core group. All members of the core group are jointly responsible for the formulation and implementation of the protection plan, refining the plan as needed and monitoring progress against the planned outcomes set out in the plan. Core group members may find it beneficial to arrange pre-planning time (immediately) prior to the full core group meeting to agree the agenda and approach to the meeting and highlight any specific issues to be addressed. Social Worker The Review Child Protection Conference ( RCPC) must be held within three months of the initial conference and thereafter at intervals of not more than six monthly for as long as the child is subject to a protection plan. Review conferences may take place earlier, if this meets the needs of the case. Independent Reviewing Officer The social worker’s report to the Review Child Protection Conference should be signed by a manager and be available on CASS five days prior to the RCPC. Social Worker Where a child protection plan is discontinued, the conference will consider and make recommendations regarding support and services that the child may still require and if a child in need plan or an Early Intervention Plan is recommended then this will be developed within 10 working days of the conference. The discontinuing of a child protection plan should never lead to automatic withdrawal Independent Reviewing Officer/ Social Worker Page 86 of 111 of help. The conference should give full consideration to and make recommendations regarding what services might be wanted or required. The multi-agency group should use these recommendations to inform any follow up planning. CHILDREN LOOKED AFTER The decision to look after the child is based on a thorough assessment. The decision to look after a child must be considered and agreed at Gateway Panel. A child should only become looked after where an assessment has been completed and determined it is in the child’s best interests to do so and other options have been fully explored. Before presentation to Gateway Panel, the assessment and application for the Panel must have been agreed with and signed off by the Practice Manager and Team Manager Social Worker Social Worker/Practice Manager/Team Manager The process of a child becoming looked after will wherever possible, be planned and child focused. Where, through a child protection enquiry it becomes apparent that a child is at immediate risk of significant harm and cannot be protected within the home or family, permission for an emergency placement should be sought from the Head of Service to secure the child’s safety. In all other circumstances, the process of placing a child in care should be planned, with the child being able to visit his/her prospective placement and meet carers and a placement planning meeting held to agree the arrangements for the child coming into care. This will minimise the potential harm and distress to the child upon separation from his/her parents. Social Worker/Team Manager Family and friend care options have been thoroughly explored. Opportunities should be given for parents or carers to propose family options to keep their child safe, where they cannot do this themselves. Care by a relative should be considered in all cases before any decision is made that a child should come into care. Family group conferences are a good way of ensuring that all resources within the child’s wider social networks have been tapped to benefit the child. There needs to be a clear record of the arrangements proposed by the family and clear evidence that the family Social Worker/Team Manager Page 87 of 111 are willing to make a commitment to keep the child safe. Child has been provided with an information pack upon becoming looked after (including details of complaints procedure and advocacy services). Children should receive a transparent service and know their rights to complain and see any records. Children should be provided with information relating to their placement, advocacy and independent visitor services and these should be discussed with the child to ensure s/he is aware of their rights and services available to them. Social Worker The Placement Information Record is completed prior or at the time of the placement is authorised by the Practice Manager and signed by all parties and distributed. Social Worker/ Practice Manager The child is allocated to a qualified social worker. Practice Manager /Team Manager The Care Plan is fully completed and identifies intended SMART outcomes and how these will be achieved. This is finalised at the placement planning meeting and at the latest within 72 hours of the child being placed. The child’s care plan should be based on an up to date assessment of the child’s needs and detail the services to be provided to meet these. The overall aim of the care plan is to reflect the plan for permanence for the child as agreed at the second review. Social Worker The Care Plan outlines the wishes and views of the child/young person and his/her parent/carer and how they have been taken into account in planning. Children and their birth families are important partners in the care planning process in line with statutory requirements. Consideration should be to the use of use of advocacy services to support children and parents throughout the process. Social Worker The Care Plan clearly details arrangements for contact between the child and his/her parents/siblings and this is communicated to child/parent/sibling/carer. The arrangements for contact must be at the heart of care planning including in processes and procedures related to adoption. Links with family and friends are vitally important to children looked after and provide important continuity and a sense of identity. Once a child becomes looked after, making appropriate arrangements for contact should be an early priority ensuring the child is able to see significant family Social Worker/ Contact Workers Page 88 of 111 members whilst maintaining their safety and wellbeing. Contact arrangements should be confirmed in writing and include a risk assessment. The social worker should observe any supervised contact at least once between each review and be able to report on and analyse its content and quality. Effective work is undertaken with the child and family to enable those children who can return home to do so in a timely way. Children should not remain in care longer than is absolutely necessary and wherever possible arrangements should be made to facilitate the child’s return home with a package of support services that will meet the needs of the child and his/her parents/carers. Social Worker A health assessment is completed within 20 working days of child/young person becoming looked after and is reviewed annually (6 monthly for children under 5). Statutory health assessments are able to identify health needs and health neglect that may otherwise go unrecognised. Social Worker Designated Nurse The child/young person has an annual dental check. Social Worker/ Carer A Strengths and Difficulties (SDQ) Questionnaire should be completed within six months of becoming Looked After and at annual intervals. The Review should identify who will do this. Independent Reviewing Officer/Social Worker The child/young person has a Personal Education Plan completed within 20 working days of becoming looked after and this is reviewed six monthly. It is important that there is an up to date record of the child’s school and social workers work in partnerships with schools and designated teachers to promote a child’s education, track their progress and agree and set priorities and targets. Virtual School/Social Worker An independent visitor is arranged for children and young people who would benefit from this service, including those who do not have contact with their birth family, in connection with the young person. Social Worker Page 89 of 111 Local authorities are required to appoint Independent Visitors for children and young people in their care who have had little or no contact with their parents for more than a year. Independent visitors are volunteers who are expected to befriend children, visiting them regularly and helping them participate in decisions about their future. The child is involved in making decisions about his/her own life and this is reflected in their plan. Decisions must be guided by the welfare checklist which may mean overruling a child’s wishes or preference based on balance of risks. Where this is the case, a full explanation will be given to the child and discussed at the Looked After Children Review. Social Worker A Permanence Plan is in place for the child/young person by the four-month review. An initial Permanence planning meeting must take place within 10 days of the child becoming Looked After. Subsequent Permanence Planning meetings must take place at least every six weeks in order to review the progress towards the Permanence plan. Permanence Planning Meeting should continue to be held up until the Permanence plan has been achieved. Social Worker/ Team Manager In the case of children who have a Placement Order in place for more than six months/Placed With Parents more than 12 months/Placed For Adoption more than nine months, Exception Reports should be completed. (See Appendix 5, Exception Reports, in the Draft Permanence Policy V8 August 2015). This version might now be different following procedures day. LOOKED AFTER REVIEWS The child/young person has a named IRO. Independent Reviewing Service (IRS)/Manager The first review is held within 20 working days of the child becoming looked after, the second within a further three months and subsequent reviews are held at intervals of not more than six monthly. If significant change in the child’s care plan is proposed, then an early review should be Social Worker/ Independent Reviewing Officer Page 90 of 111 arranged through the Independent Reviewing officer. A review is held prior to a child leaving care, if the child has been accommodated for at least 20 working days. The child/young person is given full opportunity to participate in his/her review through a variety of means. This may include a pre-meeting with the IRO. Children should be supported to participate in their looked after reviews, they may do this by attending in person, or providing their views to the meeting in writing or by other means. The review can be undertaken in a series of meetings. If they choose not to participate, the IRO should undertake a follow up visit or offer the child an opportunity to meet with the Children’s Rights Service. The means by which a child wishes to participate in the meeting should be discussed with him/her by the IRO and the social worker in sufficient time to allow for the appropriate arrangements to be put in place. If key professionals do not attend the review, they are expected to provide written information. This may include the school, the Virtual School and relevant health professionals. Social Worker/ Independent Reviewing Officer The review is attended by the child/young person’s parent/carer and key professionals. The child should be consulted about who they would like inviting to the review and this should be complied with unless there are valid reasons not to. Those attending the review will need preparation about the nature and purpose of the meeting, what will be discussed and how they will be expected to contribute to the discussion, who else will be there and how the meeting will be ran. Social Worker/Independent Reviewing Officer The Social Work Looked After Children Review Report is fully completed addressing all decisions from the previous review and available to the IRO: Three days prior to the Initial Looked After Review. Five days prior to subsequent Looked After Reviews. A care planning meeting prior to the review may assist the social worker in reflecting activities across the agency teams. Social Worker The Chair sends the recommendation of the review to the social worker and the Practice Supervisor and Team Manager within two days, Independent Reviewing Officer The Team Manager responds to confirm or challenge the recommendations within 5 Team Manager Page 91 of 111 working days of receipt of the recommendations. If the Team Manager does not respond within the timescale, the recommendations will automatically become decisions. If recommendation is challenged the subsequent dialogue and outcome should be fully recorded. Where agreement cannot be reached, the issue should be escalated through the line management process. The Chair’s report and review minutes are fully completed and available within 20 working days of review and sent to participants and key professionals. Independent Reviewing Officer ADOPTION OR LONG TERM LOOKED AFTER Work is undertaken with child to support them in planning for the future and understanding decisions taken. Life Story Work is prepared for and where appropriate with the child. For children placed for adoption, the Life Story Work has to be provided for the child and adoptive family by the 1st review in the pre-adoptive placement at the latest. The Later Life Letter has to be completed within 10 days of the Adoption Order. The local authority has a responsibility to ascertain the child’s wishes and views specifically in relation to the possibility of a placement for adoption with a new family, his/her cultural upbringing and contact with his/her parent/guardian/other significant relatives. Life Story Work is an essential part of preparing a child for a permanent substitute family and helps the child make sense of their past experience. Social Worker As soon as a possible adoptive placement is identified; the Adoption Social Worker and Social Worker must meet to review the application within two working days. Social Worker/Adoption Social Worker For children placed for adoption, information and counselling is offered to parents/birth family members. There is a statutory requirement to provide independent counselling and information to the parent or guardian of the child explaining the procedures in relation to both placement for adoption and adoption, and the legal implications of adoption and provide him/her with written information. The local authority has a responsibility to ascertain the parent/guardian’s wishes and views specifically in relation to the child, his/her placement for adoption including any views regarding his/her cultural upbringing and contact with the child. Social Worker/Adoption Social Worker Page 92 of 111 For children to be placed for adoption, an adoption support plan has been prepared. All children placed for adoption must have a support plan in place that identifies their individual needs and those of their new family. This plan may be updated and reviewed until the child is 18 years of age. Social Worker/Adoption Social Worker Exception Reports must be prepared if a child has been placed for adoption and the Adoption Order has not been made within 40 weeks. This should be repeated quarterly thereafter. (See Appendix 5, Exception Reports, in the Draft Permanence Policy V8 August 2015). This version may now have changed following procedures day. Social Worker A statutory review must take place within 20 working days of the date the child was placed for adoption; the second review must take place within three months and thereafter at intervals of not more than six monthly until the adoption order is made. Each review should consider the timing of an adoption application being made. Unless there are complexities which need to be resolved, an adoption application will normally be recommended at the second review. Social Worker/ Independent Reviewing Officer LEAVING CARE Pathway Plans 15 ½ to 17 Referrals are made at 15½ from the locality teams to the Pathway Team. The initial Pathway Pan and Needs Assessment is completed by the young person’s 16th birthday. Statutory responsibility remains with the locality team until the Initial Pathway Plan is signed off by the Pathway Team Manager at which point the case is transferred to the Pathway Team Social Worker. Pathway Plans (which incorporate the Single Assessment and the Care Plan) will be reviewed at the CLA reviews. Locality Practice Manager/Locality Social Worker/Pathway Team Manager/Pathway Social Worker Page 93 of 111 Pathway Plans post 18 Pathway Plans for young adults aged 18 to 21, or up to 25 if in Further Education will be reviewed in discussion with the young adult every six months. Personal Advisor/ Team Manager Referrals A referral will be made to the Pathway Team when a young person who is Looked After reaches the age of 15 ½. The form is called Pathway Plan Referral Risk Assessment and Transfer Summary. Locality Social Worker/ Practice Manager Case Transfers Following completion and the Initial Pathway Plan, Needs Assessment and Risk assessment, the locality team Practice Manager will ensure all tasks are complete. The Pathway Team Manager will them sign off the Initial Plan and transfer the case to the Pathway Team Social Worker. Locality Social Worker / Practice Manager Pathway Team Manager. Looked After Young People Looked After Young People transferred to the Pathway Team will have an allocated qualified Social Worker. Pathway Team Manager Supervision Frequency Formal supervision will take place monthly in respect of all cases of young people aged 16 and 17. Where young people are aged 18-21 and settled, supervision will take place every 2 months, otherwise it will take place monthly. For young people 21+ and over supervision will take place three monthly. Pathway Social Workers, Personal Advisors / Team Manager Minimum Visiting Frequency Relevant Young People remaining in a placement will be visited following Looked After Children requirements. Young people living semi, or fully independently will be seen aged up to 18, every two months, if they do not wish to see a Pathway Advisor the reasons why not will be Pathway Social Workers, Personal Advisors Page 94 of 111 recorded. 18 to 21 there will be contact or visits every two months, with the expectation that the young person will be seen within the four-month period, if they do not wish to see a Pathway Advisor the reasons will be clearly recorded. 21 to 25 where the young adult is in Higher Education contact will take place every three months. Text, e mail, and Facebook contact will be attempted where those young people do not want to see a Pathway Advisor. Vulnerable Young People Vulnerable young people who have a learning disability/difficulty or mental health problems will be referred to an adult services transition worker prior to their 17th birthday. Where a young person has a DCT Social Worker/Adult Social Care Social Worker they will remain the Lead Professional. The Pathway Team will provide access to financial support and will maintain the Pathway Plan in line with statutory requirement but will not be involved in service delivery. Pathway Social Workers, Personal Advisors At the first review following a young person reaching the age of 15½, the review will confirm that the Pathway Plan is being completed. Social Worker/Independent Reviewing Officer/ Pathway Worker A Pathway Plan is in place for the first review following the young person’s 16th birthday. A Pathway Plan records the assessed needs of the young person and the action and services required to respond to the assessed needs and to provide support during the transition to adulthood and independence. Social Worker/ Pathway Worker The young person is fully involved in developing the Pathway Plan and it reflects Social Page 95 of 111 his/her priorities and aspirations Worker/Pathway Worker Statutory reviews of the plan are held at intervals of not more than 6 months. The Pathway Plan should be kept under regular review to ensure the services delivered are in accordance with the wishes, views and needs of the young person. Social Worker/Pathway Worker/ Independent Reviewing Officer The Pathway Plan is updated following the review. Social Worker/Pathway Worker Page 96 of 111 APPENDIX FIVE This child sexual exploitation (CSE) risk assessment information sheet should be completed alongside the Child Sexual Exploitation Risk Assessment. All of the following information is required when there are concerns regarding a child being at risk of /or experiencing CSE. This assessment should be completed within 10 working days. Child’s full name Alias DOB Age Gender M/F Ethnicity Religion Is English their first language? Child Yes No Parent/Carer Yes No If no, please specify preferred language Is an interpreter required? Y/N Address and postcode Contact number(s) School (if known) Other children (under 18 years of age) in household Full Name Date of Birth/Age Gender M/F Relationship to the above child Calderdale’s Child Sexual Exploitation Risk Assessment Information Form (Part 1) Page 97 of 111 Details of Parent/Carers and other significant adults in household Full Name Date of Birth (if known) Parental Responsibility (PR) Y/N Relationship to the above child Other agency/professional involvement GP details and contact number (if known) Professional Completing the CSE Risk Assessment Name Job Title/Role Agency Address & Contact Details Date Assessment commenced Date assessment completed Initial/Review Assessment ? Page 98 of 111 West Yorkshire Child Sexual Exploitation Risk Assessment (Part 2) The West Yorkshire Child Sexual Exploitation Risk Assessment should be developed alongside with and complimenting any other plan for the young person’s welfare. Please use this tool in line with local LSCB Procedures. Professional Assessment of CSE Risk Indicators In order to identify children at risk of sexual exploitation or experiencing sexual exploitation and following a clear plan of effective inter-agency action, consider ALL of the 14 risk indicators and record a level of risk against each, before proceeding according to local procedures. Note: where a child under the age of 13 years old, and /or has learning disability and there are concerns regarding sexual exploitation, a referral to Children’s Social Work Services is required. The 14 main heading risk indicators are not exhaustive; they are simply those mostly commonly recognised which may indicate a risk of sexual exploitation; there may be other relevant factors present which require consideration and analysis. One tick in a high risk box, or several in low risk may indicate a serious risk of sexual exploitation, alternatively this might be an indication of other concerns that require addressing via the child’s overall plan, or by accessing other appropriate services The risk and vulnerability factors provided against each of the 14 risk indicator headings are also not exhaustive; they are simply prompts for consideration. Consequently, the recorded risk for each of the 14 risk indicators does not necessarily need to correspond with the risk and vulnerability factors highlighted. It is therefore important to provide analysis to evidence how the assessment of an individual risk indicator has been achieved. When assessing a child or young person’s risk of CSE, it is essential to highlight if the concerns and the information being provided is current or historic. If the concern or information is historic but relevant, it is necessary to evidence how this relates to the current assessed risk. When completing the CSE risk assessment, it is crucial that the child or young person’s use of social media is considered throughout. *Please indicate a level of risk against ALL the following 14 risk indicators Page 99 of 111 (1) Family and peer relationships Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low Carer(s) show warmth, support the child and have positive communication with the child. Appropriate boundaries are in place and effective. The child /young person has positive friendships. But reported reduced contact with family /friends which is of concern and /or there is an unexplained change in attitude from the child /young regarding the relationship, which raises some concerns. Medium Carer(s) lack understanding, tolerance and warmth towards the child. Parents fail to report missing episodes. Family relationships are strained. Friends /carers report a change in behaviour /reduced contact. Appropriate boundaries are not always adhered to. Family /Friends /peers are known offenders. High Suspected abuse in family (emotional, neglect, physical or sexual). There is little or no communication between the carer(s). There is a lack of warmth/understanding, / attachment and /or trust. Parents fail to report missing episodes / Parent/Carer does not implement age appropriate boundaries. Breakdown in family relationships / no contact. Family /Friends /peers are known offenders. Child /young person is socially isolated from peers. Friends are assessed to be at risk of CSE. Analysis Page 100 of 111 (2) Accommodation Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low Some accommodation issues / concerns, but overall accommodation meets the child /young person’s needs and the child is happy. Medium Unsuitable/ unstable / temporary/overcrowded/hostel /refuge/ unsupported. The child /young person is unhappy with their accommodation and this impacts on their risk of CSE. Lives in a gang neighbourhood. High Unsuitable /unstable / temporary/ overcrowded/hostel. /refuge/unsupported. Concerns about location and isolation. The child /young person is unhappy with their accommodation and often stays elsewhere. Homeless or Sofa surfing. Care leaver or Looked After Child. Analysis (3) Education Risk Indicator No risk Identified No concerns identified in this area which relate to sexual exploitation. Low Mainly engaged in employment / school /training. Some truanting but limited concerns, mainly positive friendships in education /training or employment setting. Medium Full time education /training or employment but irregular /poor attendance / whereabouts during school hours often unknown. Attendance at PRU /poor attendance. Regular breakdown of school /training placements due to behavioural problems. Friendships in education /training or employment setting are with others at risk of CSE. Noticeable change in attendance, performance or behaviour. High Regular breakdown of school /training placements due to behavioural problems. Not engaged in education/employment or motivated to be. Excluded. Whereabouts often unknown. Friendships /peer groups either within or outside the education/ employment /training setting are with others at risk of CSE. Analysis Page 101 of 111 (4) Emotional Health Risk Indicator No risk identified No concerns identified in this area which may relate to sexual exploitation. Low Concerns regarding fatigue, poor self-image, expressions of despair, low mood, Self-harm, Cutting, Overdosing, Eating disorder. Some sexualised risk taking. Medium Low self-esteem / self-confidence, expression of despair. Internal Self-harm: Cutting, Overdosing, Eating disorder. Sexualised risk taking. External (intensive acting out): Bullying / threatening behaviour, aggression, violent outbursts, Offending behaviour, sexualised risk taking. Concerning substance misuse. High Chronic low self-esteem / self-confidence. Mental health problems, expression of despair. Internal (Self-harm): Cutting, Overdosing, Eating disorder. Previous suicide attempts, sexualised risk taking. External (intensive acting out), Bullying / threatening behaviour, Violent outbursts, Offending behaviour, Repeated sexualised risk taking. Dependency on substances /alcohol. Analysis (5) Experience of Violence Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low No known reported incidents of the child /young person being a victim of violence or witnessing domestic abuse, (including peer relationships) although some professional concerns. Medium Concerns that the child /young person has been /is being exposed to violence in the home and /or from others. Abusive significant relationship. Physical symptoms suggestive of physical /sexual assault. Disclosure of Page 102 of 111 physical / sexual assault followed by withdrawal of allegation. Living in a gang neighbourhood. High Known abuse towards the child /young person from family members. Peers /older friends/partners are violent towards the child /young person. Abusive significant relationship. Physical injuries – external / internal / disclosure of physical / sexual assault. Evidence of coercion /control. Analysis (6) Running away / going missing Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Concerns relate to behaviours which fall within normal child /young person behaviour. Low Often comes home late / Incidents of absence without permission and returning late. Whereabouts often unknown. Medium Often staying out late or overnight without permission /explanation. Whereabouts at times unknown child /young person secretive about where whereabouts. Repeated episodes of running away / going missing / away from placement. (Including short periods). Regular breakdown of placements due to behavioural problems. High Frequently reported missing due to /extensive and /or frequent periods of missing /running away /away from placement. whereabouts often unknown. Missing with others known to be at risk of CSE. Looking well cared for /not hungry, despite having no known base. Regular breakdown of placements due to behavioural problems. Pattern of street homelessness. Analysis Page 103 of 111 (7) Contact with abusive adults and / or risky environments Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Child / Young person has a good understanding of exploitative / abusive behaviour and can use it to keep themselves safe (including how to stay safe on social media /internet). Low Associating with unknown adults and /or other children at known to be at risk of sexual exploitation. Living in a gang neighbourhood. Accessing one or more social networking sites and may be ‘friends’ with a number of unknown people, but there are limited concerns. Medium Associating with unknown adults and/or other sexually exploited children /young people. Extensive use of phone (particularly late at night, & secret use). May have use of more than one mobile phone. Has access to premises not know to parent / carer. Reports from reliable sources, suggesting involvement in sexual exploitation. Reported to have been in in areas where there are concerns related to sexual exploitation and /or street sex work is known to take place Some understanding of abusive / exploitative behaviour and may recognise risks but unable/unwilling to apply knowledge. High And /or Evidence of association /relationships with adults /older peers believed /known to be involved in grooming /exploitation. Willing to meet up with people they have only met online. Seen /or picked up, in areas where street sex work is known to take place. Gang association either through relatives, peers or intimate relationships. Very limited or no recognition of abusive / exploitative behaviour. Analysis (8) Substance misuse Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low Mild use of substances (including alcohol) drugs /alcohol, but concerns Page 104 of 111 relate to behaviours which fall within normal experimental behaviour. Medium Evidence of regular substance (including alcohol) use. Concerns for use / dependency & change / increase of use. Some concerns regarding how substance misuse is being funded. Concerns regarding how substances are being accessed. High Evidence of heavy /dependant /worrying substance misuse (including alcohol). Chronic dependency of highly addictive substances. Increased concerns for use / dependency and funding and supply of usage. Analysis (9) Coercion / control Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low Some concerns about coercion /control within significant relationships. Reduced contact with family / friends, which raises concern. Medium Limited contact with family / friends. Appears to be ‘controlled’ / negatively influenced by others. Concerns about significant relationships and domestic abuse / violence. Disclosure of physical / sexual assault followed by withdrawal of allegation. Physical injuries – external / internal. Child / Young person is known to be associating with risky adults and /or peers and does want to alter this. High No contact with family / friends. Disclosure of physical / sexual assault followed by withdrawal of allegation. Physical injuries – external / internal. Significant relationship (s) is assessed to involve abuse /violence/ or is controlling. Abduction / forced imprisonment. Disappears from system (no contact with support systems). Gang association through relatives / peers or intimate relationships. Child / Young person is actively involved with a gang or criminal group or associated to gang members. Analysis Risk Indicator No risk No concerns identified in this area which relate to sexual exploitation. Page 105 of 111 (10) Rewards identified Low Some unaccounted for monies and / or goods (new clothes, make –up, mobile top-ups, etc) and ability to fund non tangible goods. Medium Concerns about unaccounted for monies and / or goods, (new clothes, make –up, jewellery and mobile phones, mobile phone top –ups etc. Concerns regarding the funding of misuse of drugs /alcohol /use of tobacco through unknown sources. Some concerns about how the child / young person funds other items (fast food, taxi fares, etc). High Significant concerns regarding unaccounted for monies and / or goods, especially jewellery, items of clothing and mobile phones, which the child / young person is unable to provide explanation for. Has use of more than one mobile phone. Significant concerns about who / how the child / young person funds items such as fast food, taxi fares, alcohol and substance use, cigarettes, entry into clubs, trips away from home, etc. Analysis (11) Sexual health & relationships Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation, is not sexually active and is aware of where to get support and advice when needed. Low Young person is sexually active and in an equal consensual relationship with a peer. Young person does not feel pressured, they feel they can say ‘no’ and is following ‘safe sex’ advice. Possible evidence of having /had a sexually transmitted disease. Medium Recurring or more than one sexually transmitted disease. Miscarriage(s) /concerns about untreated STi’s, termination(s) Pregnancy. Young person is sexually active, is not practising safe sex and is not accessing /willing to access support from any sexual health services. High Recurring or multiple STI’s. Concerns about untreated STIs. Miscarriage(s), Termination(s) pregnancy. Physical symptoms suggestive of sexual assault. Young person presents as feeling pressured to have sex or to perform sexual acts in exchange for status /protection, possessions, substances or affection. Young person is in a sexual relationship with an adult / there is a wide age gap. Child is under 13 and sexually active, or Sex is non-consensual –young person is experiencing violence or coercion with sex, or are unable to consent due to intoxication /substance misuse. Page 106 of 111 Child / Young person is made to watch sexual acts being performed on others. Analysis (12) Sexualised Risk Taking Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low Some concerns about sexualised dress / attire. Some reports (to parent /carers) about getting into cars with unknown peers /adults. Contacting unknown adults /older peers through the internet, but concerns are limited. Medium Overt sexualised dress / attire. Reports of getting into cars with unknown peers / adults. Has access to premises unknown to parents/carers. Concerns about proactive inappropriate /risky use of the internet and social media, sharing of images, sexting, making contact with adults / peers via social media. Older boyfriend (5 + years). High Overt sexualised dress / attire. Reports of getting into cars with unknown peers /adults. Accessing premises which are unknown to parents /carers. Clipping (offering to have sex and then running upon payment) Has posted inappropriate language / information / sexual pictures, when asked to by an adult / older peer / unknown person, and /or proactively uses the internet /social media to share images, make contact / arrange to meet up with adults / peers. Socialises with children /young people/adults known to be involved with sexual exploitation. Evidence of sexualised bullying via the internet /social media sites. Older boyfriend (s) (5+ years). Analysis Page 107 of 111 (13) Risk to others Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Low No identified risk to others, but mild concerns about influence on other children & young people relating to CSE. Medium Concerns regarding negative influence on others relating to CSE. Concerns that the child might expose other children to risky situations /places /people. Bullying and threatening behaviour. Offending behaviour. High Places other children at risk of child sexual exploitation, via friendships, associations, venues. Displays violence towards others, angry outbursts (including family members and carers). Bullying and threatening behaviour. Offending behaviour. Gang association either through relatives, peers or intimate relationships. Analysis (14) Engagement with services Risk Indicator No risk identified No concerns identified in this area which relate to sexual exploitation. Concerns relate to behaviours which relate to normal child / young person behaviours. Low Lack of engagement, some difficulty in contacting the child /young person which raises concern. Medium Some engagement but sporadic contact, often misses appointments, limited explanation, professional concern, sudden or lack of engagement, secretive and unwilling to engage meaningfully. High Brief engagement, frequently fails to attend appointments, or no contact/ engagement with services. Limited explanations / secretive and unwilling to engage meaningfully, concerning change in behaviour. Analysis Other child & family factors to consider. (Please highlight if any Family: Including: Abuse /neglect in the family. Parental Substance misuse, Parental mental health, adult prostitution.) Child: Including: Learning disabilities, financially unsupported, Migrant /refugee /asylum Page 108 of 111 are relevant.) seeker, recent bereavement/ loss or illness of a significant person in the child’s life, young carer. Unsure about sexual orientation or unable to disclose sexual orientation to their families. Views of the child or young person. (regarding any identified/ potential risks and any support they would want/need) Has the child/young person contributed to this assessment (Yes/No and if no please explain why) Views of the parent / carer. (regarding any identified/ potential risks and any support they would want/need) Other information (*Such as the name of adults /peers about who there are concerns, relating to the child’s risk of CSE) Overall analysis Page 109 of 111 Calderdale’s Child Sexual Exploitation Risk Assessment Decisions and Further Action (Part 3) On completion of this risk identification tool, please make an initial judgement about the level of risk of Child Sexual Exploitation for the child / young person. Please tick against your assessed level of risk and discuss this with your Team/Line Manager /designated Child Protection Lead and take appropriate action to manage the risks, in accordance with the Local Authority / LSCB CSE procedures. Overall Assessed Level of CSE Risk No risk Whilst there may be concerns for the welfare of the child /young person, which may involve the requirement of service provision, for other assessed risks, the assessment or risk indicates that there is no current risk of the child /young person being at risk of, or experiencing sexual exploitation. (Consider an Early Intervention Single Assessment (EISA) and/or a referral to the Early Intervention Panel for additional support services if required) Low Risk The indicators and assessment raise some concerns that the child /young person is at risk of sexual exploitation, and /or places him /or herself at risk. Concern that the child / young person is at risk of being targeted or groomed, but there are positive protective factors in the child /young person life. (Please refer into the CSE hub who will provide additional support/advice and consider a joint visit – should the risk level be agreed the case will be discussed at the weekly CSE Matrix meeting to determine If the child/young person’s name should be added to the Matrix or signposted for additional services) The assessment indicates that the child /young person is vulnerable to being sexually exploited / but that there are no immediate /urgent safeguarding concerns. There is evidence the child /young person may be a risk of opportunistic abuse, or is being targeted /groomed. The child /young person may experience protective factors, but circumstances Page 110 of 111 Medium Risk and /or behaviours place him / her at risk of sexual exploitation. (Please refer into the CSE hub who will provide additional support/advice and consider a joint visit – should the risk level be agreed the case will be discussed at the weekly CSE Matrix meeting and the child/young person’s name WILL be added to the Matrix and signposted for additional services) High Risk Indicators /Assessment /Evidence /disclosure, suggests that the child /young person is assessed to be engaged in high risk situations / relationships /risk taking behaviour and is at immediate risk of, or is experiencing sexual exploitation. (They may not recognise this) (Please refer into the CSE hub who will provide additional support/advice and consider a joint visit – should the risk level be agreed the case will be discussed at the weekly CSE Matrix meeting and the child/young person’s name WILL be added to the Matrix and signposted for additional services) What support services will be provided by your own agency? Is the case being referred to the Early Intervention Panel Yes/No, if Yes what support/services are you requesting? Is the case being referred to the CSE Hub? Yes/No Date of referral to CSE Hub Line Manager/ Designated Child Protection lead verification Date agreed Process and Timescales Once the assessment is completed within 10 working days if the outcome is ‘no risk’ the assessment does not need to be sent to Calderdale’s CSE hub, however you can contact the hub via email for advice if required. If additional services are required via the Early Intervention Panel, then consent will be required by the child/young person and parent/carer. If the outcome is ‘low, medium or high’ then refer to the CSE hub via email with a copy of your CSE risk assessment and they will contact you and provide a consultation of your assessment and decide if a joint visit is required to determine/agree the risk level within five working days. Please send this assessment electronically via secure email to: [email protected] CSE HUB ONLY Date CSE risk assessment received into the CSE Hub Date CSE risk assessment discussed at daily meeting by the CSE Hub Which worker/ agency (from the CSE hub) will follow up consultation/joint visit Date contact made with the referrer Advice or action taken Page 111 of 111 Assessed Level of Risk Is this the same level as above Yes/No? If level has changed, please highlight what the lower or higher risks are Is the plan for the child young person’s name to be placed on the Matrix Yes/No? Date of Matrix Meeting Level of Risk on Matrix Review timescales For those children and young people who are judged to be at low, medium or high risk of Child Sexual Exploitation, the level of risk must be reviewed with an updated risk assessment at the following frequency unless additional concerns are raised which require an immediate updated risk assessment. Low risk – every three months Medium risk – every three months High risk – bi-monthly If you are making a referral to an Early Intervention Panel or Children’s Social Care (MAST) then please complete the Early Intervention and Safeguarding Statutory Referral/Request for Service form and attach an Early Intervention Single Assessment (EISA) and the CSE Risk Assessment if completed. For urgent or immediate Child Protection concerns, please contact MAST/or the police on 999 and do not delay by completing any forms. REFERRAL TO MAST: Secure e-mail: [email protected] NB; only works when sending from another secure email address, or FAX: 01422 392875 or Telephone 01422 393336 REFERRAL TO EIP: Upper Valley [email protected] - 01422 368279 Lower Valley [email protected] - 01422 394094 Halifax Central [email protected] - 01422 392510 North & East [email protected] - 01422 392495 Should you have any CSE information please complete the West Yorkshire information form and send to [email protected] |
NC52634 | Death of a 9-week-old-boy in November 2018 from non-accidental injuries, including a very serious injury to his brain and fractured bones. The investigation into his death is ongoing at the time of this report being written. It would appear from the post mortem that Child 'T' had fractures in his left leg at the time of a GP visit just before his death. The mother and maternal grandmother voluntarily took him to a GP as they were worried about his feeding and posseting. The symptoms as described are consistent with reflux, so a full body examination was not given and the doctor had no cause for concern in the mother's or grandmother's interactions with the baby. Concludes that: there were no obvious issues that would have suggested to staff working with the family that Child 'T' was at risk of abuse or neglect; with the exception of a missed pre-birth visit by health visitors, agencies did accord with their own policies and procedures and managers within public health and the midwifery service are taking action to resolve the communication issue; there is evidence of good practice in the record keeping by both midwives and health visitors; and staff in both agencies kept comprehensive records that clearly evidenced assessments they completed and conversations they had with parents to discuss known risk factors to babies.
| Title: Serious case review: Child ‘T’. LSCB: Barnsley Safeguarding Children Partnership Author: R. Dyson Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Serious Case Review Child ‘T’ Barnsley Safeguarding Children Partnership Independent Author: R Dyson QPM, DL, MA, PG Dip (Cantab), FIL&M Report completed June 2019 (unable to progress due to police investigation) Presented to BSCP for sign off March 2021 (unable to publish due to pending prosecution) 2 1. Introduction Child ‘T’ was born in Barnsley on the 27 September 2018. On 30 November 2018 the Mother of Child T (MCT) called for an ambulance to attend the home address as Child T was ‘Floppy’. He was conveyed to Barnsley Hospital but was later transferred to the Sheffield Children’s Hospital where he died on 3 December 2018. He was nine weeks old. Medical evidence shows that he died of non-accidental injuries which led to a homicide investigation being commenced by South Yorkshire Police. That investigation is ongoing at the time of writing this report. His injuries included a very serious injury to his brain and fractured bones. A decision was taken by the Barnsley Safeguarding Children Board to commission a Serious Case Review to establish if there were any lessons to be learned that would help to safeguard other children in the future. 2. Why Commission a Serious Case Review (SCR)? At the time of Child T’s tragic death, the partnership arrangements for Safeguarding Children in Barnsley was the Barnsley Safeguarding Children Board which was operating under the Department for Education guidance document ‘Working Together to Safeguard Children 2015’1. Included in that guidance document is the criteria of circumstances that should result in an SCR being commissioned:- Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. It can be seen that Child T’s death meets the circumstances described in Regulation 5 (2)(a&b), in that abuse or neglect of a child is known or suspected and the child has died. 1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf 3 Chapter four of Working Together to Safeguard Children 2015 sets out the principles of an SCR which includes: • there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; • The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; • Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process. The aim of this SCR is to establish if there are any lessons to be learned that may help to safeguard other children in the future; it is not to apportion any blame. This SCR does not enquire into who may be responsible for Child T’s injuries that resulted in his death. That is the role of the Police investigation. Care has been taken to ensure that this SCR does not compromise or interfere with that homicide investigation. In line with the principles shown above, it is a proportionate review. 3. Methodology The author is independent of the agencies that engaged with Child T and his family. The approach has been to-: • Look at records kept by agencies and to see if they evidence compliance with policies and procedures • Speak with members of staff who interacted with the family • Liaise with the police investigators to ensure that this review did not compromise the police investigation. • Liaise with a Doctor who has a role in Safeguarding within a Clinical Commissioning Group • Identify any aspects of good practice. Given that this review took place whilst the police homicide investigation was ongoing, it was agreed that it would be inappropriate for the author to meet with Child T’s parents. However, it was considered that it was important that his parents were aware of the review and be given the 4 opportunity to make a written submission to the author, if they so wished, on the services that they, and their child, received. The author sent a letter to the parents but received no response. 4. Background Information The parents of Child T were/are in a long term relationship and Child T was a planned first baby for the couple. Prior to MCT (Mother of Child T) becoming pregnant, the parents were not known to any services connected to children. Neither parent had any previous involvement with Children’s Social Care, nor were they known to the police for any incidents of Domestic Abuse or for any previous convictions or cautions for any offences that may give rise to concern about their ability to care for a child. They were not known to substance misuse services or Mental Health Services. The risk factors of Domestic Abuse, Mental Health and Substance Misuse, often referred to as the Toxic Trio, which are a feature in many cases of child abuse and neglect, were not evident in this case. From the point that MCT is confirmed pregnant by the General Practice Doctor, the access to universal services, that is those services which are available to all pregnant women, was as would be expected. There was one exception to that, which I detail below, but it has no bearing on the case. The Midwifery Service is provided by Barnsley Hospital NHS Foundation Trust and the Health Visitor Service is provided by the Public Health element of Barnsley Metropolitan Borough Council. The Midwifery Service informs the Health Visitor service of women who are pregnant and who have begun to be engaged by their service. In Child T’s case this notification took place in July 2017. The Health Visitor Service normally carry out a Home Assessment visit prior to the birth of the child in order to introduce themselves to the mother/family and to carry out an assessment of the home’s readiness and suitability for the arrival of the baby. Before making contact with the mother to arrange the visit, the section of the Health Visitor Service that covers where the family lives, send an email to the Midwifery Services to get confirmation that the pregnancy is still viable. The reasoning for this confirmation email is to avoid a Heath Visitor making contact with a family where there has been a problem with the pregnancy and thereby causing unintended upset. The Health Visitor Service did not receive a response to their email and so did not carry out that initial visit. As stated above, this had no bearing on the case and did not put Child T at risk; all necessary checks and assessments were completed after the birth and did not raise any issues of concern. The Midwifery Service have checked for receiving the email but cannot trace it. They do have a pathway that informs Public Health in the event of a foetal death; that pathway did not apply in this case. Managers within both Public Health and the Midwifery Service are aware of the communication issue that resulted in the missed home assessment visit by Health Visitors. They are taking action to resolve it. Whilst the missed appointment had no impact in this case, both services recognise that it could have an adverse impact in other circumstances. Throughout her pregnancy the parents of Child T fully engaged with the ante natal system run by the Midwifery Services. MCT attended all expected appointments, in some instances she was 5 accompanied by her partner, on others she was unaccompanied. This mix of accompanied and unaccompanied visits is helpful to professionals; it allows them to get to know the father (FCT) of the child and to involve him in the conversations about risk factors whilst unaccompanied visits allow professionals to speak with mother about sensitive subjects such as whether or not they are a victim of Domestic Abuse. The records kept by the individual midwives display a thorough approach to record keeping and it is clear that they spoke with MCT and FCT about relevant risk factors associated with new born babies. Child ‘T’ was born on 27 September 18 at Barnsley Hospital and discharged the following day, 28 September 18. A midwife visited the family home the following day, 29 September 18, and conducted a check of the baby’s bedroom and discussed safe sleeping, shaken baby syndrome, safe smoking. Child ‘T’ was stripped and examined. A midwife visited on 30 September 18 due to Child ‘T’ being a first child for the parents and noted that he was slightly jaundiced. This is not an unusual situation for new born babies. An additional visit was made the next day, 1 October 18, to check on the jaundice. At that time both parents and maternal grandmother (MGCT) were present. Child ‘T’ was seen again by the Midwifery Service on 2 October 18 at a local centre for a routine blood test. It was noted that he was slightly jaundiced but this was not a cause for concern. The last contact with the Midwifery Service was 8 October 18 when there were no concerns and Child ‘T’ was discharged. At this point contact passed to Health Visitors employed by Public Health with the first visit taking place on 10 October 18. The Health Visitors, an experienced Health visitor accompanied by a Student Health Visitor, discussed a range of known risk factors with the parents who were both described as being very loving. On 9 November 18, GP1 carried out a routine examination of Child ‘T’. All new born babies are seen by a GP between six and eight weeks after birth. The primary purpose is to check for any congenital conditions but a thorough examination took place including examination of the, eyes, nose, mouth, abdomen etc. The baby is stripped for this examination. MCT did inform the GP1 that the baby was struggling to breathe through his nose when feeding; nasal drops were prescribed. The examination of Child ‘T’ did not raise any concerns. There were no signs of any injuries. Other routine visits took place by Health Visitors. On 28 November 18, Child ‘T’ was seen by GP 2 having been taken to the surgery by MCT and MGCT Maternal Grandmother Child T) for two issues. Child ‘T’ was described as being irritable and not feeding normally, only taking 3oz of feed rather than 5oz. He was also posseting after feeds. GP2 did not physically examine Child ‘T’. The GP advised adding Gaviscon to his feed and gave a prescription. A discussion also took place about a potential change of milk with MCT being advised to discuss with Health Visitors (MCT did speak with a Health Visitor after the visit to the GP). The second issue was a skin tag on baby’s ear which MCT wanted removing. There was nothing in the interaction between MCT and baby that concerned the GP. 6 It is understood that the post mortem examination of Child ‘T’ shows that he had fractures to the main bones in his left leg which pre date the ambulance call on 30 September 18. It would appear that Child ‘T’ had those fractures when seen by the GP2 on 28 September 18. This raises the question as to whether or not this visit to GP2 was a missed opportunity to identify non accidental injuries prior to the day when he received injuries that led to his death. It is important to remain objective and to avoid hind sight bias when conducting reviews. This was the first presentation by MCT and MGCT of a baby who was reported not to be feeding normally and posseting. MCT and MGCT gave no cause for concern in their interactions with the baby and had brought it to see a Doctor at their own volition. There had been no concerns from any professionals about the family throughout the pregnancy or during Child T’s tragically short life. Consequently, there was no information recorded that might have caused the GP to suspect that Child T was the subject of physical abuse. Having discussed this situation with a Doctor who has a Safeguarding role within a Clinical Commissioning Group, it does not seem unreasonable for GP2 to have acted as they did, and that is to not conduct a full physical examination. The symptoms as described are consistent with reflux. A full examination was unlikely to discover the fractures. That said another GP may have chosen to examine the baby’s abdomen despite that having happened just 19 days previously at the six week check. This visit to the GP was the last occasion that Child ‘T’ was seen by a health professional prior to the ambulance call on 30 November 18. 5. Conclusions This review has not found any concerns about the way that professionals worked with the family. There were no obvious issues that would have suggested to staff working with the family that Child ‘T’ was at risk of abuse or neglect. Those professionals who met with the family and/or visited the home speak in positive terms of their interaction. With the exception of the missed pre-birth visit by Health Visitors agencies did accord with their own policies and procedures. The author is satisfied that managers within Public Health and the Midwifery Service are taking action to resolve that communication issue and does not feel that it warrants a formal recommendation. There is evidence of good practice in the record keeping by both Midwives and Health Visitors. Staff in both agencies kept comprehensive records that clearly evidenced assessments they completed and conversations they had with parents to discuss known risk factors to babies. The National Child Safeguarding Practice Review Panel, that oversees the system of Serious Case Reviews and Child Safeguarding Practice reviews acknowledge in their guidance document published in April 20192 that children can be abused or neglected despite good work by professionals; 2 Child Safeguarding Practice Review Panel: practice guidance, April 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793253/Practice_guidance_v_2.1.pdf 7 ‘we recognise that because of the nature of maltreatment, children may die or be seriously harmed even when practice is exemplary. And often despite the good work that is being done by practitioners’ It is considered that this case is an example of such circumstances. The only person/persons who have responsibility for Child T’s abuse and tragic death, is those that inflicted the non-accidental injuries. The police investigation will seek to identify them. |
NC048269 | Death of an 8-year-old boy in October 2014 as a result of a normally treatable kidney infection. LN15 was known to paediatric services from the age of 14 months for developmental delay, chronic constipation and floppiness. Attendance at physiotherapy, neurology and occupational therapy appointments was sporadic and he was not registered with a GP for two years before his death. In September 2014 his school attendance decreased due to ill health. Issues identified include: correspondence not received due to frequent house moves; not seen by paediatric services for three and a half years prior to his death; safeguarding issues when a child is not registered with a doctor especially those with long term conditions; evidence of the mother making decisions about treatment and medication; the child's needs and global development not recorded by staff caring for him. Lessons learned include: changes to practices at the Trust including an end to the partial booking system for children and provision of a key worker to link between services; the need to record address, telephone number and GP details at every appointment; updating interagency cross authority procedures to provide more detail of medical neglect. Makes recommendations to strengthen cooperation between hospital-based services and general practitioners; to have policies in place to change Did Not Attend records to Was Not Brought to emphasise the child's vulnerability; for NHS England to review Royal College of Paediatrics and Child Care standards for the care of children with long term health conditions.
| Title: SCR LN15: overview report. LSCB: Nottinghamshire Safeguarding Children Board Author: Hayley Frame Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SCR LN15 Overview Report A serious case review under Regulation 5(1) (e) and (2) of the Local Safeguarding Children Boards Regulations 2006 Author Hayley Frame 2 Contents 1. Decision to hold a Serious Case Review 3 2. Parallel Processes 3 3. Scoping period 4 4. Lead Reviewer 4 5. Organisations involved in the review 4 6. Methodology 6 7. Terms of Reference 7 8. Involvement of family members 7 9. Perceptions of the family 8 10. Background Information 8 11. Case Narrative (scoping period) 12 2011: the last involvement of the paediatric outpatient clinic 2012 - 2013: Including de-registration from the GP practice 2014: LN15 becomes acutely unwell 12. Information that has become available subsequent to LN15’s death 19 13. Family Perspectives 20 14. Practitioner perspectives 23 15. Analysis 25 16. Changes to Practice 33 17. Conclusion and recommendations 34 3 1. Decision to hold a Serious Case Review 1.1. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. A serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2. This review has been initiated following a referral to the Nottinghamshire Safeguarding Children Board on 24th July 2015 following the death of LN15 on 28th October 2014. LN15 died as a result of pyelonephritis (kidney infection), which is normally a treatable condition, and there were concerns regarding abuse or neglect. The delay in the referral to the LSCB was as a result of waiting for the post mortem results to become available. 1.3. On 9th September 2015, the NSCB Serious Incident Review (SIR) sub group recommended that a Serious Case Review be completed in respect of LN15 and the decision to complete a Serious Case Review was made by the Independent Chair of the Nottinghamshire Safeguarding Children Board on 14th September 2015. 2. Parallel Processes 2.1. Following the unexpected death of LN15, a rapid response child death review process was instigated in accordance with Working Together to Safeguard Children 2015. This process included 4 multi agency meetings being held to review the factors related to his death. 2.2. In addition, Sherwood Forest Hospitals NHS Foundation Trust completed a Serious Incident Investigation following LN15’s death. 2.3. In the autumn of 2015 an inquest took place in respect of the death of LN15. The findings and conclusions were 16 pages in length. The conclusion was that he died of natural causes. The Coroner stated that she did not make any findings of neglect in relation to the sudden onset of pyelonephritis which led to LN15’s death. However a Regulation 28 Preventing Further Deaths Report was made by the Coroner in respect of the system for registering children with GPs. 4 2.4. The decision to conduct a serious case review was reviewed in light of the findings and conclusion of the inquest. The Independent Chair of the Nottinghamshire Safeguarding Children Board concluded that the criteria for a SCR were still met in that neglect was at least suspected to be a factor in LN15’s death and that if medical attention had been sought he was unlikely to have died. Given the volume of information available as a result of the robust investigative processes that had already been undertaken, it was decided that the review would adopt a proportionate and streamlined methodology (as outlined below). The review would focus upon agency learning to ensure that all lessons arising from LN15’s death were learned and lead to achievable actions for change. 3. Scoping period 3.1. The focus for the review is from the date of LN15’s last consultation with a paediatrician, 10th March 2011 until his death on 28th October 2014. 4. Lead Reviewer 4.1. Hayley Frame, Independent Safeguarding Consultant, has been commissioned as the lead reviewer in this case. 5. Organisations involved in the review 5.1. The following organisations have been involved in the review. The relevant services that each organisation provided are described below: Sherwood Forest Hospitals NHS Foundation Trust Consultant Paediatric service providing inpatient and outpatient neonatal care as well as an Emergency Department which LN15 attended on one occasion within the scoping period prior to his death Primary School Provision of state education to LN15 Nottinghamshire County Council Children’s Social Care Responsible for Children’s Social Care Services, Children’s Disability Services and Occupational Therapy Services (to provide support within the home) Nottinghamshire County Council Education 5 Provision of Physical Disabilities Support Services which provide support to LN15’s school. GP Practice Provision of general practice services to LN15. LN15 had very little contact with his GP. He was not registered with a GP after 29th November 2012, following a move to a different area. LN15 was not registered with a dentist. Nottinghamshire Healthcare NHS Foundation Trust School Health offer a service to all children aged 5-19 years, including children and young people who do not attend school. The team review health at key stages and provide information, advice and support about health issues. Where a child has complex needs and support is in place from other services, then often no school nursing intervention is required. Specialist School nurse (continence) - a specialist service. Paediatric Physiotherapy and Paediatric Occupational Therapy service - provides physiotherapy and occupational therapy assessment and treatment for children who have a disability or long term condition affecting their movement or mobility. (Occupational Therapy focuses on fine motor skills and not equipment like the Occupational Therapy Services which are part of Children’s Social Care). Speech and Language Therapy Services NHS England Commissioners of health services including co-commissioner of GP services with Clinical Commissioning Groups (CCGs) and oversight of CCGs. Mansfield and Ashfield Clinical Commissioning Group Co-commissioner of GP services Nottingham University Hospitals NHS Trust (prior to scoping period) Provision of outpatient neurology services 6 6. Methodology 6.1. Working Together to Safeguard Children 2015 (WT2015) allows Local Safeguarding Children Boards flexibility around the methodology to be adopted for serious case reviews. This review will adhere to the principles laid out in WT2015 and the NSCB local procedures. 6.2. In view of the significant investigations and the inquest which have already been completed a proportionate methodology was adopted for this review. The Lead Reviewer had sight of and considered the following documentation: Child death review documentation including minutes of relevant meetings held as part of the rapid response into unexpected deaths; Summaries of agency information submitted to the SIR sub group and additional information provided directly to the Lead Reviewer; Sherwood Forest Hospitals NHS Foundation Trust Incident Investigation Report; Coroner’s Findings and conclusions, including the Regulation 28 Report 6.3. In addition, the Lead Reviewer interviewed key practitioners who worked closely with LN15 and his family. 6.4. This overview report was considered by a Serious Case Review Panel consisting of the lead reviewer and agency representatives and was also circulated to the practitioners for their comments. 7 7. Terms of Reference The following terms of reference/ key issues were agreed for the Serious Case Review (SCR): 7.1. Examine the circumstances which allowed LN15 to remain open to paediatric services despite not being seen between March 2011 and the date of his death. Give consideration to the ongoing safeguarding risks identified in the SFHFT Serious Incident Investigation Report. 7.2. Examine the circumstances which led to LN15 not being registered with a GP between 29th November 2012 and the date of his death despite having long term health needs. a) Consider this in relation to the matters of concern identified in the Regulation 28 Report to Prevent Future Deaths issued by the Coroner. b) Consider if agencies had the opportunity to identify and address this gap in his care. 7.3. Were there indicators of neglect that should have been reasonably identifiable to services throughout their contact with LN15 and if so were the responses of agencies appropriate? 7.4. Was LN15’s deteriorating health in the weeks leading up to his death identified by agencies and responded to appropriately? 7.5. Did agencies hear the voice of the child and was it acted upon by agencies working with the family? If not, what were the barriers to them doing so? 7.6. Were agencies sufficiently responsive to LN15’s needs, in particular, those arising from his disability? 8. Involvement of family members 8.1. Both mother and father of LN15 have contributed to the SCR and have met with the Lead Reviewer. 8 9. Perceptions of the family 9.1. The physiotherapist described LN15 as a very confident and noisy little boy who knew his own mind. She described him as having very good communication skills and very good play skills. He was cheeky and appeared to be a happy little boy who did not cry or moan. He was well presented and appeared to have a good relationship with his mother. The physiotherapist described LN15’s mother as vey engaged with her son; sometimes she appeared to be coping and other times she would be tearful. 9.2. School staff who knew LN15 well, described him as a force to be reckoned with, a big personality who was confident and had a good sense of humour. He could be challenging, stubborn and outspoken but he was popular and appeared to be a happy little boy. He enjoyed maths but did not like writing. Physically he was described as lacking muscle tone, having a dainty face and being quite ethereal looking with red curls framing his face. He was described as a character within the school and that his classmates missed him. School staff described LN15’s mother as very friendly and chatty who would talk about how things at home were difficult. She presented herself well and was supportive of the school. 9.3. The school described how there were a high level of demands within the family and how the mother was very supportive of the school in their management of her children. 10. Background Information 10.1 On 6th February 2007, LN15 was seen in Sherwood Forest Hospitals NHS Foundation Trust paediatric clinic with concerns in respect of developmental delay which included him making no attempts to shuffle, crawl or roll to the sides. LN15 was by now 14 months old. His past history identified a wheeze and constipation alongside developmental delay. 10.2 There then followed a long history of health involvement in connection with his history of gross motor delay; hypotonia (floppiness) and chronic constipation and frequent faecal impaction. Referrals were made for physiotherapy and Speech and Language Therapy in 2008. LN15 was fitted with gaiters and given a standing frame. 9 10.3 Between 2007 and 2009, LN15 was subject of substantial investigations including muscle biopsy and MRI scans but these failed to identify the cause of his floppiness. 10.4 LN15’s parents separated in 2009 and LN15 lived with his older sibling and mother. 10.5 LN15 attended primary school and his attendance was generally very good. Over the years absences were in relation to influenza; sickness; stomach bugs; constipation and bowel problems. LN15 received support in class from a Teaching Assistant and had help with personal care, with PE and swimming. LN15 also had sessions of ‘Fun Fit’ in school with exercises to help with coordination and confidence. Referrals to Children’s Social Care 10.6 The agency information indicates that two referrals were made to Children’s Social Care between 2009 and 2010, prior to the scoping period of this review. 10.7 In September 2009, the physiotherapist referred LN15 to Children’s Social Care to request practical and emotional support for his mother, including respite care. This followed concern regarding LN15’s mother’s stress levels as she felt tired and unsupported, was feeling low, struggling to cope with LN15’s sibling’s behaviour whilst having to work full time. As a result, a number of physiotherapy appointments had not been attended. It is recorded that Children’s Social Care left several messages for LN15’s mother but received no response and so the case was closed. A letter was sent to LN15’s mother stating that there was no role for the department and as such they would not be offering a social care service to the family. The letter identified a number of services that might be helpful, and included written information about them: A Place To Call Our Own Inclusion Support Local Health Visitor Children's Information Service Welfare Rights Service Short Breaks Service 10 10.8 LN15’s mother told the physiotherapist in December 2009 that the request had been declined as he did not meet the criteria. 10.9 On 1st December 2009, the physiotherapist had clinical supervision where it was agreed that due to the nonattendance of appointments that LN15 would be seen in school by the physiotherapist to ensure his needs were met in the short term. 10.10 On 16th March 2010, the physiotherapist wrote to LN15’s mother, copied to Child Health, neurologist and consultant paediatrician stating that LN15 had not attended physiotherapy since 12th October 2009 (6 months prior). The letter stated that they had tried unsuccessfully to contact LN15’s mother by telephone and letter and that if the physiotherapy service had not heard from her within two weeks, LN15 would be discharged from the service. [Author comments: In interview the physiotherapist explained that it is very unlikely that a child would ever be discharged from their service but they will write to state this as an attempt to get parents to respond and re-engage. The physiotherapist also contacted LN15’s school and his GP to ensure that she had the right address. It is evident that although the letter sent by the physiotherapist was well intentioned, it would not be in line with relevant DNA policy. The Healthcare Trust DNA policy advises that if a child misses a follow up appointment then consideration should be given to initiation of a Common Assessment Framework (CAF). The DNA policy is under review.] 10.11 On 23rd March 2010, a referral was made by the consultant paediatrician to Children’s Social Care for respite and support with aids. The letter stated that LN15’s mother was struggling to get him in and out of the bath and keeping the boys entertained. It also stated that she would benefit from support and respite. 10.12 As a result of the referral, a letter was sent to LN15’s mother asking her to make contact with a duty social worker within the disabled children’s team. 10.13 On 1st April 2010, the physiotherapist wrote a detailed letter to the consultant paediatrician. The letter described how LN15 had made progress over the years with his mother’s help and had been a pleasure to treat. It described how attendance had deteriorated and that his mother had discussed feeling tired and low since LN15’s father had left the family home and she was caring for both children alone. The 11 physiotherapist wrote that she had referred the family to children social care but that LN15 did not meet their criteria as he was too young. The consultant paediatrician was asked to give additional support with the referral. The physiotherapist also explained how despite numerous phone calls and appointments, LN15 had not attended since 29th September 2009 and as a result she had been meeting LN15’s physiotherapy needs by visiting him in school and setting up a school therapy programme there. 10.14 The consultant paediatrician wrote again to Children’s Social Care on 19th April 2010 requesting a sitting and befriending service. As a result the children’s disability team sent information to the referrer and the LN15’s mother regarding the 100 hours scheme, a sitting/befriending service for disabled children and parents. [The letter from the consultant paediatrician is brief and does not contain any of the detailed information provided to her by the physiotherapist.] 10.15 LN15’s mother re-engaged with physiotherapy services on 21st June 2010 following an appointment letter being sent via the school which was an example of good practice. LN15’s mother stated that things were really difficult as the sibling continued to display problematic behaviour and they were having to move house. On 22nd June 2010, the physiotherapist spoke with the consultant paediatrician who stated that she had spoken with social care and they had said the family did not meet the criteria for intervention or support, but had agreed to pass onto mother a phone number for support. In addition the physiotherapist arranged for additional physiotherapy input to be delivered within school. 10.16 On 22nd August 2010 LN15 was seen at home by a school health community practitioner for a transfer-in visit as the family had moved home. Mother, both siblings and mother’s boyfriend were present. Mother reported she felt that all services were in place for LN15 but stated that he was doubly incontinent and was querying whether she could be assessed for help with nappies. 10.17 LN15 progressed well with the support put in place within school and was mobile by October 2010. He continued to require only slight assistance and supervision from staff as he could be unsteady on his feet. 12 10.18 LN15 attended a physiotherapy appointment on 7th January 2011. The plan was to contact the consultant paediatrician regarding jerky movements and to contact the health visitor regarding nappies. 11. Case Narrative (scoping period) 2011: the last involvement of the paediatric outpatient clinic 11.1. On 10th March 2011, aged 5 years and 3 months, LN15 was seen in the paediatric outpatient clinic. The muscle biopsy results were normal and it was discussed that LN15 should be seen by a Consultant Neurologist for consideration of an EEG (electroencephalogram), a test used to find problems related to electrical activity of the brain. 11.2. A referral was made to the Local Authority Occupational Therapy Team which was part of the Council Children’s Disability Service in March 2011. The purpose of the referral was for a bathing and toileting assessment. LN15’s mother did not respond to requests for contact. LN15 was discharged from the Healthcare Trust Occupational Therapy Team on 8th April 2011. [The reason for the discharge is not recorded.] 11.3. On 26th May 2011, LN15 was not brought to his neurology clinic appointment. 11.4. On 22nd June and 11th July 2011, LN15 was not brought to planned physiotherapy appointments and a letter was sent stating that he had been discharged from the Rebound list. [Rebound is physiotherapy using a trampoline.] 11.5 On 15th August 2011, the physiotherapist attempted to contact LN15’s mother by telephone to arrange a joint Healthcare Trust Occupational Therapy and physiotherapy review. [It is unclear why Occupational Therapy are again involved when the records indicate that he was discharged in April.] 11.6 On 2nd September 2011, he was not brought to his paediatric outpatient appointment. A letter was set to the GP regarding poor clinic attendance. The GP replied and identified the new address for the family. [The hospital records were updated but in actual fact this too was an incorrect address.] 13 11.7 From June 2011 until October 2011, LN15 was not brought to his 4 planned physiotherapy appointments. He was seen however on 13th September 2011 by the Healthcare Trust Occupational Therapy service. 11.8 On 17th October 2011 the physiotherapist wrote to LN15’s mother about the missed appointments and the next day the physiotherapist visited LN15 in school. 11.9 On 20th October 2011, LN15 was not brought to a second appointment at the neurology clinic and as a result the Consultant Paediatrician wrote to the mother on 27th October 2011 outlining her concerns regarding poor attendance and requesting an updated address. The mother was informed that if they failed to attend the next appointment in December 2011 then a referral would be made to Children’s Social Care. The paediatrician was also aware that LN15 had been discharged from the Local Authority Children’s Disability Service Occupational Therapy service due to the mother’s failure to make contact. [This letter was an appropriate response however it was unfortunately sent to an incorrect address and never received by LN15’s mother.] 11.10 On 25th October 2011, the Healthcare Trust Occupational Therapist sent an appointment to LN15’s mother for LN15. [It was noted that the Occupational Therapist had three addresses for LN15 and a letter was sent to all three; this poses questions with regard to information governance and data protection.] 11.11 On 31st October 2011, LN15 was seen by both the Healthcare Trust Occupational Therapist and physiotherapist. LN15 had made good progress, no longer needed his standing frame and was in Piedro boots and managing to walk. LN15’s mother reported being under significant stress, her mother had died, she had split from her current partner, had lost her job and was struggling to manage LN15’s sibling’s behaviour. It was noted that during the session that LN15 and his brother were arguing resulting in the brother attempting to push and kick his mother. When asked if she was ‘ok’, LN15’s mother started to cry, and was asked if she required support with both children’s behaviour to which she said she did. The Occupational Therapist sought permission to refer to CAMHS which mother gave. [It is noted that LN15’s mother gave permission to refer the ‘family’ to CAMHS. Part of the noted plan was for the Healthcare Trust Occupational Therapist to complete a referral to CAMHS for help with behavioural strategies for both brothers at home and possibly within school.] 14 11.12 LN15’s continence remained of concern and this was expressed to the Healthcare Trust Occupational Therapist and Physiotherapist who arranged for LN15 to be assessed by a specialist continence nurse at home that same day. LN15 was provided with continence products on 2nd November 2011. This continued until July 2012. [LN15’s mother asked to be assessed for support with nappies on 22nd August 2010. It was over a year later, and two further requests, that this was actioned.] 11.13 On 3rd November 2011, the Healthcare Trust Occupational Therapist spoke to LN15’s mother on the telephone and informed her that a referral to CAMHS had been made and that a re-referral had been made to the Local Authority Occupational Therapy Team which was part of the Children’s Disability Service. 11.14 As a result of this referral, on 16th November 2011 a home visit was completed following which it was agreed to provide a shower stool and a specialist toilet seat. Telephone calls were made to LN15’s mother and 2 letters sent, with no response and as such it was agreed to put a hold on the equipment and close the case to the Children’s Disability Service. 11.15 It was recorded on 14th November 2011 that a referral to Emotional Health and Well-being (CAMHS Tier 2 services) had been received. 11.16 LN15’s mother left a message for the Healthcare Trust Occupational Therapist who had made the CAMHS referral on 22nd November 2011. The message was in respect of an update regarding the CAMHS referral. The Occupational Therapist tried to call her back without success. 11.17 Also on 22nd November 2011, LN15’s mother contacted CAMHS stating that she did not experience any behavioural, social or emotional issues with LN15 and she thought the referral was going to be made in relation to her other son. She stated that she had contacted the referrer to request another referral be made for her other son and cancelled the initial assessment appointment for LN15 scheduled for 28th November. 11.18 In October, November and December 2011, LN15 did attend appointments in the Orthotic clinic (for his splints). He had made massive improvements and was walking independently and with only limited mobility aids. One appointment, 5th December, was a joint appointment with the physiotherapist. 11.19 LN15 was due to attend a paediatric outpatient appointment on 15th December 2011, which was 10 days after his last attended Orthotic/ physiotherapy appointment. However a partial booking system was introduced by the hospital meaning that the 15th 15 December appointment was cancelled and mother was sent a letter asking to contact the hospital to make another appointment. [LN15’s mother would not have been aware of the 15th December appointment as the letter had gone to an old address. This letter also made reference to a referral being made to Children’s Social Care but was not followed up due to the appointment being cancelled. The letter informing of the cancelled appointment also went to the wrong address. LN15 was not seen again in the paediatric outpatient clinic but continued to be seen by Physiotherapy and Orthotics.] 2012 - 2013: Including de-registration from the GP practice 11.20 The CAMHS notes indicate that LN15 was discharged on 6th January 2012 due to an inappropriate referral. The reason for this is not recorded but a further update notes that LN15 is now on the waiting list for the CAMHS community learning disability team. [The review has established that the referral is in LN15’s name but makes reference to his brother and mother’s need for support in relation to both of their behaviours.] 11.21 On 23rd January 2012, when he was 6 years of age, LN15 was seen in school for a routine school entry review. His weight and height were noted to be at the lower end of normal limits. 11.22 In January 2012, LN15 was not brought to an Orthotic clinic appointment but he did attend two Orthotic appointments in October 2012. 11.23 LN15 was not brought for 3 physiotherapy appointments in April, May and July 2012. 11.24 On 20th July 2012, the continence nurse stopped the prescription for nappies, pending a further continence assessment, due to allegations that they were being sold for financial gain. This assessment did not occur. The school reported that LN15 was still wearing nappies. It was also noted LN15 had moved house. [It is unclear why it was felt appropriate to stop the supply of nappies based on a piece of unsubstantiated information, especially given the school’s confirmation that LN15 was still attending wearing nappies. From this point on, LN15’s mother had no further support from continence services regarding nappy provision and purchased nappies for LN15. The review has established that it is expected practice that a continence assessment be completed prior to 16 a prescription for nappies being stopped. Individual practice issues have been addressed.] 11.25 LN15 attended a physiotherapy appointment on 22nd October 2012. During the appointment LN15’s mother stated that he had been discharged from the neurology and neuromuscular clinic and remained under the care of the paediatrician. She stated that LN15 still had no formal diagnosis. The physiotherapist noted that LN15’s compliance with the session became an issue on a number of occasions. [It is not recorded whether the physiotherapist asked when was the next appointment with the consultant paediatrician.] 11.26 On 29th October 2012, LN15 was seen by orthotics and the physiotherapist jointly. 11.27 In November 2012, LN15’s mother de-registered LN15 from the GP practice saying that she was moving out of the area. The practice held the records for the required 28 days following de-registration then forwarded them to NHS England. 11.28 In December 2012, a six monthly review was completed by the Physical Disability Support Service in school. There continued to be no requirements for manual handling, LN15 remained independently mobile and was no longer requiring the use of a standing frame. 11.29 On 17th January 2013, LN15’s mother went to collect the monthly supply of continence products. She was given two packs as the receptionist was unaware that the order had been cancelled. 11.30 LN15 was seen in school on 19th April 2013 by the Healthcare Trust Occupational Therapist to review his chair. A new one was ordered which was subsequently delivered and assessed in June 2013. 11.31 LN15 was not brought to two physiotherapy appointments in July and August 2013. An appointment letter for 13th August 2013 was returned by Royal Mail. 11.32 In September and October 2013, LN15 attended two Orthotic appointments, one of which was joint with the physiotherapist. At this appointment, LN15’s mother reported that the situation at home had improved and that she was coping better. [It is good practice that joint appointments were made.] 11.33 On 6th December 2013, the school informed the Occupational Therapist that LN15’s special chair was no longer being used. LN15 was therefore discharged from the Healthcare Trust Occupational Therapy services. 17 2014: LN15 becomes acutely unwell 11.34 LN15 attended one out of two scheduled physiotherapy appointments in January 2014, and attended two out of three in February 2014. A block of rebound therapy was arranged for the summer. [This was LN15’s last contact with his allocated physiotherapist.] 11.35 On 27th March 2014, when LN15 was 8 years of age, an annual physiotherapy review was held at school. Toileting was mentioned and LN15’s mother agreed to go to the GP to get a referral to the paediatrician regarding this and discussed using pads rather than going straight to pants. It was also suggested that LN15’s medication may need to be adjusted to allow faecal control to be improved. [The reason for a request to be referred to a paediatrician when LN15 was already under the care of a paediatrician is unclear however it was not LN15’s usual physiotherapist who completed the annual review. Given that a colleague was already visiting school that day it was agreed that she would complete the review. She met with LN15 in advance on 4th February 2014 and was provided with a handover by his allocated physiotherapist. In interview the physiotherapist explained that their service has minimal direct contact with GPs but that this is normal practice.] 11.36 LN15 was due to have a block of hydrotherapy over the summer of 2014 but this was cancelled due to the unavailability of the pool. Rebound physiotherapy sessions were arranged for September, the first of which being 3rd September which was attended. 11.37 On 7th September 2014, LN15 attended Emergency Department (ED) having trapped his foot in a car door. He had a minor fracture and was discharged with antibiotics and advice. ED records have missing data with regard to GP details; LN15’s mother had indicated that following a house move she was in the process of registering with a GP. [This should have prompted a referral to the paediatric liaison health visitor but this did not occur. LN15 had not been registered with a GP since November 2012 although ED would not have been aware of this.] 11.38 On 8th September 2014, LN15’s mother cancelled rebound physiotherapy sessions scheduled for 10th, 17th and 24th September due to LN15 having fractured his toe. 11.39 From 15th September 2014, LN15’s attendance at school decreased. In the weeks commencing 15th, 22nd and 29th September 2014, he attended for two days only each week. His absence was due to stomach pains. 18 11.40 On 1st October 2014, LN15 attended a rebound physiotherapy appointment and his mother reported that he had been constipated for three weeks, was not feeling well and had a solid tummy. The rebound physiotherapist recorded that LN15 looked unwell but was talkative and active throughout the session. It was recorded that he showed moderate compliance but sometimes refused to follow instructions. [There is no record of advice being given to the mother to seek medical attention for LN15. Again as this was a rebound session, the session was not held with his allocated physiotherapist as it usual practice as it would not be an expectation that the allocated physiotherapist would offer all therapies.] 11.41 In the week commencing Monday 6th October 2014, LN15 only attended school on the Tuesday. On that day the Head Teacher advised LN15’s mother to take him to the GP. LN15’s mother stated that he was not due to see a paediatrician for another six months. 11.42 LN15 was not brought to his rebound physiotherapy appointment on 8th October 2014 due to being unwell. 11.43 On 9th October 2014, the school Special Educational Needs Coordinator (SENCO) telephoned LN15’s mother with regard to his ongoing stomach/ bowel issues and advised her to go to the GP or contact the consultant paediatrician. LN15’s mother stated that she had sought medical advice and had been told to give him medication to help his constipation and to give him pain relief. [It is now known that LN15’s mother misled the school and did not seek medical advice. The school does not have an allocated School Nurse and in their experience it takes a great deal of effort to engage the school nursing service. Under new commissioning arrangements, all schools will have a named school nurse. In interview the Teaching Assistant (TA) explained that she had advised LN15’s mother to go to the drop-in centre when his mother gave the impression that it took time to get a GP appointment. The TA recalled telling LN15’s mother that she was worried about him and thought that he had lost a bit of weight as his legs looked thinner when she changed him.] 11.44 LN15 attended school on Monday 13th October 2014 but did not attend for the next three days. On 15th October, LN15’s mother rang the school and left a message to say that she had taken LN15 to the GP and that he had been prescribed strong medication for his stomach and might be back in school that Friday. 19 [It is now known that LN15 had not been seen by a GP. In interview, school staff explained that LN15’s mother was coming in at lunch times to give him medication which they believed to be pain relief.] 11.45 In week commencing 20th October, LN15 attended school on Tuesday only, due to a stomach ache and temperature. He was not brought to a physiotherapy appointment on 22nd October. The half term holidays commenced on 27th October. [In two months, LN15’s school attendance plummeted from 96.3% in the preceding academic year to approximately 50%. There had been no previous patterns of absence that were of concern.] 11.46 LN15’s mother had obtained employment and the half term week was her first week in work. She arranged for LN15 and his brother to be cared for by a childminder. The first day at the childminders was on 27th October 2014 and was reportedly uneventful. 11.47 On 28th October 2014, LN15 was admitted to the Emergency Department in cardiac arrest and died. He was 8 years of age. 12. Information that has become available subsequent to LN15’s death 12.1 LN15’s mother reported that LN15 had been ill for the last 3 -4 weeks which she attributed to an episode of chronic constipation and was treating with diluted adult Movicol which she had purchased over the internet as it seemed easier and quicker than registering with a new GP and attending an appointment to obtain a new prescription. When purchasing adult Movicol on line it is stated that this should not be given to children under the age of 12 years. LN15 had been prescribed paediatric Movicol previously and being given adult Movicol was not a factor in his subsequent death. 12.2 LN15’s mother admitted during the inquest to having misled the school with regard to recent attendances at the GP. 12.3 LN15’s mother recalled that he had become somewhat down and withdrawn in the 5 days prior to his death and had lost his appetite. 12.4 The evening prior to his death LN15 had complained intermittently that his stomach hurt. He went into his mother’s bed at around 11.00pm. He awoke at 1.00 am and vomited. He had a drink, woke again at 5.00 am and vomited again. He was given pain relief and settled. On waking LN15 had another drink, and asked to go to McDonald’s for breakfast on the way to the childminder, although he only ate a small amount of his meal. 20 12.5 At the childminders, LN15’s mother informed her that LN15 had been vomiting. The plan was to go out for the day however LN15 vomited three times in the child minder’s car. She returned home and LN15 asked for some water. The childminder contacted LN15’s mother by text message asking for her to collect him. When the child minder returned, she found LN15 unconscious and unresponsive. An ambulance was called and all attempts to revive him by the paramedics and later in ED were unsuccessful. 13. Family Perspectives 13.1 The paragraphs below reflect views and perspectives of LN15’s parents. It would appear that after the parent’s separation, LN15 had limited contact with his father. 13.2 LN15’s mother described him as a funny, outgoing and bright little boy who was very sensitive. 13.3 When asked to describe LN15’s health needs, his mother stated that his condition was undiagnosed but that he displayed hypotonia and hypermobility, suffered constipation and faecal impaction and poor bladder control. She described how he was unable to dress himself, and needed help to get in and out of the bath and up and down the stairs. Physiotherapy meant that he made huge progress and was able to walk unaided, although he wore splints for stability as his ankles rolled inwards. LN15’s mother spoke of the intrusive tests that he underwent, which were distressing for him, with no outcome with regard to a diagnosis. She stated that she was told at first that he might not ever talk or walk but with hard work significant improvements were made. She spoke of the stress of not knowing what the future held, what the prognosis was for LN15, and that the impact of not knowing led her to lose faith in health agencies and for her to come to the conclusion that she would do things ‘her way’. 13.4 When asked to consider the help that would have been of benefit to the family, LN15’s mother spoke of the referral to Children’s Social Care for respite but that LN15 did not meet the criteria. She said she also requested help with bathing aids but this took a long time to arrange and by the time it was resolved they had moved house and didn’t need them in the new property. LN15’s mother also spoke of the referral to CAMHS that was for LN15’s sibling given some of his behaviours but was not progressed as the referral as made in LN15’s name. She spoke of ringing CAMHS and being told to go back to her GP which she said felt like going back to ‘square one’. 21 13.5 LN15 had speech therapy from the age of 3 years but progressed well within nursery. With regard to constipation and faecal impaction, this improved with diet. He was prescribed Movicol and lactulose but over the years his bowel condition improved and mother said she did not give LN15 Movicol. She spoke of having LN15’s nappies cancelled without warning and no response given when she enquired why this had happened. She stated that the continence nurse never returned her calls so she began purchasing nappies for LN15. She spoke of de-registering LN15 from the GP when she moved house and got forms for registration with a local GP but did not fill them in. 13.6 LN15’s mother described a positive relationship with school, and that LN15 had wonderful TAs and a very supportive SENCO team. The Healthcare Trust Occupational Therapy Services provided input with fine motor skills and strengthening muscles and worked in conjunction with the school. LN15’s mothers spoke of the special chairs that LN15 had in school, his standing frame and how he engaged in the Fun Fit programme run by schools to help with balance, control and coordination. LN15’s physiotherapist was described by mother as a wonderful woman who had a very special bond with LN15 even though he was sometimes resistant to physiotherapy. Mother spoke of now being aware that positive improvements made by LN15 were not fed back to the consultant paediatrician and as such there was no trigger for renewed contact with the paediatrician. She said that she assumed this feedback was happening and therefore that LN15 did not need to be seen by the consultant paediatrician. 13.7 LN15’s mother described 2011 as a time of significant stress for the family as she was working full-time, her mother was terminally ill and she received little family support in her care of the children. Neighbours had complained about the noise that the children made and she was referred to neighbourhood wardens. She said she took voluntary redundancy to look after her mother and then accrued rent arrears and had to move. 13.8 LN15’s mother spoke of the house moves that the family had often due to circumstances beyond her control – being unable to financially meet the rent on properties and the landlord selling the property that she was renting. She found the property where she is currently living towards the end of October 2014 when LN15 was unwell. She also secured a part-time job but for the first two weeks was full-time. She found a childminder to complete the school runs and have the children over half term. 22 13.9 LN15’s mother spoke of how LN15 did not like change and every time they moved house he would get upset. He was aware she was starting a new job and that there would be a childminder; this upset him too. She described LN15 as becoming withdrawn, very clingy to her, and off his food. She had seen him present in the same way many times previously and did not think that there was anything to be concerned about. She increased his fluids and felt that she knew how to deal with his ill-health as she had managed it before without issue. She spoke of her guilt and the tragedy of her son’s death. 13.10 Despite sporadic contact with his son, LN15’s father described him as a bundle of joy, a brave boy who never gave up, who was soft, gentle, loving and intelligent. 13.11 LN15’s father was concerned that letters from health agencies were not sent to him to alert of appointments not being attended. With regard to the letter stating that consideration might be given to a referral to Children’s Social Care due to non-attendance, LN15’s father felt that this should have been sent to all with parental responsibility. His view was that had he known, he would have intervened. LN15’s father confirmed that he did not seek information or updates from agencies working with LN15. 13.12 LN15’s father stated that LN15 could not manage without Movicol and queried why there was not a flag about a child not being issued with a repeat prescription. It has been established as part of this review that although Movicol was on repeat prescription, when patients leave a GP practice all repeats are removed automatically as part of the patient deduction. 13.13 LN15’s father queried why ED staff had not had sight of all of LN15’s missed paediatric appointments (in 2011) when he had presented at ED in 2014. The review has established that it would not be realistic to expect ED practitioners to do this even if technically they could. There would have to be a specific reason/ concern for looking at past medical history and previous attendance at appointments. 13.14 LN15’s father was also concerned to have never had contact from the school when there were concerns about absence due to ill-health, particularly in the last weeks of his life. He felt that due to a lack of information he was unable to exercise his parental responsibility although he did not independently make contact with the school. 23 13.15 As a result of the concerns raised by LN15’s father, enquiries were made with agencies in respect of their policies regarding contacting/ alerting/ keeping informed non-resident parents who have parental responsibility. 13.16 In education settings, if separated parents with parental responsibility are not in amicable contact with each other, for whatever reason, then one parent will normally be responsible for care and decisions and receive information/ involvement from schools. Statutory Department for Education guidance (2016) states that every parent, whether resident or not has a right to participate and receive information. When non-resident parents request from schools to be kept informed of their child’s affairs, then schools and agencies comply with this although human error will occasionally mean that a parent may be left out of the loop. 13.17 When a child accesses a health service for the first time, the attending parent/s will be asked to clarify parental responsibility and an address for correspondence. Any requests to send correspondence to separate parents would be respected but would rely on parents making these requests. 13.18 In summary, the principle of parental responsibility places a duty on parents to promote their child welfare. 14. Practitioner perspectives 14.1 In interview, the physiotherapist explained that LN15 was first referred to her when he was 23 months old. She described him as having very poor muscle bulk and that bone could be felt around his shoulder and pelvic girdle. Although he looked undernourished the physiotherapist explained that it was not about weight, it was in respect of muscle bulk which was always poor. At first LN15 had very poor strength, was very floppy and delayed physically. At 23 months he was unable to crawl or get on to all fours. 14.2 At first LN15 had weekly appointments and between treatments the parents were expected to complete the exercises at home on a daily basis. The physiotherapist described LN15’s mother as very committed and that LN15 made a lot of progress which would not have been possible without completion of the daily exercises. The physiotherapist stated that physiotherapy is about what a therapist can engage the parents to take on as physiotherapy sessions alone will not be effective. 24 14.3 The physiotherapist described his mother as being an active participant in the sessions, joining in and getting down on the floor with LN15. Due to progress made, appointments reduced to fortnightly. Once LN15 was mobile and on his feet, appointments reduced to monthly and then in the later stages he was seen for review every 3 to 4 months and if a need was identified he would be referred for a block of treatment. LN15 was referred for hydrotherapy and rebound therapy (therapeutic use of trampoline to develop core strength and stability). These would be in blocks and completed by different physiotherapists. 14.4 The physiotherapist explained how LN15’s mother yearned for a diagnosis for her son and it was very difficult for her to manage when no diagnosis was made and was a cause of significant stress. She described how demanding both children could be and in sessions and wondered how LN15’s mother coped at home alone. 14.5 The physiotherapist was unaware that LN15 did not have a GP. As is usual practice, there was no routine communication between the service and GP and although they are copied in to any reports written, none were written in respect of LN15. 14.6 With regard to communication with the Consultant Paediatrician, the physiotherapist explained that communication decreases as children improve, especially if they are just seen for review. 14.7 The physiotherapist reported that she will have 70/ 80 children on her caseload and does not have the capacity to write an ‘all is well’ letter after each appointment. 14.8 LN15’s physiotherapist had not seen LN15 since February 2014, when he was seen for review; his last block of rebound therapy was with a different therapist, as would be expected within the team approach of the service, each having different specialisms. 14.9 LN15’s head teacher, school TA and SENCO were also interviewed. They described how LN15 was not mobile when he started school but in the later years he was able to walk independently. The main area where he needed support was with his personal care. The SENCO explained how LN15 showed no interest in toilet training and that she met with his mother to develop toileting plans on several occasions but with no success. The SENCO stated that she also tried to engage the school nurse in this process but ultimately LN15 would not try and as such he stayed in nappies. The SENCO said she never understood why LN15 was still in nappies. 25 14.10 LN15 was assessed as having special educational needs, the main issue being his personal care. Although the school received no funding for him, he had the support of a TA every morning. He did not require academic support. LN15’s mother didn’t always attend parent’s evenings or meetings held to review his progress. The SENCO felt that this was more so when mother was not concerned about his progress. If she had concerns she would be in frequent contact with the school. LN15’s mother kept the school up to date with changes of address. 14.11 School staff explained that LN15 did not have a network of professionals around him as his needs reduced and his mobility improved. They had a good relationship with the physiotherapist but never had any communication with the consultant paediatrician which they did not feel to be unusual. 14.12 The school staff were not overly concerned about the family, and felt that LN15’s mother was coping in difficult circumstances. 15. Analysis Examine the circumstances which allowed LN15 to remain open to paediatric services despite not being seen between March 2011 and the date of his death. Give consideration to the ongoing safeguarding risks identified in the SFHFT Serious Incident Investigation Report. 15.1 LN15 was not brought to a second appointment at the neurology clinic on 20th October 2011 and as a result the Consultant Paediatrician wrote to mother outlining concerns regarding poor attendance and requesting an updated address. Mother was informed that if they failed to attend the next appointment in December 2011 then a referral would be made to Children’s Social Care. This letter was sent to an address held on the records which was an incorrect address and was never received by LN15’s mother. 15.2 A partial booking system was introduced by the hospital meaning that the December 2011 appointment was cancelled and mother was sent a letter asking to contact the hospital to make another appointment. The partial booking system was introduced across the Trust, not just within paediatrics, to provide increased choice to patients and reduce the number of DNAs resulting from pre-made appointments. The Serious Incident Investigation Report (SIIR) completed by the hospital outlined that at the point 26 of going live onto the new system, all arranged appointments were cancelled and standard letters were issued to families explaining why this had happened and guiding them what to do next. The expectation was that patients would ‘opt in’ to arrange subsequent appointments, which clearly put full responsibility to arrange future appointments with the patient and in the case of a child, with the parent or carer. The partial booking system did not generate an alert where a patient did not make an appointment and as such there was no system to alert the named physician, in this case the consultant paediatrician, of non-engagement. 15.3 As LN15’s mother did not know that responsibility rested with her to arrange appointments, given that she had not received the letter advising her of such, plus the fact that she did not enquire whether he was due an appointment, LN15 attended no further appointments in the paediatric outpatient clinic. As no appointments were ever arranged, the hospitals Did Not Attend (DNA) processes were not triggered. 15.4 As a result, LN15 was not seen by paediatric services for three and a half years prior to his death, although he could have been re-referred into the service had he been registered with a GP. 15.5 The partial booking system has now been amended in light of the findings of the risk assessment undertaken as a result of SFHFT Serious Incident Investigation Report. The Elective Access, Booking and Choice policy has a specific pathway for children and young people under 18 years of age and states that: ‘The important aspect regarding children and young people’s appointment changes is that the consultant with overall responsibility for the patient MUST be kept up to date and consulted in the event of repeated appointment changes and/or appointment cancellations to make a decision on the correct course of action to be taken. Example of appropriate decisions may be i.e. discharged to GP, reappointment agreed, referral to another service, safeguarding procedures followed, other professionals involved. The child should not be discharged without this plan being agreed by the consultant.’ 15.6 In the event where a patient is referred but an initial appointment is never made by the parent then the GP would be alerted in writing. 15.7 All clinical and administrative staff have had training in using the new pathway but it still needs to be embedded, after which the Trust will undertake an audit to monitor its effectiveness. 27 15.8 As part of this review, assurance was sought from SFHFT with regard to any other children that may have been adversely affected by the partial booking system and had not attended appointments. The Trust were asked to confirm that all children who were under a consultant paediatrician at the time of the changeover in the SFHFT appointment system; i) have been seen or assessed or ii) there is a plan for them to be seen. Unfortunately, available systems did not allow the Trust to identify other children whose carers had not responded to the letter inviting them to make an appointment. A risk therefore remains that other children may not have had medical oversight or intervention. SFHFT is aware of the risk which is being managed within their risk register process. With the passage of time, the review panel are hopeful that the risk is reduced as the expectation is that children would be re-referred. Examine the circumstances which led to LN15 not being registered with a GP between 29th November 2012 and the date of his death despite having long term health needs. a) Consider this in relation to the matters of concern identified in the Regulation 28 Report to Prevent Future Deaths issued by the Coroner. 15.9 The matters of concern identified by the Coroner were as follows: There is no legal requirement to register or re-register a child with a General Practitioner There is no reliable system in place to identify when a child has been de-registered from a General Practice There are potential safeguarding concerns if a General Practitioner can de-register a child, particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration The paediatric team and physiotherapy services were not directly informed that LN15 was going to be deregistered or had been deregistered. 15.10 All responses to the Regulation 28 report were received by the SCR review panel and their contents are incorporated within the analysis of this report. Public Health England responded by stating that they do not have a direct role in determining the process for registration of patients in general practice and referred the matter to NHS England, as commissioners of primary care services. NHS England’s current operational procedures do not include patient deregistration. 28 15.11 The General Medical Council helpfully set out the fact that there is no requirement upon a patient to inform a GP that they are leaving the practice and so a GP may be unaware that a patient has left the practice area. They may also be unaware of a patient’s new location. Requests to transfer a patients records are triggered by registration with a new GP. It is standard practice for GPs to remove patients from their list should they become aware that they have left the practice area, which is known as ‘administrative removal’. GPs are expected to notify NHS England of administrative removals which did occur in LN15’s case. If a patient does not re-register within 28 days then the records are sent to NHS holding services. 15.12 The issues appear to centre on the fact that the responsibility to register a child with a GP lies with the parents. Existing systems with health services which should mitigate risks of children not being registered with a GP require healthcare services to check GP registration status at each attendance. Although implemented in this case when LN15 attended ED, these systems were not effective as the staff were reassured by LN15’s mother’s response that following a house move they were in the process of registering with a new GP and as a result a referral was not made to the liaison health visitor in line with expected policy. 15.13 There is nothing to prevent a parent deregistering their family with a GP practice and not registering again. It is not compulsory to be registered with a GP whether an adult or a child. To amend this there would need to be legislative change. Such legislation would encroach on areas of personal freedoms and patient and parental rights so may attract resistance. 15.14 The Royal College of General Practitioners have advised that there are potential safeguarding concerns if a GP can administratively de-register a child with chronic health needs before a new GP has been identified as taking over the care of that child. Work is ongoing to improve the clinical guidance available to GPs to support decision making in relation to children with long term conditions. The Royal College of Paediatrics and Child Health is working to produce standards for the care of children with long term health conditions. This is due for publication in 2017. 29 b) Consider if agencies had the opportunity to identify and address this gap in his care. 15.15 LN15 was without a GP for the 23 months prior to his death. There were a number of health professionals working with him during this time frame, including a Physiotherapist and the Orthotic department. There were no attendance or review letters which would have been sent to the GP, and therefore there was no recognition of the fact that LN15 was not registered with a GP by these health professionals. 15.16 Although it is not realistic for the physiotherapy service to write to the referring consultant paediatrician or the GP after every appointment if all is well, the outcome of annual physiotherapy reviews could be communicated to them. This may offer a trigger if a child has not been seen by the paediatrician or has no GP. The review has established that not all children have or need an annual physiotherapy review, as this is dependent upon the child’s needs, however all reports written by the physiotherapists are routinely copied to the consultant and GP. 15.17 The hospital has an agreed pathway in place for alerting cases of concern to the paediatric liaison health visitor. This pathway is triggered where no GP is known or recorded. When LN15 attended the Emergency Department he should have been referred to the paediatric liaison health visitor. The Serious Incident Investigation Report (SIIR) completed by the hospital was unable to establish why this did not happen but it was suggested that this may have been influenced by the mother stating that they were in the process of registering with a new GP following a house move. In addition the nurse who dealt with LN15 was new to the organisation. 15.18 A paediatric attendance letter was electronically generated following this attendance but as there was no GP recorded, it remained on hospital systems. The SIIR has deemed that this was an opportunity to raise the matter with a clinician or administrative personnel. Reconceptualising ‘Did not attend’ to ‘Was not brought’ 15.19 Appleton and Powell (2012) undertook a review of the evidence for practice in this area. As part of their research, they examined the Ofsted Biennial reviews of serious case reviews, and relevant child death review literature (Why Children Die CEMACH 2008, Preventing Childhood Deaths, Sidebottom et al 2008). It was established that 30 missed health appointments were a prominent feature in the SCR/ child death literature. 15.20 The outcome of their research was that in order to encourage health professionals to take a proactive and child centred stance in ensuring the wellbeing and safety of children who miss appointments, ‘Did Not Attend’ should be reconceptualised to ‘Was Not Brought’. To do so would remind professionals to think about the child’s vulnerability and their daily lived experiences. It also clearly puts the focus of responsibility for attendance at appointments upon those with parental responsibility. To describe the missed appointments in these terms focuses the mind more upon parental responsibility, and questions the underlying reasons for why a child would not be brought to so many appointments. 15.21 In addition, it is clear within this case that there was a reliance upon the mother engaging with referral to support services, and that the impact of non-engagement was also upon the child. Were there indicators of neglect that should have been reasonably identifiable to services throughout their contact with LN15 and if so were the responses of agencies appropriate? 15.22 The physiotherapist had significant involvement with LN15. A review of the notes has indicated that whilst LN15 was seen regularly, there is no record of his presentation or physical development. There is no comment of his general presentation or interaction with his mother. The entries by both the physiotherapist and Healthcare Trust Occupational Therapist focus upon the exercises completed rather than a full overview of his presentation. Having interviewed the physiotherapist it is clear that she had in depth knowledge of LN15 and worked very hard to engage his mother. It was an example of good practice that she sent a letter to the mother via the school. 15.23 It is not evident that professionals were aware of the lack of GP registration or paediatric overview. LN15’s Mother appeared engaged and responsive when she had contact with professionals and her presentation did not raise concerns to those in contact with her, in fact LN15’s mother would alleviate professional concern when raised. 31 15.24 As part of the inquest, LN15’s mother accepted that she had deceived the school in to thinking that she was seeking medical attention for LN15. The school could not have known any different. 15.25 It is evident that LN15’s mother was struggling to manage the demands upon her, as a single mother of two children with additional needs, who was working full time at the time of LN15’s death and had very little family support. She also dealt with house moves and the review has considered that a house that she could afford, local to the children’s school, might have alleviated some stress. Environmental settings and conditions are key to the development of all children and young people, and this clearly includes the impact of housing. One might suggest that some factors, including housing, are even more critical to the functioning of family life of those with a disability. The impact of house moves in this case meant that correspondence with LN15’s mother was sometimes not received, and attempts to provide support, such as the referral to Children’s Social Care, did not progress. 15.26 The review has highlighted that there is evidence of LN15’s mother making decisions about treatment and medication for LN15 without any medical/health professional oversight. Professionals were unaware of this and there was no sense of professional concern with regard to neglect. 15.27 Improved communication and a multi-disciplinary meeting might have uncovered what was happening, although this would have been dependent upon LN15’s mother being honest with the professionals working with her and LN15. However it is unlikely that a multi-disciplinary meeting would have been held. Was LN15’s deteriorating health in the weeks leading up to his death identified by agencies and responded to appropriately? 15.28 The chronology of events indicates that school staff and to a more limited extent the rebound physiotherapist were aware of LN15’s deteriorating health in the weeks before his death. The school urged LN15’s mother to seek medical attention and she gave reassurances that she had done so. It is not evident from the records whether the rebound physiotherapist recommended that medical attention be sought although it is clear from the records that LN15 was not so unwell that he could not undertake the rebound therapy and asked for a free bounce at the end of the session. 32 15.29 LN15’s mother failed to seek medical advice and appropriate treatment during the last few weeks of LN15’s life although she led the school to believe that she had done so. Due to this no agency was aware of the seriousness of LN15’s condition and were therefore unable to influence the tragic outcome for this child. Did agencies hear the voice of the child and was it acted upon by agencies working with the family? If not, what were the barriers to them doing so? 15.30 A review of the physiotherapy and Healthcare Trust Occupational Therapy notes has indicated that neither LN15’s needs nor global development were recorded by staff providing care to him. In interview the physiotherapist indicated that she was knowledgeable of LN15’s needs and knew him well. He was described as strong willed; would often take persuasion to comply with exercises and was vocal with his views. 15.31 The fact that LN15’s mother intermittently engaged with services was never explored in depth and the reason for this established. Professionals were aware that she was managing a number of stressors and felt sympathetic towards her. The physiotherapist went to significant efforts to engage the mother yet remained focused upon LN15’s needs, evidenced by her arranging to see him in school. 15.32 The impact of his mother’s intermittent engagement with health services upon LN15 was never explored or the problems relating to his incontinence and subsequent constipation considered in the wider context of his physical and emotional well-being. Efforts were made by the school to address toilet training but LN15 was resistant to this. A continence assessment was never completed after the prescription for nappies was stopped and as such management of his ongoing double incontinence was not reviewed. The reason for his incontinence is not known. 15.33 Within the records there is little sense of LN15 as a child, his feelings, his thoughts and how he was coping. This has been established via interviews with the practitioners that knew him and knew him well. Practitioners have described a happy and confident little boy, who was able to express his views. There was no sense of significant professional concern regarding LN15 and he made very good progress, which was felt to be attributable in part to the care provided by his mother. 33 Were agencies sufficiently responsive to LN15’s needs, in particular, those arising from his disability? 15.34 The interviews with practitioners that knew LN15 indicate that they had a good understanding of his needs and were responsive to these needs. The school worked well with Physical Disabilities Support Services (PDSS) and the Physiotherapist to meet LN15’s needs within school. The Physiotherapist made significant efforts to engage his mother. 15.35 One area where there was a lack of focus upon LN15’s needs was when the continence nurse stopped his prescription for nappies based on an unsubstantiated allegation. Given that the school confirmed to her that he was still wearing nappies, her decision to stop the prescription clearly lacked child focus. 16. Changes to Practice 16.1 The partial booking system for children has now ceased at Sherwood Forest Hospitals NHS Foundation Trust. The DNA policy has been amended. The Trust had an action plan in place to manage the risks identified as a result of this case and all actions are now complete (see paragraph 15.2 and 15.8). 16.2 A child in similar circumstances to LN15 would now meet the criteria for the Integrated Community Children & Young People’s Health Programme which covers occupational therapy, physiotherapy, specialist nursing services and the provision of a key worker to be a link between services. A key worker would have made an impact on the provision of services to LN15 as enhanced communication would have established a lack of paediatric overview and a failure to register with a GP. 16.3 The policy with regard to GP details has now changed within the physiotherapy service. Since LN15’s death, parents are asked at every appointment to confirm their current address, telephone number and GP details. 16.4 As a result of similar learning arising from a review undertaken by Nottingham City Safeguarding Children Board, the inter agency cross authority procedures have been updated to provide greater details with regard to indicators of medical neglect. 34 17. Conclusion and recommendations 17.1 It is evident that there have been improvements to systems and practices but these may not have impacted upon LN15’s death. The purpose of the SCR is to review agency responses given what was known at the time. It is clear that professionals were not concerned about the quality of care being provided to LN15 in the later years of his life. LN15’s mother was clearly trying to manage a number of stressors, as a single parent, and made decisions that she thought were best for her son. Tragically, LN15 was seriously unwell and medical attention was not sought for him which could have prevented his death. 17.2 The following recommendations are made: i. Nottinghamshire Healthcare Trust to ensure that annual Physiotherapy reviews are copied to the referring Consultant Paediatrician and the GP. ii. Nottinghamshire Healthcare Trust and Sherwood Forest Hospitals Foundation Trust to complete an audit to provide assurance that routine enquires are made with regard to GP registration. iii. Nottinghamshire Safeguarding Children Board to seek assurance that all agencies have policies in place in respect of parents who disengage from services and have systems in place to monitor compliance with ‘DNA’ policies, which should be reconceptualised as a child not being brought to appointments. iv. NHS England to review the Royal College of Paediatrics and Child Health standards for the care of children with long term health conditions, due for publication in 2017, and strengthen guidance for GPs on patient de-registration as appropriate. v. The Independent Chair of NSCB to seek assurance that agencies give due regard to safeguarding children during organisational change and as part of equality impact assessments. This will be included in the NSCB annual section 11 audit. |
NC52697 | Overdose by an adolescent boy, Eddie, in May 2019, following an argument with a friend on the phone and following negative comments from his father. There had been four incidents of intentional self-harm since 2016. Learning themes include: taking a 'think family' approach that recognises successful change within the family requires working with all members as a whole; the importance of agencies constructively challenging each other; contextual safeguarding/harm; the importance of trauma informed practice; self-harm and suicide risk and prevention; continued support when making a decision to end social care involvement. Recommendations include: agencies to agree what a 'think family' way of working means, supported by a practical approach and the tools to deliver this; request all partner agencies refresh their escalation procedures with a reminder of professional responsibility to escalate if they consider a child is in need or remains at risk; training to be provided for awareness of the social and professional tolerance of cannabis use and associated harms, including use for self-medication to manage trauma and contextual harms; request all providers of training incorporate trauma informed practice, 'think family' and ACE's in course materials and delivery; review the provision of trauma based services for boys experiencing domestic abuse, neglect, poverty and risk of exclusion; in conjunction with a 'think family' approach, implement a universal family friendly template for a single plan designed with users of services; support a trusted adult approach in working with young people by considering adaptive mentalisation based integrative treatment training.
| Title: Partnership review – “Eddie”. LSCB: Merton Safeguarding Children Partnership Author: Debbie Eaton Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 1 October 2021 Partnership Review – “Eddie” Lead Reviewer – Debbie Eaton 1. Executive Summary 2. Recommendations 3. Reason for the Review, Methodology, and Scope 4. Family and Background (Restricted Content) 5. Analysis and Lessons 6. Good Practice 7. Missed Opportunities 8. Organisational Safeguarding 9. The Parent and Carer’s Views 10. The Practitioners’ Views 11. Appendices Appendix 1 Summary of agency involvement (Restricted Content) Appendix 2 Key Lines of Inquiry – responses (Restricted content) Appendix 3 Panel membership January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 2 October 2021 1. Executive summary In May 2019, a child, referred to in this review as ‘Eddie’, took an overdose of 9 Ibuprofen following an argument with a friend on the phone and following negative comments from his father. Following a Critical Incident Notification from the Youth Offending Team, this was escalated to the QA Sub-Group and then to Statutory Partners to consider whether the incident met the criteria for a Local Child Safeguarding Practice Review under Working Together 20181. At an Extraordinary Meeting of the MSCP in June 2019, it was agreed that the case did not meet the criteria for a Local Safeguarding Child Practice Review and did warrant further investigation through a Partnership Review - Working Together 2018, chapter 4, paragraph 17. What worked well for Eddie is that he was held in mind across agencies over time. Youth Justice workers used a holistic assessment framework, including self-assessment and made efforts to develop a relationship with Eddie and his sister. The SMART centre kept an oversight of Eddie’s education when in alternative education placements and tuition. The decision to undertake the Education Health and Care Plan was effective and the assessment well informed. The Child and Adolescent Mental Health Service (CAMHS) provided an immediate response to crises and tried to work with the views of Eddie’s mother to meet his needs. When Eddie was on remand his vulnerability indicated he would struggle to settle with strangers and there was good partnership working between Children’s Social Care (CSC) and Youth Justice to find a carer in the family network rather than foster care. Police officers were able to engage with him and family members to find out his circumstances at different times, which helped inform the action taken. Since the end date of the period under consideration a number of changes have been made across agencies in response to adolescents. The MARVE Panel (Multiagency Risk, Vulnerability and Exploitation) provides robust oversight of contextual harm and decisions are agreed with a multi-agency approach. Contextual Harm tools have been developed to understand risk and are being embedded in practice in Children’s Social Care and Youth Justice Services. The tools should support an integrated assessment and response to missing, exploitation, offending, mental health needs and substance misuse. In addition, Youth Justice workers are embedding attendance at the weekly Missing Panel to ensure allocated workers know about young people going missing and the need to complete follow up actions. As part of the Youth Justice Liaison and Diversion Service there is a multi-agency panel which considers all Merlin reports from Police and screens for a child’s vulnerabilities that may require further work to divert them from the criminal justice system and the court disposal process also considers this further. CSC has implemented a leadership alert process for the notification of serious or worrying events, which provides key and important information as and when events happen for leaders and are reflected in records for children. In addition, there have been improvements to documentation and recording to ensure information is shared appropriately to inform decision making. Worries about the response to Eddie: January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 3 October 2021 Safeguarding adolescents: Where behaviour forms part of the risk, especially within the context of familial harm, this proves a challenge to the multiagency partnership. Adverse Childhood Experiences (ACEs) are significant childhood traumas that may affect a child’s learning ability and social skills, and can result in long-term health problems. Adolescents can turn to a number of potentially destructive behaviours in an effort to avoid or defuse the intense negative emotions that accompany traumatic stress, including self-harm. Any child or young person, who self-harms must be taken seriously, as risky behaviour in response to distress can be serious, even accidentally. There were times when Eddie was involved with Police and tried to harm himself, this information should have reached CSC. This may have been an opportunity for assessment and intervention, particularly if considered in the context of other events and behaviours at the time e.g. aged 12. Service fatigue: The chronology indicates similar concerns and continued referrals between agencies where support had not previously achieved change. Holding and sharing information is a step in the right direction but of itself is inactive in safeguarding children, how the information influences plans and the child’s trajectory is the use of information in practice. It is difficult to see how the multi-agency knowledge, information and activity over time have informed planning with Eddie and the family to impact on outcomes. Assessments and interventions should have fully considered historical information as part of a comprehensive assessment; these were sometimes focused around single events. At times, there was a reliance on the interpretation of events and discounting of concerns by Eddie’s mother and sister without the context of Eddie’s views. It is important, if accepting family views and their discounting of concerns, to consider the potential of disguised compliance and resistance so decisions are made in the child’s best interests. Parents may have difficulty in consistently seeing good intent and be suspicious of the worker’s motives or may not agree interventions are purposeful or making a difference. Workers described being braced for confrontation with family members while still keeping Eddie and his needs in mind which also would have contributed another element of fatigue. A ‘Think Family’ approach would have supported family members to address their own needs to increase their caring capacity to meet Eddie’s needs. This was of particular significance given the family plan was for Eddie to be cared for by his older sister who had experienced her own unaddressed trauma, which was witnessed by Eddie. The handover of responsibility between agencies when stepping up or down was inconsistent and meant there was a fractured approach to support for Eddie and his family. When making a decision to end social care involvement, in the context of repeat referrals and concerns, there should have been a step-down Team Around the Child/Family meeting (TAC/TAF), including the family to find a TAC/TAF lead and agree a support plan within targeted and universal services. When there was no social worker involved and there was consideration of worries increasing for Eddie or re-referring to CSC any of the involved agencies could have held a complex case discussion and reviewed the step down plan to consider the level of safety as well as risk. Agencies should have constructively challenged each other about commitment and responsibility if concerns remained about safeguarding and risk. January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 4 October 2021 Impact of preconception on response: when professionals received similar information or referrals and considered the history for Eddie there may have been a preconception of him and his family. This was likely to be based on family history/knowledge - particularly male family members’ mental health, offending and substance misuse and potentially influenced the ambition to achieve positive outcomes and drive forward plans and intervention. Eddie expressed a clear view he wanted to be in education and being out of school was seen negatively by Eddie, adding to his low sense of success. Given the few hours of occupation from education and youth justice activities, it is understandable he struggled with his emotions and was vulnerable to criminal exploitation and activity, particularly if he felt his ambitions were unsupported. While it was understood Eddie wanted to talk to and work with adults with whom he had a trusted relationship, it does seem that organisational structures and service limits meant his perspective was not always sought or given weight. Racism in the form of low expectations: The Lammy Review 2017 and research since shows although there are fewer young people offending and going into custody, the BAME proportion has risen. The review acknowledges many causes of and solutions to BAME over-representation in the criminal justice system lie outside the CJS itself, for example, black and mixed ethnic boys are more likely than white boys to be permanently excluded from school. The Youth Justice Service first became involved with Eddie in 2016 when he was aged only 12. In 2017 Eddie (aged 13) received a Referral Order for Possession of Knife, the order was extended for two common assault matters. Before the Referral Order ended, in early 2018 (not yet aged 14), he received a 12 month Youth Rehabilitation Order. It is possible the organisational, structural and environmental domains of explicit and implicit racism and unconscious bias in the wider criminal justice system are influencing decision making and outcomes for BAME youth locally in Merton. ‘Helplessness’ in responding to emotional distress and trauma for adolescents: It is challenging within current constructs to safeguard children and young people who are expressing their distress in their behaviour and asking for help, especially where there are no current significant concerns around parenting. A Plan to increase safety and reduce risk should be family and community based with the support of professionals, it can be led by CSC or any other TAC/TAF Lead. A safety plan would have underpinned the work with Eddie and his family, setting out the family’s input and agreement, and designating people to do what and by when. TAC/TAF or Child in Need (CIN) meetings, with clear and direct overview, analysis of risk and safety, and the use of Signs of Safety/Wellbeing scaling would highlight both family and professionals view of risk and see the progress being made. 2. Recommendations Racism and low expectations Rec. 1 MSCP to engage partners, in particular Police, Youth Justice and Education, to review the implementation of the Lammy Review recommendations (2017). This review should utilise the tools provided by the Youth Justice Board to consider organisational, structural and environmental domains of explicit and implicit racism and should hear from those who have been subject to the system. January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 5 October 2021 Think Family Rec 2. Partner agencies to agree what a Think Family way of working means. This needs to be supported by a practical approach and the tools to deliver this. Constructive Challenge Rec 3. MSCP to request all partner agencies refresh their escalation procedures with a reminder of professional responsibility to escalate if they consider a child is in need or remains at risk. MSCP should also alert partners that the multi-agency Escalation Policy can be found on the MSCP website. Contextual Safeguarding/ Harm Rec 4. Training to be provided for awareness of the social and professional tolerance of cannabis use and associated harms, including use for self-medication to manage trauma and contextual harms. It is recommended this is refreshed for all practitioners. Rec. 5 Contextual Harm tools and guidance to be linked to updated health guidance and disseminated throughout the MSCP to support a shared understanding of the presenting needs and experiences of harm that compound risk, and of how contexts can increase harm or provide safety and protection. Rec. 6 The Local Authority to consider whether changes since May 2019 to the adequacy of provision for children excluded from school, including those awaiting education placements on tuition, are sufficient. If not, can the risks to those children be reduced as part of the Children Missing Education process Trauma Informed Practice Rec. 7 When tendering or specifying the delivery of training requirements MSCP to request all providers to incorporate trauma informed practice, Think Family and ACE’s in course materials and delivery. Rec. 8 Early Help and Neglect sub-group of the MSCP to review the provision of trauma based services for boys experiencing domestic abuse, neglect, poverty and risk of exclusion and present findings to the MSCP Executive to inform service development and delivery. Rec. 9 Health and Wellbeing Board to be asked to review the commissioning of a targeted trauma informed service in accordance with NICE guidelines, ensuring a flexible and responsive service to children and young people who are demonstrating their trauma in their behaviours. Self-harm and suicide prevention Rec. 10 All services should make sure staff know about the Stay Alive app. SWLStG have advised the CCG is to commission a community Dialectical Behaviour Therapy Service, in line with NICE guidance, for young people in SW London who struggle with their emotions. Planning Rec. 11 In conjunction with a ‘Think Family’ approach MSCP to implement a universal family friendly template for a single plan designed with users of services. This should be able to combine single agency plans and be easily and regularly updated whether the services involved are universal or targeted. The family/young person friendly template should include the practical back up plan that can provide long term support if needed. January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 6 October 2021 Stepping Down or Up and the TAC/TAF Lead Rec. 12 MSCP to agree and disseminate guidance about who can be a TAC/TAF lead (aka Lead Professional), who can convene a Team Around the Child (TAC) or Family (TAF) meeting, and, how and when it should take place. Child’s voice Rec. 13 To support a trusted adult approach in working with young people the MSCP should consider Ambit (Adaptive Mentalisation Based Integrative Treatment) Training. The Youth Justice Team have implemented this and have capacity to deliver and support partners. Rec. 14 MSCP to use the s11 questionnaire (or similar) process to ask about service threshold and capacity limits and whether this impacts on children's access to services and continuity of support. Rec. 15 The Children's Trust to be asked to consider an agreed protocol and guidance for workers to continue to deliver services within their remit and with the support of their organisations so young people can maintain relationships with trusted professionals Multi-Agency Assessment of risk Rec. 16 When there is the potential that children and young people will return home from being in care MSCP partners should contribute to a CSC led multi-agency assessment of risk and need and parallel planning – similar to child protection processes Rec. 17 MSCP to seek assurances from Met Police on the training and understanding of adolescent risk of self-harm and suicide to support the completion of Merlin’s with full information in a short timescale. Rec. 18 MSCP to ensure partners understand the introduction of Partnership Reviews (Working Together 2018), including the change from Individual Management Reports to Individual Agency Information Reviews, emphasis on learning, use of Terms of Reference and Key Lines of Enquiry. 3. Reason for the Partnership Review This young person was escalated to the Merton Safeguarding Children Partnership’s (MSCP), Quality Assurance Sub-Group on 15th May 2019, following a Critical Incident Notification from the Youth Offending Team. This was then escalated to the Statutory Safeguarding Partners to consider if the incident met the criteria for a Local Child Safeguarding Practice Review under Working Together 20181 At an Extraordinary Meeting of the MSCP in June 2019, it was agreed that the case did not meet the criteria for a Local Safeguarding Child Practice Review and did warrant further investigation through a Partnership Review - Working Together 2018, chapter 4, paragraph 17. 1 Working Together 2018, chapter 4, paragraphs 10-12, pages 83-85 January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 7 October 2021 On 7th May 2019, the child took an overdose of 9 Ibuprofen following an argument with a friend on the phone and following negative comments from his father. He had stayed with a friend overnight (details unknown) and gone to his mother’s late morning. He told his mother what happened, she called 999 and he was taken to hospital. The child left the hospital the same day following a disagreement over doing a blood test. When he found out the Police were informed of him being missing, he had gone to maternal grandmothers. He returned home once he was advised by his mother she would ask the Police to call off the search. The child agreed to attend an appointment with CAMHS rather than having a MH assessment over the phone which he did not attend. There have been four incidents of intentional self-harm since 2016. 3.1 Methodology It was agreed that the methodology for the review would be an adaptation of the Welsh Practice Model. This will include a Collaborative Review event with frontline workers and supervisors who had direct involvement with the child and / or their family. This event will be an opportunity to complete an appreciative inquiry to make sure the information in the draft report is accurate, captures good practice and identifies learning across and within agencies. This methodology provides a significant change in both emphasis and learning and partners had not understood how this would need to be implemented. 3.2 Scope The time period of this Learning Review is from October 2016 when Eddie first attempted to harm himself to 7th May 2019 when Eddie attempted further self-harm. 4. Family and Background Content Restricted 5. Analysis and Lessons While outside the timeframe of this review it is important to note there are two significant missed opportunities for Eddie, aged 9 and 12. Aged 9 Eddie was considered to be his father’s favourite in a violent and abusive household and he identified with him as a means of safety. The assault during contact by his father was a significant trauma from which his mother was unable to protect him. It is unrealistic to expect a non-abusive parent, who is self-medicating to manage their own trauma, to be able to emotionally support and protect a child without safety planning that is jointly owned between parent/family and professionals. When aged 12 there is a series of incidents that should have been assessed holistically, this included his father’s court appearance for assault, self-harm in a police cell, attacking his brother, assaulting his mother, school exclusion and cannabis use. This was a turning point for Eddie at a time when he was traumatised and services could have intervened to reduce the risk of Eddie becoming without hope of his life being meaningful. In considering this review period individual agencies have met their statutory duties in general and have continued to support the family over a number of years in the hope of producing long-term January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 8 October 2021 change. The information provided indicates interlinking factors that, in combination, have contributed to form the response to Eddie and his family, particularly when reaching adolescence. These include: Service fatigue – continued similar referrals and concerns where support has not previously achieved change (chronology); Preconception based on family history/knowledge - particularly male family members’ mental health, offending and substance misuse; Racism in the form of low expectations as black and mixed ethnic boys are more likely than white boys to be permanently excluded from school; and, ‘helplessness’ in terms of how to safeguard children and young people who are clearly expressing their distress in their behaviour and asking for help, especially where there are no current significant concerns around parenting. 5.1 Think Family is the recognition that families are complex systems and successful and long lasting change within the family requires working with all members as a whole. It means securing better outcomes for children, young people and families with additional needs by co-ordinating the support they receive and strengthening the ability of family members to provide care and support to each other. Eddie is an adolescent with complex emotional and behavioural needs identified from age 9. There are strengths in the family in supporting him and there are elements of dysfunction and questions about whether they can maintain this over his childhood. They offer ongoing support and there have been changes in Eddie's behaviour, which may be in response to the family care in place. Both immediate and wider family members while offering support, had their own emotional and physical needs. There was reference to knowledge about family functioning from a number of agencies with the only direct work being that of Transforming Families. Plans were either focussed on Eddie as an individual or were service based for family members i.e. parenting programmes. There does not appear to have been a network meeting for all relevant people that was effective in creating change, for example, using the Signs of Safety approach to consider how to change the trajectory and how to get there for the family. There appears to have been a number of revolving doors across agencies, in part due to organisational constraints, which is not congruent with Think Family and the principle of ‘no wrong door’. It is difficult to see how the multi-agency knowledge, information, and activity over time have informed planning with Eddie and the family to impact on outcomes. It is noted there is an action in the MSCP Business Plan from 2018 for a Think Family strategy which has not been realised. 5.2 Constructive challenge Agencies should have constructively challenged each other about commitment and responsibility. A complex case discussion, led by the TAC/TAF Lead or the social worker if open to CSC or formal escalation procedures could have been used if needed. A case discussion could have mapped out the worries with Eddie, family and professionals, and agreed who would do what and the timescales for January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 9 October 2021 each member of the network, including family. This could have encouraged Eddie and his family to participate and make use of the support available. If, for example, trauma therapy is required, how does the child’s network make sure this happens co-operatively and not in a blaming way that contributes to ‘remaining stuck’ if it is not available? For individual children concerns should be escalated and decisions challenged to improve their outcomes; for service provision and delivery to be changed to meet need overall the information needs to be escalated through agencies and to the MSCP. 5.3 Contextual Safeguarding/Harm When professionals received similar information or referrals and considered the history for Eddie there may have been a preconception of him and his family that influenced ambitions to achieve positive outcomes and drive forward plans and intervention. For example, while respecting Eddie’s need for fewer professionals to be involved, his substance misuse was not addressed. This may have been due to a normalisation and minimisation of cannabis use particularly among young people by practitioners. Eddie has strong ties to a peer group, friends, and associates and there was a gap in knowledge for some agencies of possible gang affiliation, county lines, and drug use. Eddie’s choices have been linked to incidents or events in his peer networks. Safeguarding adolescents whose behaviour forms part of the risk albeit within the context of familial violence proves to be a challenge to the multi-agency partnership. Contextual Safeguarding Services in the Adolescent and Family Service (Merton Council) and across CSC, are being embedded and evidence suggests effectiveness at articulating and refining risk during consultations, in meetings and in reports. It has been acknowledged police officers are not always sharing information with CSC about a child being stopped and searched which, depending on the circumstances of each incident, could be a potential safeguarding issue. It seems not enough account was taken of concerns raised around Eddie associating with three high-risk individuals, possible drug dealing, carrying a knife, and having ‘youngers’ he could call on to hurt people, for example. Where this is based on information or ’intelligence’ instead of hard evidence, workers need to be supported to explore the concerns and challenge behaviour especially with resistant young people. There were four missing incidents between August 2016 and December 2018, each reported by Eddie’s mother. These were seen as isolated incidents related to his peers and Eddie usually returned home within 24 hours. It would have been important to talk to Eddie about where he had been, explore the contextual risks and consider the return home information, if available, when reviewing the progress of the plan. It is important to note that although there is an independent provider for return home interviews consideration should always be given to the best person to complete this with a young person, preferably a trusted person. 5.4 Trauma informed practice Adverse Childhood Experiences (ACEs) are significant childhood traumas that can result in actual changes in brain development. These changes may affect a child’s learning ability and social skills, January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 10 October 2021 and can result in long-term health problems. The traumas for Eddie include emotional and physical abuse, a parent treated violently, household substance abuse, household mental illness, parental separation and a household member in prison. In addition, Eddie has experienced loss and bereavement in the relationship with his father. It was noted there is a link between poverty, neglect, domestic abuse and trauma and a lack of hope for these families that indicates a need for a preventative approach with early and easy access. In the Youth Justice Team it is not unusual to see a connection between ACES and young people’s behaviour, whether offending, outbursts or self-harm, with the behaviour ‘explained away’ due to the young person’s history and current chaotic environment. However, it is important for workers to continually review incidents and attempt to understand triggers and work with partner agencies to address these. This can be difficult for Youth Justice Practitioners who have a role and not a lead responsibility in safeguarding and who hold a time limited relationship where an order needs to be enforced if young people do not attend. 5.5 Self-harm and suicide prevention Adolescents can turn to a number of potentially destructive behaviours in an effort to avoid or defuse the intense negative emotions that accompany traumatic stress, including self-harm. In understanding and responding to trauma, how do professional and family networks resist the pressure of a medical/individualised model to understand and assess the distress of young people? There is a need to keep the focus on the question ‘What has happened to you?’ rather than ‘What is wrong with you?’. For Eddie the perception of medical conditions and labelling made it more difficult to manage the worries. This meant it was even more important, when wanting to resolve trauma experienced over years, to find the best agency to provide holistic support. It also may need to be accepted that these services do not currently exist and they need to be delivered in a way young people can use. Any child or young person, who self-harms must be taken seriously as risky behaviour in response to distress can be serious, even accidentally. The worries for Eddie were that he could take another overdose impulsively when there is conflict with others and he might seriously hurt himself or kill himself. There appears to have been agreement he would need to be able to manage difficult feelings and conflict to a safe degree without hurting himself or anyone else, and, have a clear and safe plan around what he needs to do when things get difficult. There does not appear to have been a coherent plan in place to address this and it is not clear how much awareness non-health professionals have of suicide risk and prevention. https://www.londoncp.co.uk/chapters/self_harm_suic_behv.html#intro 5.6 Planning A plan to increase safety and reduce risk should be family and community based with the support of professionals, it can be led by CSC or any other TAC/TAF Lead. A clear safety plan would have underpinned the work with Eddie and his family, setting out the family’s input and agreement, and designating people to do what and by when. TAC/TAF or CIN meetings, with clear and direct January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 11 October 2021 overview, analysis of risk and safety, and the use of Signs of Safety/Wellbeing scaling would highlight both family and professionals view of risk and see the progress being made. Eddie was supported to manage his distress with joint working by Youth Justice, Cressey College and - at times – CAMHS, who had a good understanding of what was working well for him. Eddie was supported by his family and linked to services where he was able to establish some working relationships, which was important to him. This young person presented with a number of needs and experiences of harm that could have resulted in him being exploited into very serious and extensive offending. However, to date, the protective factors within himself, his family and the network of professionals supporting him have managed to halt an escalation into a more complex situation. It will be important for all those working with young people presenting with similar needs to understand the positive impact of quality engagement. Plans also need to be supported by regular summaries of current and historical factors and concerns. This information need to be considered when new information emerges and in the event there needs to be a more urgent review of risk and action required. 5.7 Stepping Down or Up and the TAC/TAF Lead At times, there was a reliance on the interpretation of events and discounting of concerns by Eddie’s mother and sister without the context of Eddie’s views. There was also an over optimism about the ability of family care to meet his needs without a ‘Think Family’ approach that would have supported family members to address their own needs to increase their caring capacity. When making a decision to end social care involvement, in the context of repeat referrals and concerns, CSC should have held and chaired a step-down Team Around the Family (TAF) meeting, including the family to find a TAC/TAF Lead who could continue to support Eddie and his family with the agreed plan. If the family were not in agreement with this it should have contributed to the risk assessment of stepping down and, if the decision remained, the rationale communicated to the family and professionals. When there was no social worker involved and there was consideration of worries increasing for Eddie or re-referring to social care any of the involved agencies could have held a complex case discussion and reviewed the step down plan to consider the level of safety as well as risk. Had such a discussion taken place to share information across agencies it may have reduced the fractured approach to support for Eddie. Assessment and planning tools can be based on individual organisations, funding sources and KPIs. These could contribute to the understanding of risk and need through a TAF transition document supported by each agency’s assessment. If one of the worries were family members or Eddie not working with the plan, it would be important to understand why by asking them if they fully understood the worries, concerns and plan. This would have enabled the Team around the Child, particularly family, to consider if alternative action and input was required, what could be done differently to engage Eddie, reduce the risk of harm, or consider if safeguarding was needed. Strength based work needs to be utilised more in work done with young people who have experienced considerable trauma and/or have high levels of shame and January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 12 October 2021 ‘hard to reach’ young people (high risk, complex, entrenched and not conventionally help-seeking) need to be supported by a team around them who can build trust and understanding. Any organisation working with Eddie should have informed the other agencies in writing it was ending the service or had decided not to be actively involved to reduce the risk of misunderstanding what the service provision is and what was in place. It is important in the face of non-engagement that all agencies, including CSC should maintain a level of perseverance so that all agencies remain committed to trying everything in the context of high demand on services. 6. Good Practice: Youth Justice workers use a holistic assessment framework that includes a self-assessment by the young person to capture their views. The workers made efforts to develop a relationship with Eddie and his sister, who was often caring for him during his orders, and significant efforts were made so Eddie attended follow up appointments. The progress of the plan and consideration of risk issues was supported by good liaison with Sutton CAMHS, Education and Cressey College and referrals were made to the MARVE Panel for oversight of contextual factors and risk. The Self-Assessment was completed by Eddie who was able express his ambitions and acknowledge family, friends, and behaviour issues including trying to hurt himself. The Youth Justice Team appropriately referred to MASH and challenged the closing of referrals, particularly if the YJ Team considered there was an expectation to address parental capacity to safeguard against significant harm. The SMART centre kept an oversight of Eddie’s education when in alternative education placements and tuition. The decision to undertake the Education Health and Care Plan was effective and the assessment well informed. The Education Psychology Report was referenced to the adverse childhood experiences, contextual trauma he had faced, built on 3 previous assessments and included the voice of Eddie, his mother and sister. Any period of time out of school on one to tuition potentially increases risk. Interim part time education was provided while a placement was sought, taking account of mother’s wishes. Although Eddie did not always take part in the tuition, the SMART centre worker kept an oversight and was flexible by moving the tuition to the grandmother’s house. General practice consultations are mostly time limited, however during the majority of the consultations, GP’s discussed Eddie’s other needs. For example, when attending with exacerbation of asthma, the consultation focussed on all of the needs of Eddie rather than just one symptom. CAMHS provided an immediate response to crises; were receptive to mother’s request for a new consultant; and provided a flexible response to family perceptions, agreeing to trial Concerta at the request of Eddie’s mother. The CAMHS consultant asked for a full chronology from social care to inform CAMHS intervention and notified CSC when concerns escalated. When Eddie was on remand his vulnerability indicated he would struggle to settle with strangers. There was good partnership working between CSC and Youth Justice to find a carer in the family network and not resort to foster care unless absolute necessary. The social work team tried to January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 13 October 2021 understand Eddie’s needs and encourage his engagement, including with safety-planning work; working with his mother and sister and all key agencies to deliver appropriate interventions. Although there is limited opportunity for a ‘think family’ approach with Eddie police officers were able to engage with him and family members to establish circumstances including medication not being taken and mental health concerns at 3 different times which helped inform the action taken. 7. Missed opportunities 7.1 Eddie’s voice Eddie expressed a clear view he wanted to be in an education placement and it would have been an opportunity to build a trusted working relationship. Eddie’s adverse childhood experiences affected his secondary education and the gap between him and his peers grew although he had been assessed as of average ability. It is clear from the Education Psychologist’s report that being out of school was seen negatively by Eddie, added to his low sense of success and that low expectations became self-fulfilling. Given the few hours of occupation he had, it is understandable he struggled with his emotions and was vulnerable to criminal exploitation and activity. The GP practice identified the importance of speaking children and young people on their own where appropriate; they should feel safe to speak and clinicians should explain how the information they disclose may be used. When completing the self-assessment as part of the work with Youth Justice Eddie positively expressed his ambitions however while his plan recognised this there were no steps or actions to support his growth towards those ambitions. Eddie when 9 years old expressed an opinion he was ‘not listened too’ – this would indicate that for him although we had heard and recorded his words it does not necessarily mean we listened. Eddie was also clear that he wanted to talk to and work with adults with whom he had a trusted relationship. He said he did not talk to CAMHS workers even when he had the opportunity to do so as he did not trust them. After building relationships with Youth Justice workers this ended as Eddie was no longer on an order, this meant the adults in his life were no longer able to work with him in his version of his world and understand the motivation for his voice and views. While it was understood Eddie may have wanted to talk to someone outside of the family he trusted, it does seem that organisational structures and service limits meant his perspective was not always sought and an opportunity was missed to shift his negative view of himself. 7.2 Multi-Agency Assessment of risk Assessments and interventions should have fully considered historical factors as part of a comprehensive assessment and were sometimes focused around single events. In CSC the rationale for decision-making does not appear to have included whether the views of immediate family members were accepted or how this was challenged if professionals had alternative views. It is also not clearly evidenced if CSC had considered legal proceedings when they believed the family were not fully able to support Eddie and manage his behaviour, for example, at the point of remand. Additionally, in responding to referrals family members appeared to discount the worries and January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 14 October 2021 concerns on occasions and it would have been important to consider the potential of disguised compliance and resistance. Eddie was a looked after child for 3 weeks in 2016 due to being remanded with bail conditions. When YOS and Social Care supported a placement with his grandmother instead of foster placement Eddie’s mother was asked if he could remain in care so that interventions could happen however his mother did not agree and there was a need for parallel planning at this time. Systems thinking would suggest that moving a young person into local authority care removes the risk and this is not reassessed when they leave care, usually to go home. When Eddie’s bail conditions were changed he returned to his mother’s care, what was missing at this time is the assessment of risk including the parenting capacity of Eddie’s mother and sister, stability of care and safety when he left the grandmothers home and the potential of risk recurring. There was an unmet education need at times for Eddie and there is no evidence of any single or multi-agency challenge. In September 2016, the multi-agency plan was to progress to ICPC. The CAMHS consultant psychiatrist stated at a CIN meeting, in front of the family, it was not safe for Eddie to return to his mother’s care from what was known then about risk, family function and the level of care provided. CAMHS considered Eddie was at risk of significant harm and a child protection plan would have been appropriate although it could not be known how effective it would have been. When the decision was taken by CSC to continue with a CiN Plan it would have been helpful for this to have been as part of a multi-agency meeting with the family and for the decision and rationale to be communicated to all partners. In retrospect CAMHS should have constructively challenged this decision and escalated if needed if the CAMHS view was safeguarding concerns and risk remained. Youth Justice involvement and plans could have been more holistic about Eddie’s wellbeing concerns from the time of his first low level offence aged 12 up to the most recent. There was clearly the motivation to deliver support for Eddie’s ambition and the plan could have also addressed his substance misuse and potential exploitation. ESTH missed opportunities during earlier attendances to make a referral to CSC. At times, professional curiosity, speaking directly to the child and seeking information from CSC would have supported a referral being made. There were times when Eddie was involved with Police and tried to harm himself, this information did not reach CSC and may have been an opportunity for assessment and intervention, particularly if considered in the context of other events and behaviours at the time e.g. aged 12. While it is the responsibility of Met Detention to make sure the Merlin is complete it would be helpful to understand what role the custody nurse has in recording and sharing information about incidents of self-harm for child detainees. From national clinical commissioning guidance, there is no direct communication between GP practices in one borough and Social Care in neighbouring boroughs. Consideration needs to be given to how that liaison can take place as there is an increased need for good communication between all the agencies involved. January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 15 October 2021 When CSC are communicating with partner agencies to complete assessments or inform of outcomes, plans and meetings it is essential to confirm which borough or area the child’s school or health team is located in. There are a number of Merton children who live near the borders of neighbouring boroughs and a child may not attend a Merton school even if they live in the borough. 8. Organisational safeguarding The Lammy Review 2017 and research since shows although there are fewer young people offending and going into custody, the BAME proportion has risen. The review acknowledges many causes of and solutions to BAME over-representation in the criminal justice system lie outside the CJS itself. The Youth Justice Service first became involved with Eddie in 2016, this involvement was brief and required no further intervention due to it being low gravity and his first offence – he was aged 12. In 2017 Eddie (aged 13) received a Referral Order for Possession of Knife, the order was extended for two common assault matters. Before the Referral Order ended, in early 2018 (not yet 14), he received a 12 month Youth Rehabilitation Order. In Youth Justice the first two overdoses should have been recorded as a significant incident and escalated to Head of Service for review. Consideration is needed as to how oversight of young people who are vulnerable and not yet presented to MARVE panel or do not meet threshold for CCE / Serious Youth Violence takes place. Embedding of the Trauma based approach in Youth Justice means Case formulation can be undertaken for high risk and/or high vulnerability young people and at an earlier stage. Strength based work needs to be utilised more in work done with young people who have experienced considerable trauma and/or have high levels of shame. There is guidance as to when School Nurses should withdraw from involvement in safeguarding and there is an added layer of liaison with a safeguarding specialist nurse or the Named Nurse for Safeguarding Children. This is to ensure that learning for health partners from Serious Case Reviews considers all needs in any analysis before withdrawal from involvement. Decisions not to be involved in the child’s network should be communicated to partner agencies Practice has changed in ESTH since 2016 with an emphasis of obtaining the voice of the child, being curious and clearly documenting all information accurately. The Trust has a visible safeguarding team that ensures processes are embedded. This has been strengthened with the recruitment of a Liaison nurse who coordinates safeguarding processes in the Emergency Department and ensures appropriate referrals are completed in timescale In relation to Education there are questions as to whether an earlier assessment for an EHCP would have been a protective factor given the level of trauma Eddie had experienced. There is a lack of evidence of therapeutic interventions available to school settings to prevent education breakdown and the seeking of a unique SEND placement meant Eddie was out of tuition for longer than was helpful. This case highlights the importance of clinicians speaking to the children on their own especially in presenting for behavioural and mental health problems. GP’s do need to speak to the children wherever possible on their own to record their wishes, their feelings and importantly, the child’s January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 16 October 2021 understanding, explanation and interpretation of events. This vital information will be valuable for further assessments and enable clinicians to signpost in the right directions for further management. Documentation gaps identified at St Georges have been corrected with effective liaison between teams from St Georges Mental Health Trust and St Georges Hospital Trust. The CAMHS team now record their attendance and brief summary of assessment on the St Georges documentation with the in depth assessment being completed on the Mental Health Trust records. In the latter part of 2019, Children’s Social Care supervision policy was updated and implemented across services to improve management oversight and recording of decision-making that will help assessments to consistently demonstrate the in-depth links and evidence from exposure to domestic abuse or drug abuse and the impact for children. This is supported by more robust quality assurance that includes a strong audit cycle embedding management oversight, providing a level of scrutiny, and sampling cases around decision-making and quality of assessments via the audit process. Where young people are missing this is now specifically recorded and brought to the attention of the Head of Service in CSC who chairs the weekly Missing meetings and MARVE panel. There is robust oversight and decisions agreed with a multi-agency approach. In addition, a leadership alert process has been implemented for the notification of serious or worrying events, which provides key and important information as and when events happen for leaders and are reflected in records for children. 9. The Parent and Carer’s Views Eddie’s mother and sister were spoken to by a known professional and it was arranged to speak to them however this was unsuccessful. A further contact made in writing which was also unsuccessful. 10. The Practitioners’ Views An Appreciative Inquiry Meeting was held with practitioners directly involved with Eddie or representing agencies where practitioners had moved on. This sought to confirm whether the Panel and Review had appropriately identified what worked in and across organisations, to be able to learn from this and identify what may need to change to support the best of what was done. Safeguarding children is about living with high and unpredictable levels of risk and uncertainty. This can result in defensive practice which is driven by fear of making a mistake and an overreliance on ‘doing things right’ rather than ‘doing the right thing.’ (Munro, 2012). Representatives from Education Services, Youth Justice and Epsom and St Helier Hospital (ESTH) took part and considered that, in the main what worked well had been capture through the review. There were two areas that were clarified for emphasis in the worries about the response to Eddie: Service fatigue - there was another dimension to this which for some workers was a helplessness created over time by the worry of not getting things right for Eddie’s mother. Parents may have difficulty in consistently seeing good intent and be suspicious of the worker’s motives or may not agree interventions are purposeful or making a difference. There was a sense of not knowing January 2022 Merton Safeguarding Children Partnership STRICTLY CONFIDENTIAL 17 October 2021 whether the worker would be seen as part of the services who were failing Eddie and if there would be a negative reaction. This meant workers were unconsciously braced for this response while still keeping Eddie and his needs in mind. Think Family – the family plan was for Eddie to be cared for by his older sister when he could not live at home with his mother and they did not want him to go to a foster placement. It would have been helpful to think explicitly about the older sister’s capacity to parent, both in the context of Eddie’s needs and her own unaddressed trauma, which Eddie had also witnessed. From a practical perspective this could have included consideration of how the sister could be supported to provide stability in sustaining a tenancy and access to education; and from an emotional perspective, how to sustain a parenting role when Eddie’s mother was still very present in decision making and family life. 11. Appendices: Appendix 1 Summary of agency involvement Restricted Content Appendix 2 Key Lines of Inquiry - Responses Restricted Content Appendix 3. Review Panel The review is being undertaken on behalf of the safeguarding partnership by Debbie Eaton, Quality Assurance Manager, Audit and Practice Improvement, Children’s Social Care and Youth Inclusion. Panel Membership: London Borough of Merton, CSF – MASH & First Response; Safeguarding and Care planning London Borough of Merton, CSF – Head of Service, Adolescent Family Service (Youth Justice) Merton and Wandsworth CCGs NHS South West London Alliance Kingston, Richmond, Merton, Wandsworth & Sutton CCGs– Designated Nurse Looked After Children South West London and St George’s Mental Health NHS Trust – Named Nurse for Safeguarding Children Central London Community Healthcare NHS Trust (Merton) - Named Nurse Safeguarding Children London Borough of Merton, CSF – Head of Service, Education Inclusion GP – Bishopsford Surgery – Supported By Sutton CCG London Met Police, BCU – Detective Chief Inspector Epsom and St Helier Hospitals (ESTH) St. Georges University Hospitals NHS Foundation Trust – Named Nurse Designated Doctor Merton CCG |
NC51184 | Death of a 16-year-old boy following a road accident in 2017. Child Q was one of the 60 vulnerable children included in the Vulnerable Adolescents Thematic Review, an analysis of multi-agency involvement by Croydon SCB. He had unaddressed behavioural and emotional challenges; he was a looked after child with Croydon Children's Services; he was believed to be a gang member and was known to Youth Offending Services. He had frequent moves to various locations within a short space of time often for short periods. The family are Black British Caribbean. Learning includes: provide support to parents as early as possible in a child's life paying particular attention to attachment in early years and experiences of separation and loss; equip children's workforce to provide a trauma informed response to adults and children; Child Q's behaviours were not adequately addressed in school, which led to exclusion; ensure that transfer or transition arrangements are as robust as possible; Child Q required intervention and treatment for various emotional and mental health issues, but treatment was unacceptably delayed. Recommendations: the need to strengthen working protocols between Adult Mental Health and Children's Services to facilitate development of integrated whole family health care pathway; to influence the Department for Education to review alternative education and agree a consistent methodology of working with high-risk pupils in a multi-agency context; join up multi-agency risk and safety planning forums to improve services for children at high risk in the community, such as gangs, serious youth violence, missing and all forms of exploitation.
| Title: Serious case review summary: Child Q: “where were you when I was six?” LSCB: Croydon Safeguarding Children Board Author: Charlie Spencer Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. P a g e 1 | 25 Serious Case Review Summary Child Q “Where were you when I was six?” Charlie Spencer March 2019 P a g e 2 | 25 The contribution made by family members to this report has been invaluable. The CSCB are extremely grateful for their courage in coming forward to share their experiences of the services provided so that other children and families may benefit from the lessons learnt by this review. The CSCB offer sincere condolences to Child Q’s family for the tragic loss of their child who was loved by all family members. P a g e 3 | 25 Contents Section Subject Page no: Chapter 1 Introduction 4 Chapter 2 Background to this SCR 6 Chapter 3 Methodology 6 Chapter 4 Family Perspectives 9 Chapter 5 Practitioner Perspectives 10 Chapter 6 Case History, Analysis, Findings & Recommendations 12 Chapter 7 Conclusion 22 Appendix 1 Bibliography & References 24- 25 P a g e 4 | 25 CHAPTER 1 - Introduction This Serious Case Review concerns Child Q, who was aged 16 years when he died following a moped crash. When this SCR took place, the Vulnerable Adolescent Thematic Review 1 was underway in Croydon. This Thematic Review involved a comprehensive analysis of multi-agency involvement with 60 children who were known to be vulnerable, Child Q was included in this review. The Vulnerable Adolescent Thematic Review should be read in conjunction with this Serious Case Review (SCR). At the time of Child Q’s death, he was a looked after child (LAC) with Croydon Children’s Services and was living in the Midlands with members of his extended family. On the day of the collision, Child Q had been released on conditional bail from a remand court for breach of his court order. Family members and professionals requested that Child Q should be made the subject of a curfew and tagging, but this was not put in place and he returned to London where the fatal accident occurred. Child Q was described by his family as a bright intelligent young man who loved his family. He was a talented young footballer and he aspired to be a professional footballer. Child Q’s first conviction ended his aspirations and motivation to play football. Throughout his life, he lived with various family members and foster carers. He was often missing, was both a victim and perpetrator of various offences, was involved in high risk behaviour and believed to be a gang member.2 Child Q seemed to understand the concerns of professionals and family members that his high-risk behaviour could end very badly, but he appeared resigned to this being almost inevitable and the role of the gang in his life was very important to him. During the latter stages of professional involvement, Child Q asked a professional “where were you when I was six?” Although it is unclear exactly what he meant by this, it was understood it may have been a recognition of the help his family needed when he was young. This question has been used as the title for this report and is used as the basis for questions posed about service delivery within the Vulnerable Adolescent Thematic Review. National and Local Context The Vulnerable Adolescent Thematic Review details the national and local context in relation to children who are vulnerable to exploitation, serious youth violence and gang activity and refers to the Ending Gangs and Serious Youth Violence3 strategy (EGYV). This strategy report identifies that a high proportion of males from Black and Minority Ethnic (BME) backgrounds were disproportionally involved in gangs or serious youth violence. The EGYV strategy illustrates the ‘journey of a gang member’ and suggests that children and young people who are involved in this behaviour came to 1 Croydon Safeguarding Children Board: Vulnerable Adolescent Thematic Review. C. Spencer, B. Griffin, M. Floyd. February 2019 2 In order to determine whether or not a child is a member of a gang, police, the gangs’ team and YOS gather relevant intelligence and conduct specific assessments in order to make this decision 3 Ending Gang and Youth Violence. A Cross-Government Report including further evidence and good practice case studies. HMG 2011 P a g e 5 | 25 the notice of key agencies from an early years setting, throughout primary and secondary education and were known to key agencies such as police, youth offending, Children’s Services and health (including CAMHS). Alongside the increase in gang membership, serious youth violence and knife crime, moped enabled robberies have significantly increased in recent years. London has seen more than 22,000 moped-related crimes in the last year, more than double the number in the previous year.4 Children’s Services are increasingly expected to respond to safeguard children via child protection or child in need (CIN) approaches. However, in isolation, these responses are not effective in dealing with the complexity, risk and vulnerability of a child with behaviours like Child Q.5 The blurred line between vulnerability and risk, in the home or in the community or both, creates an uncertainty amongst professionals as to how best to respond. Should children at risk be taken into care, made the subject of child protection plans or receive services as children in need? If not, what are the viable alternatives? This Serious Case Review suggests that where preventative services are not available, where there is narrow focus on the risks inside the home and restricted multi-agency working, there are few viable alternatives. This SCR will explore some of these key issues for the wider children’s safeguarding partnership. Could this happen again? The Vulnerable Adolescent Thematic Review identifies several practice, policy and procedural issues that need to be addressed locally and nationally in order for services to have the desired impact on children and young people to prevent further incidents of serious youth violence, and to curb the pull for young people to gang allegiance, these issues are relevant to this SCR. The prevalence of knife crime, or other gang-linked behaviours such as moped robberies, and the complexities of providing services to children affected by gangs and serious youth violence presents significant challenges for services. The lack of a comprehensive understanding of the risks and vulnerabilities in the home and community is exacerbated by reducing resources to constructively engage young people to divert or prevent involvement in gang related activity. Given the size of London and how transient some young people involved in this lifestyle can be, especially when placed in various locations for their own well-being (requiring handovers, transfers and complex information sharing), the challenge for multi-agency services are acute. The reduction of preventative services for young people often results in a reactive, rather than a pro-active, response. As children’s high-risk behaviour escalates so does the service response and the statutory mechanisms used to safeguard a child reach the highest possible levels. 4 https://news.sky.com/story/why-moped-crime-is-rising-and-how-you-can-avoid-being-a-victim-11399439 5 That Difficult Age - Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014 P a g e 6 | 25 CHAPTER 2 - Background to this SCR Croydon Safeguarding Children Board Serious Case Review Subgroup reviewed the circumstances of Child Q’s case and agreed that the statutory6 criteria had been met for a Serious Case Review. This guidance specifies the following: a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Serious Case Review should be conducted in a way which: Recognises the complex circumstances in which professionals work together to safeguard children; Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; Is transparent about the way data is collected and analysed; and Makes use of relevant research and case evidence to inform the findings. The purpose of the SCR is to: Look at what happened in the case and why and what action will be taken to learn from the review findings Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children. Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children. 7 CHAPTER 3 - Methodology Two independent consultants were commissioned to undertake this Serious Case Review. Exemplary co-ordination and administrative support was provided by the CSCB Business Manager and team. 6 Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2015 7 Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2015 P a g e 7 | 25 Bridget Griffin, Independent Consultant, was appointed as Chair of the Serious Case Review Panel. Bridget has extensive experience in statutory safeguarding children work with specialist knowledge of being a chair and author in Serious Case Reviews. Charlie Spencer, Independent Consultant, was appointed as the Lead Reviewer and author of this SCR report. Charlie has extensive experience in Youth Offending, young people services, and has led and participated in numerous multi-disciplinary peer reviews on behalf of the Home Office, in ending gangs and serious youth violence. A serious case review (SCR) panel was established, chaired by the Independent Chair, and attended by the lead reviewer/ report author and senior professionals from all agencies to manage and oversee the review. A key role of the panel members was to facilitate the completion of independent management reports (IMRs) and chronologies relating to their agency’s involvement. Five SCR panel meetings were convened, where members were able to analyse, explore and challenge the information gathered to identify learning across all agency involvement with the family. The membership of the panel is set out below: Bridget Griffin Independent Safeguarding Consultant – Independent Chair Charlie Spencer Independent Consultant – Lead reviewer/ author Manager Croydon Safeguarding Children Board Head of Targeted Services Croydon Children’s Social Care and Early Help, People Department Service Leader Head of Youth Offending Team Croydon Youth Offending and Gangs Service (YOS) Head of School Place Planning Admissions and learning Access Croydon Education Detective Sergeant Police Specialist Crime Review Group (SCRG) Head of Safeguarding, Designated Nurse Children Croydon Clinical Commissioning Group (CCG) Designated Doctor Safeguarding Croydon Clinical Commissioning Group (CCG) Associate Director Nursing Adults and Children’s Safeguarding Croydon Health Service (CHS) Contracts & Partnership Manager Community Rehabilitation Company Team Leader Redthread, St Georges Hospital Director of Projects Safer London Young Person Team Manager Drugs & Alcohol, Croydon Recovery Network, Turning Point Head of Family Safeguarding Hertfordshire County Council Service Manager Cafcass (Children and Family Court Advisory & Support Service Deputy Director, Quality South London and Maudsley NHS Foundation Trust (SLAM) including CAMHS Head of Safeguarding Wolverhampton City Council P a g e 8 | 25 Deputy Designated Nurse, Safeguarding Children Wolverhampton Clinical Commissioning Group Head of Quality Assurance Children’s Social Care, London Borough of Southwark Terms of reference The Terms of Reference (TOR) agreed by the Panel included learning outcomes and the SCR timeline. It was agreed that the period under review would be from Child Q’s birth to his death, with the proviso that agencies would summarise any other relevant information pre-dating this period to add context and background to their report. The review had several key strands including: Individual agency chronologies Individual management reports (IMRs) Composite chronology of all agency events Practitioner learning event and interviews with key professionals Family member contact Completion of overview report Review of various key documentation, including reports, minutes and assessments Learning outcomes To gain an understanding of the factors that might be present in the child’s life that would make him vulnerable to a life-ending result. To gain an understanding of what services or provision has been made to this child and family in order to inform what might work for others in the future to prevent the same outcomes. To influence commissioning of timely and appropriate services to address these issues. To ensure the learning from this SCR is disseminated across partner agencies, in order to inform future practice. Practitioner Learning Event (PLE) Key professionals from a number of agencies, who were involved in providing services to Child Q and his family, came together for a one-day event to contribute to the review and case analysis. Child Q’s case summary was utilised to enable participants to reflect on their agency’s involvement with the family in a supportive, non-judgemental environment. This enabled practitioners to express their views of the challenges, responses and actions taken, whilst being able to think about service improvements that could reduce the likelihood of other families experiencing such a devastating outcome. Family composition The family included Child Q and his mother (Ms R), his father (Mr S) lived separately from the family but continued to be an important part of Child Q’s life. Child Q had a close relationship with his P a g e 9 | 25 mother and with his paternal aunt and paternal grandmother, with whom he lived on a number of occasions throughout his life. Identifier Family Member Ethnicity Child Q Subject Black British Caribbean Ms R Mother Black British Caribbean Mr S Father Black British Caribbean Mrs T Paternal Grandmother Black British Caribbean Ms T1 Paternal Aunt Black British Caribbean CHAPTER 4 - Family Perspectives The perspectives of the family has been gained by two meetings each with Ms R and Mr S individually, plus two joint meetings with Child Q’s paternal aunt and grandmother. The death of Child Q has been an enormous loss for his mother, father, aunt, grandmother and extended family members. Understandably, their grief remains acute. It took great courage for family members to speak to the Lead Reviewer and the Independent Chair and for some family members there remains some understandable anger and frustration about the lack of assistance provided by services to support the family to care for Child Q and keep him safe. Ms R and Mr S were very open and reflective in their views that they shared with the Independent Chair and Lead Reviewer. Ms R loved her son deeply and wanted the best for him, she says that the combination of own ill health and her worries for Child Q’s safety were extremely challenging for her, especially as she had few support networks of her own. Mr S reflected on the fact that he was not there for his son as much as he should have been due to his criminal activity, for which he received custodial sentences, he regrets that he was not consistently available to be a positive father figure to Child Q. Whilst both agreed there were some behavioural issues in primary school and secondary school, they were taken aback by his first offence. This proved to be a very difficult time for all family members. As Child Q’s behaviour became more concerning Ms R sought assistance from various agencies and from Mr S, who would visit the home to physically chastise his son in an attempt to control his behaviour. Nevertheless, Mr S fully accepts that physical punishment is not acceptable and does not work. Both parents recognised the influence of Child Q’s peers, he was consistently drawn to these peers, despite how his parents felt. Young people would congregate at Child Q’s home address and Ms R had the dilemma to ask them to leave (if she did Child Q would leave with them) or allow them in the property where she knew he was safe. Ms R highlighted that she tried to work with professionals, but often felt judged by them. She said that, at times, she was confused as different workers from different agencies would give her contradictory messages of what she should do for the best. P a g e 10 | 25 Paternal aunt and grandmother are angry, they felt they did everything they could to keep Child Q safe including moving to a place where they had no family and placed themselves in financial hardship as a result. They were very open with practitioners about their fears about Child Q returning to London and disclosed conversations they overheard between Child Q and his friends on the telephone that indicated his intention to return to London but feel that it made no difference. Mother, aunt and grandmother are extremely angry and upset that an electronically monitored curfew was not requested at his final court appearance and strongly believe that if the curfew had been reinstated on that day Child Q would not have travelled to London and therefore would not have lost his life. All family members believe that services did not assist Child Q as they had hoped. They recognise that he had some emotional and behavioural challenges that went unaddressed. He was strong-minded and strong-willed but was very loving towards his siblings and his family members. His loss has left a great void in their lives, they have found it difficult to move on and to leave behind their experiences of working with various agencies, and the anger they feel. After Child Q’s death, mother, aunt and grandmother were disappointed by the limited support and sympathy demonstrated by agencies that worked with Child Q. Aunt and grandmother acknowledge that a few individual workers contacted them to send condolences and offer support, but their overwhelming feeling was that they were no longer important. The financial support was withdrawn almost immediately creating financial challenges. Ms R, who had already suffered the devastating loss of her mother and father, was left in a state of deep grief without a supportive practitioner who could assist her to access bereavement counselling. The Independent Chair and Lead Reviewer referred Ms S to counselling after our interview, some seven months after Child Q’s death. Gang membership Ms R does not accept that Chid Q was a gang member. She advised that she saw no evidence of this and did not think this should be included in the report. Where this has remained in the report, Ms R requested that a clear statement be made as to the basis for the view regarding gang membership is included. Mr S advised during his two interviews that he believed Child Q was an influential member of a local gang. CHAPTER 5 - Practitioner Perspectives This section is informed via a practitioner learning event attended by over 30 practitioners from the various areas that held responsibility for providing service to Child Q and his family, the majority of whom had direct experience of working with Child Q. Several practitioners had a great affection for Child Q and were evidently still coming to terms with his death. When asked to describe Child Q, they used words such as: ‘strong minded, intelligent, well spoken, popular, well liked, engaging and endearing’. He was a good footballer, who wanted to do well in life and look after his family. P a g e 11 | 25 He was described as ‘loyal, a good friend, ‘he had an amazing smile’, but some felt he often seemed lost and they felt he was let down from the beginning. There was a general belief amongst some practitioners that services did not take the right actions at the right times, allowing behaviours to become more entrenched and riskier and responses were often characterised by ‘crisis management’ mode. There were significant parts of Child Q’s life that they were not aware of, this was reinforced by the schools in attendance who said they had not received any background information on Child Q which did not enable an intelligence led approach to his education. School’s also highlighted they did not feel they had the skills, expertise or resources to work effectively with children who have needs as complex as Child Q. Going forward, if another child with such needs was currently on their caseload, practitioners were not confident that the outcomes would be more positive. They pointed out that gaps in service provision, or current practice arrangements, must change to better assist children like Child Q. The areas highlighted included: Improved emotional wellbeing support for parents and carers delivered in the context of a whole family plan in partnership with Children’s Services, early help, health and adult services, to include parenting support. Strengthened information sharing at an earlier stage and throughout. School staff commented that they are often unaware of a child’s early years and this is important to understand to inform the support provided. Many practitioners highlighted the need for workforce development to improve the knowledge and skills needed to work with children who have complex needs and vulnerabilities such as Child Q (to include teaching staff, police and the wider children’s workforce). Better resourced, and better-defined preventative services in early years so all parents who need it can be supported. Improved targeted prevention for those children who display concerning or risky behaviours so that they can be supported or be subject to intervention and so that behaviours can be addressed far earlier, before they become entrenched. Improved collaborative working between agencies and inter-agency departments. An example of this was joining up gangs’ work, with YOS and Children’s Service interventions. An improved understanding of roles, responsibilities, and tools agencies have at their disposal that can be synchronised with other multi-agency interventions to make them more successful. Increased practitioner skills to build multi-agency ways of working - far too often staff said they had to learn on the job through experience of working with other agencies : ‘if you do not hold a case that requires this level of collaboration, then you will not develop the skills and knowledge required to work effectively as a multi-agency partnership’. Timely decision making at senior management level, complemented by trust in the practitioner’s judgements and assessments. On the flip side, some decisions were hasty, ill-advised or unsupported by the professional network. Such as stepping down the case to a lower level of service intervention, or repeatedly trying the same options when they had P a g e 12 | 25 already proven to have not worked. For example; ‘continually identifying foster placements for Child Q that he was never to going to stay in.’ Management oversight applied more rigorously, with decision makers better sighted and informed to make more timely decisions. This was felt to be important as it was said that the time taken to convince managers of actions required to address behaviours led to important delays in securing a service that a child needed. Explicit contingency plans to promote proactivity rather than reactive interventions and crisis management. More responsive child and adolescent mental health services that are flexible and creative to meet the needs of children. It was felt this may require an adjustment to CAMHS thresholds to enable more children to meet the criteria at an earlier point in their lives and/or CAMHS delivering more universal work across the range of children’s settings, such as schools. Police and other agency safeguarding approaches should be joined for children missing, absent and/or children on the gang’s matrix, at risk of criminal or sexual exploitation. Families should be more involved in supporting their children and treated as a part of the solution, rather than ‘the problem’. There should be a clearer, agreed collaborative approach to family engagement to avoid mixed messages, confusion and labelling of children and their parents/carers. Practitioners felt they needed to be better trusted by their organisations and better supported so the risks associated with a case like Child Q are recognised and held by the organisation, not by the individual practitioner. Too often practitioners said they experienced holding the risks alone and went home worrying about the safety of a child they are working with. CHAPTER 6 - Case History, Analysis, Findings and Recommendations The Vulnerable Adolescent (VA) Thematic Review identified five key findings, all of which are relevant to Child Q, the detail of these findings and recommendations will not be repeated. Only findings and recommendations specific to Child Q are included. Finding 1. Early help and prevention The Vulnerable Adolescent Thematic Review identified the need to provide help to families as early as possible, in this SCR the following was highlighted: Provide support to parents at the earliest possible point in a child’s life paying particular attention to attachment in early years and experiences of separation and loss. Equip the children’s workforce to provide a trauma informed response to adults and children and to work together across children and adult services to meet the needs of children and parents. Recommendations Finding 1 in The Vulnerable Adolescent Thematic Review is relevant to Child Q : Early help and prevention is critical as are the corresponding recommendations. An additional recommendation is made in respect to Child Q’s specific circumstances. P a g e 13 | 25 SCR Child Q: Recommendation 1. Working protocols between Adult Mental Health and Children’s Services to be strengthened to facilitate the development of integrated whole family health care pathway so that a holistic multi agency treatment and support model can be provided, complemented by consistent timely information sharing and progress reviews. Finding 2: Education, transitional points, managed moves and alternative education Child Q displayed concerning behaviours in primary and secondary school resulting in numerous managed school moves, and ultimately to permanent exclusion and attendance at alternative education establishments such as a Pupil Referral Unit. It is unclear what level of information was exchanged during the various points of Child Q’s transition to different schools or education establishments, but it was clear that his behaviours were not adequately addressed in school. After Child Q’s first exclusion, it was difficult to maintain stability for Child Q and his multiple placement moves compounded the disruption to his education and impacted on the ability of services to provide the care and treatment he required. Why is this important? The prevalence of children of school age being involved in violence, or who display high risk behaviours as victims or offenders, is increasing. This creates a dilemma for schools on how they continue to educate these young people, and to keep other pupils safe. It is recognised that schools have a duty to keep all pupils safe, but it is the view of the panel that ideally a more productive approach would be to create alternative provision for some pupils within the mainstream school environment. School staff were very clear in the Practice Learning Event that they did not feel they had the information, skills, knowledge or expertise to work effectively with children like Child Q. The development of staff, underpinned by consistent resources, will be required in order to enable schools to undertake the tasks required. How widespread and prevalent is this? This issue is not specific to Croydon, there is a plethora of information evidencing that children educated in a PRU achieve far less academically than children in mainstream education and are a greater risk of forming an association with a negative peer group. The latest statistics on exclusions show that following a downward trend, the rates of permanent and fixed-period exclusions have risen since 2013/14.8 A significant number of children attend alternative education settings due to behaviour and/or special educational needs. In addition, some BAME groups such as African Caribbean, White and Black Caribbean are over-represented in alternative education. It is understood that the Government are in the process of reviewing 8 Creating opportunity for all Our vision for alternative provision DFE March 2018 P a g e 14 | 25 alternative provision. It is suggested that this review should include the experiences of children like Child Q. Recommendations The Vulnerable Adolescent Thematic Review identified two relevant findings. Finding 2: Schools should be at the heart of multi-agency intervention and Finding 5. Disproportionality, linked to ethnicity, gender and deprivation, requires attention and action. These findings are relevant to Child Q, as are the corresponding recommendations. An additional recommendation is made in respect to Child Q’s specific circumstances. SCR Child Q: Recommendation 2. CSCB to utilise the learning from this serious case review to influence the outcome of the Department for Education (DFE) review of alternative education and work with school leadership locally to agree a consistent methodology of working with high-risk pupils in a multi-agency context. Finding 3: Dealing with fast paced risky behaviour, vulnerabilities and needs During Child Q’s adolescence he spent more time in the community engaging in serious risky behaviours and crime. He frequently came to the notice of the Police, there were numerous missing episodes and behaviours that led to frequent moves from one carer to another. During the latter period, incidents were being noted almost on a weekly basis that resulted in agencies responding to the presenting issue and not being able to address one incident, before another was highlighted. Various placements were tried, but stability of placement could not be achieved and much-needed treatment to address his mental health needs could not start. Agencies were aware of Child Q’s illegal use of mopeds but did not put in measures to address this risk. Overall, multi-agency services struggled to grip his case and put long-term solutions in place. The SCR panel recognises the unprecedented challenge presented to agencies attempting to provide services, and the need to address the immediate risk presented. Nevertheless, in cases such as Child Q it is crucial for agencies to reflect on the collective tools they have available and deploy them in a consistent coherent single multi-agency plan supported by impact measures and a contingency plan. The assessment completed by the Consultant Social Worker in July 2017 determined that Child Q’s anti-social identity, purpose and strength were intrinsic to his sense of self and suggested that to make himself available to change would have meant he would have needed to totally re-construct who he was happy to be. This assessment demonstrates how challenging it would have been to try and help Child Q overcome the traits and behaviours he had developed as coping mechanisms. P a g e 15 | 25 Why is this important? Throughout Child Q’s life, his initial vulnerabilities progressed to significant risk to himself and others. These continued to escalate up to his death, with the multitude of agencies having little or no impact. Agencies continued to work informed by traditional ways of working; they held regular multi-agency meetings and briefings and tried whatever tactics available to them, to no avail. Risks were identified early but went unaddressed and were not appropriately prioritised until Child Q started offending. There were many multi-agency meetings where multi-agency plans were developed, but these did not adequately keep Child Q safe or create the stability needed for the necessary treatment to take place. The longer treatment was not delivered, the less likely it was that treatment would meet Child Q’s needs or reduce the risks he posed to himself and others. The multi-agency partnership need to reconsider what is required in order to mitigate the fast-moving dynamic risks some young people present and consider ways of working that directly focus on the long-term outcome, as opposed to a single focus on the presenting issue. Child Q had a good understanding of criminal justice processes and was able to position himself in the service gaps, and to navigate the systems in such a way that enabled him to do as he chose, challenging agencies to keep up with him. Joining up actions from across the multi-agency partnership was of great importance. Child Q was reported as missing on 28 occasions, but his missing episodes were managed separately to his gang membership.9 Inevitably, children who display high risk behaviours are known to services and, dependent on the behaviour, will normally be subject to monitoring via a multi-agency forum. For example, gangs managed via a gangs’ partnership, missing via a missing panel, and children at risk of sexual exploitation are managed via multi-agency sexual exploitation (MASE) meetings; offenders managed via YOS risk or compliance panels etc. It is understood there are significant overlaps between cohorts of high-risk children that could be better managed via a single multi-agency forum, with sub strands of such a forum to deal with specific issues or develop integrated management plans to incorporate all these risks, including criminal exploitation of young people. In addition, further evidence suggests that there is a link between experiences of victimisation and becoming a perpetrator of violent crime. Child Q informed his family (long after the incident) that he had been a victim of a similar offence to his first serious conviction and he was the victim of a knife point robbery and had been stabbed. This suggests a need for an effective preventative response to include work with young people who have been the victims of violence to help them overcome the experience without recourse to violence.10 How prevalent and widespread is this? It is estimated by The Centre for Social Justice that gang membership has increased by approximately 20,000 to 70,000 in the past 10 years.11 9 Gang membership is determined by an assessment of relevant intelligence held by police, gangs’ team and YOS 10 Teenagers at risk. The safeguarding needs of young people in gangs and violent peer groups. NSPCC 2009 11 IT CAN BE STOPPED A proven blueprint to stop violence and tackle gang and related offending in London and beyond. Centre for Social Justice August 2018 P a g e 16 | 25 Child Q’s case is not predominantly about gang membership, however the risk Child Q presented to himself and/or others was exacerbated by his gang membership.12 We know more and more about children from a younger age who are affected by serious youth violence and research suggests that the multi-agency response to children with high risk behaviour has been problematic for some time. ‘Because young people are particularly sensitive to social threat, social status and their identity (compared to those older or younger than them), they may be at risk of gang involvement if they live in a neighbourhood where gangs operate, and they have few other means to feel safe, develop their sense of self, and connect to peers. The (often gradual) choice to join a gang can be adaptive, but over time, gang culture, demands and warfare drive young people into blind alleys of risk (Palmer, 2009)’13 Recommendations Finding 3, in The Vulnerable Adolescent Thematic Review, identified that: An integrated, whole systems approach, is needed across agencies, communities and families. This finding, and the corresponding recommendations, are relevant to Child Q. An additional recommendation is made in respect to Child Q’s specific circumstances. SCR Child Q: Recommendation 3. Croydon Children’s Services have recognised the need to join up multi-agency risk and safety planning forums to improve services for children at high risk in the community (such as gangs, serious youth violence, missing, all forms of exploitation – including county lines), multi-agency partners are encouraged to review current operational arrangements to support this new approach. Finding 4: Transition and transfer arrangements between localities and services Child Q’s chaotic lifestyle, behaviour and needs resulted in numerous changes to his living arrangements which required his case to be ‘care taken’ by another local authority area or transferred in full. Effective transfer between agencies and locations is dependent upon early exchange of information (including key documentation such as reports or assessments that are further explained via dialogue between professionals) to enable the receiving area to continue working with the child as seamlessly as possible. It is incumbent on services to ensure transfer or transition arrangements are as robust as possible, especially given that these children are likely to be leaving their school, friendship groups and possibly family., Why is this important? In Child Q’s case, there was an urgency and necessity for specific intervention and treatment to be delivered to address his conduct disorder (and possible ADD), his missing episodes and offending 12 Gang membership is determined by an assessment of relevant intelligence held by police, gangs’ team and YOS 13 That Difficult Age: Developing a more effective response to risks in adolescence. Research in Practise November 2014 P a g e 17 | 25 behaviour. Child Q moved to and from various locations often within a short space of time and for short periods. Sometimes these moves happened at short notice (such as after Child Q was bailed unexpectedly), leading to transfer arrangements not happening until after his move, but there were many occasions when there was time to plan for his transfer of care. Overall, there were delays in information transfer to different services across three different localities. The implication of this was that professionals spent more time than was necessary to chase up information, this led to agencies playing ‘catch up’, crisis management, poor continuity of service, and delays in putting in place the required interventions. In other instances, as Child Q was placed in foster care as a ‘red rated gang nominal’14, police practice was to transfer his offender management to police in the local area. As his placements broke down quite quickly it resulted in gaps in his management that allowed behaviours to persist and get worse, without being gripped by police. The logistics of managing cases such as Child Q present resource and geographical challenges. This was starkly illustrated when bail conditions were requested by one youth offending team to include a curfew, but this was not requested by the other youth offending team (in the area where Child Q was living at the time) in Child Q’s final court appearance. It is important that current practice is reviewed to improve the continuity of case management and intervention. Where possible, consideration should be given to the case holding local authority, or local police offender managers, maintaining day to day responsibility to avoid unnecessary transfer (and to maintain an existing relationship the child or young person may have with professionals), supported by professionals from the host authority and/or host borough command unit. Some children will require bespoke tailored arrangements that fall outside of existing protocols. How widespread and prevalent is this? As described in: Pathways to harm, pathways to protection: a triennial analysis of serious case reviews (2011 to 2014), cross border working remains difficult to co-ordinate. ‘Working across regional borders within England can present hurdles for agency operation and information transfer between area centres is potentially problematic. Work between geographical areas can cause logistical issues as well as differences in professional opinion with regards to how to proceed with cases’15 Further anecdotal information gleaned from practitioners, and from the Lead Reviewer’s experience on conducting gangs and serious youth violence peer reviews on behalf of the Home Office, highlights that case transfers (including young people moving from one geographical area to another) continues to present challenges to multi-agency services as transferring local authorities do not provide sufficient, timely information, supported by a transfer-in meeting. This makes it difficult for the receiving borough/county council to effectively pick up the case and can have a knock-on effect to the safety and well-being of the children who are being transferred. 14 There is a RAG (red, amber, green) rating which is a grading system devised to manage risk and define level of response, activity or engagement by police 15 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report. DFE May 2016 p187 P a g e 18 | 25 Finding 5: Provision of Child and Adolescent Mental Health Services Child Q was referred to CAMHS when he was at primary school. The school stated their referral was urgent and noted various concerns. After attempts were made by CAMHS to contact the family, the case was closed. Later, Child Q was the subject of a psychiatric assessment when it was identified that he had various disorders that urgently required treatment. CAMHS practitioners attended several meetings and were an active part of Child Q’s professional network. There are 3 key issues to reflect upon: CAMHS were aware of Ms R’s ill health and Child Q’s behaviour, but stuck rigidly to their model of engagement that did not engage the family, had they been more creative and more flexible, Child Q may have been assessed at an earlier point CAMHS could not or would not provide treatment due to the lack of stability in Child Q’s life CAMHS understood all agencies were working exceptionally hard to achieve stability without success. Child Q’s risk increased, and his lifestyle became more chaotic, but CAMHS insisted on what appeared to be unattainable stability before treatment would be initiated. Whilst the SCR panel agree optimal conditions promote better outcomes and recognise the difficulties CAMHS had in attaining the family’s full engagement to support the necessary treatment. However, Child Q’s treatment was urgent. What would have made it possible for other creative, possibly non-perfect options, to have been tried by CAMHS? How could other agencies have assisted to ensure Child Q benefitted from the necessary treatment? Why is this important? All professionals agreed that Child Q required intervention and treatment for his various emotional and mental health issues, but treatment was unacceptably delayed and his risk taking, impulsive behaviour continued to escalate. Had Child Q been engaged at aged nine, when he was first referred to CAMHS, the deterioration of his emotional well-being and mental health may have been prevented. How prevalent and widespread is this? There have been extensive reports, representations and evidence, submitted to Government in the past few years calling for change in the delivery of Child and Adolescent Mental Health Services and an increase in resources. It is suggested that far more children from all backgrounds need support with their mental health and emotional well-being. SCR Child Q: Recommendation 4 Multi-agency partners to review and reinforce transfer or care taking arrangements to ensure timely information sharing takes place and consistent practice is adhered to, prior to and during these arrangements. P a g e 19 | 25 Research identifies that 20% of adolescents may experience a mental health problem in any given year,16 50% of mental health problems are established by age 14 and 75% by age 24,17 10% of children and young people (aged 5-16 years) have a clinically diagnosable mental problem,18 yet 70% of children and adolescents who experience mental health problems have not had appropriate interventions at a sufficiently early age.19 Recommendations Finding 2, in The Vulnerable Adolescent Thematic Review identified: Greater recognition of, and response to, children’s emotional health and wellbeing is needed. This finding and the corresponding recommendations are relevant to Child Q. The following recommendation is made in respect to Child Q’s specific circumstances SCR Child Q: Recommendation 5 CAMHS to review current models of service delivery and consider how they may be adjusted to provide treatment to children with mental health needs who exhibit high risk behaviour and have limited stability, and further consider how preventative services for children in their early years can be provided. Finding 6: The availability of appropriate accommodation Agencies attempted to mitigate the risks to Child Q and create stability of residence to enable treatment work to be initiated, as a result Child Q experienced numerous placements moves and was placed with foster carers across London. Child Q frequently went missing from these placements and they all broke down. Children’s Services reported searching 160 different providers to secure a suitable placement, without success. When Child Q attended court for his index offence, a secure placement was authorised. However, there was ‘considerable difficulty’ in identifying a placement. If a secure placement had been available, it may have been possible for Child Q to receive the treatment he needed which could have had a significant impact on the behaviour he displayed thereafter. When it became apparent that a secure accommodation order was to be made (given Child Q’s progressive offending, risk taking behaviour, vulnerability and need for treatment) a national search for secure 16 Caring for children and adolescents with mental disorders: Setting WHO directions. [online] Geneva: World Health Organization. 2003 17 Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Archives of General Psychiatry, (2005). 62 (6) pp. 593-602. 18 Mental Health of Children and Young People in Great Britain: 2004. Green, H., Mcginnity, A., Meltzer, Ford, T., Goodman, R. Office for National Statistics. 2005 19 The Good Childhood Inquiry: health research evidence. London: Children’s Society 2008 P a g e 20 | 25 accommodation was made. Only one secure unit were willing to take Child Q, but this did not provide the treatment he required. Evidence submitted to this review highlights the lack of suitable, open or secure, placements for children who display complex risky behaviours (especially if they have diagnosed mental health needs and have previously been violent). There appears to be a lack of options available to children’s services to provide security and containment for these children, to enable interventions and treatment to be delivered. Why is this important? It took 18 months for Child Q to be placed in secure accommodation from the initial agreement for a secure placement. At the time of his placement, the risks and challenges of working effectively with Child Q had become more difficult, more entrenched and more complex and he was now participating in increasingly high-risk behaviours. The delay in decision making and the lack of available placements to meet Child Q’s needs compromised decision making by agencies and in the judiciary, and ultimately compromised Child Q’s safety. More suitable secure, and other, accommodation is needed to mitigate risk, provide treatment and safeguard children. How prevalent or widespread is it? Data from Cafcass,20 shows that there has been a year on year increase in the number of Secure Assessment Order applications in England since 2011/12 (apart from in 2014/15 when there was a slight decrease). 2011/12 - 10.4% increase 2012/13 – 15.8% increase 2013/14 – 35.4% increase 2014/15 – 2.9% decrease 2015/16 – 4.4% increase 2016/17 – 10.5% increase 2017/18 - 9.7% increase In London, throughout the same timeframe, secure order applications have increased by 68%. It is apparent that the judiciary are extremely concerned about the lack of available secure beds in the country, as detailed in a recent summary local judgement below: This case represents yet another sorry example of the state failing a child in need, and highlights the impact of there being far too few secure accommodation unit places for children like O. In summary, I have been driven not to grant a secure accommodation order for a child who needs one due to the unavailability of appropriate placements. That is clearly a wholly unacceptable situation. He is a child in local authority care who is at risk from his disordered background and the depredations of gang life. This is the opportunity to help him and make him safe, and it is being lost. Like my colleagues before me, whose published judgments increasingly feel like heads banging against brick walls, I am dismayed, frustrated 20 Data supplied by CAFCASS: Child and Family Court Services. November 2018 P a g e 21 | 25 and outraged; and to quote the former President of the Family Division from last year’s case of Re X, I am deeply worried about the risk that ‘we will have blood on our hands’ (#39). I have directed that this judgment be sent by O’s solicitor to the Secretary of State for Education, the Secretary of State for Communities and Local Government, and to the Children’s Commissioner for England.21 Finding 7: The impact of parental criminality Child Q’s main male role model was his father, but as a recidivist offender, he had numerous convictions and cautions over many years. He was in and out of prison throughout Child Q’s life. Child Q was said to have respected his father and responded to him when he was not in custody. His use of physical punishment has been previously mentioned. Mr S recognised during interview that he was not there for his son as much as he should have been, due to his offending. He said he would try to instil messages and discipline into Child Q to get him to change his lifestyle, but at the same time Child Q witnessed some of the behaviours that his father was asking him to refrain from, Mr S says he was committed to be a good father but is aware that he was not a good role model for his son. Why is this important? Professionals shared their concerns about Mr S, and the criminal activity to which Child Q would be further exposed. There was no specific plan of how agencies could minimise the impact of Mr S’s criminal activity on Child Q. Joint work could have been completed between the probation officers, members of the YOS and social workers with father and son but this is not routine or expected practice. Mr S’s behaviour was entrenched, and Child Q’s behaviour was of increasing concern therefore whilst it may have been very difficult to achieve work with father and son, it was not a strategy that was actively considered. That said, joint work with father and son might have had the potential to make a significant difference to Child Q. If agencies are to effectively prevent and tackle gangs, crime and the associated lifestyle, agencies should consider how they can effectively work with parents of children like Child Q to have a more positive constructive influence over their child’s behaviour, health and wellbeing. 21 LONDON BOROUGH OF BROMLEY - Applicant -and- MRS. O -and- O [4\10\18] Summary secure accommodation order judgement. SCR Child Q: Recommendation 6. Children’s Services to utilise available data and intelligence to complete a report for Croydon Safeguarding Children Board to evidence the challenges in identifying suitable placements for young people with high risk behaviours and make national representation on the issue. P a g e 22 | 25 How widespread and prevalent is this? The Ministry of Justice estimates there are approximately 200,000 children who are affected by parental imprisonment.22 At present, there is no legislation or policies that recognise these children as a distinct group who require additional support. As a result, Local Safeguarding Children Boards often do not have a targeted work plan to support this specific group of children. Research suggest that the impact of parental criminality can lead to negative outcomes for these children. For example, in comparison to their peers, children affected by parental imprisonment are twice as likely to experience mental health problems, and three times as likely to have had a history of poor living conditions and a poor employment record. Studies have also consistently found psycho-social problems including depression, hyperactivity, aggressive behaviour, withdrawal, regression, clinging behaviour, sleep problems, eating disorders, running away, truancy, low academic achievement, low self-esteem, delinquency and anti-social behaviour.23 Given the findings of this SCR, the work undertaken by Local Safeguarding Children Boards24 should be further explored to consider how these children could be better identified and their needs met. SCR Child Q: Recommendation 7. CSCB to investigate the prevalence of this issue in Croydon and learn from Local Safeguarding Boards who have implemented service changes to meet the needs of children effected by parental criminality and imprisonment. CHAPTER 7 - Conclusion Despite the love of his family, and the commitment and expertise of professionals, making any significant alteration to Child Q’s trajectory proved completely unsuccessful. The influence of his peers, criminal associates and gang25 members was significant, and he held a deep-rooted attachment to these peers. His anti-social behaviour, lack of remorse or emotional recognition, were defining factors in Child Q’s life. He was a respected member of a gang that afforded him an identity and a niche, and he was perpetually drawn to this gang. He was involved in risky criminal behaviour which included extreme violence of which he was both a victim and perpetrator. For professionals, Child Q’s case was unprecedented. Whilst the professional network had a wealth of experience, skills, knowledge and expertise, they did not always have the tools they required at the time they required them. A gang lifestyle provides groups of like-minded children and young people, a forum where they apply their own rules, concepts and understanding of what acceptable behaviour is and what is not. 22 http://www.barnardos.org.uk/what_we_do/our_work/children_of_prisoners.htm 23 Children Affected By Parental Imprisonment: Needs, Solutions and Rights – the Evidence from Across Europe. Lucy Gampell OBE, President of Children of Prisoners Europe. NIACRO 24 This work requires evaluation 25 Gang membership is determined by an assessment of relevant intelligence held by police, gangs’ team and YOS P a g e 23 | 25 This is partly due to children and young people not believing they can either trust or depend on adults, professionals, teachers or parents to keep them safe or to support them to be successful members of their communities; they create networks they believe they can depend on, with peers they believe they can trust. Whilst the media impression is that serious youth violence and gang related activity is significantly affecting communities across the country, current data suggest there has been some recent improvements in Croydon. This momentum needs to be built upon, with parents, carers, communities, professionals, politicians, and most importantly young people, coming together to collectively find ways to make a difference to children such as Child Q. P a g e 24 | 25 Appendix 1: Bibliography & References This list of references are sequenced in the order they appear in the report. Dying to Belong: An In-depth Review of Street Gangs in Britain. Centre for Social Justice 2009 www.centreforsocialjustice.org.uk/library/dying-belong-depth IT CAN BE STOPPED - A proven blueprint to stop violence and tackle gang and related offending in London and beyond. Centre for Social Justice. August 2018 p5 Ending Gang and Youth Violence -A Cross-Government Report including further evidence and good practice case studies. HM Government 2011 https://news.sky.com/story/why-moped-crime-is-rising-and-how-you-can-avoid-being-a-victim-11399439 That Difficult Age - Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014 Croydon Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. OFSTED September 2017 Contextual Safeguarding: An overview of the operational, strategic and conceptual framework. (Firmin November 2017) Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2018. Offenders as victims of crime? An investigation into the relationship between criminal behaviour and victimisation. Derek Deadman and Ziggy MacDonald, Public Sector Economics Research Centre Department of Economics University of Leicester. October 2001 Serious Violence Strategy. HMG April 2018 ‘now all I care about is my future’ Beyond youth custody 2017 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report. DFE May 2016 p187 Teenagers at risk. The safeguarding needs of young people in gangs and violent peer groups. NSPCC 2009 Caring for children and adolescents with mental disorders: Setting WHO directions. [online] Geneva: World Health Organization. 2003 Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Archives of General Psychiatry, (2005). 62 (6) pp. 593-602. Mental Health of Children and Young People in Great Britain: 2004. Green, H., Mcginnity, A., Meltzer, Ford, T., Goodman, R. Office for National Statistics. 2005 The Good Childhood Inquiry: health research evidence. London: Children’s Society 2008 LONDON BOROUGH OF BROMLEY - Applicant -and- MRS. O -and- O [4\10\18] Summary secure accommodation order judgement. Forgotten children: alternative provision and the scandal of ever-increasing exclusions. Fifth Report of Session House of Commons Education Committee 2017–19 p3 Creating opportunity for all Our vision for alternative provision DFE March 2018 P a g e 25 | 25 http://www.barnardos.org.uk/what_we_do/our_work/children_of_prisoners.htm Children Affected by Parental Imprisonment: Needs, Solutions and Rights – the Evidence from Across Europe. Lucy Gampell OBE, President of Children of Prisoners Europe. NIACRO Child Welfare Information Gateway, 2009 ACES: a Blackburn and Darwen study http://www.blackburn.gov.uk/Pages/aces.aspx Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Bellis, M.A et al. Journal of Public Health, Volume 36, Issue 1, 1 March 2014, Pages 81–91. https://www.independent.co.uk/news/uk/politics/cuts-to-youth-services-will-lead-to-poverty-and-crime-say-unions-9659504.html https://www.cypnow.co.uk/cyp/news/1158579/youth-services-cut-by-gbp387m-in-six-years The Foundation Years: preventing poor children becoming poor adults. Frank Field 2010.Murdoch Children’s research institute Early intervention: the next steps, An Independent Report to Her Majesty’s Government Graham Allen. HMG 2011 p20 |
NC045399 | Death of a 4-month-old baby in Summer 2013. Baby V was admitted to hospital after suffering a cardiac arrest at home and died the next day. Hospital staff were told that Baby V had choked on food; tests later revealed a rib fracture, which occurred somewhere between 10 days and 3 months prior to the incident, a linear skull fracture and brain damage due to lack of oxygen. Father was found responsible for causing the injuries and convicted. Family were known to universal services only. Mother had reported concerns to professionals that father was not bonding with Baby V and that Baby V was pinching itself, leaving scratches and bruising to its face. Identifies four key findings: insufficient professional awareness and understanding of how to respond to bruising in non-mobile infants; need for greater clarity of the level of child protection training required by professionals within different agencies and how this is monitored and compliance measured; need for respectful scepticism; and need for improved communication between GPs and community care. Makes various recommendations in relation to the findings.
| Title: Serious case review: on the services provided for Baby V. LSCB: Hampshire Safeguarding Children Board Author: Alan Bedford Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW On the services provided for Baby V IN STRICT CONFIDENCE October 2013 updated July 2014 Independent Author: Alan Bedford 2 Para Page SUMMARY 3 1 INTRODUCTION 5 1.1 Rationale for Serious Case Reviews (SCRs) 1.5 Terms of Reference 1.7 Summary of Circumstances Leading to the SCR 6 1.8 Anonymity 1.9 Family Details 1.10 Methodology 1.14 Independent Reviewer 7 1.15 Family Involvement 1.16 Introduction to the Review below 2 THE FACTS 8 2.1 Background 2.10 Opportunities 9 3 ANALYSIS and APPRAISAL 11 3.1 Introduction 3.2 Areas of Opportunity 3.3 Analysis by Agency 17 3.4 North Hampshire Urgent Care (NHUC) 3.5 General Practice 18 3.6 GP Communication out of hours 20 3.7 Southern Health NHS FT (SH) –Health Visiting 3.8 Solent NHS Trust 22 3.9 South East Coast Ambulance Service NHS FT (SECA) 3.10 South Central Ambulance Service NHS FT (SCAS) 23 3.11 Hampshire Police 3.12 Frimley Park Hospital NHS FT (FPH) 24 3.13 University Hospital Southampton NHS FT (UHS) 25 3.14 Removal of Life Support and Safeguarding Processes 26 3.15 Family Views 4 KEY FINDINGS 27 4.4 ‘Bruising in Children who are Not Independently Mobile Protocol’ 4.5 Training 28 4.6 Scepticism and Challenge 4.7 Primary/Community Care Communications 5 CONCLUSION 30 6 COLLATED RECOMMENDATIONS 31 APPENDICES App 1 Agency updates on Actions in Response to the SCR 33 App 2 Significant Events 41 App 3 Index of Acronyms 42 3 1 SUMMARY i. As Serious Case Reviews (SCRs) are now published, this summary is not designed as a stand-alone as in the previous SCR “Executive Summaries” but is a way of outlining the key facts, findings and recommendations from the Review that may help the reader make good use of the more detailed report that follows. ii. The Review is around the services provided to the family of a baby, called ‘V’ in this report, only a few months old, at the time of death. V was found to have a skull fracture, facial and body bruising, and a healed rib fracture. Unlike many SCRs, there were no indications from the background of either parent, or V’s older sibling, that V would be at any risk of violence. However, there were some indications during V’s lifetime that might have been explored further at the time. iii. The family was not known to social services, and all dealings by the GPs (which were frequent), health visitors and midwives with the parents or the older child were not deemed to be out of the ordinary. Police and the GP were aware of some instability in the lives of the maternal grandparents (who provided the mother with much support), but there was no recorded involvement of children during these periods. The Review looks at whether knowledge of the instability should have been shared with health staff who worked with the children. iv. V was born by emergency caesarean section which the mother found very distressing but midwifery, in the mother’s opinion, helped her work through this. v. The mother found V more difficult than her first child, and reported to family and 3, possibly 4, professionals that V got angry and the cheeks were pulled, causing scratches and bruises. She also told at least two that V was not bonding with the father. No professional who either heard about or saw bruises followed the agreed Hampshire protocol on what to do when there are bruises on a non-mobile baby, which is to alert social services and for there to be a paediatric examination. The Review found that neither the nursery nurse (who was told of the bruising) nor the out of hours GP (who saw it) were aware of the protocol, nor were they trained sufficiently to be clear about what they should have done. vi. The school heard about the bruising from mother at around the same time she was sharing with the GP the lack of bonding with father, and around the time the mother says she told a midwife or health visitor about the bonding, pinching and bruising. Had either of those who heard about the bruising in such a young baby told social services there may have been a pooling of information which would have brought those threads together. vii. The day before the baby was admitted to hospital with what proved to be the fatal injuries, V was taken to an out of hours GP surgery very poorly. Two bruises on each cheek were immediately noticed and the pinching explanation was given. Other than asking the family GP Practice to monitor for further bruising no action was taken, which was in breach of a clear local protocol of which the GP was unaware. The GP also had no past experience of referring injuries to social services. As it was a bank holiday Sunday the message only got to the GP two days later when the surgery reopened, by which time V was on life support. The delay made no difference in this case, but might do in other cases. There is a recommendation about looking at safeguarding communications out of hours. The out of 4 hours GP provider has acknowledged that at the time there was an assumption that GPs they employed would be sufficiently trained and experienced, and have now introduced mandatory evidence of safeguarding training. viii. This Review identifies a number of areas which help understand individual staff actions by looking at the organisational context within which they work. The protocol about bruising in non-mobile babies, and updates, are not clear and not always easy to find so, even if aware of it, professionals might not always be clear to whom it applies and exactly how to follow it. There are recommendations about the review of, and implementation of, the protocol. Some staff are not receiving training to equip them for dealing with bruising in young babies, and there are recommendations about the Hampshire Safeguarding Children Board (HSCB) and member agencies having arrangements to monitor compliance with required training. ix. Even putting to one side whether training was adequate, the opportunities for further consideration of what was happening in this family suggest that there may be some reticence to be sceptical about explanations, and to challenge. The HSCB will need to consider how widespread this is beyond this case, and there is a recommendation about agencies modelling a culture of proper challenge through the way they supervise staff. x. There are also some illustrations of communications between GPs, and between GPs and community staff, which did not affect this case but which might benefit from further review. xi. The overall conclusion is that there were no historical warning signs that could have alerted staff, and contacts with services were mainly unexceptional. There were one or two opportunities which might have led to a helpful pooling of information that might have led to concern, and one opportunity which almost certainly would have led to intervention which would have protected the baby. All these instances need to be seen in the context of how individuals were prepared for their work. 5 1 INTRODUCTION 1.1 Rationale for Serious Case Reviews 1.2 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures as set out in ‘Working Together to Safeguard Children’ (HM Government, March 2013), referred to here as WT2013. 1.3 When a child dies, and abuse or neglect is known or suspected to be a factor in the death, the LSCB should conduct a Serious Case Review (SCR) into the involvement that organisations and professionals had with that child and their family. WT2013 says SCRs should: provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence (recommend) actions which result in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and (have) transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of SCRs with the public. 1.4 The Hampshire Safeguarding Children Board (HSCB) Chair decided in June 2013 to hold an SCR because the child in this case had died and abuse was suspected. This report and its recommendations were accepted in full by the HSCB on 14 October 2013, but the publication (of a slightly updated report) was delayed until September 2014 so as not to prejudice the criminal trial. There was one conviction, with the father found to be responsible for the injuries. 1.5 Terms of Reference (TOR): The LSCB set the following terms: Identify and analyse key events/opportunities for assessments and decision making. Were any child care or safeguarding concerns recognised and responded to appropriately? Identify and evaluate decisions, assessments and plans made and services offered by agencies in relation to members of the household. To what extent were the children’s needs, views and wishes taken into account? Examine and analyse the level and effectiveness of exchange of information and communication between agencies and across areas. Identify any gaps which may have impacted upon assessment, service provision or outcomes. Was the work in this case consistent with each agency’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards? Were there any organisational difficulties being experienced within or between agencies? Were these due to lack of capacity within the agency? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? Highlight ways in which practice can be improved and make recommendations as appropriate. 6 The time frame was from the mother’s first pregnancy to the death of V: late 2008 to early summer 2013 1.6 The author’s style is not to write overview reports using the headings in the TOR, but to get over the story and analysis in a way that suits the case, whilst ensuring the TOR questions are covered. 1.7 Summary of Circumstances Leading to the SCR: Child V, who was not yet five months old, was admitted mid-morning to the local general hospital by ambulance after respiratory arrest at home. The presenting story was that V had choked on food. The baby was very seriously ill and close to death so was moved after two hours to a specialist hospital with a paediatric intensive care unit. V was artificially ventilated but treatment was withdrawn the following day and they died. Tests showed that V had suffered a rib fracture ten days to three months old, a linear skull fracture, and brain damage due to lack of oxygen and significant trauma. 1.8 Anonymity: The details relating to the family and individuals are anonymised where possible. Specific dates, and dates of birth, are omitted to aid anonymity. Agency names are included, other than the School and GP Practice involved as that would make identification of family members much easier. 1.9 Family Details: All are white British. Only relatives with whom the mother lived at some point within the timeframe are listed: Mother The mother of baby V Father The father of W and V W Their first child V Their second baby and the subject of this SCR Maternal grandmother (MGM) Maternal grandfather (MGF) The mother lived with her parents at the time of the first birth until W was several months old. She then lived alone with W until the father joined them in early 2012. 1.10 Methodology: Since the publication of WT2013, LSCBs have had flexibility on which method they use to undertake an SCR, as long as the method fulfils the principles set out in that guidance. This enables the method to suit the nature and complexity of a Review. For this case, where there was limited agency involvement and most contact was with the NHS, the LSCB decided to engage a single reviewer to undertake the necessary inquiries without the full agency reports required under the previous methodology. A reviewer (see 1.14) was chosen with considerable safeguarding and NHS experience. 1.11 Agencies were asked to produce a chronology and a very brief summary of agency involvement, and thereafter the reviewer reviewed files and interviewed staff as seemed necessary from the emerging evidence. Any one interviewed had a copy of the interview notes to check accuracy and understanding. There was no SCR Panel for this SCR, but the standing SCR Subcommittee was kept appraised of progress and discussed the final draft. There was a small Reference Group of staff from involved agencies which the reviewer could use for advice or as a sounding board, and they offered feedback on an early draft and facilitated further inquiries. 7 1.12 Agencies were asked at a senior level in August and September 2013 to check the draft for accuracy, and to submit a note on progress stemming from the developing learning in this case. See Appendix 1 which is updated to July 2014. 1.13 The following agencies participated in the SCR: Agency Acronym Hampshire Safeguarding Children Board HSCB Frimley Park Hospital NHS Foundation Trust FPH Hampshire Police Police Southern Health NHS Foundation Trust SH Solent NHS Trust SOL University Hospital Southampton NHS Foundation Trust UHS South East Coast Ambulance Service NHS Foundation Trust SECA South Central Ambulance Service NHS Foundation Trust SCA North Hampshire Urgent Care NHUC Hampshire County Council HCC Nursery School Nursery North East Hampshire CCG CCG Family GP Practice Out of hours GP’s GP Practice 1.14 Independent Reviewer: Alan Bedford was selected by the HSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He now works independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted a number of SCRs, is accredited as a SCIE Systems Reviewer and completed the 2010 and 2013 national training for SCR authors. 1.15 Family Involvement: Both parents, and the maternal grandparents were invited to meet the reviewer, as they have a right for their views to be heard. The paternal grandfather declined as his concerns were outside the terms of reference. The father did not respond. The mother agreed, but only with the presence of her own mother. The HSCB Chair and Business Manager met the mother and her mother to feedback the Review’s findings. The father and maternal grandfather did not accept an invitation for a similar discussion. 1.16 Introduction to the Review below: Compared to many SCRs the volume of agency involvement in this case was relatively small and the family was not known to Hampshire County Council’s Children’s Social Care. The review does not describe in day by day detail the ‘normal’ events but summarises them, and focusses on issues of concern or from which something can be learned. The review describes the facts, and then analyses them with any necessary appraisal of agency actions. There is then an assessment of why events occurred as they did, followed by an overall conclusion. There are recommendations from this review for the HSCB and member agencies. 8 2 THE FACTS 2.1 Background: This section describes what happened in the case, and includes events or knowledge that was or may have been relevant to looking at whether what happened might have been prevented, and to looking at the quality of services to the family. In order to aid anonymity, specific dates are not given, with the age of the baby at any given point being the main way of tracking developments. This section does not contain any judgement about agency performance. 2.2 As most events contained in the chronologies produced by agencies are ‘normal’ or not of concern, what is given here is firstly a summary of the known facts of the case, and then a summary of missed opportunities. 2.3 When the mother became pregnant with W, the midwifery services and then health visiting services had no cause for concern. The mother was living with her own parents and the mother felt this was a supportive environment. Ante natal contacts were normal and unexceptional, as was the birth and post natal visits by midwives and health visitors. . 2.4 The family had frequent contact with the GP surgery in the nearly four years between W’s birth and V’s death. Excluding tests and immunisations, the MGM had over 25 contacts, mother over 40, W around 15, with V only 2. The practice considered the level of contact to be unexceptional given the presenting problems, and not unusual amongst the Practice population. The Practice had no concerns that warranted passing information to midwives, health visitors and certainly not children’s social care. The mother was depressed for a brief period after W’s birth, but again the Practice GPs were clear that this was a fairly typical presentation and not one which would have led to any onward transmission of information. 2.5 With the second pregnancy (V) there was again nothing exceptional in antenatal care, but after admission to hospital in late 2012 for routine induction of the baby, a baby heart problem was identified and there was an emergency caesarean section which the mother found distressing, and led to debriefing discussions in hospital and then at home with the midwife. There were three midwife home visits, and none led to any concern. No risk factors were identified, although the routine domestic violence question was not asked as the father was present. There were three health visitor visits up to V being around 6 weeks, and apart from mother’s worry about the baby’s colic there were no concerns and nothing to suggest any risk to the baby. 2.6 V was taken to see a GP twice (other than for jabs). Firstly at two months, when mother was worried V was not bonding with father. She told the Review that V would only settle with her or the grandmother and no one else. Secondly, ten days before the final admission to hospital the mother raised concerns about V pulling at both cheeks. She says there was a facial bruise, but the GP Practice says they never saw any bruise. 2.7 Neither midwifery nor health visiting services were aware that in W’s second year, the mother’s mother, V’s maternal grandmother (MGM), had been involved in incidents of domestic abuse, and had related convictions for assault and criminal damage, connected to a drink problem. Two months later the MGM was arrested and her daughter, V’s mother, was slightly hurt. The MGM was cautioned for assault. This 9 was after the mother and W had moved into their own accommodation. There had also been overdoses. The GP practice was aware of the MGM being an alcoholic, either recovering or relapsing, and also treated her for depression. When V was a month old the GP recorded that the drinking was uncontrolled again. (Section 3 looks at whether any of this information should have been passed to health colleagues). Police attended the grandparents’ home twice the month before the fatal injuries as a result of a violent domestic dispute between the grandparents after the MGM had been drinking. Adult Social Services were informed of both attendances. No children were reported as present in any police attendance at the grandparents’ home 2010-13. 2.8 The police had no other information of relevance about the parents. 2.9 The baby was taken to hospital, still not five months old, after the father called 999 saying V was not breathing, and may have choked. CPR advice was given. Ambulances attended, and V was taken to Frimley Park where abuse was not considered (and no history of trauma was given by the family) as frantic efforts to save V were undertaken. After two hours V was sent to Southampton where there is a paediatric intensive care unit (PICU) for more specialist care. The following morning, a healed rib fracture was identified and considerations that the symptoms were secondary to non-accidental injury (NAI) came to the fore. Ophthalmology tests showed retinal haemorrhages and a brain stem test showed clinical death at 1pm that day. During the later test, an examination of V’s head showed three bruises on the left face, a bruise by the clavicle, and another on the chest. Treatment was withdrawn early evening and V died. A CT scan showed a short linear skull fracture and brain haemorrhages. It is now known that there were three skull fractures, brain haemorrhages, three rib fractures, and multiple bruising. It is understood these covered up to four separate episodes. 2.10 Opportunities: There were several areas of opportunity to provide either wider professional thought about the risks, or protective action. Each relates to descriptions or sighting of marks on V explained by the parents as being self-inflicted. These are analysed in section three. 2.11 Nursery School: When V was three months old the mother (without V) visited W’s nursery school for an open session and spoke to W’s nursery nurse. She told the nursery nurse that she was worried that she could not take V to be weighed as she was embarrassed by scratches and bruises. The mother said that the baby kept ‘hurting itself’. The nursery nurse says a report was written that V was scratching and pulling, leaving scratches and bruises to face arms and legs. (The mother told the Review that there were never bruises on arms or legs). She added that unlike W, V cried all the time. The nursery nurse advised her to take V to the GP. Later that day the mother did attend the GP surgery for V’s immunisations (by a nurse as usual), but no GP was seen. 2.12 Midwifery/Health Visitor: The mother indicated to the school and later to the SCR that ‘the health visitor’ already knew about the baby pulling at its self and had also advised her to see the GP. No health visitor who had seen the baby has recalled any discussion about the baby pulling/pinching itself, and it is possible that the call was to midwifery as mother said she called Frimley Park Hospital. Despite a full search no record or memory of such a call has been identified by the NHS. However the Police 10 have found a record of a long call from mother to health visitors the month before speaking to the nursery nurse, so this may well have been the call mother described. The mother told the Review that the person she spoke to advised her that questions would be asked if the baby was taken to clinic, and they also discussed the use of mittens to prevent the baby hurting itself. 2.13 Relatives: At an unspecified time a relative, who had at one time child-minded W, said she had heard from other relatives that that V ‘had a temper’ and would scratch and leave marks. The relative had not seen the marks described. 2.14 GP: Four days before the admission to hospital with the fatal injuries V was taken to the GP with a mild viral infection, a blocked nose, and slightly off food. Also, ‘pulling at cheeks’ which the GP witnessed. The GP was unaware of what the mother had told the school described in 2.10 above. The GP said that at least the chest and face would have been examined and nothing suspicious was noticed. The mother told the Review that she pointed out a bruise on the baby’s chin to the GP. 2.15 Out of Hours GP: The last professional contact that was a missed opportunity was the day before V’s admission with the fatal injuries. At around 1pm the mother called 111 from the MGM’s home, with the presenting complaint being a cough and refusing food. She was advised she needed to see a GP in 12 hours, and as it was a Sunday she was called an hour later by the out of hours GP. Hearing of the cough and refusing food the parents were asked to attend the out of hours GP centre at Frimley Park Hospital run by North Hampshire Urgent Care (NHUC- a not for profit organisation commissioned by the NHS). The parents took V to Frimley Park Hospital straight away. 2.16 The out of hours GP immediately noticed two small round bruises (four in all) on either cheek, and asked for an explanation. The parents told the GP that V had been pinching cheeks in anger. Whilst the GP was suspicious, no referral was made, and the notes asked for the GP to be faxed as well as getting the automatic notification so the family’s Practice would be aware of the request to ‘watch for further bruising’. The mother was concerned V was losing weight, and the GP advised that V be taken to the health visitor for weighing. Medication was prescribed. As the examination took place on a bank holiday Sunday, neither fax nor normal electronic transmission of the event were received until the Tuesday as the GP surgery was closed, and V was already in hospital on life support. 11 3 ANALYSIS AND APPRAISAL 3.1 Introduction: This section aims to assess how well agencies worked around this family by analysing their contact with the family. This involves looking at individual work in the systemic context within which they work so it becomes more understandable. The section first looks at the two areas of opportunity, then at learning by agency which included obtained in the review but which may not have had an impact on this particular case, but might on future cases. Section 4 identifies any overarching themes. Recommendations by the author from this review are in bold, and listed together in Section six. 3.2 Areas of Opportunity: The aim is to look in more detail at these areas, look at what happened, or should have happened, and explore why. 3.2.1 The mother says that when V was around two months she called ‘a health visitor’ at ‘Frimley Park’ (FPH) and told them about the pinching and marks, and lack of bonding with father. Midwives, not health visitors are based at Frimley Park. A call to midwifery has not emerged from a list of contacts submitted by FPH and a search has not identified any record. There is though a phone log of a call to health visitors by mother at the right time, so the call was probably made to them although, if it was, nothing was recorded. If the account is true, then it would have been inappropriate not to record this in the notes. The mother says she was warned that questions would be asked if the baby was seen and the use of mittens was discussed. Also, and again assuming marks/bruises were mentioned (and especially in the context of discussing a bonding problem), the call should have led to some sort of action. This could have included passing the information to the GP who may have had other relevant information, and the health visitor on whose books was V. At about this time the mother told the GP about V not developing an attachment with the father. 3.2.2 Bruising Protocol: In Hampshire at the time of the baby’s death there was an April 2010 protocol called ‘Bruising in Children who are Not Independently Mobile’ which is produced and agreed by the four separate Safeguarding Children Boards in Hampshire (“4LSCB”- Hampshire, Southampton, IOW and Portsmouth). The purpose of the Protocol itself can be summed by this extract “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken”. It also emphasises the non-discretionary nature of the policy. It requires, regardless of explanation, a referral to the Council Children’s Services for any bruising on a non-mobile baby and that social workers should then arrange a paediatric examination. 3.2.3 That version was marked ‘for review 2011’ and is under review now although this had not been completed by the approval of this SCR in October 2013. It applies to all front-line clinical staff, and does not say it applies to non-clinical staff. Note: Since the completion of this SCR a reviewed and single version of the protocol has been produced. 3.2.4 However, there were two guidance updates. Both refer to the ‘3B Protocol’ which from deduction refers to the logo at the top of the guidance which says “Baby, Bruising, Be Aware’. However the Protocol to which the update guidance refers makes no reference to 3B so this must have been confusing. The first one, dated 12 May 2010, which could be found in the 4LSCB Procedures on line, but not in the HSCB Procedures, says it is for ‘health and social care professionals’ and results from concerns that full protocol might lead to over referral. However, the only judgement allowed is to decide if it is a bruise, if so the protocol must be followed. In my opinion, it confuses the guidance as it allows children’s services and a paediatrician not to have an examination, whilst the full protocol requires a paediatric examination and the guidance to two distinct professional groups is not clear to whom any particular section relates. 3.2.5 The second update is in the HSCB Procedures but not the 4LSCB Procedures. This is headed “Guidance for Partner Organisations’ and dated July 2010. It asks all members of the 4 LSCBs to train it staff to be aware of the Protocol and use it. In my opinion this muddies the waters further. This is because the main protocol requires any health professional seeing bruising in a non-mobile baby to refer to social services who then arrange a paediatric examination. This update Guidance asks partner organisations, which means in this context, everyone other than health not to refer to social services (Children’s Services), but to refer to a health professional (anyone from a GP to A&E to a midwife). That health professional, if they follow the main Protocol would have to refer to Children’s Services, which appears to add an unnecessary step. 3.2.6 This is because a health professional has no discretion under the main Protocol but to refer to Children’s Services – which the partner organisation could have done direct. (Yet another document- the ‘Protocol Summary’ says clearly that such bruising ‘…..should result in an immediate referral to Children’s Services and an urgent paediatric opinion’). 3.2.7 The danger of having a range of documents, each with a slightly different take on what has to be done, increases the likelihood that professionals do not refer and that they might make a judgement that referral is not needed. Such individual decision would be contrary to what the Protocol Summary clearly states ‘It is the responsibility of Children’s Services and the local acute or community paediatrician to decide whether bruising is consistent with an innocent cause or not’ and by implication no one else’s decision. Note: Since the completion of this SCR a reviewed and single version of the protocol has been produced. 3.2.8 As said above, the purpose of the Protocol itself can be summed by this extract “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken”. It also emphasises the non-discretionary nature of the policy. It requires, regardless of explanation, a referral to the Council Children’s Services for any bruising on a non-mobile baby and that social workers should then arrange a paediatric examination. 3.2.9 In the case of the call to ‘the health visitor’, the baby was not seen, and there would have been no clarity about the nature of any marking. When nothing is actually seen the duty under the non-mobile bruising protocol to refer to Children’s Services is not specifically covered in the protocol, but the significance of such bruising in the protocol should have triggered some action. As indicated in 3.3, such a conversation with a mother would need to be discussed with someone else: firstly as it is describing marks in a non-mobile baby, and secondly the reference to non-bonding. 13 There was no proof that any marks were caused as the mother explained, and professionals need to have a degree of scepticism in a baby’s interests. A health visitor, for example, has similar colleagues who could be consulted such as team leader or the named nurse. It is accepted that the facts are not verified, so the recommendation is general. It is recommended that health visiting (and midwifery) services review message taking processes, and make it clear that calls must be recorded and procedures followed, even if the family is not currently being seen. 3.2.10 As at this point there were no concerns about the family, and as is described later, an out of hours GP who saw such bruises did not refer on. It would be wrong to assume that had the midwife discussed the call with anyone it would necessarily have led to any action that would have prevented the later injuries. The chances of identifying a growing problem would though have been much higher with wider discussion. 3.2.11 The second professional to hear about the story of the baby hurting itself was a nursery nurse caring for W when V was three months old. Again the baby was not seen. The nursery nurse believes the mother described scratches/bruises to face, arms and legs so the episode is appraised on that basis, although the mother said she only mentioned face. 3.2.12 The School has a ‘Child Protection Policy, Procedure and Safeguarding Guidance dated September 2012 which requires all staff to ‘follow the procedures set out by the LSCB…….’. This would not be easy as the internet links to the 4LSCB procedures or the national guidance on ‘What to do if you are worried a child is being abused’ do not work as they are outdated. For example the government sites concerned are no longer there. 3.2.13 The Guidance requires staff ‘to be aware of and alert to the signs of abuse’. In this particular case, the nursery nurse did not hear what was said as being about ‘abuse’ but simply about the behaviour of a baby that was leading to marks. The nursery nurse considered the ‘bruises’ to be part and parcel of the pinching and scratching. Having also heard that a ‘health visitor’ knew about it and had recommended taking V to the GP, it was thought the matter was in hand. The Child Protection Policy requires a discussion with the Head (who is also the safeguarding lead) and a full record kept if abuse is suspected, but as the worker took the story at face value these actions were not triggered under the policy. 3.2.14 It was only after V’s death that the nursery nurse recalled and recorded the conversation. The worker was at a disadvantage, not recalling having received any safeguarding training in six years at the school. There was no awareness of the non-mobile bruising policy, and said that with older children (there are no babies at the nursery school) practice was for staff to form a view on whether any marks were worrying before recording and passing the information on. 3.2.15 The head teacher accepted that the case had identified a weakness in training arrangements. The nursery school is one of a few still maintained by the council and as such, she felt, can get left out. The head said that while there had been a recent inset day on safeguarding (at the head’s request) by the Council for the staff of the primary school it had not covered the nursery school. Having said that senior school 14 staff did provide updates/briefings on safeguarding for nursery staff. Whilst the Council can provide training it is the responsibility of School Governors to ensure that safeguarding arrangements are satisfactory and staff appropriately trained. This would include at induction and annual updates. 3.2.16 HCC reminds schools annually that they must do an annual audit of safeguarding arrangements, and ask for a copy of the results to be sent to the Council. The school did complete audits in 2011 and 2012 and in the latter requested help from the Council for inset day training. They were referred to the Workforce Development Department. In the 2012 annual safeguarding report the box that says ‘staff receive up to date high quality appropriate training, guidance support and supervision to undertake effective safeguarding of pupils’ was ticked. V was not a pupil but the lack of training for nursery staff was acknowledged to the Review. 3.2.17 The conclusion of this review is that the nursery nurse was unprepared for the situation faced and in the absence of training it is somewhat understandable that mother’s story was believed with no personal conclusion that it was suspicious. However, a note of the conversation should have been made at the time and shared with a senior colleague because what was heard was an unusual presentation. There can be no guarantee that had the matter been referred on that there would have been a different outcome. The baby may not have had marks at that time, and the explanation may have been believed (although this is unlikely if there had indeed been bruises on face, arms and legs). 3.2.18 It is recommended that the governors of the school ensure that nursery staff are fully trained in safeguarding as per school policy, and that the board of governors receive regular assurance reports on compliance. It is also recommended that HCC work with both its maintained school nurseries to support governors to provide appropriate safeguarding training. (This needs to include guidance about babies even if no babies are at the nursery). 3.2.19 The examination by an out of hours GP the day before V’s final admission to hospital is of some concern, but again the individual performance needs to be considered in the context within which the GP worked. The facts of the examination that day are described in 2.14-15. The GP is a salaried GP (ie not a partner) in a neighbouring county, Surrey, doing an average of 5 sessions weekly. The GP had done additional sessions for North Hampshire Urgent Care (NHUC) at its out of hours clinic at FPH for 16 months before the examination in question. It is an independent organisation, and not part of FPH although providing service there. 3.2.20 The GP was faced with a decision which was outside that doctor’s experience. Although qualifying over 20 years ago, the GP had no experience of physical abuse, and had never referred a case of suspected physical abuse to social workers. Although self-regarding as not being trained in safeguarding, the GP had been to a Level 2 session in mid-2013 led by the GP who took the lead for safeguarding in the Practice. This covered general principles and understanding of abuse, but did not cover the Surrey non-mobile baby bruising policy as the GP presenting the session was unaware of it. This being the case, the out of hours GP would not have had such guidance in mind when working for NHUC nor known that the family’s county Hampshire had a similar policy. Although attending the training session, the GP was unaware of the formal role of ‘Lead GP’ for safeguarding at the Practice. The GP 15 wonders if the whole training session was attended as a meeting at that time can rarely be attended at the start. In any case the training provided did not include the non-mobile bruising policy 3.2.21 GPs have a personal responsibility to remain up to date on safeguarding. A 2009 letter from the chair of the Royal College of GP’s Council and the chair of its GP Committee says “As noted above, all GPs have a duty to remain up-to-date. This is set out in the GMC’s Good Medical Practice. As a GP’s work is likely to include child protection, you must maintain your skills and competence in this area in line with GMC guidance. There are various ways that this can be achieved – for example, by attendance at courses, by distance learning, practice team meetings, etc”. (GP’s of course, by definition, have a huge range of topics on which they must remain up to date and proficient, so there are always judgements to be made by individual GPs or their employers as to the weight they can give each). 3.2.22 Whilst there is much training material available, there is no nationally agreed training in the contract GPs would have with NHS England. In Surrey, GPs are encouraged by the Named GP to have at least level 2 training, then moving to the more detailed level 3 training. Level 3 training courses are being provided by the CCG safeguarding advisers, and there is high demand for places. However, no NHS authority can currently insist through their contract that GPs are trained to a specific level, but providers such as NHUC can set such standards as a condition of employment. 3.2.23 Having said that, the combined medical Royal Colleges (including the Royal College of GPs) do have “Safeguarding Children and Young people: roles and competences for health care staff INTERCOLLEGIATE DOCUMENT September 2010” which says the following “It is now recognised that the complexity of relationships with child and young people patients and their parents and carers in the primary care context (see RCGP Curriculum section 8) requires level 3 competences. For the purposes of being up to date and revalidated, GPs should have all the competences in level 2 and be working towards level 3”. 3.2.24 Working that day at the Out of Hours service at FPH, the GP was not aware of the specific non-mobile bruising policy in Surrey, (or that Hants had a similar policy), so was unaware of the requirement to refer such bruising to Children’s Services. The doctor was however rightly suspicious and properly asked questions about the four facial bruises seen. However, the baby was not examined unclothed for further marks, nor was any drawing made of the bruises. NHUC did not provide body maps on which to do this, but has now committed to make them available. 3.2.25 The doctor had had no briefing from NHUC on how to deal with any safeguarding issue, and NHUC presumed that GPs arriving to work for them were properly trained. As a result of an external audit, and confirmed by this review, the risks in such an assumption are clear and NHUC is now to ask GPs to provide evidence of training. There was no reference to safeguarding in doctors’ induction to NHUC and no reference to it in the handbook provided which gave guidance on a range of clinical conditions. Nor was there any briefing from NHUC on what might be different about policies in neighbouring counties from where patients might arrive. 3.2.26 The actions in hand by NHUC to remedy these weaknesses are described in 3.5 below and in Appendix 1. The SCR recommendations for NHUC are in that section. 16 3.2.27 The GP openly accepts that in hindsight there should have been an onward referral but at the time, although suspicious, was not sure enough to do that. The doctor also ‘didn’t want to do the wrong thing’ by which was meant that, in hindsight, probably worrying too much about the parents eg being unfair to them. This is the sort of thought process which, whilst a natural human reaction, would have been helped by good training. The GP has acknowledged personal distress in now realising the oversights. 3.2.28 The GP was concerned enough to note that there should be monitoring by the GP for further bruising, and to ask for the electronic note to be faxed ahead of the normal later electronic transmission. Apart from this being a bank holiday and there being no GP to receive the fax for some time, there are other issues about out of hours to GP communication which will be looked at under ‘General Practice’ below. 3.2.29 The GP had two options. The Protocol, of which the doctor was unaware, says there should be a referral to Children’s Services who would then have arranged a medical examination. Not knowing of the Protocol, it would not have been difficult to use the adjacent A&E to obtain a paediatric opinion. This opinion, whether requested by the GP or Children’s Services, might have accepted the parental explanation, but on the other hand a skeletal x-ray would have seen the healing rib fracture and the baby would have been protected. This Review took the advice of an independent Consultant Paediatrician who has worked on SCRs, is a Designated Doctor, and chairs a regional designated doctors and nurse group. Asked ‘Can babies of 3 weeks to 5 months bruise (ie a real bruise not a red mark) their face by pinching and the answer was an emphatic ‘no’. 3.2.30 No inquiries were made of other agencies at the time, and to be fair had there been, given it was a bank holiday Sunday, it was unlikely this would have led to any information that would have helped the GP. Also, there was nothing in agency records which would have strengthened the GP’s concern. 3.2.31 The extreme rareness of bruising on non-mobile babies (the chances are set out in the Protocol), the fact they were somewhat symmetrical, and that they were small and round as in finger-tip bruising, all mean that there should have been action beyond just letting the family GP know in a few days’ time that such bruises had been seen. Compared to other illustrations above where bruises were heard about but not seen, this is a clear instance of where a referral should have been made to Children’s Services, and this may well have prevented the fatal injuries that are believed to have occurred in the next 18 hours. 3.2.32 The Review sought the views of a manager of the County Council Social Services Out of Hours Service (unfamiliar with this case) on what reaction there would have been had such a case been referred. The response was immediately that such bruising would be of considerable concern given the age of the baby, that a paediatric examination would have been sought, and depending on the diagnosis, any necessary protective action taken. The non-mobile baby bruising protocol was regarded seriously. The Review was assured that the level of response from social work would have been no less because of the bank holiday. Assuming this is an accurate description of the likely social work response, then the non-referral was indeed a critical moment. 17 3.3 Analysis by agency: This section looks at both issues which may have made a difference in the case, but also at other learning that might have an impact on other cases in the future so is included here as it is a learning exercise. There are also sections on issues which overlap agencies. Note: There are updates on progress from each agency in Appendix 1 as at August 2013, refreshed at July 2014 where necessary. 3.4 North Hampshire Urgent Care (NHUC) 3.4.1 NHUC has a ‘Child, Young Person and Vulnerable Adult Guidelines’, and a ‘Safeguarding Children and Vulnerable Adults Policy’. The latter says the CEO has ultimate responsibility for the effective discharge of safeguarding, and that the Medical Director with responsibility for safeguarding is responsible for ensuring the highest standards are achieved. It says their procedures must be in line with and support the Surrey, Berkshire and Hampshire LSCBs’ procedures to which there are online links. It goes on to say that NHUC will ensure that all staff are trained appropriately and are competent to be alert to potential indicators of abuse or neglect in children and vulnerable adults and know how to act on their concerns consummate to their role, this should be in line with the intercollegiate document 2011 – “Safeguarding Children and Young people: roles and competences for health care staff – September 2010”. It requires each staff member to sign a declaration that they have read both policy and procedures. There is no such document for the GP concerned, nor evidence of induction including safeguarding. 3.4.2 NHUC’s contract with the NHS requires it to provide training if the GPs have insufficient training in their other work. NHUC has acknowledged that both the 2012 external review of their governance by Urgent Health UK, and this SCR had identified that too many assumptions were made that the GPs they hired, who mostly would have worked in their own practices too, arrived well prepared on safeguarding. This may stem from GPs being independent contractors and largely responsible for ensuring they meet appropriate training standards. For example, there was an assumption that GPs would know about the protocol on ‘Bruising in Children who are Not Independently Mobile’ from their own practice files. This was exposed in this case as the policy was unknown to the Practice where the GP mainly worked. 3.4.3 NHUC, and the GP concerned, accept that a referral should have been made. NHUC both from their external audit and the sad learning from this case have realised the need to tighten up considerably, and have communicated to the review a strong commitment to do so. The two NHS Clinical Commissioning Groups which commission Out Of Hours Services will be working together to ensure that there are consistent commissioning expectations around safeguarding and appropriate monitoring of compliance. 3.4.4 NHUC have now decided that by the end of September 2013 all clinical staff will have to demonstrate that they have completed level 3 safeguarding training. This was an action for September 2012 after the external audit. NHUC have also identified that staff they took on who may have worked for them before were missing induction. This is to be remedied by checking annually that all doctors are up to date. NHUC will be preparing a new hard copy folder of procedures for ease of access. They will be cascading the non-mobile bruising policy to all its staff wherever they 18 work. Their records are almost wholly electronic, but body maps will be made available. Instead of there just being a GP safeguarding lead for all NHUC there will now also be a safeguarding lead for the centre at Frimley Park Hospital. 3.4.5 The actions from the 2012 audit were behind plan, and whilst this cannot excuse any delays, NHUC explained that the NHS contract for the service ended in March 2011 and there have only been short term extensions since, and tendering processes slipping. Whilst now awarded the contract, there was a long period of uncertainty about the future which may have impacted on developmental activity. 3.4.6 The external audit was repeated in July 2013 and on safeguarding the rag rating moved from red to amber, as despite some improvements, the audit identified some on-going weaknesses in arrangements- although there are plans in place to address each issue noted. 3.4.7 The case was discussed by the Reviewer with Hampshire County Council Out of Hours Service to test out what might have been the reaction should the GP had made the referral under the Bruising Protocol. The response was that there would have been immediate suspicion about the explanation, and an assumption that it needed full paediatric examination. The Review was told that there would have been a good knowledge that bruising to non-mobile babies is very rare, and a working assumption that a baby could not harm itself like that. A paediatric examination would have been advised, and monitored both to see it happened and so that any appropriate protective action was taken after the diagnosis. 3.4.8 A similar discussion took place with a Consultant Paediatrician at FPH to assess what would have been the likely outcome of a referral to them for a safeguarding examination. On that Sunday the baby would have been seen by a paediatric registrar if no consultant was there, and the examination discussed with the consultant on call. Relevant x-ray and other tests would have been available, and although they may not have had the most expert interpretation until after the weekend, the baby would have been kept in hospital until all results were back. 3.4.9 It seems likely then that the non-referral of the four cheek bruises shortly before the fatal injuries was a very significant matter, but as said above has to be seen in the organisational context within which the individual doctor worked. 3.4.10 There are a number of recommendations in relation to NHUC: It is recommended that the CCGs who contract with NHUC work together to ensure there are consistent organisation wide expectations of NHUC in their contracts, and there is a joint approach to performance management. It is recommended that the CCGs monitor closely the rapid achievement of the actions set out in the plan following the external audit and any actions from this SCR. 3.4.11 It is recommended that NHUC ensure that all staff working for them are aware of and have easy access to safeguarding guidance, both internal and county wide. Also that any training in house or induction covers not only the principles of safeguarding but practical consideration of what GPs on call need to do in specific scenarios. 19 3.5 General Practice: The family’s Practice is a large multi GP practice serving a relatively poor population which tends to make high use of their services. The Practice was very cooperative with the review and engaged constructively in what might be learned from this case. The Practice has a lead GP for safeguarding and whole practice training was provided in 2012 via the Medical Defence Union. Further training by the Named GP for safeguarding is to be arranged. Daily informal meetings of all staff allow for an exchange of information about cases of concern. There is an internal messaging system so staff can be alerted to risks e.g. a violent patient. The GPs were aware of the Bruising in Non-Mobile Babies Protocol, and said such bruises were so rare such an occurrence would be taken seriously. The nurse practitioner who saw the baby was also aware of the Protocol and said that should bruises have ever been seen, it would have been discussed with the duty GP for the day. 3.5.1 There were a number of issues which are worthy of further consideration. One, about which the GPs are themselves concerned, is about continuity of care when patients both use the Practice often and insist on seeing the first available GP rather than ‘their’ GP. This can be illustrated by this case, as excluding appointments for tests and jabs members of this family saw numerous GPs across the period of this review. The mother saw 14 GPs in over 40 attendances, the grandmother saw 12 GPs in over 25 attendances, and W saw 8 GPs in 15 attendances. The chances of getting a good sense of accumulating issues in one patient, never mind putting together information about a family must be reduced significantly by such a spread of GPs involved. 3.5.2 There is a flagging system at reception that tries to get specific patients to a specific GP, but as the Practice had no special concerns about the family this did not apply. The risk here is that concerns could be missed as small factors are not pieced together, reducing further the chance of say linking a parental issue with child well-being. Even in hindsight the Practice cannot see that a concern to the level of say a referral to Children’s Services, or even a discussion with say health visitors or midwives was warranted. This Review is not saying that anything was missed by the Practice- but is saying that there is an inherent risk in the lack of care being provided by a smaller number of staff. The Practice has tried to find a way of improving this, but would appreciate advice. It is recommended that the CCG in conjunction with the local area team of the NHS Commissioning Board work with the Practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs. 3.5.3 A second, and case related, issue is whether there was a need for GPs caring for the maternal grandmother to share any information about her illness with either the notes of one or both children, or with community staff like midwives or health visitors. It should be emphasised that the issue being discussed was not any direct risk, but whether there might be an impact on the mother’s degree of stress, especially when she was for a while a single parent. It is important to look at this without hindsight, and to assess it as it was at the time. 3.5.4 There is no record of GPs dealing with any alcohol/aggression/family dispute related matter with the grandmother from W’s pregnancy until after mother and W had moved out to live on their own, so there was no obvious need to consider a child related link. Other than one drink related conviction it seems that the Practice was 20 unaware of other convictions/cautions so was probably unaware of the extent of the problems, although aware of overdoses. The mother told the Review that her own mother’s problems did not affect her, and both she and the grandmother thought that information about the alcohol problem should not have been shared with other people. The mother never disclosed it to any professional. 3.5.5 It is clear from the GP records that the Practice was aware of the grandmother being in a state of recurrent relapses through V’s pregnancy, and after birth. For example when the baby was less than one month old a counselling service wrote to the Practice that the grandmother ‘feels (the alcohol dependency is) greatly influencing her moods and relationships with her family’. It is easy in hindsight to say that a quiet word with the midwife or health visitor would have enabled them to check that mother was not too distressed by all this- but at the time the GP to whom the letter was addressed had only seen one of the children once, and mother (for non- child related issues) on only 4 of her 40 plus attendances, so would be most unlikely to have made any mental link. In any case, no one would have suspected that, whatever the stress, V would have been at risk. 3.5.6 The GPs no longer have a role during normal antenatal care, so do not refer to maternity as in the past with details of the case including any risks. Midwives, who have access to the Practice records, identify any risks from their own scrutiny. In this case the midwife would not have known to look at any other family records, and was thus unaware of any wider family stresses. 3.5.7 In discussion with the GPs, their view and that of the reviewer coincided. This is that there were no obvious risk factors to children in what was known, and even if it had all been pieced together the information would still have been some way below the threshold for referral to Children’s Services. 3.5.8 When V was two months old mother told a GP about the pulling at cheeks and not bonding with father- but this was assessed as nothing out of the ordinary. The GP who saw V a few days before death said there were no bruises, although the mother says she pointed out one facial bruise when discussing the pinching. This difference of memory cannot be clarified further, so the Review can only recommend that should a GP see any bruise on a non-mobile baby, regardless of the explanation, it should be recorded, drawn, and referred under the Protocol. 3.5.9 In considering what information can be easily shared with colleagues, the Practice felt strongly that their access to health visitors and opportunities for informal exchange was much reduced. In March 2013 the Practice wrote to Southern Health NHS FT (SH) expressing concern about lack of meetings with health visitors, when their presence at practice meetings would be valued. “We currently feel we have no health visitor support at the Practice and given the high number of at risk children and problem families we have we do not feel this is acceptable……. (and they hoped) to … get some system in place for a regular meeting so that doctors are able to discuss any concerns they may have.” There was a discussion and the Practice reported a little improvement. This family is most unlikely to have been discussed in this way, but GP- health visiting links in other cases might be more important. 3.5.10 The Review also had discussion with the Practice from which the out of hours GP came. The Practice’s Lead GP for safeguarding, who did provide a session last year 21 for the clinical staff on safeguarding, was not familiar with Surrey’s non-mobile bruising policy and so it was not incorporated into the training provided. Although happy and willing to give the in house training with the material provided, the lead did not feel particularly well prepared as a trainer, and this will be fed back to the local LSCB’s Named GP. (The current practice in Surrey is for training to be CCG led and not by practice leads). It is recommended that the HSCB shares this report with the Surrey LSCB. 3.6 GP communications out of hours: This will be a national issue, but from a safeguarding point of view it is interesting that there is no way that a family GP can be contacted out of hours to see if there is any information which might help an out of hours doctor on say a safeguarding decision, as responsibility is wholly transferred to the out of hours provider.(There is a system, which the Review was told was not fully used across Hampshire called Hampshire Health Record which is designed to show other GPs headline issues from cases). In this case the out of hours GP asked for the child’s GP to get a fax and not just the electronically transferred attendance record. This might draw more attention, but can only be received when a practice is open. In addition, neither NHUC nor the GP Practice keep records of faxes so this Review could not see what the fax contained. 3.6.1 There is also the issue of follow up. NHUC would not have known if the GP had seen the message about monitoring future bruising two days later. Sometimes, a professional needs to know if a recommended action happened e.g. a parent did indeed take a child to see another professional, but it is not clear that with sessional staff whether such follow ups occur. It would be worth out of hours’ providers and safeguarding advisers to explore with some case illustrations how such providers can manage child protection cases in long out of hours periods. It is recommended that the responsible NHS bodies in Hampshire review with out of hours providers processes for communicating with GPs and seeking additional information about possible child protection issues 3.7 Southern Health NHS FT (SH) – Health Visiting: There is no evidence that the health visiting service missed any observed warning factors that might have predicted future harm to the baby. Records of assessments do not show anything of concern (although with V the standard question about domestic violence was not asked as both parents were seen together). Contacts were routine, in the expected number and were unexceptional. Health visitors were unaware of any potential stress arising from the maternal grandmother’s recurrent drink problems. 3.7.1 Although it is most unlikely that it would have made any difference, there was no antenatal visit by a health visitor with V as required for all mothers (and their families) under the Trust’s 2011 guidelines. It is designed to cover liaison with the midwife/GP and a safeguarding assessment. Exceptions to this universal policy are to be raised with line managers. I was advised by SH that in 2012-13 the target set by commissioners of their service was 50%, and SH have now set an 80% internal target. The health visiting clinic concerned was under staffing pressures in 2012-13 and was not doing antenatal assessments. 3.7.2 Health visitors visited V on three occasions. There were no concerns passed on by the midwives so a visit was made just after the fourteen day target (bank holidays intervened). Other than the baby already being on ‘hungry baby milk’ which the health visitor would have discouraged for a first baby – there was nothing memorable 22 about the visit. The same nurse went again two days later to do the hearing check. Again, no concerns, nor any other plan than routine care. The final visit was at seven weeks for the ‘six week check’ by a student health visitor (unexceptional as no known concerns). The baby had gained weight but had some colic which the nurse said should be discussed with the GP. The next contact was to be at eight months. 3.7.3 The health visitors told the Review their caseloads were around 800 each which would be well above recommended levels, but they all agreed , as does this Review, that had they been less pressured the level of contact with the baby would have been the same. 3.5.9 described the GP concern about the frequency of health visiting contact with the Practice, which they think is only partially resolved, although SH said a recent audit had not identified current concerns. 3.7.4 If the phone call by mother about bruising was made to a health visitor then it should have been recorded, and if it described bruising to a non-mobile baby should have led to at least discussion with a colleague, and further action. SH say that if a call had been made an email to the team’s generic email would have been sent, where either the family or duty health visitor would see it. If any action, it is recorded on the electronic record. However prior to March 2014 there was no system to record emails that had been dealt with, so it is possible no action was taken and the email now gone. The recommendation is at 3.5.8 above. SH has informed the review that it will audit the post March message taking process in all its health visiting teams to assure robustness 3.7.5 The mother said that three visits only from the health visitors was enough, and she was pleased there were not more as she found their inability to give a time for their calls a bind. 3.8 Solent NHS Trust: This Trust’s only involvement was in providing alcohol services for the maternal grandmother from early in V’s pregnancy, from which she was discharged (after a phone call the previous month) when V was five weeks old after ‘successful completion of a recovery programme’. (Interestingly this was eleven days after the grandmother reported uncontrolled drinking again to the GP, which was followed two days later by a letter to the GP from another counselling service saying she was being discharged also for good progress). The records show no mention of grandchildren or the impending birth of V. 3.8.1 There is no suggestion that not doing this at the time had any impact at all on the case, but the Trust is considering extending its standard query about children of its adult patients to include whether the patient has any regular child care duties. This might prove helpful in other cases. 3.9 South East Coast Ambulance Service NHS FT (SECA): This was the ambulance service which took V to hospital with the fatal injuries. There had been no prior call outs to either V or W, but there had been four calls to the maternal grandmother and at none of these calls was there any reference to there being a child on the scene, and the calls were not in the period when W was living with his grandmother. 3.9.1 The Review has studied a report of the ambulance attendance to V, and it was prompt and well attended. There was nothing to make the crew think of non-accidental injury and their priority was resuscitation. From call to arrival at the pre-alerted hospital it took 23 minutes. SECA says that police should be routinely notified 23 of life threatening events to children before arrival at hospital, but were not in this case- although it would have made no difference, and staff will be reminded of this expectation. 3.10 South Central Ambulance Service NHS FT (SCAS): This service does not cover the area in terms of ambulance attendance, but had three contacts with the family in the year leading up to V’s death, as the provider of the recently created 111 call service. The first was for W when V was two months old, for a routine illness. The advice was to speak to the GP Practice within an hour (which was not followed). The second was about V when nearly four months old after constant screaming, an abdominal rash and a temperature. The ‘chief complaint’ was noted as a choking episode (not described or timed) in the previous 24 hours. The SCAS advice was to go to A&E in an hour, and this was done. V was admitted overnight with an infection. 3.10.1 The final contact was the day before V’s admission with the fatal injuries, with the presenting issue being a cough and off food, and the advice was to contact a GP within 12 hours. As it was a bank holiday and hence out of hours- in this case NHUC at FPH The call handlers would have known neither child was subject to a child protection plan as this would have been flagged on screen. 3.10.2 The records kept by the 111 service are not what a layman would recognise as a medical record, but a series of questions – computer generated- where the symptom is logged as present or not, and a series of outcomes against possible developments with the illness. Non clinical call handlers adhere rigidly to the computer generated process. It is not possible to see from the record what was volunteered by the caller, and what was a response to a question. Whilst it is likely this works well for most routine cases, one could imagine it would be hard to pick up from the record any subtlety about a possible abuse case. In the case of V, especially when choking was said by the father to be what led to the collapse on the final day, it would have been more helpful in hindsight to know more about the ‘choking’ episode a month before her death. There does not seem to be room for free text in the 111 records. 3.10.3 The record also says the patient was advised to speak to GP in 12 hours and if out of hours to call the out of hours GP. In fact, the mother was already speaking to the number she would have had to ring to call the out of hours doctor, so what happens is that the 111 service get the out of hours GP to call the patient, which is what would have occurred in this case. It is recommended that SCAS consider whether any amendments could be made to the way 111 calls are recorded to provide clearer descriptions of what is being conveyed in calls that may relate to safeguarding. 3.11 Hampshire Police: The police had no involvement with either child. When they attended the maternal grandparents’ home for incidents, this was when the mother was living away from her parents. The police notified adult social services of the two attendances made on the same day ten days before V’s final admission: one about a violent dispute between the grandparents, and the other as the grandmother had taken excess alcohol and pills. Had there been any known child issues at that address (there were not) then they could have been linked with this police notification. The forms routinely completed at domestic abuse attendances are always assessed centrally and any child related issues followed up, so there does 24 seem to be a proper system in place- even if not relevant to this case. There were no issues from the police involvement from the identification of injuries. 3.12 Frimley Park Hospital NHS FT (FPH): This NHS Trust was involved in three ways: as the provider of maternity and community midwifery services, as the provider of A&E, and as the provider of paediatric services. 3.12.1 Maternity/Midwifery: The booking checklist used to identify any possible problems was completed for both pregnancies, and there were no concerns even in hindsight. They were aware of mother’s chronic gynaecological problems. As mentioned in 3.5.6 above, at least at the family’s practice, GPs are not involved in referring a mother to maternity, and the discovery of background risk factors is left to the community midwives to make their own inquiries- which they can through the patient’s GP records. There must be a risk that issues relating to the family or to the mother can be missed if not then self-reported. This can be seen in this case, because even if there is no evidence that the grandmother’s illness affected the mother, had it been having more impact the midwives would not have known. 3.12.2 At the birth, the risk to the baby was spotted and immediately acted upon with an emergency caesarean. The mother naturally found this very distressing and thought that hospital staff could have been more sensitive to her after the operation. She also found the attitude to her about the fact she smoked ‘unpleasant’. She was discharged home at 8.30pm which is quite late given a new baby and the stress mother had been through. Mother could see no reason for the delay other than the wait for a clinician to approve the discharge, and thought she and baby were ready hours earlier. The community midwife’s later de-briefing with mother about the emergency birth was appreciated by the mother. 3.12.3 There were three midwifery visits in all to the home, a normal number which does not seem unreasonable in the circumstances, and a contact number was left should there have been any issue before the health visitor started. 3.12.4 Paragraph 3.2.1 describes the call made to health visitors or midwifery about the pulling/scratching/bruising. The Reviewer has seen in another SCR how a similar call to another midwifery service which required action could not be traced, and whether or not a call was made in the V case. It would be useful for FPH to review the guidance and process around the recording of calls- especially when the case is no longer active, making it clear that all calls should be noted, and that anything of concern should follow procedures whether it is an open case or not. The recommendation on this is in 3.2.9 (Note: it is likely the call was made to health visiting) 3.12.5 A&E/Paediatrics: A FPH Consultant Paediatrician reviewed with the Reviewer the notes of V’s admission via A&E a month before V died, to see if there was any indication of missing, for example, signs of abuse given that the rib fracture may have occurred by then. The Review accepts the conclusion that there were no such signs. Even had checks been made with other agencies, nothing would have emerged to raise concerns. There was one scenario which might just have spotted the rib. The consultant said that V’s temperature seemed too high for the assumed cause of illness and this might have led to a chest x-ray which might have seen a healing rib fracture- if indeed it was there by them.(One rib was fractured up to two 25 months before the final injuries). Even if such an x-ray had been taken, it would have been examined for infection not trauma and the rib might not have been noticed. The review concluded that this theoretical opportunity to notice an injury was too speculative to be a learning point. - 3.12.6 When V was taken to hospital following the fatal injuries, V was at FPH for only two hours as the clinicians realised that the most specialist of help elsewhere was needed if there was to be any chance of survival. In those two hours abuse was not suspected, and the clinical mind-set was totally focussed on saving the baby’s life. Given that the baby had facial bruises the day before, and more were seen the next day (plus two body bruises) it is likely that V had bruises when at FPH. None were recorded. V would have had a mask on at all times and considerable amounts of tape too holding mask and tubes in place. Had bruises been seen it would have made little difference to what the clinicians were doing, but University Hospital Southampton (UHS) would have received V knowing that abuse was a possibility, and the diagnosis of abuse may have been slightly earlier. 3.12.7 It is quite understandable that the whole focus was in reviving V. However, the Reviewer is aware of other SCRs elsewhere where the local hospital has not identified considerable injury because the focus was on the presumed problem, say a catastrophic infection. It is recommended that FPH look at its procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma, unless to do so would harm treatment. 3.12.8 Finally, as described above, FPH would have had appropriate systems in place should V have been referred there by the out of hours doctor the day before her injuries. 3.13 University Hospital Southampton NHS FT (UHS): Part of the UHS response to the arrival of V for care in their PICU was a notification from the Trust child protection team- which is done routinely for an out of hospital child cardiac arrest. A history was not taken from the father as one had been taken at FPH when no history of trauma was given. Like FPH, the bruises on V were not noticed during the frantic effort at recovery, but a chest x-ray taken for the infection showed a possible fractured rib which triggered immediate further tests and appropriate safeguarding procedures. The head bruises were seen during tests for brain stem death. A formal history was then taken from the parents. The same recommendation as made to FPH in 3.12.7 about checking for bruises when there is no clear cause of serious illness is made for UHS. The UHS PICU Director has written to all PICU consultants and senior nurses about looking for and recording bruises ‘particularly in circumstances where there is no clear diagnosis’. 3.13.1 A strategy meeting was called to share multi agency information and prepare a plan. In the evening V’s treatment was withdrawn and in the presence of the parents V passed away. 3.13.2 The mother did feel that the announcement by the clinician that V had finally gone was perfunctory and insensitive, and the mother wanted visible sign of sympathy. I suspect this may have occurred as the hospital staff would have wanted to interfere as little as possible with the parents’ last moments with their baby. 26 3.13.3 UHS asked the Review to raise the issue of the Child Death Overview Procedure ( a statutory review process required after any unexpected child death) being commenced before V had actually died, and that they found the suggestion that the safeguarding strategy meeting also be designated as the stage one Child Death Overview Panel meeting inappropriate. 3.14 Removal of life support and safeguarding processes: The mother raised an interesting ethical issue about the timing of safeguarding processes and the removal of life support. She was aware Children’s Services wanted to interview them, and she asked if it could be done before the support for V was removed. This was because she wanted clarity in her own mind if trauma might have been involved before saying goodbye. She said the response she received was that the social worker wanted them to say their goodbyes to V first, and this is what in the end happened. Like the doctor in 3.14 above, it may well have been that the social work stance was thought to be a sensitive one but perceived differently by the family. In the subsequent discussions with the social worker, the mother said that a relative there “counted the worker threatening numerous times to remove W into care” which she found insensitive in the circumstances. (It is clear that W would have needed to be protected in a safe place). 3.15 Family Views: The SCR sought the views of parents, and maternal grandparents. The father has not responded. The grandfather declined when he realised his concerns were outside the timeframe of the Review, but the mother (with V’s grandmother in attendance) did meet the reviewer. Given how difficult it must have been for the mother to speak to the Review given the sad loss of V, and decisions not yet being taken about any culpability if any, she was able to make a number of comments worthy of agency consideration in here and at other points in the report. 3.15.1 Her views have been given in relation to a number of issues above which are not repeated here. At the time of the meeting the mother did not accept that trauma had taken place so there could only be a limited discussion about how services did help or might have helped. Her general view was that she was well supported by her family, did not require more public service than she received. 3.15.2 As no professional to whom she mentioned marks on V made an onward referral, the mother was asked what her reaction might have been had they done so. She thought she would have been very annoyed as she knew how the bruises were caused. On the out of hours visit the day before the final hospital admission she would have accepted an onward referral to hospital paediatrics if it was to look more into V’s illness, but not if it was related to the marks. 3.15.3 She raised two incidents of what she said were false assurances about V’s situation in her last 24 hours. At FPH she said a nurse assured her V would be fine, when the mother said the nurse must have known this was not the case. At UHS she said a doctor assured the parents that the baby’s condition could not have been prevented and they were not to blame. The Review has not sought confirmation of this, but it does illustrate how parents might interpret (probably well intentioned) attempts to be positive. 27 4 KEY FINDINGS 4.1 This section identifies four overarching issues which have emerged from the Review. Given that the Review was case specific it is not easy to determine whether any issue occurs frequently, or how broadly it may occur across the County. The HSCB and its partner agencies will need to form their own views about this when determining their actions following the Review. 4.2 The section looks at the context within which professionals worked, as it is only in understanding why decisions were made or not made that improvements can be made. Working around child protection is not easy, nor are judgements at the time as straightforward as they might appear in hindsight. Making a decision as to whether to take something further involves knowing when to do that, knowing how to deal with any uncertainty about that decision, knowing what to do, overcoming any innate tendency to believe what one is told, bravery to challenge when to do so might create a backlash that makes future contact more difficult, and the innate hope that things are not as bad as they might seem. To get this right requires good training and supervision, a management culture that values challenge, and systems which have clear processes and which are reviewed. 4.3 The previous section on analysis and appraisal showed how some of these conditions for good practice were not sufficiently in place. 4.4 ‘Bruising in Children who are Not Independently Mobile Protocol’: The lack of clarity in the existing policy statements was analysed in paragraphs above This is critical guidance, with the clear intention that all bruises to non-mobile babies should be subject to further scrutiny and more than one professional involved in decisions. As written this is not discretionary. The finding from this review is that there are some staff who are unaware of its existence, and therefore do not know the key principles within it, and who are therefore vulnerable to error which might leave a baby unprotected. It needs to be understood by all who work with families, as information may come about a baby even if the case focus is an older child. 4.4.1 The HSCB and its members must study the awareness and understanding of the protocol to ensure that there are not gaps. In another review elsewhere the reviewer identified four groups of staff; those who knew about the protocol and followed it, those who knew about it and didn’t follow it; those who knew about but thought it did not apply to them, and those who were unaware of it. In this case the nursery nurse and out of hours GP were in the latter category. 4.4.2 The message from this Review is that unless there is a rigorous approach to universal application of the protocol the chances of mistakes are high. 4.4.3 This Review made an early draft of the section on the Protocol available to the HSCB group reviewing it. Both the revision and its roll out to all staff who work with children needs to ensure, following the categorisation on 4.4.1, that staff are aware of it, know it applies to them, and that the guidance is followed. This will require audit. 4.4.4 It is recommended that the HSCB ensure that the Non Mobile Bruising Protocol is reviewed in light of this SCR, that its use is a core part of local training, and that compliance is monitored. 28 4.5 Training: This case illustrates the risks of organisations not being clear about training expectations, or what is in place. The nursery nurse says no formal training on safeguarding had been provided at the school. NHUC did not know how well its staff were equipped to handle child protection issues. The out of hours GP had had little training or experience of child protection. This had a clear connection with decisions not to refer on as per guidance (which was not actually known about). 4.5.1 It is recommended that the HSCB and its member agencies should review their arrangements for being clear about what level of training is required, its frequency, and compliance. Also agency Boards or equivalent should receive assurance about compliance levels with safeguarding training requirements, and, the HSCB can then review the overall position in its annual report. 4.5.2 It is important that training looks at practical examples and not just principles, and also is grounded in local procedures. The out of hours GP had had some training but this did not include the local bruising protocol which was unknown to the Practice. The fact that despite being suspicious the baby was not examined unclothed suggest that any training was not that detailed. The nursery nurse, even if trained, might not have known of the bruising protocol as the nursery did not work with babies. 4.6 Scepticism and Challenge: Even if one puts to one side any lack of preparedness from training, staff working with families need to have a respectful scepticism about what they hear, and not automatically accept self –report. Staff from at least two different professions- education and medicine – who saw or heard about bruising were insufficiently sceptical or challenging to talk to others about it or refer elsewhere. This may have also have applied to a heath visitor when ( says the mother) told about a lack of bonding and bruises in a 2 month old baby. 4.6.1 Sometimes this can relate to training weakness so the professional may not realise there is indeed something to be worried about, but often it is to do with either the dynamic of the relationship with the family (eg the out of hours GP recalls being worried about the impact on the parents), or the degree to which organisational culture supports challenge (eg supervision which is challenging provides a model for work with families). There are two types of ‘challenge’. One is a summons to a fight, the other is a request for more information. Sometimes professionals shy away from the latter in case it comes over as the former. 4.6.2 This is a difficult concept to turn into a tangible recommendation, but the value of taking a sceptical stance in the interests of child safety, the appropriateness of challenge as a search for necessary information, and the need for managers, supervisors and boards including the HSCB to model this approach, needs to be something borne in mind in training and organisational arrangements. It is recommended that HSCB and its member agencies consider how they can model good challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse 4.7 Primary/Community Care Communications: The way in which GPs, health visitors and midwives communicate with each other, did not have a significant impact on this case, but issues were seen that merit further thought in the interests of future 29 cases, and those agencies which carry responsibilities in this area may want to use these points to review current arrangements. The issues are summarised below. 4.7.1 Out of hours- GP communications: There does seem to be a gap in the ability to gain GP information out of hours, extended over long weekends, which might be very important in weighing up risks. It also impacts on the follow through of any actions agreed during out of hours. There is also the related issue of the speed by which GPs will actually see any messages that out of hours deem important. 4.7.2 GPs and Midwives: In this case the Practice was positive about the ability to communicate with midwives as they hold clinics on site. One issue that needs thought is midwives only finding out information about pregnant women they care for if they make their own researches, rather than having an informed briefing/referral from the GP- and how this might miss family connections. 4.7.3 GPs and Health Visitors: The view of the family Practice in this case that there was insufficient contact with health visitors, is not uncommon nationally as health visitors have been more centrally rather than GP based to make the best use of staff in any particular area. The Reviewers experience of leading peer reviews of health visiting and GP services (not in Hampshire) showed that contact worked best where there is a written agreed policy of how health visitors link with Practices and information is shared, which is then audited to ensure it is happening. 4.7.4 It is recommended that, in each of these three illustrations about communication, organisations should look at their own processes, with the HSCB holding the overview, to assess whether improvements can be made. 4.7.5 SH informed the review that there is a written GP Communication Guidance (updated in March 2013) with a list of link health visitors made available to GP Practices. SH says it is for the link health visitor to negotiate a minimum level of monthly contacts with each Practice which can be n person or through message books etc. This would work better if there was a clearer expectation and not left to front line negotiation. For the Practice concerned SH say the new link health visitor has planned meetings arranged. In light of the review SH will re audit GP-health visitor links across the Trust. 30 5 CONCLUSION 5.1 Other than the time when a doctor saw several facial bruises shortly before the baby’s death there were no occasions where one could conclude that a critical opportunity was definitely lost. This is because others heard about but did not see any marks on V, and one could only speculate about what might have been seen and how it would have been interpreted if investigated further. However, it is possible that had staff who heard about bruising followed the guidance in the bruising protocol that information would have been pooled, and at least a decision taken on whether more could be done. 5.2 On that one occasion when the baby was presented to a doctor with facial bruising, it is reasonably certain that had there been an onward referral, the baby would have been admitted and not at home to have received the final injuries 5.3 The Review has identified that the two staff, definitely known to have either heard about or seen bruising, were not aware of the non-mobile bruising policy , and neither were sufficiently sceptical about what could cause bruises in such a young baby- which was probably also knowledge/training related. Neither had prior experience which would have helped them. In the case of the out of hours GP, the employer was unaware of any training or experience deficits. In the case of the school, the nursery school seems to have been overlooked in formal training programmes. 5.4 The largest number of recommendations are about the HSCB ensuring that the proper infrastructure, especially around training or procedures, is both in place, and monitored to ensure there is good compliance. Also, on reviewing the bruising policy. There are also recommendations for specific agencies. The HSCB and agencies need to examine their own arrangements so they are aware of the extent to which any issues raised in this SCR is prevalent beyond this case. 31 6 COLLATED SCR RECOMMENDATIONS The recommendations are divided into organisational responsibility, but all agencies should look at each to be sure no key action is missed. The origin of each recommendation is in parentheses. There are some updates from agencies in progress in Appendix 1. It is recommended that: Frimley Park Hospital and Southern Health NHS FTs 1. Health visiting services (and midwifery) review message taking processes, and make it clear that calls must be recorded and procedures followed, even if the family is not currently being seen. (3.2.9) Frimley Park Hospital and University Hospitals Southampton NHS FTs 2. FPH and UHS look at their procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma, unless to do so would harm treatment. (3.12.7 and 3.13) General Practice 3. Should a GP see any bruise on a non-mobile baby, regardless of the explanation, it should be recorded, drawn, and referred under the Protocol. (3.5.8) Clinical Commissioning Groups (CCGs) 4. CCGs which contract with NHUC work together to ensure there are consistent organisation wide expectations of NHUC in their contracts, and there is a joint approach to performance management. (3.4.10) 5. The CCGs monitor closely the rapid achievement of the actions set out in NHUC’s plan following the external audit and any actions from this SCR. (3.4.10) CCGs and NHS England 6. The responsible NHS bodies in Hampshire review with out of hour’s providers processes for communicating with GPs and seeking additional information about possible child protection issues. (3.6.1) 7. The CCG in conjunction with the local area team of the NHS Commissioning Board work with the GP Practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs. (3.5.2) North Hampshire Urgent Care 8. NHUC ensure that all staff working for them are aware of and have easy access to safeguarding guidance, both internal and county wide. (3.4.11) 32 9. Also that any NHUC training in house or induction covers not only the principles of safeguarding but practical consideration of what GPs on call need to do in specific scenarios. (3.4.11) South Central Ambulance NHS FT 10. SCAS considers whether any amendments could be made to the way 111 calls are recorded to provide clearer descriptions of what is being conveyed in calls that may relate to safeguarding. (3.10.3) School Governors 11. The governors of the school ensure that nursery staff are fully trained in safeguarding as per school policy, and that the board of governors receive regular assurance reports on compliance. (3.2.18) Hampshire County Council 12. HCC work with its maintained school nurseries to support governors to provide appropriate safeguarding training. (This needs to include guidance about babies even if no babies are at the nursery). (3.2.18) Hampshire Safeguarding Children Board (HSCB) /member agencies 13. The HSCB ensure that the Non Mobile Bruising Protocol is reviewed in light of this SCR, and that its use is a core part of local training, and that compliance is monitored. (4.4.4) 14. In each of the three illustrations about primary/community care communications, organisations should look at their own processes, with the HSCB holding the overview, to assess whether improvements can be made. (4.7.4) 15. That the HSCB and its member agencies should review their arrangements for being clear about what level of training is required, its frequency, and compliance. (4.5.1) 16. Also agency Boards or equivalent should receive assurance about compliance levels with safeguarding training requirements, and, the HSCB can then review the overall position in its annual report. (4.5.1) 17. It is recommended that HSCB and its member agencies consider how they can model good challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse. (4.6.2) 18. HSCB shares this report with the Surrey LSCB. ( 3.5.10) 33 APPENDIX 1 Agency Updates on Actions in Response to the SCR (originally submitted as at October 2013, and updated where necessary at July 2014 These submissions below are self-reported by the agencies which were asked to inform the Board of actions taken already and significant plans. The School: The School has shown the Review an updated version of its action plan following the SCR. At the annual health and safety update INSET session in September 2013 the child protection input covered the usual policy and practice, but included information for all staff about the significance of issues of vulnerability that come to school attention about siblings, raising of any injuries, bruises etc and referring sibling issues to health professionals and social service as appropriate. Records will be kept of any concerns raised about siblings of children attending the school/nursery, and reported to CPLO. The policy about non mobile bruising was brought to staff attention. The school organised child protection training for all Nursery staff and the early years SEN outreach team through an organisation recommended by HCC in September 2013. The Nursery Teacher undertook training in the management of child protection through the Guildford Diocese in September 2013. The Head Teacher undertook the HCC three yearly refresher training for school child protection liaison officers (CPLOs) in January 2014. The school governors undertook the annual safeguarding audit. An action plan was completed and this is monitored termly. This was shared with Ofsted in November 2013 during an inspection. Solent NHS Trust: As a result of the SCR V, Solent NHS Trust instigated a review of the HOMER (Substance Misuse Service) assessment paperwork. Since the end of October 2013, the paperwork for HOMER now includes a question for all clients presenting at HOMER services, asking whether they have regular caring responsibilities and/ or contact with children. South Central Ambulance Service NHS FT: They had nothing to add. Hampshire Safeguarding Children Board: The existing working group for the four LSCBs reviewing the protocol on bruising in children who are not independently mobile were informed of the draft findings of the SCR at the earliest opportunity and subsequently produced a single document in December 2013. Raising awareness of the protocol has been a core part of HSCB training, especially in the eight sessions on learning from case reviews that took place from October 34 2013 to March 2014. The revised protocol was launched at the HSCB Joint Working Conference on the 27 February 2014 which was attended by 100 practitioners. In January 2014 HSCB undertook a survey in order to gain an overview of practitioners’ awareness and application of the protocol. Of the 279 respondents, 64% said they had an awareness of the protocol. The survey was repeated in June 2014 following the launch of the protocol in February 2014. Of the 197 respondents, 88% said they had an awareness of the protocol. On the communications issues raised, the HSCB required the lead NHS CCG for safeguarding to report back to the HSCB January 2014 Board an overview on these issues, together with actions taken and planned. The outcome of this piece of work is outlined in the response from Hampshire CCGs below. On the recommendation that the HSCB and its agencies review arrangements for being clear about requirements for/level of safeguarding training, a revised training policy was published in January 2014. HSCB has required partner agencies to report on training compliance levels through the 2014 Section 11 Audits and the single agency training audit for 2014. The overall position on safeguarding training across the workforce will be reported in the 2014/15 Annual Report. On the modelling of ‘good challenge’, the theme is included in the HSCB workshops on lessons from case reviews. The HSCB learning and improvement framework and quality assurance frameworks both promote rigorous inquiry and challenge. Following from another SCR (Child S and R) partner agencies are already committed to reporting to the HSCB on the robustness of their internal supervision arrangements to ensure fixed thinking is identified and challenged. The report has been shared with the Surrey SCB. Hampshire County Council: Action has focussed around respective responsibilities for safeguarding between HCC and Schools, and in particular those 11 with nurseries. A letter has been sent to these schools saying, “The responsibility for staff training and support, including safeguarding training, rests with the governing body of the school, although from a day to day management perspective, this may be delegated to the Head teacher……..but, for the purpose of clarity, it may be helpful to reinforce that this responsibility relates to the whole school staff, including staff working in nursery classes.” The letter went on to describe the potential sources of training, including a subscription scheme for training provided by HCC. It also provides a web link to the LSCB policies on bruising and emphasising that the bruising might be seen or (as in this review) reported. Following the review of the bruising protocol a web link to the updated version was sent to all schools via the schools communications. At the November 2013 meeting between officers of HCC’s Services for Young Children and the 11 schools with nursery units, there was an item reinforcing the messages from the letter and to provide any further clarification necessary. 35 ‘Clarification about schools’ responsibility will be strengthened, following the publication of Keeping Children Safe in Education document, April 2014, at the briefing for schools on 11th November.’ Southern Health NHS Foundation Trust: It had become evident that, whilst messages were taken, it was impossible to demonstrate later whether a message had been taken and actioned or more importantly demonstrate that a call had not been received. The Trust reviewed the message taking process across the Health Visiting Service in Hampshire and developed a standardised approach for use across the Children’s division including Health Visiting and School Nursing. This standardised approach means that when staff move around within the Trust they will always be able to follow the same process. The messages are recorded straight on to the child’s record so that the process is auditable and the information available at a later date if required. In addition the Trust has provided a specialist training package to all staff directly working with non-ambulant infants following the launch of the updated HSCB Bruising protocol. The Bruising Protocol is included in training for all Trust staff not just Children’s Division. The Trust has also developed a Single Point of Contact to provide advice and support Trust wide when staff have concerns regarding the welfare of the child. The Single Point of Contact is staffed by an experienced member of the Safeguarding Children Team which supports the exculpation of concerns particularly around challenge when other agencies do not respond as expected or there is dissent around decision making. The Surrey GP Practice: The doctors in the practice have all been circulated with the bruising policy on non-mobile children, with a reinforcing letter. The practice child protection policy (based on the RCGP model policy) and list of local safeguarding contacts has been available on practice computers for the last couple of years. To this has now been added a list of appropriate codes for recording concerns about children/family members and a body map for recording any bruising. An update course on child protection issues run by the MDU was run at the practice in September 2013. The Family’s General Practice: No submission, but have accepted the accuracy of the Report. See the CCGs/Wessex Area Team response below. South East Coast Ambulance Service NHS FT: The Service reports that “….We have published a Child Death Procedure for all operational staff that was subsequently supported by a further instruction to our Emergency Operational Centre staff, entitled 'Community based death in under 18's”. Both of these provide direction on who in our Trust should contact the receiving hospital and/or police in the event of unexpected or expected cardiac or respiratory arrests in under 18's. These two documents were combined as the 'Procedure for Managing Death or Life Threatening Incidents in under 18’s' and issued in April 36 2014. Our procedures themselves are not changing, we are simply making sure there is only one document for guidance, that details staff responsibilities in an even more comprehensive format than the previous documentation”. Frimley Park Hospital NHS FT: In relation to the SCR recommendation about the management of phone calls: As part of the review and at the request of the legal team a full review of telephone calls during the given time-frame received into the organisation was carried out with no evidence of a call being received by midwifery. There are telephone record sheets in triage and a communication record book in Central Delivery Sheet and on the Postnatal Wards to document calls received for advice from parents regardless if the family is under the care of the midwifery service. On the 31st January a dedicated telephone advice line manned by a qualified midwife was implemented in the community midwives office. A recent audit of this has shown that recording advice and information is robust and can be easily traced. The Trust telephone system has changed recently and the Cisco system does not allow the tracing of telephone calls into individual department as before, this is apparently due to incomplete software, this was identified in a recent Serious Untoward Incident. Frimley Park Hospital is reviewing the feasibility of purchasing additional software. Secondly, the SCR asked FPH (and UHS) to look at their procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma unless to do so would harm treatment. The following was already in place. All paediatric middle grade and consultant staff are APLS (Advanced Paediatric Life Support) trained and are aware that non accidental injury can present with altered consciousness or the clinical picture not correlating with the history given by the care giver. APLS guidelines suggest as part of ‘exposure’ in the secondary survey of the critically ill child, a search for bruising be included following stabilisation of the child. (V was in the department for about two hours and active resuscitation and stabilisation of this child was still being addressed until care was transferred). The ‘Bruising in non-mobile children’ policy is in the Paediatric Guidelines on the intranet. We have recently re-presented the policy to the Paediatric Department as we have frequent staff changes. The policy has also been re-iterated in training packages to all staff. What has changed at Frimley Park Hospital since V presented: A proforma for the transfer out of the critically ill child has been developed. This now forms part of the transfer letter to the Paediatric Intensive Care Unit that retrieves the ill child. It has been ratified through the clinical governance process. This ensures that a general physical examination of the child will be carried out to actively look for and document the presence or absence of bruises/evidence of neglect/suspicious behaviour in all ill children transferred out of the Trust. 37 University Hospitals Southampton NHS Foundation Trust : The UHS Paediatric Intensive Care Unit Director has written to all Paediatric Intensive Care Unit consultants and senior nurses about looking for and recording bruises ‘particularly in circumstances where there is no clear diagnosis’. North Hampshire Urgent Care: North Hampshire Urgent Care has made the following improvements: All clinicians working on the rotas have completed Level 3 Safeguarding training (either through E-learning or face to face). In addition to this they must have training in local arrangements for referrals. This training will be completed by 30th September 2014. The NHUC Management Council will receive training on their responsibilities for Safeguarding of Children on 6th August 2014. The Safeguarding Children Policy has been thoroughly reviewed and updated. The policy is available to clinicians electronically on the intranet and NHUC website and paper copies are available within the Primary Care Centres. The flowchart for Safeguarding is available in every consulting room. Electronic links are being developed to give out of hours’ clinicians access to the list if children on a Child Protection Plan The clinical system, Adastra, is being configured to send a copy of the consultation notes for any child under five to the health visitor in addition to the patient’s GP The Bruising in non-mobile babies protocol has been recirculated and knowledge of it will be audited to ensure that it is embedded within the organisation. Clinical Commissioning Groups (CCGs) Hampshire: Following on from recommendations 4 and 5 North Hampshire CCG (NHCCG) awarded the out of hours contract to North Hampshire Urgent Care (NHUC) in October 2013. It was updated in February 2014 with a clause that it would be reviewed annually. The next review is in October 2014. Regarding performance reviews, North Hampshire CCG and North East Hampshire and Farnham CCG (NEHF CCG) have a joint Clinical Quality Review Meeting (CQRM) quarterly to monitor the compliance and quality of care provided by NHUC. The most recent meeting was held on 10 July 2014. In addition to the CQRMs, a bi-monthly review on the progress of the V action plan will be submitted to the Chief Nurses of North Hants CCG and NE Hants and Farnham CCG by NHUC. The bi-monthly reviews will also monitor the quality of induction of new staff, the level of training and compliance to legislation, ensuring that all NHUC employed GPs are trained to Level 3 (RCPCH toolkit). The training must include the Bruising Protocol and domestic abuse awareness. 38 Regarding staff access to guidance on safeguarding children on their website, NHUC was asked to forward their updated safeguarding children’s policy to the CCGs. The safeguarding children’s policy was forwarded to the CCGs on 18 July 2014. NHUC confirmed that the policy is now accessible to staff on their website via the staff portal. A significant aspect of the recommendations was to ensure that GPs accessed face to face training that was scenario based. The Wessex Area Team through the Named GP offered training in March 2014 which nurses attended. NHCCG has offered NHUC places on their training schedule for GP’s 2014/2015 where the teaching will be scenario based. The named GP will continue to work with NHUC to provide professional support. Following on from recommendation 7 regarding communication between out of hours providers and GPs: NHUC out of hours doctors send a fax to the child’s GP following every contact. GPs can also access further information regarding a child through: The Health Care Record. This is dependent on all GPs using Read Codes for any risk factors within the nuclear or extended family. For individuals accessing out of hours services at Hampshire Hospitals NHS Foundation Trust, the GPs should access additional information via the triage system within the Accident and Emergency Department. This would provide them with information regarding contact with Social Care. This will be further explored by the Named GP and Designated Nurse who will also discuss this difficulty with senior members of the children’s services team. NHUC out of hours doctors could access information directly from the local authority social care department by telephone. The Bruising Protocol has been updated by Designated Doctors, Named GPs and Designated Nurses across Hampshire and Solent CCG’s and has been sent to all GP practices, including North Hampshire Urgent Care (NHUC). The SCR also recommended (3) that GPs record and draw any bruises seen on a non-mobile baby, and refer the child using the Bruising Protocol. Part of the recommendations to other agencies highlighted the need for the Surrey County Bruising protocol to be in line with the Hampshire Bruising protocol. The Designated Nurses for each area have been reviewed the respective protocols to ensure that there is no difference in the management of non-mobile babies with bruises. This ensures that all staff (clinical and non-clinical) follow the same procedures. The Hampshire Bruising protocol can be accessed by staff/public on the following web-sites and links: Wessex Local Medical Committee (LMC) https://www.wessexlmcs.com/safeguardingbruisingprotocols The Hampshire Safeguarding Children Board 39 http://www.hampshiresafeguardingchildrenboard.org.uk/resources-policies-guidance.html The Hampshire five CCGs website which has a clear link to the protocol on the HSCB website http://www.westhampshireccg.nhs.uk/about-us/safeguarding-children/useful-links-and-training-information The following will be carried out to ensure reinforcement of the messages and maintain the awareness amongst staff members: In September 2014 NHCCG will resend the protocol to all out of hours GP providers in North Hampshire which will be six months after the initial HSCB launch. The Wessex Area Team is sending the protocol to all dental practices, opticians and pharmacists. On receipt of the results of the HSCB audit for the bruising protocol due to be presented in September 2014, the CCG and Wessex Area Team will take forward any identified gaps, providing the HSCB with clear timescales of completion of actions. The Designated and Named teams for Hampshire will: Use this SCR within the scenario based training delivered to primary care. Wessex Area Team of NHS England: The Wessex Area Team and the CCG have worked with the GP practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs. The Wessex Area Team is committed to ensuring high standards for children accessing GP practices. The team has explored how continuity of care can be improved by patients seeing fewer different GPs. The Wessex Area Team emphasises the importance of applying Read Codes to highlight risk factors within a family with regard to safeguarding through its safeguarding training programme. The GP audit conducted by the West Hampshire CCG (on behalf of the five Hampshire CCGs) in October 2013 informs us that some practices aim to ensure complex families are seen by the same GP. This is encouraged by the Wessex Area Team. Surrey Named GP (for Surrey CCGs/SSCB): There have been some similar issues in relation to bruising in non-mobile in another recent SCR, and we are currently implementing some recommendations. We have reviewed our procedures, protocol and guidance regarding bruising. The Named GP for safeguarding has now embedded this protocol within the Surrey GPs’ level 3 training. This training is accessible to all Surrey GPs, not just practice safeguarding leads. She is also in the process of circulating the protocol to all the leads, asking them to ensure ALL clinicians are made aware of it. 40 The Named GP has informed the LSCB of further actions. As a result of a Surrey SCR, all practice leads have been asked to ensure that ALL their practice staff are aware of who their practice lead for safeguarding children is. On continuity of care in large practices, this is an issue across the whole of primary care. Many practices do encourage patients to see the same GP whenever possible. This, however, is increasingly difficult to achieve, particularly with acute presentations, when a patient wants or needs to be seen on the same day. With extended surgery opening hours, and more GPs working less than full time with their practice, this will remain a difficult problem to solve. The key is more in robust record keeping, and appropriate Read coding, so that any concerns are picked up quickly and reliably by any clinician in the practice. Regarding access to the patient's own GP by out of hours services, there is a prompting system that allows out of hours providers to contact us regarding specific patients, but this is pre-arranged, for example, with a terminally ill patient receiving palliative care at home. It is hard to envisage a scenario where any GP can be contacted day or night regarding individual patients; this is why the OOH service is commissioned in the first place. 41 APPENDIX 2 Significant events V’s approx. age Significant Event 2 months Mother shares with GP concerns about lack of bonding with father Mother calls a health visitor or midwife about the lack of bonding, pulling at cheeks and bruising. Probable earliest time rib fracture may have happened 14 weeks Mother tells nursery worker that V keeps ‘hurting self’ and there are bruises and scratches- and that the ‘health visitor’ knew. 15 weeks Admitted overnight with an infection. A week before death Mother discusses with GP V pulling at cheeks, and says there was a chin bruise- but not noted by the GP. Day before last admission Out of hour GP sees two bruises on each cheek. 20 weeks Admitted with the fatal injuries. Day after admission V dies after life support removed. 42 Appendix 3 Index of Acronyms CCG Clinical Commissioning Group CEO Chief Executive FPH Frimley Park Hospital NHS FT HSCB Hampshire Safeguarding Children Board LSCB Local Safeguarding Children Board NAI Non Accidental Injury NHS FT NHS Foundation Trust NHUC North Hampshire Urgent Care PICU Paediatric Intensive Care Unit SCAS South Central Ambulance Service NHS FT SCR Serious Case Review SEC South East Coast Ambulance Services NHS FT SH Southern Health NHS FT SOL Solent NHS Trust UHS University Hospital Southampton NHS FT Final v H1b |
NC52791 | Death of a 17-year-old girl, Chloe, by suicide when in a state of mental crisis. Findings include: the need for resources to be available to support families in a child's early years; language used by professionals to describe help seeking behaviour can infer judgement or nuanced negative undertones; the importance of family, friends and kinship for children who are looked after; the importance of a sense of self for children who are looked after. Recommendations for the partnership include: consider how to build a child's sense of identity using existing processes; assess progress made following the vulnerable adolescent thematic review, with a particular focus on how trauma-informed practices are being enacted in services provided, and are supporting the multi-agency workforce; guided by the national reviews, embed relevant learning in mental health and wellbeing services for survivors of CSA; ensure the therapeutic work a child needs is detailed in a child's care plan; criminal compensation should be pursued for all children who have been the victim of sexual abuse; identify opportunities to provide support to carers in the local area and for this scaffold of care to be detailed in a child's care plan; consider how to reduce false transition points within agencies (including the private and voluntary sector) to maximise opportunities for practitioners to build consistent relationships with children; promote the briefing by the NSPCC on findings from young people who complete suicide, in particular the advice that suicide threats should be routinely assessed for motivation and level of intent.
| Title: Child safeguarding practice review: ‘Chloe’. LSCB: Croydon Safeguarding Children Partnership Author: Bridget Griffin Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 CSCP CSPR Chloe Croydon Safeguarding Children Partnership Child Safeguarding Practice Review ‘Chloe’ 20th July 2021 (including post inquest review Sept 2023) 2 CSCP CSPR Chloe “There’s a bomb in my heart”. Chloe Being traumatised means continuing to live your life as if the trauma were still going on – unchanged and immutable – as every new encounter or event is contaminated by the past. Van der Kolk – The Body Keeps the Score 2014 3 CSCP CSPR Chloe Contents Executive Summary ................................................................................................................................ 4 Reason for this review ........................................................................................................................... 6 Involvement of families & practitioners................................................................................................ 7 Summary of Chloe’s life ......................................................................................................................... 8 Findings ................................................................................................................................................... 9 Compassionate Care ....................................................................................................................... 9 Working hard to catch up .............................................................................................................. 9 Early Help ...................................................................................................................................... 10 The language we use and the meaning of this ............................................................................ 10 The importance of family, friends and kinship ........................................................................... 12 Wishes and feelings ...................................................................................................................... 13 A sense of self ............................................................................................................................. 155 Recommendations & Conclusion ....................................................................................................... 188 Recommendation 1 .......................................................................................................................... 18 Recommendation 2: ......................................................................................................................... 20 Recommendation 3 .......................................................................................................................... 21 Recommendation 4 .......................................................................................................................... 21 Recommendation 5 ........................................................................................................................ 244 Recommendation 6 ........................................................................................................................ 255 Recommendation 7: ....................................................................................................................... 266 Recommendation 8 ........................................................................................................................ 299 Recommendation 9 ........................................................................................................................ 299 Recommendation 10 ........................................................................................................................ 31 Recommendation 11 ...................................................................................................................... 311 Recommendation 12: ..................................................................................................................... 322 Recommendation 13 ...................................................................................................................... 344 Conclusion ...................................................................................................................................... 366 ‘Chloe’ - Post Inquest Addendum (v5) ............................................................................................... 377 4 CSCP CSPR Chloe Executive Summary At the heart of this Child Safeguarding Practice Review (CSPR) is Chloe. Chloe was 17 when she sadly died. She took her own life however the inquest verdict was ‘accident’; that she did not freely intend to take her own life. When she carried out the fatal act she was in a state of mental crisis. The coroner noted that several factors contributed to her death as they negatively impacted her mental health. Many of these findings are included in this report. They have not been included in full in an effort to protect the identity of Chloe. Publication of this CSPR has been delayed as the inquest concluded 3 years after her death. The CSCP Executive Partners have considered the inquest findings and where appropriate, this final version of the CSPR includes references to it. Additionally, an Addendum will be published alongside the report, which helps the reader to see what progress has been made against the original recommendations of the CSPR. Chloe was a child who experienced early trauma and who came into statutory care just before her teenage years. Her story illustrates the appalling legacy of sexual abuse, exploitation, trauma and re-traumatisation. Chloe lived in multiple homes throughout her life in care, she never experienced a safe loving home or a safe loving adult on whom she could consistently depend. Sadly, this is a familiar story for children who come into care late and who face extreme risks at the hands of those who seek to exploit them. This review examines Chloe’s story and the services that were provided. As identified in relevant guidance 1, it is not the purpose of CSPRs to conclude issues such as predictability or to hold organisations or individuals to account; there are separate processes for this purpose that must be followed. The purpose of CSPRs is to focus on a child and family, often in extremely tragic circumstances, to try and understand and make sense of their experiences of multi-agency services, to consider what these experiences might tell us about the health of the multi-agency safeguarding system and decide what is needed to strengthen the way children are safeguarded. There were many practitioners who knew Chloe at different times, a conservative estimate suggests that the number would be in the hundreds. There were also multiple services involved. There are examples of highly committed practitioners/clinicians/teachers/police officers/key workers who showed care and compassion and did their very best to provide Chloe with what she needed. It is almost inevitable that any case that is the subject of a CSPR will identify a need to improve service provision. This CSPR does not conclude that, had these things been in place, Chloe would be with us today. This CSPR considers relevant legislation, policy, practice, and procedure, reflects on research, literature and national guidance, and draws learning from the extensive experience and wealth of knowledge held by those who work within the multi-agency safeguarding arena. As this CSPR was being completed, a national review of children’s social care was underway. The findings of this national review paint a stark picture of a system that is not fit for purpose and almost entirely mirrors Chloe’s experiences from her early years to her death. Fundamental systemic changes are needed, these changes have been identified in perennial national reports stretching across Chloe’s entire life. Few recommendations are made in this CSPR, the handful that are will merely tweak the system. 1 Working Together to Safeguard Children 2018 & Child Safeguarding Practice Review panel: practice guidance DfE 2019. 5 CSCP CSPR Chloe As this version comes to completion, the Government has since published its response: Stable Homes, Built On Love. There is much intended in the report to improve outcomes for children who experience many of the features seen in Chloe’s life, however this will take time. Professionals and their systems must continue to press for change as identified in this report. Examples of intended changes include: The proposal to make ‘Care Experienced’ a protected characteristic. The publication of a National Kinship Care Strategy and equipping the system to respond to the complexity of the harms all children face, whether from inside or outside their homes. The Case for Change: The independent review of children’s social care. June 2021 My hope is that as a country we are better able to understand how life changing it is for children to grow up without the safe and loving foundations many of us can take for granted. These foundations are the first base for a good life and without them everything else is harder. One of our most fundamental obligations to children in care should be that they grow up and grow old with a strong loving tribe of people around them. We are currently not meeting this most basic of obligations. Our children’s social care system is a 30-year-old tower of Jenga held together with Sellotape: simultaneously rigid and yet shaky. There have been many reviews and attempts at reform since the landmark introduction of the 1989 Children Act and though each has ushered incremental progress, we are now left with a high stack of legislation, systems, structures, and services that with their sheer complicatedness make it hard to imagine something different, let alone address foundational problems. Improving children’s social care is not something that national government, local authorities or other partners can achieve on their own. The statutory children’s social care “system” is only the tip of the iceberg: promoting and protecting children’s welfare and rights must be a priority that goes beyond any single agency. Government’s primary focus should be on supporting the resources of families and the wider community to keep children safe as close to a family environment as is possible, whilst still acting decisively and swiftly where children require protection. Too often we are allowing situations to escalate and then being forced to intervene too late, severing children’s relationships and setting them on a worse trajectory. 6 CSCP CSPR Chloe Reason for this review Chloe’s body was found in a public building, she had a ligature tied around her neck. Chloe was a dual heritage British child who was living in a semi-independent unit in the London area. Chloe was the subject of a Care Order. After Chloe’s death, Croydon Safeguarding Children Partnership held a Rapid Review to consider the circumstances of her death. It was concluded that her death met the criteria for a Child Safeguarding Practice Review and the National Child Safeguarding Review Panel were advised. Purpose and methodology The purpose of a CSPR is to learn lessons through a systems analysis of the single and multi-agency work undertaken to support children2 and their families. The methodology used in this CSPR endeavours to understand professional practice in context, identifying systemic factors that influence the nature and quality of work with children and families. By using one case the aim is to get to systemic patterns, which are generalisable beyond this particular case. The purpose is to provide a proportionate and meaningful account of what happened from the perspective of the child and to add reflection and learning into the local safeguarding system. Process of review Independent reviewer and CSPR chair: A key aspect of the model is for an independent reviewer to work with a review team to plan and organise the key tasks, participate in the meetings, read key documents and analyse the data in order to produce the findings. An independent reviewer, Bridget Griffin 3, worked alongside an independent chair, Elizabeth Murphy 4. Bridget has significant experience as an author of Serious Case Reviews and more latterly Child Safeguarding Practice Reviews. Elizabeth is a Child & Adolescent Psychotherapist who has extensive experience of clinical work and of leading child and adolescent mental health services. CSPR Panel: A panel was appointed to work with the independent reviewer and chair during the review process. The panel was comprised of multi-agency representatives from across the different services who provided services to Chloe. These representatives were independent, in that they had no direct involvement with Chloe or her family and no management responsibility for the services that were provided during the period under review. Research questions & documentation: Independent agency reports, and an integrated chronology informed this review. The independent reviewer and chair had access to a range of other relevant reports from across the agencies. Several panel meetings were held to analyse the data and discuss the emerging findings. Several key lines of enquiry were set at the start of the CSPR, which included a request to reflect on the learning from the Croydon Safeguarding Children Board Vulnerable Adolescent Thematic Review 5. These lines of enquiry are addressed in the findings. 2 In line with legislation, the term child, or children (applied to all who are under the age of 18) will be used throughout 3 CQSW, BA (Hons), MA (Tavistock & Portman and MHT), SCIE accredited reviewer. 4 MSc, MACP (Member of the Association of Child Psychotherapists) 5 Croydon Safeguarding Children Board Vulnerable Adolescent Thematic Review (2019) 7 CSCP CSPR Chloe Involvement of families & practitioners Family perspectives: The independent reviewer and chair had the pleasure of meeting Chloe’s mum, dad and sister during the course of the review. The following quotes are an extract of what they shared. Chloe was a bubbly child who loved to share, she loved family parties and always wanted to help. I feel sad that because we could not cope with her behaviour she wouldn’t be invited to some of our family gatherings or would not be allowed to see her grandparents – all she wanted was family. When she was little she needed someone to talk to, she wouldn’t talk to me. As she got older, she acted in ways that I did not understand – I did not know what was wrong – I did not know how to help her – I was frightened (mum). Chloe was such a sweet little girl; we had such happy times together - something happened when she was 8 – I don’t know what, but she changed. She always loved being an auntie and often brought presents for her niece. She was so caring of her family and friends (sister) We loved her - everyone loved her – I was scared for her – I didn’t feel able to help her – I felt I was treated like the enemy – that I was a bad person (in the eyes of services). She had 2 brothers – we are all feeling guilty that we weren’t able to help her or see her more when she was alive – we didn’t know how to cope with her sometimes – we did not understand what was wrong (dad) Grateful thanks are extended to Chloe’s family for the time they willingly gave in being part of this CSPR. Their commitment to contribute to the learning, and their desire to prevent other families from suffering such unbearable loss, cannot be commended highly enough. Practitioner involvement: Practitioners who knew Chloe were invited to contribute to this review. The views of practitioners were sought in a number of ways; they were invited to contribute to the agency reports, one to one meetings took place with the independent reviewer and chair and two learning events took place. These events were attended by practitioners who had known Chloe and included other experienced practitioners who are currently working with children in the local area. It is clear that practitioners and clinicians were deeply committed to Chloe; they worked hard to try and support her and were deeply saddened by her death. Practitioners engaged well in this process and offered several insights into service provision based on their wide experience of partnership working in Croydon. 8 CSCP CSPR Chloe Summary of Chloe’s life Chloe was living in another London borough in her early years. She was known to multi-agency services when she was 2 years old and was made the subject of a child protection plan as a result of concerns about domestic violence. Chloe was referred to a Children’s Social Care service (CSC) when she was 11, at this point she had not been in school for several months. A Children’s Social Care (CSC) assessment identified that Chloe was at risk of sexual exploitation; referrals were made to the local Child and Adolescent Mental Health Service (CAMHS) and the NSPCC, a child protection plan was put in place and multi-agency network meetings took place at regular intervals. Just before her 12th birthday, Chloe alleged she was raped by an adult male, and she was found to have 3 sexually transmitted infections. The court case concluded with a not guilty finding – the reasons for this outcome are unclear 6. Chloe was missing from home on several occasions and there were ongoing concerns about sexual exploitation. Parents were concerned that they could not keep her safe; Chloe was placed in foster care which lasted only one week as carers struggled to provide her with the care that she needed. Subsequently, a care order was granted. Over the following months and years Chloe was placed in 18 different homes7 across the country. These included foster homes and residential homes. On four occasions, Chloe was placed in a secure unit, on four occasions she was detained under Sc136 (Mental Health Act 1983) 8and on two occasions she spent a few days on a psychiatric intensive care unit. Throughout her life Chloe was often missing, there were significant concerns about ongoing sexual exploitation by a range of perpetrators across the country. Chloe often misused drugs and alcohol and she was extremely vulnerable to being exploited in a range of situations. Chloe could be violent and aggressive, she experienced feelings of low self-worth, she self-harmed and there were many occasions when her mental health/emotional wellbeing was of significant concern. Chloe was also a child who could be bright and funny, playful and creative, who loved her family and had hopes and dreams for the future. Her overriding desire was to live an ordinary life, in an ordinary home. 6 Note: police colleagues did try to ascertain the reason, but records do not show the reasons for a particular verdict, just the verdict itself 7 Children who have experienced care by local authorities have said that they do not like use of the term ‘placement’ – when referring to their homes. Therefore, when referring to the different places Chloe lived – the word ‘home’ will be used throughout 8 Under Sc136 police can take someone to a place of safety if there are significant concerns about their mental health, an assessment by a mental health clinician is then completed to determine whether compulsory detention under the MHA is needed. 9 CSCP CSPR Chloe Findings Compassionate Care The overall response by practitioners, clinicians, police officers and key workers was characterised by sensitivity and compassion. The following are of particular note: • The relationship formed with Chloe by several social workers, clinicians, key workers, and her guardian ad litem, who demonstrated they knew her as a person and responded to her with thoughtfulness, kindness, compassion and generosity. • The relationship that was formed between a number of Independent Reviewing Officers (IROs) and Chloe whose consistent involvement over time, and evident empathy, led to her investment in an IRO as a trusted adult who she called when in crisis. • The response by the majority of police officers to Chloe when they were called on multiple occasions to intervene/ locate her. The compassion and sensitivity demonstrated was noteworthy and there were examples when Chloe seemed to trust that the police would provide protection and containment. • The response of ambulance crews who responded promptly and provided Chloe with sensitive care and containment. • The care provided in one of the secure units and the trusted relationships that were formed that led to Chloe seeking and receiving comfort and reassurance. • The work of the Adolescent Outreach Team (AOT) who were persistent, consistent, and compassionate in their approach. • The trusted relationship that was formed with Chloe by the manager of the semi-independent unit when Chloe’s likes and dislikes, joys and sadness were understood and, despite the vast damage she caused to property on numerous occasions, the manager’s commitment to providing Chloe with a home. Working hard to catch up With increasing demand at the acute end of the system, the costs of children’s social care are spiralling and shifting towards crisis management 9 It was clear that multi-agency intervention in Chloe’s life was characterised by crisis intervention - as one practitioner put it – constantly firefighting. Social workers (SWs) frequently contended with missing episodes, placement moves, placement searches, placement planning meetings, strategy meetings, court appearances, court reports, information sharing, moving Chloe/collecting Chloe, collecting her belongings & dealing with a vast array of practical and bureaucratic tasks. Working hard to catch up was an enduring feature of multi-agency involvement. The unintended consequence of this crisis mode was that, too often, the urgent drove out the important. This resulted in important actions/interventions that were needed being missed, especially if they fell outside statutory or procedural requirements, and opportunities to pause and reflect were lost. An example of this was noted at the inquest where insufficient attention was placed on her anxiety at attending court, resulting in her heightened risk not being recognised (or recorded) and therefore she may not have been adequately supported at court. 9 The Case for Change: The independent review of children’s social care. June 2021 DfE 10 CSCP CSPR Chloe Given the size of caseloads, and the volume of work in Croydon at this time, it is remarkable that much of the required timescales were met (such as: visits, Looked After Reviews, strategy meetings and court appearances). Early Help Reviewing the involvement of services during Chloe’s early childhood is not within the scope of this review. However, it is not possible to understand how agencies were in a position of working hard to catch up without reference to these early years. As a small child Chloe lived in a neighbouring London borough, she was 2 years when she first came to the attention of statutory services. There were concerns that she was suffering from significant harm as a consequence of living in a household where there was domestic violence. Results from Myer’s et al (2002) research findings10 show that the adverse impact on children’s development who are exposed to family violence is similar to the adverse impact for those who directly experience physical violence. There is little evidence that the impact of these early experiences were addressed when she was 2 or during the rest of her life. Conclusion Chloe’s mother spoke about Chloe’s early life, she acknowledged that she needed significant support at this time and asked why she couldn’t have been taken into care with Chloe so that she could have learnt how to parent Chloe. There is almost a timeless quality to the research and national reports that have been produced for many years about the importance of these early years, and the need for resources to be available to support families to prevent difficulties escalating. The national review of Children’s Social Care is underway, the interim report repeats the messages known and known well that creative, flexible approaches are needed underpinned by resources that stand the test of time. This is not something that local areas can resolve; it requires national action. Therefore, no recommendations are made. The language we use and the meaning of this Realities are socially constructed, constituted through language, and organised and maintained through narrative. Communication is the creation and exchange of meaning11 Whilst compassion and sensitivity was an important theme, there were also examples of professionals and clinicians from across the multi-agency network using language to describe Chloe that suggested she was making informed lifestyle choices by placing herself at risk &/or conveyed negative attitudes/ inferred judgement about her behaviour. This is of particular note during the start of the timeline (when Chloe was 11) and although this improved over time, it was a consistent theme. This has been highlighted in many of the agency reports, examples of phrases include: 10 The APSAC handbook on child maltreatment (2nd ed.). Myers, J., Berliner, L., Briere, J., Hendrix, CV., jenny, C., & Reid, T. (2002). Thousand Oaks, CA: Sage 11 From the work of M White & D Epston 11 CSCP CSPR Chloe She is engaged in sexually harmful behaviour and (needed to) acknowledge the risks she posed to herself. Superficial cuts were seen on her arm. She can be spiteful and defiant. She is resourceful and street wise. She has been putting herself at risk with older males. She is having sex with adult males for money. Her early sexualisation experiences (when referring to the rape at 11). She is now known to have been sexually active with an adult. The use of this language was important, it has the potential to: • minimise, hide, confuse, and truncate trauma and vulnerability • shape service response by inappropriately conferring choice, and therefore culpability • shape a child’s internal narrative by inadvertently conferring shame and responsibility • strengthen an abusers’ power and control over victims • compound the silence that shrouds sexual abuse & exploitation • inadvertently support an abusers’ internal narrative that the victim is to blame A summary of key issues taken from SCRs between 2018 – 201912 highlights that practitioners sometimes struggle to work with teenagers who are experiencing complex issues. The report identifies that the language used about teenagers by professionals can mask a child’s vulnerability and convey that a child is responsible for making choices to engage in harmful high-risk behaviour. The adults in a young person’s life, and young people themselves, sometimes viewed sexual activity as a “lifestyle choice”, rather than recognising it as a potential indicator of abuse. This meant there was a perception that the child was responsible for what had happened to them, and appropriate action was not taken to keep them safe. The use of language has broader ramifications. At various times, the words used to describe Chloe’s help seeking behaviour was peppered with inferred judgements or nuanced negative undertones. This language can shape an internal narrative of being bad/out of control/ difficult/ challenging to love or provide care to, and this remained an important theme. Conclusion: The view expressed by panel members and practitioners was that the use of language remains an issue today and work is in place to raise awareness of the impact and address the language that is used. The question that needs to be asked is why is this language used? The reasons for this are not completely clear. In the practitioner learning events the following was observed: The language used by professionals is a reflection of what they feel. This is a valid observation – as was the observation that practitioners experience the trauma of a child’s experiences vicariously. In other words, repeatedly seeing, hearing and reading about the experiences of a child who has been hurt and abused (and who may feel lost and alone) leads to anxiety and has an emotional cost – a cost that may lead to unconscious defences13 being constructed. These defences can provide an individual and collective buffer within a system that faces the unbearable reality of a child’s suffering, and few viable options to provide meaningful help. This may provide an explanation for why this language continues to be used – it may sanitise a child’s experiences, place responsibility on the child and thereby make the unbearable bearable. Relevant issues are discussed in the section: Trauma informed approaches. 12 Teenagers: learning from case reviews briefing. NSPCC Feb 2021 13 Jacques, E. (1953) On the dynamics of social structure: a contribution to the psychoanalytic study of social phenomena deriving from the views of Melanie Klein, in E. Trist and H. Murray (eds) 1990 27 Menzies, I.E.P. (1960) ‘Social systems as a defence against anxiety: an empirical study of the nursing service of a general hospital’, in E. Trist and Murray (eds), 1990. The Unconscious at work: Individual and Organisational Stress in the Human Services. The Members of the Tavistock Clinic Consulting to Institutions Workshop: Eds: Obholzer & Roberts 1994 12 CSCP CSPR Chloe The importance of family, friends and kinship Changing the trajectory of children’s lives, and making a significant difference to children’s outcomes, cannot be achieved by professional intervention alone. There is a need to understand and embrace family, kinship, and communities14 She made it clear to me that memories of her past are constantly in her mind – I was struck by the significant sense of sadness about her life experiences and that she felt alone – family separation was a measure of her despair and loneliness.15 Throughout the five years Chloe was looked after, her most consistent wish was to be placed close to her friends and family and to have contact with them. In the records seen, there are frequent references to a close family friend, various passing references to a sister and brothers, and to long term friends in the local area. The records of Chloe’s missing episodes (66 reported to police over the timeline) show that Chloe was frequently found in the local area, often after travelling some distance from her placements. Whilst it is not entirely clear where Chloe had been, she often mentioned seeing her family and friends. As discussed later, Chloe’s Looked After Reviews (LARs) repeatedly recorded a need for contact to be arranged between Chloe and her mother (and on occasions her father) and attempts were made to enable this to happen. However, the CSC agency report provided for this review makes the following comment: Chloe was just over 17 years old when she took her life. Throughout the years in care it is sad that little was done to connect her more with her sister and brother. If there was a connection of contact that would be because Chloe arranged it herself. There is little information in Chloe’s file about her family. There are numerous benefits in mapping and understanding a child’s family, kinship and friends. It can promote a sense of belonging, nurture connections, establish sources of safety and risk, engender a felt sense for the child that they are held in mind and facilitate a collaborative approach to care and safety planning. Whilst the various practitioners, key workers and clinicians may well have held knowledge about Chloe’s kinship - this did not translate to a coherent picture. Chloe’s journey in care, characterised by the involvement of multiple practitioners and numerous transitions, meant that this knowledge was lost over time and is an example of how Chloe’s identity and sense of belonging was fragmented and scattered – this is discussed later. The independent review of children’s social care interim report makes a powerful case about the basic human need for children to grow up with a loving tribe around them, and that this is not being provided for children who are in state care. There are many complex reasons for this. In Chloe’s case, this was partly due to the reasons discussed later (about whether contact was thought to be harmful). In part, it is attributable to the constant flux of social workers in children’s lives which is a national issue. However, overall, the central issue relates to the issues raised earlier about working hard to catch up. When responding to children who are at high risk, it is simply not possible for social workers (who carry high caseloads and who are dealing with extensive tasks/legislative and procedural requirements) to do the extensive work that is often needed to build a loving tribe of family and kinship around a child. 14 CSCB VA Thematic Review 2019 15 Quote from a psychiatric assessment of Chloe at a secure unit 13 CSCP CSPR Chloe If we consider that the greatest value of social work is in the interaction between social workers and children and families, then it should be an ongoing source of alarm that 1 in 3 of all social workers in children’s services do not work directly with children or families (Department for Education, 2021a). Even those in direct practice spend less than one third of their time with families (Department for Education, 2020a). This is a staggering misuse of the greatest asset that children’s social care has - its social workers16. Conclusion: The need to nurture this tribe for children who are looked after is recognised in Croydon – it is known well and understood. The inhibiters are having the skilled resources and capacity to do the work. There is a plan in place to recruit systemic practitioners who would be able to do this work. However, once again, the issue remains that if insufficient financial resources are available, and if social workers continue to be unable to do their jobs, this will not be possible. These are issues that are well known to government across all political groups, they have existed for many years and have been identified in numerous reports17 over time. National action is needed; therefore no recommendations are made. Wishes and feelings i. Placement in foster care Chloe was often asked about her wishes and feelings on a range of subjects, and she frequently gave her views. Her most consistent wish was to be placed in a foster home in close proximity to her family and friends. This was achieved, it seems more by accident than design, after her first period in secure accommodation when she was placed in such a foster placement. It was clear that she was very happy in this home. However, the plan agreed at court had been to move Chloe from secure to a therapeutic residential placement. It was difficult to find a residential placement that would be able to meet her needs and was prepared to accept her. As a result, she was placed in an emergency foster placement in her local area. Sadly, within weeks, she was told she would be moving to a residential placement out of borough. The SW who informed her of this decision described Chloe’s distress on hearing this news – Chloe remained quiet as tears streamed down her face. From this point Chloe’s behaviour changed, and as to be expected, she then had to be moved in a hurry – the pattern of moving in a time of crisis continued. The CSC and IRO reports express concern about this period stating that although there was no guarantee, there appeared to be signs that this placement might have worked. It has been described within the CSC agency report and by the IRO as such a missed opportunity and as Chloe said she was not given a chance. Risk sensible decision making, transition, discharge planning and placement options are discussed later in this report. ii. Contact with family: Care must build rather than break relationships 18 One of our most fundamental obligations to children in care should be that they grow up and grow old with a strong loving tribe of people around them. We are currently not meeting this most basic of obligations 19. 16 The Case for Change: The independent review of children’s social care. June 2021 17 Such as: The Munro Review of child protection: a child centred system. 2011 DfE. No Good options: Report of the Inquiry into Children’s Social Care in England. All Parliamentary Group for Children. NCB March 2017. Storing up trouble. A post code lottery of children’s social care. All Parliamentary Group for Children. NCB July 2018 18 The Case for Change: The independent review of children’s social care. June 2021 DfE 19 The Case for Change: The independent review of children’s social care. June 2021 DfE 14 CSCP CSPR Chloe Her parents might not have been able to always act in her best interests, but they had a special place in her heart and professionals have not considered that well enough20. Chloe consistently expressed her wish to have contact with family and friends and her desire to be close to her mother (both physically and emotionally) remained evident throughout. This was apparent to her IROs who were frequently clear that contact should be facilitated and supported. At times, due to her distance from the family home, this contact was difficult to achieve but it is clear that creative ways of achieving contact with her mother were made at different points. At various times, Chloe was distressed after contact with her mother or father. During a LAR, when Chloe had been admitted to PICU, she told the IRO that on her birthday (a few days before admission) she had felt upset after seeing/speaking to her parents. There were differences of opinion about whether contact with her mother and father met her needs. Whilst it is understood and appreciated that risk sensible decisions about contact must be made, it is simply not possible for professionals to prevent young people seeing their parents if they choose to do so. Many children, particularly those who come into care during adolescence, will return ‘home’ in some shape or form. The reasons are numerous; it can be driven by a simple reality that they have no other options, it can be driven by anger, resentment or blame, a desire to understand the past, to establish a sense of connection and belonging &/or a wish to seek parental love. Therefore, there is a need to prepare children for lifelong relationships with their families. Facilitating contact is one aspect of this but in the absence of attempts to make these relationships the best they can be, there is a risk of compounding harm and perpetuating harmful dynamics in the short and long term. Both Chloe and her mother were vulnerable, there was a need to support their relationship to enable this relationship to be the best it could be – an emotional scaffold needed to be built. An IRO observed that Chloe seemed to take a paternal position in this relationship, this needed to be better understood. Understanding this within the context of Chloe’s early childhood experiences, Chloe’s unrelenting desire to be placed close to her mother and her frequent missing episodes (when she returned to Croydon and often visited her mother) may have had the added benefit of supporting efforts to keep her safe. Conclusion: At various times there was an acknowledgement that relationship work was needed but this lacked a coherent plan. It seemed that the requirement to deal with urgent matters drove out the capacity to deal with important matters such as this. This has been acknowledged in the independent review of children’s social care interim report: Process continues to dominate over direct work with families. Recommendations could be made that CSCP should ensure SW caseloads are reduced to enable social workers to take on direct work with children and families, and that there are sufficient resources in place to ensure that skilled practitioners are in place to facilitate this work. These would be unrealistic recommendations that are beyond the gift of CSCP. The issues discussed in previous sections are relevant, as stated - these are systemic national issues that require a national response. 20 Croydon Children’s Social Care Agency Report for the CSPR 15 CSCP CSPR Chloe A sense of self i. Enabling a unique sense of self Chloe consistently expressed her interest in animals and spoke of her desire to study catering or hair and beauty in further education. Various practitioners identified; her interests, her likes and dislikes, areas where she excelled (such as gardening and art), areas where she excelled (such as maths), areas that calmed and soothed her (such as being with horses) and areas that filled her with joy (such as dancing). Sadly, the sheer number of professionals involved in her life, and the multiple placements, scattered this knowledge and Chloe’s sense of self was fragmented. This is not unusual for children looked after by the state whose experiences are similar to Chloe. Within the fragmented system that we call ‘corporate parenting’, Looked After Reviews (LARs), Personal Education Plans (PEPs), health assessments and pathway plans (PPs) have the potential to hold a composite memory of a child and paint a unique portrait of self that stands the test of time. In a sense, they are the documents that can represent and hold innate ‘parental’ memory and knowledge about a child – this is discussed later. ii. I belong in this world - identity and belonging. Relevant research and literature about adolescent development describes the formation of personality during this time. Critical components of this include identity formation and a search to belong. For children who are looked after by the state, a sense of belonging can be difficult to achieve - although a stable placement and a school place can facilitate this. Chloe had neither, as a result her sense of belonging was thwarted, and her scattered and fragmented memories undermined a sense of self. A child’s understanding of their story is carried with them throughout their life journey. How a child makes sense of this journey provides an internal narrative that gives them a sense of who they are. LARs repeatedly recommended that life story work (LSW) was needed, but this was not achieved throughout Chloe’s life. During this review, it was said that LSW was just not possible as this work required consistency and stability - LSW seemed to be a mountain that practitioners felt was just too high to climb. Whilst this is understood - to consistently note this as an ambition (within LARs) and for it never to be achieved, did not meet Chloe’s needs. At the Practitioner Learning Event, it was said that the lack of life story work was common. As suggested in the children’s social care report (CSC) and Independent Reviewing officer (IRO) reports, LSW needs to be demystified. Flexible and creative opportunities should be found to engender a sense of identity and belonging. Storing cherished memories is one aspect and, as discussed below, one way this can be achieved is by using the established recording mechanisms. There have been promising developments in CSC which include IROs writing letters to children and examples were seen of letters written by IRO’s to Chloe that contained important memories and offered validation that she had been heard. Further work is currently in place to enhance the potential therapeutic value of these letters, this is excellent practice. In addition, CSC staff spoke about the use of memory boxes which allows a child to hold mementos of their past - providing sensory triggers to unlock memories. Whilst this is also a good practice, it was not something that happened for Chloe. 16 CSCP CSPR Chloe Throughout the Child Looked After Reviews, Chloe persistently asked for a number of things that she wanted, such as: • a passport • her birth certificate • a provisional driving licence • a record of her savings • her exam certificates • return of belongings from previous placements. The reviews repeatedly made recommendations that these needed to be gained, and at each review Chloe’s frustration about the lack of action was clear. Just before her death, Chloe was given her passport and birth certificate. Sadly, at the time of her death, she was still waiting for some of her belongings. It is understood there were concerns for her safety should she have a passport. Whilst this is appreciated, the symbolic meaning of these items as a reflection of her identity had the potential of promoting a sense of self and a feeling of belonging in this world. iii. Hopes and Dreams and the Importance of Ordinary Things Chloe’s Looked After Reviews, and conversations with practitioners, revealed that Chloe had aspirations and dreams. This was regarded as a mark of her resilience and engendered a sense of hope for Chloe’s future. The chaos of her life in care; the repeated trauma and cycling of unresolved trauma, was mirrored in the chaos management within the system. The unintended consequence was that the urgent obscured the need to celebrate and promote the intrinsic value of ordinary life and to honour Chloe’s ordinary hopes and dreams. There were some exceptions to this, as demonstrated in the attempts to give Chloe an experience of ordinary life in the semi-independent unit at the end of her care journey. Amongst other things, it was impressive to note that Chloe was supported to secure employment for a short while in a well-established fast-food restaurant. However, throughout her life in care, there was no holistic view of Chloe. Reviewing the records and speaking to practitioners revealed that; Chloe aspired to working to earn money by legitimate means, she loved receiving something that showed the person knew what she liked (such as a box of Maltesers), she enjoyed experimenting with her hair and makeup and found joy in ordinary things. She was described as astute, empathetic, engaging, bright and articulate. One practitioner said that a light shone through her, and others said that at heart she was an ordinary girl who wanted ordinary things. As already described, the fragmentation of her care journey and the involvement of multiple practitioners resulted in a fragmented ‘knowing’ of Chloe. Sadly, this can be a familiar experience for children in care. Children living in foster homes have a better chance of this knowledge being held by their carers but for children who experience multiple moves, or who spend much of their lives in residential placements, this innate knowledge can be fragmented and lost. Once again, the question that arises is where can this vital ‘parental knowledge’ be held to stand the test of time? The need for a lead professional has already been discussed but it is important that this is not regarded as an aspirational panacea. Other established mechanisms need to play a part in the gathering and storing of innate parental knowledge. Child Looked After Reviews are one way this can be achieved, and the recent initiative of IROs writing letters to children is an excellent development. Contributions from the Independent Reviewing Officer (IRO) service to this review highlighted that the Child Looked After Review process is peppered with targets and performance indicators which can have the unintended consequence of placing an undue emphasis on process checking. 17 CSCP CSPR Chloe Whilst this has certainly improved over time, it was clear that the weight of process checking can skew an IROs valuable time and attention away from understanding the uniqueness of a child. This is discussed at the end of this report. Other established mechanisms that are well embedded in the Child Looked After systems and processes are Child Looked After health assessments, Personal Education Plans (PEPs) and Pathway Plans. PEPs were not consistently completed, those that were completed were characterised by a narrow focus on formal education achievements and there were blank spaces throughout. Chloe engaged in completing her PEPs, she wrote about the activities she enjoyed and her dreams and aspirations – it was sad to see what little attention was paid to these things. It seemed these PEPs were a sign of hitting the target but missing the point. This has been recognised by the Virtual School and the considerable changes that have been made to build capacity, and improve the focus on pro-active oversight and intervention, is encouraging. The need to celebrate and promote a child’s talent and aspirations (within and beyond the confines of what is judged to be formal educational success) has been recognised and is now actively promoted. Child Looked After (CLA) health assessments are not intended to have a linear focus on health needs/outcomes alone, instead - a child’s holistic needs are considered, including a child’s identity and their wishes and feelings. The relevant agency report to this review addresses the CLA health assessments that were completed and identifies that these assessments, by necessity of Chloe’s placements out of area, were frequently completed by various health professionals and were not consistently completed. As a result, it was difficult to get a sense of Chloe’s health and wellbeing from these assessments. This, together with the limits of how a trauma informed approach was enacted (as below), meant that Chloe’s identity and lived experiences were difficult to see. Several recommendations have been made in this agency report about how this will be better achieved in the future. Pathway Plans should be written three months after a child’s 16th birthday, it is written with a child and sets out the plans for a child’s future. Included in this plan are steps that need to be taken to meet a child’s needs as they move into independence and covers areas such as identity, family contact, health, education/employment, finances and accommodation. It provides a platform for future planning so that a child can feel confident of this future, and how they will be supported. In addition, it provides another opportunity to; promote a sense of belonging, to reflect a sense of self, to hold parental ‘knowing’ and engender a sense of future. IROs made repeated recommendations that a pathway plan needed to be completed. Just before Chloe’s death, a pathway plan was completed. Again, it was sad to see the scarcity of information contained in this document. 18 CSCP CSPR Chloe Recommendations & Conclusion A sense of self. The interim report, setting out the initial findings of the independent review of children’s social care, states: When we do remove children from their birth parents, we need to ensure they are cared for in consistent and loving relationships that support their development and identity. We agree with the Care Inquiry that permanency should mean children feeling security, stability, love and a strong sense of identity and belonging (The Care Inquiry & Family Rights Group, 2013). These are unquestionable truisms that all those in children’s social care, and across the multi-agency network, would agree with and there is a collective desire to achieve these things for all children. The issues identified earlier (about the lack of capacity within CSC to complete direct work with children) are relevant, as are the issues raised later (about a system which is not designed or set up for the task of caring for children like Chloe). However, children cannot wait for the national changes that are needed. CSC, together with the multi-agency workforce, need to find flexible and creative approaches to build a sense of self and belonging in real time for children. Therefore, it is recommended that the opportunities currently available within the multi-agency system should be used to maximum advantage. This requires a collective understanding about the importance of a child’s identity, and a multi-agency approach to identify the opportunities that will enable this work to happen. These opportunities need to be scoped and built to enable children to understand their life story, including their racial and cultural origins - their lineage and heritage. Thereby, a positive narrative of self and a sense of belonging in this world may be constructed. Recommendation 1 Multi- agency partners to consider how identity will be prompted within the current system by using existing processes (such as care plans, Child Looked After plans, Personal Education Plans, health assessments and Pathway Plans) and other multi-agency processes/points of contact with a child. IROs to lead on scoping opportunities within the child’s network for building a positive identity. CSCP to maintain on overview of progress and provide support and challenge. Trauma- informed approaches Taking a trauma informed approach in our work can enable this shift away from asking “What is wrong with you?” towards an orientation of “What has happened to you?”, enabling the possibility of survivors of abuse being seen by themselves and others as just that – survivors. With this change in ethical orientation a child or young person’s responses to trauma are seen as understandable and courageous attempts to survive which were absolutely necessary at the time 21. Chloe’s variable relationship with practitioners was frequently noted. Whilst it is completely normal for children and adolescents to have a preference about which adults they like or can trust, research suggests that children who experience trauma are often in a state of hyper vigilance and alert to the body language of others, and what they feel is being communicated: Am I being judged/criticised? Is there threat? Can I trust this person? Am I safe? Tomlinson22 describes this as an attempt to survive. 21 Trauma – informed approaches with young people. Research in Practice Front Line Briefing 2018 22 Communicating with Traumatised Children P. Tomlinson, 2013. 19 CSCP CSPR Chloe At various times, it was clear that trauma informed approaches were enacted when working with Chloe. Examples that stand out include the care provided by the Adolescent Outreach Team (AOT), the work of several IROs, social workers and key workers, who clearly understood her trauma and provided a trauma informed response. However, the extent and consistency of these approaches were variable. As identified in the CSC agency report - the majority of Chloe’s social workers do not appear to have been trained in trauma-informed practice. Early involvement with Chloe suggested little understanding of trauma and impact - instead, a behaviour management approach was adopted: There is a sense at times that Chloe is being judged for her behaviours rather than them being understood through a trauma informed lens. The Croydon Health Services (CHS) agency report identifies a need for health professionals to focus not just on risk but on how the trauma is being reflected in behaviours. The author observed: The shift in language (from describing a set of needs) from complex to more trauma informed can move the paradigm from the child is complex to the child has experienced trauma. It is fair to say that in Chloe’s early years, the concept of trauma informed practice was not understood and there was little in place to guide practitioners in this approach. Since then, there has been an expansion in how trauma informed approaches are understood and can be enacted23 and the phrase ‘trauma- informed’ has become part of the language used by the children’s workforce and is promoted in various national reports and research. However, as noted in many of the agency reports, this is not consistently applied/understood. In addition, it is not clear whether foster carers are trained in trauma-informed approaches or whether external placements are expected to base interventions informed by the principles of trauma informed practice. It is recommended that approaches are adopted that seek to address the child’s trauma and services provided that are flexible enough to adapt to the child’s circumstances and needs. The benefits of a key worker relational approach24 needs to be better understood and the barriers to this approach addressed. Recommendation: CSCP to consider best practice examples of implementing a trauma informed response25 (demonstrated elsewhere in the UK) and consider how the multi-agency workforce might be suitably supported to implement this approach 26. Conclusion: There have been local and national initiatives to support trauma-informed approaches; this CSPR has found that these approaches are inconsistent. The question that must be asked is: What gets in the way of providing a consistent approach? - there are multiple reasons for this. First and foremost, it is important to recognise the issues raised in the section – working hard to catch up; not only were practitioners working hard to catch up with Chloe’s movements (in completing the multiple tasks involved and contending with a system that is not fit for purpose) they were also providing care to a child who was the victim of frequent re-traumatisation. This was happening not only as a result of the abuse perpetrated by multiple adults in the community, but also as a result of system failures. The trauma was ever present for Chloe, and the secondary trauma was ever present for practitioners. 23 Such as: Research in Practice: Trauma- informed approaches with young people 2018 24 That Difficult Age: Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014 25 Developing and leading trauma-informed practice: Leaders' Briefing Research in Practice 2018 26 Croydon Safeguarding Board Vulnerable Adolescents Thematic Review 2019 20 CSCP CSPR Chloe The independent review of children’s social care has made the case for national change, these national changes offer a hope that the system may prevent retraumatising children such as Chloe. A further important issue that was identified by practitioners was that unless practitioners are supported by their organisations to cope and recover from the secondary trauma experienced when working in a human service (that routinely faces the pain of children and adults and the challenges of an imperfect system), it is not possible for trauma-informed work to be consistently provided. The emotional burden of the work squeezes out our capacity to provide an empathetic human response – if this is not acknowledged or understood no amount of trauma-informed training will help. Relevant research supports this position and strongly encourages organisations to embed the principles of a trauma- informed approach in strategic plans, policies, procedures and in day-to-day management and leadership 27 to enable consistent trauma informed services to be provided. Elements of this approach have recently been set out in the National Institute for Health and Care Excellence consultation document 28 : This guideline covers how organisations, professionals and carers can work together to deliver high quality care, stable placements and nurturing relationships for looked-after children and young people. It aims to help these children and young people reach their full potential and enjoy the same opportunities in life as their peers. A key aspect of the guidance highlights the need to provide good quality supervision to staff, characterised by reflective practice and emotional support. Recommendation 2: CSCP to review what progress has been made following the recommendation made in the Vulnerable Adolescent Thematic Review, with a particular focus on identifying evidence to demonstrate how trauma-informed practices are being enacted in services provided to children (including commissioned services/homes) and how trauma-informed organisational approaches are supporting the multi-agency workforce. Providing support to survivors of sexual abuse The consequences of child sexual abuse can include depression, eating disorders, post-traumatic stress, and an impaired ability to cope with stress or emotions (Allnock et al 2009). Self-blame, self-harm, and suicide are commonly mentioned as consequences of sexual abuse.29 There are two important issues that arise in this review about the therapy Chloe received; one relates to availability and the other to suitability. This section covers the availability and suitability of therapy for survivors of sexual abuse. It is unclear from the records what therapeutic intervention Chloe received to enable her to start her healing journey from the pernicious harm caused by sexual abuse and exploitation. The Child Looked After Reviews in the early part of the timeline, when Chloe was in various residential establishments, raise concern about the lack of therapeutic intervention. In part, this was due to the number of times Chloe was missing however, there were periods when therapy could have been undertaken. 27 Developing and leading trauma-informed practice: Leaders' Briefing. Research in Practice. Dartington (2018) 28 https://www.nice.org.uk/guidance/gid-ng10121/documents/draft-guideline 29 NSPCC Practice Briefing: Sexual Abuse 2013 21 CSCP CSPR Chloe The variable provision in residential units provides a partial answer as to why this was not achieved, and the fragmentation in CAMHS provision (caused by referral, rereferral, and delay) was also a critical factor - this is discussed later. Chloe was referred to various services to address her need for therapeutic intervention - this included Safer London, the NSPCC and various private and voluntary (charitable) providers. It is unclear what was provided and there was little seen to suggest that this work was reviewed, evaluated, or integrated within Chloe’s care plan. The IRO agency report identifies this as a missing component as does the CAMHS agency report. A systematic review30 reveals the scarcity of research about the different treatment approaches/modalities available for survivors of Child Sexual Abuse (CSA), and the current lack of evidence to demonstrate effectiveness. It is suggested that the provision of therapeutic support to survivors of sexual abuse requires review and that some approaches are at best unhelpful, and at worst harmful. Work is currently underway, led by the Home Office and the Centre of Expertise (CoE), to review therapeutic services for survivors of CSA and national guidance is expected in the coming months. A further aspect of therapeutic intervention for survivors of CSA is criminal injuries compensation. Whilst the therapeutic benefits are not widely recognised, panel members have rightfully raised this as an important oversight. On one occasion the need to pursue criminal compensation was recognised in a Child Looked After Review but as with a number of other recommendations made in Chloe’s Reviews, this recommendation was lost overtime (Child Looked After reviews are discussed at the end of this report). Research emphasises the critical importance of justice for survivors of sexual abuse/exploitation - this can restore dignity and promote feelings of validation in being believed, of not being responsible, and thereby alleviate feelings of shame. Recommendation 3 CSCP to be guided by the national reviews and embed relevant learning in the future service provision of mental health and wellbeing services for survivors of CSA. This should include the services provided by the voluntary sector and commissioned services that are provided to Looked After Children who are living out of area. Recommendation 4 The therapeutic work a child needs should be detailed in a child’s care plan. Child Looked After reviews to monitor what therapy is being provided, evaluate outcomes and determine what future services are needed. Criminal compensation should be pursued for all children who have been the victim of sexual abuse, Child Looked After Reviews to maintain oversight. 30 Systematic Review: Effectiveness of psychosocial interventions on wellbeing outcomes for adolescent or adult victim/survivors of recent rape or sexual assault. Jane Lomax and Jane Meyrick. SAGE 2020. 22 CSCP CSPR Chloe A place called home. Few good options We continue to hear that there are not enough of the right homes for children with the most complex needs…... What is clearly true is that at present the state is not meeting the needs of a very vulnerable group of children. We desperately need better planning, coordination and investment for this group with leadership across health, justice and children’s social care. Instead of simply doing more of the same, we need to consider the needs of these children and ask whether any home that currently exists is able to meet their needs while still providing a loving environment31. Chloe spent five years in the care of the Local Authority. She moved across the country living in at least 18 different ‘homes’. The longest period she lived in a home was 12 months, this was a residential children’s home. Chloe was placed in secure accommodation on 4 occasions – 10 months in total. She spent brief periods in foster care, but the majority of her placements were in residential care. Few placement endings were planned; they happened as a result of concerns that a particular establishment could not keep Chloe safe, or at the request of the placement due to their difficulties in managing her aggressive outbursts, assaults on staff &/or destruction of property. There were 3 homes that stood out as important for Chloe; the first was the 1st secure unit, where she accessed therapy and seemed to respond well to containment and care, the 2nd was the foster home she moved to from this secure placement, where she wanted to stay, and the 3rd was her final placement within the semi-independent unit that provided her a home in spite of assaults on staff and extensive destruction of property. There were differences of opinion about whether her last home met her needs, and these concerns were the subject of active multi-agency debate and challenge when Chloe was alive, and during this CSPR. The harsh reality is that there are few good options. Placement planning and sourcing include a matching process (where a child’s needs are matched with a provider/foster carer) however, it is clear that placement decisions were driven by an overriding desire to keep Chloe safe. In reality, the only placement that achieved this was secure accommodation. Finding placements for children with needs such as Chloe’s is extremely difficult. Decisions about placements are often not about choice but based on which placements are willing to provide care – it is an extremely time consuming and costly endeavour where compromises have to be reached. Experienced practitioners and managers in CSC said there was no such thing as a placement resource that would have met all of Chloe’s needs regardless of the amount of money that CSC were prepared pay. As identified by senior managers in CSC - it is a very sad reality that sourcing placements for children who are in state care is a marketplace: residential placements (businesses) are paid very significant sums of money to care for a child but there are no incentives for the business to contend with the challenges of a child with complex needs, when they can be replaced with another child who is less challenging/less risky to provide care to. Chloe’s experience of care; characterised by swift moves from one foster home to another, to placements in various residential homes across the country and punctuated by frequent placement breakdowns and periods of secure accommodation, is familiar. It has been identified in the independent review of children’s social care interim report that placement options for children who are exploited, and at high risk within communities, are few and far between. 31 The Case for Change: The independent review of children’s social care. June 2021 DfE 23 CSCP CSPR Chloe Sadly, this is often the experience of children who come into care late who have a history of trauma, high risk behaviour and exploitation. Relevant CSPRs, concerned with children who have been criminally and/or sexually exploited, are a testament to this. 32 Changes in statutory guidance and safeguarding practice over the past few years have prompted a necessary shift from seeing a child’s high-risk behaviour in teenage years as a lifestyle choice to seeing these children as requiring robust state intervention to safeguard them from harm. The CSC agency report emphasises that use of secure units should be a last resort and that risk sensible decisions about placements need to be made, these are relevant and important principles. However, it seems that the resources needed to realise these principles (including viable local placement options, flexible and creative intervention across the multi-agency partnership, multi-agency ownership of risk and responsibility at a senior level) are not in place. As a result, what appears to have happened is that without the necessary infrastructures and resources on the ground, the clear commitment to protect these children, supported by statute, has swung the pendulum from laissez-faire to restrict and confine. We would question whether there is no other alternative for the two thirds of children currently placed in secure children’s homes who are the victims of sexual exploitation (A. Williams et al.2020)33 Despite all the best intentions, Chloe returned to the local area a more traumatised child then when she had left home 5 years ago. This meant that the risks she faced were considerable and the challenges of providing stability and containment were more complex. It is a tragic irony that at this late stage there was an acceptance that continuing to confine Chloe would not be in her best interests. The involvement of the AOT, and the relative stability of her placement, offered a glimmer of hope that she might have been safely held. Conclusion: Chloe’s enduring wish was to live in her local area close to her family home, this was achieved at the end of her life. The question that arises is whether this could have been achieved at a much earlier point. It seems that two main factors stood in the way. One relates to the local and national shortage of suitable homes for children who are at high risk and have complex needs. The other relates to how risk is managed within organisations. During the practitioner learning event, experienced managers spoke about the fear and anxiety that can be felt in organisations about risk. This can lead to risk adverse decision making at a senior level which can close down options. There are number of systemic reasons for this; not least the political context within which public services operate, the search for certainty in an uncertain world, the inspection regime and the individual, collective, organisational and political costs of failure. During the period when Chloe was in and out of secure accommodation, an inspection of CSC was being carried out by Ofsted. It was said that at this time there was an organisational freeze; fear and anxiety pushed the organisation into a position where risk was intolerable and as a result locking Chloe away, and others like her, felt like the most sensible thing to do and the numbers of children in secure accommodation rose. Care for children who need secure accommodation reflects short term siloed thinking across government 34. 32 A local example: CSCB Child Q Where were you when I was six? 2019 33 The Case for Change: The independent review of children’s social care. June 2021 DfE 34 The Case for Change: The independent review of children’s social care. June 2021 DfE 24 CSCP CSPR Chloe Risk sensible decision making, supported at a senior level within organisations and within the local and national political landscape, is a perennial issue that will continue to influence decision making regardless of the amount of homes that are available. Making recommendations about how the workforce can be supported to make risk sensible decisions or about increasing the quality and availability of resources, including a place to call home, is beyond the gift of CSCP. Once again these issues are recognised in the independent review of CSC; they are issues that require a national response. However, once again, children cannot wait for these changes. Panel acknowledged that there was little practitioners could do on the ground to make the systems changes that were needed but were committed to making the best of the limited resources that are available. Therefore, the following recommendation is made: Recommendation 5 CSCP to identify opportunities within the current system to provide multi-agency support to carers in the local area (informed by initiatives in other areas) and for this scaffold of care to be detailed in a child’s care plan and reviewed in Child Looked After reviews and multi-agency planning meetings. Transition & discharge planning Transition: The multiple placements and practitioners involved in Chloe’s life meant that there were multiple points of transition. For Chloe this meant there were frequent endings and frequent beginnings. Children’s experiences of ordinary transitional points is widely researched and the need to pay attention to a child’s response, and provide careful management by an adult, is recognised. Chloe’s experience of transition was extra-ordinary, the inherent loss, confusion, fear, and rejection in so many of these transition points was stark. Transitions between services and across geographical boundaries must always be considered from the point of view of the young person 35. Conclusion: These transition points would have been overwhelming for Chloe and for the practitioners involved. There did not seem to be space within the system to pay attention to the impact of these multiple transitions on Chloe’s wellbeing. It is simply unreasonable and trite to suggest that more training is needed or more policies are required – these things will not make any difference to children. Once again, Chloe’s experiences are a reflection of a national picture that requires fundamental changes to be made to a system that is broken. The question that arises is what can be done in the meantime; children cannot wait for the national changes that are needed. A number of themes discussed in this review may assist in reducing transitions although the central issue about use of secure accommodation, and the limitations of viable placement options, are fundamental issues that are beyond the power of CSCP to resolve. However, it may be fruitful to consider how ‘false’ transition points within services could be avoided. An example of this is provided in the later section about how CAMHS are commissioned, and CSC have commented on the number of Social Workers involved and how consistency might be better achieved: Chloe had 9 Social Workers – some of whom she clearly trusted and felt a strong connection with – sadly, each of these relationships ended. Research suggests that having a long-term relationship with a trusted Social Worker is of critical importance to children who are looked after away from home. 35 CAMHS agency report 25 CSCP CSPR Chloe The Social Worker workforce is highly transient, as a result it is not possible to guarantee a long-term Social Worker. However, as identified by the CSC report author, there are examples of service structures that follow the journey of a child thereby avoiding ‘false’ transition points (that lead to a change of Social Worker). There are examples of this kind of structure across the country, Camden CSCs was provided as an example. The action required to remedy these issues require fundamental systemic changes including changes in commissioning and organisational structures. Recommendation 6 Multi–agency partners to consider how false transition points within agencies (including the private and voluntary sector) might be reduced to maximise the opportunities for practitioners to build consistent relationships with children. CSCP to maintain overview and provide support and challenge. Discharge planning Importantly we must remember that any secure intervention must be purposeful and prepare a child for returning to a home, whilst the trusted adults around that child are using the time to ensure appropriate support in the community. Secure settings must not be seen as a place to merely ‘contain’ a child 36. On occasions plans were made for Chloe’s discharge from a service (such as from the Psychiatric Intensive Care Unit - PICU) and although her discharge from secure accommodation involved planning meetings, it is unclear how these meetings supported Chloe in real terms once she was in the community. This was particularly apparent when she moved from the 1st secure placement. During the Child Looked After review that took place just before she moved back into the community, the following was noted by the IRO: Her demeanour and presentation is entirely different – she presents as happy and relaxed for today's review; she has made considerable progress emotionally socially and educationally whilst in the Secure Unit. However, once in the community, it was apparent that very little was in place to meet Chloe’s emotional, educational, social and mental health needs. As a result, the progress Chloe had made was reversed and this glimpse of Chloe faded. It is fully accepted across the multi-agency workforce that discharge planning meetings are critical to enable smooth transition and after care. There are several CSPRs that identify how the decisions made at discharge planning meetings have not translated into the care provided in the community. The CSC report identifies the problems associated with the variable responses across the agencies in terms of holding responsibility for children who are placed out of area in a secure unit: When young people are placed in secure units local agencies should all retain responsibility and plan ‘safe’ discharge 37. This is relevant for all agencies and services, including services provided by the private and voluntary sector and (as highlighted in the next section) is particularly relevant to CAMHS: ……the originating CAMHS and/or the CAMH service covering the area where the young people will be discharged needs to be involved in the planning arrangements for mental health care at the earliest opportunity, ideally at the point of the young person accessing secure accommodation 38. 36 The Case for Change: The independent review of children’s social care. June 2021 DfE 37 Children’s Social Care CSPR agency report 38 CAMHS CSPR agency report 26 CSCP CSPR Chloe Conclusion: Planning for a child’s discharge from secure accommodation must start at the point they are admitted, this planning should include the full multi-agency group that are involved with the child prior to their admission. There are specific planning mechanisms in place when a child is in secure accommodation which are additional to Child Looked After reviews. The discharge meetings that took place did not translate well across the Child Looked After reviews. The reason for this may lie, in part, with the timing of these (which are required to take place at set intervals and may be out of sync with discharge planning meetings). Although it seems reasonable to suggest that there should be sufficient flexibility within the system to better synchronise planning meetings and for Child Looked After reviews to address discharge planning at the earliest possible point. Recommendation 7: Multi-agency services to review how changes in the current system can be achieved to provide consistent intervention and oversight of children placed in secure accommodation, and robust discharge planning at the point of admission. CSCP to maintain oversight and provide support and challenge. The mental health needs of looked after children. A consistent finding in repeated surveys has found that Children Looked After are more likely to have psychological difficulties of such severity that warrant mental health services (Tarren- Sweeney, 2008) and have higher incidents of learning & language difficulties and poorer physical health (Crawford, 2006). Studies using standard caregiver reporting scales e.g. CBCL, SDQ and Rutter Scales have consistently found that the mental health difficulties of Children Looked After is in a similar range to children referred to mental health services39. Children in residential care are identified as having greater need than children in foster families40. It is appreciated that Children Looked After present with a more complex constellation of social, emotional, developmental, and mental health needs but there is a need to consider the type of service provision required to ensure a sufficient and effective response to the needs of this vulnerable, at risk, disadvantaged population. 39 Armsden, G., Pecora, P.J., Payne, V.H., & Szatkiewicz, J.P. (2000). Children placed in long-term foster care: An intake profile using the child behaviour checklist/4-18. Journal of Emotional & Behavioural Disorders. Cappelletty, G., Brown, M., & Shumate, S. (2005). Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a sample of children in foster placement. Child and Adolescent Social Work Journal, Crawford, M. (2006). Health of children in out-of-home care: can we do better? Journal of Paediatric & Child Health. Tarren- Sweeney, M., & Hazell, P. (2006). The mental health of children in foster and kinship care in New South Wales, Australia. Journal of Paediatrics & Child Health. Tarren- Sweeney, M. (2008). The mental health of children in out-of-home care. Current Opinion in Psychiatry, 21:345-349. Burnes, B.J., Phillips, S., Wagner, H., Barth, R.P., Kolko, D., Campbell, Y., et al., (2004). Mental health need and access to mental health services by youths involved with child welfare: A national survey. Journal of American Academy of Child & Adolescent Psychiatry, 43(8): 960-970. 40 Hukkanen, R., Sourander, A., Bergroth, L., & Piha, J. (1999). Psychosocial factors and the adequacy of services for children in children’s homes. European Child and Adolescent Psychiatry, 8: 268-275. 27 CSCP CSPR Chloe i. Meeting Chloe’s therapeutic needs We have repeatedly heard from parents, carers and care experienced adults that there should be an assumption made that therapy should be provided to any child in care, and not something which needs to be argued or pleaded for. This does not necessarily mean that every child and family will require CAMHS clinical support, but it does mean we should be exploring who is best placed around the child to provide consistent therapeutic support. Lack of mental health support, a lack of understanding of attachment and trauma and the impact this can have on children in care and care leavers is too high a price to pay for us as a society. We see the human cost of not properly supporting children and families in the increasing need for acute services and homes 41. As discussed earlier in this report, Chloe had little therapeutic intervention throughout her life. The therapy that was provided in the community was provided either by the residential establishments or was commissioned through the private/voluntary sector. This was inconsistent and the evidence base underpinning the therapy provided, and outcomes, were unclear. Chloe received therapeutic support at the secure units although again, this was inconsistent, and the evidence base and outcomes were unclear. During Chloe’s first stay in secure accommodation, there was one notable exception to this. The following was noted by the IRO: Being placed in secure accommodation has afforded Chloe the time and space to reflect and process her life to date. She has demonstrated ability of self-analysis and is displaying emotional intelligence. A much softer, vulnerable side has emerged. At times, Chloe has broken down and cried, needing hugs and reassurance that she will be supported in overcoming past, negative experiences. On occasions, Chloe was described as not wanting therapy or of being ambivalent about therapy. However, it was clear that she did engage with therapy when it was offered and at various times she asked for a referral to be made to CAMHS. Whilst Chloe’s need for therapy was an enduring part of her care plan, it is clear that there was little understanding within CSC about what kind of therapy Chloe needed. Given that ambivalence towards accepting help is common for young people who have experienced severe trauma and disruption in their life, the multi-agency plan should include specification of available advice and guidance for foster carers and/or residential carers and other relevant adults in the young person’s life. This should focus on how to support ongoing conversation about the dilemmas of accepting help for mental health needs as well as access to crisis care, as needed. The development of a multi-agency care plan should be supported through regular opportunities for professionals to meet and review, the identification of a lead agency (if not Children Social Care) and the inclusion of all relevant agencies working with the young person 42. Conclusion: Important factors that inhibited the provision of ‘therapy’ was the fast-paced nature of Chloe’s movements and constant moves across geographic boundaries which required multiple referrals and re-referrals to be made. This was combined with delays in the referrals made to CAMHS, and the variable urgency applied to the referrals by local CAMHS across the country. Of greatest importance seems to be the local commissioning arrangements for the provision of CAMHS to Children Looked After. Other issues underpinning this theme include the gap between community (Tier 3) and inpatient (Tier 4) CAMHS provision, the limited understanding about the acute vulnerabilities of children in care, the possible implications of a lack of diagnosis and the absence of multi-agency ownership and joint planning. These issues are discussed below. 41 The Case for Change: The independent review of children’s social care. June 2021 DfE 42 CAMHS CSPR agency report 28 CSCP CSPR Chloe ii. Responding to the mental health needs of Children Looked After Service boundaries that are threshold led, rather than needs led, often result in multiple people working with a child and frequent changes of worker, a different approach is needed that places the needs of the child as central to the decision making 43. The lack of CAMHS provision for children who are looked after was said to be a perennial issue. There was a sense of fatigue felt by practitioners that nothing will change: It’s an age-old exhausting cycle. It was clear that this had significant implications for how a child, like Chloe could be supported with her mental health needs/emotional wellbeing. It was equally clear that this issue can lead to frustration and exasperation about the lack of provision. This has the potential to cause splits in the safeguarding workforce and a despondency that no matter how many referrals to CAMHS are made, a child will not get the help they need. However, it was equally clear that within the local CAMHS there is a strong desire for this status quo to be different. Transitions between services and across geographical boundaries must always be considered from the point of view of the young person. At times this will require flexibility with regard to service provision: for example keeping an episode of care open after a young person has moved out of area and until they have engaged with local services, agreeing arrangements for joint working, ensuring contact with young people who are inpatients etc. The accommodation of more flexible working models requires clarity of commissioning arrangement and between different providers44. Conclusion: As discussed, Children Looked After have complex mental health needs by the sheer nature of being removed from their families of origin and living in the care of the state. It is not unusual for children to be placed out of borough and, for children like Chloe, it is not unusual for there to be frequent placement moves across geographic boundaries. Chloe, and others like her, need to be supported by a mental health service that hold them in mind and assists the network to provide a prompt and a consistent approach to meet their needs. The current commissioning arrangements in Croydon CAMHS does not allow this to happen, the result is a cycle of referral, re-referral and delay with no oversight. The result for Chloe was that her mental health needs were not understood or met, her internal journey was not held in mind and the network were adrift. The agency reports to this review clearly evidence that this is a systemic issue that has implications for a large group of children. It is of such importance that it was the most consistent and most highly rated learning identified in the agency reports and by practitioners. ICB’s should consider commissioning a Child Looked After CAMHS team to follow children across local boroughs and enable an element of consistency of care45. Having a lead clinician involvement in formulating and co-ordinating mental health support, even if trauma related, would have greatly benefitted Chloe- CAMHS local to the child’s local authority should lead on this provision46 . 43 Croydon Safeguarding Children Board Vulnerable Adolescents Thematic Review 2019 44 CAMHS CSPR agency report 45 Southwest London & St Georges MH NHS Trust 46 Croydon Children’s Social Care 29 CSCP CSPR Chloe More robust arrangements need to be in place to address the mental health needs of Children Looked After placed out of Borough, with clarification of the role of the Child and Adolescent Mental Health Service in the Local Authority looking after the child/young person (the originating CAMHS). The provision of day-to-day mental health care from the originating CAMHS would be difficult and arguably unsafe in cases where risk is a significant factor; therefore, this arrangement would best work on a consultation only basis. Nonetheless, for young people frequently moving across geographical boundaries, it would be highly desirable to retain this indirect connection with the originating CAMHS, with the aim of supporting access and engagement with local services, clarifying thresholds across different provisions as well as identifying and avoiding gaps. If adequately resourced and appropriately staffed, this resource would undoubtedly add value to the professional network of care supporting the young person and minimize the impact of frequent changes to the access and quality of services received by the young person47. Recommendation 8 CSCP to strongly request that the local Integrated Care Board (ICB) take steps to commission a ringfenced CAMHS team for Children Looked After which provides a flexible approach to meeting the needs of looked after children in the local area and across borough boundaries. iii. Service Gaps The many gaps in resources and infrastructure, and the part this plays in the life experiences of Children Looked After, have been discussed. The variable provision sitting between community (Tier 3) and inpatient (Tier 4) CAMHS is another example. Children who have mental health needs that sit between these tiers require an outreach home based service and at the end of Chloe’s life she was provided with support from a team that provided intensive outreach support, this was an excellent example of how a child with significant mental health needs can supported in the community. However, the variable provision across the country means that this kind of service is not always available, and it is a tragedy that this service was only available shortly before Chloe died. The variable commissioning of these services is a national issue: Community-based services as an alternative to inpatient admission or as an adjunct to discharge planning following admission for young people presenting with significant risk behaviours also vary in their availability, access thresholds and levels of provision across different areas48. The result is a post code lottery, and this is particularly important for children who are looked after and are living across the country. Recommendation 9 On behalf of looked after children living across the UK, CSCP to make representation to NHS England about this variable provision and ascertain how this might be addressed. iv. Thresholds & the possible value of diagnosis As described by a renowned trauma expert 49: there is no other diagnostic entity that describes the pervasive effects of trauma on child development, these children are given a range of comorbid symptoms as if they occurred independently from the PTSD symptoms. 47 SLAM: South London & Maudsley NHS Foundation Trust – local CAMHS 48 Local CAMHS agency report 49 Bessel A. van der Kolk, MD 30 CSCP CSPR Chloe Chloe was known to self-harm, and she had various tentative diagnoses. The most consistent diagnosis was depression, for which she was prescribed medication. She was also variably diagnosed with possible conduct disorder, bi-polar affective disorder, affective instability, drug induced psychosis and emotionally unstable personality disorder50. Apart from depression, these diagnoses did not appear to be known to CSC - they were not recorded within the care plan or within Child Looked After reviews. As stated in the CSC agency report to this review: Chloe did not have a specific diagnosis. In part, this is correct, Chloe did not have a formal mental health diagnosis. Chloe’s background was of multiple traumatic experiences from the age of 2. She suffered from depression, had extremely low self-worth, exhibited emotional dysregulation, had aggressive and violent outbursts, self-harmed (cutting but also extensive drug and alcohol misuse) was known to tie ligatures, to precariously run-in front of traffic, she attempted to jump from a window and at various times she expressed a wish to die. She told police officers and her drugs worker that she was suffering from Post-Traumatic Stress Disorder – this appeared to be a self-diagnosis. Chloe was regarded by mental health clinicians as having psycho-social needs – with an emphasis on social rather than psychological. This meant she was not regarded as having a diagnosable mental health condition and this was universally accepted by clinicians and seemed to have an impact on whether her needs met a threshold for intervention, and the speed at which referrals were responded to. It is argued that diagnoses per se are not as important as the formulation and the approach that is enacted and of critical importance is the meaning the diagnosis has for a child/young person. For Chloe, the diagnosis of PTSD made sense to her. It is accepted that a formulation and an approach, rather than a diagnosis, is the key to providing children with the support they need. However the question that arises for Chloe is what difference it would have made if a diagnosis had been made? The view of practitioners in CSC is that approaches can be lost over time and for children who are looked after within an infallible system; where knowledge and memories about a child are fragmented and lost, their care is chaotic and crisis management holds sway. It was also their view that current thresholds within CAMHS services means that if a child does not have a formal diagnosis – they do not meet a threshold for provision. This was challenged by some CAMHS clinicians saying that a child does not have to have a diagnosis in order for treatment to be provided. Senior managers in CSC strongly disagreed pointing to numerous examples of children living across the country who are not in receipt of CAMHS treatment because they do not have a formal diagnosis. There is wider evidence that supports this view. Conclusion: It is clear that with all the best possible intentions, underpinned by research and evidence-based practice, that children should not be unnecessarily labelled/given a diagnosis. However it is a harsh reality that for children such as Chloe, formulations and approaches are easily lost. It is beyond the role, remit and scope of this CSPR to enter the ethical debate about the helpfulness, or not, of diagnoses. What seems of utmost importance is the need for commissioning arrangements to change to enable local CAMHS to provide a service to children in Chloe’s circumstances. This would go a long way to resolve this issue and potentially render this issue about diagnosis redundant. However, as previously highlighted, there is a need to provide a response to children in real time. By the very nature of being in state care, all Looked After Children have experienced complex trauma - this should be consistently acknowledged and responded to. 50 Emotionally Unstable Personality Disorder is also known as Borderline Personality Disorder 31 CSCP CSPR Chloe Recommendation 10 A child’s mental health needs should be prioritised in all planning meetings and care plans and should include an accurate recording of these needs and an informed approach to meet these needs. CSCP to maintain an overview of implementation and provide support and challenge. v. Drugs, alcohol and mental health Chloe told her drugs worker that she started to smoke cigarettes and cannabis when she was 11 years old and drank alcohol from the age of 12. She said that by the age of 14 she was smoking 1-5 spliffs a day and although said she wanted to cut down she felt unable to do so. Chloe said that cannabis chilled her out and was a coping strategy when she was stressed. She spoke of taking spice, lean and cocaine at various points in her life and said she started taking MDMA (ecstasy) regularly when she was 16. Chloe did not hide her use and spoke freely about her intake; therefore, her misuse of drugs and alcohol was well known. Referrals were made to local drug and alcohol services, services were provided/offered and there was communication between these services and other agencies. It is unclear what was provided to Chloe when she was not in Croydon, and it seems that nothing improved her misuse of drugs and alcohol 51. Panel members and practitioners have asked: What was the meaning of drugs in Chloe’s life? There is no indication that this was thought about in depth and there seemed little in place to facilitate agencies coming together to think about this, and to plan for how Chloe’s drug use might be addressed. As a result, the effect of these drugs on her short- and long-term mental health and on all aspects of her social and emotional functioning and wellbeing was unclear. Panel members and practitioners spoke about how the separate commissioning arrangements has led to tenuous links between mental health services and drugs and alcohol services. They raised concerns about the lack of integrated work which seems to impact on a number of levels including, at minimum, a lack of shared IT systems. The CAMHS agency report makes the following recommendation: The access to and provision of advice and support regarding alcohol and drug use for Croydon Children Looked After, placed out of Borough should be reviewed in light of the known negative impact on mental health presentations and alongside risk, for example, of sexual and criminal exploitation. Recommendation 11 CSCP to ascertain how improved integrated work between drug and alcohol services and mental health services will be achieved and how the recommendation made above will be taken forward. The risk of suicide The endpoint of chronically experiencing catastrophic states of relational trauma in early life is a progressive impairment of the ability to adjust, take defensive action, or act on one’s own behalf, and a blocking of the capacity to register affect and pain, all critical to survival52. 51 Drug use was a significant precipitating factor in her presentation prior to both of her admissions to the psychiatric intensive care unit when she it was concluded she was experiencing a drug induced psychosis. 52 Relational trauma and the developing right brain: the neurobiology of broken attachment bonds. In T. Brandon (Ed.), Relational trauma in Infancy. Shore, A. London: Routledge. 2010 32 CSCP CSPR Chloe Chloe experienced multiple traumas, she was depressed and self-harmed from the age of 9 years. There were frequent references to Chloe using sharp objects such as a knife to cut her forearms. At the end of her life it was described that: there were no areas on her fore arms that were not scarred. Chloe took a range of drugs over many years; she was often the victim of sexual exploitation and frequently in situations of high risk when she was repeatedly harmed. There are references to Chloe tying ligatures, being restrained from running in front of traffic and prevented from jumping out of a window. Chloe was unable to protect herself, her care givers and other adults/professionals/practitioners could not keep her safe but there appeared little attention to the risk that Chloe would take her own life. When speaking to practitioners, many spoke about their shock at hearing that Chloe had taken her own life and said that although they feared she may die by other means, they never considered she was at risk of suicide. The Adolescent Resource Team were an exception to this, and safety planning took place. However, it was clear that the risk of suicide was not universally understood or factored into the care and safety planning that took place within CSC or across the network. Given Chloe’s history, the question that arises is why not? When considering this question it is easy to fall into the alluring trap of hindsight bias and it is important to hold in mind contemporary research 53; that there are limits to the interventions provided to people intent on taking their own lives, people have ultimate autonomy including a freedom to occasion their own death if they are really committed to do so. That said, there has been considerable attention paid to the prevention of suicide by government54 and public services. Guidance suggests there should be ‘zero – tolerance’55 to any suggestion that little can be done to prevent someone taking their own lives. It is recognised that prevention remains difficult so many times people will say that it was a complete surprise when someone they knew died by suicide and that: Suicide is often the end point of a complex history of risk factors and distressing events; the prevention of suicide has to address this complexity 56. Recommendation 12: The CSCP should promote the briefing by the NSPCC on findings from young people who complete suicide, in particular the advice that suicide threats should be routinely assessed for motivation and level of intent. Conclusion: When considering the question of prevention it seems of greatest importance to children that the inherent limitations in the system, identified across the entire range of findings in this CSPR, need to be addressed. However, as said before, children cannot wait for these changes to happen. The following section suggests some practical ways in which children might be helped in real time. Working together The teenagers in these case reviews had long-standing and complex problems and received a wide range of support from different agencies. If services work in silos, this can mean that there is no overall picture of the young person’s situation and no overarching plan about how to support them in the best way57. 53 Why People Die By Suicide. T. Joiner 2007. 54 Preventing suicide in England A cross-government outcomes strategy to save lives. Department of Health 2012 Cross-Government Suicide Prevention Workplan HMG 2019 55 Zero Suicide Policy NHS England 2015 56 Dr David Fearnley Associate National Clinical Director for Secure Mental Health at NHS England 57 Teenagers: learning from case reviews briefing. NSPCC Feb 2021 33 CSCP CSPR Chloe i. Across the multi-agency network Professionals and parents trying to safeguard teenagers facing harm outside of the home, are being faced by a system that was not designed for the task58. There were several occasions when meetings took place within the network involving different services and professionals. Some of these were professional meetings (when a meeting was called to discuss a specific issue), others were more formal meetings such as Looked After Reviews/ meetings held in secure accommodation and Care Programme Approach (CPA) meetings held at the end of Chloe’s life. So whilst interagency communication took place, there was incomplete and inaccurate information held across agencies and there was little sense of a shared knowledge and understanding about Chloe, or a shared ownership of her needs and plans. This compromised care and safety plans and decisions about risk. A failure to grasp the complexity of these cases where children are open to numerous services, are both victims and perpetrators, and face harm from different and harder to manage sources has led to ineffective and confused responses and lack of accountability. Different parts of children’s social care, justice and health systems are responding differently to the same teenagers. This leads to confusion, gaps and ultimately the worst outcomes for these children59. All CSPR agency reports identified the limitations of multi-agency work and the pressing need for this to be resolved: For young people with the high level of need and complexity experienced by Chloe, it is crucial that a multi-agency care plan is in place and that it includes consideration of mental health needs and emotional wellbeing, alongside risk and safety planning. The system is complicated, bureaucratic and risk averse60 Practitioners identified these issues as critical shortcomings in the system. The lack of multi-agency ownership and responsibility for risk sensible decision making at a senior level was highlighted. Practitioners were challenged about this and were reminded that Chloe’s case was discussed at 2 senior multi-agency panels. The response from practitioners who knew Chloe well was that they were not aware of this, and it seemed to make no difference to how risk was held within the organisations and across the hierarchies or to risk mitigation. The review of children’s social care interim report describes a disjointed national picture which translates into a similarly complicated picture locally where multi-agency boards and meetings dominate. As pointed out in this report: each service has its own footprint, objectives, accountability arrangements and inspectorates, which in turn leads to a system that is confusing and difficult to navigate for professionals let alone children and families. It describes these siloed approaches as creating a bureaucratic labyrinth. 58 The Case for Change: The independent review of children’s social care. June 2021 DfE 59 The Case for Change: The independent review of children’s social care. June 2021 DfE 60 The Case for Change: The independent review of children’s social care. June 2021 DfE 34 CSCP CSPR Chloe It is important to highlight an important exception to what was said to be senior management avoidance of risk sensible decision making. This relates to the period of time Chloe was in semi-independent accommodation. At this time, the risks faced by Chloe were high; on many occasions she assaulted staff, destroyed property, and her mental health was of significant concern. There was a view that she should be placed in secure accommodation, but it was concluded that another period of confinement would do little to mitigate risks in the medium - long term. Instead, enabling Chloe to have as much autonomy and freedom as possible to enjoy and achieve in the community, whilst attempting to mitigate risk, was felt to be in her best interests. It is commendable that every effort was made to achieve this - this required risk to be held at a senior level within CSC and this was done. It is unclear how the senior manager was supported in taking this sensible position and it would be of interest to know how far inspectorates (such as Ofsted) would support this kind of sensible and realistic approach to deal with the inherent limitations of the system. Conclusion: Once again, the issues identified in the review of children’s services mirrors Chloe’s experiences and mirrors the experience of multi-agency practitioners. In terms of addressing these issues in real time, the most consistent request from multi-agency practitioners was to have the opportunity to come together as a multi-agency team, to pause and reflect and think together. It was suggested that the advantages realised during the pandemic of using virtual platforms should be built upon. It was strongly argued that unless this is set out as an absolute requirement it simply would not happen as, once again, the urgent drives out the important and performance indicators and bureaucratic tasks are prized higher in the organisations within which they work. It could be argued that Child Looked After Reviews provide a statutory forum for multi-agency meetings. However, whilst some changes in Child Looked after Reviews are needed (these are discussed in the next section) they are not the forum that would enable this kind of multi-agency reflection and decision making. Examples 61 of these kind of multi-agency forums were discussed by panel; these examples of best practice should be used to inform future developments in Croydon. Recommendation 13 CSCP to set as a requirement of all partner agencies that children with complex needs are the subject of regular multi-agency group discussion and planning. This requirement should feature in multi-agency policies and procedures and a suitable approach should be set up and embedded with support provided by CSCP. ii. Working together as corporate parents within Children’s Services As this report draws to an end, it is important to return to a central issue of how CSC can be supported to fulfil their responsibilities as corporate parents. Chloe’s experiences reveal how the system we call ‘corporate parenting’ is made up of multiple practitioners, teams, systems and processes across Children’s Social Care. It is clear that moving beyond this to a system of care that achieves what children need simply cannot happen without the care of children being shared across the multi-agency network. That said, there are some aspects of work within CSC that require attention. 61 Such as: London Borough of Merton CAMHS in Social Care Team. Community in Practice: Reflective Space 35 CSCP CSPR Chloe Despite all the good intentions of practitioners within CSC, there was a strong sense that responsibility was left in the hands of front-line social workers. The absence of ownership of risks at a senior level and the lack of a multi-agency approach would have been contributory factors but it also seemed that the wider CSC workforce did not share equal ownership. It is clear that a lack of resources plays a key part but there was also a sense that teams/services, who had an important role to play, stepped back. In part this was about a lack of investment in building capacity but there was also a sense that the front-line social work team did not see or trust the wider system to support them in their work. Of particular note was the work of the Independent Reviewing Service/IROs. iii. The importance of IROs in a child’s life IROs hold a central position of responsibility, and it was clear that a number of Chloe’s IROs had a significant place in her life – and held a composite memory of Chloe across the multiple changes of Social Workers and placements. Whilst it was apparent that they attended several important meetings in-between Child Looked After reviews, when they advocated for her needs, it was also clear that several recommendations made in reviews were repeatedly left unaddressed from one review to the next. It is understood that there have been significant improvements in the relationship between IROs and Child Looked After Teams with an improvement in the speed at which recommendations are completed, these changes are a welcomed development. However, in learning from Chloe’s experiences there are additional areas that require attention which include the need to: • Promote a greater appreciation of the relationship that can exist between a child and an IRO within CSC. • Consider the meaning they may hold for a child as a trusted adult and how this might be enacted in a child’s life. • Continue to pay attention to how IROs/Child Looked After reviews can move further away from process checking to achieve more nuanced consideration of the important issues in a child’s life. • Consider how the mental health needs of children can be better reflected in Child Looked After reviews and how the outcomes of intervention are evaluated and recorded. • Promote an understanding across multi-agency partners about the role of IROs and the position they occupy in children’s lives. • Consider how Child Looked After reviews can be better aligned with other planning forums/processes. • Routinely review safety planning as part of Child Looked After reviews Author: Bridget Griffin – Independent Reviewer Post Inquest Amendments: Donna Świrski – CSCP Business Manager 36 CSCP CSPR Chloe Conclusion Chloe’s story is a tragic picture of a child in the care of the state who suffered early trauma, who was repeatedly exploited and traumatised, who had no adult she could consistently rely on, whose sense of self was fragmented, who did not belong and had no place to call home. The resilience of the workforce, in providing compassionate care in a system that at every turn has few good options, is a testament to the skill, courage and bravery of the workforce. Whilst the inquest found (and indeed agencies admitted) some factors which contributed to her death, these were reflective of the challenges of working in a system stretched thin, and on the whole are factors visible with the benefit of hindsight. No prevention of future deaths report was issued. Notwithstanding the above, learning with the intention of changing practice has occurred and will be continued. This CSPR has made a number of recommendations however, the changes that are needed are beyond the gift of multi-agency practitioners and beyond the gift of the CSCP. National wholescale change is needed. Without this, it is an immutable tragedy that Chloe’s life story is currently the lived experience of other children, and these lived experiences will be mirrored across the country for some time to come. 37 CSCP CSPR Chloe ‘Chloe’ - Post Inquest Addendum (v5) Chloe was a 17-year-old Child Looked After who took her own life when in a state of mental crisis. She was subject to a Care Order and was living in semi-independent accommodation in another London Borough. She was open to the Croydon Looked After & Care Leavers Team. As the CSPR and recommendations were concluded long before the inquest finished (and we were in a position to publish), the following addendum gives some clarity about the action taken to progress the recommendations, between the original review being completed and the publication date. No. Key - Complete, In Progress, Outstanding No. Recommendation Status / Evidence of completion 1 Multi- agency partners to consider how identity will be promoted within the current system by using existing processes (such as care plans, Children Looked After (CLA) reviews, Personal Education Plans (PEPs, CLA health assessments and Pathway Plans (PPs) and other multi-agency processes/points of contact with a child. IROs to lead on scoping opportunities within the child’s network for building a positive identity. CSCP to maintain on overview of progress and provide support and challenge. Pilot training event for practitioners, in collaboration LBSC, took place in February with a focus on self-harm/suicide/LGBTQ2+ (unique training content) This training was positively received and has led to more sessions being planned for 2023/24. Successful funding applications will develop the training model so it will become a sustainable social enterprise business product, with the aim to roll out to other local authorities. The CSCP has commissioned an online training program 'Trauma Informed Approach' to support practitioners' awareness and influence how they respond to young people who have experienced trauma. Team Managers within the Children Looked After Service have received 15 days training on systemic practice and now deliver systemic group supervision periodically with social workers. Within any group supervision a young persons' identity is a central theme. Considering their GRACES (Geography, Race, Age, Culture, Ethnicity, Sexuality etc) and people who are important to them are identified using a cultural genogram. There has also been training provided on direct work tools that help young people to establish their identity, such as the 'Tree of Life' that helps young people reflect on where they have come from and develop positive narrative about their foundations. For continuity and oversight of health needs, Croydon Child Looked After (CLA) health team now allocate a specific nurse to each CLA including those placed out of area. Part of the health assessment focuses on identity and offers referral pathways to relevant agencies. 2 CSCP to review what progress has been made following the recommendation made in the Vulnerable Adolescent Thematic Review, (VAR60) with a particular focus on identifying evidence to demonstrate how trauma - informed practices are being enacted in services provided to children (including commissioned services/homes) and how trauma - informed organisational approaches are supporting the multi-agency workforce. • Training event took place in Sept-2022: Young People at harm of suicide. • Oct 2022 Exec reviewed the VA60 Recommendations • '7-minute briefings' about the learning have been disseminated across the partnership. • CSCP have commissioned from the local substance misuse provider to provide Substance Misuse Awareness, Harm Reduction Training as well as a discussion of their safeguarding procedures and how they work in partnership with agencies regarding Safeguarding. • Staff the in children in care service have received a 2-day training course on 'narrative approaches to why am I in care'. The course 38 CSCP CSPR Chloe is delivered by a care experienced and well-respected trainer who provides social workers with the tools to help young people explore their history and why they are in care. • There has also been training for staff and managers on trauma informed practice and writing. This is about understanding the impact of trauma on the developing brain and on behaviour. Case summaries are being written in the first person and visits are now being written directly to young people, promoting a child-centred approach to case recording as part of a broader cultural shift to a more trauma informed culture within the practice system. This programme is ongoing. • The virtual school has commissioned training on suicide and self-harm, supporting practitioners to understand the relationship between suicide and self-harm and how to develop safety plans with young people experiencing suicidal thoughts. • Since the training a number of social workers have gone forward to use safety planning their work with young people and networks with greater confidence. 3 CSCP to be guided by the national reviews and embed relevant learning in the future service provision of mental health and wellbeing services for survivors of CSA. This should include the services provided by the voluntary sector and commissioned services that are provided to Children Looked After who are living out of area. • Croydon has signup for CSA (Centre of expertise for Sexual Abuse) training with the CSA Centre, accessible via Croydon Learning. • CSCP supported the coordination of CSA training that took place in March 2023. • VAWG strategy being written by FJC, scope of this piece of work was shared at the January (2023) LIG meeting. • The CSCP established a Priority Group looking at mental health because of this and other SPRs. Commissioners are involved and we have influenced the Public Health Schools Survey to understand the cohort who do not access support for mental health issues as well as supporting the next Joint Strategic Needs Assessment for mental health provision. • At a London level the CSCP has asked its counterparts to share learning involving children who have taken their own lives. Redacted facts about this case will be part of a case study as well as other learning and resources on reducing self-harm and suicide. 4 The therapeutic work a child needs should be detailed in a child’s care plan. Child Looked After Reviews to monitor what therapy is being provided, evaluate outcomes, and determine what future services are needed. Criminal compensation should be pursued for all children who have been the victim of sexual abuse – Looked After Reviews to maintain oversight. • The social work teams are aware of this requirement and have a system that managers through supervision or the IROs should ensure it is applied for. • There is a renewed focus on ensuring that therapeutic goals are identified in young people's care plans. At the point of commissioning a therapeutic resource, there is an agreement about the how therapeutic goals will be reviewed and what level of reporting will be provided by the therapist. • Children receive therapeutic support through schools and the goals are named within their personal education plan (PEP) which are then assumed into their wider care plan. • There are currently two dedicated psychotherapists within the Children Looked After Service who support staff 5 CSCP to identify opportunities within the current system to provide multi-agency support to carers in the local area (informed by • CSCP L&D attended a Foster Service business meeting to discuss risk assessments this is included a Q&A session to discuss the training that is on offer to support their practice. 39 CSCP CSPR Chloe initiatives in other areas) and for this scaffold of care to be detailed in a child’s care plan and reviewed in LAR’s and multi-agency planning meetings. • The development of the local authority permanence strategy includes review of the data around stability of placement for children in care and consideration of the support provided to carers, to promote the stability of young people’s placements as a key aspect of their permanence. 6 Multi-agency partners to consider how false transition points within agencies (including the private and voluntary sector) might be reduced to maximise the opportunities for practitioners to build consistent relationships with children. CSCP to maintain overview and provide support and challenge. • The Croydon Adult Safeguarding Board (CSAB) and CSCP are due to carry out a joint activity to audit and review transition. This has also been discussed in learning and Practitioners have shared best practice. • A working group has held two meetings to discuss the transition of children to adult services. They have agreed on points of transition, role clarity and responsibility, referral points, and a pathway for facilitating helpful transitions. The pathway will be presented to the Croydon Senior Leadership Team for approval and establishment within the governance process. This process supports young people with complex physical and learning needs. • Future work will focus on developing a shared pathway for referral to adult mental health services. This pathway will be agreed upon by both organisations' governance structures and implemented jointly to ensure smoother transitions for young people experiencing mental health crises. • There is now a recently formed adolescent team within the Children Looked After Service, comprised of support workers who are capable of providing direct assistance to vulnerable teenagers. • Two care experienced adults (CEA) nurse specialist have recently commenced and are co-located with 16 plus local Authority team. They will provide CEA in the borough with a universal and targeted health offer, to ensure there are no sudden gaps in services for young people leaving care once they turn 18 years of age. 7 Multi-agency services to review how changes in the current system can be achieved to provide consistent intervention and oversight of children placed in secure accommodation, and robust discharge planning at the point of admission. CSCP to maintain oversight and provide support and challenge • When a young person is leaving a welfare secure placement, a mobility plan is agreed upon during the secure accommodation review (SAR) and the children CLA review to ensure a smooth transition. • The local authority is clear about best practice in supporting young people to exit secure and a joint risk assessment has been created that is shared between the Youth Justice Service and the child's social work team. • The Croydon Adult Safeguarding Adult Board (CSAB) and CSCP are due to carry out a joint activity to audit and review transition. 8 CSCP to strongly request that the local Integrated Care Board (ICB) and/or local commissioners, take steps to commission a ringfenced CAMHS team for Looked after Children which provides a flexible approach to meeting the needs of looked after children in the local area and across borough boundaries. • This links with National issues raised in SPR Jake. The CSCP will link with SW London and national (TASP) work to join up challenges in the system and articulate to Government. • The ICB members are prominent and proactive partners in every subgroup in the CSCP. This recommendation is aspirational and unlikely in the present climate to become a reality at this stage. This has been signed off at the CSCP Executive who include the DCS and the Chief Nurse for the ICB (Croydon Place) & CUH. • Children's Social Care has a dedicated in-house team of clinicians and dedicated staff who provide training, support practitioners, and work directly with children and their families and carers. • All permanent social workers have had access to a full 15-day training course in systemic practice that is accredited training. This training enables staff to use a range of systemic skills and 40 CSCP CSPR Chloe idea to understand and work with looked after children and their families. • There are two dedicated systemic psychotherapists who provide direct and indirect support to the children in care and care experienced young people and they are ring-fenced to the Children Looked After Service. 9 On behalf of looked after children living across the UK, CSCP to make representation to NHS England about this variable provision and ascertain how this might be addressed. • Linked to recommendation above. • This has been raised at TASP (The Association of Safeguarding Partners) to gain an understanding of the national position and use their influence to jointly approach NHS England and Government. It is recognised that there is variable provision in respect of children's mental health and a lack of secure placements, and this needs to be addressed at a national level. 10 A child’s mental health needs should be prioritised in all planning meetings and care plans and should include an accurate recording of these needs and an informed approach to meet these needs. Failure to gain relevant mental health services should be escalated. CSCP to maintain an overview of implementation and provide support and challenge. • At service level, service managers in the children looked after service and IRO service have held service meetings with front line staff considering how young peoples' emotional wellbeing can be better understood and referred to in their care plans. • An operational health and wellbeing group has been established. This consists of health champions in each service has enabled oversight of the plan to address the child's health and wellbeing. This group that reports to the clinical commissioning group and the Croydon Senior Leadership Team. • A Health Needs Assessment (HNA) was carried out by Public Health Croydon between December 2019 and February 2021. In order to improve local understanding of the health needs of children looked after in Croydon and to inform the future direction, priorities, and commissioning of the services. • In October 2021 Croydon refreshed its Health and Social Care Plan in consultation with key stakeholders. Children looked after's health has been identified as one the key priorities, under our 'Best Start to Life' outcome. • The CSCP's Multi-agency Mental Health Priority Group provided oversight and scrutiny of the single agency and multi-agency arrangements to ensure planning takes in to account a child's mental health needs. • The bi-monthly audit carried out by all managers has been developed to include a section about children looked after and specifically monitors how young people's emotional needs are being met. The findings from the audit are shared at CSLT meetings and with the CSCP. • This is also part of the CSCP audit plan for 2023/24 11 CSCP to ascertain how improved integrated work between drug and alcohol services and mental health services will be achieved and how the recommendation made above will be taken forward. • The CSCP have met with Public Health and substance misuse commissioners. The substance misuse commissioners and Public Health are working with Youth Justice Service, CAMHS and CGL (substance misuse provider) to develop an integrated pathway so that young people can have a clear pathway on how to access/move through the services. • The service will be asked to provide a Safeguarding Standards Report to the partnership in quarter 2 of 2022/23. This will provide assurance of what the provider is offering, how they are 41 CSCP CSPR Chloe meeting their safeguarding duties and what difference the service hopes to make. 12 The CSCP should promote the briefing by the NSPCC on findings from young people who complete suicide, in particular the advice that suicide threats should be routinely assessed for motivation and level of intent. • This has featured in our briefings and learning events and is a resource on the CSCP website. 13 CSCP to set as a requirement of all partner agencies that children with complex needs are the subject of regular multi-agency forums that facilitate group discussion and reflection. This requirement should feature in multi-agency policies and procedures and a suitable approach should be set up and embedded with support provided by CSCP. • CSCP have regular multi-agency learning events that are focused on themes affecting children with complex needs. Part of those meetings include group discussion and reflection. This would be an aspiration and, actively promoted as for the purpose of good practice. • As part of its continuous improvement plan the IRO service is focussing on the multi-agency contribution to CLA reviews. • The CSCP has requested audit activity to examine the quality and attendance of multi-agency professionals at Child Protection Conferences which is currently underway. • The CSCP Project Officer attended the Complex Adolescent Panel, where there was evidence of good practice relating to information sharing. • Young Croydon Service has been established and includes a multi-agency provision for young people at risk of extrafamilial harm and vulnerable adolescents. |
NC52447 | Life-threatening injuries to a 17-year-old boy. Riley was hit by a car and assaulted by the driver. Learning includes: recognise and reflect on cumulative risk, including parenting history and adverse childhood experiences; the need for active communication between agencies involved in assessing need; undertake joint assessments to ensure all needs are identified; see a child's behaviour as their way of communicating and be reflective about what the behaviour could be telling us; use language that recognises a child's behaviour as a means of communication; recognise the impacts of neglect and trauma, understanding how this can manifest in adolescence; not overloading a child with referrals/workers but considering what needs to be prioritised and who is the best person to deliver; understanding a child's needs, and being needs led rather than service led; practitioners work together to respond to multiple needs such as underlying learning needs and child protection concerns; creativity about where and how appointments take place to maximise engagement and attendance. Recommendations include: a review of children who have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs; explore the use of a communication passport which can be reviewed at key stages in a child's life, so all agencies understand the strategies needed to engage with a child with additional needs; consider the partnership's approach to adolescents receiving hospital treatment.
| Serious Case Review No: 2022/C9665 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Local Child Safeguarding Practice Review Riley (August 2022) 2 Case Synopsis Riley was 17 years old when he was hit by a car and suffered significant life-threatening injuries. After hitting Riley with the car, the driver exited the vehicle and assaulted Riley before driving away. Riley was found with a quantity of cannabis on his person and later admitted to having taken this from a cannabis farm before being followed and attacked by the perpetrator of the incident. Riley suffered a fractured eye socket and a perforated pancreas. He initially refused to engage with the necessary treatment for his injuries, however, has since made a good recovery. Longer term impact will not be known until further assessments can be undertaken. Riley is currently refusing to have these assessments. Riley is the eldest child. He has two younger half-siblings whose father is step-father to Riley. Riley’s biological father is currently in prison and Riley has no contact with him. At the time of the incident Riley was living in supported accommodation. This had been sourced by the Local Authority in the months prior to the incident following Riley being arrested and bail conditions stipulating that he could not enter his parental address; due to being involved in stealing a neighbour’s car. Riley was open to children’s social care on a child in need basis at the time of the incident, had a number of missing from home episodes and had been recently referred to MACE (Multi-Agency Child Exploitation) Hub. Rapid Review Whilst the Rapid Review into the serious incident was able to gather the facts of the case and identify potential opportunities for improvements to safeguard and promote the welfare of children, it was felt that further learning could be identified through taking a long-term perspective on Riley’s life to better understand his needs, how these were identified and responded to, and how these impacted upon the vulnerability and risk in adolescence. Review Methodology This Local Child Safeguarding Practice Review was undertaken in two parts. Part one took a long-term perspective on Riley’s life, learning needs and how agencies supported him throughout childhood. This took the form of a deep dive analysis of records and in depth look at a chronology of Riley’s full history of involvement with services; to answer specific questions set by the Rapid Review. Part two was facilitated through an appreciative enquiry approach. A focus group with frontline practitioners and a learning event with managers and strategic leads were undertaken. These events focussed upon the child’s journey, voice and perspective. They examined Riley’s lived experience through a lens of best practice, to support systemic learning and practice improvement. 3 PART ONE The Long-Term Perspective on service involvement with Riley Riley first became known to services when he was three years of age. He had suffered accidental ingestion of turps and a thermal burn to his leg from hair tongs which had been followed up by the health-visiting service. A school nurse referral was made following concern for Riley’s growth and weight loss which resulted in a referral to the paediatric team, however, Riley was not taken to the appointment by Mother. There was further involvement from services when Riley was six years of age. There was a domestic incident in which Mother’s partner set fire to Mother’s belongings in the garden and Police and the Fire Brigade attended the property. Mother’s partner was arrested but later returned to the family home. When Riley was aged 8, Mother requested help from services due to struggling with his behaviour at home and Riley expressing to his Mother that he wanted to kill himself. The family were supported via Early Help for approximately a year. Riley underwent an educational psychology assessment which showed that his cognitive age was significantly lower than his chronological age. ADHD and Autism assessments were undertaken but were unsubstantiated. He received a diagnosis of Dyspraxia and sensory processing disorder at age 9. He struggled to access mainstream curriculum and attended a specialist school part time alongside his mainstream school. He was reported to have difficulty sleeping and a low appetite. The case transferred from Early Help to the Children’s Disability Team when Riley was aged 9; this was to support Mother with direct payments. Riley spent time living with grandmother as support for Mother (approximately twice per month), supported by the direct payment. Riley was open to the Children’s Disabilities Team for seven years and closed to them approximately 8 months prior to the incident which led to this review being undertaken. A referral was made to TEWV for anger management support for Riley. Riley was taken to three of the five sessions by Mother. During one of these sessions, he expressed that he wished he was dead. There were further Domestic Abuse incidents reported between Mother and Step-Father when Riley was 10 and 11 years old. In one such incident, Mother was physically assaulted and both Mother and Step-Father had been intoxicated at the time. Due to the case already been open to the disability team, the incident was passed on to the worker who undertook a home visit during which Mother expressed that she had left her partner. School made a referral to CAMHS due to deterioration in Riley’s behaviour at school. CAMHS reported no assessed mental health need but felt that the mainstream school was not right for Riley. Riley transitioned to a specialist secondary school. Riley was re-allocated to the LD CAMHS team who undertook an initial home visit, followed by a number of ineffective visits and cancelled appointments by Mother resulting in discharge from the service. 4 School reported concerns with Riley’s behaviour and Riley received a number of fixed term exclusions. His school attendance dipped and he was spending time during school hours out in the community with friends. At age 13 he was located by Police during the school day at local shops and was found to be in possession of a knife. He worked with Youth Offending for a period of time and was reported to have engaged well. A further referral was made to CAMHS due to concerns around behaviours and suspected ADHD. An assessment was completed with Riley who expressed that he finds it hard at school due to not understanding and that he also does not ask for help. Due to no evidence of a Learning Disability, LD CAMHS allocated a Primary Mental Health Worker (PMHW) for assessment, however Mother did not engage in taking Riley to the initial assessment. At age 14, Riley’s behaviours both in and out of school escalated. He started to smoke cannabis and spend more time out with friends; with reports of anti-social behaviour. Riley was located by Police in the early hours of the morning with peers who had been reported missing by their parents. School and Riley himself reported that he was often angry and unable to control his emotions. A referral was made to Domestic Abuse Services for anger management support for Riley, however, Riley was not brought to appointments and attempts to contact Mother were unsuccessful; therefore, Riley was discharged from the service without receiving support. When Riley was 15, there was a further domestic abuse incident in which Step-Father had attacked Mother and Riley was head butted when he had tried to intervene. A strategy and Section 47 enquiries were undertaken which concluded this to be an isolated incident and Riley continued to be supported by the Disabilities Team on a Child in Need basis. Riley spent more time living with Grandmother. At the age of 16 he was arrested for assaulting his girlfriend during an argument over money for cannabis. Riley was reported to be suffering with mental health issues and suicidal thoughts. Domestic Abuse services attempted to contact Riley but telephone contacts were unsuccessful. Substance misuse services also tried to make contact with Riley but this was unsuccessful. Riley started attending college. Riley was closed to the disability team just prior to his 17th birthday. It was felt that the direct payments were no longer required. Two months following the case closure, a disclosure was made in school by Riley’s half-sister. The disclosure was in relation to a domestic abuse incident in which Step-father had assaulted Mother in front of the children and threatened to kill Riley. A strategy and Section 47 enquiries were undertaken by the Safeguarding Assessment and Support (SAS) team, resulting in Riley and his half-siblings being supported on a Child in Need basis. Riley’s behaviours escalated further. Riley began to disengage from college. He was arrested on a number of occasions (breaking into cars, threatening someone, smashing windows at home, burglary) and was rumoured to be involved in other criminal activity (setting fire to a car, hitting someone with a hammer) although this was not proved. There were numerous missing episodes and Riley was discussed at the VEMT (Vulnerable, Exploited, Missing and Trafficked) meetings due to hitting the 3 missing episodes in 90 days trigger. Youth Justice Service attempted to work with Riley; with some examples of good engagement. Riley assaulted staff at placement and he displayed an increase in anger and frustration. He was referred to MACE (new VEMT arrangements) shortly prior 5 to the serious incident but was considered not to be at risk from exploitation as there was no new intelligence or information to indicate exploitation and it was felt that his needs could be met through his robust CIN plan which was overseen by his Social Worker and his core group of practitioners. Key Questions posed by the Rapid Review 1. What were the child’s early emerging needs, how were these assessed and met? Did need change over time and were assessments and interventions responsive to this? On the face of it, the only need Riley had was support with his behaviour and the difficulty mum had in managing this behaviour. However, a review of Riley’s life journey through the combined chronology, shows a different picture. There are incidents of domestic abuse and early indicators of possible concerns re: supervision of Riley by mother (at a very early age) which were not explored. There is no evidence of a holistic assessment being undertaken to review previous history to understand lived experience. Practitioners responded to mothers request for support in relation to Riley’s behaviours without exploring further what was happening for Riley. There appears that there was no-one who knew all of Riley’s needs; as practitioners were looking at only their bit of the system. Prior to 2020 (the point when Safeguarding team got involved) practitioners across the system did not talk to each other to triangulate information. There was a cycle of referrals for assessment for Riley’s behaviour and then either non engagement by Mother or assessment findings not shared with the wider workforce. There was an additional complication of self-reporting and this becoming fact. There are records stating Riley had ADHD but then TEWV records state that he did not have ADHD or ASD and no learning disability. However, the EHC plan states that Educational Psychologist assesses cognition as low and extremely low. There is no evidence of multi-agency discussions to bring all this together to fully understand Riley’s needs. In conclusion: The information collected indicates that the child’s early emerging needs were not properly assessed and therefore not met. Assessments undertaken were single agency with limited sharing of information across agencies to understand Riley’s lived experiences. This was the position throughout Riley’s early childhood. 2. What was the child’s lived experience? How did these shape his childhood? Riley’s Lived Experience has been set out below (this has been taken from his records) 6 7 8 9 Riley’s lived experience can only be seen when all the chronologies have been combined (this indicates that combined chronologies are a powerful tool to understand a child’s journey). In isolation each practitioner did not have a full view of Riley’s life. It is felt by all those involved in this review that Riley’s lived experience has shaped his childhood and subsequent decisions he has made in his teenage years. Once the combined chronology was completed, Riley’s voice was very loud in telling us at every point of his life that he didn’t understand what was wrong with him and that no-one helped him. The review group felt that Riley’s experiences shaped his later years as follows: Not understanding why he was struggling at schools and as a result disengaged from education Listening to people saying he was the problem which has translated into self-blaming and internalising that he is the problem Not understanding why he feels as he does and self-medicating with drugs Witness to domestic abuse and has subsequently been a perpetrator of domestic abuse Multiple needs that have not been met which has subsequently made Riley vulnerable to exploitation In conclusion: Riley’s behaviours and response to situations are as a result of his childhood experiences. Practitioners needed to work together to assess Riley’s needs and work together to understand what support he needed to meet his needs. It is important at this stage that expertise across the system worked together to identify needs. 10 3. Were there early indications of risk and vulnerability? How were these responded to in order to reduce harm? (From 2010 -2018) There were early indicators such as domestic abuse and lack of supervision that, at the time, should have been more robustly reviewed. It is unclear (due to length of time since these incidents) whether this was further explored however there is no indication of follow up and a curiosity to know more. It is assumed by the lack of interventions in the records that workers were not curious to explore Riley’s lived experience. Practitioners very quickly decided that Riley’s learning and behavioural needs were the main issue and therefore everyone saw this case through that lens. Domestic abuse incidents appear throughout Riley’s life however there does not appear to be further exploration of this in terms of impact on Riley and no understanding of the impact of this DA on mum and her ability to be available for Riley. Education, Health and Care plan and Speech and Language service records show that Riley has communication needs and there were strategies set out in the records that would help to communicate with Riley. However, there is no evidence that this was discussed with practitioners working with Riley such as Early Help worker therefore it is unknown if Riley understood what was being said to him. There were numerous assessments started, across organisations, however it is not clear how many of these were completed or shared. There were a number of times when mother did not take Riley to appointments which is a potential early indication of concern. It does not appear at this stage that organisations shared this information to understand if this was a significant concern. It feels a missed opportunity that everyone’s efforts at this early stage in Riley’s life were focused on Riley being the problem however there was never a joint understanding of Riley’s needs across the workforce. It is also evident through this period of time that there were no discussions with Dad/stepdad. The review group understand that Riley’s Dad was in prison at this point however there is no exploration of the impact of this in Riley’s life. There is also no exploration with stepdad about his involvement/ relationship with Riley. This should have been fully explored in all assessments. Riley and his family were supported by the Children with Disabilities Team through this period. Records show that the focus was on the family accessing direct payments. There does not appear to have been any exploration about what family life looked like for Riley, parenting capacity and the impact of domestic abuse. In conclusion: There were definitely early indications of vulnerability such as domestic abuse incidents, possible lack of supervision, early signs of neglect and these were not sufficiently explored or addressed to reduce harm. 11 4. How well was the child’s learning needs understood by those working with Riley and his family? Was this taken into account in practitioners’ engagement of him and work tailored accordingly? There is a mixed picture across organisations of what Riley’s needs were at the time and continue up to today. Self-reporting by Mother is accepted by some practitioners, educational psychologist indicated low to extremely low cognitive ability however TEWV records show Riley did not have a learning disability. It is also clear in the records that Riley is accepting the view that something is wrong with him and feels helpless and hopeless to know what to do and starts to self-blame. Reflecting on this when reviewing the whole chronology indicates a self-fulfilling prophecy of a young boy behaving in a way that is “expected” of him. There was no multi-agency discussion held to understand the full picture. It is expected that the team around Riley would discuss the difference in opinions in relation to Riley’s needs alongside the wider needs of Riley and family and agree the best plan to support Riley. The EHC review process may have been a useful mechanism to have the discussion about Riley’s wider needs however social care and health input is limited with the focus being on education. In conclusion: it is evident in the records that workers did not understand Riley’s learning needs. There was one Speech and Language assessment that indicated some strategies to use with Riley however it does not appear from the records that this was shared with the wider system to enable workers to engage with Riley in a meaningful way. 5. To what extent did practitioners understand and intervene in Riley’s early indicators of vulnerability, particularly to exploitation (2018 – 2019)? What impact, if any, did this have to divert him from harm? What else could have been considered? Riley’s early indicators of vulnerability can be seen as early as age three. There are potentially multiple vulnerabilities which includes neglect, domestic abuse and learning needs. One of these in isolation would potentially impact on a young child however the cumulative effect of all of these with little evidence of effective multi-agency intervention is highly likely to lead to an increase in vulnerability to exploitation. As Riley grew up, records show that he was increasingly labelled as troublesome. It is important that we reframe our response to children and young people that present with challenging behaviour. This behaviour is often a way for them to communicate their emotions, and needs to be explored to understand the child/ young persons lived experience. The review group reflected that the use of language by professions is incredibly important as children will internalise this and this will become their narrative as they grow up. 12 There is evidence that practitioners tried to better understand Riley’s needs in 2018 /2019/ 2020 which had a mixed response which is likely due to the trauma he has suffered throughout his childhood. In conclusion: the review shows that practitioners (in 2018/2019) tried to engage with Riley during this time but they did not have an understanding of Riley’s childhood or is learning needs and therefore saw him through “troublesome lens”. This means that any potential support/ intervention was ineffective due to a lack of understanding of Riley’s needs. 6. Learning Difficulty / Disability – Do agencies and practitioners working with children and young people have a sound working knowledge of characteristics and associated potential impact of a diagnosis of learning difficulties versus learning disabilities? How did they manifest in this case and how can practitioners tailor their work with young people at risk of exploitation to respond to their learning needs? What are the most meaningful and effective ways of engaging young people with a learning need at risk of exploitation What would be the impact of tailored assessment, intervention and management of risk and vulnerability? What would we see that is different? It is evident that practitioners are using learning difficulty and learning disability interchangeably without knowing the difference. However, when identifying and responding to a child’s needs do we need to be labelling to meet need? The IQ difference between a learning difficulty and disability can be negligible and only defines access to services instead of helping us understand how to meet a child’s needs. This highlights the need for a needs led response instead of label/diagnosis. Once learning needs are identified there needs to be an agreement about the best strategies to use to support a child/ young person. On this occasion some strategies were identified but the lack of a multi-agency plan meant that these were not used consistently. It is clear that Riley has some learning needs and if practitioners had understood this there may have been a way to understand his lived experience. However, practitioners didn’t look at the wider issues which would have been impacting on Riley. It is likely Riley’s behaviour in his early years was a combination of people not listening to him and seeing traumatic events such as Domestic Abuse incidents. Domestic Abuse, although a feature through the chronology, was not considered. In this case there was a need for a holistic assessment with all Riley’s needs explored and then a multi-agency plan to ensure we could meet these needs. Interestingly Riley was referred to and attended anger management sessions. Reflecting on Riley’s voice within the review indicates it is highly likely Riley was feeling frustrated that no-one was helping him. In addition, Riley had learning needs that were not clear. On reflection, it is not surprising Riley would feel anger however an exploration of what Riley’s lived experience was would have probably been more appropriate than a referral to anger management. In conclusion: In this case the workforce did not have a full understanding of Riley’s needs and therefore did not know how to engage with Riley. However it appears that the workforce were expecting a “diagnosis” to enable them to support Riley. It is clear from Riley’s voice that he just wanted people to listen to him and understand what his life looked like. 13 7. Early Indicators of Vulnerability to Exploitation To what extent did practitioners understand and intervene in Riley’s early indicators of vulnerability, particularly to exploitation? What lessons can be learned from the effectiveness and efficiency of the Contextual Safeguarding system and agency response; in order to inform continuing developments to the safeguarding system moving forwards? As stated above there were indicators of vulnerabilities for Riley at a very early age. All responses seem to have been that Riley was troublesome without an understanding that Riley was traumatised through his early life experiences. He told us that he was struggling to make friends at primary school which extended into secondary school. Based on the multiple vulnerabilities that were evident it is highly likely that Riley would have struggled to maintain relationships which may have made him a target to exploitation. In conclusion: As indicated throughout this review the lived experience of Riley in his childhood has made him vulnerable to poor outcomes. This may not have been exploitation but his vulnerabilities made him at more risk from harm than his peers. These early vulnerabilities were not considered as he grew up and therefore not addressed to reduce his risk to exploitation. 8. Escalating Indicators of Exploitation To what extent did practitioners understand and intervene in Riley’s escalating indicators of exploitation (2020 – 2022)? What impact, if any, did this have to divert him from harm? What else could have been considered? What lessons can be learned for the effectiveness and development of the local area’s response to Contextual Safeguarding to inform and optimise the safeguarding system moving forwards? (This is to go beyond the date of the incident to include the potential links between Riley’s exploitation and how he responds to treatment and the response of services to this). There is evidence within the chronology and in discussions with practitioners that there were concerns about Riley’s escalating challenging behaviours and needs. This appears to have increased anxiety across the workforce and resulted in numerous referrals being made to “specialist services”. At one point (Sept 2021) Riley was expected to work with: Social Worker, Family Support Worker, Substance Misuse Worker, Youth Justice Service Worker, Forensic CAMHS, One Stop Shop, Domestic Abuse services, YJS Speech and Language Therapist AFOS clinical psychologist. This must have felt overwhelming and Riley stated very clearly that he doesn’t know what everyone does and doesn’t understand why they all want to work with him. He says at this point that no-one listened to him before. This also needs to be considered in the context that Riley has learning needs and that he has a cognitive age of 11; so it is unclear what his understanding was. 14 This was discussed within the review group and it was highlighted that the two allocated social workers and family support worker developed a highly effective way of engaging with Riley. They developed an ongoing relationship with Riley and they ensured that Riley was supported to access the services that are set out above (many of these were required under the court order that Riley was subject to at this time). This is good practice and should be adopted when working with young people. There was also an email group set up specifically to share information on an immediate basis. This allowed all practitioners who were involved to share the risks and the plan. This is an area of good practice and is now being undertaken for young people at risk of exploitation through the MACE. There is one occasion when Riley opened up to a YJS worker and this seemed to be a good opportunity to build a relationship to start to work with Riley to reduce the risks. However this happened just before the incident and, unfortunately, could not be sustained after his treatment. This interaction showed that Riley was upset, scared, and wanted help and if this model of one worker had been further developed earlier this may have improved the chances of Riley engaging and thus reducing his risks. Another example of good practice was the interaction between Speech and Language Therapist (YJS) and Riley. Riley engaged and this was a positive intervention however on reflection, it is unfortunate that this came too late. This type of interaction should have taken place earlier in his life to prevent the risks associated with exploitation. In addition, services were not “going to” Riley. He was expected to respond to workers on their terms. A number of agencies only used telephone contact however this was not successful, but they kept trying resulting in closing the case as they could not contact. There was an increase in in Riley’s aggression from August 2021. The review group reflected on this and although there wasn’t one specific incident workers thought it was likely linked to the substances Riley was now using. In addition, the social worker reflected that a young person had been moved out of area which left a gap in the group that were leading the criminal activity. It is likely that Riley then filled that gap. This led to a discussion within the group of the importance of mapping all the young people collectively to try and understand the interaction of these groups. It was acknowledged that this has now started within the MACE and is expected practice. A significant event for Riley at this time was when his girlfriend miscarried, and Riley’s aggression further increased. Workers were very respectful of the girl’s family’s wishes and Riley’s wishes at this point and workers backed off allowing them time together. However due to the subsequent incident being only a week after, there hasn’t been any specific work with Riley about this loss. It is likely that this will have significant emotional impact on Riley. It is evident in reviewing the notes from the incident (Dec 2021 until Feb 2022) that there was no shared understanding of Riley’s learning needs which meant that there was a delay in understanding how his needs could be meet in relation to his treatment. The records are very robust throughout this period however it is clear that there was a delay in deciding if he had capacity. Discussions took 15 place across 12 days until he was deemed not to have capacity to make medical decisions. If there were records that set out some of the strategies outlined by speech and language services in his earlier life this may have prevented some of his distress at the hospital It is also evident through the records and discussion with the review group that the joint work between children’s social care and the Foundation Trust safeguarding team was excellent. However the review group raised a number of concerns across this period of time which were contributing factors to Riley not receiving the treatment he needed: Riley being placed on an adult ward without understanding his needs shifts changes of nurses with no time to understand Riley’s needs delay in transfer to Hospital 2 due to Riley contracting COVID a significant lack of communication between the Hospital 1 and Hospital 2 Hospital 2 allowing Riley to leave without transferring back to Hospital 1 and allowing him to leave with Oramorph when he was known to have substance misuse issues. There was also no follow up re: ongoing assessment required to monitor effectiveness of treatment. This has resulted in Riley not wanting to engage with any health assessments which could be placing him at ongoing risk. In conclusion: Practitioners at this stage were working together to try to support Riley. However this was without the full knowledge of Riley’s needs/ childhood experiences and therefore ended up being reactive rather than proactive. Riley’s perception was that services had not supported him in the past therefore why would they help now therefore making it more difficult to engage with him. In future it would be beneficial for MACE to review childhood experiences to understand why a young person is behaving in a certain way and putting themselves at risk. RILEYS VOICE Riley was spoken to via phone to get ask him about the support he had been offered and whether he felt it had helped him. Riley was happy to talk about his experiences and was engaging to speak to. He said: “I knew something was wrong with me but no-one told me what it was. School helped me as they gave me a one to one. I went to CAMHS a couple of times but it didn’t make any difference. Everyone thought I was a naughty boy.” When asked about domestic abuse he had witnessed he said “no-one asked me. Every boyfriend my mum had there was violence and I couldn’t help my mum. They would be taken away and then come back the next day.” When asked about drugs he said “I use weed as it makes me calm and makes me sleep.” Riley stated that he felt “what I have seen has made me.” (when he discussed his past) 16 Riley commented on being in hospital saying “there were loads of really ill people with cancer in there and didn’t have time for me.” MUM’S VOICE Mum was spoken to for a short time via phone and her response stated: “I never got any support from anyone. I had to fight for help with Riley’s behaviours and I never got any help. I remember he had one psychological assessment but nothing came of it and no support.” RECOMMENDATIONS: MAIN RECOMMENDATION 1 Reflecting on this case it is highly likely that there are other “Riley’s” that will be at risk of exploitation if we do not intervene early. In order to prevent similar cases, it is recommended that the partnership undertakes reviews of all children that have disengaged with school/ learning to ensure that robust multi-agency plans are in place to meet their needs. In addition, there are two further supplementary recommendations: Recommendation 2: Explore the use of a communication passport which can be reviewed at key stages in a child’s life, so all agencies understand the strategies needed to engage with child/ young person with additional needs Recommendation 3: Consider the partnership’s approach to adolescents receiving hospital treatment This review covered a significant period of time in order to understand Riley’s lived experience. This means that there has likely been a change in practice since that time. It is therefore proposed that the partnership assures itself that practice has improved and includes: 1. The use of combined chronologies in multi-agency meetings 2. Children with disabilities workers fully understand safeguarding concerns in all cases and act as appropriate to safeguard children 3. Assessments take into account all vulnerabilities at the earliest opportunity – ensuring the Right Support at the Right Time 4. Agencies work together to understand the needs of a child and the strategies needed to work with them if they have learning needs. Ensure this is clearly recorded in all agency records. 5. Workforce to understand that children/ young people with challenging behaviour are usually trying to communicate with us and we need to find a way to understand their lived experience to ensure we can meet need. 6. Workforce know that learning needs can be a risk for young people to be exploited and the team around a child/ young person with learning needs consider this within their planning 7. “Was not brought” policies are robust and implemented effectively 17 PART TWO Systemic Learning and Practice Improvement Two sessions were held to review this case through Riley’s voice as it appeared through the chronology that the system did not always respond to what he was telling those around him. We explored Riley’s life journey from age 3 to the present day through an appreciative enquiry approach and discussed what best practice we would expect to see at each stage of his life. (Please note that practice may have changed since Riley’s early childhood and many elements of best practice set out below will already be in place). There were three themes identified within these discussions which are set out below: Identifying Need Best practice in identifying need would be a workforce that was professionally curious. The workforce will be looking at all children’s and family’s needs including parenting capacity in the context of their history. Workers would listen intently to children and young people to understand what life feels and looks like to them and ensure that children and young people voice is valued. Workers would understand that children’s behaviour is a way for them to communicate. Workers would keep checking in with children and young people to ensure that assessments are dynamic as needs change. If there were concerns raised about any learning needs workers would work with specialists to understand these needs and the strategies needed to engage with these children would be recorded. Best assessments are based on a positive relationships with child and family and recognise the importance of valuing the time needed to build these relationships; acknowledging that assessments need to be timely but not to the detriment of quality. Practitioners should seek to: recognise and reflect on cumulative risk including parenting history, ACEs actively communicate between agencies involved in assessing need undertake joint assessments to ensure identifying all needs see a child’s behaviour as their way of communicating and be reflective about what the behaviour could be telling us be mindful of and use verbal and language that recognises the behaviour as a means of communicating; ensuring the child is seen as troubled rather than troublesome be curious about the context / root causes behind presenting issues recognising the cumulative impact of neglect on a child and the impact of trauma on brain development; understanding how this can manifest in adolescence 18 Responding to Need Best practice in responding to need involves, in the first instance, building effective relationships with both the child and family but also within the team around. Practitioners who communicate effectively with each other to ensure that everyone understands the bigger picture and knows about changes as they occur are more informed and able to make more effective evidenced-based decisions. Children / young people and their families who own their plans and understand what practitioners are going to do to support, but also what their responsibilities are, are more likely to engage with the plan and to make the changes required. Organisations that do not have organisational silos enable true multi-agency working and ensure that the most appropriate worker (that family most engages with) supports the family; with specialist services supporting the worker. This maximises trusted relationships leading to more successful engagement and intervention. A workforce that understands that a child’s behaviour is a way for them to communicate with us is more in tune to early indicators of vulnerability and does not see children/ young people as troublesome but actively seeks the reasons why they are behaving in a certain way in order to match response to need. A workforce that fully understands the impact of trauma (such as Domestic Abuse) on brain development and how this may affect learning needs are more able to respond effectively to need. Support is based on meeting needs rather than a label or diagnosis. Learning needs and the way to engage children with these needs are shared across the multi-agency team around to ensure that we are working with children in a way that they can access. Substance misuse and mental health services work together to develop shared plans to support young people to improve their emotional wellbeing and reduce their substance misuse. Practitioners should seek to: • place high importance on relationships - allowing themselves time to build trusted relationships with a child and family • where child is not brought to appointments, be creative in how and where these are offered to maximise possibility of engagement in these (assertive outreach) and explore the barriers for parents not attending • co-ordinate the Team Around – not overloading a child with referrals / workers but considering what needs to be prioritised and who is the best person to deliver • quality assessment rationale to evidence when not able to meet timescales. • understanding needs - be needs led rather than service led • Joint Working – workers working together to be able to respond to multiple needs such as underlying learning needs and child protection concerns 19 Meaningful and Effective Engagement Best practice in meaningful and effective engagement means that the workforce is creative, innovative and persistent in engaging with children, young people and their families. It is built on the development of positive relationships which can take time however we commit to that approach. Workers work together across organisational boundaries to ensure that the right people are supporting the child and young person. The workforce work together as a multi-agency team around the family to identify the worker that has the best relationship with child and family. “Was not brought” processes are robust and workers tirelessly follow up if children are not brought for appointments and escalate as required. Cases are not closed for non-engagement and workers seek support from the team around to support engagement. The child knows we listen to them and act on what they say and we also feedback to child/ young person to ensure that they understand why we have done something. Practitioners should seek to: • Be creative about where and how appointments take place to maximise possibility of engagement and attendance • Be up to date / creative when working with / engaging young people and have appropriate systems / resources / technology (Snap Chat) in place to talk to children in the way they prefer • The team around are consistent in their approach to engage young people and regularly review this to adapt their approach to meet the needs of the young person Summary The initial focus for this review was to look at the way that partners across the system worked together when a child is identified at risk from exploitation. However it was clear once Riley’s life was explored that Riley’s potential exploitation was inextricably linked to his childhood experiences. Riley has additional needs and witnessed and was subject to domestic abuse. These needs were not met and these experiences shaped Riley as he grew up and ultimately became at risk of exploitation. It is important that the workforce understand the importance of understanding a child’s lived experience to ensure that children are supported at the earliest opportunity. This will reduce the risk of children being at risk of exploitation as they become adolescents. The workforce must also be aware that a child with additional needs is at a potential greater risk than those of their peers. |
NC52555 | Non-accidental injuries to a ten-month-old in 2017. Learning and recommendations include: a need to ensure that every child subject to a multi-agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate; ensure action is taken to enhance the ownership of child in need plans amongst constituent agencies; support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making; ensure gaps in understanding of sexual abuse and specialist services is addressed; request briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals; and ensure that at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research-based information given to carers.
| Title: Child E: serious case review. LSCB: Cheshire East Safeguarding Children’s Partnership Author: Cheshire East Safeguarding Children’s Partnership Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child E Serious Case Review February 2021 Page 1 of 4 Child E Serious Case Review Executive summary In 2017 Child E suffered significant non‐accidental injuries and a Serious Case Review was conducted. Cheshire East Safeguarding Children Partnership fully accepts all the findings and recommendations from this. The summary circumstances of the experience of Child E can be described as a child who suffered a significant non‐accidental injury at the age of ten months. The baby was taken to hospital where medical investigations revealed these to be non‐accidental injuries. No adult who had had responsibility for the care of Child E was able to offer a suitable explanation as to how the injuries could have occurred and a police investigation commenced. Between the age of six and eight months, a number of agencies were involved with the family for Child E who was subject to a child in need plan during this period, following a child and family assessment. The child in need plan was ceased six weeks prior to the injury. The Serious Case Review was Independently Chaired and authored and all the services involved in the case contributed. The Serious Case Review made the following recommendations which reflect the focus for learning: That the Cheshire East Safeguarding Children Partnership 1. are reassured that every child subject to a multi‐agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate 2. takes action to enhance the ownership of child in need plans amongst constituent agencies 3. support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making 4. are reassured that the highlighted gaps in understanding of sexual abuse and specialist services is addressed 5. That the views of the Family Support Service with regard to consistent application of threshold are specifically considered within a wider strategic context 6. request a. briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals. b. That at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research‐based information given to carers. The publication of this Serious Case Review has had to be delayed to allow for other processes to be completed. This executive summary will focus on the practice learning and what has been undertaken to apply that. Actions undertaken by the Cheshire East Safeguarding Children Partnership in response to the Serious Case Review Recommendations That the Cheshire East Safeguarding Children Partnership 1. are reassured that every child subject to a multi‐agency plan has a safety plan in place that is commonly understood by professionals, relevant family members and the child where appropriate 2. takes action to enhance the ownership of child in need plans amongst constituent agencies Over 800 Senior Leaders, Team Managers and Practitioners from across the partnership; and 14 key partner leads from Cheshire Police, Education and Health, who are responsible for leading and Page 2 of 4 supporting the practice to embed within their own organisations and practitioners have been trained in Signs of Safety. The feedback and post course evaluations on this training were very positive. The principles are now embedded in all Cheshire East Safeguarding Children Partnership training and specific Signs of Safety training has continued. Plans for children now reflect the Signs of Safety model including safety plans, safety goals, Words and Pictures that are more accessible for the child and family and understood by them. 3. support the development of critical thinking skills to enhance professional curiosity and analytical approaches to decision making Evidence based face to face course developed considering critical thinking and professional challenge in Safeguarding and provided with the Cheshire East Safeguarding Children Partnership training programme. Adult service practitioners have access to the training. All Signs of Safety training includes critical thinking skills within all aspects of practice, over 1300 professionals have now attended courses that include this. 4. are reassured that the highlighted gaps in understanding of sexual abuse and specialist services is addressed A risk assessment document for assessing adults who pose a risk of sexual harm has been developed. This was informed by Police, Probation and Adults Forensic Services. It provides guidance and a format for which Social Workers can assess the sexual risk that an adult pose to a child. Not all adults that pose a risk have a conviction and this assessment tool is to support safety planning. It has been disseminated across Children Social Care. 5. That the views of the Family Support Service with regard to consistent application of threshold are specifically considered within a wider strategic context A Threshold of Need guidance was completed and communicated to all partner agencies. Signs of Safety has been introduced within the Integrated Front Door to ensure children receive the right level of help and protection. Early Help services have been re‐designed to focus on Early Help assessment and planning. Fortnightly auditing meetings of contacts, no further actions and repeat contacts received at the Front Door have been introduced. Family Service Managers, Health and Police participate. This support decision making around application of threshold through multi‐agency reflective discussions. All Family Service Managers have completed the professional challenge training and understand the application of the escalation process. Family Service Managers contribute to weekly meetings considering the step‐up step down of cases. The Local Authority had a peer review of their arrangements at the Front door in 2019 to provide independent assurance that it operated safely and decisions for the child were appropriately reached The Ofsted Inspection of children’s social care services in November 2019 reported that “When needs or risks increase, cases are stepped up appropriately from early help to children’s social care. This escalation is timely and ensures that children receive more specialist support when needed. Page 3 of 4 When professionals from partner agencies have concerns about children, they make appropriate contacts to children’s social care”. 6. Request a) briefing from key organisations working primarily with babies how the issues of risk of abusive head trauma is being addressed and in particular, how consciousness is raised for professionals. b) That at all routine health contacts it will be evidenced that safe handling is discussed, and consistent and research‐based information given to carers. All relevant health providers have given assurance that the National guidance for Safe Handling are being worked to by practitioners and recorded in parents’ records. Workshops have been conducted within Children’s Social Care and the Cheshire East Safeguarding Children Partnership has promoted the guidance in its Frontline bulletin. Safe handling/don’t shake information is now included in every parent held record book. Health Visitors now have to record at every visit that they have discussed this. Involved health professionals discuss with parents from pre‐birth to post‐birth. Page 4 of 4 |
NC52844 | Suicide of a 16-year-old boy in March 2021. Simon suffered a serious fall in 2018 which left him with a brain injury which is said to have affected his behaviour and led to mental health problems. Learning includes: assessment of risk which considers the cumulative effect of adverse childhood experiences; effectiveness and closure of child in need plans; dealing with allegations of sexual abuse; voice of the child in decision making; cultural and language challenges; impact of Covid-19; and the relationship between brain injury and mental health. Recommendations include: the partnership should seek assurance on effectiveness of child in need plans in the context of providing support to young people at risk of suicide and how these relate to other relevant plans; local children services and partners should review the process of receiving and responding to notifications under section 85 of the Children Act 1989; police should provide assurance that victims, and where appropriate parents, reporting offences of rape and sexual assault are appropriately updated and offered support; consider how learning on this review links to the Exploitation Strategy and is used to help develop a trauma informed approach for child sexual abuse; where there is a risk of suicide, to consider a Think Family approach, with particular consideration to areas of culture; the partnership should consider a multi-agency audit on the use of interpreters; the partnership should seek to embed a new model into the CAHMs contract to move towards a needs led approach; and all professionals should seek to work with families when proposing measures involving the removal/storage of items potentially used to cause harm.
| Title: Local child safeguarding practice review: ‘Simon’: overview report. LSCB: Warwickshire Safeguarding Adults and Children Partnership Author: Jon Chapman Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review ‘Simon’ OVERVIEW REPORT Final Version Published:27/09/2023 Author: Jon Chapman Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 2 Acknowledgements Governance The author can declare that he has found no conflict of interest in completing this review, and that he is independent to Warwickshire Safeguarding Adults and Children Partnership Board and partner agencies. The report has been commissioned by, and written for, the Partnership and overseen by a multi-agency child safeguarding practice review panel of local senior managers and practitioners from the following agencies: • Coventry & Warwickshire ICB formerly CCG (GP) • Coventry & Warwickshire Partnership NHS Trust • George Eliot Hospital • Hunterscombe Hospital • Park View Hospital Birmingham • Secondary School • University Hospital Coventry & Warwickshire • Warwickshire Police • WCC Children’s Social Care • West Midlands Ambulance Services • West Midlands Police The details of the child and their family, as well as the individuals providing care to them, have been anonymised in accordance with statutory guidance and best practice. Version Control Version Event Date 0.1 To second panel 0.2 Following feedback from second panel 01/06/22 0.3 Following feedback from third panel 24/08/22 0.4 For presentation to review sub-group 15/11/22 0.5 Following presentation to review subgroup 22/11/22 Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 3 Contents 1.0 Introduction and Background 4 2.0 Narrative Chronology: 6 3.0 Discussion 9 4.0 Recommendations 24 Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 4 1.0 Introduction and background 1.1 This review focuses on the life of, and how agencies inter-acted with, Simon. In March 2021, Simon was found hanged in a wooded area, he was 16 years of age at the time of his death. Simon had previously made a significant attempt to hang himself in May 2019 and since that time a number of agencies engaged with him and his family. 1.2 The review has been commissioned by the Warwickshire Safeguarding Children Partnership in accordance with statutory guidance1 which states that where a child dies or is seriously harmed in an area and it is known or suspected the child has been abused or neglected, the Local Authority for that area must notify The National Child Safeguarding Practice Review Panel.2 A rapid review meeting will be convened by Safeguarding Partners for that area and as well as identifying immediate learning and action, a decision will be made on whether a Local Child Safeguarding Practice Review is required. 1.3 Simon came from a family where English was not their first language. Whilst Simon spoke fluent English neither of his parents did and they required the services of interpreters. Simon’s mother and father separated around 10 years ago. 1.4 In September 2018, Simon suffered a serious fall which left him with a brain injury, which is said to have affected his behaviour. Simon returned to school and there is good evidence that he was well supported by the school. Simon engaged well and this included him leading an assembly to discuss his injury with other students. He returned to a full timetable in January 2019. 1.5 In February 2019, the school were informed by Simon’s family that they had concerns regarding Simon’s behaviour outside of school. The school in discussion advised a referral to RISE3, which was done. In March 2019, Simon presented to hospital reporting suicidal thoughts. 1.6 In May 2019, the family informed the school that alcohol was missing from home, and they believed Simon had it. Simon was sent home with his mother. The following day Simon attempted to take his own life himself at home. 1.7 The case was referred to the Warwickshire Safeguarding Partnership who discussed the case and agreed that although it did not meet the criteria for a review there was learning to be drawn from the case, so the group undertook a tabletop learning review. The review identified a number of areas of learning for practice. • Referrals to the Multi Agency Safeguarding Hub (MASH) should be made by use of a Multi-Agency Referral Form (MARF). • There was learning for some agencies in recording Simon’s voice to evidence that he had been a part of the decisions being made regarding him and his care. 1 Working Together 2018, HMG 2 Section 16C(1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017) 3 Rise is a family of NHS-led services providing emotional wellbeing and mental health services for children and young people in Coventry and Warwickshire (CAMHS) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 5 • The use of interpreters and agencies, not relying on Simon or other family members when communicating with non-English speaking members of his family. • Learning around support being offered to Simon’s family and for agencies to ensure they adopt a Think Family approach. 1.8 Following Simon’s death the case was again referred to the Rapid Review group. Following scoping and discussion it was agreed that the case should be reviewed as a Local Child Safeguarding Practice Review. The following agencies provided information for the purposes of scoping and subsequently providing an agency report. • Coventry & Warwickshire ICB formerly CCG (GP) • Coventry & Warwickshire Partnership NHS Trust • George Eliot Hospital • Hunterscombe Hospital • Park View Hospital Birmingham • Secondary School • University Hospital Coventry & Warwickshire • Warwickshire Police • WCC Children’s Social Care • West Midlands Ambulance Services • West Midlands Police 1.9 Terms of reference for this review determined that the period in focus would be from 1st April 2019 to the time of Simon’s death, in March 2021. The rapid review developed some key lines of enquiry, which the review was asked to focus on. These are detailed below: - • Was there recognition of the relevant risk factors in this case and did this result in appropriate analysis and mitigation of the risk? • Where assessments were undertaken, was historical information effectively used to inform them? • In the assessment of risk was the cumulative effect of Adverse Childhood Experiences (ACEs) considered? • How effective was the support afforded to Simon after his first suicide attempt and in particular the Child in Need plan implemented at this time? Were the identified outcomes achieved and was the closure of the plan appropriate? • How were allegations of sexual abuse dealt with, was information effectively shared and the appropriate action taken? • What consideration was given to the wider risk presented by the allegations made by Simon during his work experience, and allegations made by hospital staff including the involvement of the Local Authority Designated Officer and actions taken to safeguard young people during work experience opportunities? What support was available for Simon following the allegation of sexual abuse? • How apparent was Simon’s voice in the recording of interactions with agencies and how was it used in decisions, assessments and interventions being delivered? What were the concerns raised by him on his appearance and did these impact on his self-esteem? • Were the right areas of learning identified in the tabletop learning exercise of 2019? Were the areas of learning communicated effectively to professionals and did this result in the necessary improvements? Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 6 • Were the cultural and language challenges to Simon and his family identified in the table top review and appropriately addressed? • What was the effect of Covid both on Simon and his family and on the ability of agencies to deliver services? • Was Simon’s brain injury factored into risk assessments and was the relationship between this and his mental health considered? Did professionals working with Simon adapt their approach when engaging with Simon to ensure he fully understood the support being provided? 2.0 Narrative Chronology: 2.1 In April 2019, Simon presented at hospital, just prior to this he had been at a first-floor window and told his parents that he intended to take his own life. At the hospital Simon was assessed by the mental health crisis team and stated that he had no intention to jump and denied any suicidal thoughts. He did state that he was sad all the time and that he had lost all interest in his previous hobbies. These changes in his behaviour were attributed to a serious fall that Simon had suffered and as a result was left with a brain injury. A referral was made to Children Social Care (CSC) and this was passed to Early Help. The hospital also made a referral to RISE. 2.2 In May 2019, Simon made a significant attempt to take his own life. This took place in his home and Simon was discovered by his family. This was a significant attempt where Simon was unconscious for 8.5 minutes4. Simon was treated in hospital. CSC undertook a child and family assessment which recommended that Simon and his family should be supported by a child in need plan (CiN)5. This plan was effective from May 2019 to June 2020. For significant periods of this plan Simon was an inpatient in hospital under section 2 and 3 of the Mental Health Act 19836 and was not discharged until the end of October 2019. 2.3 In mid-November 2019, Simon self-presented to hospital with what was described as an acute deterioration in his behaviour. Simon had been having persecutory thoughts and auditory hallucinations. It was recorded that there was no suicidal ideation. Simon made attempts to abscond from the ward and his medication was increased. He was detained under section 2 Mental Health Act awaiting a Tier 47 bed. 2.4 Towards the end of November 2019, a Tier 4 (Psychiatric Intensive Care Unit – PICU) bed became available, and Simon was transferred to another hospital. This hospital was a considerable distance from Simon’s family home, some 200-mile round trip. The day before this happened West Midlands Police (WMP) were informed by Warwickshire Police that Simon had alleged that he had been the victim of a serious sexual assault. WMP were being informed as the offence was alleged to have occurred in their policing area. WMP initiated enquiries and established that there was no potential for forensic evidence due to when the 4 Coroner bundle 5 Section 17 Children Act 1989 - Children in Need (CiN) are defined in law as children who are aged under 18 and need local authority services to achieve or maintain a reasonable standard of health or development/ need local authority services to prevent significant or further harm to health or development. 6 Section MHA 1983 – hospital admission for assessment/ Section 3 MHA 1983 – hospital admission for treatment. 7 Tier 4 - CAMHS Tier 4 are specialised services that provide assessment and treatment for children and young people with emotional, behavioural or mental health difficulties (NHS England) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 7 offence had occurred. Call handlers from WMP spoke to the hospital where Simon was now admitted under section 3 Mental Health Act. It was established that at this time Simon was too ill to be interviewed regarding the allegations he had made. There is no record at this time that there was a strategy discussion8 between professionals or any consideration of what other support could be made available to Simon. 2.5 In mid-December 2019, there was a CiN review. This review was undertaken by email updates, the reason given for this was that the parents were at the hospital every day and the lack of professional availability. On the same date as the CiN review the hospital social worker notified the Local Authority social worker of what was by then a historical allegation of sexual abuse whilst Simon had been on informal work experience, which had been arranged by his family. It is apparent that this was the same allegation previously made to WMP. During this communication the hospital also informed the social worker of allegations that Simon had made relating to peers at his school being involved in the use of drugs and alcohol and girls being sexually abused whilst under the influence of substances. There is no record of this information being shared with a manager or any consideration of a strategy discussion. 2.6 During December 2019, Simon’s school liaised with the Tier 4 hospital regarding his education and arranged for an Education and Health Care Plan (EHCP) to be put in place for Simon. The details of the plan were explained to Simon’s family using a member of staff who spoke the family’s language. 2.7 In January 2020, Simon again told his social worker that he had been sexually abused by an adult, this was a repeat of the allegation made previously. On this occasion the information was shared with a manager and a strategy discussion was arranged. Warwickshire Police were invited to the strategy discussion but declined the invitation on the basis that the allegation occurred in the West Midlands Police (WMP) area. It is not clear whether WMP were invited to the strategy discussion, but they did not attend. The strategy discussion considered that the allegations should be taken seriously and investigated. Staff at the Tier 4 hospital and the social worker re-visited the allegation with Simon on a number of occasions however Simon was not deemed fit to engage in a formal interview. It was the view of CSC that the hospital, who were in contact with Simon would establish when Simon was ready to be interviewed and contact the police. There is no evidence that this was recognised by or communicated to the hospital. The only reference to the sexual abuse was in April 2020 during a Care Pathway Approach (CPA) meeting where it was recognised that a combination of physical and psychological trauma, which included the alleged sexual abuse had contributed to a decline in Simon’s mental health. 2.8 In mid-April 2020, the hospital social worker notified the CSC that Simon had made a complaint regarding unprofessional behaviour of a member of staff. The hospital confirmed that a report had been made and the member of staff had been moved from the ward. Consideration was being given at that time for notifications to be made to the Local Authority Designated Officer (LADO) and CQC. It is not clear if this happened and there was no further information passed to CSC. 8 Strategy discussion - A strategy meeting/discussion is an opportunity to share as much of the available information as possible between participants to inform the next steps. (West Midlands Multi Agency Safeguarding Procedures) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 8 2.9 During his hospital admission Simon was treated with anti-psychotic medication. This medication caused some significant weight gain for Simon, and this became what the RISE care coordinator would describe as a source of unhappiness for Simon. Advice was given to Simon regarding his weight gain on diet and exercise. The family confirm that the weight gain did cause Simon some concern but did not feel that this was a major factor for him. 2.10 Simon was discharged from the hospital at the end of April 2020. The hospital communicated this to RISE, there had been no period of home leave due to the Covid pandemic. There was no notification of the discharge to other agencies until the day and therefore the only agency to attend the CPA discharge meeting was RISE. The care plan included the local authority social worker to support Simon to pursue his allegation of sexual assault and for the care coordinator to have daily phone contact with Simon. 2.11 At the beginning of June 2020, there was a joint review of the CiN and EHCP plans. This meeting had an interpreter present, and the options were explained to Simon and his parents. Simon was offered a place at college to study motor mechanics which he accepted. In July 2020 the CiN plan was closed. During the course of the CiN plan there had been four meetings all of which had been conducted whilst Simon was in hospital and by email or virtually apart from the final meeting. 2.12 In May 2020, August 2020 and March 2021, Simon had three admissions to hospital following accidents on his pushbike. In the incidents he sustained relatively minor injuries. 2.13 In June 2020, Simon was referred to the Early Intervention Psychosis Team9 (EIP). At this time, he had a diagnosis of schizoaffective disorder and Post Traumatic Stress Disorder. Simon was not accepted into this service as it was deemed that he had an organic presentation, in that it was believed that his condition emanated from his brain injury. The Psychiatrist sought clarity on this from Neurology at the hospital. In mid-September 2020, a response was received that Simon had symptoms of mental health prior to the brain injury. Two months later in November 2020, the EIP communicated with the Psychiatrist that Simon was not suitable for the service, re-stating that his condition resulted from his brain injury. During this time Simon continued to express unhappiness regarding his increase in weight. 2.14 There was continued contact from the care coordinator and in February 2021 a review was conducted by a consultant by telephone. During this meeting Simon interpreted for his mother who expressed some concerns over Simon’s recent behaviour. There was ongoing and regular contact between Simon and the care coordinator. In Mid- February 2021, Simon presented at hospital with deteriorating mental health, he stated that he felt unsafe and had suicidal ideations. After being assessed by CAMHS Simon was discharged. Two days later there was a face-to-face review by the Consultant Psychiatrist with Simon’s parents present. There was no interpreter or measures put in place to aid the parents understanding, with Simon being asked to translate for the meeting. The reason given for this was the relatively short notice for the meeting being arranged. A further referral was made to EIP, which was on this occasion accepted. 9 EIP - A team of NHS and Social Care professionals working together with other teams, including hospital services and the Crisis teams, to provide care to people in the community who have been diagnosed with a form of psychosis, such as schizophrenia or bi-polar disorder. They provide treatment and signpost to other services depending on individual needs. Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 9 2.15 Whilst there is evidence of good contact by the care coordinator there is also evidence of Simon feeling that his mental health was deteriorating. In mid- March Simon again attended hospital and expressed overwhelming feelings that he wished to harm himself. Earlier the same day Simon had been contacted by the care coordinator and expressed to them that he had no concerns, this was an indication of how Simon’s feeling could fluctuate quite quickly. Following a review by CAMHS Simon was again discharged with care to be followed up by the care coordinator. This contact included a face-to-face meeting with a EIP care coordinator, who now accepted that Simon’s condition was not attributed to his brain injury. It is not clear how the language barrier issue with the parents was dealt with at this meeting. 2.16 On 18th March 2021, the hospital made a referral to the MASH expressing concerns that Simon had presented to the hospital with overwhelming suicidal thoughts. The referral stated that Simon had no actual plans to harm himself and had felt like this on numerous occasions. It noted that Simon had been a previous hospital inpatient for mental health issues and was under the care of CAMHS. There was no discussion with other agencies or apparent consideration of previous incidents. Some 8 days later a letter was sent to Simon’s mother stating that no further action would be taken and signposting the family to the Family Information Service, this letter was sent in English. 2.17 The day following the meeting Simon was in town with a female friend, who he had discussed during the meeting. Simon was the subject of an un-provoked attack by a group of youths and punched and kicked several times. This was reported to police but Simon did not seek medical attention. 2.18 At the end of March 2021, Simon attended a routine mental health review which was conducted face to face, Simon’s mother was present and aided by the services of a translator. Simon disclosed feeling unsafe at time and having thoughts to harm himself but not having plans to do so. Simon’s mother agreed to take steps to ensure that the home environment was as safe as it could be. The agreed plan was to increase medication, whilst acknowledging Simon’s unhappiness over his weight gain and the link to medication it was considered that the stability was required. 2.19 Following the review, on 26th March 2021, both family and professionals attempted to contact Simon on a number of occasions. A report was received that a young person had been found unresponsive, it was established that this person was Simon and that he was deceased. It was apparent that Simon had met a female friend in the park and had been informed by her that their relationship would not progress in a way that he had hoped. 3.0 Discussion 3.1 How effective was the support afforded to Simon after his first suicide attempt and in particular the Child in Need plan implemented at this time? Were the identified outcomes achieved and was the closure of the plan appropriate? 3.1.1 The CiN plan was initiated in May 2019 and concluded in June 2020. For extensive periods of the plan Simon was an inpatient in hospital following the first attempt he made on Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 10 his life. Simon was often deemed too unwell to engage in visits from his social worker or to be involved in reviews of the plan. At a review of the plan in September 2019, which was attended by all relevant agencies, it was discussed that within the hospital and whilst on home leave Simon had engaged in risk taking behaviour and this included being found in the ward toilets with a belt around his neck. This was said to be following his first return day to school, which he had found challenging. At a review meeting in October 2019, Simon’s return home was discussed. It was agreed that Simon had engaged well and an EHCP10 had been put in place for his return to school. 3.1.2 On his discharge from hospital Simon felt too unwell to return to school and was to be supported by the Flexible Learning Team. Before this arrangement could be put in place in mid-November 2019, Simon self-presented to hospital with what was described as an acute deterioration in his behaviour. Simon had been having persecutory thoughts and auditory hallucinations, this was only three weeks after his previous hospital discharge. 3.1.3 Simon then remained in hospital as an inpatient until April 2020. During this period the CiN plan was only reviewed by email contribution or by virtual meetings. The hospital did not have access to an interpreter and therefore the contribution by the family was limited. 3.1.4 When Simon was discharged from hospital it would be fair to anticipate that the CiN plan would become more relevant and perhaps more focused on support and monitoring Simon’s progress as he transitions back into the community. This is not evident from the plan. There were no further review meetings except the joint CiN/EHCP meeting, which effectively closed the CiN plan. 3.1.5 The Warwickshire Child in Need Policy11 commits to a whole family and culturally competent approach to recognise the needs of the whole family. It is not apparent that either of these areas were considered within the plan or that there was sufficient consideration of the family background and the support they may require. 3.1.6 It is evident there was a perception from CSC staff involved in plan of feeling redundant due to the time that Simon spent in hospital, and they felt that their role was more to be a ‘friend’ to the family. The CiN closed at time when a plan with SMART objectives which was family centred could have provided a better multi agency approach to support Simon and his family. That said there was evidence of continued good support from the school and RISE coordinator after the plan closed. 3.1.7 Careful consideration should have been given to the closure of the plan for Simon. His discharge from hospital had been quite recent, there had not been a monitored period of the plan being in place whilst Simon had been in the community. At the time of closure Simon had not been provided support from the Early Intervention Psychosis Team, this was still being negotiated up to the time of Simon’s death. At the time the plan closed it was also relatively close to the first national covid lockdown (March 2020). This was a time of uncertainty, and it was not clear what the ramifications to the pandemic and consequences of it would be. 10 EHCP – Education, Health and Care Plan 11 Warwickshire Country Council Child In Need Plan, The Right Support at the Right Time,2018 Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 11 3.1.8 Section 85, Children Act 198912 places a duty on local authorities to check on the safety and welfare of children living in residential education or hospital provision for any continuous period exceeding and / or likely to exceed 12 weeks. The intention behind the legislation is to provide a ‘safety net’ for vulnerable children living away from home where the child is not accommodated under Section 2013 and where the child is not subject to the usual processes of Care Planning and review by an Independent Reviewing Officer. 3.1.9 This requirement was relevant on Simon’s first admission to hospital in May 2019, which lasted 5 months and also in November 2019, which lasted 6 months. On both occasions Simon was being supported within a CiN Plan. The statutory guidance for this requirement14 states that where a child or young person’s needs have been assessed for the purposes of section 17 of the Children Act 1989 in the preceding 12 months, the representative must visit within three months, and thereafter at intervals of not more than six months. There may have been consideration of section 85 within the context of the Child in Need plan, but this is not evident to this review. Consideration should be given to offering clarity to professionals regarding making notifications regarding section 85 and how Children Services should respond to this, particularly where other assessments are in place. Learning A Child in Need Plan should adopt a family wide approach that seeks to identify and address the hidden issues and harm. The plan should have set out clear measurable outcomes for Simon and expectations for his family. It should have included areas of concern and how these would be addressed. Careful consideration should be given to the closure of a plan where it is not clear that key issues have been addressed and how the transition will be managed by a step-down plan. Children Services and other agencies involved with care of children need also to consider section 85 Children Act and how this works with other assessments. Recommendation 1 The Warwickshire Safeguarding Partnership should seek assurance on effectiveness of Child in Need Plans in the context of providing support to children and young people at risk of suicide and how these relate to other relevant plans such EHCP, RISE Care Plans and Risk Plans. 12 Section 85, Children Act 1989 - https://www.legislation.gov.uk/ukpga/1989/41/section/85 (accessed 20/07/22) 13 Section 20, Children Act 1989, Section 20 agreements allow the local authority to remove a child and place them in foster care without the need for a court order. Whether or not to enter into a section 20 agreement is a voluntary decision made by the parents with the local authority. 14 HMG, 2017, Statutory visits to children with special educational needs and disabilities or health conditions in long term residential settings Statutory guidance for local authorities, health bodies and health or educational establishments Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 12 Recommendation 2 Warwickshire Children Services and relevant partners should review the process and policy of receiving and responding to notifications under section 85, Children Act 1989. 3.2 How were allegations of sexual abuse dealt with, was information effectively shared and the appropriate action taken? What consideration was given to the wider risk presented by the allegations made by Simon during his work experience, and allegations made by hospital staff including the involvement of the Local Authority Designated Officer and actions taken to safeguard young people during work experience opportunities? What support was available for Simon following the allegation of sexual abuse? 3.2.1 In November 2019, Simon was detained under section 2 of The Mental Health Act awaiting admission to a Tier 4 provision. This provision became available towards the end of November. The day before Simon was transferred to the provision, he made an allegation of a very serious sexual assault. This allegation centred on a person who Simon had worked with on a voluntary basis to gain experience in motor mechanics. This arrangement was one that had been put in place by Simon’s family and was not one that was facilitated by any of the agency working with Simon or one that they were aware of. This allegation was passed to Warwickshire Police, but it was quickly established that the alleged activity had occurred within the jurisdiction of West Midlands Police. West Midlands Police were duly notified. 3.2.2 West Midlands Police recorded the alleged offence and call handers made contact with CAMHS and established that Simon was held under the MHA, and it was a view that Simon was too ill at that time to be interviewed. Although CSC, CAMHS, Police and hospital staff were aware of the allegation there was no consideration of a strategy discussion at this stage. Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, a strategy meeting/discussion should be held.15 At the time agencies were working with Simon under a Child in Need Plan, this new information which clearly indicated potential significant harm should have initiated a strategy discussion. 3.2.3 The lack of a strategy discussion led to an uncoordinated approach to the sexual abuse allegation which overly focused on the police led investigation and did not focus on what the trauma implications were to Simon and his health. There was no clear plan on how the investigation would proceed and who would be taking the lead. There was a lack of consideration of what support may be available to Simon to support him in both progressing the criminal investigation or his overall support. There is no evidence that an Independent Sexual Violence Advisor (ISVA) was considered. 3.2.4 There is a lack of evidence that the risk of the allegation was considered in a wider sense. It is not clear that the alleged offender was identified, and consideration given to possible access to other vulnerable young people. There was also information given by Simon that peers at his school had indulged in alcohol and drugs and had been sexually 15 West Midlands Multi Agency Safeguarding Procedures Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 13 assaulted. It transpires that this information was vague, and identification of individuals would not have been possible, but this information was not followed up or shared with the school, at the time, so the appropriate enquiries could be made. 3.2.5 Other recent reviews have shown that the lack of a timely strategy meeting involving the right agencies results in uncoordinated and poor action leading to poor outcomes. The sexual assault allegation was made again and raised by the hospital social worker to the local authority social worker in mid- December 2019, this was immediately following a CiN review. Again, there was no consideration of a strategy meeting, this was not considered until January 2020, when the allegation came to the attention of a manager. This would indicate that there was a lack of appropriate management oversight at the earlier stages. 3.2.6 West Midlands Police were not invited to the strategy discussion, which was now some 6 weeks following the allegation by Simon. Warwickshire Police declined to attend the strategy discussion on the basis that West Midlands Police were dealing with the allegation. The net result was that police did not attend the strategy discussion and it would therefore have to be viewed as a professional’s discussion as opposed to a strategy discussion as set out in the guidance. The meeting agreed that the allegation should be taken seriously but there is no clear evidence on how this would be taken forward. It is recorded that CSC and hospital staff re-visited the allegation with Simon on a number of occasions but information on this is lacking. It was accepted by Warwickshire Police at the learning event for this review that it would have been good practice for them to attend the strategy discussion even though the location of the offence was outside of their area. 3.2.7 The matter was not effectively re-visited by West Midlands Police. There is a record that there was discussion between police and the local authority social worker in January 2020, around the time of the strategy discussion but there was no plan as to how the matter would be progressed. It would appear that West Midlands Police were not informed when Simon was discharged from hospital and the next time they attempted contact with Simon or his family was in September 2020. They record that attempts to speak to Simon’s family and social worker were unsuccessful and contact regarding this matter was not achieved before Simon’s death in March 2021. The family when spoken to for this review were not aware of any attempts to contact them and their contact details had remained the same. 3.2.8 Overall the coordinated response to the allegation made by Simon would have to be viewed as poor. The CiN plan was closed in July 2020, without consideration of the allegation and how it was to be resolved. The West Midlands Police initial enquiries established that the likely date of the alleged offence, it may be significant that it was shortly after this that Simon presented to hospital with what was described as an acute deterioration in behaviour, with persecutory thoughts and auditory hallucinations. There is little evidence that the potential trauma of being subjected to very serious sexual assault was considered in the context of Simon’s deteriorating mental health and how this would be addressed. 3.2.9 Learning from multi agency inspections found that practice in the area of child sexual abuse is too police led and not sufficiently child centred.16 The Independent Inquiry into Child 16 Multi-agency response to child sexual abuse in the family environment: joint targeted area inspections (2020) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 14 Sexual Abuse17 is clear that it is important for survivors to feel heard, listened to, understood, believed, and not judged, by a caring, empathetic professional. As identified in the strategic direction statement by NHS England18 when providing services to children who have been the victim of sexual abuse a trauma informed approach is needed that appreciates the devastating impact of CSA, and one that is centred on the needs of the survivor to build a trusting relationship with those who can help. 3.2.10 It has been established that the work placement that Simon was undertaking when he made the sexual abuse allegations was not one arranged by any of the agencies involved but one arranged by his family. The alleged perpetrator involved was not a person working with children and therefore it did not fit within the requirement to involve a Local Authority Designated Officer (LADO). There was information regarding potential use of drugs and alcohol leading to sexual abuse of Simon’s peers. This information was not discussed when a strategy meeting was finally arranged. Whilst the information was vague it should have been appropriately shared with the school via the strategy meeting for the necessary enquiries and action to be taken. Learning Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm, a strategy meeting/discussion should be held. This discussion should include all relevant partners and in a case such as this it should include relevant health professionals and the school. Where a strategy discussion does not take place, the following action is uncoordinated and lacks the necessary follow up. The issue of strategy discussions not occurring in relevant cases has been noted both locally19 and nationally. There should be good management oversight to ensure that strategy discussions are appropriately convened and attended. The timeliness strategy discussions was also identified the Warwickshire thematic review on exploitation. In addition, a number of audits indicated that strategy meetings were delayed, however there was no evidence that this had been escalated as a concern by the partner agencies involved.20 Where there are allegations of sexual abuse relevant agencies should ensure that the approach is not over reliant on the criminal prosecution. That the child and their family are put at the centre of the approach and that the approach is trauma informed and appropriate support considered. Where an allegation is made the police should ensure that the victim and where appropriate those acting for him receive regular updates on the progress of the case. 17 Independent Inquiry Child Sexual Abuse 2020 18 Strategic Direction For Sexual Assault And Abuse Services - Lifelong care for victims and survivors: 2018 – 2023 NHS England 19 Warwickshire SCR Alice and Beth September 2020 Warwickshire SCR Child K February 2020 20 Warwickshire Safeguarding Exploitation Strategy (2020-2023) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 15 The approach to dealing with survivors of exploitation in Warwickshire will be trauma informed.21 Recommendation 3 Considering the findings of this review, previous local reviews and National reviews the partners of the Warwickshire Safeguarding Partnership should seek to understand if there are barriers to convening strategy discussions in relevant cases. This should also look at the timeliness, attendance, management oversight and effectiveness of strategy meetings that do take place. Consideration should be given to how this assurance can be monitored going forward. Recommendation 4 The Warwickshire Safeguarding Partnership should ensure that the learning on this review is considered by the Exploitation sub group to consider how they link to the Exploitation Strategy and are used to help to develop a trauma informed approach for child sexual abuse. Recommendation 5 West Midlands Police should provide assurance to Warwickshire’s Safeguarding Partnership that victims and where appropriate parents of children and young person’s reporting offences of rape and serious sexual assault are appropriately updated and offered support. 3.3 How apparent was Simon’s voice in the recording of interactions with agencies and how was it used in decisions, assessments and interventions being delivered? What were the concerns raised by him on his appearance and did these impact on his self-esteem? 3.3.1 There are areas where Simon’s voice is reflected and captured well and that this then featured into discussions and considerations regarding plans and interventions for Simon. Equally there are areas where the same consideration is not evident. 3.3.2 Simon’s school involved Simon in discussions on the plans for his return to school following his accident. This involved allowing Simon to educate his peers about his injury in discussions and a school assembly. There is good evidence of the school approach being child centred with them securing support from the Brian Injury Trust and an Education, Health and Care Plan (EHCP) and supporting him towards post 16 learning. 3.3.3 There is a lack of evidence of the CiN plan being child centred. The first review was conducted by email updates due to lack of professional availability and the parents being at the hospital every day. The subsequent meetings were also conducted in this fashion. This approach was partly as a consequence of the covid virus, and this is more fully discussed in the previous section. 21 Warwickshire Safeguarding Strategic Thematic Review on ‘Exploitation of Children and Adults (November 2019 to February 2020) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 16 3.3.4 Simon’s voice was well documented within interactions with his RISE coordinator and Consultant Psychiatrist, this is particularly the case around his medication and weight gain. It was noted that his weight gain had a significant impact on his self-confidence and a plan was put in place to support him, which included support from a dietician. Simon requested to have his medication reduced but this had to be balanced against stabilising his mental health. Simon’s care coordinator is said to have formed a good trusting relationship with Simon and as a result was able to discuss many issues and areas of interest with him. 3.3.5 Simon’s voice was lacking in the allegations that he made regarding being sexually abused. He was not interviewed for the criminal matters at the time of the allegation, or when he repeated the allegations due to the fact that he was unwell. There was no follow up to the allegations as discussed in the previous section. This would have had the effect of leaving Simon unheard and possibly not believed in this regard. 3.3.6 Part of the picture of a young person will come from their family and those close to them, as well as what they say themselves. This may have been impeded due to the language barriers with Simon’s parents not having English as their first language. From discussion with family for this review there are also differences with how agencies approach support in the UK with that of what the family were accustomed to in their own Country. It would demonstrate good cultural awareness for agencies to explore this aspect where the family have experiences in other Countries. Recommendation 6 When agencies are dealing with children, young people where there is a risk of suicide consideration should be given to a ‘Think Family’ approach, with particular consideration to areas of culture. 3.4 Were the right areas of learning identified in the tabletop learning exercise of 2019? Were the areas of learning communicated effectively to professionals and did this result in the necessary improvements? Were the cultural and language challenges to Simon and his family identified in the tabletop review and appropriately addressed? 3.4.1 In May 2019, Simon made a significant attempt to take his life at his home and was found by his family. This incident was discussed at a Rapid Review meeting. The aim of the rapid review is to enable safeguarding partners to: • gather the facts about the case, as far as they can be readily established at the time • discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately • consider the potential for identifying improvements to safeguard and promote the welfare of children Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 17 • decide what steps they should take next, including whether or not to undertake a child safeguarding practice review 22 The meeting confirmed that there was learning to be achieved but did not feel that the case met the criteria for a Local Child Safeguarding Practice Review. It was agreed that the Partnership would arrange a tabletop review on the case and this took place in November 2019. 3.4.2 The tabletop review identified the following areas of learning. These areas were subject of learning briefing, which was disseminated to the Partnership. • Recording of issues in the Multi Agency Safeguarding Hub (MASH) and these concerns being followed up by a written referral (MARF). • Evidence that Simon’s voice was sought and he had real involvement in decisions being made. • Evidence was lacking that Simon’s parents and wider family were involved in discussions and a Think Family approach should be sought with emotional support being offered to the family. • English was not the parents first language, some agencies relied on either Simon or his English-speaking sibling to translate for them. The review recommended that accredited interpreters, signers or others with special communication skills should be used. 3.4.3 Generally there should be more evidence that the learning from the tabletop review has resulted in action to ensure that the lessons are understood and embedded into practice. The benefit of the learning briefing is limited as it will only be accessed by a limited number of staff. Some of the areas from the tabletop review are repeated themes as those being considered in this, the subsequent review. 3.4.4 The tabletop review was undertaken at a time when Simon had recently been admitted to hospital and detained under section 2 MHA. This was an ideal opportunity to discuss what support was to be offered to the family, as identified as a learning theme but there is limited evidence that this was done and feedback from the family would indicate that this was not the case. 3.4.5 The tabletop review rightly identified that agencies when dealing with families where English is not their first language should use accredited interpreters to ensure that the views from families are accurately given and recorded. There is evidence of good practice with Simon’s school and CSC either using interpreters or introducing staff who had the necessary language skills. Despite the learning achieved in the November 2019 tabletop review there continued to be some instances where Simon or his sibling were used to interpret for their parents. In February 2021 the care coordinator asked Simon to interpret for this mother and in February and March 2021 during consultations with the consultant psychiatrist it is not clear that there was support of an interpreter. During this meeting important information was given on diminishing the risk of suicide, which was vital that the parents and family fully understood. 22 Working Together 2018, HMG (Chapter 4.20) Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 18 Learning There still remains an issue with the ability of agencies to access appropriate interpreting services. There will be a difficulty with this where agencies are responding to an unplanned dynamic situation but where there is a long-term relationship between professionals and families there should be scope to pre-plan the appropriate support. Where there is a learning process and the subject of that review is still living there should be built into that process the ability to review the case at given points to evaluate whether the learning identified has been implemented and the same issues do not still exist. Recommendation 7 The Warwickshire Safeguarding Partnership should seek assurance to ensure that the learning from the Simon tabletop review of 2019 is effectively communicated to all agencies and should in due course consider a multi-agency audit on the learning theme of the use of interpreters. 3.5 What was the effect of Covid both on Simon and his family and on the ability of agencies to deliver services? 3.5.1 The UK went into the first national lock down in March 2020, at this time Simon was still at in the Tier 4 hospital under the Mental Health Act. He was discharged in April 2020, other agencies involved in supporting Simon were not informed of the discharge. The Covid restrictions also impacted on the periods of home leave that Simon was able to have, this had bearing on his discharge. 3.5.2 The restriction implemented as a result of the pandemic had a notable impact on the ability of agencies to undertake face to face visits. Simon articulated to the RISE coordinator that he preferred face to face contact. Where it was not possible to have face to face meeting a number of other alternatives were used. 3.5.3 The CiN plan was started in June 2019 and most of the reviews and subsequent meetings were undertaken virtually and by email. This approach cannot be entirely attributed to the pressures brought about by the covid pandemic. 3.5.4 The school acted very responsively when Simon was discharged from the Tier 4 hospital. This included placing him in the most vulnerable cohort and resulted in him being contacted regularly by the school. The school liaised well with other agencies and facilitated a joint CiN/EHCP review meeting. The school sourced an accredited interpreter for the meeting. The school had researched an area of work which Simon was interested in and provided translated information for Simon’s parents. 3.5.5 Whilst there is a lack of consistent evidence to support the view that children and young people with pre-existing mental health conditions before the pandemic were exacerbated as a result of the pandemic and resulting restrictions23, there can be little doubt 23 Covid 19 mental health and wellbeing surveillance report, April 2022 (Chapter 4), Office for health improvement & disparities, HMG Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 19 that the pandemic presented challenges for Simon. One of these was recorded as him not being able to have the face to face contact with professionals that he would have wished. 3.6 Was there recognition of the relevant risk factors in this case and did this result in appropriate analysis and mitigation of the risk? Where assessments were undertaken was historical information effectively used to inform them? Mental Health Assessment 3.6.1 There were indications that Simon was prone to risk taking behaviour. His accident in 2018, which resulted in his brain injury, involved him climbing on a building and falling through the roof. After his accident the family describe Simon as angry, impulsive, anxious and stressed. In April 2019, Simon jumped from a window in his family home and Simon described this as thrill seeking activity having lost his ability to ride motorbikes since his injury. There was also evidence during the course of the timeline of this review of Simon having at least three accidents on his pushbike. Simon’s family, when spoken to for this review, felt that Simon’s behaviour was unpredictable and the evidence available would support this. 3.6.2 There is good evidence that Simon recognised his mental ill health and self-presented to hospital on four occasions seeking support (April 2019 leading to first hospital admission, November 2019 leading to second admission, February 2021 where he was reviewed and discharged pending psychiatric review in the community and March 2021 which was a week before Simon’s death). Following the February 2021, presentation Simon was reviewed by his psychiatrist who felt that his visit to the hospital two days previously was an early sign of relapse24, although there was consideration of substance misuse (Simon denied recent use of alcohol and drugs). In this appointment Simon agreed to an increase in his medication. Following this meeting a further request was made by letter for involvement with the EIP team. 3.6.3 Following Simon’s last presentation at hospital he was reviewed by the psychiatrist a week later as part of a follow-up review, which also considered the recent hospital attendance. There was continuity in the psychiatrist involved as they had reviewed (either virtually or in person on 13 occasions since November 2019) so the history was well known to them. The care coordinator was also involved who had regular contact with Simon for a considerable time. 3.6.4 During this review Simon again requested a reduction in his medication. This had been an enduring feature of Simon’s requests over a period of time and it was felt that this was mainly due to Simon’s weight gain whilst being on the medication. There had been agreed gradual reduction to maintain engagement, and this was supported by regular review. Following the February 2021 and March 2021 presentations at hospital the medication was increased. Simon’s desire to reduce his medication was acknowledged but this was counterbalanced by the need to keep Simon stable. The level of medication was addressed regularly in reviews with Simon and advice and suitable guidance was given. 24 Inquest witness statement, CWPT Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 20 3.6.5 Simon’s last mental health assessment was on the morning prior to his death. During this review Simon stated that he felt unsafe but there was no specific reason for this feeling. Simon admitted fleeting thoughts of harming himself. These thoughts were probed, and Simon detailed means of causing harm but stated he had not gathered such items as they were freely available at home. Simon stated that he had no immediate plans of suicide, and he was future orientated discussing future plans freely. Simon rated his mood at 3/10 (1 being low and 10 being good) and his anxiety 8/10 (1 being no anxiety and 10 being very anxious). Simon was assessed as having capacity to make decisions about his treatments and management. 3.6.6 The psychiatrist felt that there were possible risks of further deterioration of Simon’s mental state if he was non-compliant with his medication. They acknowledged that there were unpredictable risks of self-harm or even suicidal acts, also that due to Simon’s past history and recent reported abuse of substances it could lead to an impairment of Simon’s mental health or influence his decision-making ability, including increased impulsiveness. Simon’s previous attempt take his own life in May 2019, had been a concerted attempt at hanging where he was discovered in the family home having been unconscious for 8.5 minutes. There had been no red flags to this behaviour to alert family or professionals before it occurred. This also supported the potential for impulsive but concerted action by Simon. 3.6.7 There was discussion (through an interpreter) with Simon’s mother who stated that she was not aware of Simon’s suicidal thoughts. Simon and his mother agreed to safety strategies. Simon’s mother was asked to remove/lock away all the potential materials that Simon could use to cause harm to himself. Advice on crisis support was given and arrangements for the RISE care coordinator to call on a daily basis. 3.6.8 Simon’s mother disclosed that she supervised Simon at night by sleeping in the same room. From discussion with the family for this review, they found the advice regarding the removal or articles difficult both in practical terms but also the onus and responsibility it put on them for what was almost an impossible task. Whilst this course of action is understandable, as a risk mitigation measure the effectiveness is questionable as it was not clear to the family that there was an expectation that someone should be with Simon on a 24/7 basis. Where the act of suicide is completed, it also had the effect of increasing the sense of guilt and feeling of responsibility for the family. There may be an opportunity to review how this request is made and what support can be offered to families to help them achieve the request whilst sharing responsibility. 3.6.9 Whilst this review does not seek to question or challenge the mental health assessment made on the day of Simon’s death it does highlight the difficulty of such assessments where there is potential of such fluctuations and tendency to impulsive and extreme behaviour. MASH assessment 3.6.10 Following Simon presenting at the hospital in March 2021, the hospital made a referral to the MASH. The referral was made in the required fashion using a Multi-Agency Contact (MAC). The use of this process had previously been highlighted in this case during the tabletop exercise and this contact complied with the identified learning. 3.6.11 The MAC stated that Simon had attended the hospital with mental health issues and suicidal thoughts. He disclosed that he wanted to physically harm himself and these feelings were overwhelming. He went on to say that he had no actual plans and was not aware of the contributing factors. The MAC covered that Simon had previously been a psychiatric inpatient and that both Children Social Care and CAMHS were involved with him. Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 21 3.6.12 This referral in the MASH was dealt with poorly. There was no consideration of the history of the case both within CSC and other agencies. The referring agency was not contacted nor were any agencies currently involved with Simon (RISE and school). Simon and the family were not contacted and there was no consideration of an assessment of what support could be made available. The only action was that a letter signposting support was sent to the family. This letter was in English and despite previous interactions with the family and the recommendations of the tabletop review, there was no consideration of language and cultural issues. 3.6.13 There was recognition of this poor response following Simon’s death and the Rapid Review and as a result remedial actions were implemented in the MASH. In September 2021, the Warwickshire MASH was replaced with the Warwickshire Families Front Door, which incorporates Early Help and Family Support. There is support from partner agencies, with plans to incorporate RISE. This review would suggest that RISE should be incorporated as a matter of priority. Warwickshire Safeguarding Partnership will be completing a full multiagency review of the Front Door and MASH provision. Early Intervention Pathway 3.6.14 The guidance for implementing EIP and setting the standards for waiting times25 identifies good evidence that these services help people to recover and to gain a good quality of life. EIP services have demonstrated that they can significantly reduce the rate of relapse, risk of suicide and number of hospital admissions. The guidance was introduced due the unacceptable level of persons with psychosis being able to access timely treatment. The standards set out two high level aims:- • Anyone with an emerging psychosis and their families and key supporters can have timely access to specialist early intervention services, which provide interventions suited to age and phase of illness. • Individuals experiencing first episode psychosis have consistent access to a range of evidence-based biological, psychological and social interventions as recommended by the NICE guidelines and quality standards for psychosis and schizophrenia. For children and young people, the standards set a week target form the time of first referral. The importance of an effective EIP is also recognised locally in the CAMHS Transformation Plan.26 3.6.15 Upon discharge from the Tier 4 setting in April 2020, Simon was diagnosed with schizoaffective disorder and Post Traumatic Stress Disorder, due to this and Simon’s continued presentation with psychotic symptoms the treating psychiatrist referred Simon to the EIP in June 2020. Simon was not accepted by the service on the basis that he had a head injury which may have contributed to his condition. In a dialogue that lasted throughout 2020 and into 2021, clarity was sought from the Consultant in Paediatric Neurology who treated Simon when he received his head injury. Simon was not accepted onto the EIP caseload until March 2021, some eight months following the first referral. 3.6.16 The NICE and NHS England guidance state that when dealing with access to the service that the only exceptions to these services will be where a person has a confirmed organic cause (such as brain diseases or tumours). This was not the case and as the final 25 NICE and NHS England, 2016, Implementing the Early Intervention in Psychosis Access and waiting time standard: Guidance 26 Coventry and Warwickshire's Child & Adolescent Mental Health Services (CAMHS) Transformation Plan Year 5 Refresh: 2021/22 Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 22 acceptance recognised, Simon should have been accepted at a much earlier stage to the service. 3.6.17 Early acceptance to the service would have provided several benefits including support to Simon and his family, supporting Simon with co-existing health conditions such as weight gain, supporting with social issues. It would also have supported Simon as he transitioned into adult services. Learning The identification and management of risk for those with mental health conditions and experiencing suicidal ideation is difficult. Simon had demonstrated a real previous intent to take his life, there had been instances where he had been found with items to cause harm to himself and had also talked about suicide. It was recognised that Simon could act impulsively and that on and around the time of his death he was suffering high levels of anxiety. It would not be appropriate for this review to comment negatively on the mental health assessment that was undertaken on the day of Simon’s death but the circumstances should act as a reminder to all working in this very challenging area of the changeable dynamics of a person’s mental health and despite their assurance and future orientation, completed suicide is an potential outcome at almost any stage. When working with families, professionals need to be aware of the realities of mitigation measures, such as the cleansing of homes from items which may be used to cause harm. It may be that balanced and informed written guidance could be provided or professional support, but being mindful of what is actually achievable. The MASH has undergone some changes since the events of this review but there is a need to understand that these changes will result in more positive outcomes. The panel for this review recognised that there needs to be greater representation of the RISE service within the front door. Local discussion is required to establish what this service looks like. The pathway for early intervention for Psychosis needs to be more easily achievable than it was in this case. Recommendation 8 In reviewing the forthcoming contract for child and adolescent mental health services, the partnership should seek to embed a new model into the contract that should move away from a medicalised model based on diagnosis towards a needs led approach to ensure that appropriate support is provided in a timely manner whilst a young person awaits assessment or a treatment plan is agreed Recommendation 9 All professionals managing the risk of suicide with families should seek to work with them when proposing measures involving the removal/storage of items potentially used to cause harm and consideration should be given as to the best method of delivering this information. Recommendation 10 The Warwickshire Safeguarding Children Partnership in the planned review of MASH and the Front Door should be assured that a concern of the same nature as in this case would be appropriately and effectively dealt with. The Partnership should seek assurance that RISE Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 23 presence within the Front Door model is a priority and there is local dialogue to shape and achieve this. Recommendation 11 The commissioners of the Early Intervention in Psychosis Access pathway should ensure that the service is delivering within the NICE and NHS Guidance on Access and Waiting Time standards. 3.7 In the assessment of risk was the cumulative effect of Adverse Childhood Experiences (ACEs) considered? 3.7.1 Adverse Childhood Experiences (ACEs) are defined by Public Health Wales ACE’s as ‘traumatic experiences that occur before the age of 18 and are remembered throughout adulthood’ They state that ‘Evidence shows children who experience stressful and poor-quality childhoods are more likely to develop health-harming and anti-social behaviours and are more likely to experience poor mental health due to poor self-image and self-worth’ A thematic review of child suicides in The Black Country27 looked at 6 cases of confirmed and suspected childhood suicides and found that in 5 of the 6 cases (83%) there were 3 or more recognised ACEs present. Different childhood experiences and the duration of exposure to them will have an effect on the impact of the experience.28 3.7.2 A recent report exploring the rate of likely suicides among all children and young people between April 2019 and March 2020 found that the top three factors that were present amongst many suicides were household functioning (69%), loss of key relationships (62%), and the mental health needs of young people (55%)29. 3.7.3 Simon had alleged sexual abuse and there was evidence that he felt that there was an important person in his life, the close friend who he may have felt he was losing contact with30. Simon’s parents were estranged. There was also more latterly in the chronology of the case information from the family that there had been two instances of family suicide in their home Country. Simon also suffered an injury that had a significant social impact on him, there is evidence that he was searching for the person that he used to be before his accident31. 3.7.4 The Black Country Thematic review made two recommendations concerning ACE’s and suicide antecedents. There should be a consideration of incorporating ACE’s and the link to increasing suicide antecedents into all assessments and discharge planning processes within mental health services and to ensure professionals understand ACE’s, the risk of cumulative harm and the impact of these adversities and for this approach to be applied within decision making, whether the child is seen to be coping or not. 27 Black Country and West Birmingham CCG, 2021, Safeguarding Review of suspected child suicides in The Black Country and West Birmingham 28 BMJ 2020;371:m3048 29 NCMD. (2021). Suicide in Children and Young People—National Child Mortality Database Programme Thematic Report. https://www.ncmd.info/wp-content/uploads/2021/11/NCMDSuicide-in-Children-and-Young-People-Report.pdf 30 Record of Inquest 31 Family interviews Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 24 3.7.5 There should be consideration of ACEs and the recognised suicide antecedents when undertaking assessments and discharge planning within mental health and that professionals understand ACEs and the impact of cumulative harm. 3.8 Access to and provision of Tier 4 settings 3.8.1 In this case a Tier 4 provision was found for Simon but this entailed him moving some 100 miles away from his family and therefore required the family to make a 200 mile round trip on an almost daily basis. The inability to access a more local provision put considerable additional pressure on the family and undoubtedly caused Simon additional concern. This is a national issue and was recognised in the CQC Review of Children’s Mental Health Services32 which states ‘For those children and young people who need more intensive and specialist care, there are significant challenges in accessing services. There are long waiting lists for many of the services that provide specialist mental health care in the community, and the imbalance between demand and capacity in inpatient care means that children and young people cannot always find an appropriate bed in an inpatient ward close to home.’ 3.8.2 Simon was discharged from the Tier 4 in April 2020, the hospital was inspected in November and December 2020, with a report published in February 2021. The hospital was deemed to be inadequate overall and placed in special measures. The findings included young people and families not being involved in care plans and risk assessments. A new management team has since been established in the hospital but the changes made it difficult for this review to access all records, although the current leadership did their best to assist the review. Recommendation 12 NHS England should be made aware of this review to assist in informing the national review of the service specification for Tier 4 CAMHS services. 4.0 Recommendations: Recommendation 1 The Warwickshire Safeguarding Partnership should seek assurance on effectiveness of Child in Need Plans in the context of providing support to children and young people at risk of suicide and how these relate to other relevant plans such EHCP, RISE Care Plans and Risk Plans. Recommendation 2 Warwickshire Children Services and relevant partners should review the process and policy of receiving and responding to notifications under section 85, Children Act 1989. Recommendation 3 32 CQC, 2017, Review of children’s and young person’s mental health services phase 1 Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 25 Considering the findings of this review, previous local reviews and National reviews the partners of the Warwickshire Safeguarding Partnership should seek to understand if there are barriers to convening strategy discussions in relevant cases. This should also look at the timeliness, attendance, management oversight and effectiveness of strategy meetings that do take place. Consideration should be given to how this assurance can be monitored going forward. Recommendation 4 The Warwickshire Safeguarding Partnership should ensure that the learning on this review is considered by the Exploitation sub group to consider how they link to the Exploitation Strategy and are used to help to develop a trauma informed approach for child sexual abuse. Recommendation 5 West Midlands Police should provide assurance to Warwickshire’s Safeguarding Partnership that victims and where appropriate parents of children and young person’s reporting offences of rape and serious sexual assault are appropriately updated and offered support.33 Recommendation 6 When agencies are dealing with children, young people where there is a risk of suicide consideration should be given to a ‘Think Family’ approach, with particular consideration to areas of culture. Recommendation 7 The Warwickshire Safeguarding Partnership should take action to ensure that the learning from the Simon tabletop review of 2019 is effectively communicated to all agencies and should in due course consider a multi-agency audit on the learning theme of the use of interpreters. Recommendation 8 In reviewing the forthcoming contract for child and adolescent mental health services, the partnership should seek to embed a new model into the contract that should move away from a medicalised model based on diagnosis towards a needs led approach to ensure that appropriate support is provided in a timely manner whilst a young person awaits assessment or a treatment plan is agreed34. 33 Recommendation requested by WS Executive Board 34 Recommendation requested by WS Executive Board Final Simon CSPR Report vs 1.0 10 07 2023 NO PM.docx 26 Recommendation 9 All professionals managing the risk of suicide with families should seek to work with them when proposing measures involving the removal/storage of items potentially used to cause harm and consideration should be given as to the best method of delivering this information. Recommendation 10 The Warwickshire Safeguarding Children Partnership in the planned review of MASH and the Front Door should be assured that a concern of the same nature as in this case would be appropriately and effectively dealt with. The Partnership should seek assurance that RISE presence within the Front Door model is a priority and there is local dialogue to shape and achieve this. Recommendation 11 The commissioners of the Early Intervention in Psychosis Access pathway should ensure that the service is delivering within the NICE and NHS Guidance on Access and Waiting Time standards. Recommendation 12 NHS England should be made aware of this review to assist in informing the national review of the service specification for Tier 4 CAMHS services. |
NC044717 | Serious injury of a baby girl in late 2011. Child F was stabbed by her father who was described as suffering a severe psychotic episode at the time. Father was arrested and subsequently received psychiatric care in a secure setting. Father had intermittent contact with mental health services from his late teens onwards, which included episodes of drug-induced psychosis. He received a four year prison sentence for a serious violent crime prior to the birth of Child G. Issues identified include: lack of access to significant history contained in court and prison psychiatric reports and prison health records; pattern of agency involvement with the family by two distinct sets of professionals, focusing separately on the father and on mother and children; overreliance on self-disclosure in assessing risk; and lack of agency knowledge about degree to which father was involved in care of children. Identifies learning, including: the need for GPs to 'think family'; and the need for the probation service to improve its approach to notifying social care of the birth of children to supervisees. Makes various recommendations covering GPs, probation services, accident and emergency services, mental health and health services. Review was undertaken using elements of a systems approach.
| Serious Case Review No: 2014/C5017 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Child F Serious Case Review Overview Report Services provided for Child F and Child G and members of their family from January 2009 – October 2011 Serious Case Review Overview Report Author Keith Ibbetson 1 Services provided for Child F and Child G and members of their family from January 2009 – October 2011 CONTENTS Section Serious Case Review Findings Page 1. Arrangements for the Serious Case Review (SCR) 2-9 2. Details of family members 10 3. Narrative of agency involvement with the children and their family 11-25 4. Evaluation of the services provided 26-57 5. Key findings and conclusions 58-62 6. Additional recommendations of the SCR overview report and SCR panel 63-65 Appendices I Terms of reference of SCR 66 II Membership of the SCR panel 67 III Background documents and references 68 IV Excerpt from Healthy Child programme on engagement of fathers 69 V The response of emergency services 70 VI Recommendations of individual management reviews 71-73 2 1 ARRANGEMENTS FOR CONDUCTING THE SERIOUS CASE REVIEW Introduction 1.1 This report was prepared for (TEXT REDACTED) Local Safeguarding Children Board (LSCB) in order to fulfil the requirements of Chapter 8 of the Working Together guidance.1 The guidance sets out the arrangements for the local interagency review of cases which have given rise to serious concerns about the safeguarding of children and where there may be important lessons for the local network of agencies with child protection responsibilities. The purpose of this report is to highlight the most important findings of the review with the objective of improving local child protection practice. 1.2 (TEXT REDACTED) The terms of reference of this Serious Case Review (SCR) were agreed in January 2012 in line with the statutory guidance published on 1 April 2010. 1.3 This document is the LSCB overview report on the SCR. It summarises and complements the findings of the individual management reviews conducted by the agencies that were directly involved. The guidance under which the SCR conducted its work provides for the SCR overview report to be published in full. The child who is the focus of the review was seriously injured but is now well. She has an older brother. Before publishing the report the LSCB has a responsibility to remove from it any information that might lead to the identification of the children or cause an unnecessary intrusion into the privacy of the children or other family members. 1.4 An Executive Summary will be published which sets out the circumstances of the case (without publishing anything that would risk identifying the children involved) and the lessons of the review. The SCR completed its initial work in June 2012. At that time the events which led to the SCR were still the subject of a criminal investigation. The completion of this report has been delayed until the conclusion of the criminal proceedings in order to take full account of information from the criminal proceedings and also to ensure that premature publication of the SCR findings did not prejudice the criminal trial. 1.5 The review concerns services that were provided to two children and the members of their family: Child G was aged 2 and Child F was (TEXT REDACTED) an infant in late 2011, when Child F was stabbed by her father. At the time he was suffering from what has been described in psychiatric reports as a ‘severe psychotic episode’. 1.6 The children lived with (TEXT REDACTED) other members of their family at an address in (TEXT REDACTED). Their father lived at this address for some of the time and at the home of his own mother which is also in (TEXT REDACTED). Child F suffered a number of stab wounds before her father could be (TEXT REDACTED) arrested by police officers who had been sent to the family home following a 999 1 HM Government, Working Together to Safeguard Children – 2010.. 3 call (TEXT REDACTED). The children’s father was detained in custody after the incident but subsequently received psychiatric care in a secure setting. (TEXT REDACTED) The scope, focus and terms of reference of the Serious Case Review bearing in mind the circumstances in which Child F was injured and the involvement of agencies with the family 1.7 The Working Together guidance states that the LSCB in the area where the child lived should consider conducting a SCR when a child sustains a life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children (Working Together Section 8.11). Initial reports indicated that the injuries had been life threatening and so the LSCB decided to conduct a SCR. 1.8 It is part of the function of the SCR to judge whether there are concerns about the way in which agencies and professionals had carried out their child protection responsibilities. In reaching the decision the LSCB noted the following background information which would require attention in the review: • The children’s father had been in intermittent contact with mental health services for a number of years – both in (TEXT REDACTED) and when he was in prison (TEXT REDACTED) • He had a number of criminal convictions and he had been supervised by the probation service (TEXT REDACTED) • A number of agencies and professionals had been involved with the family but had not identified any concerns about the children • The father and members of his family had sought help from local health services about his mental health in the days prior to the incident. Neither of the children had ever been referred to the local authority or been the subject of a child protection investigation or child protection plan. 1.9 The recommendation to hold the SCR was made on 21 November 2011. The independent chair of (TEXT REDACTED) LSCB made the decision to undertake the SCR on the same day. Work began at that point to agree the scope and terms of reference of the review. Following early meetings, formal notifications of the review and the methodology for its conduct were sent to all LSCB member agencies. Through a review of agency records the LSCB determined which agencies needed to contribute individual management reviews. A full list of the agencies involved in the review is set out in section 1.14 below. 1.10 The Working Together guidance makes the LSCB responsible for determining the scope and terms of reference for the SCR taking into account the circumstances of the particular case. Consideration was given to this within the SCR panel and there was also consultation with participating agencies. The general terms of reference for the SCR adhere to the objectives for SCRs set out in the Working Together to Safeguard Children 2010: 4 to draw together a full picture of the services provided to establish whether there are lessons to be learned from a case about the way in which local professionals and agencies work together to safeguard children to identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and hence improve interagency working and better safeguard children 1.9 The terms of reference agreed for this review are contained a separate document which contains family details. Key sections highlighting the focus of the review are reproduced as Appendix 1 to this document. The scope of the SCR covered a period of nearly three years, beginning in January 2009 and ending when Child F was stabbed. 1.10 The Terms of Reference address issues identified in Working Together to Safeguard Children 2010 as being of general relevance and also issues specific to the case history. The terms of reference were followed by the authors of individual management reviews and the independent author of this overview report. Section 3 of this report provides a chronological account of agency involvement with the family. Section 4 of the report focuses on the following questions and themes: Historical information (prior to 1 January 2009) on the family members about factors that may have led to risk to the children or impacted on the parenting capacity of either the mother or the father The quality of assessment undertaken, particularly the assessment of risk and parenting ability The plans made following assessments, whether they were consistent with the assessments undertaken and whether plans were fully implemented? The quality of information sharing within and between agencies Whether the focus of agencies‘ activities focus on the needs of children Whether agencies responded appropriately to any risk factors identified in the course of their work with the family Were the diversity needs (ethnicity, religion or any disability) of the family were recognised and responded to? Did staff have the knowledge, skills and experience to respond to the needs identified in the case? Were staff appropriately supervised and supported in their work with the family? Did any issues or capacity or resources within agencies limit the ability of the agency to meet the needs of the family? 1.11 The overview report also makes recommendations on changes that need to be made to implement the lessons of the SCR. These take account of the recommendations contained in individual management reviews and developments in services that have occurred since the events in question took place. The SCR 5 either makes recommendations on matters that are not already part of the work programme of individual agencies and the LSCB, or in some matters it makes recommendations to strengthen work that is already taking place. Critical periods of agency involvement covered by the SCR 1.12 The scope of the SCR runs from the beginning of the mother’s pregnancy with Child G to the incident in which Child F was stabbed. Agencies were asked to scrutinise any earlier information in their records. Agency files showed that the children’s father had had a significant amount of earlier involvement with health, education and criminal justice agencies. This has been provided as background information because it demonstrates the long standing nature of many of the difficulties that he experienced. However it was agreed by the SCR panel and the overview report author that the focus of the review should be on current and recent service provision. Agencies involved 1.13 The following agencies and contracted professionals provided services to the children and to other family members within the period covered by the review and have provided a full chronology of their work with the family and an individual management review: (TEXT REDACTED) Hospitals NHS Trust Integrated Care Organisation (which provides community health visiting services in (TEXT REDACTED)) (TEXT REDACTED) NHS Foundation Trust (which provided community mental health services) (TEXT REDACTED) Hospitals NHS Trust (which provides hospital services at (TEXT REDACTED) NHS (TEXT REDACTED) (in relation to GP services) (TEXT REDACTED) NHS Trust (antenatal services in relation to Child F) (TEXT REDACTED) Police Service (TEXT REDACTED) Probation Trust 1.14 A number of other agencies had very limited involvement in the case history and were therefore either asked to provide chronologies, background information and reports or to contribute via additional discussions with SCR panel members: (TEXT REDACTED) Ambulance Service A substance misuse service involved with the father Limited information was also obtained from the father’s school records and Connexions records (referred to in section 3 of the report). No faith, voluntary or community groups were identified as having been involved in relation to the welfare of the children. 1.15 The Working Together guidance stipulates that a health overview report should be prepared on behalf of the commissioning Primary Care Trust (from 1 April 2013 Clinical Commissioning Group). Its purpose is to provide an overview of health 6 provision and to identify the key findings from the SCR which have implications for NHS commissioning of health services. The Designated Doctor for Safeguarding for NHS (TEXT REDACTED) prepared this report. The findings of the health overview have contributed to the findings of this SCR overview report. 1.16 At the point when the SCR began the government was actively considering how best to respond to the recommendation made by Professor Eileen Munro that a ‘systems’ model should be used to conduct SCRs. 2 The LSCB Chair had brief discussions with the Department for Education and with the Social Care Institute for Excellence (SCIE) about whether it would be possible to seek dispensation from the current statutory guidance in order to use this review as a ‘pilot’ systems SCR. For a number of practical reasons it was not possible to do this. However a decision was made to try to use elements of the systems approach in the way in which the SCR was conducted while adhering to existing guidance. This has resulted in a much greater level of direct involvement of staff in the SCR than would normally occur giving them an opportunity to add important detail to the findings and to test them against their own experience of their work with the family. This has been a useful experience which the LSCB will evaluate as part of its wider learning and preparation for the revised statutory guidance published in draft in June 2012. Staff accounts of their involvement are taken in to account as part of the overall information evaluated by the SCR. Availability of records 1.17 With the exception of the mother’s antenatal records in relation to her first child all of the relevant health and medical records were accessed for the SCR. (TEXT REDACTED) Council was asked to locate educational records for the father because it became clear that he had experienced difficulties going back to his childhood and he had been educated in part in (TEXT REDACTED). (TEXT REDACTED) was unable to locate these records because school records from the relevant period have not been fully archived and indexed. Some limited records were found. Although the inability to locate records is always a concern, neither of these records is likely to contain information which would significantly alter the findings of the SCR. 1.18 All of the other relevant agency records were available for the review and so far as could be established there were no significant gaps in the records. Appointment of the SCR panel, the SCR panel chair and the appointment and role of the independent overview report author 1.19 (TEXT REDACTED). SCR panel members are senior managers in member agencies or designated professionals with substantial experience of safeguarding children. 2 The Munro Review of Child Protection: Final Report: A Child centred system, Cm 8062, May 2011, The Stationery Office 7 1.20 The SCR panel was chaired by (TEXT REDACTED). This arrangement is consistent with the statutory guidance. He is not employed by any of the agencies involved in the review. He has substantial experience and expertise in child protection services. (TEXT REDACTED). 1.21 The SCR overview report was prepared by Keith Ibbetson. He has no relationship of any kind with any of the agencies involved in the review or to anyone involved in the case or the SCR. He has not previously worked for (TEXT REDACTED) LSCB. He is an experienced author of SCRs and chair of SCR panels. The independent author has not been a decision making member of the panel but has taken the following roles: to attend meetings of the SCR panel and provide professional advice as required to review the agency management reviews and to seek out and evaluate along with the SCR panel additional relevant material to corroborate or develop the findings made by agencies to meet with staff members who were involved in two health agencies in order to discuss their role in the case to assist the panel in improving the quality of the agency management reviews to prepare the overview report on behalf of the panel to present an outline of provisional findings to staff who were involved and receive their feedback and comments to meet with family members to discuss their views of the services provided to finalise the overview report taking into account the views of professionals involved, the views of family members and the discussions at the panel to prepare the executive summary on behalf of the LSCB 1.22 The SCR panel has met on six occasions in order to: make decisions on the conduct of the review manage the review so as to ensure that it complied with the statutory guidance consider progress in the production of agency individual management reviews and chronologies receive and consider an initial draft of this overview report and of the health overview report to decide when and how it would be best to engage members of the family in the review to consider and agree recommendations to consider a draft action plan to agree the overview report, the recommendations and action plan and to agree the executive summary for recommendation to the LSCB 8 Quality of Individual Management Reviews and steps taken to improve their quality 1.23 The SCR panel and the overview report writer have scrutinised the quality of the individual management reviews to ensure that they provide a full and objective evaluation of the work of each agency. The quality of the individual reviews has largely been good and some are considered to be of a very high quality. They have all made an important contribution to the findings of the SCR. All of the review writers were asked to clarify points of detail in their reports. The SCR asked for a small number of the reviews to be amended and resubmitted because they did not adequately cover areas that were considered essential. There has been a high level of cooperation in that process and support from all of the participating agencies. Parallel processes that have impacted on the conduct of the SCR 1.24 The (TEXT REDACTED) Police Service conducted a criminal investigation into the wounding of Child F. The individual management review prepared by the police contains some details of the police investigation and the progress of criminal proceedings. The criminal proceedings have now been concluded and relevant information has been taken into account by the SCR. Agreed extensions to the normal timescale for completion of the SCR 1.25 Chapter 8 of Working Together (April 2010) makes the Chair of the LSCB responsible for determining what action to take when the SCR panel considers that it is necessary to exceed the six month timescale laid down in the statutory guidance for the completion of SCRs. 3 The SCR has over run the timescale by approximately four weeks because of the practical difficulty of starting the review during the Christmas period and because of the additional steps taken (described above) to build some additional aspects of the ‘systems’ approach into the process. 1.26 The SCR panel has been mindful of the need for member agencies to take action in the meanwhile in order implement recommendations while the review continued. The progress made in the implementation of recommendations is reflected in the agency action plans linked to the SCR. Involvement of family members 1.27 It is normal practice in SCRs to seek the views of family members who have been in receipt of services or closely involved with the child. Often this is not possible because of the parallel criminal investigation. In this case it was agreed that it would be possible to do this because, despite the continuing police investigation, as there was no risk that discussion with family members would prejudice any criminal trial. 3 Section 8.23 – 8.24 9 1.28 Unfortunately it has not been possible to obtain the views of the children’s father (who is referred to in the report as Mr B) because it was judged that he remained too ill to understand the purpose of the SCR and to contribute to it in a meaningful way. Individual meetings were held between the SCR overview author and three family members (one of whom was assisted by a close family friend). The purpose of these meetings was to seek the views of family members about the services that were provided and to seek additional information from family members in order to understand the involvement of professionals more fully. The SCR is grateful that family members were able to make a contribution over a recent event that continues to have a severe impact. 1.29 It was apparent that family members were dissatisfied with a number of aspects of the services that were provided and family members have expressed the view that Mr B was badly let down by professionals and that this has had a devastating effect on the family. The views of family members are reflected at a number of points in this report and have influenced its findings. There are however points at which the report reaches a different final understanding of some events than the one held by family members because it has taken into account of all of the information that is available in agency records. (TEXT REDACTED). 1.30 Family members were made aware of the findings of the SCR before they were published. (TEXT REDACTED) The papers constituting the SCR and arrangements for publication 1.31 The SCR consists of the following reports and documents: the overview report the combined chronology of agency contacts the individual management reviews (and background reports from agencies with very limited involvement) the integrated multi-agency action plan the draft executive summary 10 2 DETAILS OF FAMILY MEMBERS 2.1 Child F was under a year old when she was injured. She lived with her older brother, her mother, her aunt and her maternal grandmother. 2.2 Child F’s father lived for part of the time in this household and for some of the time with his own mother and her family. 2.3 The father’s own family consisted of his mother, father and four brothers and sisters (three of whom are adults). 2.4 The ethnicity of family members is recorded in different agency records as Black British or Black Caribbean. Records do not identify the religion of family members. The approach taken by agencies to respond to the specific needs of service users from a minority ethnic background are set out in detail in Section 4.7. (TEXT REDACTED) 11 3. Narrative of key events and professional involvement 3.1. Key events and professional involvement in the case history prior to the start date of this review (January 2009) The children’s mother - Ms A 3.1.1. Ms A is in her late twenties. (TEXT REDACTED). She had routine contacts with health professionals, but no significant health concerns. None of the background information obtained by the SCR about Ms A gives any indication of potential risk to her children. The children’s father - Mr B 3.1.2. Mr B is also in his late twenties. Initial review of his records indicated that he had experienced significant adversity in his childhood and adolescence, including problems in health, mental health, substance misuse and education. The SCR therefore obtained and considered background information about his childhood in order to understand how his earlier difficulties had been addressed by professionals, what his experience of services had been and whether professionals who were in contact with Mr B more recently had had access to relevant information about his past. 3.1.3. Mr B’s GP records were available to the review because along with other members of his family he had attended the same GP practice for many years. Only a very brief summary of school and education records has been obtained because there are difficulties in retrieving some archived education records in (TEXT REDACTED) which the authority has undertaken to investigate further. Mr B also attended schools outside of (TEXT REDACTED) and these records were not sought. 3.1.4. (TEXT REDACTED) Mr B experienced difficulties at school from the age of 8. 3.1.5. (TEXT REDACTED). 3.1.6. It is not the focus of this review to comment in any detail on these childhood adversities or to evaluate the response of services to them. However it is apparent that Mr B did not complete his education and left school with no academic qualifications. Although he later tried to obtain some vocational skills it is evident that his early problems severely limited his later life opportunities. 3.1.7. Mr B was cautioned by police for causing damage to property at the age of 14 and for receiving stolen goods at the age of 15. From age 17 - 21 he was convicted of (TEXT REDACTED) (including the possession and supply of drugs), (TEXT REDACTED). Initial contact with mental health services 3.1.8. Mr B had his first contact with mental health services in his late teens when his parents brought him to A&E. (TEXT REDACTED). He was prescribed an antipsychotic medication as well as medication to reduce anxiety and referred for an urgent outpatient appointment 12 with the Community Mental Health Team (CMHT). He was encouraged to make a self-referral to a substance misuse service. 3.1.9. As a result of the referral Mr B was assessed by a community psychiatric nurse in the mental health intake service. (TEXT REDACTED). The assessment made a referral to a young people’s mental health service and recommended him to continue taking medication, under the care of his GP. Subsequent GP records indicate that Mr B’s mother continued to collect prescriptions for him for a further two years. Later probation records indicate that Mr B would not take his medication on a regular basis despite support from his mother and other family members. He never attended the young people’s mental health centre. 3.1.10. This pattern of contact with mental health services was to be repeated later in the case history: Mr B’s parents or other family members sought medical help for him Mental health assessment in the community did not identify any psychotic symptoms or underlying mental illness Mr B did not engage with mental health services offered His mother remained motivated to help him and keep up his treatment by collecting prescriptions and medication. Violent assault in 2006 leading to a lengthy prison sentence 3.1.11. In mid-2006 Mr B violently assaulted another male following a confrontation in the street. (TEXT REDACTED).He received a four year prison sentence. 3.1.12. There are contradictory accounts and judgements as to the role that mental illness played in this episode. On arrest Mr B reported that he had suffered from psychosis for two years and that he had been taking medication. He was medically examined and there were no concerns about his fitness to be interviewed by the police. Mr B linked his actions to perceived threats from the victim and his own involvement in criminal activity. He stated that (TEXT REDACTED) he had acted in self-defence in fear of his life. (TEXT REDACTED) 3.1.13. It is not certain whether family members knew all of the details of this offence or interpreted them in the same way. (TEXT REDACTED) 3.1.14. Whilst on remand at a Young Offender Institution (YOI) Mr B’s mental health deteriorated leading to contact with prison health service health and he was again treated with anti-psychotic medication. A psychiatric report was prepared, though the contents are not known. 3.1.15. At sentencing (TEXT REDACTED) a report commissioned by Mr B’s solicitors and prepared by a Consultant Forensic Psychiatrist was presented to the court. This (TEXT REDACTED) concluded that Mr B’s actions in committing the assault might have been influenced by his mental state, leading him to overestimate the threat posed by his victim. (TEXT 13 REDACTED). The report pointed to the potential for the development of a ‘severe and enduring mental illness such as schizophrenia’. The judge’s sentencing took into account the fact that Mr B had (TEXT REDACTED) been suffering from a mental illness. 3.1.16. Section 4.1 of the SCR overview report comments on the differing diagnoses of Mr B’s condition and his engagement with mental health services over the 8 years before he stabbed his daughter. At this stage it is most significant to note that the reports referred to in the preceding paragraphs were used and known about only in the court arena. The information in the report and the tentative diagnosis that Mr B had an underlying mental illness were not provided to Mr B’s GP or to the mental health trust, despite drawing on local records in compiling the report. The health service had no access to information about health care of Mr B whilst in the YOI. The probation service – which subsequently supervised Mr B for almost two years – had no knowledge of this report. This is a clearly a concern and it is the subject of recommendations in this report. 3.1.17. In 2008 Mr B was released at mid-point of his sentence. His licence condition was the normal one that if he breached the licence he would be returned to prison to serve the remainder of his full sentence. Prior to release he had had had a series of overnight and week-long home visits. (TEXT REDACTED).There appear to have been no concerns about these stays. 3.1.18. On release Mr B reported to his probation officer and was assessed as being a Tier Four (high) risk, required to report weekly to his supervising officer The following areas were identified for work during the supervision period which if not addressed would lead to a heightened risk of reoffending: overall risk, lack of accommodation and employment, substance misuse (cannabis and alcohol) and mental health. Mr B was referred to the multi-agency risk assessment panel (MAPPA) which coordinates the supervision of offenders judged to pose a risk. The case was discussed at two MAPPA meetings. The main focus was on the potential risk of conflict between Mr B and his victim, but professionals believed that this had receded. The second MAPPA meeting agreed that case management would be by the single agency involved (probation) and that there was no need to refer the case back for further multi-agency discussion, unless there were significant new developments. 3.1.19. Probation records state that during his prison sentence Mr B had ‘engaged with mental health services’ so that by the time he was released he was stable and did not require medication. He was strongly warned not to return to cannabis use because it was detrimental to his health. 3.1.20. As part of the supervision arrangement the probation officer referred Mr B to a substance abuse service. This provided an assessment and individual counselling sessions which continued until 2008. In all Mr B attended five sessions. This was a voluntary arrangement and at this time service users’ progress was not reported back to the probation service. During his assessment the father said that he had attended courses in prison designed to reduce substance misuse. Mr B did report having suffered from depression and drug 14 related psychosis, but he did not specifically state when this had been. He reported that he had been abstinent from cannabis for two years (coinciding with his imprisonment) and he reported currently using alcohol, drinking occasionally only. 3.1.21. Information provided by a substance misuse service indicates that Mr B (TEXT REDACTED) does appear to have been genuinely motivated to remain drug free (or to show that at that point he was drug free) and at one point he asked for a drug test. At that time the probation service would not have commissioned a drug test in these circumstances. During this period Mr B had no children or caring responsibilities and this was reported correctly by Mr B to a substance misuse service as part of the assessment. (TEXT REDACTED) 3.1.22. In order to understand his current mental health status and to ensure that he had access to relevant services the probation officer also referred Mr B to the mental health trust. He was assessed by an experienced psychiatrist who noted that Mr B had recently been released from prison (TEXT REDACTED). Mr B reported that he had been monitored and tested for drug use and that he had been clear of cannabis use for 2½ years. At the time of the assessment Mr B had been off all medication for the previous seven months. The assessment did not reveal any signs of a psychotic illness. It described a man motivated to engage in his probation supervision and to attend a substance misuse service. Mr B was discharged back to the care of his GP which appears to be in keeping with the fact there was no evidence of psychotic symptoms despite taking no medication for the previous seven months. 3.1.23. For six months Mr B reported to his probation officer regularly and in compliance with the requirements of his licence. No home visit was made after his release. There is no evidence of offending or contact with the police during this period. The probation officer discussed all of the matters identified in the risk assessment with Mr B and he was believed to be benefiting from the various support services and referrals made. He completed programmes commissioned or provided by the probation service focused on victim empathy and an offending behaviour programme. Training opportunities were arranged in order to promote Mr B’s future prospects for employment. (TEXT REDACTED).Mr B remained under supervision under the terms of his licence until mid-2010. 3.2. Key episodes during the period under review (January 2009 onwards)and their significance in the development of the case history 3.2.1. During March and April 2009 the father reported to his probation officer that he was keeping busy helping family members with informal jobs. (TEXT REDACTED). His probation officer believed him to be drug free and not suffering any mental health problems. 3.2.2. At the end of April 2009 Child F’s mother attended her GP her because of her pregnancy. (TEXT REDACTED) She was seen routinely (TEXT REDACTED) during the pregnancy and there were no concerns. (TEXT REDACTED). 3.2.3. The father continued to report to his probation officer. He spoke of continuing efforts to find work and training. At this point he did not give any information about his partner’s 15 pregnancy. (TEXT REDACTED). During June and July the father attended a number of courses and applied for training opportunities. He attended a further Offending Behaviour Programme which met weekly and as a consequence his reporting requirement in relation to this probation officer was reduced. 3.2.4. In August 2009 the father’s probation officer left her post and he was allocated a new supervisor. The father continued to report regularly. The new probation officer did not consider making a home visit because it was assumed that her predecessor would have done so, but in fact no home visit was ever made. 3.2.5. In September 2009 Mr B told a probation group that (TEXT REDACTED) his girlfriend was pregnant. (TEXT REDACTED) He stated that he was looking forward to fatherhood. He said that he was aware of the extra responsibility and that he would need to earn money. (TEXT REDACTED) Key events between the birth of Child G in September 2009 and August 2010 when the father reported a deterioration in his mental health to his GP 3.2.6. Child G was born (TEXT REDACTED) in early September 2009. The pregnancy had been without complications. The delivery and post natal period were routine and mother and baby were discharged the following day. 3.2.7. Shortly after the birth of Child G the father reported to his probation officer that he had given up college and was actively seeking work. A week after the birth the father reported that he was adjusting to life with a baby and that it had completely changed his life. He stated that he was fully involved in all aspects of child care intending to seek temporary work to earn more money. 3.2.8. The health visitor’s new birth visit took place at the end of September 2009 at the home of the children’s maternal grandmother and the mother. Health visitor 1 completed the Family Health Assessment with the mother who identified her own health, housing and finances as her main concerns. Child G was reported to be alert and well. The health visitor recorded the details of the father who stated that he lived elsewhere. The health visitor recalled that the father was present at this visit though she did not note this in the records at the time. There was no detailed discussion with either parent about expectations in relation to the father’s role, except that he would be involved and supportive. No information was provided about the father’s history of mental health, drug misuse or offending. The health visitor did not know that the father was under the supervision of a probation officer. 3.2.9. In early October 2009 the father told his probation officer that he (TEXT REDACTED) was abstaining from cannabis. 3.2.10. Shortly after Ms A brought Child G to the child health clinic (TEXT REDACTED). There were no identified concerns and the baby (TEXT REDACTED) was growing steadily and thriving. The mother was advised to attend clinic again in four weeks and to attend her own post 16 natal GP check. The GP post natal checks of mother and baby were routine and satisfactory. Subsequently Child G was taken for clinic checks, immunisations and doctors’ appointments in an entirely routine way and there were never concerns about her health or development. 3.2.11. In late November 2009 the probation service sent a notification to the local authority social care service giving details of the father, mother, Child G and the mother’s address. This was a standard probation trust procedure when an offender under supervision notified the birth of a child with whom he had a close connection. It was not a referral because of concern about the child and it was not asking the local authority to take any action. The notification was received and checked by a social care administrator who confirmed that the individuals concerned were not known and that Child G was not subject to a child protection plan. The address was also checked and it was confirmed that social care were not involved with any child at that address. As the response had not identified child protection concerns or an involved social worker the probation officer took no further action because there was nothing to indicate that there were any risks to the child. No entry was made in relation to such checks on the local authority client index. The value of this notification procedure and subsequent changes in policy and practice are discussed further in section 4.6 below. 3.2.12. Records show that the probation officer used the last supervision session in November 2009 to discuss the father’s previous cannabis use. The father explained how this was no longer a risk factor for him stating that his best friend did not drink or smoke cannabis and therefore was a good influence. The father also stated that (TEXT REDACTED) he was caring for Child G at night and that this was (TEXT REDACTED) positive experience. 3.2.13. (TEXT REDACTED). 3.2.14. During December 2009 – January 2010 the father continued to attend at probation supervision sessions. He reported that at this point he had obtained a (TEXT REDACTED) job on a scheme for ex-offenders. He reported keeping this up for some months. The father continued to describe himself as being very involved in the care of his child (TEXT REDACTED). During February and March 2010 the father continued to report to his probation officer that his home life was settled and positive and he stated that he continued to have worked approximately 25 hours per week and was still seeking further ways to make himself more employable. 3.2.15. In mid-January 2010 the father’s GP records contain a report of mental health review and personal health plan. Mr B was noted to be coping well and working. His mental health was noted to be stable. 3.2.16. (TEXT REDACTED). 3.2.17. (TEXT REDACTED). 17 3.2.18. During April and May 2010 the father continued to report to his probation officer and asked for advice over housing. (TEXT REDACTED). Discussions began about ending the contact with probation as the licence period was due to expire shortly. 3.2.19. In mid-May police records show that the father’s family home was the location of an aggravated burglary during which (TEXT REDACTED) the father’s parents were robbed and threatened with serious violence. (TEXT REDACTED) In August 2010 Mr B told his GP that he had been threatened with a knife during a burglary and that this event had triggered deterioration in his mental health. (TEXT REDACTED). 3.2.20. During May - July 2010 the father had six further contacts with his probation officer. He cited his desire to care for his son as being a motivation not to reoffend and discussed further ways to avoid reoffending with his probation officer. The father continued to be unemployed (TEXT REDACTED) but said that he had not signed for Jobseekers Allowance as he intended to get work as soon as possible. 3.2.21. The final probation appointment was in early July 2010. The review of progress noted that the father had stopped smoking cannabis and that his mental health problems had not recurred. He stated that he was aware of the risks of reoffending and the likelihood of a substantial sentence if he did. The records show that the probation officer believed that the father remained living with his partner’s mother. There were no reports of contact with the police during the licence period and so far as the probation officer was concerned the father had not reoffended. He had no employment but there was no evidence of a reoccurrence of mental illness or substance misuse - the other risk factors previously linked to his offending. 3.2.22. (TEXT REDACTED). August 2010 – deterioration in the father’s mental health 3.2.23. It is not possible to know if there was any connection but within a short time of his probation supervision ending the father reported evidence of renewed substance misuse and deterioration in his mental health. 3.2.24. In mid-August 2010 the father attended his GP with his partner. He said that his mental health had been stable for 2 years. (TEXT REDACTED). 3.2.25. (TEXT REDACTED) Since the recent burglary he had started smoking cannabis and had developed paranoid thoughts that people were talking about him. He said that he had started to avoid going out and that he had been unable to sleep. He said that he lived with his partner. He appeared to be withdrawn and was emotionally ‘flat’ giving vague responses to questions. He denied hearing voices and he was not aggressive. The father’s GP made a detailed referral to the mental health services. (TEXT REDACTED). The GP had prescribed an antipsychotic medication and (TEXT REDACTED) asked the father to return to the surgery if his condition deteriorated. This referral makes no reference to Child G. There is no indication in the records that the GP knew that Mr B shared responsibility for a child. 18 The SCR has established that the GP who knew the family best did know that Mr B had become a father through his general knowledge of the family, but it is not certain whether he knew this at this time. This is discussed in section 4.3. 3.2.26. The mental health trust notes contain no detailed record of this referral. However there is evidence that Mr B was offered an outpatient appointment because there is a copy of a letter from the mental health trust in the GP records (dated late September) indicating that the father had failed to attend an appointment. It is not known why he did not attend. There was no further follow up in relation to the missed appointment by the mental health trust or the GP. The father also failed to attend a review appointment at the GP surgery. 3.2.27. A month after the initial appointment the father contacted the GP surgery seeking further medication (TEXT REDACTED) and he was offered an appointment that afternoon - which he did not keep. The next contact that the father had with professionals over his mental health was almost a year later in October 2011, approximately a week before he stabbed his daughter. Key events between October 2010 and October 2011 3.2.28. In late 2010 the mother attended her GP to seek confirmation of her second pregnancy. The mother was (TEXT REDACTED) given advice about some minor health concerns. (TEXT REDACTED) She did not provide the GP with any information about the identity of the father or his circumstances. This is considered further in section 4.3. As a result and because the mother and father had different GPs the antenatal referral contained no information about the father or any potential risk related to him. 3.2.29. The mother attended the scheduled maternity ‘booking appointment’ in late October 2010 when it was documented that (TEXT REDACTED) she lived alone with her one year old son. (TEXT REDACTED) No details of the father were provided. (TEXT REDACTED). Notification of the pregnancy was sent to the community health service including a midwife risk assessment and proposed shared ante natal care arrangements. As the only risk factors identified were (TEXT REDACTED) minor medical ones there was no reason for an antenatal visit to me made by the health visitor and no action was taken until after the birth. There were no later concerns about the mother or baby in the antenatal period. 3.2.30. (TEXT REDACTED). 3.2.31. There were no significant events involving the father during the pregnancy, though he began to have a number of minor contacts with the police. (TEXT REDACTED). No arrest or prosecution arose from these episodes. 3.2.32. Child F was born in early 2011. The delivery was routine. The following day a hospital notification of birth was received in the (TEXT REDACTED) Child Health Department and forwarded to the local health visiting team (TEXT REDACTED). The new birth visit was allocated to a new Health Visitor and took place at age 13 days, (TEXT REDACTED). 19 3.2.33. During the home visit both children were seen along with Ms A and the children’s maternal grandmother. The father was not present but his details were recorded. The health visitor was told that the father lived elsewhere, but that he continued to be supportive. Both children were well and the health visitor had no significant concerns. The health visitor (TEXT REDACTED) gave advice about (TEXT REDACTED) the heightened risk of cot death associated with smoking (TEXT REDACTED). The Family Health Assessment was undertaken. This was a booklet which the mother completed asking for self-reported information about both parents. It was recorded that the general health of both parents was good. No details of the father’s mental health problems or of his cannabis use were provided by the mother when she completed the family health assessment, although the document has sections that refer to these issues. The mother reported that she had a good network of family support. The outcome of the new birth visit was that no specific risks were identified and the mother was invited to attend child health clinics and to seek additional advice if needed. 3.2.34. (TEXT REDACTED) Section 4 considers the approach taken by professionals to obtaining information about fathers. 3.2.35. Over the following six months the mother was offered four clinic appointments for Child F and she attended twice. On each occasion there were no concerns about Child F’s health and development and she continued to gain weight in line with normal expectations. Advice was given in relation to a number of routine health matters. The mother made and kept GP appointments for developmental checks, primary immunisations and her own post natal check. No significant concerns were noted. (TEXT REDACTED). 3.2.36. The last health visitor contact with the mother and Child F was in late May. Child F was not brought to a scheduled clinic appointment in July 2011. Child F was not brought to the GP for second primary immunisations at the GP surgery in June, but these were given at an appointment in August 2011. This was the last contact that primary care professionals had with Child F prior to the incident in which she was injured in October 2011. A GP appointment for the third primary immunisations was missed on 19 September. There was no immediate follow up by the GP. 3.2.37. In late May 2011 the father was stopped on two further occasions by police. On both occasions his behaviour had given rise to strong suspicion about possible drug possession. (TEXT REDACTED) Family contact with professionals in the week prior to Child F being injured 3.2.38. In mid-October 2011 Mr B was taken to an appointment at his GP by a member of his family who was concerned that he was (TEXT REDACTED) smoking drugs again and as a result behaving oddly. (TEXT REDACTED) This was four days before Child F was stabbed. 3.2.39. (TEXT REDACTED) When asked about his mental health Mr B stated that there was nothing wrong and that he had no paranoid thoughts. However he mentioned that everyone was 20 ‘saying things about him’ or (TEXT REDACTED) had ‘bad thoughts about him’. (TEXT REDACTED). The family member described how Mr B was locking himself in his room. He confirmed the information in the GP records that the father had taken medication in prison but that he had not taken anti-psychotic medication for some two years. 3.2.40. The father agreed to be referred to the mental health trust Primary Care Liaison Team and it was noted that his mother could be contacted over the appointment if needed. The GP requested an urgent appointment within the next two weeks. There is no evidence that Mr B was asked any questions about any caring responsibilities towards children or children with whom he might have contact. This GP did not know from the records that Mr B was a parent and was viewing him as part of his own family of origin. Family members told (TEXT REDACTED) the SCR that they were disappointed that Mr B had not been given medication. They say that they were advised that the appointment would come in 7-10 days. There is no confirmation of this in the GP records. 3.2.41. Later records in the mental health trust show that the referral letter was sent by post (rather than being faxed) arriving on the morning that Child F was injured. The referral was acknowledged to the GP immediately and Mr B was offered an appointment approximately four weeks later. The mental health team did not know that Child F had been injured when they dealt with the referral. 3.2.42. Two days after the GP appointment Mr B’s mother telephoned his GP again because her son was not sleeping at night and ‘his mind was racing’. He was awaiting the mental health service appointment but she said that she was unsure if he would be able to take it up as he might not pick up calls on his mobile phone because he was anxious and suspicious. This was 36 hours before Child F was stabbed. 3.2.43. Mr B’s mother spoke to another GP who agreed to prescribe a small dose of sleeping tablets for the next seven days. The family’s account is that the grandmother went to the surgery to collect this prescription urgently and it was agreed that she would also call Mr B’s own GP the next day to explain the circumstances and ask the GP to chase up the referral that had been made to the Primary Care Liaison Team by phoning the on call mental health worker. Subsequent records show that Mr B’s partner did go to the GP the following morning, but there is no evidence that any contact was made with the mental health trust to hurry up the appointment. Mr B’s attendance and mental health assessment at A&E 3.2.44. That evening the father presented at A&E (TEXT REDACTED), initially with his mother and joined shortly afterwards by his partner. This episode began approximately 30 hours before Child F was stabbed. 3.2.45. Mr B was first seen by a triage nurse. (TEXT REDACTED). The nurse took (TEXT REDACTED) samples and requested a medical assessment. She noted that Mr B had not slept and that he had been very anxious for two days and she noted the medication prescribed by the GP. The notes include the term ‘PMH (previous medical history) – induce psychosis’. The senior 21 nurse recorded the reasons for referral to the psychiatric team as ‘?drug induced psychosis’. 3.2.46. 30 minutes later Mr B was seen by an A&E doctor who (TEXT REDACTED)noted that he had been exhibiting paranoid, angry and erratic behaviour; he was also noted to be tearful and suffering from insomnia, based on the history given by his mother. The A&E doctor noted that Mr B had suffered from ‘induced psychosis in 2004’ and that he had been treated with (TEXT REDACTED) medication for two years. Mr B stated that he was ‘scared of gangs’ and that he had ‘lost a lot of family over the last year’. The medical record states that he ‘denied hearing voices or seeing things’ and the risk assessment recorded was that he was ‘no risk to others’, no risk to self – not suicidal’ and ‘no risk from others but paranoid’. 3.2.47. Mr B attributed his condition to smoking too much ’weed or skunk’. According to his mother, he had had similar episodes earlier in the year (2011). She reported that ‘when he is like this’ he could smoke up to 40 cigarettes a day and drink up to 2 bottles of brandy, ‘but not most days’. Mr B said that he had not smoked skunk (TEXT REDACTED) for about four weeks. The family’s account is that the doctor said that she did not believe this and told him, though that is not recorded in the notes. It was recorded in the A&E notes that Mr B lived with his girlfriend and their children. 3.2.48. The A&E doctor prescribed antibiotics for a chest infection and told Mr B to return to A&E or to go to his GP if (TEXT REDACTED) his physical health deteriorated. His family say that he was reticent to take this medication as he was worried about his state of mind, rather than any infection. Mr B was also referred to the (TEXT REDACTED) Mental Health Crisis Resolution Team (which as part of its function provides a mental health assessment service within the A&E department) noting the possibility of a drug-induced psychosis. He was also strongly advised to reduce his consumption of alcohol and drugs. 3.2.49. The team which offered a service to the A&E department on this evening consisted of an experienced mental health worker on rota who had access to advice and support on call from a junior doctor in her second year post qualification who was undertaking her training in adult psychiatry. Mr B was seen shortly after midnight by them both which was the practice of the service in relation to new patients. Prior to seeing Mr B the mental health worker checked for records of Mr B on the mental health trust’s information system and recorded basic details of the referral. 3.2.50. As this was the last assessment and the last substantial professional contact with Mr B before he injured his daughter the records of this contact have been reviewed closely and the incident has been discussed with the staff involved. The contact has also been discussed fully with family members who are critical of the assessment that took place. The assessment is evaluated in detail in section 4.3 of this report. The following paragraphs set out (TEXT REDACTED) the best possible reconstruction of events, taking into account all of the sources of information available. Where there are discrepancies between the records, 22 the recollections of the professionals and the recollections of family members these are noted. 3.2.51. The mental health worker recorded the reason for the referral as follows: ‘drug induced psychosis – paranoid – scared of going out. Erratic, angry’. 3.2.52. The check made on the mental health trust electronic information system showed that Mr B had been a trust patient in the past but did not give details of contacts, assessments or diagnosis. This was because records of Mr B’s earlier contacts had not been transferred when the trust had adopted a new electronic recording system. This was because his previous contacts with the trust had only been very limited (as described earlier in this section of the report) and because as far as the mental health trust was concerned his mental health had not posed a risk of harm to himself or to others. This is discussed further in section 4. 3.2.53. The junior doctor and the mental health worker carried out a mental health assessment of Mr B. The professionals both recollect firstly briefly interviewing Mr B alone, then seeing him with his mother, until she left the interview and then with his partner. A very close family friend arrived separately but was not interviewed as part of the assessment. Family members told the SCR that they do not recall Mr B being seen on his own. 3.2.54. According to the doctor and the mental health worker Mr B was seen alone only briefly (for two to three minutes) and provided relatively little information before they decided that it would be best if his mother joined him. During discussions when his mother was present Mr B was very open about his recent very heavy use of drugs and alcohol. He said he had a ‘spliff’ for breakfast and continued to smoke cannabis (including very potent ‘skunk’ that he said people called ‘Amnesia’) and drink throughout the day. According to the mental health records he was also very frank about his involvement in the supply of illegal drugs and the money he made from this. Mr B’s mother said that he had used cannabis for the last 6 years. Mr B said that he felt his symptoms were due to his drug use and he added that he did not suffer from any mental illness. Mr B’s mother said that it was important for him to be very frank about everything that was going on. 3.2.55. It was noted that in the past Mr B had been diagnosed with drug induced psychosis on three occasions and treated with medication. The doctor states that she quizzed Mr B and his mother as to where this diagnosis had been made (whether it was by the GP, a psychiatrist or in prison) but Mr B did not provide any details. She was aware that he had been in prison and formed the impression that this had been because he had been involved in a fight. 3.2.56. The assessment was not able to elicit any symptoms of psychosis or other mental illness (such as depression) arising either from Mr B’s recent drug misuse or from an underlying mental illness. The mental state examination indicated that there was no formal thought disorder and no evidence of auditory or visual hallucinations. Mr B showed no evidence of 23 thoughts of harming himself or others. He was noted to have ‘full’ insight, suggesting that at this point the clinicians believed that there was a rational connection between his explanation for his symptoms and his account of his own behaviour. 3.2.57. Mr B’s mood was recorded by the doctor to be ‘objectively slightly paranoid and anxious’ but ‘subjectively paranoid’ (which is taken to mean that Mr B said that he felt paranoid but that in psychiatric terms he was not experiencing paranoid delusions). The assessment noted that his paranoia was ‘exacerbated by weed use’ and that the basis for his fear and suspicion of others was in good part grounded in reality. It was recorded that ‘he often feels paranoid in public, as well as in the area that he lives, which he describes as being unsafe (shootings etc.)’. Subsequently the mental health worker has confirmed that insofar as Mr B was anxious and erratic in his behaviour she believed that it was due to the large amount of cannabis and alcohol that he was consuming and the stress and insecurity caused by being involved in risky criminal activity. 3.2.58. The clinicians say that family members were also very surprised by his account of the extent of his drug use (TEXT REDACTED). They state that family members did not provide any additional information about Mr B’s paranoid behaviour or other psychiatric symptoms. 3.2.59. The outcome of the assessment was that Mr B was believed to be experiencing symptoms consistent with heavy drug and alcohol use (TEXT REDACTED). The judgement was that there was no indication that he presented any immediate risk to himself or others and that he had very good family support at home. The medical records state that Mr B indicated that he had no thoughts about harming himself or others and that at that point he had ‘full insight’ into his circumstances (i.e. he himself had a very good idea what it was that was making him feel paranoid). In contrast Mr B’s partner told the SCR that she remembers Mr B saying he had suicidal intent. However there is nothing in the medical record to support this and the written records state the opposite. 3.2.60. The management plan formulated was for Mr B to be allowed home and discharged back to the care of his GP who had already made a referral to the (TEXT REDACTED) Primary Care Liaison Team. Mr B and the family were given up to date information leaflets about local drug and alcohol services. The clinicians state that they felt that this plan had involved Mr B and his family and that they were in agreement with it. Mr B was given (TEXT REDACTED) one dose of a medication to help him sleep that night and the mental health worker agreed to expedite the referral that was already in place to the mental health service. Family members say that they questioned whether more needed to be done. 3.2.61. The assessment was documented on the trust electronic record system. The mental health trust risk documentation was not fully completed at the time of the assessment. Family members state that when he returned home Mr B took the medication (TEXT REDACTED) prescribed by the doctor at the hospital and the one earlier prescribed by the GP. (TEXT REDACTED). This was some 24 hours before Child B was stabbed. 24 3.2.62. For their part family members have expressed frustration and disappointment to the SCR about this assessment (and also directly to the mental health trust). They have expressed concerns about some remarks made by the doctor and the mental health worker which they feel conveyed a negative attitude towards the family. Mr B’s partner did not think that there was sufficient probing in depth of his mental and emotional state and how he was feeling. The close family friend was present at the hospital though she did not sit in during any of the assessment. She has had some experience of mental health assessments before and states that she was surprised how short a time the assessment lasted. The children’s maternal grandmother was not present at the hospital. However she states that she believes that there should have been a longer assessment. With hindsight all family members feel that too much emphasis was placed on Mr B’s self-reported misuse of cannabis and alcohol. They now state that they find the extent of his reported consumption to be implausible and feel that this detracted from a fuller exploration of his mental health needs. Family members state that Mr B was willing to be admitted to hospital and that this is what should have happened. (TEXT REDACTED) Family members believe that they did everything that was possible to get help for Mr B in the days before he stabbed his daughter. The assessment of potential risk to the children at A&E 3.2.63. The A&E doctor recorded that Mr B lived ‘with girlfriend and children’. The doctor who undertook the psychiatric assessment recorded that Mr B was ‘currently in a relationship with girlfriend with whom he had two children’ correctly noting their ages. (TEXT REDACTED) Based on the records available and interviews with the staff involved it is agreed that no specific information was recorded about exactly where the children lived or the nature and extent of Mr B’s contact with them or his caring responsibilities. 3.2.64. No one present during the assessment perceived there to be any risk at all to the children or stated any concern in relation to this. The doctor and the mental health worker say that they were reassured about the welfare of his children by the following factors: 1) Mr B was not being aggressive or violent at all 2) He was affectionate to other family members, particularly his partner 3) Mr B spoke about his children in a very positive way and he specifically cited his desire to be a better father as his main reason for wanting to stop taking drugs and drinking 4) The clinicians were reassured by the presence of key members of the extended family who they felt mitigated any potential risk –both in relation to Mr B’s mental health and in relation to the care of the children. The mental health trust provides a format for recording the risk assessment in relation to patients and service users who have contact with children. This was not completed at the time of the assessment. The wounding of Child F 3.2.65. Mr B’s partner told the SCR that (TEXT REDACTED) although he had taken the medication she did not believe that Mr B slept that night. Later that day Mr B’s partner telephoned Mr B’s GP surgery. She explained that Mr B had been seen at A&E (TEXT REDACTED) and had 25 been told to contact the GP surgery to ask for a further prescription. She states that she did not know what dose had been given to Mr B by the doctor. Additional medication was prescribed to help Mr B sleep. This was the last professional contact with any family member before Child F was stabbed. 3.2.66. Ms A describes Mr B as being calmer the next day, but emotional, clingy and very childlike. She states that Mr B was in all day and so far as she is aware he did not take any drugs or consume any alcohol. She recalls that before he went to bed he spoke to her about winning the lottery. (TEXT REDACTED). This was based on a story in the newspaper, but Mr B genuinely believed it related to him. 3.2.67. The account provided by family members is that Mr B woke family members in the small hours (TEXT REDACTED). After a few minutes it was clear to everyone that he was becoming more agitated and behaving and speaking in a very odd way and Mr B’s partner called 999 speaking first to the emergency call handling centre and then to the police operator. (TEXT REDACTED). Ms B’s partner told the operator that he had mental health problems (TEXT REDACTED). At the time of the call Mr B was not holding a weapon. Police officers and an ambulance were dispatched – the police officers to attend the home as quickly as possible and the ambulance was asked to wait at a rendezvous point 200 yards away which it did. Both responded to the children’s mother’s request not to use their lights and sirens as this would frighten and agitate Mr B further. 3.2.68. After initially being calm Mr B had become more agitated and grabbed Child F, holding her to his chest. Before the first two police officers directly approached Mr B (TEXT REDACTED) they were told by family members that he was now holding his child and behaving in a threatening way with a knife. Given the potential seriousness of the circumstances approximately ten more police officers arrived at the scene. When police officers entered the room Mr B was holding Child F, holding a knife in a menacing way and speaking in a deluded way. In the course of a brief standoff it became apparent from blood on her clothing that Child F had been stabbed. 3.2.69. Mr B had also cut himself (TEXT REDACTED) and he was restrained and arrested. Child F was noted to have suddenly gone very quiet and because of the urgency of the circumstances she was conveyed immediately to the nearest A&E department (which is a very short distance from the family home) in the police car. This was with the agreement of her grandmother who accompanied her. (TEXT REDACTED). During the journey there was dialogue between the police operator, the ambulance service and the helicopter emergency medical service (HEMS) which had also been dispatched. HEMS asked the police to keep Child F at the scene as they believed that they could provide better immediate care than the hospital. Police records show that this message did not reach the police until they were 800 yards from the hospital, so a decision was made to continue. Child F was treated in A&E at the hospital before being transferred by HEMS to another hospital. 26 3.2.70. Child F’s grandmother was interviewed by the A&E sister at the hospital who recorded the following her account about Mr B in the medical notes as follows: ‘Grandmother informed me before mother’s arrival that (Mr B) had been @ A&E yesterday after a 4 day history of not sleeping with associated agitation… ?Secondary to smoking skunk / cannabis. Was discharged home. ? plan of Rx (plan of care)’ and then described the incident in which the infant had been injured. (TEXT REDACTED). 3.2.71. According to police records Mr B was arrested for attempted murder and treated by the ambulance service at the scene where his self-inflicted cuts were found to be superficial. (TEXT REDACTED). He was taken to hospital for further medical assessment and then to a police station where he was taken into police custody where a mental health assessment was arranged. 3.2.72. (TEXT REDACTED) The descriptions of Mr B’s behaviour given by those who were present (TEXT REDACTED) when he injured his daughter indicate that he was floridly psychotic (TEXT REDACTED) and that there had been a significant deterioration in his mental state since he was seen at A&E. 4 Evaluation of practice 4.1 Structure of the findings of the SCR Introduction 4.1.1 This chapter of the SCR overview report evaluates the effectiveness of the services provided to the children and other family members and the actions taken by professionals in order to identify any possible risks to the children and to safeguard the children. It examines the provision made by agencies individually and by the network of professionals who have responsibilities to safeguard children as a whole. The findings of this report draw on the individual management reviews. This summary has also taken full account of the overview of the case made possible through the scrutiny of all of the available information as well as discussions in the SCR panel meetings and discussions with the authors of individual agency reviews. Relevant documents were made available by participating agencies to the author and the SCR panel. 4.1.2 The evaluation contained in sections 4.2 – 4.10 provides the best account that can currently be given of the effectiveness of the services provided to the children, based on the information available from all agencies and the views of family members. It has not been possible to interview Mr B about this because during the time when the SCR was being carried out he remained too ill to make a meaningful contribution to the review. 4.1.3 In this SCR the evaluation in the overview report serves two functions. First it evaluates whether the actions and decisions of agencies with child protection responsibilities had any bearing on the episode in which Child F was wounded. The SCR has sought to establish 27 whether agencies had any evidence to suspect that the children were at risk of suffering serious harm and whether the incident involving Child F could have been prevented if agencies had been able to take different decisions or act differently. Second the SCR provides a wider evaluation of the services provided to the children and their family during key episodes in the case history. The objective is to identify whether there are any lessons that can be learnt so as to improve safeguarding services, independently of any possible link to the harm caused to Child F. Judgements about the actions and decisions made by professionals 4.1.4 The Working Together guidance requires that the SCR should bring hindsight to bear in evaluating the actions of professionals and public bodies.4 Self-evidently there is value in seeking to look back objectively at a case history, knowing the outcome and with a fuller knowledge of the events and the actions taken by all of the professionals who were involved. However as well as the insight that comes from hindsight the SCR is aware of the danger of what is termed ‘hindsight bias’. 5 This arises when the evaluation is unduly influenced by knowledge of the outcome. 4.1.5 So far as is possible the SCR has therefore sought to avoid hindsight bias. In some circumstances it is easy to criticise the decisions and actions of professionals because it can now be seen that they were part of a chain of events that had a tragic outcome and they are judged out of the context in which they occurred. Much more valuable learning can be obtained by seeking to understand and explain why actions were taken and decisions were made and to consider the influences over professionals arising from the context within which they were working. It is only possible to learn lessons that are relevant to other professionals who may be working in similar circumstances if hindsight bias is set aside. 4.1.6 When evaluating the actions of individual practitioners and managers and groups of professionals and agencies the SCR has taken the following approach. Judgements about actions and decisions take into account the information that was available to those who took them. At certain points it is necessary to evaluate the overall service provision in relation to information that was known to the network of child protection professionals as a whole and would have been available if relevant information had been sought and provided. The review has sought to judge the actions of professionals and agencies against established standards of good practice as they were believed to apply at the time when the events in question took place. The evaluation will distinguish and outline the influence of individual and wider organisational factors in the decisions and actions taken by individuals as well as focusing on the individuals themselves. Structure of the evaluation 4 Working Together to Safeguard Children 2010, Chapter 8 describes the evaluation in the overview report as being ‘the part of the report where reviewers can consider, with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events. 5 David Woods et al, Behind Human Error, Ashgate (2010) second edition; Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate (2006) 28 4.1.7 This chapter of the SCR overview report addresses all of the matters set out in the specific terms of reference of this review and others that all SCRs are required by Working Together to Safeguard Children to address. The evaluation in this chapter begins by describing the roles of different professionals working with different family members. The remainder of the evaluation is presented as follows: Was there evidence of risk factors from the period prior to January 2009? Did information about them inform later professional contacts with the family? What assessments were undertaken and what was the quality of those assessments? Were plans made to provide services consistent with assessments and were they fully implemented? Did agencies respond appropriately to any risk factors identified in the course of their work with the family? Did the activity of agencies focus on the needs of children? What was the quality of information sharing and joint working within and between agencies? Did any issues arise in the work with the family that prompted, or should have prompted, agencies to seek information from agencies involved before the start date of the review? Were the specific racial, cultural and religious needs of the family recognised and responded to? Were any other matters relating to diversity addressed? Did staff have the knowledge, skills, and experience to respond to the needs identified in the case? Were staff appropriately supervised and supported in their work with the family? Did any capacity issues within the agency limit the ability of the agency to meet the needs of the family? The section concludes with a summary of the key findings and learning and an assessment of whether the wounding of Child F could have been anticipated or prevented? Preliminary theme arising from an overview of the narrative of events – the separation of professional attention on different family members 4.1.8 The evaluation will consider all of the matters arising from the terms of reference in detail. However there is one key pattern that is easily discernible from the narrative and underpins many of the other review findings. The narrative shows how across all of the key events there were two distinct groups of professionals who had contact with different members of the family. 6 As this strongly influences many other aspect of the evaluation it is useful to set out a brief overview of the pattern of services provided to the different 6 The following paragraphs give only a broad overview. Section 4.6 focuses on the joint working and information sharing between professionals in detail. In particular it will examine the points in the case history at which there were opportunities for individuals to share information and collaborate across the professional network. 29 members of the family before evaluating specific issues such as risk assessment and service provision. 4.1.9 A small number of professionals were in contact with the children’s mother. She had contact with her own GP and midwives in relation to her own health and her antenatal care. She then had contact with health visitors and the same family GPs over the health of her children. The father had a different GP. The mother’s family GP and the midwives did not know the identity of the father and they had no contact with him. The health visiting records show that health visitors asked for and recorded basic details of the father. Neither of the family health visitors recorded having direct contact with Mr B, though one recalled having met him on one occasion. Child F’s mother told the SCR that both health visitors met the father. The question of knowledge about the father is discussed in detail in section 4.3. 4.1.10 On his side the father had contact with a number of professionals arising from the offences that he had committed, his drug misuse and his mental health problems. His family GP knew him and treated him as part of a family unit in which the key people were his mother and his siblings, whom the GP had known for some years. Mr B’s GPs knew from his contact with Mr B’s mother that he was a father but he never recorded this fact in his notes and he never asked Mr B directly whether he had responsibility for any children. Other members of the practice did not know this. 4.1.11 Mr B had limited contacts with professionals in the mental health trust in 2004 and 2008. These contacts were all very brief as when he was examined in a community mental health setting he did not show signs of a serious or enduring mental health problem and so was never allocated to the service or appointed a care coordinator. On both occasions he was discharged back to the care of his GP and referred on to other services (the young people’s mental health service and drug services) which he did not attend. In 2010 a further referral was made but Mr B did not keep the appointment and it cannot be confirmed that he received it. In 2011 a further referral had been made by the family GP to the local mental health service shortly before Child F was wounded. 4.1.12 Mr B was supervised by two different probation officers during 2008 - 2010. They made referrals to the mental health trust focused on his possible mental health needs and for support from substance misuse services. Probation officers focused on work required to reduce the risk factors that they believed had contributed to his offending. 4.1.13 There was no contact between these two groups of professionals at all. There were a small number of times when it might have been possible for the professionals who were dealing with Mr B to bridge the gap between the two sets of professionals and to consider the potential impact of his behaviour on his children. A brief account of these shows that this did not happen for different reasons at different times. 4.1.14 The family health assessment format that was used by the health visitors during the two new birth visits invites the parents to offer information about themselves, their relationship and the wider family environment. The mother chose not to provide 30 information about his history or any current risk factors, either during the new birth visit or at any other time. As a consequence the health visitors did not know that Mr B had a conviction for a serious violent offence against an adult or that (until mid-2010) that he was in regular contact with a probation officer. 4.1.15 When his first probation officer became aware that Mr B had a child a notification was sent to the local authority to find out if the child was subject to a child protection plan or if the family were known. The replies were negative. Section 4.6 evaluates this contact. By the time Child F was born Mr B was no longer subject to licence requirements and no longer had contact with the probation service. 4.1.16 During the A&E assessment that took place 24 hours before the wounding of Child F, mental health service professionals were aware that Mr B had children and lived in the same household with them. They had only brief contact with him and the only information about his history of mental health problems was information provided by Mr B and his family. Their assessment was the first one which was able to any degree to take account of possible risks to the children arising from his mental health and substance misuse because they were the first to know of a direct connection at a time when he was not functioning well and seeking support. Section 4.3 evaluates this contact in detail. The most important factor that limited the extent to which this assessment could thoroughly assess potential risk to the children was that it took place within the A&E setting. This is explored further in section 4.3. 4.1.17 Having noted as an initial point of evaluation that discrete groups of professionals worked with different members of the family, it is important to note that this is not necessarily a criticism. This may have been entirely ‘normal’ and understandable. Given their roles and the nature of the risks identified it may not have been considered necessary for them to communicate with one another. This is discussed in detail in section 4.6. The evaluation of mental health services and the nature of Mr B’s mental health problems 4.1.18 The primary focus of the SCR is not on mental health or substance misuse services provided to Mr B. However given the key events in the case history the SCR panel and the overview author have considered these carefully, focusing on the implementation of the responsibilities of mental health services to safeguard and promote the welfare of children. Where this touches on the wider provision of mental health services the findings of the report have been discussed with senior representatives of the mental health trust who have both clinical expertise and relevant management responsibility. 4.1.19 At different points in the case history psychiatrists gave different diagnoses of Mr B’s mental health problems. When Mr B’s mental health was assessed in local community settings (2004, 2008 and 2011) his paranoia and anxiety were always understood to have been linked to or triggered by misuse of cannabis and alcohol. None of the assessments that took place elicited any clear evidence of psychotic thought patterns. When the extent of his criminal activity was factored in, this was identified as being an understandable 31 cause of real fear and anxiety for him. His strategy of smoking significant amounts of strong cannabis and drinking to reduce his anxiety are likely to have worsened his symptoms and his vulnerability. There were long periods when Mr B was not taking medication and he remained free from psychiatric symptoms. These usually coincided with times when he reported that he was not taking cannabis. 4.1.20 On the one occasion in 2006 when Mr B was assessed and treated within the prison system the psychiatrist arrived at a different view, stating that he believed that Mr B was suffering from an underlying psychotic illness and that there was the potential for the development of a ‘severe and enduring mental illness such as schizophrenia’. It has been noted that this assessment was only ever used in the court setting where it influenced sentencing to Mr B’s benefit. This finding, the assessment that it was based on and his health records while in prison were never made known to Mr B’s GP or to others in community mental health settings. 4.1.21 It is not the role of this report to judge which diagnosis was correct. Moreover it would be impossible to do so. Psychiatric diagnosis is often difficult and uncertain. Some patients closely and consistently fit diagnostic criteria. The behaviour of many others will fluctuate a great deal leading them to be given different diagnoses at different times. In some cases psychiatrists only feel able to offer a firm diagnosis after they have observed the impact or lack of impact of treatments. It would in any event never be possible to prove that Mr B did not have an underlying mental disorder. The role of cannabis as a trigger or a cause remains unclear. 4.1.22 It is clear that the nature of Mr B’s mental health problems did vary a great deal. In particular it is clear that his presentation and behaviour in the episode during which he wounded his daughter was drastically different from any account of his previous behaviour and drastically different from the way that he had presented to professionals 24 hours earlier. 4.1.23 The remainder of this report will refer to Mr B’s ‘mental health’ and his ‘mental health problems’ rather than to any specific psychiatric condition. The purpose is not to minimise the nature of his difficulties, but to underline that it is impossible to be certain what caused them. It is also important to underline that the primary focus of concern of this report is to understand whether the professionals who were aware of his mental health problems were sufficiently mindful of the potential impact on his children. 4.2 If there is evidence of risk factors from the period prior to January 2009 establish whether or not information about these risk factors informed later professional contacts with the family 4.2.1 There is no significant information about risk factors in relation to the mother or other members of her family during the period prior to the terms of reference of the SCR. There is no indication that any important information about risk in relation to the mother was not 32 known to professionals. No information about risk factors in relation to the mother or other members of her family has subsequently emerged. 4.2.2 Sections 3.1.2 – 3.1.22 above give an outline of the considerable difficulties that Mr B experienced during his childhood and adolescence. This included: (TEXT REDACTED) Chronic cannabis use which the family stated occurred from age 12 onwards Educational and behavioural difficulties resulting in school moves and eventually permanent exclusion from secondary school Involvement in petty offending and convictions associated with the illegal supply of drugs from age 16 onwards The onset of anxiety disorders and psychosis associated with his sustained drug misuse, first recognised in late adolescence. 4.2.3 In 2006 Mr B committed a serious violent offence against another adult, by his own account this was linked to his involvement in the illegal supply of narcotics and at time when he was a heavy cannabis user. While he was on remand in a Young Offender Institution his mental health deteriorated. 4.2.4 Taken together the combination of violent offending, drug misuse and mental health difficulty (whatever its cause) might easily have had a significant negative impact on Mr B’s capacity to parent children in a safe way. The narrative indicates that - until Child F was injured - they did not. The reasons for this cannot be known fully but it is likely that the following are relevant: When Mr B first became a parent he was on licence to the probation service and (according to his own accounts and some supporting evidence) he was not using cannabis and he was not committing offences. The evidence is that his pattern of cannabis use changed after his licence supervision ended Although there is abundant evidence that Mr B cared deeply about what happened to his children, it is not possible to be absolutely certain how much day to day responsibility he had in caring for them Had he behaved in a way that placed his children at risk it is very likely that other members of the family would have been concerned and acted to protect them against any risk. 4.2.5 The report is concerned to establish whether the professionals who were involved with the family knew about these potential risks. 4.2.6 The professionals who were most directly involved with the mother and the children knew little or nothing at all about Mr B. They were not in a position to assess the potential risk and relied on their observations and evaluation of the children to judge whether they were living in a safe environment and developing well. The evidence was that they were and that the mother was taking the steps necessary to promote their health and development. She missed a small number of appointments but this was not considered unusual or concerning. 33 4.2.7 The probation officers who supervised Mr B were aware of his criminal record and the general pattern of his behaviour and offending. Substance misuse and mental health were identified as risk factors when supervision began and updated assessments were requested and provided. At that point Mr B did not have children. 4.2.8 After the birth of Child G in 2009 the probation officer established from the local authority that the child and family were not known to the local authority. This is discussed in section 4.3 below. 4.2.9 The psychiatrist who assessed him in 2008 knew about key aspects of Mr B’s history and convictions, but again at that time he did not have children. 4.2.10 Mr B did not keep his appointment when his GP referred him to the mental health trust in 2010. Mr B did not attend the planned GP review and the GP did not re-refer him. At that time he had one child and the extent of his responsibility for the child could have been explored if a mental health assessment had taken place. 4.2.11 The mental health professionals who assessed him at the A&E department in 2011 established that he had children. They had no access to information about his mental health history or his previous offending though he gave a frank account of his current lifestyle and indicated that he had previously suffered from drug induced psychosis. Their assessment could not take full account of the historical indicators of potential risk. This assessment is discussed in detail in section 4.3. 4.2.12 The most significant aspect of the history that remained inaccessible to any professional who was working with Mr B or the children were the court and prison psychiatric reports prepared in 2006 and prison health records from 2006-2008. These were only used within the court and in the prison service and never made available to local professionals. It is not possible to know what effect it would have had if the GP, mental health trust and probation service had had these records. They showed what Mr B was like in a different setting at a particularly stressful time in his life and they offered a different opinion as to the nature of his mental health problem. Even though it cannot be said that access to these records and reports would have made a difference in this case it is clear that careful consideration needs to be given to making such records available in future. 4.2.13 The professional who had the best overview of Mr B’s background and relevant history was his GP, though he too had no access to prison and court records and reports. So far as the SCR can determine Mr B’s GP did know from his mother that he had children but he did not record this in the records so that colleagues could easily take account of it. None of the GPs established what the care arrangements for the children were. The GPs focused on Mr B’s current mental health problems, taking into account his past, but viewing him as part of his family of origin. This is likely to have been reinforced by the fact that he was often brought to the surgery by family members (although on at least one occasion the surgery had contact with Mr B’s partner) and his mother continued her role in collecting prescriptions and medication. GP contact with Mr B took account of his past, but did not establish the significant changes in his life and family network. This highlights important learning for GPs 34 about the need 1) to view patients in relation to their current life and not just their medical history, 2) to ask questions about whether patients have children and 3) in some instances to communicate with other GPs and health professionals who are responsible for other individuals in a patient’s network. Recommendations are made in relation to this. 4.3 What assessments were undertaken and what was the quality of those assessments 4.3.1 The pattern of assessments was shaped by the overall pattern of professional contact with different family members set out in section 4.1 above. This section of the report evaluates the key assessments undertaken. In some areas it also deals with the service provision that followed from this where the two are hard to separate. Probation assessment 4.3.2 The assessment carried out by the probation service was necessarily determined by the focus of the service on reducing the risk of reoffending. Assessments took place shortly after Mr B was released on licence and identified the factors that the probation officer believed to be likely to influence possible reoffending. Mr B was assessed as a high risk of reoffending and referred to the local multi-agency risk assessment panel (MAPPA). The probation supervisor commissioned additional assessments in relation to risks associated with mental health and substance misuse. All of these assessments were within the framework of probation responsibilities and correctly carried out. They occurred at a time when Mr B did not have responsibility for children. Additional referrals were made in relation to employment and training. The assessments and services were subject to review and areas of progress were noted. It was also noted that Mr B never demonstrated any genuine ‘victim empathy’. 4.3.3 It is impossible to tell how motivated Mr B was in relation to the services that he was offered. However the evidence is that he attended and complied with all of the requirements of his licence. There is no evidence of offences committed while Mr B was under probation supervision. 4.3.4 These assessments were undertaken at the beginning of his licence period when Mr B did not have children. When his probation officer became aware that he did have a child, she contacted the local authority to establish if the children were the subject of a child protection plan and if the family were known to social care staff. There was a negative response to both of these questions. As she saw no indications of possible risk to the children she did not seek additional information from any other professional. 4.3.5 The only shortcoming identified in the provision made by probation services is that no home visit was made in order to establish more about his family circumstances and verify the information given by Mr B. This would have been justified given the nature and circumstances of his offence, (TEXT REDACTED) and the repeated weight that Mr B placed on family members in supporting him and helping him not to reoffend. The potential value of a home visit would have been even greater once it was known that Mr B had a child. 35 4.3.6 At the time probation officers were expected to undertake a home visit shortly after release for high risk offenders. Current practice is to undertake a home visit for all offenders on licence. Midwifery assessments 4.3.7 Midwifery assessments were focused on the pregnancy. In booking and subsequent appointments midwives are required to follow up any information about risk highlighted in the GP antenatal referral and also to seek to identify any additional information about risk factors. There is no detailed information about the maternity care provided during the mother’s pregnancy with Child G. During her pregnancy with Child F she was seen at (TEXT REDACTED) hospital. No risk factors had been identified in the GP referral. (TEXT REDACTED). No social risk factors were identified. The mother said that she lived with her one year old infant. The mother indicated that she was well supported by family but no details of wider family circumstances were recorded. The identity of the father was not sought and no information was obtained about him. There is no evidence that standard, obligatory questions about domestic violence were asked though there was opportunity to do so because the mother attended her appointments alone. (TEXT REDACTED). 4.3.8 This was a limited assessment focused on the immediate medical and health needs of the mother and any medical issues that might impact on the pregnancy. It was led by the information provided by the GP and by the information that the mother was prepared to disclose. 4.3.9 The (TEXT REDACTED) NHS Trust does not issue specific guidance to staff working in antenatal clinics about identifying fathers, where they do not attend and where this information is not offered by the mother. Reliance is placed on the professional responsibility of the midwife to consider the care offered to the mother in the context of the whole family (whatever its composition). Recording formats offer space for information to be collected about fathers. Health visitor assessments 4.3.10 Health visitors undertook family health assessments in relation to both of the children at the time of the new birth home visits. (TEXT REDACTED). The content of these assessments has been described in detail in the management review provided by (TEXT REDACTED) community health service. Both assessments led to the decision to allocate the children to the universal service because they had no additional needs that required a proactive health visitor intervention. This involves regular clinic appointments to track the children’s health and development, but otherwise the children’s mother was left to seek advice on the children from her GP and the health visitor. If factors pointing to heightened levels of need or potential risk had been identified then a higher level of provision would have been offered (‘universal plus’ or ‘partnership plus’) which would have involved more active monitoring and response by the health visitor. 36 4.3.11 The family health assessment at the new birth visits focused on the health and development of the two children, placing this within the wider context of the family circumstances. The assessments undertaken follow broadly the children in need assessment framework with a focus on 1) health and development of the infant, 2) parenting capacity and 3) environmental factors. The assessment has four components: observation and assessment of the infant; observation of the care provided; discussion with parents and carers and completion of a self-reported questionnaire which gives the parent an opportunity to provide information about the wider family circumstances and any risk factors, which the health visitor will then discuss further. In principle this offers the opportunity for information about domestic violence, parental drug misuse and mental health problems to be identified. Relevant background information may have been identified in relation to another child in the family or by the GP or midwife in the antenatal period. If this has not happened the health visitor is reliant on the information provided by the parent during the new birth visit. In this case the mother did not provide any detailed information about the father or her knowledge of any indicators of risk relating to him. 4.3.12 Based on the information provided there is no reason to suggest that it was not correct to assign both Child G and Child F to the universal level of health service. However two issues have been identified from which there is the potential for further learning: 1) the role of the father in the assessment and the knowledge that professionals had of him and 2) the response of health professionals when the children were not brought to appointments. The role of the father in the assessments and health professionals’ knowledge of him 4.3.13 The exact role of the father was not established. (TEXT REDACTED). 4.3.14 With hindsight it is apparent that in this case the strengths and protective factors in parenting came from the mother and members of the parents’ extended families, whereas the only risk factors were linked to the father’s substance misuse and mental health problems. These were not static throughout the lives of the children; they increased as time progressed particularly in the weeks before his final psychotic episode. 4.3.15 In the new birth visits nothing was said that would have caused the health visitor to seek more information about the father or to contact any other professional about him. The father was present during the first home visit and his details were taken. The health visitor states that he was not present at the second, but his details were confirmed. It was noted in general that he was playing a supportive role but not living in the household. The health visitors did not know this but this was at odds with the information that the father provided in many of his contacts with his probation officer which suggested that he was staying and living with his partner and her mother. It is very likely that if the health visitors or the midwives involved had had a better understanding of the role of the father and the potential risk factors in his background the overall assessment of need in relation to Child F would have been different. 37 4.3.16 Health visitors say that if it had been known that the father had a history of mental health problems, drug misuse and a conviction for a violent offence it is much more likely that the children would have been allocated a higher level of health visiting service, even if this was just to allow the health visitor to remain actively involved for a longer period until an assessment of any potential risks had been made. It is impossible to say whether this would have made a difference to the services offered by the point at which Child F was injured. 4.3.17 The SCR has tried to understand how much the mother knew about the risk factors that have been identified in relation to the father and why it is that she chose not to share information about the father’s history with the professionals that she was in contact with. (TEXT REDACTED). 4.3.18 (TEXT REDACTED). Both she and her own mother expressed the view that it was important not to judge people by what they had done when they were juveniles and that individuals could overcome past bad experiences. 4.3.19 Neither of the health visitors saw it as their responsibility to challenge the mother to provide more information about the father or to seek background information from other sources. This was consistent with the prevailing practice and culture of the health visiting service and this is an underlying pattern in practice that goes beyond the individual case. This is identified in the community health management review as an area of potential learning, given that recent government guidance places great stress on identifying fathers and encouraging the involvement of fathers in the care of their children. 7 4.3.20 At present it is clear that there is a gulf between the guidance produced by government and the implementation of this aspiration by many front line staff. Guidance sets very high expectations about the involvement of both resident and non-resident fathers highlighting the value of direct communication with fathers, assessment of fathers and arranging appointments at times when fathers can attend. Practitioners aspire to achieve this but know in practice that in many settings contacts will usually be with the mother and practitioners will rely on the information that the mother provides. The reasons for this will be shaped by different reasons in different health settings and in work with different communities. In practice it will often be most difficult to engage the fathers and other male carers who most need to be engaged because they engage in risky behaviour and are less likely to be cooperative. 4.3.21 If it is to be successful the work to engage fathers requires a significant change in culture, expectations and working practice. The management review of community health provision suggests that further training is required and makes a recommendation in relation to this. The reviews of midwifery practice do not address this aspect of practice. Guidance alone will not achieve significant changes. Training will be beneficial because it is clear that many practitioners find it hard to know how to broach the issue of father’s involvement with mothers and to find out more about fathers in a way which does not appear to be intrusive 7 Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life. A key section is reproduced as Appendix 4 of this document 38 and threatening. However it is unlikely that in isolation training will make a significant difference and it is recommended that health trusts need to provide a much more comprehensive approach. This could include: issuing clear guidance; offering training; and monitoring the extent of engagement with fathers and the effectiveness of contacts. Staff will need to be consulted so that there is a shared understanding of why this aspect of practice is so difficult and to have an opportunity to contribute their own ideas. Many of the ideas suggested in guidance (such as offering appointments when it suits fathers) will clearly have resource implications and trusts need to decide at a senior level whether they are prepared and able to ask staff to prioritise this area of activity. This needs to be addressed by all health trusts providing midwifery and health visiting services. 4.3.22 It is recognised that there are particular practical difficulties in applying this approach in midwifery, not least because midwives are also expected to exclude male partners from part of the antenatal assessment while they ask obligatory questions about domestic violence. Notwithstanding these difficulties the full force of recommendations made in relation to this issue in this report and the health overview report should apply in relation to antenatal services. The response when appointments were missed 4.3.23 The decision to offer contact within the universal provision framework, linked as has been explained to the lack of specific information about the father, shaped the response when the mother did not bring Child F to clinic appointments. As no specific risk factors had been identified the response of the health visiting teams was to send the mother a further appointment or to phone her with a reminder. This was left to the individual practitioners to undertake and the length of time between missed appointments and follow up varied. Usually this led to the mother attending some weeks later. 4.3.24 Had the health visitors been offering a targeted intervention in which specific needs or risk factors were being addressed through a planned series of contacts, they are likely to have taken a different stance when an appointment was missed because they would have wanted to establish the reasons and to ensure that appointments were rearranged as soon as possible. 4.3.25 Discussions with the individual management review author and with the staff directly involved in this case have shown that since the events under review the policy and practice of the trust have been changed so as to ensure that there is now a standard practice when any clinic appointment is missed (bearing in mind that attendance at such appointments is voluntary). The management reviews recommends that the need to implement this policy is reinforced through training and supervision. It is recommended in addition that is should be subject to audit. The use of the Family Health Assessment 39 4.3.26 Since the new birth visits in relation to these children the RIO electronic record keeping system has been introduced to the community health trust. This records the information gathered in new birth visits in a different format from the one currently used to collect it. In interviews with the health visitors it has been established that they place great value on the use of the family health assessment at new birth visits. There appears to be some uncertainty as to whether the introduction of RIO will lead to changed expectations about the role of the family health assessment. The strong positive feedback given by practitioners in this case review strongly suggests that the community health services should be extremely cautious about making any substantial change in the use of the family health assessment. It is recommended that there is a full consultation with front line staff before any significant change is made to the Family Health Assessment Mental health assessment in Accident & Emergency department Introduction 4.3.27 Paragraphs 3.2.44 - 62 above set out the best account that can be reconstructed of this episode. It has been evaluated in detail by the SCR panel and the overview report author because it was the last professional assessment of Mr B before Child F was wounded. Family members have also expressed concerns about the outcome of this assessment and the way in which it was conducted. 4.3.28 The SCR has sought to evaluate and learn from the assessment taking into account the evidence that was available to professionals at the time. The function of the SCR is to establish whether there were shortcomings in the assessment, whether these led to shortcomings in care and treatment, to establish whether as a result opportunities were missed to reduce risk from Mr B’s behaviour that could have been predicted and to learn from these findings. It is recognised that there may have been significant changes in Mr B’s mental state and behaviour after the assessment. It might not necessarily have been possible to predict these at the time of this assessment. 4.3.29 In order to evaluate the A&E assessment, the following have been considered: Evidence of the involvement of the family at the time and the views of family members given to the SCR The actions that the professionals took to try to elicit information from the Mr B and his family The evidence that was presented and the quality of the assessment of Mr B’s mental health The plan or service provision made by the professional in the A&E department The assessment of the safety of the children The SCR has taken account of the management review provided by the mental health trust but the authors of the SCR overview report and the health overview report have also directly reviewed the relevant medical notes and held discussions with the staff involved. 40 4.3.30 The SCR obtained the views of family members, to set them out in a systematic way and to evaluate them alongside the evidence from the medical records and the additional information provided by the professionals who were involved. The views of family members 4.3.31 It was not possible to interview Mr B to establish his views about this assessment because he remained too ill. 4.3.32 The following family members have given their views about the A&E assessment: Mr B’s mother -who was present during part of the assessment Mr B’s partner - who was present during part of the assessment A close family friend who attended the hospital and drove Mr B home but was not present during the assessment The children’s maternal grandmother -who was not present. 4.3.33 Taken together family members have expressed the following criticisms or concerns about the assessment: Too much emphasis was placed on Mr B’s self-reported misuse of cannabis and alcohol The extent of his self-reported consumption of drugs and alcohol was implausible and family members state that they have no evidence to support his account of being involved in criminal supply of drugs; family members feel that this may have been part of his deluded thinking The ready acceptance of his account of his drug use and involvement in criminal activity led the doctor and the mental health worker not to make a full exploration of Mr B’s mental health needs. There was insufficient probing in depth of Mr B’s mental and emotional state, how he was feeling and the extent of his unhappiness at recent deaths of people close to him. They are surprised how short a time the assessment lasted; for example, drawing on experience in the ambulance service the family friend has noted how mental health assessments associated with compulsory detention in hospital sometimes take several hours Mr B was willing to be admitted to hospital and this is what should have happened. The children’s maternal grandmother believes that there is a specific 6 hour holding power under the Mental Health Act (1983 and 2007) that could have been used to secure his admission. 4.3.34 Family members have also expressed concern about what they feel was an abruptness and negative attitude in the way in which some aspects of the assessment were conducted. The perceptions of family members must be treated as genuine, though some have been disputed by the professionals involved. However this aspect of their account is impossible to address without knowledge of everything that was said during the assessment and exactly how it was said. The findings of the A&E assessment of Mr B’s mental health 41 4.3.35 The evidence from the mental health trust records is that the interviews with Mr B and members of his family did attempt to explore the areas that should be included in a mental health assessment, including Mr B’s presenting symptoms, his mental state, his behaviour towards other people and his use of drugs and alcohol that might be influencing his mental state. The records show that the examination of Mr B’s mental state included recording of his mood, speech, perception of his circumstances and the level of his insight into his own circumstances. A view was formed based on observations made in the assessment about his risk of harm to himself and to others. 4.3.36 The formulation (explanation) of Mr B’s condition viewed drug and alcohol misuse as the cause of his current mental state rather than any underlying mental illness. The junior doctor and the mental health worker both independently arrived at this conclusion. This was because Mr B gave a great deal of information about his use of cannabis and alcohol and he was very frank about his involvement in criminal activity. The professionals who saw Mr B formed the view that his agitated state, his anxiety and his suspicion of other people could largely be explained by the combination of his heavy use of cannabis and alcohol and by realistic fears arising as a result his criminal lifestyle. They believed that he was taking cannabis and drinking heavily to calm his nerves to the extent that he had become dependent on both. Their judgement was that using them in this way had become counterproductive as one of the recognised effects of significant cannabis intake is that it can make the user suspicious and exacerbate feelings of paranoia. 4.3.37 In contrast, Mr B gave only very little specific information when asked about any psychiatric symptoms or history such as depression, anxiety or psychosis and about his history of mental health problems. The medical records show that Mr B’s mother was present when the doctor and the mental health worker tried to gather information about his history of mental health problems and to establish when and where he had previously been diagnosed as having drug induced psychosis. Mr B’s mother did urge him to be frank about everything but according to the records she did not provide any detailed additional information about his history of mental health problems. The records show that she left the assessment while this was being discussed. The professionals believe that this was because she was very upset to hear him talk about the extent of his recent drug use. 4.3.38 Based on the records made at the time the family members who were involved in the assessment did not provide any significant additional information about other psychiatric symptoms. It is clear that it was much more difficult to establish information about Mr B’s mental state and mental health history, but the evidence is that attempts were made to do this. There is no evidence that these factors were neglected or downplayed in the assessment. 4.3.39 Most of the symptoms of mental health concerns that family members have used to describe Mr B’s behaviour and emotional state coincide with the behaviour recorded in the mental health assessment. There is also considerable evidence that at a number of points family members had explained the deterioration in his mental health as being attributable to 42 drug use. For example: medical notes show that his partner was present in August 2010 when Mr B told his GP that he was smoking weed and becoming paranoid; GP records state that Mr B’s mother told the GP in October 2011 that he was ‘smoking drugs again and as a result behaving oddly’. In later discussions with psychiatrists who were preparing reports for the criminal proceedings Mr B and his father confirmed accounts of his significant use of drugs and alcohol and his involvement in offending at this time. It is of course very possible that different members of Mr B’s family had different information about his lifestyle and his use of cannabis. The plan made and discussion about possible admission 4.3.40 There are significant differences between the records and recollections of the professionals and the recollections of family members. Medical records written at the time indicate that the professionals attempted to engage the family in trying to gain further information and to explore whether Mr B presented a risk. The professionals believe that the family members present were involved in the assessment and discussed and agreed with the treatment plan. Family members state that their concerns were not taken into account and that they were surprised by the plan to discharge Mr B home without further active treatment or support and monitoring. It is impossible to be certain as to why such strong differences in perception exist. 4.3.41 The records indicate that family members were not seen on their own in the absence of Mr B. Had this happened it might have meant that family members were freer to provide more detailed information about their concerns. It is agreed by everyone that this was a weakness in the assessment. 4.3.42 The plan or service provision made by the professionals was in accord with the assessment that they made. Mr B and his family were given information about local drug and alcohol services; he was given medication (TEXT REDACTED) to help him sleep that night and he was discharged back to his GP in the knowledge that he had already referred him to the mental health trust Primary Care Liaison Team for a fuller psychiatric assessment. 4.3.43 The family have subsequently stated that their expectation was that Mr B would be admitted to hospital that evening as the strain of coping with him was proving too much for his mother. The records do indicate that the strain on Mr B’s mother and other family members was mentioned during the assessment. From the descriptions given of Mr B’s mental state and circumstances at the time of the assessment there is no indication that the professionals involved would have considered hospital admission to be necessary or justified. This has been considered in detail in the individual management review prepared by the mental health trust. The evaluation made in that report was prepared by an experienced consultant psychiatrist and the trust’s head of social work and social care. It states that: ‘Mr B’s presentation in A&E did not exhibit features of a clear psychotic episode to warrant his care being taken on by the Home Treatment Team. His presentation was also not 43 consistent with an admission to hospital being offered, not least given the principles of least restrictive practice we operate under. Thus someone, as in Mr B’s case, who is acknowledging a problem, seeking help for it and is accepting of advice and further treatment options, should be offered support in the community without recourse to the often disturbing environment of an acute admission ward.’ 4.3.44 The SCR accepts this judgement. Although subsequent events did not prove this to be correct, on the basis of the information that was available at the time the admission of Mr B to an acute psychiatric ward was not justified because on the basis of experience it would have been likely to have done him more harm than good. 4.3.45 The records show that approximately 30 minutes was spent with the family. Longer would have been spent if family members had been seen without Mr B. It is correct that – as family members have pointed out – when an assessment is taking place under Section 2 of the Mental Health Act in order to consider whether it is necessary to detain a patient in hospital can take considerably longer than the assessment of Mr B in the A&E department. This is not relevant to the circumstances of Mr B because these assessments require a very detailed scrutiny of the medical and legal grounds to admit a patient. There were no medical or legal grounds to detain or admit Mr B. 4.3.46 The children’s maternal grandmother has specifically suggested that there was a power to detain Mr B for 6 hours for an assessment. This most likely relates to Section 5.4 of the Mental Health Act (1983 and 2007) which enables a nurse to detain a patient in hospital who is already a hospital inpatient. This also was not a legal power that is relevant to the circumstances in which Mr B was being assessed. Assessment of the potential risk to the children 4.3.47 The trust mental health risk assessment framework contains a section dealing with risk to children. This should be completed when it has been identified that a patient lives with or has caring responsibilities towards children (or is a risk to children). Interviews with the professionals involved and review of the records demonstrate that an assessment of the potential risk to the children formed part of their thinking but that it relied on a series of assumptions being quickly formed based on impressions of the family, rather than there being based on a systematic assessment of the children’s circumstances. Details of the children were obtained and recorded but no specific information was recorded about the nature and extent of Mr B’s contact with children and his caring responsibilities. The component of the mental health trust risk assessment format focused on children was not completed. The clinicians say that they were reassured about the welfare of his children by the very positive way Mr B spoke about them and by the presence of key members of the extended family. 4.3.48 The details of the assessment and the thinking of the professionals in relation to this aspect of the assessment were not recorded. This means that it is impossible to be absolutely sure what was discussed and considered. However if a systematic and comprehensive 44 assessment had been undertaken it is almost certain that it would not have come to the conclusion that the children were at risk. There was no evidence that Mr B had ever posed any risk to the children in the past. Insofar as Mr B was noted to have any psychiatric symptoms there was no indication that he was focused on or preoccupied with the children. Had this been the case it would have led to a high level of concern and it is very likely that the clinicians would have recognised this. Potential risk to the children was not discussed with other family members but it is easy to understand how professionals could conclude in the circumstances that the other members of the family network would ensure that neither adults nor children would come to any harm. Members of the family did not think that Mr B could pose a risk to his children and it would have been extremely difficult to imagine circumstances in which the professionals involved would come to that conclusion. 4.3.49 Although family members say that they do not believe the account given by Mr B of his drug use, the doctor and the mental health worker did. It was therefore a shortcoming of the risk assessment that it did not consider in detail whether the misuse of drugs and alcohol might adversely impact on the care of the children. If a detailed assessment of this had been made it is very likely that it would have come to the same conclusion i.e. that the family members would be alert to any concerns and would be able to protect the children from any potential harm. 4.3.50 Although there is no evidence that it would have identified a high level of risk to the children the assessment illustrates that mental health trust staff were insufficiently aware of the need to make a specific assessment of risk to children. The individual management review prepared by the trust makes two recommendations in relation to this which the SCR endorses. Learning from the A&E assessment 4.3.51 The narrative in section 3.1 and the preceding analysis indicate that there were two important shortcomings in the assessment and in the way it was documented: there was no separate time given to interviews with family members without Mr B being present and the risk assessment of the children relied on an instinctive judgement rather than being the systematic. The SCR has highlighted the following as being most important factors contributing to these shortcomings. 4.3.52 The mental health trust’s internal information system did not allow the assessors access to previous records of Mr B’s mental health trust contacts in 2004 and 2008. The records would also have shown that his current presentation was consistent with the way in which Mr B had behaved, intermittently for at least 8 years. Knowledge of the length and severity of the problem would have been useful. Access to records of the mental health trust’s own 2008 psychiatric assessment (conducted following the probation referral after his release from prison) would have provided information about Mr B’s history of violence. It is very likely that if this information had been available it would have made it easier for the doctor and the mental health worker to explore the history with Mr B and with his family. This might have influenced the assessment of future risk. However had these records been accessible 45 they would have confirmed the information that Mr B’s previous psychotic symptoms were linked to cannabis use. This would have tended to reinforce the assessment that the professionals had made. 4.3.53 There was uncertainty between the clinicians involved in the A&E assessment about what risk assessment documentation needed to be completed and whose responsibility it was to complete it. There was a mistaken belief that if someone was not taken on by the crisis resolution service there was no need to complete the risk documentation, including the safeguarding children documentation. Completing this documentation would not have altered the assessment but not completing it would have hampered the assessment of other clinicians if Mr B had presented at A&E or in the mental health trust at a later point. 4.3.54 The case history highlights potential vulnerabilities in the way in which the mental health liaison services to the A&E department are designed and delivered. There are specific challenges for relatively junior or inexperienced staff in undertaking mental health risk assessment and the associated risk assessment of children in the A&E department. Rapid assessment is required and judgements are required about potential risks to children when there is often no opportunity for contact with children or with professionals who know them and little or no access to relevant records. Given this the actions and decisions of the individual professionals are likely to have been repeated if other individuals had been on duty that evening. They were not the result of wayward judgements by those involved. 4.3.55 Section 4.8 describes the level of training and experience of the staff members involved. It was broadly what would be expected. It is possible that if the assessment had been carried out by a psychiatrist with more experience it might have obtained more information from the patient or the family which would have led to different treatment options being considered. Although it is extremely unlikely that any psychiatrist would have considered admitting Mr B to hospital a more experienced psychiatrist who was aware of the full history might have prescribed Mr B antipsychotic medication. However even if this had happened it is impossible to say with any degree of certainty that it would have changed the course of events. The conclusion of the experienced consultant psychiatrist who has evaluated the case history is that ‘the speed of action of an anti-psychotic would not have altered his presentation the following day’. (Mental health trust individual management review) 4.3.56 Whether or not it would have made a difference to the management of this case, it is important for the mental health trust to explore further whether the training in mental health and safeguarding children that relatively inexperienced staff received prepares them adequately for the types of cases they would see when undertaking an acute assessment outside of normal working hours in the A&E department. 4.3.57 The mental health trust review states that the trust is currently developing trust-wide operational guidance on the work of staff which will address the skills, medical leadership, induction of staff and safeguarding training necessary for tailored to the task of assessment in A& E. The mental health trust review has made a series of recommendations in relation to 46 these matters. The SCR endorses these recommendations and the action plan developed by the trust which recognises that specific and urgent action is needed. The conduct and professionalism of the staff involved in the A&E assessment 4.3.58 Taking into account all of the evidence available, the view of the SCR is that the assessment was undertaken in a professional way. The evidence is that it was conducted in good faith and to the best ability of the professionals who carried it out. Wider family contact with health professionals during this period 4.3.59 Family members went to great lengths to get help for Mr B in the days before he stabbed his daughter. In evaluating the service provision that was made the SCR has therefore considered the A&E assessment as part of the wider pattern of contacts that family members had with health professionals in the four days before Child F was stabbed. 4.3.60 There is no doubt that Mr B’s mother, his brother and his partner did everything that they could reasonably have done to obtain care and support for him during the four days leading up to the wounding of Child F, contacting his GP three times and taking him to A&E. However the evidence shows that there was a mismatch between what members of the family believed was happening and the action that professionals were taking. It also suggests that coordination of the involvement of different health professionals could have been better. 4.3.61 When Mr B was first seen by his GP he was told that an urgent referral would be made and (family members say) that this would lead to an appointment in 7 – 10 days. This could not have happened because the referral was sent by letter to the mental health trust and it arrived four days later, after Child F had been injured. The referral was screened immediately by the mental health trust. 4.3.62 Although the referral letter asks for an urgent appointment ‘within the next two weeks’ nothing else in the letter indicated that the circumstances required an urgent response because Mr B was seriously ill or a risk to himself or others. The key section of the letter refers to him as ‘a patient with known paranoid schizophrenia’ whose family ‘have recently become concerned about him’. The GP did not identify that Mr B’s circumstances had changed and that he now had responsibility for children. If this referral was genuinely urgent it is strongly suggested that it should have been faxed or sent electronically and followed up with a phone call. 4.3.63 Family members contacted the GP twice more in the following four days, and although it was suggested that there could be a follow up call to the mental health trust to hurry up the referral, no further contact was made with the trust. 4.3.64 The plan recorded at the end of the A&E assessment (written by the psychiatrist) indicates that the discharge letter to the GP would be used to expedite the existing referral to the mental health team. However the actual letter (which was written by the mental health 47 worker) does not do so and there is no indication that the Primary Care Liaison Team were contacted in order to provide information about the attendance at A&E. This might have altered the response of the Primary Care Liaison Team. 4.3.65 The SCR has established that (without any knowledge about what had happened to Child F) the Primary Care Liaison Team offered an appointment to Mr B for 23 November (5 weeks after the GP referral). The view of the mental health trust is that although the letter asked for an urgent appointment there was nothing in the referral letter that conveyed the need for urgency and that this time scale was justified. However before making this decision it would have been better for the members of the mental health team who decided how to respond to this referral to seek to clarify directly with the GP (i.e. on the phone) why he thought that the referral was urgent. 4.3.66 There is no evidence that these actions would have altered the outcome for Child F. However if such approaches are repeated in other cases confusion about whether a case is urgent or not and the failure to pass in information about developments in the case history may cause delay in referrals being made and dealt with. 4.3.67 It is also noted that Mr B was never referred by his GP to substance misuse services, even though this was always believed to be the cause of his mental health problems. Yet whenever he was assessed by the mental health service he was found not to have an underlying mental illness. This combination of approaches meant that he never received a service for his drug problem (except when he was referred to the drug service by the probation service). 4.3.68 It is therefore recommended that 1) the mental health trust and GPs in (TEXT REDACTED).rify criteria and arrangements for urgent mental health referrals, highlighting the responsibilities of GPs to follow up referrals as circumstances change and 2) that (TEXT REDACTED) GPs are asked to review how they respond to information in relation to heavy or sustained drug use and consider how they can make better use of local drug services. The deterioration in Mr B’s mental state after the assessment 4.3.69 As the description in sections 3.2.66 onwards above shows there was a sudden and severe deterioration in Mr B’s mental state some 24 hours later. The impact of Mr B’s mental state on his understanding of his actions and his criminal responsibility for his actions at the time when he stabbed his daughter has been determined by psychiatrists and the courts. However the observations that are available from family members and police statements strongly suggest that he was severely disturbed and psychotic. His behaviour and mental state at the time when he harmed his daughter were qualitatively different and markedly worse than when he was seen at A&E and at any other point where his mental state was documented in the case history. It is not possible to know exactly what caused this sudden deterioration. The description that has been provided by family members of his behaviour during the day before he stabbed his daughter indicates that he was not substantially worse than when he was taken to hospital. Their account is that he did not take any alcohol or 48 cannabis during this period and that this can be verified because at least one family member was with him the whole day. The evidence is that it was only when he woke up early in the morning that he was in a psychotic state. 4.3.70 This should serve to underline to clinicians from all agencies that there is always a risk of sudden deterioration in patients with a history of psychosis which needs to be taken into account in assessment and care planning and which needs to be explained to patients and carers. However in this case there is no evidence that either family members or professionals could have anticipated the rapid and drastic deterioration in Mr B’s mental state. The response of emergency services 4.3.71 Family members have raised a number of concerns about the response of emergency services to the incident in which Child F was injured. Whilst it was not the intention of the SCR to examine the response of the emergency services in detail additional information has been obtained from the (TEXT REDACTED) Ambulance Service and the (TEXT REDACTED) Police Service in order to address the questions posed by family members. This is set out separately in Appendix 5. 4.4 Were plans made to provide services consistent with assessments and were they fully implemented? Introduction 4.4.1 This section of the report will provide an overview of the findings in relation to this, looking at the work of the network of agencies with child protection responsibilities as a whole. It draws on the findings of the individual management reviews which evaluate in detail the provision made in individual agencies. Throughout the case history the provision made to Mr B and to the family was consistent with the assessments that were made and agencies implemented the plans that followed from the assessments that were undertaken. 4.4.2 In this case the main service provision in relation to Mr B was made by probation. The main provision made to the mother and the children was made by health trusts. Both parents were in contact with their GPs and the children shared a GP with their mother. The father received a number of assessments from the mental health trust but he missed some appointments and he did not take up an opportunity to attend a young people’s mental health service (in 2004). He was never allocated to a mental health team because throughout the history the finding of the assessments was that his problems were largely caused by his cannabis use and that he did not have a severe or enduring mental disorder. In relation to the mental health trust the key contact was the assessment in the A&E department shortly before Child F was injured. Findings about service provision from the mental health trust have been integrated into the findings on assessment in section 4.3 above. 4.4.3 There is no indication at all that lack of service provision or the nature of the service provision made was significant in relation to the injuries to Child F. 49 Probation provision 4.4.4 All the evidence is that service provision by the probation trust complied with all of the expected requirements. Mr B received a range of services that were related to the original assessment of the factors that put him at risk of offending. He complied with the terms of his licence attending individual supervision sessions regularly and attending at a number of programmes. He also attended at the substance misuse service for assessment and a number of individual sessions. 4.4.5 The provision made was effective insofar as Mr B did not reoffend or have any contact with the police during the time when he was under supervision, he reported being drug free and showed no adverse signs of substance misuse. It is impossible to know whether Mr B complied with the requirements because he was genuinely motivated to or whether he did so in order to avoid breaching his licence. By his own admission Mr B resumed his cannabis consumption and his associations suggestive of criminal activity soon after the end of his supervision Health visiting and antenatal provision to the mother and the children 4.4.6 The provision made was in keeping with the assessments of need made in relation to the mother and the children. Ms A missed a small number of antenatal and child health clinic appointments but attended sufficiently for professionals to be satisfied that health needs were being met. Section 4.3 has discussed the policies of health trusts in relation to missed appointments. There is no suggestion that any additional health provision to the mother or the children would have prevented the injuries to Child F. GP services 4.4.7 The family GPs separately provided services to the father and to the mother and children. Section 4.3 above has described how that the father’s GP did not identify the significant changes that had occurred when he became a father. 4.5 Did the activity of agencies focus on the needs of children? 4.5.1 This aspect of the terms of reference has also been addressed through the discussion on assessment in section 4.3 above. 4.5.2 Health visitors and midwives are required to have their main professional focus on the needs of children. The narrative and the evaluation of assessment and service provision indicate that this occurred. There were some weaknesses in the assessments carried out within these services (outlined above for example section 4.3). These largely arose because of the specific circumstances and difficulties of the case and not because the focus was not on the needs of children. 4.5.3 The father’s GP was primarily concerned with his mental health needs and the one GP who had knowledge that Mr B had responsibility for a child did not record it in his medical record. There is potential learning for all GPs in this. 50 4.5.4 The mother and children’s GP was focused on the children’s health and development in the small number of contacts with family members. Immunisation appointments were missed on a number of occasions and the GP practice offered follow up appointments. 4.5.5 The main focus of probation service activity was entirely appropriately on the task of reducing the risk of the father re-offending. However when the father acknowledged that his partner was pregnant the probation officer contacted the local authority to see if the family were known and if the children were subject to a child protection plan. This episode is discussed in detail in section 4.6. 4.5.6 The only contact that the father had with the mental health service when he had responsibility for children was shortly before he injured his daughter. This episode has been discussed in detail in section 4.3 above. It shows that mental health professionals were mindful of the children but did not take all of the steps expected to undertake a detailed assessment of possible risk to them. 4.6 What was the quality of information and joint working within and between agencies? 4.6.1 Individual agencies with a different role and focus were working with different members of the family. Sections 4.1.9 – 4.1.18 set out an overview of the agencies that were working with the father and with the mother and children. Prior to the incident in which Child F was injured there was never any reason to believe the children were at risk of harm or in need or additional services. As a result no formal information sharing arrangements – such as those that would occur during a child protection enquiry or plan - were in place. Information sharing was limited to the normal referral arrangements that exist between health professionals or the normal sharing of information that associated with discharge arrangements between antenatal care, GPs and community health services. 4.6.2 The lack of any concern about the children meant that the limited sharing of information between professionals that took place was understandable. However the case history has highlighted three specific areas in which there is the need to improve information sharing arrangements between agencies: Notifications by the probation service when service users are known to be responsible for a child Sharing of information about adults who may pose a risk with health staff working with children and Sharing of medical information from the prison service and criminal justice system. Probation notifications to other agencies 4.6.3 The overview of agency involvement has established that there was only one active attempt to share information between the professionals working with the father and an agency that might have been working with the mother and children. This was when the probation officer notified social care of the birth of Child G with the intention of establishing if there was any local authority involvement with the children (see paragraph 3.2.11 above). This was an 51 established part of probation service procedures in order to enable probation officers to identify any concerns about a child and if necessary to open up lines of communication between the probation officer and the local authority. In this case there was no need for further communication because the family were not known to the local authority and the probation officer had no reason to believe that Child G was at risk. At that point Mr B was not offending, (by his own account) not misusing drugs and alcohol and he was showing no signs of mental health problems. Discussion in the SCR panel clarified that this was not intended as a referral to the local authority and confirmed that there was no reason for the probation officer to make a referral at that point. 4.6.4 The probation procedure to make a notification in these circumstances might safeguard the probation officer from working with the parent of a child who was at risk without being aware of it. This is of value. However in such circumstances there would have been more value in the probation officer identifying the child’s health visitor and notifying the community health service of the birth of a child and the link to a probation service user. This is for the simple reason that health visitors are to different degrees involved with all infants, whereas the local authority social care service works with a very limited number of families. Such communication would alert health professionals to important background information about the family and inform their assessment of the child’s circumstances and needs. In this case it would have been of particular assistance because the mother gave no background information to the health visitor about the father. 4.6.5 It is therefore recommended that the (TEXT REDACTED) Probation Trust should undertake a review of its procedures to widen the scope of information sharing about service users who have substantial contact and involvement with children to include key health professionals. Sharing of relevant information about adults who may pose a risk with front line health professionals 4.6.6 When the health visitors who were involved with the children were interviewed they indicated that they are often not aware of the involvement of adult services with the parents of children on their caseloads, including in some cases adults who it was subsequently revealed had been the subject of multi-agency risk assessment (MAPPA) discussions and plans. This was not relevant in this case because the father did not have responsibility for any children at the point of his release from prison and discussion at MAPPA. However in other circumstances this sharing of information could be very important. 4.6.7 It is therefore recommended that the local MAPPA coordinator and local health agencies should review the effectiveness of the current arrangements for health involvement in MAPPA panels and the sharing of information sharing within health agencies so as to ensure that front line health professionals are made aware when parents and carers are discussed in MAPPA panels in all cases where this is necessary. 52 The sharing of information about offenders from court reports and prison health services 4.6.8 Forensic psychiatrists and the prison health service both sought information from local health professionals in order to inform their assessment and treatment of Mr B. However the flow of information was only in one direction. Information contained in court and prison psychiatric reports and wider information from the prison health service were never shared with local health professionals – either the GP or mental health trust. This is not in the interests of offenders or the wider community because the discontinuity in health records that occurs when offenders are in prison reduces the effectiveness of health care to them making them more vulnerable and may add to the risk to others. There may be sound reasons why some court reports might not be shared outside of the court setting. However in general there is no logical reason why prison and court health records and reports should not be shared with a patient’s general practitioner. 4.6.9 In this specific case it is not known what information is contained in the prison health service records of Mr B so it is impossible to say whether access to them might have altered the approach of local health professionals. The forensic psychiatric report prepared on Mr B in 2006 was the most comprehensive report prepared on his mental health prior to the current incident. It only became known to local health professionals after the incident during the course of subsequent reviews. The report offers a different perspective on Mr B’s mental health, based on an assessment in different conditions. Regardless of whether the diagnosis suggested within it is correct or not, access to it would clearly have been of value to Mr B’s GP and to local mental health staff. 4.6.10 It is believed that the lack of information sharing from court and prison records is a national issue. There may be practical difficulties but it is a problem that should be resolved. It is recommended that local health commissioners take whatever steps are necessary, either at a local or a national level, to investigate and resolve this problem. 4.6.11 At present GPs do not necessarily realise that prison health records may contain important information. Regardless of the progress in resolving the wider policy in relation to this, (TEXT REDACTED) NHS should make local GPs aware of the issue and be encouraged to take steps to obtain prison health records for patients in every case. This is the subject of a recommendation in Section 6 below. 4.7 Were the specific ethnic, cultural and religious needs of the family recognised and responded to? Were any other matters relating to diversity addressed? Recording of ethnicity 4.7.1 The individual management reviews have listed how the ethnicity of family members is recorded in agency records. The children are consistently recorded as being ‘Black British’, except for the GP records which do not record the ethnicity of Child G at all. The mother is recorded as being ‘Black Caribbean’ except in midwifery records where she is recorded as being ‘Black British’. The father is recorded as being of Black Caribbean origin. It is not clear 53 whether these records arise from family members being asked to define their ethnicity, or whether these were assumptions made by professionals. 4.7.2 According to Mr B’s father (information provided to a forensic psychiatrist after the incident) Mr B has a much more complex ethnic heritage (TEXT REDACTED). There is no point in the agency records before Child F was stabbed that captures this information. The probation records identify Mr B as being of Black British Caribbean origin. Again it is not certain whether this was his self- definition. The ethnicity of professionals providing services 4.7.3 The majority of the key professionals working with the family and managers of services (GP, junior doctor, mental health worker and two health visitors) were members of minority ethnic groups, underlining that at front line practitioner level the workforce in (TEXT REDACTED) is very diverse reflecting to a considerable degree the composition of the population of (TEXT REDACTED). Insofar as there were shortcomings in the services provided to these children and their family it is important to underline that they did not result from the services being provided or managed by individual workers who have no ordinary empathy with or connection to the day to day life experiences of the local population. Attention to ethnicity, culture and religion in assessment and service provision 4.7.4 There is no evidence that ethnicity, culture or religion were ever explored in detail in the assessments that were undertaken. To the extent that social factors were identified in relation to Mr B’s offending and drug misuse he attributed his difficulties to being associated with the area in which he grew up and the people he associated with as a young person. There is no suggestion in relation to the service to the children and their mother that there were any shortcomings in the assessment or provision made which resulted from lack of attention to ethnicity. 4.7.5 (TEXT REDACTED). 4.7.6 (TEXT REDACTED). Mental health and drug provision for Mr B 4.7.7 Although the overall mental health provision to Mr B is not the main focus of the SCR, the overview report has carefully considered its effectiveness - because there is no doubt that it was Mr B’s mental health problem that led him to harm his daughter. 4.7.8 The SCR has sought to understand whether some aspects of Mr B’s overall experience of service provision mirror the wider experience of mental health services of many young black men from his social background. The wider position is summarised by a recent review of 54 relevant research 8 which describes a how young black men are over-represented in some aspects of mental health services (such as compulsory detention and hospital admission) and under-represented in others (such as detection of mental health problems by GPs). It also notes that: ‘Black Caribbean, Black African and White/Black Caribbean mixed groups are 40 – 60 per cent more likely than average to be admitted to hospital from a criminal justice referral which means their mental health problems are often only detected when they come into contact with law enforcement agencies’.9 The research goes on to note that a combination of factors is believed to lead to ‘a high level of fear’ among service users ‘that they will receive inappropriate and poor treatment’. This results in a position where ‘those who are in most need of support are the least likely to access the services which provide this support (and) the provision of good medical care tends to vary inversely with the need for it in the population served’. 4.7.9 Whilst it true that Mr B has had two significant contacts with the criminal justice system linked with mental health problems and drug misuse, not all of the issues identified in the wider research apply in his case. For example his GP was clearly sensitive to his mental health from an early age, before he entered the adult criminal justice system. Mr B has never been compulsorily detained in hospital and has been referred on a number of occasions for voluntary assessments. At times he has engaged in treatment coordinated by his GP, largely because his mother and other family members have actively encouraged him and supported him by taking him for appointments and encouraging him to take medication. On one occasion (August 2010) he was offered an appointment but did not take it up. 4.7.10 Whenever Mr B was assessed in the community his mental health problems were attributed to his misuse of drugs. Unfortunately with the exception of the period when he was under probation supervision he has never attended or engaged with local drug services (in part because he has never been referred or self-referred). Although the professionals involved in the A&E assessment would not have known this from his history, Mr B was very unlikely to have attended the drug service that they suggested. 4.7.11 It is not clear whether Mr B had a fear that he would receive ‘inappropriate and poor treatment’ (as the wider research suggests). However it is clear that his mother and other family members went to considerable lengths to try to have his problems assessed and to keep him engaged with health services. 8 The Centre for Social Justice (February 2011), Mental Health: Poverty, Ethnicity and Family Breakdown - Interim Policy Briefing http://www.centreforsocialjustice.org.uk/client/downloads/CSJMentalHealth_Final_20110205.pdf 9 The source given is the Care Quality Commission survey, Count Me in 2009: Results of the 2009 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales. Care Quality Commission, 2010 55 4.7.12 No additional recommendations arise from this aspect of the SCR. However the difficulty that professionals experience in engaging service users such as Mr B reinforces the need for the recommendations made in section 4.3.68 above. 4.8 Did staff have the knowledge, skills, and experience to respond to the needs identified in the case? 4.8.1 All of the individual management reviews examined this question. 4.8.2 The probation officers and health visitors had the necessary experience and knowledge to respond to the needs identified in the case. All of the professionals in these services had received relevant supplementary training on safeguarding. 4.8.3 The mother was seen by a student midwife and an experienced and qualified colleague at her antenatal booking appointment. 4.8.4 The level of knowledge, experience and training of the mental health professionals who assessed Mr B in the A&E department has been examined in detail by the mental health trust. The findings are summarised here. The mental health worker was a qualified Mental Health Nurse who had worked for many years in the local mental health service. This gave her a very good understanding of how the local mental health services and partner agencies worked together. Before undertaking the psychiatric assessment role in A&E she had undertaken a period of closely supervised work with senior mental health nursing staff and had undertaken a number of A&E assessments. She was judged by the trust to have the training and experience necessary to undertake this task. 4.8.5 The doctor involved in the assessment was a Foundation Year 2 doctor. She was in the second month of a four month post in psychiatry working across an inpatient and community mental health settings, supervised by an experienced psychiatrist. She had studied psychiatry and had knowledge of risk assessment and management and the role of substance misuse. This doctor has identified from discussion with other junior doctors that it is only within the (TEXT REDACTED) sector of the mental health trust that A&E psychiatric assessments are carried out by doctors of the F2 grade of post qualification training. It is much more common in other specialisms and in other sections of the trust for duty psychiatry cover to the A&E department to be provided by a CT1-3 doctor. This is a more experienced junior doctor, who has chosen to specialise in psychiatry. 4.8.6 Safeguarding children’s awareness training is part of the familiarisation with the trust’s key responsibilities that all mental health staff receive as part of their induction. However this provides only a brief overview and the mental health worker involved had been an employee for many years. She had received a small amount of additional training in safeguarding. 4.8.7 The junior doctor had received limited training in relation to safeguarding children during her induction. She received training in risk assessment and management and this included reference to related policies including safeguarding children which were left for her to access and read as part of her professional development. Given the weight which is now 56 placed on the need to evaluate potential risk to children when undertaking mental health risk assessments and the range of responsibilities facing junior doctors it is wrong to leave this to the initiative of individual doctors. The trust has recognised this and will in future make safeguarding training in relation to children and vulnerable adults a mandatory and fuller part of doctors’ induction. 4.8.8 It is recognised that there are a number of factors that make the task of mental health risk assessment in A&E department challenging, especially when the assessment has also to be mindful of the potential risk to children. The individual management review indicates that there may be benefits in future from implementing measures which make a closer link between the safeguarding training that staff receive and the implementation of that training in relation to the types of cases that staff are likely to see in the A&E department. This will ensure that potential risk to children is fully assessed and the findings of assessments are shared with other professionals. 4.8.9 In the mental health trust child protection training at level 2/3 is delivered by staff with specialist responsibilities for child protection is also part of the mandatory training requirement. It is recommended that the LSCB should seek an update from the trust on the provision and take up of this training provided. 4.8.10 Taken together the relative lack of training of key staff in children’s safeguarding must have contributed to the shortcomings in the risk assessment in relation to the children in the A&E department (set out in section 4.3 above). However the SCR has found that even if a fuller risk assessment had been carried out in relation to the welfare of the children it is very unlikely that it would have identified the severe risk that Mr B posed to the children 24 hours later. 4.9 Were staff appropriately supervised and supported in their work with the family? 4.9.1 Each individual agency has supervision arrangements for staff and specific arrangements that apply where there are child protection concerns. GPs are independent contracted professionals who do not receive supervision, but they may contact the named GP with responsibility for safeguarding or the designated doctor to seek advice on individual cases. Each of the individual management reviews has evaluated the use of supervision within individual agencies. The findings are summarised here. 4.9.2 Expectations about how supervision should be accessed vary according to the perceived level of risk and complexity of the case. Health professionals are expected to bring cases in which child protection concerns have been identified to the attention of their supervisor. The size of caseloads in universal services precludes supervision discussion of all cases. Part of the professional responsibility required of health professionals is to screen caseloads in order to identify cases that should be discussed with a supervisor. For the reasons described in section 4.3 and in the narrative section of this report no professional had had any reason to identify this as a case that merited or required supervision. 57 4.9.3 Particular attention has been paid to the supervisory arrangements that apply in relation to staff undertaking mental health assessments in A&E. 4.9.4 This report has noted at a number of points the particular challenges in undertaking a mental health assessment in A&E. Both of the professionals involved had access to more senior nursing and medical support, including support from the on call consultant psychiatrist. Neither believed that they needed to have access to this senior support in this assessment because they did not believe that it was a complicated assessment. Senior professionals in the mental health trust and the trust’s Executive Board have supported this judgement through fully endorsing the findings of the trust’s individual management review. 4.9.5 The Crisis Resolution Team which has responsibility for the psychiatric assessments in the A&E Department of the (TEXT REDACTED) Hospital also has structures in place to allow an opportunity for staff working in A&E to discuss assessments undertaken in this role at the next available multi-disciplinary meeting. In this case there was no opportunity for this to happen as Child F was injured within 24 hours of the assessment. 4.9.6 In addition all letters summarising mental health assessments and action plans that take place in A&E are reviewed by a manager before they are sent to the service user and their GP. The manager believes that this enables her to monitor quality and standards and gives her a good overview of the range of work that staff are undertaking. Both staff members received regular supervision and the mental health nurse had additional opportunities for informal and group support. The individual management review however noted that there was a lack of clarity about who was responsible for the clinical work undertaken by the junior doctor when she was a working as duty psychiatrist in the A&E service. 4.9.7 In summary there is no indication that which Child F was injured. Some shortcomings have been identified in the arrangements for the supervision of staff undertaking mental health assessments in A&E and these arrangements will be strengthened. 4.10 Did any issue of capacity or lack of resources limit the ability of agencies to meet the needs of the family? 4.10.1 There is no evidence that lack of capacity or resources adversely affected the provision of services to any member of the family. 4.10.2 The health overview author has identified that some weeks after the father was assessed in A&E the department closed for a number of nights due to longstanding staffing problems. (TEXT REDACTED). However there is no indication that the concerns underlying this had any impact on the service provided to Mr B. 58 5. Summary of key findings and conclusions Key findings 5.1 There were two distinct sets of professionals who were involved with different family members. Mr B was under probation supervision for two years from 2008 – 2010. During this period Child G was born. Mr B’s family GP knew him well and had treated his mental health problems during 2004 – 2006. Mr B’s family GP also knew that he had become a parent but did not record this on the medical notes or refer to this in any referrals or correspondence. 5.2 Mr B had also had a number of contacts with mental health services, both in the community (in 2004 and 2008) and while he was in prison (during 2006-2008). He was referred to the (TEXT REDACTED) mental health service in 2010, but he did not attend the appointment. A week before Mr B injured his daughter his GP referred him to the mental health service again and he was waiting for an appointment. Mental health professionals saw Mr B in the A&E department 24 hours before he injured his daughter. 5.3 A separate group of professionals were in contact with the children and their mother. This group included midwives, health visitors and her family GP. Prior to the incident that triggered this review there had been no child protection concerns about the children. The children were in good health and developing well without the need for any additional services. They had missed some voluntary clinic appointments but this was not considered significant and the mother kept in touch with the family GP. The health visitors knew the identity of the children’s father but none of them knew any background information about him. The children’s mother did not disclose this to the professionals who were working with her. No professional knew how much involvement he had in the lives of his children. 5.4 As a result of this pattern of involvement the assessment of those professionals who were working with the children could only be based on their own observations of their health and development and the care provided to them by their mother, which was always observed to be positive. No account could be taken of the potential risk that the children’s father might pose if his substance misuse triggered a deterioration in his mental health or began to impair his parenting capacity. 5.5 The professionals who were in contact with the mother and the children and those who were working with the father did not communicate with one another. This was because there was no cause for concern about the children and no cause for professionals to be in touch with one another. In any event the probation officer ceased to be involved with Mr B before the birth of Child F and the mental health service was only intermittently involved. 5.6 The weight of all the evidence is that Mr B’s cannabis use began again and increased after his probation supervision ended in mid 2010. This led his family to be concerned about the deterioration in his mental health. His GP referred him to the community mental health service for assessment. This outpatient assessment had not taken place at the time when Child F was injured. 24 hours before she was injured Mr B was assessed in the accident and 59 emergency department. His anxiety, agitation and paranoia were attributed to his heavy cannabis and alcohol use and his involvement in criminal activities and there was no sign of any serious mental illness at that assessment. Could the assault on Child F could have been anticipated or prevented? 5.7 There is a clear contrast between the view of the case history that it is possible to obtain looking back with the benefit of hindsight and the knowledge that professionals had of the case as it unfolded. As the case history developed it is easy to understand why separate groups of professionals worked with different family members and why there was never any reason for them to communicate to one another about potential risks. Regarding the case with the benefit of hindsight it is apparent that the health professionals who were in contact with the children and their mother would have benefited from knowing more about the background history of the father and the risks that he might pose if his mental health deteriorated. 5.8 When there is no evidence of risk to children or additional needs there is no system that enables all professionals who are working with children to know everything about the involvement of other professionals with the family. This depends entirely on parents sharing this information, which they may not choose to do. In this case the mother had some knowledge of her partner’s history of mental health problems and drug misuse but did not consider that it was relevant to discuss them with professionals because she did not feel that he presented any possible risk to the children. 5.9 From the professional perspective this means that there are cases - such as this one - when professionals will not know some information that later turns out to be significant. 5.10 Even if they had had background information about the father, the health visitors or other health professionals may not have acted very differently. Prior to the deterioration in Mr B’s mental health there were no concerns about the children. The family members who had the main responsibility for the children were viewed as competent and supportive and it would have been assessed that they would have protected the children if there had been any problems. There might have been a higher level of health visitor involvement in the family, but in this family there would never have been sufficient concern to trigger a child protection investigation or any other form of social care intervention. The professionals who were involved would not have been able to anticipate the very sudden and dramatic deterioration in Mr B’s mental health. In particular it would not have been possible to predict that when his mental health did deteriorate he would immediately pose such a serious risk of harm to his daughter. Neither the family nor the professionals had ever seen the slightest hint of this before. 5.11 Mr B had been referred for a community-based mental health assessment, four days before he injured his daughter. The GP asked for an urgent assessment, but did not provide the sort of information that would have triggered an urgent response or communicate the referral quickly enough to the mental health trust. 60 5.12 The psychiatric evaluation of the father that took place in the A&E department 24 hours before the father injured his daughter was a critical incident. Some shortcomings in this assessment have been identified. It would have been better if family members had been seen on their own without the father being present. There was no systematic assessment of potential risk to the children. However the SCR has found that there was no indication of psychotic illness shown during the assessment. The SCR is confident that if there had been evidence of psychosis or overt indicators of risk to the children they would have been recognised. The assessment of risk to the children was based on the observation that the father was not psychotic and not acting in an aggressive way and that he enjoyed a good level of family support. If that assessment had been completed in a more comprehensive and systematic way it is very likely to have come to the same conclusion. There was no reason for the professionals involved to believe that the children might be seriously harmed by the father because of the active concern and the level of involvement and engagement of the family. 5.13 24 hours after this assessment the evidence is that Mr B was in a severely psychotic state and suffering from delusions (TEXT REDACTED). So far as can be established this was completely unprecedented. 5.14 In his review of services to safeguard children in England in March 2009 Lord Laming recognised that it is not always possible to prevent the serious abuse of a child, noting that serious injuries and even deaths can arise from ‘the sudden and unpredictable outburst by an adult towards a child’. He notes that such circumstances are ‘entirely different from the failure to protect a child or young person already identified as being in danger of deliberate harm’. 10 The evidence is that this is such a case and that there was no indication to any professional (or indeed to members of the family) that the children were at risk of serious harm. Additional learning from the SCR 5.15 Although there is no indication that the injuries to Child F could have been anticipated or prevented a number of additional learning points arise from the evaluation in this report and in the individual management reviews. 5.16 The review has highlighted opportunities for better information sharing between the prison and criminal justice system and community based health professionals, both through the sharing of prison health records and court reports and through the greater engagement of health agencies in the multi-agency risk assessment arrangements (MAPPA). 5.17 The review has highlighted the complexity and difficulty of undertaking mental health risk assessments within the A&E service, particularly noting the difficulty of assessing potential risk to children especially when they are not present, contact with professionals who know them is not possible and there are often no records available. The mental health trust review 10 The Lord Laming (March 2009), The Protection of Children in England – a Progress Report., HC330 Stationery Office 61 has made a recommendation in relation to this and the LSCB will closely monitor its implementation since this is a point of vulnerability within current services. 5.18 There are clearly grounds to refine and improve the approach taken by the probation service in notifying social care of the birth of children to probation service supervisees. Consideration need to be given to making this procedure more sensitive to individual circumstances and also to providing channels of communication from probation officers to GPs and other health professionals. 5.19 The case history underlines the need for GPs whose patients have mental health problems to actively ‘think family’. That means specifically: 1) asking whether their patients are parents or have substantial caring responsibilities towards children; 2) recording this in medical notes so that all members of the primary health care team have access to the information; and 3) emphasising it in all referrals and correspondence about the patient. 5.20 All of these areas are the subject of recommendations in this report or in the associated health overview report. Additional recommendations from individual management reviews 5.21 These recommendations stand in addition to the recommendations made in individual management reviews prepared by agencies that had direct involvement with the family. Additional recommendations have also been made in the health overview report prepared on behalf of commissioners of health services. These are set out in full in Appendix 6 and in the multi-agency action plan that accompanies this report. The deal with the following areas. 5.22 (TEXT REDACTED) NHS Trust Integrated Care Organisation The use of the Family Health Assessment The implementation of the ‘did not attend’ policy in child health services 5.23 (TEXT REDACTED) NHS Foundation Trust A consistent trust wide operational policy for mental health assessments undertaken in A&E departments A revised safeguarding children programme tailored to staff working within A&E In future all junior doctors will have information about safeguarding children and adults as part of their risk assessment induction. Clearer procedures for staff about documenting risk assessments and management plans Improved access to records of service users with a historic history of severe risk that had been documented on previous recording systems Better information sharing protocols between agencies involved in mental health services (such as the prison health service) to ensure that all relevant information and reports are shared 5.24 NHS (TEXT REDACTED) (in relation to GP services): The need for GPs to have a proper family focus Information sharing between GPs working with different members of the same family 62 The need for GPs to seek information about drug and alcohol use GP working arrangements with the health visiting services 5.25 (TEXT REDACTED)NHS Trust: Improving compliance with the audit of postnatal discharge documentation 63 6 Additional recommendations arising from the SCR overview report and SCR panel discussions Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation 1. Mr B’s GP did not record the fact that he had become a parent on his medical records or communicate it to colleagues and other professionals (TEXT REDACTED) GPs / health commissioners (TEXT REDACTED) (TEXT REDACTED) GPs should ensure that information about patients family details and their links with children are recorded in all relevant medical records and communicated to other professionals when this is relevant to the assessment of need and the provision of services 2. The Healthy Child Programme sets high expectations about the involvement of fathers in maternity and early childhood health services. However the evidence is that staff do not have the confidence, training and necessary support to make the implementation of this aspiration meaningful (TEXT REDACTED) health commissioners and all health providers All health providers involved in the SCR Health trusts should create a clear expectation of staff that fathers are fully engaged in services and support staff in doing this through practice guidance, training, supervision and audit of services 3. Health visitors told the SCR that they value the current Family Health Assessment tool and are uncertain whether its use will continue because of the introduction of new electronic recording systems including RIO Community health trust (TEXT REDACTED) (TEXT REDACTED) NHS Trust should consult front line staff and managers fully before making any change to the use which might dilute the advantages of the use of the Family Health Assessment by health visitors and their teams. 4. The family GP believed that he had made an urgent referral on Mr B, but the information (TEXT REDACTED) NHS Foundation Trust and (TEXT REDACTED) The mental health trust and GPs should jointly review criteria and arrangements for urgent mental 64 Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation provided and the way it was provided did not trigger the expected response from the mental health trust. There appears to be a mismatch in expectations (TEXT REDACTED) GPs health referrals to ensure that these are fully understood and effective 5. Mr B was never referred by his GP for drug services, although this was believed by all the professionals involved to be the cause of his psychosis (TEXT REDACTED) health commissioners and all (TEXT REDACTED) GPs (TEXT REDACTED) (TEXT REDACTED) GPs should review how they respond to information about sustained drug use so as to make better use of local drug services 6. The probation officer sought information from the local authority when he became aware of the birth of Child G. However it would have been more fruitful if communication had been with health colleagues as well (TEXT REDACTED) Probation Trust (TEXT REDACTED) (TEXT REDACTED) Probation Trust should undertake a review of its procedures to widen the scope of information sharing about service users who have substantial contact and involvement with children to include key health professionals 7. Information from prison health service records and court reports was never made known to local health professionals, despite the fact that they had provided information to both forensic psychiatrists and the prison health service (TEXT REDACTED) health commissioners (TEXT REDACTED) / (TEXT REDACTED) Health commissioners should improve access of local health professionals to information in prison health records and court reports. 8. Mental health professionals were generally aware of the need to be mindful of risks to children but did not systematically assess their circumstances. The trust has made recommendations on this and this is an additional recommendation (TEXT REDACTED) NHS Foundation Trust (TEXT REDACTED) The mental health trust should provide an update to the LSCB on the provision and uptake of its level 2/3 training on the safeguarding of children 65 Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation 9. Information about MAPPA discussions is not consistently communicated to front line health professionals. In 2008 it is known that there was insufficient health representation at the (TEXT REDACTED) MAPPA, this has been included as a recommendation because it was identified by health visitors as a wider problem which persists despite current guidance. (TEXT REDACTED) Community Safety Partnership, (TEXT REDACTED) MAPPA co-ordinator and community health services (TEXT REDACTED) It is therefore recommended that the local MAPPA coordinator and local health agencies should review the effectiveness of the current arrangements for health involvement in MAPPA panels 66 Appendix 1 Terms of reference of the SCR Specific Terms of Reference: 1. To establish what risk factors were known to agencies from their historical involvement with family members prior to the start date of this review, January 2009? 2. What assessments were undertaken and what was the quality of those assessments? 3. To what extent did assessments identify risk factors within the family? 4. Were plans consistent with assessments and were they fully implemented? 5. What was the quality of information sharing within and between agencies? 6. To what extent did the agencies’ activities focus on the needs of children? 7. To what extent did agencies identify the competencies and limitations of the parents in their parenting tasks. 8. Did agencies respond appropriately to any risk factors identified in the course of their work with the family? 9. Did any issues arise in the work with the family that promoted, or should have promoted, agencies to seek information from agencies involved before the start date of the review? 10. Were the diversity needs of the family recognised and responded to? 11. Did staff have the knowledge, skills, and experience to respond to the needs identified in the case? 12. Were staff appropriately supervised and supported in their work with the family? 13. Did any capacity issues within the agency limit the ability of the agency to meet the needs of the family? 14. (Overview report writer only) What were the key incidents/ practice episodes and what was the learning from them? 67 Appendix 2 Membership of the (TEXT REDACTED) LSCB SCR panel on Child F Independent Chair (TEXT REDACTED) Council Social Care Head of Safeguarding (TEXT REDACTED) Police Service Detective Inspector (TEXT REDACTED) Child Abuse Investigation Team NHS (TEXT REDACTED) Designated Nurse (TEXT REDACTED) NHS Foundation Trust Assistant Director of Operations 68 Appendix 3 Background documents and references Brandon et al, (2009), Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 DCSF Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007) Analysing child deaths and serious cases through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. DfES Care Quality Commission survey, Count Me in 2009: Results of the 2009 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales. Care Quality Commission, 2010 The Centre for Social Justice (February 2011), Mental Health: Poverty, Ethnicity and Family Breakdown - Interim Policy Briefing, http://www.centreforsocialjustice.org.uk/client/downloads/CSJMentalHealth_Final_20110205.pdf Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate (2006) Department of Health (2010) Healthy Child Programme- Pregnancy and the First Five Years of Life. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdf HM Government Working Together to Safeguard Children 2010, The Lord Laming (March 2009), The Protection of Children in England – a Progress Report., HC330 Stationery Office The Munro Review of Child Protection: Final Report: A Child centred system, Cm 8062, May 2011, The Stationery Office Ofsted (2011) Ages of concern: learning lessons from serious case reviews - A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 David Woods et al, Behind Human Error, Ashgate (2010) second edition; P Reder, S Duncan and M Gray, Beyond Blame – Child Abuse Tragedies Revisited, Routledge (1993) 69 Appendix 4 Good practice for engaging fathers in the Healthy Child Programme (HCP) From the beginning, promote the father’s role as being important to his child’s outcomes. Make it explicit that the HCP is there for the whole family – including the father – and demonstrate this by providing suitable seating for him as well as for the mother. Address him directly, encourage him to speak and make it clear that you are listening. Arrange meetings, services, groups and reviews to maximise the possibility of fathers attending. Stress the importance of their presence to both them and the mother. Include positive images of fathers from different ethnic groups and of different ages in the literature that you produce and display. Record fathers’ details – including those of non-resident fathers. Most mothers will give this information willingly, and two in three pregnant women who are not living with the father of their child describe him as ‘a good friend’ or as their partner. Include an assessment of the father’s needs as well as the mother’s, as these will have a direct impact on both the mother and the child. Include an assessment of the father’s health behaviours (e.g. in relation to diet, smoking, and alcohol or drug use), asking him directly wherever possible. These behaviours have a direct impact on both the mother and the child, and specifically on the mother’s own health behaviours. Signpost fathers to all of the relevant services. Make sure that fathers (as well as mothers) are in possession of information about, for example, the benefits of stopping smoking and strategies for doing so. Where possible, provide fathers with this information directly (rather than secondhand, via the mother) and ensure that it also incorporates information on their role in relation to their child. Offer antenatal preparation to fathers, including at times that will be convenient for working fathers (e.g. evenings). This will also make it easier for working mothers to attend. For further information, see the Fatherhood Institute website at www.fatherhoodinstitute.org and Including New Fathers (Fathers Direct, 2007). Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life Page 26 70 Appendix 5 The response of emergency services The following information has been obtained in order to address specific concerns of family members about the response of emergency services. Dispatch of an ambulance When police officers arrived at the home an ambulance was called to the house and asked to wait at a rendezvous point 200 yards from the house until it was certain that it was needed. Police records indicate that the ambulance had not arrived Mr B was treated at the scene by the (TEXT REDACTED) Ambulance Service before being taken to hospital. The assessment and treatment of his self-inflicted wounds was impaired because his hands and feet were bound for his own safety and the protection of others Attendance of a doctor and psychiatrist It is not the practice of the ambulance service to dispatch a doctor to the scene of an incident except in relation to the Helicopter Emergency Medical Service (HEMS) HEMS was dispatched to the house but was not able to attend at the house before Child F had been taken directly to hospital because the incident developed so quickly HEMS attended at the hospital and took responsibility for the care of Child F before she was transported to a hospital that was better equipped to stabilise and treat her condition It is never possible to dispatch a psychiatrist in order to undertake an assessment of a mentally ill patient within the time that was available in this incident. When assessments take place under the Mental Health Act the psychiatrist becomes involved after any immediate risk to the individuals involved has been dealt with by the emergency services Actions and decisions of the police The police are satisfied that it was necessary to deploy a large number of officers to the family home once it became clear that there was a potential threat to life. The account given by the police and family members is that Mr B was threatening Child F with a knife (and may have injured her) before police officers entered the room The judgement of the officers dealing with the incident was that Mr B’s thinking was too disturbed to make him amenable to any negotiating strategy in the short term. However, the senior officer at the central control room decided that the on-call co-ordinator for negotiators should be alerted about the incident as he or she might have been able to give advice to the police officers on scene. The incident developed very rapidly and in 5 minutes it took for the co-ordinator to respond to the call, the incident was over. It is normally possible for a negotiator to be on the scene within one hour. The circumstances of the case did not permit this 71 Appendix 6 Recommendations from Internal Management Reviews (TEXT REDACTED) Hospitals NHS Trust RECOMMENDATION INTENDED OUTCOME Audit compliance with completion of postnatal discharge documentation. Improved compliance and performance in postnatal discharge documentation to partner agencies. GP should document any antenatal consultation in the hand held maternity record. Effective multidisciplinary team communication (TEXT REDACTED) NHS Trust (Community Services (TEXT REDACTED)) RECOMMENDATION INTENDED OUTCOME In order for health professionals to collaborate and work more effectively with parents/carers/agencies, it is vital that significant information is shared in relation to Family and Environmental Factors – in particular the Family History and Functioning; of all significant adult in the household and their role in the child’s life. This can be achieved through single/multi-agency safeguarding levels two and three refresher training– using the Assessment Framework DOH (2000) (TEXT REDACTED) NHS Foundation Trust RECOMMENDATION INTENDED OUTCOME 1.The Trust needs a Trust-wide operational policy for A&E assessments whether it has separate teams or distinct functions in one team carrying out this role A Trust –wide operational policy will address staff skill set, medical leadership, induction and ongoing safeguarding training tailored to the needs of assessment in acute situations. It will clarify what risk documentation, including safeguarding of children and adults, is required for people assessed but discharged by the service. 2. (TEXT REDACTED) will deliver a training Safeguarding Children programme tailored to staff working within A&E Trust staff working in A&E settings will be able to translate child safeguarding into practice in acute situations. Children and Adult Safeguarding awareness training will be part of all junior doctor induction. 3. All junior doctors need to have safeguarding children and adults as part of their risk The Trust A&E operational policy will ensure that staff are clear what their specific role is with 72 assessment induction. regard to documenting risk assessments and management plans 4. Staff must be clear what their specific role is with regard to documenting risk assessments and management plans Where the Trust has seen service users who have a conviction then information most be obtained via the Offender Care Service Line which will be entered onto the clinical patient system. 5. Information sharing systems To look at information sharing protocols between agencies to ensure that all relevant information and reports are shared. NHS (TEXT REDACTED) recommendations for GPs 1. All information held by a practitioner should be passed on, printed out in its entirety, to subsequent practitioners. 2. All newly registered patients should be given opportunities for disclosure of mental health, abuse of drugs and/or alcohol, past history of violence 3. When parents are on different GP lists, practitioners should have an overview of family dynamics composition both within and without the household. 4. GPs should link formally with the HVS. 5. All available details should be entered in the records of children, as well as in the maternal records - e.g. birth notifications, 6 week check up 6. Prison Medical Service records should be joined with GP records and vice versa when a patient moves from one jurisdiction to another. Health Overview Report Mental health assessment and contact with patients A recommendation is that front line practitioners need standardised risk assessments for adults or mental health problems/drugs who are parents in line with CQC requirements. Assessments should include a history of violence and a past criminal record as specific questions to be documented and reviewed. A recommendation is that when patients and families seek attention for a mental health crisis, the patient and family’s expectations, coping strategies networks and safety nets for any children in the and support networks are explored and noted. A recommendation is that GPs ask patients, especially ex prisoners, if they have accessed mental services and reports and records should be collated (with their consent). Patient referrals: 73 A recommendation is that the rationale for an ‘urgent referral’ to a service is communicated per phone, by fax then post with a clear expectation of when the case is to be seen. Involvement of fathers A recommendation is that services commissioned for women and children should follow the Healthy Child Programme guidance, 2009, of including and promoting the father’s role in outcomes for children. (Ref: Healthy Child Programme guidance, 2009, Page3 25,6). Public Health A recommendation is that commissioners are advised of this review to include the recommendations in services for drug users. Hospital Liaison and A+E A recommendation is that A+E staff must be alert to the issues for children when they are providing services to adults who have contact or caring roles with children, and should refer to the Hospital1 liaison nurse as necessary. |
NC52180 | Child sexual exploitation and neglect of an adolescent girl. An incident of rape and sexual abuse of a 15-year-old girl by teenage males in February 2019 involved other children as victims, perpetrators or witnesses. Review focuses on one child, BR19. Criminal proceedings ongoing at the time of the review; BR19 and her sibling have been taken into care. Maternal history of Adverse Childhood Experiences (ACEs) including sexual exploitation; being in care; and domestic abuse. Mother had BR19 as a teenager; was imprisoned when BR19 was young. BR19 lived with Father until aged 10-years-old, when she returned to Mother. Both BR19 and her sibling were made subject to Child Protection Plan in 2013 for neglect. BR19 was not in school throughout most of an 18-month period; concerns expressed by Mother of possible child sexual exploitation (CSE) of BR19; became subject to a Child Protection Plan in September 2017 and 2019 due to ongoing concerns around CSE and Mother's ability to protect BR19. Ethnicity or nationality of family not stated. Learning includes: multi-agency planning and analysis of risk; impact of CSE and services for survivors of CSE who are parents; parental engagement and consent; professional challenge and escalation; professional curiosity of the child's lived experience; contextual safeguarding and perception of sexual activity between teenagers being consensual. Identifies good practice from professionals. Recommendations include: strengthening multiagency decision making and practice in relation to child protection processes; understanding and responding to the link between adolescent neglect, CSE and contextual safeguarding; understanding the impact of traumatic adverse life experiences on parenting through partnership assessments.
| Serious Case Review No: 2020/C8549 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Classification: OFFICIAL SENSITIVE 1 Classification: OFFICIAL-SENSITIVE Serious Case Review BR19 REVIEW REPORT Independent Reviewer: Alex Walters This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with Local Area 1 Safeguarding Children Partnership prior to publication. Classification: OFFICIAL SENSITIVE 2 Classification: OFFICIAL-SENSITIVE CONTENTS Item Page Introduction 3 Process for conducting the review 4 Family Structure and views 5 Relevant background information prior to the timeframe under review and brief summary of engagement 6-9 Involvement of agencies in SCR time frame and single agency learning 9-15 Findings & analysis - The quality & effectiveness of information sharing and risk assessment - Impact of CSE and services for survivors of CSE - Parental engagement and consent - Professional challenge and escalation - Professional curiosity of the child’s lived experience - Contextual safeguarding 15-20 Effective Practice Recommendations 20 21-22 Classification: OFFICIAL SENSITIVE 3 Classification: OFFICIAL-SENSITIVE 1 Introduction 1.1 Local Area 1 Safeguarding Children Board (LSCB) commissioned a Serious Case Review (SCR) following a decision by the LSCB Chair that the circumstances met the statutory criteria for an SCR because a child had suffered serious harm as the result of abuse or neglect. 1.2 Local Authority 1 notified the Department for Education (DfE) of a serious safeguarding incident in February 2019, which related to the rape and sexual abuse of a 15-year-old girl by other teenage males. There were a number of other children who were involved as either, victims, perpetrators or witnesses. However, facilitated by the LSCB the key agencies undertook a Rapid Review process as required by Working Together 2018, which specifically focused on the child subject to this review, BR19. The Rapid Review requires all agencies to undertake a review of their records and to submit a timeline, analysis and summary of agency involvement. 1.3 The Rapid Review Report was submitted to the national Child Safeguarding Practice Review Panel in March 2019. There was subsequent agreement between the Independent Chair and the National Panel that the criteria had been met in relation to BR19 and a Serious Case Review was commissioned on 01/05/2019. It was recognised that the review could indicate, if appropriate, any areas for future exploration and learning relating to the circumstances of other young people involved in the case. 1.4 BR19 and Sibling 1 are subject to current care proceedings. Criminal investigations are still ongoing and there have been no charging decisions made. This review has been undertaken in a proportionate way to ensure the key learning is identified to support improvements in practice. It is, therefore, deliberately not detailed but provides a summary of the family circumstances and key agencies’ engagement with the family. 1.5 The purpose of a SCR, as confirmed in the current statutory guidance, Working Together to safeguard children 2018: Chapter 4 is clear that the focus is on learning, not holding individuals or agencies to account. 1.6 Much work has been undertaken by the Local Area 1 to improve the partnership response to child sexual exploitation (CSE) and this has been recognised by subsequent statutory inspections. This SCR report will seek to offer consideration around whether improvements in services were reflected with this families’ experience. Classification: OFFICIAL SENSITIVE 4 Classification: OFFICIAL-SENSITIVE 2 Process for conducting the SCR 2.1 The LSCB recognised the criteria for undertaking a SCR was met and there was potential to learn lessons from this review regarding the way that agencies work together in Local Area 1 to safeguard children. 2.2 An SCR Panel was established and met in May 2019 to discuss the Rapid Review and scope the Terms of Reference (TOR). This was attended by the Independent Reviewer Alex Walters. Alex is an independent safeguarding consultant, experienced Local Safeguarding Children Board and SCR Panel chair and SCR author, fully independent of the LSCB and its partner agencies. 2.3 An Agency Report Authors briefing was held in June 2019 with the Independent Reviewer to discuss the scope and TOR in detail. Agency reports provided agencies with the opportunity to consider and analyse their practice and identify any systemic issues. They provide details of the learning from the case within their agency, but also allowed agencies the opportunity to reflect on actions and make recommendations for improving practice within their own services. Information reports were requested from agencies where there was less involvement. 2.4 Agency reports were submitted from 9 organisations/functions from Area 1. In addition, background information reports were provided from Local Area 3 and Local Area 2 Local Authorities, Probation and Health services and Local Area 1 Clinical Commissioning Group (CCG) for the GP service. 2.5 The Authors of the agency reports and the SCR Panel then all met together in July 2019 to discuss their reports, identify the learning, areas of effective practice and identify any further information required. Further information and clarification was subsequently sought by the Independent Reviewer through follow up e-mail exchange. It was agreed that the timeframe under review would be from 1 February 2017-January 2019. Relevant information prior to these dates was also considered, particularly historical involvement with the family. 2.6 A central component of the SCR process is understanding the perspective of front-line practitioners and the opportunities and challenges about the 'system' within which they work to analyse why incidents occurred and the contributory factors rather than just what occurred. A key element of the methodology, which underpins this review, was therefore the learning event for front line practitioners. There were some limitations as some front-line staff had left, but their managers contributed instead. Th Event was held in September 2019 and involved 11 practitioners or team managers from: - Local Authority 1 Children’s Social Care including the Specialist CSE Team; - Early Help multi-systemic therapy service; Classification: OFFICIAL SENSITIVE 5 Classification: OFFICIAL-SENSITIVE - School nursing and CSE specialist nurse; - the local Secondary School; - ISVA service. Practitioners considered key themes identified by the Independent Reviewer, and the perspectives and opinions of all those practitioners involved at the time were discussed at the event and have significantly informed this SCR report. 2.7 The contribution of family members is an important part of the review. It was agreed that Father, Mother and BR19 would be informed of the SCR process and invited to participate. A letter was drafted and with the support of the social worker this was delivered to Mother by the Local Area 1 LSCB Business Manager and to BR19 following liaison with her key workers in her residential placement. Father and Paternal Grandmother were also advised by the social worker of the SCR but did not wish to contribute to the SCR. The Independent Reviewer has, however, been able to meet with both BR19 with the support of her residential key worker and with her Mother and their views were most helpful and highly valued by the reviewer in identifying improvements and are incorporated into the review and its recommendations. 3 Family Structure and views 3.1 The relevant family members in this review are: Family member To be known as: Subject child BR19 father to subject child Father mother to subject child Mother sibling 1 to subject child Sibling 1 3.2 The independent reviewer met with BR19 in her residential placement. BR19 was supported by her keyworker who then helpfully undertook some follow-up discussion the following day with BR19, which she agreed to share with the independent reviewer. BR19 is clearly thriving in her placement. She described feeling scared throughout that period of time under review and wanted to speak to a professional but was worried that she would be judged. She wasn’t speaking to many family members and didn’t speak to her Mother feeling she would take out her anger on those involved. Classification: OFFICIAL SENSITIVE 6 Classification: OFFICIAL-SENSITIVE 3.3 When BR19 was asked what might have helped her or her family she felt that if she had stayed living with dad, he would have been stricter with her and that might have helped. She recognised that she probably needed boundaries put in place from either family or professionals and that perhaps becoming Looked After earlier would have reduced her risk. She felt her mum wasn’t given enough support, particularly around domestic abuse and that there were lots of people involved with the family but a lack of consistency; particularly from social workers although she was positive about one professional who she felt she could trust. She reflected that she needed someone who she trusted to see her on a regular basis that she could have talked to and she has since experienced this. She also said she wished she’d had a part time timetable and phased introduction back into school after so long out of school as she felt that led to the education breakdown. 3.4 The Independent Reviewer also met with Mother at her home supported by her Independent Sexual Violence Adviser (ISVA). Mother held the view that overall her experience with statutory agencies historically had not been positive. She felt this had not changed over her involvement in the previous 6 years and meant she had no trust in practitioners. She described providing the police with information about BR19 and the risky situations which she had found herself in which she felt had not been responded to. She also felt that social workers and police had been judgemental and felt that as a survivor of sexual exploitation herself she was automatically seen as a bad parent and was blamed rather than helped. She felt the steps she was trying to take to minimise risk for BR19 were not recognised and that she needed more practical parenting advice. She described situations where information about her daughter’s abuse had not been shared with her sensitively and felt a lack of consistent social worker had not been helpful in the understanding of her situation and the help she needed. She also felt that her attempts to complain resulted in a punitive response from local police. Mother was, however, positive about the Multi-Systemic Therapy (MST) service she’d received, the support of the ISVA service and the specific parenting support that she is receiving now in relation to BR19’s sibling. 4 Relevant background information prior to the timeframe under review 4.1 As a child, BR19’s Mother experienced a number of Adverse Childhood Experiences (ACEs) including sexual exploitation. Research regarding ACEs identifies the long-term impact of toxic stress on individuals who have suffered a number of ACEs including sexual exploitation, violence, abuse, separation, loss and neglect as a child. Mother also had BR19 at a young age and had herself Classification: OFFICIAL SENSITIVE 7 Classification: OFFICIAL-SENSITIVE been a Looked After Child. The impact of her abuse and the need for support for survivors as parents has been highlighted. 4.2 Mother was imprisoned when BR19 was young and so BR19 lived with Father until aged 10 years and then returned to Mother. Mother had another child, Sibling 1 who lives with Mother. BR19 and Sibling 1 were made subject to a Child Protection Plan (CPP) in 2013 for neglect. 4.3 Mother has experienced domestic abuse from previous partners and was subject to a Multi-Agency Risk Assessment Conference (MARAC) process in March 2018. Mother was made subject to a 12 month Community Order in 2016 following conviction for an offence of common assault. 4.4 The family have had a number of moves, some to move away from perceived risk to BR19 and some due to Mother living in an environment/community where many of her abusers are still resident. 4.5 BR19 was not in school throughout most of an 18 month period when living outside Local Area 1. Local Area 3 Childrens Social Care Services became involved in September 2016 due to concerns expressed by Mother of possible CSE of BR19. BR 19 also received, at her request, contraceptive advice at age 13 in September 2016. 4.6 Local Area 1 Childrens Social Care Services became involved following referral by Local Area 3 Childrens Social Care Services on the families return to Local Area 1 in February 2017 and BR19 became subject to a CPP in September 2017 due to ongoing concerns around CSE and Mother’s ability to protect BR19. 4.7 BR19 was subsequently removed from a CPP in May 2018 following a period of involvement by the Multi-Systemic Therapy (MST) team for 2 months and the case remained open as a Child in Need (CIN). The case was closed to Children’s Social Care Services in September 2018 and subsequently reopened in November 2018 following concerns from the police around BR19 being seen at night in the local community and from the school around her behaviour and rumours around sexual activity involving BR19. 4.8 Father has maintained some contact with BR19 since the age of 10 but this has not been consistent. 4.9 Following the incidents of serious harm, BR19 became subject to a CPP in February 2019 and Childrens Social Care Services initiated care proceedings on BR19 and Sibling 1. BR19 is now subject to a Care Order and living in a residential placement. Sibling 1 is subject to a Supervision Order and remains at home with Mother. Classification: OFFICIAL SENSITIVE 8 Classification: OFFICIAL-SENSITIVE 5 February 2017 – January 2019: Brief summary of engagement with agencies 5.1 Following the families return to Local Area 1 in February 2017, there was referral to and involvement with the Children’s Social Care Specialist Team (a multi-agency team with a specific remit for CSE) who worked with the family given the concerns around risk of CSE, which had been identified by Local Area 3 Childrens Social Care Services function. Following increased episodes of missing and an incident in July 2017 when BR19 was found by Mother in a local hotel room with older males, the case was appropriately escalated and an initial Child Protection Conference (CPC) was held in September 2017 with BR19 becoming subject to a Child Protection Plan (CPP) under both emotional and sexual abuse categories. Her sibling did not become subject to a CPP but remained an open case to Childrens Social Care Services as a Child in Need. The CPP for BR19 included a referral for a Family Group Conference (FGC) to identify family/community support for BR19 and her Mother as well as ongoing work with BR19 to keep herself safe and recognise risk. 5.2 A review Child Protection Conference was held in December 2018 and the CP Plan had not progressed due to poor engagement from Mother, linked potentially to her own experiences of childhood sexual abuse, CSE and domestic abuse. BR19 had disengaged from her CP Advocate, there had been no engagement in the planned CSE sessions for six weeks and the Family Group Conference had not taken place. There was then a unanimous decision that a Child Protection Plan continued and that a Legal Gateway Planning Meeting (LGPM) is held to consider the instigation of care proceedings. 5.3 Significantly the case records reflect that the decision to progress to LGPM was reviewed by a Service Manager following the Child Protection Conference, with the outcome being to ensure there was progression to “Edge of Care Panel” and Family Group Conference before care proceedings were explored further. 5.4 The second review Child Protection Conference was held in May 2018 and there were five agencies in attendance. The CSE specialist team had ceased their involvement once the MST service began working with Mother, which was accepted practice. The conference heard from the MST worker about the programme, which started in April 2018 and Mother, is viewed as positively engaging and incidents having decreased with BR19. School reported attendance at 77% and engagement with the school counsellor, but that BR19 was lacking in confidence. Minutes of this meeting evidence that 3 out of the 5 agencies attended with the view that the CP Plan should continue. However, following further discussion and by a majority, the Child Protection Plan was ended in favour of a Child in Need plan. 5.5 The case continued as a Child in Need and was then closed to Childrens Social Care Services in September 2018. Further referrals were made by the School Nurse and the Police in November 2018 outlining continuing concerns that BR19 Classification: OFFICIAL SENSITIVE 9 Classification: OFFICIAL-SENSITIVE was going missing and from the school around information of sexual activity. The case was reopened by Childrens Social Care Services and a single assessment undertaken which found that Mother did not accept ongoing risk of CSE and reported improvement in her relationship with BR19. The case was therefore due for closure but reopened following receipts of further concerns from school and Police in the week before Christmas 2018. There was further discussion at the multi-agency CSE Intelligence meeting in January 2019 and the school also reported further information received from students and evidence of the sexual abuse, which led to a Strategy Meeting held in January 2019 and a further complex strategy meeting also in January 2019. 6 Agency involvement and improvements identified through the agency report process: Local Authority 1 Children’s Social Care 6.1 Allocation in February 2017 to the specialist CSE team was appropriate and they undertook some effective work with the family and escalated the case appropriately to child protection. They then continued to co-work the case with the Locality Team once BR19 was made subject to a CPP in September 2017. However, the social workers faced continued challenges in engaging Mother and BR19 consistently although some of the safety planning work was carried out. There is evidence of good liaison between the two social work teams and then with the MST team and joint visits undertaken. The decision at Review CPC in May 2018 is interesting in that both the social worker and MST changed their view through this process and this is a wider learning issue around professional challenge as identified in this SCR. 6.2 The response by Childrens Social Care Services to the information of extensive bruising on BR19’s arm seen by the Specialist Team Nurse in September 2017 was followed up but did not lead to further examination by Childrens Social Care Services/Paediatrician because BR19 provided an explanation. This was a child where CSE was recognised as a real risk and BR19 was subject to CPP and Child Protection procedures should have been overtly followed. 6.3 Following case closure, the re-referral to Childrens Social Care Services in October 2018 was not allocated to the previous social work team which would have been accepted practice given the 12 week rule (case being re-referred within 12 weeks after closure returns to the original team). This was because the social worker had left Local Authority 1. However, it is now recognised that the Team Manager would have had historical knowledge and overview and this was a missed opportunity to ensure that Local Authority 1 effectively engaged the knowledge and experience they already had in working with this family to ensure the assessment of need and risk, in the context of her history, was better understood. Classification: OFFICIAL SENSITIVE 10 Classification: OFFICIAL-SENSITIVE 6.4 The issue of the decision not to progress to a LGPM by Childrens Social Care Services which had been agreed at the December review CPC needs to be considered as it was replaced by a referral to the Edge of Care Panel and ultimately in a service from the MST team. This decision was not undertaken through the multi-agency CPC process and was a single agency decision. This is reflected in the Childrens Social Care Services agency report but there needs to be consideration of running processes concurrently rather than sequentially particularly when engagement is clearly limited. Whilst all options of support and assistance should be considered prior to entering the legal arena, there was significant history attached to the case and the family, which evidenced that previous interventions had not been successful in creating positive change for BR19. The poor engagement by Mother was a continuous concerning factor, though she did positively engage with the MST. 6.5 It is recognised by Childrens Social Care Services that the Screenings and Concerns analysis undertaken by a social worker in a different team within the First Response Service on re-referral in December 2018 was a helpful piece of analysis which demonstrated that “concerns had not lessened since 2016” for BR19. Improvements identified: 6.6 Childrens Social Care Services have recognised a number of areas for improvement and there are recommendations to further develop the use of case mapping, further enhance the Signs of Safety and use of reflective supervision. Some of the recommendations are also picked up in the multi-agency overview recommendations around professional challenge and escalation, the review of the MST service and the need to further promote a Signs of Safety approach to wider partner agencies to support multi-agency assessment of risk. Local Authority 1 Early Help services 6.7 The Initial Child Protection Conference (CPC) in September 2017 made recommendations that there should be a referral for a Family Group Conference (FGC) and in February 2018 a referral to the Edge of Care Panel resulted in referral for Multi-Systemic Therapy (MST). Both these services are line managed through the Early Help arm of the Children’s Services Directorate. In relation to the FGC the referral was made in September 2017 however FGC requested further information/clarity. This resulted in a delay to the revised referral of over 2 months and the case was allocated in December 2017, which was 11 weeks after the original referral. The family then didn’t engage, and the case was closed. Classification: OFFICIAL SENSITIVE 11 Classification: OFFICIAL-SENSITIVE Improvements identified for FGC: 6.8 The FGC service have recognised the need to minimise drift and delay as an area for improvement and have identified a need for a protocol and measures to monitor timeframes. 6.9 The MST service did, however, engage with Mother following referral to the Edge of Care Panel in February 2018. The referral was considered at the meeting on 6th March, where MST accepted the case. An initial visit to the family was made on the 22nd March and the case became active on 9th April. As a result of concerns around possible firearms linked to domestic abuse, the work took place outside of the family home in community venues, which didn’t impact on Mother’s engagement. Improvements identified for MST: 6.10 It is important to note that the learning from this case has led to a review of how MST works alongside the Social Worker, who retains overall responsibility for the family. Part of the MST model is to provide interventions directly to the family, reducing the number of relationships the family needs to build. However, there is evidence from this case that this practice model is not well understood across all of the workforce leading to other agencies feeling that they need to conclude their work with a family i.e. the CSE Specialist Team ceased their role. The learning from this case has triggered a need to ensure this service is understood by practitioners and also improvement noted to ensure that timeframes are monitored from referral to contact with the family. Local Authority 1 Housing services 6.11 Mother was given priority housing in October 2016 by Local Authority 1 following concerns around BR19 and risk of exploitation in Local Area 3. Mother took up her tenancy in January 2017. Mother had a previous tenancy in Local Area 1, which had been problematic with complaints from neighbours. Between January 2017 and June 2018, the tenancy had the locks changed three times and there were issues with rent arrears. In January 2018 BR19 was issued with an Acceptable Behaviour Contract (ABC) and Mother with a tenancy warning letter due to anti-social behaviour (ASB) and this was increased to an injunction warning letter following another incident of ASB by BR19 in August 2018 and then a notice of possession in December 2018 for rent arrears. Improvements identified: 6.12 There have been a number of areas for improvement identified by the service, primarily in relation to communication between the different housing functions and the need to share information proactively with other agencies or refer for early help and support. This lack of information sharing was further undermined as Housing was not routinely invited to CPCs and was, therefore, not asked to share Classification: OFFICIAL SENSITIVE 12 Classification: OFFICIAL-SENSITIVE information. There is a clear need to ensure that Housing Services are formally invited to all CPCs if the family is known to any of their functions. Local County Police 6.13 The Police had a number of contacts with the family over the time period under review. They were having contact with BR19 as a victim and a potential perpetrator of criminal activity. There were a number of missing episodes for BR19 which were all responded to and some allegations of threatening behaviour verbally, on social media; anti-social behaviour in the community; and another instance where BR19 was damaging the house. 6.14 On some occasions the Police did not automatically inform Childrens Social Care Services through their Gen 117 referral process and not all neighbourhood information/intelligence was shared within Local County Police itself. This was linked to neighbourhood police not always sharing information and intelligence with other areas of Local County Police or Childrens Social Care Services. This created a further missed opportunity to understand the broader context around BR19 and her friendship group, but this picture was not always well understood across the different elements of the police themselves; or effectively communicated and understood by agencies involved. Improvements identified: 6.15 Local County Police have identified two areas of improvement, which related to strengthening the systems of communication and ensuring engagement in CPP processes/conferences and reviews. These areas are further explored in their report and highlight a desire to strengthen relationships with partners locally and nationally. The Local Area 1 NHS Hospital Trust - provider of acute hospital and community services 6.16 Involvement with the family was through the CSE Nurse within the specialist multi-agency CSE team and the School/Specialist Community Public Health Nurse who saw BR19 whilst at school. The CSE Nurse became involved in March 2017 for a period of 8 months and offered a holistic health assessment and sexual health work. Improvements identified: 6.17 In terms of improvement areas, local Area 1 NHS hospital trust have recognised that there were internal issues in relation to compliance with policies on photographic information - the school nurse had photographed the bruising on Classification: OFFICIAL SENSITIVE 13 Classification: OFFICIAL-SENSITIVE BR19’s arm. They also recognised the breadth of the caseload for the Specialist Community Public Health Nurse and are piloting a scheme to prioritise the focus of work on those children who are Looked After or subject to CP or CIN processes. The local Secondary school 6.18 BR19 joined the secondary school on 23/03/2018 after a lengthy period of time out of education before the family returned to Local Area 1. The school clearly were highly involved with responding to BR19’s behaviour, missing episodes and ensuring all information and concerns were shared and undertook many home visits. Despite being unable to contact Mother on numerous occasions school staff were proactive in their efforts to ensure BR19 was safe and well. Improvements identified: 6.19 The school have recognised three areas of improvement. Firstly, to ensure that at the point of admission all background information and contact with agencies involved with the family is undertaken to ensure the right level of support is provided from the beginning. Secondly, to instigate a new starter curriculum to phase return to education and, finally, to review the sanctions and rewards policy and exclusion policy to ensure exclusion is used as a last resort following appropriate risk assessment and doesn’t lead to an increase in risk. Local Area 1, Local Area 4 and Local Area 5 NHS Trust – provider of adult and children’s mental health services 6.20 The Independent Sexual Violence Advocate (ISVA) referred Mother to adult mental health services in June 2017 but Mother did not attend her appointment and was discharged from the service. In September 2017 a further referral was made by the ISVA, which required additional information, which was received in December 2017. Mother then missed two appointments and she was discharged from the service. The ISVA referred again in July 2018 and Mother was seen and assessed in August 2018 by the Access team who referred on to the Community Therapy team who attempted to contact Mother in October 2018. Mother then failed to attend an appointment offered to her in early 2019 and was then referred to and put on a waiting list for counselling. Mother has since moved to another area and was referred to their local adult mental health service but by December 2019 was still awaiting her assessment. 6.21 The CSE Specialist team discussed concerns around BR19 with the Child & Adolescent Mental Health services (CAMHs) function in July 2017, but it was felt that BR19’s issues didn’t meet the criteria for a direct relationship with CAMHs. Concerns were also expressed by the school in May 2018 to the CAMHs Locality Classification: OFFICIAL SENSITIVE 14 Classification: OFFICIAL-SENSITIVE practitioner but again it was agreed that BR19 did not require a direct input from CAMHs. Improvements identified: 6.22 The service has identified areas for improvement around the mode of communication with adults needing to be more flexible and the consideration of non-engagement on parenting capacity. There is also a new service now – the CSE pathway for CAMHs. This includes internal support within CAMHS to improve access and highlight the needs of any current child victims of CSE including through CAMHS locality practitioner’s, although consultations direct to schools can be accessed, and a pathway from the social care specialist CSE service into CAMHs has more recently been staffed to include joint assessments as well as consultation. The CAMHs service now also includes work around the children of those who were subjected to historical adverse childhood experiences within CAMHS. At this time of the SCR the service was in its infancy, however, consultation was sought and provided in line with the CSE pathway. The service recognises the impact of adverse childhood experiences /mental health dichotomy and supports children who fall between the two. Awareness needs to now be widely promoted and the service is subject to evaluation. Local Area 2 Sexual Abuse and Rape Crisis service (providing ISVA) 6.23 The ISVA service became involved with Mother in August 2016 following a referral from a family member and has remained involved from that point. There have been three ISVA workers and contact with Mother has been sustained throughout albeit not always consistently. The ISVA has attended all 3 CP Conferences to support and advocate for Mother but had not been involved in the decision making process. There was effective liaison with local agencies, which included the ISVA facilitating joint visits with social workers and visits to introduce new social workers. There is an issue for the independent reviewer around the role of providers of advocacy services to parents and their role in the child protection process, which needs to be explored as a recommendation. GP services 6.24 BR19 registered with a GP practice in April 2017 but was not seen. The GP was not informed/ invited to the initial strategy meeting in June 2017 or August 2017 or the CIN meetings and there is a different perspective on whether they were invited to the Initial CPC in September 2017. However, it is clear they are not routinely informed/ invited to review CPCs in December 2017 or May 2018 or the Multi Agency Risk Assessment Conference (MARAC) in March 2018. There was also no contact by any other professional with the GP. Classification: OFFICIAL SENSITIVE 15 Classification: OFFICIAL-SENSITIVE 6.25 The named GP has helpfully written to all practices to remind them of their responsibilities and to support their engagement in CP processes. However, there is clearly an issue of the system needing Children’s Social Care Services to ensure contact is made with GPs but also of the health sector and the LSCP to then support and monitor engagement of GPs in key child protection processes. Background information provided from Local Area 3 Childrens Social Care Services/Children missing education 6.26 Local Area 2 Sexual Abuse and Rape Crisis Service referred BR19 to the Local Area 3 Childrens Social Care Services Sexual Exploitation Service in 2016 and an assessment undertaken which recognised there was evidence of BR19 associating with groups of young males and gifts of cigarettes, cannabis and alcohol. The risk was aggravated by her not being in school, the impact on her developmental needs and the amount of time available to seek relationships with those who gave her attention. The case then transferred to Local Area 1. 6.27 BR19 and Sibling 1 had first contact in May 2016 with education services and despite attempts due to Mother and BR19 missing a meeting and the local secondary school not allocating a place until a further meeting, BR19 did not actually attend school until her return to Local Area 1 in February 2017. The fact of non-school attendance and the additional risks that presented for BR19 does not appear to have been prioritised. Background information from Local County Community Rehabilitation Company 6.28 Mother was subject to a 12 month Community Order in 2016. There was little work undertaken with Mother during the year and a number of failed appointments and no contact for the last 2 months of the order. Probation were, however, aware of and involved with agencies in Local Area 3 in relation to BR19. 7 FINDINGS and ANALYSIS 7.1 As with any review, the process of reflection has identified some areas where the current systems and processes could be improved. All the agencies involved with BR19 and her family have identified their own learning and have captured a number of single agency improvements identified in this report and recommendations into action plans. The themes identified below set out additional learning identified by the Independent Reviewer and have resulted in fifteen recommendations. Classification: OFFICIAL SENSITIVE 16 Classification: OFFICIAL-SENSITIVE Theme One - Multi-agency planning and analysis of risk 7.2 The Child Protection Conferences (CPCs) were initiated appropriately in response to recognition of risk but were not as effective in terms of their information sharing as key agencies were absent from the process which impacted on the quality of information shared and the analysis of ongoing risk to BR19. 7.3 All three CPCs were not attended by the GP, the Police or Housing services. This has highlighted a failure of the system whereby GPs are meant to be informed/ invited to Initial CPCs. In this case there is nothing to evidence that this took place. The Police were invited but were unable to attend the Initial CPC due to resourcing issues although they did provide a report and they are not routinely invited to review CPCs. Housing services had had involvement with the family through their Housing support, Housing allocations and ASB functions but are not routinely invited. (Recommendations 1 and 2) 7.4 Additionally, it would appear that Mother had been referred to a MARAC conference by her ISVA in March 2018 which took place in April 2018 as she had disclosed two incidences of domestic abuse from her previous partner - one which had occurred in November 2017 and one in March 2018 at which the children were present. The outcome was a target hardening of the property and a restraining order. However, although attended by a representative from Childrens Social Care Services and the Childrens Social Care Services IT system being updated this information was not fed into the CPC in May by any agency and did not, therefore, impact on the multi-agency assessment of risk. Practitioners felt it was important to ensure that all agencies take responsibility for sharing information into the CP process and not assume this is just for the Childrens Social Care Services practitioner in their lead role. (Recommendations 4, 6) 7.5 However, the MARAC did trigger an Initial CPC in relation to Sibling 1 which was held in April 2018. The outcome of this conference was not to make Sibling 1 subject to a CPP but to remain as a Child in Need and essentially reflected positive reports from the school and the strong relationship between Mother and Sibling 1. This information also did not formally feed into the CPC process for BR19. 7.6 Through the SCR process it has become clear that when additional law enforcement agencies are involved working alongside local police with a parent who is a CSE survivor their interface and role within formal child protection planning is not clear. Are they there as an agency to provide information to inform the analysis of risk to a child in strategy meetings, CP conferences and engage in the process of agreeing if the CPP threshold has been met, or are they providing basic information only? Additionally, practitioners identified that their agency recording is influenced by perceived restrictions from law enforcement agencies on confidentiality. Both these issues need to be addressed by all the Classification: OFFICIAL SENSITIVE 17 Classification: OFFICIAL-SENSITIVE strategic safeguarding partners and a protocol agreed to ensure that agency roles are clear and the system of the protection of children is not undermined. (Recommendation 7) 7.7 It has also become clear through the SCR Process that the role of the ISVA is crucial to support the parent and often they have the strongest relationship with the parent but their advocacy role within the child protection process needs clarification. (Recommendation 7) 7.8 The CSE intelligence sharing meeting took place in January 2019 and was helpful in sharing information and identifying the potential risks. It is chaired by the Police, held weekly and involves the Police, NCA, Specialist Childrens Social Care Services team and Licensing. Practitioners at their event identified that schools were not represented at these meetings and should be aware of their existence and how they could share information into these meetings. (Recommendation 12) 7.9 An issue highlighted through the practitioners’ event related to the use of complex strategy meetings where there were a number of children involved and the need to ensure S.47 enquiries and assessments are undertaken on all the children. 7.10 The issue of minutes not being received from CPCs in a timely manner needs to be addressed by Childrens Social Care Services and escalated appropriately by other agencies. Work has been undertaken by LSCP around timescales to ensure there is a clear partnership expectation and understanding around plans and minutes being shared but this needs to be monitored. Theme Two - Impact of CSE and Services for survivors of CSE who are parents 7.11 Mother was both a survivor of familial child sexual abuse, which led to her removal from home at the age of 10 and of child sexual exploitation once she became a Looked After Child. These adverse childhood experiences of trauma, abuse, separation and loss as well as being a young teenager at the time of BR19’s birth resulted in a profound feeling of having been let down, to be distrustful of statutory agencies which resulted in her significant lack of engagement at times with school, social workers and the police. However, she did engage positively with the MST service, which she clearly found helpful in supporting her parenting of BR19 and focused on her needs. However, this is not a therapeutic counselling service and it is clear that a timely targeted service would have been helpful to Mother. She was referred by her ISVA twice to Adult Mental Health Services and although she mainly didn’t engage, she was seen on one occasion by a triage service and her need recognised. She was referred on to the specialist service however, this resulted in a 4 month gap by which time she didn’t engage again. There were concerns that despite agencies Classification: OFFICIAL SENSITIVE 18 Classification: OFFICIAL-SENSITIVE understanding the adverse life experiences mum had experienced and the emotional impact this continued to have on her, there was a lack of focus, other than from the ISVA service, around supporting her to access mental health support. 7.12 There was already in existence a local service to support adult victims of CSE who could not easily access therapeutic services. This service now offers a multi-agency hub which both receives referrals and offers a wraparound service to both CSE survivor’s as individuals and as parents and their children. It offers consultation and supported access to mental health services, specialist counselling, trauma stabilisation interventions and focussed support provided by the third sector. The Service works closely with CAMHs and supports practitioners to take a family-based approach within the context of the criminal justice system. The SCR process heard from practitioners about the potential barriers to accessing services and that access to therapeutic services could potentially impact on the evidence provided to court. This service is helping overcome these barriers. There is a need for survivors to access their therapeutic support at the right time for them and to support their parenting capacity. Practitioners were clear that there is a need for this for the survivors of CSE, particularly those who are parents. There are many parents who are survivors whose children will be subject to Child Protection Plans and this support is important so that they have the best opportunity to parent their children successfully. (Recommendation 13) 7.13 The Child Protection Plan for BR19 also did not include an action for direct referral/access for Mother to the right form of therapeutic therapy and this should be an explicit part of the CPP. Theme Three - Parental engagement and consent 7.14 Throughout the period under review and historically there is continued evidence of a lack of engagement with professionals by Mother and also by BR19. Although the reasons for this are understood there is an issue about how ongoing lack of engagement and the impact of this on thresholds for intervention are responded to by professionals. This must be considered as an additional risk measure in its own right especially when considering the complex issue of adolescent neglect and the risk of CSE. (Recommendation 11) 7.15 With hindsight there was probably sufficient evidence of concern to have moved into the LGPM arena earlier and for some of the interventions to be driven/ supported by the care proceedings which could have provided the boundaries. BR19 recognised that might have helped her and might also have been helpful to Mother. The Signs of Safety framework and the emphasis on safety planning Classification: OFFICIAL SENSITIVE 19 Classification: OFFICIAL-SENSITIVE may have been helpful but Mother required help to understand how to parent her daughter and some specific focus on that was missing, although met to some extent by the MST service. This should have continued past the end of the programme and there is a question around sustaining that intervention which will be considered as part of the planned review. (Recommendation 8, 9 and 15) Theme Four - Professional challenge and escalation 7.16 The decision at the May 2018 CPC to remove BR19 from the CPP was overly optimistic. The impact of the MST work with Mother and on her relationship with BR19 was significant but had not been completed and the evidenced progress had not been sustained. Given the known history of the family, the fragility of the relationship between Mother and daughter, the sporadic engagement with agencies by Mother and BR19 and ongoing risk of CSE to BR19 the expectation that de-escalation to a Child in Need plan would address those risks was unrealistic. In addition, key additional information on risk was not fed into the CPC from the MARAC process and Sibling 1’s initial CPP and key partners were absent. The agencies represented at the CPC were divided in their view and ultimately two agencies changed their view to agree to the cessation of the CPP. Having seen the conference minutes, it is also clear that there was no evidenced record of progress against the Child Protection Plan and no discussion on why the recommended LGPM had not been held. (Recommendation 3) 7.17 The school noted that they felt the decision was inevitable although they clearly had ongoing concerns. However, in discussion at the practitioner’s event no agency felt that the Child Protection Conference was unequal/unbalanced but recognised that all practitioners need to feel empowered to challenge views and decisions. (Recommendation 5) Theme Five - Professional curiosity of the child’s lived experience 7.18 Throughout the SCR process, agencies themselves have recognised occasions when they could have been more professionally curious about the lived experience of BR19 and asked more questions rather than simply responding to the presenting issue. She had many adverse childhood experiences including separation from her Mother; she spent much time out of school which will have impacted on her development alongside a poor and at times violent relationship with her Mother, domestic abuse and potential substance misuse. There were numerous instances of when professionals tried and failed to engage with BR19 or her Mother. It is important for professionals to try to understand and consider the lived experience of the child on a day to day basis in terms of the support and attention received which may increase their vulnerability to exploitation and Classification: OFFICIAL SENSITIVE 20 Classification: OFFICIAL-SENSITIVE experience of harm and the impact of non-engagement by both the parent and the child themselves on their risk of abuse/neglect. 7.19 In this case there needed to be more active consideration of adolescent neglect as an overt feature as opposed to apparent acceptance that the main risk related to the external environment. Mother was at times unable to ensure BR19 attended GP and dental appointments which clearly meant that BR19 was not accessing services to meet her health needs and not able to maintain boundaries to ensure BR19 responded more to the “pull” of home. (Recommendation 10) Theme six - Contextual safeguarding and perception of sexual activity between teenagers being consensual 7.20 This was an issue when BR19 at the age of 13 visited a Sexual Health clinic in Local Area 3 and was given contraception to prevent pregnancy. She said she had one episode of unprotected sex with her teenage boyfriend. The SCR was assured that this would now result in a different pro-active response by sexual health services in Local Area 3 which was initiated in April 2017, which includes a formal review of all 13 year olds, but this process took place in 2015. 7.21 The second issue relates to the timeframe from November 2018 to January 2019 with the school raising concerns and sharing information with both the Police and Childrens Social Care Services they had received from other children of both genders engaging in sexual activity in the local park. Mother and BR19 denied any involvement. The response from statutory agencies and the Police particularly - i.e. the Childrens & Young Persons Officers (CYPO) was this was normal teenage activity and there appeared no consideration of coercion or exploitation. The position changed over the next few weeks as the main evidence of abuse was then accessed and the specialist Protecting Vulnerable People (PVP) function of the Police became involved. (Recommendation 10) 8 Effective practices that had a positive impact on BR19 8.1 The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered effective and supports good outcomes for children. Good practice from professionals has been acknowledged and this includes, • Transfer of information from Local Area 3 Childrens Social Care Services to Local Area 1 Childrens Social Care Services and allocation to the Specialist Team • Effective intervention from the CSE specialist team Classification: OFFICIAL SENSITIVE 21 Classification: OFFICIAL-SENSITIVE • Effective intervention from the ISVA service including facilitating introductory and joint visits with Childrens Social Care Services and referrals to mental health and MARAC. • Effective multi-agency recognition of risk at initial CPC • Both the MST and the ISVA services ensured continuity of service when practitioners were off work. • Joint visit between MST practitioner and case holding social worker. • The provision of MST to Mother was helpful in addressing her concerns and supported her parenting of BR19 and appeared an effective intervention. • The proactive response of the local secondary school. • The multi-agency response from January 2019, which was felt to be robust and cohesive. 9 Recommendations 9.1 The Review concludes with recommendations to the newly created Local Area 1 Safeguarding Children Partnership (LSCP), which build on the recommendations and actions already identified for learning by single agencies during the process of researching their involvement in this case. In a number of cases, actions have already been taken to improve arrangements/systems. 9.2 The following additional actions are provided under overall themes to ensure that LSCP and its partner agencies are confident that any other areas are addressed and that the LSCP is able to monitor progress. Theme A - Strengthening multiagency decision making and practice in relation to child protection processes 1 LSCP to agree that routine invitations to CPCs are undertaken in all cases to GPs and any known to Housing service. LSCP to request Local County Police and GPs ensure that if they don’t attend Review CPPs that they provide a report with updated information. 2 LSCP to request regular reports/undertake audits to monitor the engagement of key agencies in the CP process including attendance/provision of reports. 3 Local Authority 1 to ensure Child Protection Conference chairs ensure Review Conferences evidence progress against the action plan before removal from a CPP and that this is included in the LSCP audit programme. 4 LSCP to request Local Authority 1 and Local County Police review and consider the effectiveness of information sharing between the two processes of MARAC and Child Protection when there are children involved with Childrens Social Care Services. Classification: OFFICIAL SENSITIVE 22 Classification: OFFICIAL-SENSITIVE 5 LSCP continue to promote and support professional challenge and escalation by practitioners through the escalation protocol and deliver specific training on developing professional curiosity of the child’s lived experience. 6 LSCP ensures training on understanding multi-agency practitioner’s roles and responsibilities in child protection processes is embedded in core safeguarding training. 7 LSCP to request services including commissioners of ISVA services and policing work with Local Authority 1 to develop protocols, which clarifies issues around their role in the Child Protection process and information sharing. 8 LSCP considers the wider roll out of training on Signs of Safety to multi-agency front line practitioners. 9 LSCP to request Local Authority 1 report on their review/evaluation of the MST service and how it interfaces most effectively with other Childrens Social Care Services functions. Theme B - Understanding and responding to the link between adolescent neglect, CSE and contextual safeguarding 10 LSCP continue to promote awareness and understanding of contextual safeguarding and adolescent neglect to all practitioners, particularly police colleagues, and consider the most effective interventions. 11 LSCP to consider providing specific multi-agency training around issues of parental and child non engagement with services and the impact on safety planning. 12 Local authority1 to ensure the dissemination and awareness raising with all schools of the process to share information in the CSE intelligence sharing meetings. Theme C - Understanding the impact of traumatic adverse life experiences on parenting through partnership assessments 13 LSCP acknowledges that the support service for adult victims of CSE is evaluated annually, this evaluation is reported to the partnership, the commissioners and regulators. This should continue with a view to identifying and addressing any barriers to timely access to therapeutic support for survivors of CSE. 14 LSCP to deliver training on the impact of CSA and CSE on parenting capacity as part of its core delivery offer. Alex Walters 11/8/2020 |
NC51305 | Death by suicide of a teenage girl in January 2019. A19 started self-harming in 2017 and in September 2018 mother contacted the school with concerns about A19's self-harm and suicidal thoughts. In October 2018, A19 disclosed that she had been sexually assaulted by a distant family member; school reported this to the police; A19 did not wish to support a prosecution. Towards the end of term, A19 disclosed to a teacher urges to self-harm or worse; information shared with mother who agreed to take her to a GP. In the new term, A19 messaged a former teacher disclosing self-harm the previous day and referred to the sexual assault. School was alerted; lessons included the issue of suicide that day. A19 taken to hospital later that day and died six days later. Ethnicity or nationality of A19 not stated. Learning: early help for young people suffering self-harm and/or suicidal tendencies needs development to promote multi-agency working; responses to a young person disclosing sexual abuse may be more effective if they feel included in discussions regarding decisions and potential outcomes; training required to assist social workers exercise their right to disclose information confidentially. Recommendations: to enhance the use of the self-harm referral pathway and refer young people when support is needed; to ensure similar enquiries are managed by the police in a sensitive manner when a young person feels unable to proceed with a prosecution and victims better informed if there is no intention to speak to the alleged perpetrator.
| Serious Case Review No: 2019/C7930 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Child A19 Practice Learning Review Allison Sandiford LLB (Hons) Independent Author 2 Contents 1. Introduction ...................................................................................................................... 3 2. Brief Synopsis of Events ................................................................................................... 5 3. Practitioners’ Views / Actions ........................................................................................ 7 4. Family Views ................................................................................................................... 10 5. Analysis of the Key Lines of Enquiry ............................................................................. 12 6. Additional Analysis ........................................................................................................ 23 7. Good Practice Identified ............................................................................................. 25 8. Recommendations ....................................................................................................... 25 3 1. Introduction Initiation of the Local Child Safeguarding Practice Review 1.1. This Local Child Safeguarding Practice Review (LCSPR) was commissioned in March 2019 by a Local Safeguarding Children Partnership (LSCP). The matter under review is the tragic death of a teenager (Child A19) having been found suspended by a ligature placed around the neck. 1.2. The LSCP concluded that the circumstances of this case meet the criteria for a LCSPR as per statutory guidance1. The Purpose of this Review 1.3. The purpose of this review is to consider what lessons can be learned to guide future practice concerning young people who are experiencing self-harming behaviour or considering taking their own lives. The purpose of this review is not to scrutinise the actions taken; nor is it to make a judgment of whether A19’s death was predictable or preventable. The LCSPR sought to understand 1.4. The early help offer to address Child A19’s mental health; There has been extensive learning from a previous case review that resulted in additional support to enable universal services to access emotional health and well-being provision and the creation of a self-harm referral pathway as part of the regional procedure ‘Young People and Self-Harm’. The review will investigate how learning from previous case reviews has been implemented in practice. 1.5. The closure of the Police investigation without the suspect having been formally interviewed. 1.6. The use of the Child Sex Offender Disclosure Scheme (Sarah’s Law2) to inform the suspected abuser’s partner of the allegation made against him when safeguarding procedures had already been applied. 1.7. The closure of Children’s Social Care (CSC) involvement without a comprehensive picture of Child A19’s health, particularly mental health, and the potential lack of understanding of the impact of the alleged sexual assault on Child A19 and how the family dealt with it. 1 Working Together to Safeguard Children (2018) 2 The child sex offender disclosure scheme in England and Wales (also sometimes known as "Sarah's Law"), allows anyone to formally ask the police if someone with access to a child has a record for child sexual offences. 4 1.8. How the voice of the child was heard, and the daily lived experience understood, assessed and responded to by professionals. Methodology and Agency Involvement 1.9. The review was managed by a review panel (known as the Panel) which included representation from relevant organisations within Health, Children’s Social Care, Education, the Police and representatives from the Local Safeguarding Children Partnership. Allison Sandiford, an independent reviewer (the Reviewer) was commissioned to work with the Panel and to undertake the review. 1.10. The review has been informed by: Agency chronologies and reports Background information from agencies involved Access to key documents Panel discussion and analysis Input from practitioners via a learning event Family views and experience. 1.11. All relevant agencies reviewed their records and provided timelines of significant events. These were considered by the Panel who had the opportunity to raise questions and clarify understanding of any circumstances. The agency timelines were merged and carefully analysed by the Reviewer and areas highlighted that required further consideration. 1.12. Key practitioners were identified to attend the learning event in order to assist the Panel and Reviewer to understand the detail of agency practice in this case. 1.13. The learning event was held on 4th June 2019 and was attended by 12 professionals. Most had had direct involvement with A19 and/or the family. The Reviewer facilitated the learning event assisted by the Chair of the Panel. Further to the event and with the support of the Panel and LSCP, additional enquiries were made with professionals who had been unable to attend. This information is included in the report. 1.14. The Reviewer met with A19’s family who provided their experiences of the support and services offered to A19 and themselves. 1.15. Following the learning event and family meeting, the Reviewer gathered and analysed the learning for discussion with the Panel. The findings were re-examined, and the Panel considered what could be done differently to improve future practice. 1.16. A draft report was provided to the Case Review Panel in advance of the Safeguarding Children Executive Partnership Meeting in September 2019. Period under Review 5 1.17. The review period commences from school’s first record of self-harm in January 2017 and ends with the Coroner’s Pre-Inquest Review Hearing on 13th March 2019. 1.18. The critical period is from the point that Child A19 disclosed the sexual assault to school in October 2018, up to and including the date of death. Parallel Processes 1.19. The review, although an independent process undertaken on behalf of the LSCP, was thoughtful of the ongoing Coronial Inquiry and future Inquest in relation to Child A19’s death. 2. Brief Synopsis of Events Initial Indications of A19’s Mental Health 2.1. The first reported threat of self-harm by A19 dates from early 2017; A19 threatened to self-harm if school contacted Mother regarding a disclosure of another student self-harming. 2.2. At the end of 2017 a student disclosed at school that A19 had sent a message claiming to have self-harmed. This was shared with Mother who said that A19 had been a bit down lately and was tired due to a new routine. 2.3. In September 2018 Mother contacted school stating she was worried about A19 regarding suicidal thoughts and self-harm. School spoke to A19 and self-harming behaviours were confirmed to have started when A19 was in Year 9. A19 discussed feeling relief when self-harming but did not understand why. A19 denied current self-harm and did not give any indications of future harm. A19 was informed that staff were available to talk and given support leaflets. 2.4. In the following weeks, A19 utilised the support school offered by means of attending the inclusion team3 on several occasions. A19 disclosed feeling upset around this time but did not say why. Disclosure of Sexual Assault 2.5. In October 2018, A19 disclosed to school, inappropriate touching by a distant relative (AR). The sexual assault had occurred at the end of September (the incident post-dated Mother contacting the school with concerns of self-harming and suicidal thoughts). A19 also disclosed that AR had since sent inappropriate messages. A19’s parents were 3 The Inclusion Team offers students support that may be needed for a variety of reasons. 6 recently aware as A19 had confided in a friend whose mother had told A19’s Mother. A19 had since heard Mother shouting at AR and telling him not to make any further contact. 2.6. School contacted Mother who confirmed she was aware of the allegation and had confronted AR and told him to stop all contact. Mother did not appear to be aware of all the details disclosed by A19 and she was invited into school where she was advised. Following the meeting A19 and Mother left school, but soon returned and A19 retracted some of the detail. 2.7. School reported the assault to the police and made a referral to CSC. Later that day, Police and CSC conducted a joint visit to the family home. A Police Constable spoke to A19 in the presence of Mother and Father but A19 had left the address prior to CSC attending. CSC spoke to A19 alone the following day at school. A19 reported feeling safe at home and was confident of no further contact with AR. 2.8. A few days later Mother advised the police that A19 did not wish to support a prosecution. Mother said that A19 had never envisaged the police being involved and did not want the matter to progress any further. The crime was subsequently closed as without the support of A19 there was little or no chance of a successful prosecution. 2.9. 8 days after the disclosure police, education and CSC attended a strategy meeting4 where it became clear that the police were unaware of A19’s initial disclosure to school. 2.10. In November CSC completed a C&F5 assessment. The outcome was that A19 did not wish for any support from any agency other than school and Mother and Father were confident that they could manage the situation without CSC involvement. The case was closed. Increasing Concerns and Events Leading to A19’s Death 2.11. Towards the end of the Autumn school term A19 was found in possession of a lighter during a lesson. A19 told a teacher that the lighter was to prevent self-harm. 2.12. 2 days later A19 disclosed to a teacher a want to self-harm or worse. This information was shared with Mother and it was agreed that she would take A19 to the GP during the school holidays. 2.13. In the late afternoon of the first day of the new term A19 sent an ex-teacher a message disclosing self-harm the previous day. The message referred to the afore mentioned sexual allegation. 2.14. School was alerted to the message and A19 was spoken to the following morning. A19 denied both the message and self-harm. No other agency was made aware. School 4 A strategy meeting convenes where concerns have been raised about the safety/wellbeing of a child 5 Child and Family Assessment 7 noted that throughout the morning A19 presented as usual, even when the issue of suicide was discussed in a lesson6. However, later in the day, A19 presented as tearful and attempted to speak to a member of staff but did not wait for the staff member to become available, choosing to return to class instead. 2.15. Following the end of the school day, school received a call from a concerned parent after a child had informed her of A19’s intention to end life. School contacted Mother and Father separately to alert them. 2.16. Later the same day the ambulance service reported to police that A19 had been found hanging and taken to hospital. 2.17. A19 died 6 days later. 2.18. Following an investigation, Police concluded that there was no third-party involvement or suspicious circumstances. A file was submitted to HM Coroner. Initiation of the Review 2.19. On 7.3.19 the Rapid Review Panel Meeting decided that the threshold for a Serious Case Review had been met. Due to the process change this was progressed as a LCSPR. 2.20. On 13.3.19 the Pre-Inquest Review Hearing convened. 3. Practitioners’ Views / Actions The following observations and considerations have come from agency reports and the Practitioners who attended the Learning Event. Education 3.1. The disclosure of sexual assault was preceded by 3 concerns of self-harm which had been raised at the school over a period of 20 months. School had communicated all concerns with Mother - the third being a concern raised by Mother herself. The information was not shared separately with Father as Mother was the first named contact for school and there was a presumption that she would share concerns. Mother engaged well with school, she would return calls and she presented as a very capable parent in control of the situation. School wasn’t ever aware of any outside support being sought by either parents or A19, but this did not heighten any concern as A19 continued to present well at school and work hard. 3.2. When a member of staff has a concern for a student a ‘Cause of Concern’ form should be completed. School identified occasions when this form had not been completed 6 Suicide was discussed in a lesson as the class were studying a poem about war and the poet who wrote it later took his own life. This poem is part of the GCSE compulsory poetry anthology ‘War and Conflict’. 8 correctly or had been misplaced. To improve this process school is investing in CURA which is an electronic computer system that will allow for better communication between staff. This will prevent future forms being misplaced or incorrectly filed. Training on the detail of record keeping is regularly delivered to schools by the Local Authority and highlights the importance of clear and concise records. CURA will help school to retain their records of students’ experiences and will provide complete profiles of individuals concerns. 3.3. In the weeks prior to the disclosure, school were aware that A19 was utilising the anti-bullying room in school which gives students daily access to a quiet place and/or support for issues of peer conflict. A19 disclosed feeling upset during this time but did not explain why. School were therefore expectant of some sort of disclosure coming from A19. 3.4. When A19 did disclose the sexual assault, school rightly reported it to the police. The call taker took enough detail of the disclosure to open an incident and pass it to a radio operator for allocation to an officer. The specifics regarding A19 returning to school and changing the account were not taken at this time, but school documented this on the referral that they sent to CSC. In a strategy meeting that convened 8 days later, it transpired that the police remained unaware of the alterations to A19’s account; school recall an action of the meeting being for CSC and police to consider this information. However, school reported at the learning event that they hadn’t received the minutes of the strategy meeting and this has resulted in discrepancies between agencies’ recollections of discussions and an inability for agencies to check whether they had completed all actions assigned to them. 3.5. Following the disclosure school informally monitored A19. A19 reported being okay and not wanting to talk. It was 2 months later, just before the end of the term, when a further concern was recorded; a member of staff took a lighter from A19. A19 said the lighter was to prevent self-harming. School attempted to contact Mother but had to leave a message requesting she call them back. Contact did not happen until 2 days later by which time A19 had disclosed wanting to ‘self-harm or worse’. When school communicated the 2 new concerns to Mother, it was agreed that Mother would seek advice from the GP. School and other professionals have since questioned whether too much reliance was placed on Mother to access services to support A19. 3.6. It was the late afternoon of the first day of a new term when A19 sent a message to an ex-member of school staff reporting self-harm. This was addressed at the beginning of the following day and the message was denied by A19. A19 was asked whether Mother had spoken about visiting the GP about the self-harm during the holidays and A19 said that she had not. There was no further opportunity to discuss this with parents prior to the tragic events that followed at the end of the school day, as contact with Mother was unsuccessful. 3.7. Because A19 had participated in a class that discussed suicide on the day of the incident, school has wondered whether there should be a review of the GCSE curriculum and/or more support offered to staff re preparing learners for sensitive topics. Teachers could consider issuing a warning of a topic, prior to the lesson, that could possibly cause distress. This would give learners an opportunity to identify lessons uncomfortable to them and allow staff to adapt the content if appropriate and identify support networks to learners. 9 3.8. The school was not actively informed by any agency of A19 being in a critical condition until 10:35 hours the following day when CSC had processed the referral and clarified the information with the hospital and police. This resulted in school having to contact Mother and Father at a very difficult time to confirm the incident, after a comment had been seen on social media. School said that it would have been helpful to have had official confirmation earlier to allow school to consider how to support students and staff. Children’s Social Care 3.9. A CSC worker and a police officer attended the family home on a joint visit following the sexual assault disclosure. A19 was not present when CSC arrived but had spoken to the police officer prior to leaving. CSC obtained details from A19’s parents of other children that AR had contact with, and referrals were made to safeguard them. This demonstrated good practice. The CSC worker considered that parents presented as shocked by the incident and were still processing the information during the visit but had demonstrated an ability to manage the situation and safeguard A19. Mother said that she did not need any further support from CSC. 3.10. A19 was spoken to alone by CSC the following day at school. A19 was described as quiet during this meeting. The importance of talking to someone about experiences was discussed with A19 and the role of Healthy Young Minds (HYM’s) was explained. A19 did pass comment that Mother did not want to talk about the incident at home but there was no commitment to the offer of any referral to HYM’s. A19 was able to identify a teacher at school as a source of support. At the end of the meeting the social worker said that she did not think CSC needed to be involved any further. 3.11. The strategy meeting was attended by CSC, school and an officer from the Public Protection Investigation Unit of the police. The meeting determined that the threshold was not met for a section 47 assessment. 3.12. CSC completed a C&F assessment and concluded that Mother and Father were able to manage the situation. At the learning event it was discussed whether additional consideration could have been given as to whether further support is needed to be offered to parents who find themselves supporting a child following sexual abuse by a family member. However, when the case was closed it was not challenged by any other agency. 3.13. The next involvement CSC had with the family was following A19 being found in a critical condition a few months later. Police 3.14. Prior to the sexual allegation disclosure police had not had any direct involvement with A19. 10 3.15. Following the disclosure an officer attended the home address and spoke with A19. A19 did not disclose the account that had initially been disclosed to school. The officer recorded what A19 said and this was appended to the incident log. The conversation was in the presence of parents. The only opportunity that A19 had to speak to the officer alone was in the hall of the address. 3.16. A few days later an officer spoke to Mother on the telephone in detail and explained the prosecution process including how evidence would be gathered and what support would be offered to A19. The family were given the weekend to consider their options and Mother was contacted by telephone again on the Tuesday and asked whether A19 was willing to support a prosecution. Mother said that A19 had decided not to prosecute. Mother was confident that the offender would not repeat his actions. There was no further contact with A19. Health 3.17. The GP was unaware of A19’s self-harming or the disclosure of the sexual assault. 3.18. Upon arrival at the hospital there was evidence noted of previous healed cuts to A19’s forearms and self-harm to both wrists. 4. Family Views 4.1. Parents and sibling were invited to contribute to this review. They met with the Reviewer and provided their experiences of the support and services received by A19 and themselves. The Reviewer would like to offer the family sincere condolences and thank them for their invaluable contribution. 4.2. A19 was very much loved and parents and sibling described A19 as presenting as happy in the family home. The family were unaware of how A19’s mood was changing, and A19’s death was a devastating shock. 4.3. The family did not recognise the initial concerns raised in 2017 of self-harming as serious. Mother was assured by A19 that there would be no further incidents and because no further marks were seen on A19’s arms which were frequently exposed, the family presumed that it had been a one-off incident. 4.4. The parents’ view is that they needed more information about self-harming behaviours and the possible risks around this time. School provided A19 with a leaflet at some point, but this did not raise parent’s awareness or improve their understanding. Mother remembers the leaflet containing the details of different organisations to support young people with mental health and she encouraged A19 to consider them. 11 4.5. Mother commented that she wondered whether because she is a professional person, other professionals presumed that she had the understanding and knowledge to deal with the situation. Both parents would like to see an improvement in self-harming awareness being taught to all parents. 4.6. Mother began to understand the seriousness of the implications of self-harming when school raised a concern with her in December 2018. She was sufficiently concerned at this time to contact the GP surgery, but the first available appointment was the following month. Mother was asked if A19 required an emergency appointment, but she was unsure as to whether a threat to self-harm or worse would be considered an emergency and declined. 4.7. Mother and Father both agreed that school taking the choices out of their hands by making a referral to other services on their behalf would have helped the situation. Both considered that A19 would have been more receptive to attending an appointment if the suggestion had not come from parents. 4.8. Mother described being in total shock when she learned of the sexual abuse towards A19. Parents agreed that had the perpetrator not been a family member the situation would have been easier to deal with and they would have possibly encouraged A19 to support a prosecution. 4.9. Family understood that school needed to report the incident to the police, but they did not think that A19 anticipated the police becoming involved. Neither parent is unhappy with how school dealt with the incident, but both considered that extra support in the following weeks may have helped. Mother felt pulled in many directions emotionally and would have appreciated guidance. Father said that contact from school would have needed to have something to offer them; the standard response of ‘okay’ would have likely followed the question; ‘how are you all coping?’ Parents considered that guidance on how the allegation could affect A19’s mental health would have helped. 4.10. It was Mother who explained the court process to A19, and she wonders whether it may have been better if the information had come direct from someone within the police. Mother said there was a possibility that A19 may have decided not to prosecute based on how a prosecution might make Mother feel. Professional guidance for A19 would have been appreciated. 4.11. None of the family were aware that the suspect hadn’t ever been interviewed or spoken to by a police officer. 4.12. The parents view of the social care involvement at this time was that CSC attended with the police to gain details of any other children that the suspect might have contact with. Family were happy to pass this information. Parents were unaware that a C&F assessment followed. They knew that a social worker had spoken to A19 alone the following day, but they had no memory of any other contact with CSC. 12 4.13. Parents both considered that a further offer of help may have proved useful a few weeks after the disclosure, when the family had had time to process the incident. They would have appreciated someone helping them to understand the effects the assault may have on A19 and someone offering support directly to A19. 4.14. The family all described the Coronial pre-inquest review as being made more difficult by the fact that it felt as if some professionals in attendance didn’t understand what had happened and had not prepared for the day. They said that it made the process impersonal and harder to bear. 5. Analysis of the Key Lines of Enquiry The analysis is derived from the practitioners who attended the learning event and discussions with the Panel. The analysis of practice in no way seeks to apportion blame to professionals but seeks to understand what can be learnt to support professionals to develop better future safeguarding of children. The Early Help Offer to Address A19’s Mental Health. 5.1. There is online guidance, by way of a local self-harm referral pathway, designed to help anyone working with children and young people to respond to the issue of self-harm. It contains important principles and pathways to support positive change centred around the young person at risk. Between 2016 and 2018 the Local Authority conducted intensive work to promote this early help offer by way of briefings and e-bulletins but when asked at the learning event, school staff reported being unaware of this pathway. However, whilst the school were not aware of the specifics around the referral pathway, school is very clear and confident that it knows how to access support and guidance for students who are self-harming and that it has good links with HYM’s. Several staff members were trained on the Mental Health First Aid Course and other staff members continue to be so. A few staff members have also attended general awareness courses. The paragraphs below consider the schools application of the training and their offer of low-level support to A19 who, during discussions, continued to deny any issues. 5.2. Within the timescale for this review A19 has been subject to 6 reports of concern within school which reference self-harm, 3 of which occur within the last month of life. The first concern was addressed at the beginning of 2017 and with no further concern identified for a period of 10 months and then a subsequent 11 months, it is reasonable that professionals, at this time, may have concluded that the problem had been low risk and addressed effectively. 5.3. Regardless of the level of risk, school’s initial responses to concerns remained consistent with verbal advice which included the discussion of external support networks, information leaflets and, in line with best practice, communication with Mother. This informative communication ensured that parents were in a knowledgeable position to orchestrate any further support that they considered necessary, and it is evidenced that 13 Mother felt able to seek support as she contacted the school herself with the third concern. Schools consistent communication with Mother is significant to decisions made to not refer A19 to any other services as school was in no doubt that Mother’s responses evidenced her capability of safeguarding from future harm. Mother presented as confident and able, and this was reinforced by the knowledge that she was a professional herself whose role required an understanding of safeguarding children. 5.4. Following Mother contacting school with her concerns, a member of staff spoke with A19 alone. A19 disclosed self-harming in the previous school year but denied any current harm. There was also mention of some problems between A19 and another student. School discussed the previous harm and was assured by A19 that there was no intention to harm in the future. The problem between the students was addressed by ensuring that they were kept separate and around this time, A19 began to utilise the anti-bullying quiet space. This usage was observed but although A19 admitted to being upset, the cause was not disclosed. Within weeks A19 made the disclosure of sexual abuse. The first response by school was appropriate and staff followed safeguarding guidance by listening to A19 and making it clear that they would have to share the information. Appropriate contact was made with Mother, CSC and the police and all staff involved in the disclosure made detailed statements that were attached to the referral sent to CSC. The sexual assault disclosure had the effect of becoming the focus of concern for A19 and it offered a possible explanation for A19 being upset and utilising the anti-bullying space. What does not appear to have been considered at the time was whether there was any possible link between the previous self-harming and the sexual abuse incident. If this had been deliberated there may have been some consideration following the disclosure, as to whether there was any possibility of longer-term grooming by AR. This omission is understandable as A19 made no reference to any history of abuse. However, there is indication that A19 was uncomfortable whilst discussing the incident and therefore, further disclosure would have been difficult to do. School recollect that A19 struggled to voice the account, preferring to use hand gestures and possibly as a result of subsequent miscommunication, or possibly as a result of embarrassment, A19 later retracted part of the initial disclosure. This communication difficulty is comprehensible but does mean that A19 may not have disclosed the full extent of any abuse and thus left professionals unable to respond to the full circumstances. Research7 has concluded that upon disclosure, A19 will likely have battled an extensive range of internal worries surrounding stigma, blame and shame, a worry of not being believed and fears for the consequences for the family. These concerns would have all operated to encourage silence. In the absence of obvious signs of abuse, A19 unfairly and unavoidably had the responsibility of speaking out and seeking help. 5.5. The police and CSC responded to the allegation the same day and conducted a joint visit to the home address. The police recorded a crime of Sexual Assault and CSC ensured that parents had a safeguarding plan in place. 5.6. The practitioners recall the strategy meeting being held 8 days after the disclosure, by which time the police had already closed the investigation. There is a sense at this time, 7 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/UniBed_MakingNoise-20_4_17-1.pdf 14 of the assault having been minor and parents having taken control of the situation, but it cannot be disputed that the facts remained largely unknown. The only professional who had spoken to A19 alone following the disclosure was a CSC worker who A19 had no relationship with and was therefore unlikely to disclose sensitive information to. 5.7. At the strategy meeting and during the C&F assessment, Mothers voice regarding A19 being kept safe from AR in the future was taken at face value. There was no consideration of AR finding a way to reach A19 without parents being aware and as a result no recourse was offered to A19 to learn how to keep safe and understand about abuse. This is a noteworthy omission in the early help that should have been offered to A19 and could have been achieved by a referral to the multi-agency Child Sexual Exploitation team. 5.8. The self-harming and sexual assault were not considered in relation to one another even when a few months later, A19 referenced self-harming on 2 occasions within days of one another. Upon receipt of the new self-harming concerns, school continued with its starting point response of verbal advice and communication with Mother. It may have been good practice at this point, now having both familial sexual abuse and threats to self-harm disclosed, to consider whether a school nurse and/or school counsellor could have offered any support but at no point in this review has any contact been evidenced between A19 and a school nurse and/or counsellor. However, it is necessary to note that these comments were made by A19 at the very end of a school term and in practice there would have been very little time and opportunity for staff to discuss and complete referrals to a school nurse and /or counsellor within these time constraints. School should be commended for the open-door policy offered to A19 and the continual communications with parents and it is recognised that when school’s concerns did increase at the end of the term, parents were asked to consider getting advice from their GP. This advice was acted upon by Mother and appears to only have been hindered by the lack of appointments available. There has been question as to whether or not school should have over ridden parents by contacting the GP or another service and whether this would have been done if A19’s family did not have a professional background. Whilst it is true that consideration needs to be given to how practitioners work with a professional family, there is nothing to suggest that Mother and Father were not acting appropriately and safeguarding A19. Professionals are aware that the ability to be empathetic and non-patronising with parents is fundamental to working effectively with families, but this needs to be balanced against evidence that the parental actions are ensuring that the children’s needs are met. There is verification of school’s intention to do this as Mother had agreed to update school re the outcome of a GP appointment after the school holidays. Sadly school had no further opportunity to discuss what action had been taken and consider whether a referral was necessary, as upon A19’s return to school, conversations were dominated by the message referring to further self-harm sent to an ex-member of staff and contact with parents was not possible until the school had been forewarned of A19’s intention to harm. 5.9. Whatever the outcome of the attempted GP appointment, prior to the school holidays commencing, school had no reason to override parents and refer A19 to the GP. Article 8 of the European Convention of Human Rights determines the right to respect for private and family life and as school was confident that A19 was being safeguarded, 15 interference into family life of this sort would not have been considered lawful, necessary and proportionate. It could have been construed as overstepping the mark and intervening unjustifiably into the family’s private life. The decision for A19 to see a GP was one that school could reasonably expect to be made by either or both parents and there were no factors surrounding either parents’ circumstances that would have caused school to worry about the validity of the decision made. 5.10. An additional barrier to no further referrals being made was A19’s dismissal of support. Support networks were discussed with A19 and contact details were provided by both school and CSC, but it is apparent throughout this review that A19 was consistent with the decision that further support was not needed. 5.11. Having considered the early help that was offered to A19, it is predicted that the support would not have looked very different in the event of school following the local referral policy. The difference is only that the school may have contacted HYM’s for advice as the pathway states that where a young person is expressing suicidal thoughts, the designated officer should contact Child and Adolescent Mental Health Services (now HYM’s) immediately. A19’s comments ‘self-harm or worse’ should have been construed as an expression of a suicidal thought. The effect of HYM’s having been consulted was discussed in the learning event and professionals were all in agreement that A19 would not have met the HYM’s threshold, although consultation of HYM’s can always be sought and other early help offers may subsequently be provided. It is worth noting that professionals anticipating what another service will likely conclude upon referral, could serve as a barrier to multi-agency discussions. 5.12. Research8 carried out by the GW4 partnership9 has found that ‘schools as a whole do very little work to prevent or raise awareness of self-harm’. It is therefore admirable that this school had already recognised the importance of Mental Health awareness prior to this tragic incident and started work on a new Mental Health Strategy. A place had already been secured on the ‘Trailblazer’ provision for mental health. Staff have now participated in the Mental Health Champions Senior Leadership programme and a group of students have had external training to become Mental Health Champions. It is hoped that student awareness will assist with peer support and create an environment more open to student discussions about how they feel. 5.13. The Borough’s early help offer now looks very different to how it did in January, as since the beginning of the year it has been developed and has moved towards a Neighbourhood model. This aims to improve multi-agency working and make it easier to share information when considering a child’s needs at an earlier stage. Of major significance is the Team Around the School (TAS) which is a meeting to which school can bring (with parental consent) any lower level concerns to allow interventions and actions to be agreed multi-agency. Summary of Learning: 8 clahrc-peninsula.nihr.ac.uk/research/self-harm-and-suicide-in-schools 9 GW4 is a collaboration between the University of Bath, the University of Bristol, Cardiff University & the University of Exeter. 16 • Further promotion of the local self-harm referral pathway is required to raise professionals’ awareness. • Early help for young people suffering self-harm and / or suicidal tendencies needs to be developed to promote multi-agency working. • Concerns for a young person should be escalated to allow agencies to consider other support services available. • A parent’s ability to safeguard should not override the need to educate a young person about how to keep safe. The Closure of the Police Investigation 5.14. School reported the allegation to the police. An officer attended the home address and spoke to A19 the same day. In the presence of parents A19 recounted the incident stating that during a function AR had stroked A19’s bottom under clothing and later squeezed A19’s bottom over clothing. Over the following weeks AR sent numerous inappropriate messages by social media and as a result the officer seized A19’s mobile telephone. The police subsequently submitted a crime for a sexual assault on a child under 16. Although officers were aware of the inappropriate messages, the Home Office Counting Rules10 state that where the victim and the perpetrator are the same in allegations reported at the same time, only the most serious offence is to be recorded. The sexual assault was the most serious crime of the two as determined by the length of the maximum penalty that can be legally imposed. 5.15. Prior to the strategy meeting 8 days later, an officer had spoken to Mother on the telephone on 2 occasions and it had been confirmed that A19 did not wish to support a police investigation. Mother said that A19 hadn’t ever wanted to progress the matter to the police and had been telling a family friend who worked at the school about the incident without realising that school would inform the police. She said that A19 hadn’t ever envisaged the police becoming involved. Mother also confirmed that she had spoken to AR and he had apologised and acknowledged that he had acted inappropriately. She was certain that he wouldn’t do anything like this again. The crime was subsequently closed with the rationale that without the support of A19 ‘there is little or no chance of a successful prosecution’. Mother attended the police station a few days later and collected A19’s mobile phone. It had not been sent off for any examination due to the family not supporting the allegation. 5.16. The strategy meeting minutes indicate that school discussed the amendments made to A19’s initial account at this meeting. It is listed as an action for social care to share the additional information from school with the police, but this was not completed as the crime had already been closed. Consideration could have been given at this time to reopen the investigation but without A19 providing evidence to the police in the form of a witness 10 The Home Office Counting Rules provide a national standard for the recording and counting of 'notifiable' offences recorded by police forces in England and Wales (known as 'recorded crime'). 17 statement or video recorded interview, there was still very little chance of a successful prosecution. 5.17. Also prior to the crime being closed, an action had been placed on the police log to arrest the suspect. This was not executed due to A19 not supporting the prosecution and police being confident that appropriate safeguarding measures had been finalised. It has been discussed that whilst the policy in relation to the investigation being victim focussed was followed and the case closed at the family’s request, consideration could have been made to go against the family wishes. In this event, AR would not have been considered for arrest without A19 providing a video interview or witness statement, but he could have been considered for a voluntary attendance interview under caution. This approach is legally permissible but is a strain on resources that are already under pressure. It must still be considered however that if resources had allowed this depth of investigation, AR may have made an admission that could have resulted in some form of sanction. In addition, the interview of the suspect may have provided further evidential phone data as AR had sent A19 inappropriate messages via social media following the incident. But this would have been dependent upon AR volunteering the surrender of his device. Without an arrest, a warrant from a Magistrate is required to provide legal power to seize the phone. This is a further process that would have proved problematic without A19’s support in the investigation. Subsequently, in the absence of ARs device being available for examination there has not been any consideration given to pursuing the crime ‘Engaging in Sexual Communication with a Child11’. Even though there were screenshots in circulation of the messages, it would be evidentially difficult to prove that these originated from AR’s device in order to secure a prosecution. Best practice in such investigations would be to seize and examine both the senders and the recipient’s mobile handsets but again this would have required A19’s and parents’ consent. 5.18. It is imperative to remember that any further investigations may or may not have, affected the outcome that the crime was finalised for no further action. Summary of Learning: • Responses to a young person disclosing sexual abuse may be more effective if a young person feels included in discussions regarding decisions and potential outcomes. • No further action regarding a criminal offence should not mean no further safeguarding action. • Responses to disclosures should include the consideration of all legal remedies. The use of the Child Sex Offender Disclosure Scheme (Sarah’s Law) 5.19. In the interest of safeguarding, CSC sought the details of all other known children that AR had contact with. This was good practice and within 2 days CSC attended the 11 On the 3rd April 2017 Section 67 of The Serious Crime Act 2015 inserted a new section 15A into the Sexual Offences Act 2003 and created an offence of ‘engaging in sexual communication with a child’. 18 relevant addresses and disclosed to the carers of the children that AR was subject to an ongoing police investigation as a sexual allegation had been made against him by a minor. 5.20. CSC also advised the carers to make an application for disclosure under Sarah’s Law (the Child Sex Offender Disclosure Scheme) if more information was required. The partner of AR made this application and the police made a further disclosure. This was unnecessary as CSC already has the authority to ‘share important information about any adults with whom that child has contact, which may impact the child’s safety or welfare12’. The police disclosure did not offer any further information. Summary of Learning: • Further training is required to assist Social Workers to exercise their right to disclose information confidently. The Closure of Children’s Social Care Involvement 5.21. The response to the allegation of sexual abuse by CSC was prompt. A worker attended the family in a joint visit with the police and ensured that the family had a safety plan in place. During the visit the worker obtained the details of any other children that AR had contact with a view to safeguarding others. 5.22. Concerns were raised by professionals in the subsequent C&F assessment that parents had not immediately reported the assault to the police upon it becoming known to them. Mother had become aware of AR’s behaviours 2 days prior to A19’s disclosure, when another child’s parent had sent her screenshots of conversations between her child and A19. CSC acknowledged the delay but following conversation with parents felt assured that it was due to initial shock. Mother’s first response had been to confront AR and safeguard A19 by stopping any further contact, but it is clear from discussions recorded with parents at this time that they initially struggled to come to terms with AR’s behaviours. AR was a significant person in the family who was described as always having had a good relationship with A19 and sibling and acting the fool with them. 5.23. At the end of November, the assessment concluded that because Mother and Father were safeguarding A19 and had declined support from CSC the threshold had not been met for services to be imposed upon the family. The case was to be closed to CSC and monitored by education. 5.24. It is questionable as to whether the assessment truly considered the impact that the allegation could have on a young person, in particular given that A19 had previously admitted to self-harming as a way of bringing feelings of relief and had made reference to feeling low. There is evidence that CSC had discussed support with A19 in the one to one meeting, but the evaluation appears to have lacked depth. At the time of this discussion, CSC were not aware whether A19 was intending to support a prosecution or not, but a 12 Paragraph 24 Working Together to Safeguard Children 2018 19 willingness or a reluctance to support a police investigation should not influence the efforts that must be made to understand the possible impacts of familial sexual abuse on a victim and the family environment. Familial abuse is complex and subsequently professional’s response requires distinct attention to positive welfare. The disclosure of the abuse by A19 was the beginning of a challenging process as the familial ties between A19 and AR brought unavoidable changes within the family environment. An understanding of the change and disruption that would follow the disclosure was vital in order to recognise the support that A19 undeniably would need. 5.25. The Making Noise Project13 is a study that was commissioned by the Children’s Commissioner for England and carried out in 2015/16 by staff from the International Centre: Researching Child Sexual Exploitation, Violence and Trafficking, in partnership with the NSPCC. It sought to elicit children and young people’s views and experiences of help-seeking and support after child sexual abuse in the family environment. The study highlights the importance of acknowledging that disclosure, and the consequences that follow, can represent new risks and challenges for children and young people, which must be actively considered and addressed. While a minority of interviewees described the point of disclosure as a ‘relief’, ‘unburdening’ or the beginning of things getting better, there were also many children and young people for whom this was not the case or who described ‘things getting worse before they got better’. Following disclosure, many children described significant levels of change and disruption to multiple aspects of their lives including family relationships, living circumstances, friendships, schooling and a familiar sentiment that ‘nothing was the same ever again’. 5.26. The assessment recognised that A19 did not wish to seek support from any external agencies and preferred to talk to staff at school if required. This is not unusual for a young person who following such a disclosure may be desperately seeking some ‘normality’. The assessment also recognised that parents were able to identify necessary actions to keep A19 safe from future incidents and A19 confirmed to CSC feeling safe at home. However, A19 also expressed a desire to speak about the abuse more freely at home. This would indicate that A19 recognised the discomfort the situation was causing and would strongly suggest that A19 was aware of the emotional impact the disclosure had on the family. This would have had a significant consequence on A19’s emotional well-being within the family environment. It was therefore necessary to involve direct support for A19 from the non-abusing family members and a further home visit to help parents to understand how to respond to A19 and reduce any feelings of responsibility towards the rest of the family, may have had a positive outcome. At the very least it would have given CSC the opportunity to assess parents understanding of the emotional support that A19 would require following the disclosure. Mother is of a professional background with a job that requires an understanding of safeguarding procedures, but her knowledge should not have been taken for granted in a situation that involved her own family. Given that AR was a significant figure throughout Mother’s life any inability to detach herself from the personal situation and consider it through professional eyes is understandable. 13 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/UniBed_MakingNoise-20_4_17-1.pdf 20 5.27. There may have been a number of reasons why parents felt unable to accept or ask for support with the situation, but it would be negligent to not give any thought to any disguised compliance. Especially when consideration is given to the fact that any family, but possibly more so a professional family, may not welcome CSC involvement. There is a professional need to question whether Mother could have said what she knew would need to heard to assess the risk level as low. Practitioners are aware of disguised compliance but compliance from another professional can be extremely credible. Therefore, there is a continual need to seek evidence, even from a professional parent, to corroborate what is being said. In addition, a disguised compliance is not always a conscious decision, and, in this case, the initial shock may have caused parents to play down emotions and left them unable to consider whether support would be required long term. This is a further reason why it could have proved useful if CSC had revisited the address prior to closing their involvement. It would have offered the opportunity to observe the family and reiterate what support was available and it would have also given A19 and the family more involvement in the final decision-making process. Summary of Learning: • There is a need for specific guidance on best practice in supporting a family following familial sexual abuse. • The impact of familial sexual abuse on a young person and within a family environment is often underestimated. • A young person’s disclosure of sexual abuse can significantly disrupt many aspects of their lives and may not instantly improve their situation. • Non-abusing family members may not understand the support an abused family member will need. • A young person who has been sexually abused may be unaware of how it will affect them long term and may initially refuse support but need it in the future. • A professional parent may not always be able to bring their professional knowledge into a personal experience. • A final family visit prior to closing a C&F assessment could provide further opportunity for the family. How the Voice of the Child was Heard. 5.28. A19’s voice was predominantly heard by school as A19 did not utilise support services and other agencies only became involved in times of crises. Research from previous Serious Case Reviews suggests that young people who take their own lives often decline services and the research for this review would suggest that A19 did not find it easy to seek help from professionals. A19 did communicate with staff at school but the pathway to communication had often been laid by another, with the first two concerns of self-harming behaviours being brought to staff attention by other pupils and the third being raised by Mother. In addition, A19 only discussed the sexual assault following parents being made aware by a third party. 21 5.29. The barriers to A19’s physical voice remain unknown but there is a suggestion that A19 was not always comfortable with school relaying conversations to parents. In 2017 when school reported an intention to speak to parents about a self-harm disclosure A19 showed distress by threatening to self-harm. In view of this it may have been beneficial for school to have an agreement of what information was to be shared with parents and what information, if any, could be kept confidential. This is not easy but in the absence of accepting other support A19 was left with no confidential network. A previous Serious Case Review14 has highlighted that ‘the emphasis on sharing information with parents must not override the rights of a child to privacy and the provision of a safe way to discuss their concerns with professionals.’ 5.30. The disclosure of the sexual assault was discussed in detail at the learning event and it was explained how A19 struggled to verbalise the account and preferred the use of gesticulations. This led to the account being open to interpretation and the school’s interpretation was later questioned by A19 and Mother, and subsequently changed. What is unclear is whether school’s interpretation was correct and changed due to possible feelings of embarrassment on A19’s behalf or a concern for Mother’s feelings, or whether the interpretation was incorrect. A19 was spoken to again by a police officer in the presence of parents and the account given was that AR had stroked A19 on the bottom. This is distinctly different from school’s interpretation which suggested digital penetration. The true account will always remain unknown as A19 presented as reluctant to discuss it again in any detail. It is known that some children feel inhibited to talk openly about experiences in the presence of parents and the only person who spoke to A19 alone was the CSC worker. A19 had never met the worker before and was described as not wishing to discuss the incident in any detail and not seeming to want to be there. 5.31. It is often very difficult to engage a child who hasn’t met you before about such a sensitive subject and A19’s response was not out of the ordinary. Disclosure of sexual abuse is uncomfortable and often a process not a one-off event. CSC recognised this by asking who A19 could speak to and A19 identified a teacher. School were unaware of this conversation but in any case, following the disclosure, had attempted to build a pathway for further discussions by monitoring A19 and asking how things were. A19 had not wanted to talk. There is no suggestion from any agency that following events A19 presented any differently and it is easy to consider that A19, possibly by virtue of having a supportive family, had a resilience to the incident. But it is also possible that A19 was left with an unmet need of full disclosure. This is particularly plausible when you consider that 2 months later, 2 teachers reported causes of concern regarding comments of self-harming. No link was made between the comments and a possible sign of A19 being ready to talk. It would have been beneficial at this time to consider the self-harm comments in conjunction with the sexual disclosure rather than as a separate concern. If this had been done further attempts to help A19 to engage with support services could have been made. Instead the concerns were relayed to Mother and focussed on the threats to self-harm rather than identifying and considering the underlying cause. 14 The voice of the child: learning lessons from serious case reviews April 2011, No. 100224 22 5.32. Following the disclosure of sexual abuse A19’s voice appears to be forgotten. A significant omission of A19’s voice is the lack of explanation for the first account noted by school being altered. In addition, the decision not to support a prosecution has been relayed to the police by Mother and there is no reference to this decision ever being discussed directly with A19 by any professional. A19’s views upon the matter and how it was dealt with are unknown. The focus of A19’s experience became overshadowed by the family’s capability to protect and the lived-in experience of A19 has been lost. A longer-term presence of a professional working with A19 to promote knowledge of sexual abuse and keeping safe could have helped A19 to overcome the experience. It is clear from the message sent to the ex-teacher in January, that the sexual abuse was still forefront in A19’s mind. 5.33. What is evident throughout the review is that A19 was able to talk to peers. It was to friends that A19 disclosed the self-harming, the sexual assault and an intent to end life. This is understandable as A19’s life was lived within the support of friends and outside the realm of professionals. Given the importance of this peer support, and the high level of disclosures that young people will offload to friends, it would be useful for professionals to find ways to utilise this. In addition, assistance must be given to young people to help them to respond and support one another whilst making it clear that they do not have any personal responsibility. This is important as A19 has demonstrated that it is reality that a child could be more likely to disclose self-harm and/or suicidal thoughts to another child than they would to a professional. 5.34. Although talking to friends was mainly positive for A19 the written notes imply that some peer groups were bringing additional difficulties and there may have been some experience of bullying or gossip. Bullying had been discussed at school with A19 but other than a one-off incident nothing had been disclosed. The school has an anti-bullying ambassador programme which includes an anti-bullying room being available in school for students to access for support when required. A19 utilised this room for 2 weeks prior to the sexual abuse disclosure but would not disclose what was wrong. The evening prior to the sexual disclosure A19 did disclose that some older boys had made upsetting comments but A19 had said that it could be discussed the following day. The following day the sexual disclosure took precedence and bullying was not raised again. 5.35. Towards the end of 2018, A19 expressed a want to ‘self-harm or worse’. The use of the word ‘worse’ was not explored with A19 despite research suggesting an association between self-harming behaviours and suicide15. The risk of suicide should have been discussed but there is no verification of any questions of any suicidal intent being posed to A19. Non mental-health professionals may be wary of direct questioning but there is no evidence to suggest that it will encourage a young person to pursue suicidal behaviour. In fact, it could have the opposite effect by signalling to a young person in distress that another person cares and is willing to talk about how they feel. 5.36. It is apparent from the review that A19 was not a child who found it easy to communicate with professionals and voice worries but was articulate and vocal enough to 15 https://www.nhs.uk/conditions/self-harm/ 23 engage superficially. This gave professionals a sense of hearing A19’s voice but in reality, there is little evidence of professionals being able to break the surface and fully understand what A19’s concerns were. There is a rationalisation of no referrals to other services in the context that A19 was not actually self-harming, yet the hospital noted evidence of previously healed cuts to both forearms and self-harm to both wrists. Had these marks been evident during school, staff would have been able to open a conversation with A19 with a suitable challenge for a support plan being required. 5.37. In summary there were clear barriers to A19 being heard by professionals. Firstly, there was a lack of physical evidence to corroborate what A19 plainly verbalised regarding feelings of self-harm. In the absence of notable marks A19’s comments could be construed as ‘talk’. Secondly in the presence of good behaviour and a supportive family there was no indication of the complexity of emotional problems A19 was facing. The thoughts of self-harm were clear but A19’s verbal responses to professionals concerns and general behaviour, over influenced the level of risk considered. Summary of Learning: • Professionals should be aware that embarrassment of a young person’s sexual abuse may prevent them from disclosing all the information. • Professionals need to be aware of the connection between self-harm and suicide. • A young adolescent person could be more likely to disclose to a friend than to a professional16. 6. Additional Analysis Coroner Experience 6.1. The pre inquest review hearing was attended by a principal general law solicitor from the Local Authority who takes the lead on inquest matters. Consideration has recently been given to identifying a lead specifically to attend child inquests and as a result a second solicitor was in attendance on this occasion to observe the process. The principle general law solicitor had not been updated of the response of the rapid review panel and it was by coincidence that the observer was able to respond to the Coroner’s queries and make telephone calls to clarify timescales etc. This unfortunately gave the impression of the representatives being unprepared but was not the case. 6.2. Further to the above, on 29 June 2018, local areas began their transition from Local Safeguarding Children Boards to the Local Safeguarding Children Partnership arrangements set out in Working Together to Safeguard Children 2018. This guidance set out the new process for Child Safeguarding Practice Reviews, replacing the previous process for 16https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/07/It_Takes_a_lot_to_build_trust_EXECUTIVE_SUMMARY.pdf 24 conducting Serious Case Reviews. The Coroner was unaware that this authority had made the transition and was unfamiliar with the new terminology. Summary of Learning: • It would be good practice to inform the Coroner of any procedural changes to the review process. Strategy Meetings 6.3. School made an appropriate referral to CSC and contacted the police the same day that A19 disclosed the sexual abuse, but it was 8 days before the strategy meeting convened. It would have been beneficial for a strategy meeting to take place much sooner as this delay between A19’s disclosure and the multi-agency meeting meant that all of the information was not shared between the agencies now working with the family, prior to the police closing their investigation. The meeting was attended by CSC, police and education. A health representative was not present, but it is noted on the minutes that the health information was requested. This appears to have remained outstanding as it is not included within the C&F assessment. In addition, as a result of health not being in attendance, health has no record of the abuse or the concerns of self-harm ever being shared with them. Although the strategy meeting did successfully share information between the attending agencies, it failed to consider a ‘strategy’ to keep A19 safe from further harm in the event of AR not heeding Mother’s warning to stop all contact. This was particularly important as the meeting had already discussed a concern that A19’s parents had not contacted the police themselves upon learning of the abuse. The strategy meeting would have been the ideal environment for the agencies to discuss whether any work could be provided direct to A19 regarding keeping safe and understanding abuse. 6.4. The distribution of minutes was discussed at the learning event as some professionals consider that minutes are not always circulated in a timely manner. This limits the ability of agencies to check that discussions have not been misconstrued and whether all actions have been recorded correctly. All agencies understand the importance of making their own notes and recording their own actions in emergency meetings such as a strategy meeting, but distribution of minutes ensures that each agency has a uniform record of decisions agreed by all. The Local Authorities safeguarding framework states that it is ‘the responsibility of the chair of the meeting to ensure that the decisions and agreed actions are fully recorded using an appropriate form’, and that ‘a copy should be made available immediately for all participants’. Summary of Learning: • Strategy meetings must convene in a timely manner and distribute minutes speedily. 25 7. Good Practice Identified Much good practice has been identified during this review by professionals at the learning event and by the Panel. Some has already been commented upon, but it is important to highlight the following as part of the review. 7.1. Following the incident, the Local Authority immediately offered school support from the Educational Psychologist team. The team provided invaluable guidance with regards to communicating information with staff, parents and pupils and they trained staff to support students. This support was offered in a timely manner and proved extremely helpful. This was excellent practice demonstrated at a very difficult time. 7.2. School informed other schools of individual ‘Causes of Concern’ as they became aware of them following the incident. This allowed other schools to support their students promptly. 8. Recommendations In order to promote the learning from this case, the review identified the following actions for the LSCP and its member agencies: 8.1. The early help pathway to be reviewed in consideration of the number of young people self-harming and for the LSCP to (i) effectively and continually promote its use as part of the regional procedure ‘Young People and Self-Harm’. (ii) An audit should take place 12 months after part (i) is completed to compare its usage prior to and since the recommendation was made; Proposed outcome: Knowledge and use of the self-harm referral pathway is enhanced across the authority and young people are referred when support is needed. 8.2. The Chair of the LSCP should ensure that Police are made aware of the findings of this practice review in order that any relevant areas for development can be identified regarding the force’s involvement with allegations of sexual abuse involving a young person suffering with their mental health. Specifically, how they communicate information to victims as to how the alleged perpetrator has been dealt with; Proposed outcome: The Police will be able to identify learning points from the investigation regarding A19 and the wider family and take appropriate action. This will ensure other similar enquiries are managed in a sensitive manner when a young person feels unable to proceed with a prosecution and victims will be better informed if there is no intention to speak with the alleged perpetrator. 8.3. The LSCP to audit the timeliness of strategy meetings and the distribution of their minutes to ensure that the local safeguarding framework is being adhered to. Proposed outcome: Strategy meetings will be effective, and attendees will have a uniform record of discussions and actions. 26 8.4. The LSCP to ensure that agencies have training available for professionals, to help them to understand when and how to share information regarding a person who is a risk to children. Professionals should be encouraged to seek legal advice when in doubt. Proposed outcome: Risks to children who have unsupervised contact with a suspect will be managed more effectively 8.5. The LSCP to review their processes in how and when they communicate the commission of a LCSPR to parents and their families. Proposed outcome: Parents and families will be informed of the review process in a timely manner. |
NC050377 | Non-accidental injuries to a five-month-old infant in April 2016, including a head injury and 28 fractures; toxicology findings suggest exposure to controlled drugs during his life. Child D, Jamie, was the youngest of seven siblings who lived in an overcrowded home with their mother and father. Shortly before Jamie's birth, his parents separated and mother started a new relationship. Previously, in January 2015, siblings were made subjects of child protection plans for neglect. There were questions about the mother's ability to sustain change and the youngest child, Jude, had an increasing number of bruises. In February 2016 all the children except Jude were stepped down to children in need. In April, following the fatal injury to Jamie, his siblings were taken into interim care. The mother and partner were found guilty of causing or allowing Jamie's death and were sentenced to 8 and 13 years respectively. Key lessons: the need to keep an open mind in neglectful families that injuries may not be as a result of neglect but may result from physical abuse or mishandling; the importance of engaging parents and other adults, especially new adults who join households; importance of focusing on the child's experience and life including their emotional experience; understanding implications for children missing health appointments as the term Did Not Attend puts the focus on the child. Recommendations include: to review multi-agency and single agency guidance and training on understanding and working with drug and alcohol use; to strengthen the voice of the child in safeguarding assessments.
| Title: Serious case review: Child D “Jamie”: died age 5 months. LSCB: Kent Safeguarding Children Board Author: Malcolm Ward Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Child D “Jamie” Died Age 5 months Independent Author: Malcolm Ward Agreed by the Kent Safeguarding Children Board, May 2018 Kent Safeguarding Children Board Sessions House Maidstone, Kent http://www.kscb.org.uk Kent Safeguarding Children Board 1 Contents Note: ‘Jamie’ is a pseudonym, the names of his siblings are also pseudonyms. These have been used to protect their identities. Page 1 Introduction 2 2 Executive Case Summary 2 3 Reason for the Review and its focus 4 4 Jamie’s Family - Genogram and Background 5 5 Timeline of key events and actions to support Jamie and his family 7 6 Practitioners’ and Managers’ Perspectives 14 7 Family Perspectives on the Services offered to them 16 8 Analysis and Evaluation 17 9 Key Lessons 28 10 Recommendations 29 Note about technical terms used in this Report. The Report is the outcome of a review of the formal multi-agency safeguarding services offered to Jamie and his family. Technical terms which either relate to the law, guidance or procedures are referred to throughout the report in bold lettering. For readers who wish to have more detail about these terms or procedures, they can be searched through the Kent & Medway Safeguarding Children Boards’ Online Procedures using the online search facility. http://www.proceduresonline.com/kentandmedway/ or http://trixresources.proceduresonline.com/nat_key/index.htm Use of Capital Letters: Initial capital letters are used for services when they were specific to this family; lower case when more general thus, ‘School’ – the schools attended by the children, but ‘school’ - more generally or school uniform, school attendance, etc. Kent Safeguarding Children Board 2 1. Introduction 1.1 The purpose of a Serious Case Review (SCR) is to seek to understand what happened and why it happened in the context of local agency and multi-agency safeguarding systems, rather than solely the actions of individuals relating to a single case. It is not an investigation into the death of or harm to a child, but may draw on information from parallel investigations into the cause of death or harm and who was responsible. The primary purpose of a SCR is to identify lessons and changes which may be required as a result of the analysis. The case under review is an example of local working arrangements at the time that the work was undertaken. 1.2 A SCR does not focus solely on the critical incident which has been the reason for the review; in this case Jamie’s death. It seeks to learn from the whole case and the way in which agencies have worked with the family and worked together to identify and mitigate any risks to children up to the critical incident. It is not an investigation of the incident, (that is the role of the Courts), but draws on a systemic and causal analysis to understand the dynamics of the helping relationships with the child and family and where changes may be needed in local systems to improve responses in future, similar cases. 1.3 Where possible, a review should be informed by the experiences, views and perspective of the family and practitioners, rather than just from agency records in the light of hindsight. Judgements and lessons should follow from what was known to practitioners at the time or which could or should have been known at the time; not using information which could not have been known. 1.4 A review should be proportionate, seek to understand, explain and evaluate what happened through a systems framework, but not to blame. In learning lessons from the single case, the Kent Safeguarding Children Board (KSCB) and its Partners can see how they apply more widely in the local system and whether any actions should be taken to improve the safeguarding processes. It may also note good practice, to learn from this more widely. 2. Executive Case Summary 2.1 Jamie was the youngest of eight siblings, seven of whom were under 11 and lived in the same, overcrowded home. Initially this was with Jamie’s Mother and Father, but in August 2015, shortly before Jamie was born, Mother and Father separated. Mother started a new relationship. 2.2 The case was of a large family of young children living in cramped conditions. Children sustained unexplained injuries, thought to be from lack of supervision or because of unaddressed safety risks. Injuries were not always attended to appropriately. Although there were appropriate questions whether such injuries may have resulted from physical abuse this was not substantiated; they were seen to probably arise from neglect of supervision or caused by the children themselves. Health or developmental needs, health appointments or immunisations were not attended to. The children were, at times, unkempt, dirty, inappropriately or poorly dressed and smelly. At times, they had untreated head-lice; these were denied by the parents, or claims were made that they had been attended to, when they had not been. 2.3 There were concerns about domestic abuse (initiated by both parents) and its emotional impact on the children; the domestic abuse or its impact were denied, despite evidence that the children were aware of it and upset by it. There were also suggestions of alcohol or drug use, including alleged dealing, these were also denied. There were suggestions that the children were coached to not share with professionals what was really happening at home. 2.4 Increasing concerns about the children’s welfare and ongoing neglect, with little change in the parenting, Kent Safeguarding Children Board 3 led the primary care and early intervention agencies working to support the family to refer the case to Specialist Children’s Services (SCS), in late 2014. 2.5 In January 2015, all five Siblings were made subjects of Child Protection Plans for Neglect. There was continued work from Specialist Children’s Services (SCS), Health Visiting, Schools, Nursery and Children’s Centre, with support from Housing and Community Services, Primary Care, and Hospitals. Paediatric Services and Police were also involved from time to time. 2.6 Mother’s engagement and cooperation with agencies was minimal. Father avoided attempts to involve him in work on improving parenting, although he did at times care for the children. The monitoring of the concerns noted the lack of progress and were stepped up to consider court action to safeguard the children in the spring of 2015, when Mother was pregnant with Jamie. 2.7 There were questions about Mother’s ability to sustain changes; at times she seemed to be compliant and at times she was thought to lie. 2.8 From September 2015, Mother’s Partner and his cousin, who became a Lodger, were resident in the home, although Mother initially denied this. During this period there was also disclosure by one of the children about possible inappropriate sexual behaviour between the children, although this was not followed up. 2.9 Following the commencement of relationship with the new Partner, agencies noted some improvements in the children’s school attendance and care, sufficient for SCS to cease the pre-court proceedings, in the autumn. However, the Partner was not assessed as a carer/parent, although he was frequently involved in the children’s care and at times, had sole care of some of them. The Lodger’s full history was not fully explored. 2.10 Following claims that their home was too cramped and overcrowded, the family moved home in November 2015, where the Lodger occupied one of the bedrooms intended to increase space for the children. The Review Child Protection Conference also noted some improvements but decided not to remove the children’s names from Child Protection Plans until there was more evidence that improvements were being sustained. Jamie was born at the end of the month. 2.11 In December, it was noted that Jude, (a toddler), had an increasing number of bruises and there were still questions about the adequacy of the supervision of the children. Apart from the oldest child, the children moved to a new School in January. 2.12 In February 2016, at a Review Child Protection Conference it was agreed that all the children, except Jude, should cease to be subject of Child Protection Plans and should be stepped-down to Children in Need, based on perceived improvements in the children’s care. Jude was maintained on a Child Protection Plan because of continued concern about the unexplained minor injuries. 2.13 In the days following the Conference, Police were called to the house because of a disturbance and assessed that all three adults in the house were drunk and disorderly, and there was use of cannabis. In April, the serious, non-accidental and fatal injury to Jamie occurred and his older Siblings were taken by court order into interim care. The post-mortem revealed Jamie had a head injury and 28 fractures, within 19 different bones, assessed to have been sustained in at least five different events over a ten-week period up to his death. The cause of death was ascertained to be as a result of a serious head injury. The majority of injuries were assessed by expert pathologists and a specialist paediatrician to have occurred in the few days prior to the fatal injury or at the same time. There were a number of fractures to his ribs and legs which were older. Hair toxicology showed contamination of Jamie’s system by controlled drugs, not just from external contamination. Findings suggest exposure to amphetamine and occasional Kent Safeguarding Children Board 4 exposure to cocaine throughout the four months of Jamie’s life up to the critical incident. 2.14 In July 2017, Mother and her partner were found guilty of causing or allowing Jamie’s death and causing or allowing serious physical injury to him. In November 2017 the couple were sentenced to 8 and 13 years respectively. I think it important that this should be clear from the outset. 3. Reason for the review and its focus 3.1 Jamie died in late April 2016. In mid-April, he was taken from home by ambulance to the local hospital in cardiac arrest. He was found to have an acute subdural bleed and bruising to his head and abdomen. He was transferred to a London Hospital for intensive care; his prognosis was very poor. The significant injuries were assessed to be non-accidental. It was agreed by late April that life-support should be withdrawn. 3.2 The post-mortem revealed that Jamie had a head injury and 28 fractures within 19 different bones. These were assessed to have been sustained in at least five different events over a ten-week period up to his death. The cause of death was ascertained to be as a result of a serious head injury. The majority of injuries were assessed by expert pathologists and a specialist paediatrician to have occurred in the few days prior to the fatal injury, or at the same time. There were a number of fractures to his ribs and legs which were older. Hair toxicology showed contamination of Jamie’s system by controlled drugs, not just from external contamination. Findings suggest exposure to amphetamine and occasional exposure to cocaine throughout the four months of Jamie’s life up to the critical incident. 3.3 Jamie’s siblings had been made subjects of Child Protection Plans1 from January 2015; Jamie was subject of a Child Protection Plan from before his birth. Jamie and five of his siblings ceased to be subject to child protection plans in February 2016 and were made Children in Need2. One older sibling, Jude, remained on a child protection plan because of concerns about frequent unexplained bruising. Parallel Proceedings 3.4 The Police investigated Jamie’s death. As a result, both Jamie’s Mother and her Partner were convicted of causing or allowing the death of a child and possession of a class B drug (amphetamine). They were sentenced to eight years and thirteen and a half years imprisonment, respectively. Jamie’s siblings were made the subject of Care Proceedings under the Children Act 1989. Focus of this Review: Chronic neglect and chaotic parenting versus risk of serious physical injury 3.5 It will be noted that this Review’s larger focus is on working with neglectful and chaotic parents and carers, even though the outcome was Jamie’s death from non-accidental injury. The analysis of SCRs has shown that neglect has been an important background factor in many cases where children have later died or been injured as a result of physical assault. Jamie’s injuries 3.6 As noted above, the post-mortem showed, in hindsight, that Jamie suffered a number of non-accidental injuries in his short life. Forensic evidence for the criminal trial showed that the majority of these were either at the same time as the critical head injury, or in the few preceding days. No practitioners saw Jamie in those few days. A few of the fractures to his ribs, spine and legs may have been caused on three or four occasions from up to 9 weeks previously. 1 Descriptions of technical terms can be found at http://trixresources.proceduresonline.com/nat_key/index.htm 2 Descriptions of technical terms can be found at http://trixresources.proceduresonline.com/nat_key/index.htm Kent Safeguarding Children Board 5 3.6.1 In response to the question, “could these have been identified and acted upon?” research and clinical experience, and expert advice to the court, shows that in babies and non-verbal infants and toddlers, such injuries may not be readily identified even by those who are medically trained. Unless the incident or assault has been witnessed or has been alleged, it is not clinically easy to begin to identify hidden fractures. The child may cry briefly at the time of the fracture and later be fractious for a while, but unless it is known or suspected that the possible cause is a fracture, a baby’s restlessness can be put down to other childhood issues such as colic, teething or an infection. Practitioners who saw Jamie in the nine weeks prior to his death noted that he was developing well, saw no such symptoms and had no concern about him physically, nor that he was in any pain or distress. This is common in such cases where injuries which could not have been seen by simple observation or clinical examination, later come to light through radiological examination. As there were no concerns for Jamie’s development or that he was being physically harmed, a medical examination would not have been necessary or warranted. 4 Jamie’s Family and Household (at the point of his death in April 2016) Mother 31 years Mother’s Partner 24 years Joined the household in August 2015 (although it was disputed as to whether he was resident there or visiting daily) Siblings Mikey Boy 10 years Rosie Girl 9 years Marty Girl 8 years Bobby Girl 5 years Holly Girl 4 years Jude Boy 2 years Jamie Boy 5 months at death (4 months at fatal injury) Main Subject of this review Lodger Female 36 years Relative of Mother’s Partner Father 33 years Father to all the children, except Mikey; but had co-parented Mikey for several years and they had a strong emotional bond. Lived in the household until summer 2015. An older half-sibling, an adolescent at the time of the work in this review, had been taken into care as an infant when the Mother was herself an adolescent. This half-sibling is not included in this Review. All the family and household are described as White British. It is understood that they did not practice a faith. Kent Safeguarding Children Board 6 Genogram Background 4.1 Mother’s childhood is reported (by her) to have included domestic abuse and parental alcohol abuse. As an adolescent, she was reported to have experienced sexual exploitation and drug misuse (although she denies the latter). 4.2 As an adult, Mother experienced domestic violence from partners, including Jamie’s Father and was also herself, on occasions, a perpetrator. Mother’s first child did not grow up in this household. Mother came to the attention of Police on several occasions for theft, drugs (dependency), violence and public disorder. 4.3 There appears to be no complete history of the Birth Father, his background or upbringing in the reports or assessments. He was described as unemployed and of a traveller background. 4.4 Mother’s Partner had a prior conviction for common assault as part of an affray in 2011. In the period of this Review, he became known to the police for being drunk and disorderly. 4.5 From 2005, the family had periods of being open to SCS under Child in Need and Child Protection Plan, with support provided to the family in respect of home conditions, parenting skills, routines, domestic abuse, drug and alcohol misuse, budgeting and benefit issues, and financial support for paying bills. The family were stepped down or closed when it was felt that good progress was being made. 4.6 There were concerns expressed and referred to SCS by the School around the children’s development and appearance, (unkempt, unclean, head lice infestations). The School put in support, including a Play and Learning Scheme and Speech and Language Therapy. 4.7 A number of referrals to SCS were made by the Police relating to poor home conditions, the state of the children, suspected drug use by the parents and continued domestic abuse. 4.8 Child and Family Assessments undertaken by SCS showed neglect, parental failure to follow up immunisations, and failure to follow up developmental checks and specialist health assessments; the home was overcrowded and filthy and the children were dirty. 4.9 At the end of 2013, the children were stepped down from a Child in Need Plan to a multi-agency Team Around the Child service, led by the Kent Troubled Families Service. Concerns at that time were poor school attendance, cramped housing (a two-bedroom house for two adults and 5 children), anti-social Mother Father (To August 2015) Mother’s Partner (From August 2015) Rosie Girl 9 years Marty Girl 8 years Holly Girl 4 years Mikey Boy 10 years Jude Boy 2 years Jamie Boy 5 months BobbyGirl 5 years Kent Safeguarding Children Board 7 behaviour and not keeping medical appointments for the children. There were ongoing concerns of neglect and injuries to the children. 4.10 In February 2014, following concerns being expressed by the School, SCS gave advice, but did not re-open the case; saying that a re-referral could be made, if necessary. The School was supporting the older children to compensate for the poor parenting. 4.11 By March 2014, school attendance and nursery attendance had improved, and work was being done with Mother to advise her on managing the children at home. There were concerns about dental hygiene of the older children, but the neglect was not assessed by SCS as serious enough to warrant calling a Child Protection Conference. 4.12 SCS became involved again in May 2014, after a further incident of domestic violence. A further Child and Family Assessment was undertaken and a written agreement was drawn up with the Parents that the Father would not drink in front of the children, the parents would not fight or argue in front of the children and the children were to be appropriately dressed and clean for school. The case was closed to SCS and was ‘stepped-down’ back to Team Around the Child, despite a further domestic abuse incident. 4.13 In October 2014, a member of the public expressed concern to the Police about the home, the children and parenting. The Police assessed that the state of the home did not warrant taking immediate action to protect the children, by removing them or making a referral to SCS. 4.14 The School and Troubled Families Project were increasingly worried because of the lack of progress, domestic violence, concerns about alcohol use, the state of the children, overcrowding in the small home, (including a dog), and missed medical appointments. These problems persisted despite extensive support from agencies. The family was referred to SCS for another further Child and Family Assessment. Concerns continued while the assessment was being done and included injuries and health needs not being attended to. 4.15 A multi-agency strategy meeting held in December 2014 and another Child and Family Assessment showed: injuries not being properly addressed, poor home conditions, chronic head-lice infestations, unmonitored health and safety hazards, over-crowding, missed medical appointments, a chaotic life-style, denial by parents of the concerns, lack of stimulation of the children by the parents, and concerns that the children were poorly dressed and often hungry. There were 14 reports of domestic incidents to the Police from 2007 to October 2014, some witnessed by the children, some allegedly involving alcohol. At times, the home was damaged. When there had been grounds for a possible prosecution of Father, Mother had not supported this. Father appeared to have left the home or been excluded on several occasions, but in 2014, Father was resident in the home. 4.16 This resulted in the convening of a multi-agency Child Protection Conference, in early January 2015. This detailed review of the multi-agency work starts at this point, prior to Jamie’s conception and birth. 5 Timeline of key events and actions to support Jamie and his family: January 2015 – April 2016 5.1 The SCR Panel was provided with detailed chronologies by the agencies which worked with Jamie and his family; these chronologies showed significant contacts over the period under review. 5.2 The SCR Panel has summarised and analysed these in the timeline below, setting out key phases of family life and agency and multi-agency involvement. January – June 2015 5.3 The Child Protection Conference was held. The following was highlighted: cramped and dirty conditions, Kent Safeguarding Children Board 8 with safety issues in the home, there was evidence of neglect, poor hygiene, anti-social behaviour and missed health appointments for the children, whose immunisations were not up to date. There was concern that the Parents lacked capacity to change and that, over time, there had been insufficient progress. Parents were reluctant to work with professionals to improve the parenting. The Parents did not see or accept the concerns. Father often avoided workers when they visited, unfortunately, he was not then fully assessed as a parent. A history of alleged drug misuse and domestic abuse was noted. Mother denied that there was any current drug use. All six siblings were made subjects of Child Protection Plans for Neglect. The contingency plan was: “that if there was insufficient improvement, SCS would call a multi-agency strategy meeting or consider Care Proceedings.” 5.4 In this period, the Police continued to be called to incidents of domestic abuse, with both Mother and father being victims as well as perpetrators. Although the Police recognised the poor conditions of the home, (poor bedding, children sleeping in school uniform) and the distress shown by the children, no further action was taken. When challenged, both Parents continued to deny the domestic abuse, saying that they only argued when the children were asleep. At one visit when the Social Worker challenged mother about the domestic abuse, the worker was asked to leave. 5.5 The non-attendance and cancellation of appointments was a recurring theme, with Mother also not attending the Domestic Abuse programme that she had been referred in to. 5.6 When challenged, Mother continued to deny neglect and the impact of the domestic abuse. At the first Review Child Protection Conference, she claimed that Police and School had lied and that the Social Worker’s report was wrong. She did not accept the risks described. The Group questioned about whether Mother was being honest with workers. A third-party allegation was made that Mother had admitted to drug use and dealing, but she denied this, saying that it was ‘malicious’. The Social Worker noted that there appeared to be little capacity and willingness for change. 5.7 Mother was advised that the children’s care was not yet good enough and that, if there was no improvement, a Public Law Outline (PLO)3 process would be considered at the next Core Group Meeting (to initiate possible court action to safeguard the children). Managers within SCS reviewed the case at the request of the Social Worker who was concerned about lack of progress and agreed that there should be a Legal Planning Meeting4 to consider court action. 5.8 The School continued to report concerns about the cleanliness of the children and untreated head lice. All the children were described as smelling. The children were seen as guarded and possibly advised not to talk about home. However, the children were worried about the Parents arguing. 5.9 Issues were identified about the home. It was overcrowded, and conditions were noted to be poor, with additional concern about safety hazards in the garden. The children mentioned an ‘Auntie’ who was staying in the house on the sofa. SCS had not been told about this by the Parents, for appropriate checks to be done. This person later became a Lodger in the home. 5.10 There were several reports of the children having injuries. These concerns, together with those about the older children’s appearance and hygiene were not accepted by the parents. Marty was noted to have a bruise on her arm; professionals questioned if it was a ‘grab mark’. Mother’s explanation of ‘a fall’ was doubted. Marty was seen by the GP who asked for the child to be taken to hospital, concerned about the possibility of Non-Accidental Injury. Father was reluctant to take the child to hospital. Following a welfare 3 The Public Law Outline is statutory guidance following the Children Act 1989 which sets out the steps to be taken when legal action is being considered to protect children from significant harm through the Family Proceedings Court by seeking a care order or supervision order. https://www.justice.gov.uk/courts/procedure-rules/family/practice_directions/pd_part_12a 4 A Legal Planning Meeting is a meeting internal to Children’s Social Care to obtain legal advice on a case where it is considered that the threshold for legal action may be met and whether the Public Law Outline should be initiated or what other steps should be taken. Kent Safeguarding Children Board 9 check by the Police that evening, and after discussion with the out of hours’ Social Worker, Father took Marty to the Emergency Department because of the injuries to her arm and leg. Marty and Father stayed overnight in the hospital. Non-Accidental Injury could not be confirmed as the cause. The following morning it was agreed that SCS would lead a ‘single-agency’ Section 47 child protection enquiry and that the Police would take no further action at that point. SCS agreed to seek Legal Advice on safeguarding the children. The following week, Mother was angry with the School for reporting the bruise on Marty. Several children were kept off school for several days with ‘medical issues’ or ‘fear of attending school’. 5.11 The single agency Section 47 enquiry was completed. As a result, Parenting Assessments were to be done on both Parents, singly and jointly, unannounced and planned home visits were to continue and Parents were to work on the poor home environment, hygiene and the children’s self-care. Direct work was to be started with the children to help them understand their daily life experience better. June to October 2015 5.12 By mid-June, it was known that Mother was pregnant with Jamie; the due-date was not known. From mid-July, Mother started attending ante-natal clinics at the Children’s Centre and continued to the end of October. Mother provided some misleading information and was seen as evasive. The Social Worker liaised with the Midwifery Service to advise them of the safeguarding concerns. The Social Worker also referred Mother and Father to a service for alcohol abuse. 5.13 SCS met with Mother and her solicitor in the Pre-Proceedings Meeting as part of the PLO as a precursor to possible court proceedings to protect the children. Father (and his legal advisor) did not attend. Mother denied using drugs or alcohol, claiming that the incident in March was a ‘one-off’. A Written Agreement was signed with the Mother on the actions to be taken. Father was not a party to this agreement. In carrying out the agreed work with Mother, the Social Work Assistant noted that Mother’s involvement was only superficial and that she avoided key areas of the Child Protection Plan and did not accept the need for change; Mother saw the problems as only a housing issue. 5.14 A Family Group Conference (FGC)5 was held to seek assistance from the wider family because of the concerns attended by fewer family members than were expected. They agreed practical support with child care, baby sitting and housework, when they could, about once a week. It was recognised that the family did provide support, but that this was not sustained. 5.15 The previous concerns on parental engagement continued, as did the Parent’s response. The Health Visitor and Children’s Centre Worker visited the home; despite the visit being arranged in advance, they were not expected. They were not able to see all the children. On another occasion, when following up on a report of Marty having a bruise, the Parents avoided the Social Work Assistant and Social Worker by cancelling appointments and going out quickly when the Social Worker arrived. Father also avoided a planned Parenting Assessment session. 5.16 There were numerous reports and concerns about unexplained injuries to the children and the Parent’s response in addressing these medical concerns. Mikey was off school, unwell with a persistent illness, but was noted to have gone fishing with his Father, Marty had a cut on the elbow, which was not attended to medically by the Parents. On a home visit, the Social Worker found the children unkempt and parts of the home were dirty. 5.17 A Strategy Discussion was held at the SCS District local office attended by the Social Worker, Team Manager and Police. The decision was to convene an Initial Child Protection Conference in respect of the 5 In Kent. a family group conference is a process led by family members to plan and make decisions for a child who is at risk of coming in to care. Children and young people are normally involved in their own family group conference, although sometimes with support from an advocate. It is a voluntary process and families cannot be forced to have a family group conference.” Kent Safeguarding Children Board 10 unborn baby. 5.18 At the beginning of September, Mother advised the Health Visitor that the Father had ‘left home’ and that she had started a new relationship with her Partner. Father informed SCS that Mother ‘threw him out’ and that he was worried about the Mother’s Partner, (cousin to the Lodger) having contact with his children. 5.19 Mother attended a Parenting Assessment session, leaving the children in the care of her Partner. The Social Worker stopped the session and went to the home to meet Mother’s Partner. Mother was seen to have lied about her Partner living in the house, but the children said he was living there and that he had been there for a week. Mother’s Partner agreed to police checks and not to be alone with the children. The Social Worker followed this up with an unannounced home visit and found the home conditions to be good, including the garden, which had been a worry before. Mother was showing signs of wishing to change. 5.20 The Child Protection Review Conference was held for the older siblings with a parallel Pre-birth Child Protection Conference for Jamie. The older siblings were to remain subject to Child Protection Plans at risk of neglect and Jamie was to be made the subject of a Child Protection Plan from birth. Concerns continued to be poor basic care and Mother’s inability to sustain changes. Some improvements to the home were noted, but it was too soon to confirm that these would be sustained. There was also concern about the rapid change in the Parental relationship. Because of this, it had not been possible to complete the Parenting Assessment. Due to a change in the parents' circumstances, the Social Worker was to liaise with the Legal Team for a new deadline to complete the Parenting Assessment. The Pre-Proceedings Meeting6 took place in the second week of October. No consideration was given to including Mother’s Partner in the Assessment. 5.21 At School, Bobby mentioned possible sexualised behaviour relating to one of her siblings, at home. It was Mother’s claim that it was a dream or the dog. This was not followed up and there was no Strategy Meeting/Discussion to consider how to respond to this possible disclosure. A week later, the Mother said that ‘the dog had licked Bobby’s vagina’ and this was accepted. Bobby was later seen by the GP and diagnosed with a urinary tract infection, vaginal soreness and a discharge. 5.22 A Core Group was held at the beginning of October. Positive progress was noted with Mother; Mother’s Partner had also attended one Parenting course session, (although Mother had dropped out of the course after this). Holly was reported to be scratching her vagina; sexual abuse was not considered, and as before, Mother’s explanation of the dog licking Bobby’s vagina appears to have been accepted. Mother’s Partner was seen as a positive influence. There were no concerns about unborn Jamie; the plan was for the baby to go home after birth. 5.23 A follow-up Pre-Proceedings Planning Meeting was held as part of the PLO. Mother and her solicitor attended; the Father did not. Following better engagement by Mother and reported improvements in the basic care of the children, SCS decided to end the Pre-Proceedings, but it was agreed that more work was to be done on parenting and work was to be done with the children on safe touching. Mother’s Partner’s presence was noted, but it was said that he was not staying at night, in the week. Family members were no longer offering so much help, but a friend was assisting. The friend later became the Lodger in the house. 6 The Pre-Proceedings Meeting is part of the Public Law Outline process. It is a formal meeting between the SCS the family and their respective legal advisors to set out the concerns about possible significant harm which may result in legal proceedings if not addressed, and it agrees the actions to be taken, support to be given and how progress will be reviewed. See: https://www.justice.gov.uk/courts/procedure-rules/family/practice_directions/pd_part_12a Kent Safeguarding Children Board 11 October to November 2015 5.24 Mother reported that Father was being abusive to her; this was impacting on his contacts with the children. Father met with the Social Worker to discuss contact and he signed a Written Agreement which addressed these issues. Father said the children cried when he returned them after contact and did not want him to leave. Mother stated that since the written agreement was signed, contact had been okay and there had been no further problems. 5.25 Mother was offered a move to a larger property locally. 5.26 In late October, direct work was done with some of the older children on good and bad touching. (A few days later, Jude was noted to be kissing inappropriately). 5.27 During home visits, it was noted that the home conditions were said to have improved. It was noted that the Lodger, had moved in and that Police checks would be required on her. It was noted to be a concern that Mother had introduced another adult to the over-crowded home without agreement. 5.28 In the second week of November, the family moved to a larger home. The Lodger took up a room meant to ease the overcrowding for the children. She also brought two additional dogs, meaning that there were then three dogs in the house. The Housing Provider Officer later expressed their concern that the Lodger was resident as she had been excluded from another property because of domestic violence against her own partner. It was thought that Mother’s Partner was now permanently resident, but Mother denied this. 5.29 The children were seen at School, as Mother would not let the Social Worker visit at home. The children reported that things were fine at home, but there was a suspicion that they were being coached in what to say. 5.30 The Social Work Assistant visited the home and found Mother’s Partner alone with Jude who had bruising; the explanation given was that Jude hurts his head banging when he has tantrums. 5.31 The Review Child Protection Conference was held in the last week of November. Improvements were noted, but it was decided by agencies present, that the children should remain subject to Child Protection Plans for a further three months to ensure that changes noted were sustained. School was not represented in this meeting, but provided a positive report noting improvements in the children’s appearance and attendance at school. Mother was still attending ante-natal care. The presence of the Lodger and her history of perpetrating domestic violence were noted; the presence of three dogs in the overcrowded home were a worry. It was thought that the move of home, change of school and the birth of a new baby in a few days may present challenges to the good progress noted. There was no discussion about Bobby’s disclosure of possible sexualised behaviour by one of the other children and Mother’s claim that it was a dream or the dog. Also, there was no discussion of the information that Jude sometimes hurts his head when he banged it having tantrums. 5.32 Three days later Jamie was born. December 2015 – February 2016 5.33 In early December, background information was received from the Police about the Lodger, including information about domestic abuse and drug usage, however, she was not assessed as a risk to the children. 5.34 The Social Worker visited the home. A strong smell, suspected to be cannabis, was noted outside the house. Mother denied that the Lodger used cannabis in the home. She was advised that the Lodger should not be using one of the children’s bedrooms. The house was clean and tidy, and the children were seen to be clean and appropriately dressed, but there were more bruises to Jude; Mother was advised to supervise Jude more closely. Kent Safeguarding Children Board 12 5.35 A few days later, Mother’s Partner was seen at the house with Jamie and Jude. Jude had fresh cuts to his face. It was alleged that the cuts were caused by the other children and Mother’s Partner was advised of the need for better supervision. 5.36 The Core Group met in the week before Christmas. Mother did not attend. The continued bruising to Jude was noted and thought to be increasing; it was seen as Jude not being properly supervised. It was also noted that there were complaints about the dogs and that the Lodger could be very aggressive. When these matters were put to Mother, she denied them. 5.37 The Social Worker and her Supervisor met to review the case. It was thought that the improvements were probably due to Mother’s friend’s presence. It was questioned whether Mother could sustain the improvements. The concerns about the children’s appearance and poor supervision were seen to be less serious. Mother had co-operated with what was required. It was understood that the Lodger was due to move out soon. 5.38 The Health Visitor visited the home; Jamie was putting on weight, but Mother was concerned about him vomiting and was advised to take him to the GP, however, he was not yet registered with the GP. Jude was seen with a scratch to his forehead. Holly’s speech was not clear. The Lodger was to stay in the house for a further month as the Order against her was still in place. The Health Visitor re-enforced the concern about this to Mother. The house was not yet properly furnished as there were financial issues. 5.39 In the first week of January, four of the children started at a new School. Mikey remained at his old School. 5.40 The School noticed an increase in the number of injuries sustained by the children. Marty had bruising to her leg and said that she had ‘fallen over’ outside, her Mother confirmed this. This was followed by the School noticing a bruise and lump to Marty’s head, said to have been caused when the Lodger dropped her from a piggy back. It was also thought that Marty was sleeping in her clothes at night as she was cold. Two days later, Rosie brought herself to School and her Mother was unaware. The School also reported that Bobby was filthy and crawling with headlice. Mother claimed that it was difficult to care for so many children and the baby. 5.41 The Social Worker visited the home. The children were said to be happy at school and at home. Bobby had head lice, which Mother agreed to treat. Mother was challenged about not seeming to play/relate with Jamie, but she maintained that she did. Mother appeared to be sustaining changes in the household. The Lodger and Mother’s Partner were at home, but were not part of the session. The same day, the Mother declined to take part in a session on domestic abuse with the Social Work Assistant on the grounds of being unwell. 5.42 The following day, Housing staff expressed concern about the state of the garden and rubbish. Bruises were seen on Jude and reported to the Social Worker who thought that they resulted from poor supervision. Housing sent a breach of tenancy letter the following week because of the state of the garden. 5.43 In the last week of January, the Core Group met. It was agreed that Mother should take Jamie to the GP for a development review and immunisations. Jude was to be registered at Nursery. Jude’s bruising was discussed. It was noted that he was clumsy, but there was no detailed discussion about accumulation of bruising. The Lodger was to move out of the children’s bedroom. A friend, who had not been police-checked, was said to be taking Holly to School. Mikey was grubby and not appropriately dressed, but was thought to be better than previously. Professionals thought there had been a change in the children’s behaviour over the last week; they appeared more clingy; Mother said that she had not seen such changes and that there was nothing wrong at home. 5.44 At the end of January, there was an anti-social behaviour report relating to the home, four dogs and abusive behaviour by the Lodger. 5.45 At the beginning of February, the Health Visitor visited and noted improvements in the home. Jamie Kent Safeguarding Children Board 13 appeared to be developing and was alert and responsive. Jude had a cut on his forehead and a graze to his chin; Mother’s Partner said that he only had injuries to his head. Mother said that she had spoken to the GP about Jude falling over often and had wanted a referral to a paediatrician. 5.46 On his first day at Nursery, staff noticed bruising to Jude’s face and body and suspected non-accidental injury. The Lodger picked Jude up from the nursery in her pyjamas. The Social Worker discussed the injuries with the Lodger and later with the Mother by phone. Mother maintained that the injuries were caused by clumsiness and falling and that she had asked the Health Visitor to refer Jude to a Paediatrician, (which was not the case). Mother was defensive and said that no-one helped her with seven children. 5.47 The following day, the scheduled Review Child Protection Conference was held. All the children, except Jude were removed from Child Protection Plans and ‘stepped-down’ to Children in Need. A Strategy Meeting was to be held for Jude, who was to be seen by a Paediatrician urgently. The Lodger was to be out of the property by 1 March. There were disagreements between the professionals about whether all the children’s names should be removed from Child Protection Plans. Overall, the view was that there had been improvements, however, the Independent Child Protection Conference Chair Person used their authority to retain Jude on a Child Protection Plan. The Contingency Plan noted that if the current progress was not maintained or there were any new incidents of significant harm to the children the local authority should seek legal advice. 5.48 The following day, Jude was assessed by a Paediatrician. Several bruises and healing grazes were noted. The Doctor said there was no evidence of Non-Accidental Injury, apart from bruising around the face, but there was a clear history from Mother that he bumped into a door a few days previously. Jude was noted to be very active. The Social Worker attended the examination and gave the Paediatrician the relevant history. February – April 2016 5.49 In the third week of February, Mother went to a neighbour in the early hours, four of the children were with her, she was shouting that Mother’s Partner was in the neighbour’s house. Mother had been drinking and kicked her Partner on his return. 5.50 Two days later, the Social Worker visited, unaware of this incident when Mother had been noted drunk with the children in the early hours. The home was satisfactory. The children were fine, but Jamie was not being supervised properly. 5.51 That evening, Police were called to the house at 10pm. Mother’s Partner was drunk and disorderly. Mother and Mother’s Partner were shouting at each other and fighting. The children witnessed the fighting and were unkempt and crying. Mother’s Partner was asked to leave by the Police. The Lodger was also drunk and agreed to move out. There were whisky bottles and evidence of cannabis having been smoked. One of the children later told the School that the children had been told not to talk about the domestic abuse, but reported that the Lodger had tried to strangle the Mother. When questioned, later by the Social Worker, the Mother denied that the incident happened in the way that the Police had described it. 5.52 A few days later, the Social Work Assistant visited and found the home conditions to be good, new beds had been provided for the children, the Lodger had moved out and Mother’s Partner was back in the house. 5.53 A Core Group for Jude, was held in the second week of March. Improvements were noted in all the children, Mother was engaging in the Domestic Violence Programme. There had been no further arguments between adults in the home. 5.54 The Social Worker met with Mother’s Partner who claimed that the drunken incident was a one-off and that he did not drink around the children; although one of the children said that this was not so. Mother’s Partner was observed to have a good relationship with the children. No new bruising to Jude was seen. Kent Safeguarding Children Board 14 5.55 Mother cancelled a visit by the Social Work Assistant in which it had been planned to do further work on domestic abuse, this was the second cancelled visit; she was advised of the consequences of further cancelling. 5.56 The Social Work Assistant visited in the third week of March and noted appropriate care and stimulation of Jamie; lack of stimulation had previously been a concern. Work was done on domestic abuse and Mother was said to be shocked about how sexual abuse and emotional control were features of domestic violence. 5.57 A week later, in a further session with the Social Work Assistant, Mother continued to show greater insight into the impact of domestic violence. On that visit, Jamie was described as babbling to himself and happy. 5.58 At the end of March, Jude was noted, at Nursery, to have bruising to his forehead, right eye and a cut behind his ear. Mother and Mother’s Partner said that this was because of Jude falling to the floor in a tantrum. An email was sent to the Social Worker, who was on leave. This was not picked up until her return the following week. 5.59 On her return, the Social Worker saw the fading injuries to Jude and discussed them with a Manager. Mother had said the cause was a tantrum, the cause of the injury behind the ear was unknown, but possibly caused by climbing on bunk bed. It was decided not to hold a Strategy Discussion. Mother had not sought medical advice as previously advised. Jude was known to have tantrums. 5.60 Overall, professionals were reporting improvements in respect of the children and Mother's parenting and the home and safety. Observations were that Mother’s Partner interacted well with the children and they had not shown any concerns about him. It was agreed that the Nursery should be asked to keep a log of any injuries to Jude and report them to the Team Manager if the Social Worker was not available. Jude was to be seen as soon as possible following any further injuries being reported and Mother was to be reminded that any injury that Jude sustained to his face/head should be seen by the GP, at least. The issue of unexplained injuries was to be reviewed in four weeks. 5.61 Four days later, Jude was seen at Nursery with a split nose. Mother’s Partner said that Jude had fallen out of bed on to a toy and had been taken to hospital. The Social Worker was informed. There was no evidence that Jude was taken to hospital. 5.62 Four days after this, an ambulance was called to the house as Jamie had ‘stopped breathing’. He was taken to the local hospital and assessed to have significant brain injury; from there he was transferred to specialist care in a London hospital, where he did not recover, and life support ceased two weeks later. Jamie’s siblings were removed in to Interim Care. 6 Practitioners’ and Managers’ Perspectives Lessons arising from the Practitioners’ Learning Event 6.1 As part of the methodology of this Review, a Practice Learning Workshop was convened, led by the Lead Reviewer (with some of the SCR Panel Members). The purpose of the Workshop was two-fold: to seek the views and experiences of the practitioners and line-managers who had been directly involved in the case to see whether lessons applied to this case only, or more widely as possible ‘systems issues’ and, finally, to consider what was known at the time and what was learning from retrospective reflection. 6.2 Key priority messages from the Learning Event are included in this section. The practitioners’ views are also incorporated into the analysis and evaluation of the work and wider systems in Section 8. Kent Safeguarding Children Board 15 Practitioners’ views: 6.3 The case was time-consuming and required a high number of visits and co-ordination. There was no overall planning of the contacts from different agencies to the family, this meant that sometimes, Mother had or was being asked to have several contacts in one day or week. 6.4 The case was not seen as a complex case by many of the practitioners; it was seen to be like other cases in the locality, which shared common themes of overcrowding, possible drug use, neglect and violence. 6.5 Workers did not feel competent in working with ‘disguised compliance’7. This may have been a lesson from hindsight, rather than an insight concurrent with the work. 6.6 The number of children meant it was harder to ensure one-to-one contacts with the children to get to know them well, observe them, assess all aspects of their development and ascertain their wishes and feelings. This was a big task for a single key-worker. 6.7 In terms of assessing safeguarding risk, multi-agency partners felt they lacked the knowledge and skills to assess significant harm on a ‘balance of probability’ and what this meant and how it should be judged. This may have influenced decision-making, especially the decision to remove the children’s names from the Child Protection Plan in February 2016. The Panel’s view was that the introduction of Signs of Safety had led to a greater understanding about assessing risk and that at the February Child Protection Conference there was agreement between agencies about the scorings for each child and that there had been improvement. A question arises, however, about the possibility of ‘group think’ influencing practitioners who feel less confident; and of the need to assist practitioners to have the confidence to say either ‘I don’t know’ or I don’t agree’. 6.8 Some staff outside SCS felt that it was hard to have the confidence to challenge decisions and thinking in multi-agency meetings where they felt there was no parity of voice. A similar view was also expressed with some workers feeling uncomfortable sharing their concerns about a family with the family in the same room. This may also have been a lesson from hindsight, rather than an insight concurrent with the work. It was recognised that staff attending meetings should receive appropriate support from their manager and safeguarding leads. 6.9 Practitioners from several agencies felt that information sharing was ‘jealously protected’ by Agencies, for fear of breaching the Data Protection Act. 6.10 Practitioners believed from this case and others more widely, that more energy needs to be put into ensuring that Core Groups work well and are chaired efficiently. 6.11 Practitioners outside SCS were unfamiliar with the PLO processes and did not feel that legal advice on cases was shared with them. 6.12 There was a question about the availability, quality and quantity of ‘supervision’, (sometimes called management or advice), across all agencies to support front-line workers in different services thinking about and managing the child protection work. 7 ‘Disguised compliance involves parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions and allay concerns. Published (serious) case reviews highlight that professionals sometimes delay or avoid interventions due to parental disguised compliance.’ https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/disguised-compliance/ Kent Safeguarding Children Board 16 7 Family Perspectives on the Services offered to them 7.1 Mother and Father were informed that this SCR was being undertaken and invited to make representation and to seek legal advice, given the criminal investigation of Mother and Mother’s Partner. 7.2 The Chair and Independent Reviewer of the SCR Panel met with Mother and Mother’s Partner in their new home in March 2017. 7.3 Father said that he would write a letter to the SCR Panel setting out his views, but no letter has been received. 7.4 The views of the Mother and Mother’s Partner which follow should be read in the context that they were made to the Reviewers after they were charged, but before the trial. Mother’s and Mother’s Partner’s View of the Services Offered 7.5 The purpose of the discussion was to ascertain Mother’s and Mother’s Partner’s views on the services and assistance provided to the family up to Jamie’s death. Because of the impending trial, they were advised that they would not be allowed to discuss the events of Jamie’s collapse and subsequent death, or the agency actions which followed it. At the time of the meeting, they were both facing the criminal trial and for Mother, there were also Care Proceedings for all of the children. Despite these stresses, they were both open and ready to share their thoughts. They were surrounded by photographs of the children with whom Mother was having supervised contact. They spoke about them with warmth and love. Mother spoke mostly, and Mother’s Partner confirmed some of what she said, when she invited him to do so. 7.6 What follows is a summary of the key points of Mother’s perspective and views on the issues and the services. They clearly differ from the perspectives of the Professionals who worked with her. She was advised in the discussion that Practitioners had a different view to that which she was putting forward, but that this was her chance to put her own point of view. Her account is not challenged here. 7.7 For Mother, the most important issue over ten years had been the problem of housing; two adults and up to six children in a two-bedroom property. She felt that this was the main problem which needed to be resolved. She accepted concerns about the house being cluttered at times. She also appreciated when she was given practical help, such as when Troubled Families staff assisted her with obtaining a skip to tidy up the garden and provided a fridge and tumble dryer. After the move to the new house, she would have liked more practical help and more time to get it sorted. 7.8 Mother found the insights gained through the work on the Freedom Programme (on domestic violence), undertaken with the Social Work Assistance helpful. She said that she understood more about abusive men and their attitude to themselves and to women. In her view, some of the problems were attributable to Father who caused damage in the home, breaking doors through anger and being the cause of Police being called to the home. 7.9 After Jude’s and Jamie’s births, Mother found the Health Visitor helpful. There was good advice and the Health Visitor was always there when needed. The problem with the immunisations was that Mother did not want to see the babies cry and so she would not go. She did not think that there had been delays with immunisations. 7.10 In terms of health services, Mother did not feel that she had had enough help with Mikey, who she thought had ADHD and Autism, from being a very little boy. He would not eat properly. She said that she was not offered any help or treatment for him and that, at times she rang Services (Local Hospitals) but got no service. On this issue, she was complimentary about the School, which worked well with Mikey and got him to talk. Kent Safeguarding Children Board 17 7.11 The Midwife who supported her with Jamie was helpful. 7.12 The Parenting Course at the Children’s Centre was, in Mother’s view, helpful. She thought it would have been better if Mother and Father or later Mother’s Partner had done it together. 7.13 She had a different view of the School, which she thought ‘pinpointed’ her unfairly, drawing attention to the way the children were dressed, or claiming that they were dirty or smelly, which she denied. The children regularly got headlice at School and she would always treat all the children and the adults each time, but then they would go back to School and get them again. She did accept that sometimes the care of the children did ‘slide’. As noted earlier the School helped Mikey and the other children liked School; Holly liked the Nursery. The children made friends at School and were not picked on or bullied. Mother was pleased that the School helped her with bidding for a new property. 7.14 Mother had a positive view of the longer term Social Worker and Social Work Assistant from the first Child Protection Conference. She was happy with them and the support they gave her, especially after Jamie’s birth when they thought she was caring for the children better. The work on the Freedom Programme with the Social Work Assistant was helpful. 7.15 In terms of the Meetings that she was asked to attend, (Child Protection Conferences and Core Groups), Mother thought that these could be draining and make you depressed. She saw reports in advance and concerns were explained there. She understood the ‘Scaling’ that was used to rate the concerns as part of the Signs of Safety approach. She did feel able to give her point of view in the meetings, but did not always agree with others’ scaling. However, she thought that the way of raising concerns should be ‘lighter’ so as not to ‘break’ parents and make them depressed and that more advice should be given in advance on parenting. 7.16 The Legal Meeting was ‘awful’, she was pregnant and felt on her own. Father had refused to attend. She was told what progress had to be made and she felt that the finger was being pointed at her and that she was offered no help. 7.17 Father never went to the Meetings as he had to stay at home and look after the children, but he wasn’t very good, in her view, with these things and would ‘kick off’. She did not want to separate from Father. He did at times help in the house and kept things tidy, cooked and helped with bathing the children. He was often at home all day and occasionally played with the children. He did not bring any income into the home. Mother said that she had been given advice to get Father out of the home rather than go to a Refuge. She knew she had to put the children first and so in the end, felt that she had to tell Father to leave. 7.18 On specific issues and concerns, Mother said ‘all children say things’, as if these had been taken too seriously. She said that when necessary the children were taken to hospital or the doctor. She had been worried about Jude and his balance, falling and his boisterousness and clumsiness, and had asked for help with this. She said that the Children’s Centre had witnessed this. When he cut his nose, he was taken to the Walk In Clinic for assessment. When Holly had thrush, she had got cream for her. 7.19 Mother did not say why it had taken so long to evict the Lodger, but she ‘kicked her out’ after a ‘falling out’. 7.20 She admitted to occasionally smoking cannabis, but only at night and only in the garden or at a friend’s house, and an occasional drink. Mother and Mother’s Partner were both adamant that he did not smoke cannabis. 7.21 She was clear that she loved the children and that ‘you always have to think kids first and put the children first’ and maintained that that was what she had done. Kent Safeguarding Children Board 18 8 Analysis and Evaluation Good Practice: 8.1 It was appropriate that the services working with the family in 2014, assessed that the family needed more than Early Intervention or Troubled Families Services and that the threshold for social care intervention had been met and referred the case back to SCS, which undertook a Child and Family Assessment and convened the Child Protection Conference at the start of the period under review in this SCR. 8.2 The decision to make the children subject of Child Protection Plans was appropriate given the levels of concern. 8.3 When it became known that Mother was pregnant, it was appropriate to initiate a Pre-Birth Child Protection Assessment Process and consider that the baby should also be considered for a Child Protection Plan. 8.4 As the concerns about the children’s welfare and the quality of parenting continued, it was right to initiate Pre-Court actions under the PLO and to convene a FGC. There is evidence that practitioners monitored the children’s welfare, particularly through School and Nursery, up to the move of the family home. 8.5 At times, as new concerns were identified or where there was a deterioration in care, the Parents, (mainly Mother), were challenged to improve. 8.6 Supporting the family to move home meant that there would be better chances of the children’s needs being met. 8.7 The work with Mother on understanding domestic violence, even though incomplete, was positive and appears to have given her a greater understanding of how some other people have taken advantage of her in her life. Mother certainly saw this work as a positive. Was this a Complex Case, a Complicated Case or a High-Volume Case? 8.8 This was a big family with several children with different needs, and at-times, a volatile parental relationship and later, the addition of new, unassessed adults. The SCR Panel formed the view that this was not a complex case, in that it had the common features of usual child protection work, but perhaps it was a complicated case, in that it that had many (changing) dynamics and a high volume of work was required. Such families and dynamics are not unusual, which raises the question about whether practitioners or the local child protection system can become desensitised, (or perhaps overwhelmed), particularly in a case of ongoing neglect where there appears to be no clear triggers for action. 8.9 The question was raised, of when it is appropriate to allocate a larger family where there is chronic neglect, such as this one, to a single key worker, (even with appropriate adjustment of overall caseload), as seven children and four adults, plus their networks and agencies supporting them were a lot to be held in mind by one worker. Who is also responsible for leading the multi-agency team? 8.10 The caseload management and allocation system in use in SCS allowed for the number of children, ensuring a balance across the whole of the Worker’s caseload. The Children: Were practitioners able to see the world through the eyes of each child? 8.11 This was a large family to monitor and support, to collate information and make assessments for each of the children according to her or his own needs, development and functioning. At times, they appeared to be seen as a group, not as individuals. 8.12 The Social Worker’s composite reports to Child Protection Conferences, drawing on other practitioners’ observations, as well as the Social Worker’s own, sought to provide a pen picture for each child, collating Kent Safeguarding Children Board 19 and addressing the key concerns about learning, attendance and clothing, but these do not include a thorough-enough assessment of each child’s overall emotional and general development. 8.13 All the children were seen to ‘idolise’ their Mother and to feel loved by her. In the Initial Child Protection Conference, it was considered whether this may be the children ‘normalising’ their lives. It was thought that the children were emotionally attached to their Mother. A question to be considered, however, was whether the children were, in fact, showing signs of chronic emotional neglect and insecure or disorganised emotional attachment8. This appears not to have been explored. Research into chronic neglect9 shows the importance of recognising emotional neglect as well as more physical aspects of neglect. 8.14 More attention appears to have been paid to practical matters, such as health appointments, head lice, immunisations, physical safety within the home, clothing, etc. than to the consistent emotional needs. The Assessments did not consider whether Mother, Father or any of the other adults caring for the children had the capacity to hold the children’s emotional needs in mind. Assessing the parental capacity to respond to the children’s emotional needs was the responsibility of the whole team of practitioners working to support the children. It was noted that the theme of focusing on the more practical and tangible actions at the expense of the child’s emotional world, had been a theme in other SCRs. 8.15 This raises systems questions of how well-equipped practitioners are in this area and how local Agencies and multi-agency processes work to ensure that the child’s emotional world and needs are fully assessed and supported, when necessary. 8.16 Some good one to one work was done by the Social Worker and Social Work Assistant; it must be noted that direct work with six siblings, individually was a very big task, in addition to the work on Parenting, report writing, new safeguarding assessments and coordinating the network. 8.17 At times, the children spoke out to draw attention to what was happening to them and at times they appeared to communicate through acting out. They were unhappy at the arguments between their parents, but these were minimised by Mother and Father. The practitioners’ view was that the children had been told by the Adults not to talk with practitioners about what happened at home. Assessing and working with Parenting and Parental Relationships: 8.18 Mother: Mother was known to have a difficult history from her own childhood. Her first child was brought up by relatives. She was described as having a chaotic lifestyle as a young person, involving acting out, drugs and alcohol. She would, now, be seen as a victim of exploitation and perhaps sexual exploitation, but that was not the view at the time, and not one that Mother herself shared, then. It is known that she had some volatile and abusive intimate partner relationships, including with the children’s Father. There were also historic reports, recent reports and current allegations of drug use and alcohol use, which were vehemently denied, despite strong suspicion and probable evidence. 8.19 It is not clear how much thought was given to Mother’s own history of attachments and negative relationships to know whether her own inherent attachment-style was disorganised. The information provided for this Review suggests that this could and should have been considered as it would affect her 8 Understanding disorganized attachment; Theory and Practice for Working with Children and Adults; David Shemmings and Yvonne Shemmings; Jessica Kingsley Publishers; 2011. Or The Place of Attachment in Children’s Development; by Aldgate and Jones in (Chapter 4) in The Developing Work of the Child; Jane Aldgate, David Jones, Wendy Rose and Carol Jeffery; Jessica Kingsley Publishers; 2006; and Attachment across the Lifecourse; David Howe, 2011 Chapter 4 Patterns of Attachment 9 Safeguarding children across services, Messages from research: Davies and Ward; Jessica Kingsley Publishers; 2011 These messages from research summarise a range of evidence-based research studies commissioned by the Government after the Victoria Climbie Inquiry. Kent Safeguarding Children Board 20 own ability to enter into healthy and trusting relationships with others, including practitioners. It would also have been an indicator of her ability to hold her children’s emotional needs in mind, including the need for consistency. 8.20 Given this history, there was not enough challenge and skepticism about her capacity to change and sustain change. She was challenged and made occasional improvements, but these were often short-lived and appeared more as reluctant compliance than insight-based change based in realising the impact of the neglect and domestic violence on the children. At times, she had control and refused workers entry to the home. There was a view by workers that Mother knew how to keep workers at bay and what to say to please them. Disguised compliance was thought about, but not tested out or robustly challenged. 8.21 Father: Mother and Father had been together a long time. He was the Father of Jamie’s five older siblings and had accepted Mikey as a ‘step-son’. The history showed that the parental relationship was volatile; over nine years there were several Police notifications of arguments or violence, at times fueled by alcohol. 8.22 There was no understanding of Father’s own history and the quality of his own attachments as a base of how he could offer security and affection to Mother or the children. He does not appear to have supported the home financially. He did provide some physical care for the children, taking the older ones to school, occasionally cooking for, or bathing them, but he was said to be reluctant to undertake the tidying up or the repairs to the property which were required to support a move to a larger home, which was needed. The children, some more than others, showed a fondness for him. There is no doubt that he had a role in some of the parenting and without him, Mother’s task of caring for the children, especially when pregnant with Jamie would have been greater and more challenging. 8.23 Research in child protection has shown the importance of the ‘absent men’ and the difficulties that practitioners can have seeking to engage and work with male parents. This Father was far from absent until he was asked to leave by Mother in the summer of 2015. However, he absented himself from the child protection assessments and work to improve the parenting. He was regularly asked to attend meetings, but did not do so. He avoided the Social Worker and Social Work Assistant on visits when he could or would go out. He only attended the second Child Protection Conference and the FGC and even with the threat of Care Proceedings, did not attend Core Groups or the Legal Planning Meeting when SCS were considering taking action to remove his children. He did sign a written agreement with Mother and SCS in October 2015, after he had left the home, agreeing to ‘no arguments between parents at time of contact visits, no further domestic abuse and not to abuse alcohol or any substances during contact with the children’. This appears to be reluctant compliance. 8.24 His avoidance meant that no real work could be done with him to help him change his own behaviour or parenting. It was only possible to tell him what had to change with no work being possible with him to help him change or work with Mother towards them both changing. 8.25 Mother’s Partner: Mother’s wish to conceal the relationship with the man who would become like a step-father to the children, meant it was initially, difficult to establish who he was and what his role was. Mother’s Partner came to attention because Father complained about him and expressed concerns about him, but there is no evidence that Father was asked what he was worried about in this young man. The children talked about him and seemed to like him, and it seemed evident that despite Mother’s denials, he was resident in the home. 8.26 A Police check was undertaken on Mother’s Partner which showed a historic assault in an affray; nothing indicated that he was a risk to children. Although Mother agreed that he would not be left alone with the children, there was evidence that he was and that he very quickly played quite a big role in their care, and certainly did in the latter months of the pregnancy with Jamie. 8.27 There was, in fact, evidence to show that his presence brought some stability and improvement in the Kent Safeguarding Children Board 21 conditions of the home and the parenting, yet, he was not assessed as someone who, not having any Parental Responsibility was, in fact, playing a significant co-parenting role. He was an unknown quantity and should have been joined to the pre-birth parenting assessment being undertaken for unborn Jamie and the ongoing child protection reviews for the older children, with whom he had significant contact and emotional impact. There was no separate assessment of his intellectual capacity, his personal motivation or his views about entering a relationship with Mother and ostensibly taking on a role of caring for seven children. His presence was accepted. 8.28 The Lodger: Another adult joined the over-crowded house in the summer of 2015. She was an older friend to Mother and a relative of Mother’s Partner. It is not fully clear when she joined the household; the children referred to an auntie staying but this was denied initially. Police checks were undertaken, but the information known about her was not fully analysed. There was also a misrepresentation about her being the victim of domestic abuse when in fact there was an order against her preventing her living in the home with her own partner on the grounds of her own violence. When this was later corrected by another agency, it was not fully assessed and her inappropriate presence in the home was not properly dealt with. No real attempt was made to remove her, apart from advising Mother that the Lodger should go. 8.29 No assessment was undertaken of the Lodger or of the prior relationship between Mother and Lodger, or Lodger and Mother’s Partner; explanations were taken at face value. The Lodger was known to be a strong and intimidating woman; her influence or possible control over Mother was not considered. No direct work was done with the Lodger. 8.30 She moved to the new home after Jamie’s birth and occupied one of the rooms meant to ease the overcrowding for the children. Although this was challenged, Mother allowed it to continue. More could, (and should), have been done by the Core Group to move this person out of the home, given that the children were subject to Child Protection Plans. 8.31 As with Mother’s Partner, the apparent improvement in the home and the care of the children in the Autumn of 2015 up to Jamie’s birth, was probably partly because of the Lodger’s presence and assistance. Domestic Abuse and Drug and Alcohol use: 8.32 Within the history of this family, there were known incidences of domestic abuse, with both Mother and Father as victims and perpetrators. Some of the incidents of domestic abuse appear to have alcohol, and drug use as a significant dynamic within them. 8.33 Mother was encouraged to undertake work on understanding domestic abuse and its impact on the children, which she regularly denied, despite evidence that the children were unhappy when the Parents fought. It was reported that when she finally did some work in the incomplete Freedom Programme,10 that her insight into abusive relationships and the impact they had had on her increased. However, her own behaviour could also be volatile and there were suggestions that she had also assaulted Father or initiated rows, sometimes when she appeared to be under the influence of substances or alcohol herself. 8.34 The Police assessed the severity of incidents of domestic abuse and as none were rated as High, the continued incidences of domestic violence between Mother and Father were not referred to the Multi-Agency Review and Assessment Conference, MARAC. When visiting the home in response to allegations of domestic abuse, the Police did not discover any evidence of substantive violence or any crime. At the time, Police policy was to assess the new information against previously held information and give advice to the couple, as necessary. If there was insufficient risk to warrant referral to MARAC and children were present, the concern was referred to Children’s Services. 8.35 Throughout 2016, Kent Police made significant changes to the way in which they respond to allegations 10 The Freedom Programme www.freedomprogramme.co.uk Kent Safeguarding Children Board 22 of domestic abuse, making it a priority for the Force. Actions included ensuring that where Police attend domestic abuse incidents, regardless of whether the incident is assessed as High, Medium or Standard risk, a Domestic Abuse Notification (DAN) is sent to the Central Referral Unit where they will be reviewed and where there are children in the household, appropriate child safeguarding procedures will be followed. 8.36 There were strong, but denied concerns about drug and alcohol use. These dynamics were recognised in the early assessments and attempts to tackle them were built in to the Child Protection Plans. As the suspected drug and alcohol use were denied, practitioners felt that they could not do more to tackle this, apart from advise against its use. At a later stage of legal proceedings, it may have been possible to involve testing and treatment programmes as part of court agreements or orders. Drug usage should probably have been considered more robustly in the Legal Planning Meeting and the Written Agreement with Mother. 8.37 This case and others where ‘soft use’ such as cannabis or intermittent alcohol use are common in a family, raise questions for child protection practitioners and Services about knowledge and skill where there is no agreed ‘addiction’ or mandate to test and treat; yet the use is likely to be impacting on judgement, parenting and, in pregnancy, on the developing foetus. The Effectiveness of Agency and Multi-Agency Local Safeguarding Systems as seen in this case: 8.38 Recognition and referral of safeguarding concerns: It was appropriate for the early intervention and Troubled Families Services to refer this case to SCS in late 2014; placing six children on Child Protection Plans confirms this. A question arises, however, given what was found, as to why this had not been done sooner. The SCR Panel was advised that agencies had been reluctant to refer the case sooner as they felt that it would not meet the local threshold for action as either a child in need or for child protection. This was clearly in late 2014, but local services and the KSCB need to be assured that there is an understanding of the thresholds and that where there is doubt or disagreement about them that any service can seek advice, challenge this or escalate their concern. 8.39 New concerns and safeguarding incidents: Between January 2015 to Jamie’s death in April 2016, whilst all or at least one of the children were subject to a child protection plan and all the children were children in need, a number of instances of neglect, new injuries, failure by parents to respond to injuries and domestic incidents occurred. Although most of these were followed up, they were not followed up with the robustness of a multi-agency Section 47 enquiry. Not all were subject of a Strategy Discussion or followed up at the Core Group when they should have been. Some were not seen as child protection issues. 8.40 There seems to be a confusion in the phrase ‘single agency assessment’ and its meaning to practitioners. In one incident, the Police were informed of an injury to Marty, a discussion was held between the Police and SCS where following a decision that the Police would not be taking any further action, it was agreed that SCS would lead a ‘single-agency’ Section 47 child protection enquiry involving other appropriate agencies. In this case, health partners or school were not always involved in the Strategy Discussions about new concerns, even when they had been the agency raising the concern. 8.41 Assessments: The Child and Family Assessment is the responsibility of all agencies, led by a Social Worker. The Assessment provided to the Initial Child Protection Conference was fairly robust, however, it lacked a proper chronology of family history which would have enabled a picture of the Family, Parents’ own histories and parenting over time. This would have given a better assessment of the Parents’ understanding of concerns and what interventions or support had been used previously as a way of assessing their ability and capacity to change and care for and protect the children. There was no separate Pre-Birth Assessment for Jamie. 8.42 Ongoing ‘assessment’ was provided to the Child Protection Conferences through updating what had happened, rather than revised full assessments. Kent Safeguarding Children Board 23 8.43 When there were new concerns of physical injury which were suspicious, or not wholly consistent with explanation, or suggestive of neglect or when there was a possible disclosure of sexual behaviour by the children or a dog, which possibly met the child protection thresholds, there was no separate multi-agency strategy and assessment process. 8.44 More attention should have been paid to repeated suspicion of injuries with Jude, even if it was thought that they may be self-inflicted through clumsiness. This lack of a multi-agency approach led to inappropriate response and delays. 8.45 The disclosure about possible inappropriate sexual activity petered out, and the Mother’s suggestion of the dog licking Holly, appears to have been accepted without Holly being interviewed. Local procedures were not followed. The information shared at a Core Group and Mother’s explanation was accepted. This may have contributed to a more optimistic picture in the consideration of whether the children could be removed from the Child Protection Plan. 8.46 Child Protection Conferences: There were five Child Protection Conferences relating to children in the family during the period under review. In Kent, during the period under review, the Signs of Safety11 methodology was being introduced in a programme which trained the Chair Persons and Social Workers first. 8.47 Mother attended all of Child Protection Conferences, including one just a few days before Jamie was born. Father only participated in the first Review Conference. He did go to the office for one other meeting, but was excluded on the grounds of his aggressive behaviour prior to the meeting. The Lodger attended the September Conference but was appropriately excluded from participating by the Chair Person as she was not seen as impartial as she was expressing greater concern about the risk of her own homelessness rather than the needs of the children. Mother’s Partner did not attend any of the meetings. 8.48 The Review Conference in September was also a parallel Initial Pre-Birth Conference for unborn Jamie. The baby’s name was to be placed on a Child Protection Plan at birth, based on the continuing concerns and lack of progress in protecting the older siblings. There were differing views of the scaling of risk held by the multiagency practitioners, some of whom thought that there were signs of improvement. The Social Worker and Independent Chair thought that the risks were, in fact, greater than noted in March and that it was too soon to say that there was sufficient improvement or that it would be sustained. Mother’s Partner had just moved in, (denied by Mother), and was an unknown. The decisions to retain the older children’s names on a Plan and to make the expected baby subject to a Plan from birth were correct. 8.49 A further Review Conference was required within three months for the baby, who had not yet been born. The meeting was held a few days before Jamie’s birth in late November. SCS had reviewed and ceased the Pre-Legal Proceedings between the two conferences on the basis that there had been improvement and that there was no longer a need to consider Care Proceedings for the children. The family had just moved home and some improvements were noted; the children’s appearance had improved, school attendance was good and there were no concerns about the pregnancy, Mother was engaging with the Social Worker and Social Work Assistant, there was a new and larger home. There was a concern about the Lodger still being present in the home and that the children would face a change of school and children’s centre. There was no discussion about Holly’s recent disclosure of inappropriate touching, nor of Jude’s bruising by banging his head in tantrums. 8.50 The professionals present at the Review Conference thought the risks should be scaled lower, but that the children should remain subject to Child Protection Plans for a further three-month period in order to 11 Signs of Safety http://www.signsofsafety.net/signs-of-safety-2/ See also the NSPCC Review of the Methodology and its use in England 2013 https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/signs-of-safety-model-england/ Kent Safeguarding Children Board 24 see that the improvements were sustained. The SCR Panel’s view is that the Review Conference view was the correct decision 8.51 A further Review Child Protection Conference was held in February 2016. Although continued improved home conditions were reported, with the children being seen as happy and their basic needs were being met, it was also noted that there were hygiene issues for the girls. At times, the children were not supervised well enough and new and unexplained bruising had been noticed on Jude at his new nursery which had not yet been investigated. In addition, a complicating factor was the relationships between the four adults, two of whom had not been assessed. Mother was given an ultimatum to ask the Lodger to leave by the beginning of March. Mother’s Partner was to be included in final work with Mother on the Freedom Programme on domestic violence. 8.52 The overwhelming view presented to the Chair of the Conference by professionals present was that the scale of risk was lower and that improvements had been sustained and that the children should no longer be subject of child protection plans. The Chair felt that there were still some uncertainties and would not agree to the removal of Jude’s name until there was clarity about the cause of the repeated bruising. There was also the matter that the Lodger was still resident, and little was known about Mother’s Partner, who had not been assessed. Jamie and the five oldest children ceased to be subject to Child Protection Plans and were designated as Children in Need. As Jude remained the subject of a Child Protection Plan, the other children would automatically be considered at the next Child Protection Conference and at Core Group Meetings. 8.53 The SCR Panel’s view is that the decision to remove the older children and Jamie from Child Protection Plans and to retain Jude was not appropriate. Despite the apparent improvement in care for the older children, if one sibling is sustaining unexplained bruising, (even if thought to be self-caused, but from neglect of care), it was premature to remove the other children until expert advice had been given about the causes of the bruising and there was a resolution to the problem. However, it is unlikely that this was a key factor in Jamie’s’ death. 8.54 Child Protection Plans, their creation and monitoring through Core Groups and Review Conferences: Child Protection Plans are at the centre of the multi-agency safeguarding process. It is the actions agreed as a result of the assessments, interventions and monitoring which will protect children and improve their lives. The Plan is also an opportunity to make clear, in writing, to Parents and any advisors they may have, what the concerns are and what must be done to remove those concerns and by whom, including by the Parents. 8.55 Throughout the programme of Conferences, Review Conferences and Core Groups, Child Protection Plans were produced and shared with the Parents and with attending professionals. The Plans considered the key issues identified for the Parents and professional and contingency plans were also put in place. 8.56 A theme that continued in the reviewing of the Plan was that the family were showing limited improvements, however, these improvements were short term and not being sustained. The Parents continued to be in denial in relation to the identified concerns. Evidence was provided that demonstrated that the Plans were clearly not working. On one occasion, the Social Worker was appropriately concerned about the lack of progress and she warned Mother of the possibility of legal action and, after the Core Group, asked Managers to agree to Legal Advice being sought. 8.57 The Plans were reviewed when it was known that Mother was pregnant with Jamie. 8.58 Towards the end of 2015, the Core Group noted good progress against the Plan, however, it did not properly review the need to plan for the assessment of the involvement of the Lodger or the Mother’s Partner. The latter was being seen as a positive influence. SCS ended the Pre-Proceedings under the PLO, given the improvements noted by the Core Group, which agreed with this decision. 8.59 The family moved to a larger home, however, this brought problems, (the Lodger had moved in to one of the rooms meant for the children), which required changes to the Child Protection Plan which were made. Kent Safeguarding Children Board 25 The Contingency Plan was a repeat of the previous contingency; to convene an early Core Group if necessary or to rely on the PLO process, which was no longer in place. This was clearly inadequate. 8.60 It is to be noted that tasks in the various versions of the Plans, were agreed for Father, but he did not attend the Conferences, was no longer engaged with services and had not been responding to the Social Worker’s attempts to contact him; there must be a question, therefore, about the realism of ascribing tasks to him in absentia. 8.61 Overall, it appears as if some small improvements led to an ‘optimism’ by the network that Mother had turned around the long history of concerns. Also, reviews of the Plans failed to take into account some of the newer concerns, e.g. Holly’s recent disclosure of inappropriate touching, Jude’s bruising by banging his head in tantrums, supervision of the older children in the community, (perhaps being left to supervise each other or to their own devices). 8.62 This review of the Child Protection Plans overall raises the question of how KSCB and Partner agencies ensure that Child Protection Plans properly reflect changes in family circumstances, including assessment of new risks and the use of contingency planning as part of the safeguarding process. The only two contingency plans noted before the children, except Jude, were removed from Plans, were ‘to convene a Core Group earlier if that would be useful’. The final contingency plan, when the children were taken off a Child Protection Plan, was to seek legal advice if there were any new incidents of significant harm. What is of concern here is that when there were new concerns and / or insufficient progress or insufficient compliance, no consideration was given to convening Core Groups earlier, or even having a new strategy discussion, or seeking legal advice. It is not clear why Partner Agencies did not query or challenge that the contingency plans had not been triggered, when they should have been. 8.63 Written agreements: These are helpful to put in writing to Parents what the concerns are and what actions they, and Agencies need to take to improve parenting and lessen risk. There is little research into the efficacy of such written agreements12. There were three written agreements with Parents during the review period. 8.64 The written agreements were in plain English and the actions addressed the key concerns at the time. They related to expectations from both Parents. The final written agreement was drawn up between Mother, Father, (who had left the home), and SCS in October 2015. It clearly set out the concerns and the expectations on each Parent and on SCS, but no other agencies. It is signed by all three parties and stated that it may be used as evidence in court. 8.65 The SCR Panel questioned how much partner agencies within a Core Group are aware of, or party to written agreements, in order to be able to support them and monitor them, including being able to challenge parents who are not compliant with ‘agreed’ actions. 8.66 Family Group Conference (FGC): These aim to engage the wider family in finding solutions to concerns put by Safeguarding Agencies (usually SCS) about the welfare or safety of the children. An independent facilitator supports the family in a confidential discussion to seek their own solutions. 8.67 A FGC was held in June 2015 with Mother, Father, the two Grandmothers and a Great Aunt to the 12 It is usual policy and practice to include a written agreement as part of child protection plans in order to spell out to the parents the concerns and what actions must be taken by whom, and possibly what the consequences will be of non-compliance. There is not a base of research into the efficacy of such agreements and how best they should be constructed. It could be argued that they provide a clear statement about what is expected and so meet a form of fairness with parents. But there are questions about how they are negotiated and whether they are realistic. See Community Care Survey published September 2017: http://www.communitycare.co.uk/2017/09/21/written-agreements-still-common-part-child-protection-practice/ Kent Safeguarding Children Board 26 children. It was clear that the meeting was in the context that the Local Authority was considering legal action to protect the children. Extended family members offered to provide support to Mother and Father. The family agreed to monitor the plan. The Plan was produced but it is not clear if copies of the agreement were given to the family and, unlike a written agreement, it is not signed by any party. It did not agree what would happen if the family support did not happen in the way agreed, which was the case. Information given to Core Groups later in the year, suggested that the wider family was assisting, which was no longer the case, perhaps leading to a false positive view. 8.68 Public Law Outline (PLO) and Consideration of Legal Action: Given the long history of neglect and poor parenting, and the lack of progress from January 2015 when the children were made subject of Child Protection Plans, it was appropriate to consider legal action. It was noted by the SCR Panel that Partner Practitioners can feel optimistic when a case gets into PLO and they can sometimes feel that they can stand back, but many do not understand the process and are rarely involved in any court proceedings. 8.69 Multi-agency staff need to understand the PLO process and the agreed actions to support parents and challenge any lack of progress. It is also important that they understand that Pre-Proceedings are not court action, but a warning and a formal attempt to bring about change and make it clear that lack of the required change will lead to consideration of an application to a family proceedings court. However, such an application is not a guarantee that children will be removed. 8.70 Practitioners need to understand that ceasing a PLO process does not mean that there are no risks but may be an indicator that risks have reduced sufficiently to mean that there may not be grounds for a care or supervision order, which have a higher threshold than child protection plans. 8.71 With the benefit of hindsight but using information that was readily available at the time and therefore knowable, the SCR Panel questioned why the Pre-Proceedings were stood down when they were. It appears to have been that there were some minimal improvements, noted by the professional network, and that Mother had co-operated when in fact she had not done so fully, and the changes in the family structure were not fully assessed. Was the ceasing of the PLO was a false positive, and was there unwarranted optimism13. 8.72 Later, when there were new concerns, it is not clear why the legal processes were not re-considered as required by the final Contingency Plan. 8.73 Multi-Agency Work: Several agencies were involved in the case and sought to work together to improve the children’s care and reduce neglect. Overall, there was commitment in the network. Inevitably, however, there is a systems issue in that when children become subject of Child Protection Plans and Pre-Legal Proceedings, the leadership of the network rests with SCS, and some agencies are not so involved in the direct work, such as FGC and legal meetings. 8.74 At the Practitioners’ Learning Event, non-social work Practitioners spoke of ‘lack of parity of voice’ and that they felt that their voices were not given weight or that they deferred to SCS colleagues’ views; an issue not just in this case. 8.75 This raises questions about how the local agencies’ supervisory systems prepare and support Practitioners from the wide network of services in advance of attending meetings where they will be required to give their professional views about child protection and the need for and content of plans with the parents present. 8.76 The introduction of the Signs of Safety Model in Kent over the period of this case enables each Practitioner’s views and reasons for it to be heard. It was noted by the SCR Panel that the training provided in Kent on the role and processes of child protection conferences was not well-attended. The 13 Revisiting the Rule of Optimism; British Journal of Social Work, Vol47, Issue 6; Sept 2017 pages 1624-1640 https:doi.org/10.1093/bjsw/bcx090 Kent Safeguarding Children Board 27 training and advisory role of Agency-based Safeguarding Advisors/Leads, (in schools known as Designated Leads) is important in this. 8.77 A key role of the network is to hold the child’s experience, (including emotional experience), in mind and to act as a balance to ensure that this does not get lost in the demands of parents. The network saw minimal improvements, which were not being consistently maintained, but did not pro-actively ask ‘is this good enough?’. There is a question from the SCR Panel about whether the minimal improvements and the departure of the Father led to ‘fixed thinking’14 which prevented relapse or new concerns being fully assessed. The possible ‘normalisation’ and acceptance of levels of chronic neglect in some geographic areas is also a kind of ‘fixed thinking’ and may have acted to prevent the network seeing that the inconsistent care of the children was not good enough. 8.78 The SCR Panel’s view was that differing systems, busy workloads, larger sibling groups and parental needs or behaviours could easily get in the way of seeing the individual child’s experience. A fundamental question in every meeting should be, ‘What is this child’s experience and is it good enough?’ 8.79 At the time of this case, KSCB had not introduced some of the research into the impact of neglect15 across the sectors. Subsequently the KSCB has implemented a multi-agency ‘Neglect’ strategy accompanied by an associated training programme. This has been followed up by neglect focused multi-agency audits. 8.80 Use of supervision and professional oversight of complicated and distracting cases: It is well known that safeguarding practice needs critical and reflective thought to understand and work with the dynamics in families. Workers can get caught up in processes, such as fixed thinking, disguised compliance, false positives, or optimism and may be easily distracted by uncooperative parents. Professional curiosity and respectful scepticism are important. 8.81 Personal responsibility is important to understand role and tasks, but Agencies’ have a responsibility to support the frontline staff in thinking through, and perhaps challenging the workers themselves, about what may be happening, assessments and plans. Supervisors must be curious and challenging and seek evidence for real change in long-term cases. 8.82 In relation to the support and reflective supervision of the Social Worker, (the Key Worker), and Assistant Social Worker, there were supervisory arrangements in place. SCS review of the quality of supervision in this case has noted the following: the formal supervision for both workers did not happen with the frequency expected, but there was also ad hoc supervision. This was not in line with policy. The two workers were supervised by different senior staff and at no point in the management of the case was there joint-supervision to co-ordinate and plan the work that they were doing in parallel. It is noted that the two workers did have regular conversations and shared information about their progress. This does not, however, replace reflective questioning and advice by a third party as a ‘critical friend’ to challenge and inform the continual re-assessment and proposed actions. For both practitioners, the standard of recording of supervision was not met. The social work supervisor did, appropriately, take into consideration pressures on the worker from outside the case which may have had an impact on the Social Worker’s capacity and competence. 8.83 There was inconsistent social work case supervision. 8.84 It is known that such formal case supervision is not routinely used by other Agencies as in social work. 14 Thematic Reviews of previous SCRs have noted previously that flexible thinking rather than fixed thinking is required. Once a view had been formed there is often a reluctance to revise a judgement about the family, or about individual family members. Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; Brandon, Bailey and Belderson; DfE 2011 15 Safeguarding children across services: messages from research; Davies and Ward, 2011 Kent Safeguarding Children Board 28 8.85 In Health, ‘clinical supervision’ is expected. The Kent Community Health Foundation Trust (KCHFT) has a Safeguarding Supervision Policy which sets out mandatory Safeguarding Supervision for all safeguarding cases, which cases must be brought for supervision and the minimum frequency of safeguarding supervision meetings. This case was not discussed with the Health Visitor. Previously, practitioners chose which cases to discuss with supervisors, but now the practitioner and their manager regularly review which cases will be discussed in Safeguarding Supervision. The Trust has now introduced a system to track how child protection cases are being monitored and supervised. 8.86 The Education and Early Help analysis undertaken for this Review noted that ‘professional supervision in schools remains something of a concern’. Keeping Children Safe in Education 2016 refers to ‘support and training’ rather than supervision and is aimed at the school’s Designated Safeguarding Lead. Safeguarding consultation or supervision, (which are different processes), are available to schools through the Kent Education Safeguarding Team, but the resourcing of such a service is down to the school and its governing body. A question remains, therefore, in complicated or complex cases, how are school staff (in Kent) supported and challenged to think about child protection and the needs of the children in their school who are subject of child protection processes? In the absence of a clear internal supervisory process or access to a well-trained Designated Safeguarding Lead or Safeguarding Governor, School Heads are likely to rely on the leadership and guidance of the Social Worker or the Child Protection Conference chair, who will not necessarily hold the required perspective or specialism of the school setting. 8.87 This case underlines the importance of good quality supervision, particularly where there is long term neglect and/or parental denial and avoidance, so that workers are helped to think through what is happening and if it is ‘good enough’ for the children. Supervision has a role to challenge assumptions, question evidence, help workers think about possible blind spots, monitor professional standards and provide constructive advice. 8.88 Health Agencies involvement with the Family: The Health economy is a vast and complex structure in both the commissioning and provider arrangements. Within Kent, healthcare services can be commissioned by National Health Service England (NHSE), Public Health or Clinical Commissioning Groups (CCGs) and the delivery of healthcare can vary across Kent as services may be commissioned differently by one or all of the seven CCGs. 8.89 Health visitors and GP services are probably the most common services that are readily accessible to families and professionals. However, in complex cases it would be beneficial for specialist services, like Community Paediatricians, who have the expertise in providing an overview of development in children, to be involved in giving a comprehensive overview of children’s health and development to be involved. Additional information which can influence the safeguarding plans for these children and the attendance of Community Paediatricians/ Paediatricians at targeted case conferences would allow a comprehensive overview of the health and development of these children. In this case there was no overview of each child’s health and development. 8.90 It was evident in this case that the children ‘Did Not Attend’ (DNA) a number of health appointments. The issue of DNA and how to manage them in the context of safeguarding concerns have been addressed in research16. It is more pertinent to say that ‘X’ ‘Was Not Brought’, which then shifts the responsibility to the parent or carer. This hopefully then focuses the mind of professionals in dealing with frequent 16 Lisa Arai, Terence Stephenson & Helen Roberts; The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS; Archives of Disease in Childhood, March 2015 http://adc.bmj.com/content/early/2015/03/16/archdischild-2014-307294 and Munro, Eileen (2012) Review: Children and young people's missed health care appointments: reconceptualising 'Did Not Attend' to 'Was Not Brought' - a review of the evidence for practice. Journal of Research in Nursing, 17 (2). pp. 193-194. ISSN 1744-9871 Kent Safeguarding Children Board 29 non-attendances to appointments as possible neglectful behaviour. Encouraging and responding to community concerns about child neglect and maltreatment: 8.91 After the Trial the Kent Safeguarding Children Board received representation from the local Community that concerns about these children had been raised to public agencies from within the Community over several years. The Board agreed that the Panel should look into how local services had responded to community concern about the children from the period before the children were made subject of Child Protection Plans. The Panel Chair and the Independent Reviewer met with one representative of the community. 8.92 People in the local community had been worried about the children as they perceived very poor hygiene, untreated head-lice, lack of food, lack of supervision, unsafe garden conditions, and parental domestic violence and regular drug use (including anti-social behaviour relating to visits to the home by others seeking to use drugs and possibly obtain drugs). As more children were born the seeming neglect appeared to be become worse; older children being expected to care for the younger children. At times improvements were noted in the children’s care, particularly after Agency intervention and in the months up to Jamie’s birth. 8.93 These direct referrals from community members were taken seriously and followed up at the time, assessed and appropriately shared with SCS. When different Agencies received information from the community, they did respond and did find that some of the observations and concerns of community members were founded and yet accepted the parents’ denials or did not see the neglect to be serious enough to use child protection procedures. 8.94 Where wider family, friends or community members repeatedly make referrals about a family, and these are credible, these should not be seen as one-offs but should be seen and tested as a possible true pattern of family life, rather than the life represented by parents in denial to officials. There needs to be curiosity in assessments about what additional supports community members may provide in a family’s life. 8.95 Reports of child abuse or neglect from the wider community must be encouraged and taken seriously but there are challenges about confidentiality and assessing motivation. The national ‘Together we can tackle child abuse’ campaign raises these issues.17 9 Key Lessons In summary, this case highlights the following key lessons: 9.1 The need to keep an open mind in neglectful families of the possibility that any injuries may not be as a result of neglect or caused by children themselves, but may result from physical abuse or mishandling by adults, especially for babies and toddlers; 9.2 The importance of undertaking full assessments of all new adults in the household, regardless of their standing of ‘Parental Responsibility’; 9.3 The importance of engaging Parents and other adults, especially new adults who join households where children are already subject to safeguarding concerns; 9.4 The need for the continuing assessing the Parents’ capacity to change and sustain change in cases of chronic neglect; 9.5 The need to engage with men and consider gender dynamics in households; 17 Together we can tackle child abuse: Department for Education https://tacklechildabuse.campaign.gov.uk/ Kent Safeguarding Children Board 30 9.6 The importance of focussing on the child’s experience and life, including their emotional experience; 9.7 Ongoing assessing for emotional neglect and insecure or disorganised attachment as part of assessing neglect in ‘chaotic’ families; 9.8 Working with adults who may be domestically abusive and confronting the reality of the impact on children of living in a violent world; 9.9 Working with drug and alcohol using parents, including where the level of use does not evidence dependency; 9.10 The importance of analysing history, new concerns, assessing new injuries or disclosures for children who are already subject for CP Plans; 9.11 Recognising how the term ‘single agency assessments’ might exclude other partners from contributing to the assessment process; 9.12 The need to develop confidence in multi-agency staff to undertake appropriate inter-disciplinary challenge and escalation; 9.13 The need for critical thought and Reflective Supervision; 9.14 The adequacy of a child’s physical home circumstances is an important factor in neglect and this must be fully considered within a safeguarding assessment. 9.15 Ensuring that holistic assessments of children who have experienced long-term neglect, include emotional neglect; 9.16 The understanding of the implications for children missing health appointments/assessments or specialist services assessments as ‘Did Not Attends’ and how this term puts the focus on the child as opposed to the Parent/carer; 9.17 The need to encourage and respond to community concerns about child neglect and maltreatment. 10 Conclusion 10.1 It is known that Jamie died as a result of injuries inflicted on him by his Mother and her Partner. Given the timing of the injuries and his tragic death, there is no evidence to suggest that any professional working with the family saw or could have seen any indication of the violence experienced by Jamie. 10.2 At the time of his death, Jamie was known to SCS as a child in need, as were his elder siblings, except for Jude, who was under a Child Protection Plan. Partner agencies had been working with the family for a significant period. The level of this support varied according to the assessed needs at the time, from Public Law Outline to child in need. 10.3 There was a history of domestic abuse and drug and alcohol use by the adults in this family. The impact of this on the children was not assessed. Physical neglect was recognised, and despite being considered for legal proceedings, due to limited and sometimes disguised compliance, was never really addressed; emotional neglect was not assessed. 10.4 On occasions, there were signs of improvement in how the children were cared for, however, these improvements were never sustained despite continued support from professionals working with the family. There was evidence of workers being overly optimistic with the observed improvements and the parents were rarely challenged when the improvements were not sustained. Kent Safeguarding Children Board 31 10.5 The known history of the family and negative parental behaviour was not fully explored or used to assist in the undertaking of more detailed assessments. In general. incidents and concerns were dealt with in isolation and not viewed as part of an ongoing pattern of behaviour, nor was their impact on the children fully assessed, including the emotional impact. 10.6 Father’s history was unknown and later when Mother’s Partner and the Lodger moved in with the family, although this was initially denied by Mother, full assessments of them, including motivation and caring capacity, were not undertaken. 10.7 During involvement with this family, and especially when Mother’s Partner and the Lodger were resident in the family home, there were occasions where new concerns came to light, e.g. Jude sustaining unexplained bruises and Holly’s disclosure of inappropriate touching. Mother’s explanation as to the causes was accepted without challenge and these did not result in more detailed multi-agency investigation. 10.8 There was a history of behaviour in the family, that if fully explored and challenged, may have resulted in agencies being more aware of the potential implications of how these children were being raised. 11 Recommendations Considering the findings from this report and in response to the key lessons identified the following recommendations were made to KSCB and its Partner Agencies which agreed them and will implement an Action Plan to manage them: Recommendation 1 The KSCB will review policies, procedures and training of relevant practitioners in the recognition of assessment of physical injuries to young children to require that consideration must always be given to whether unexplained or repeated injuries in babies and toddlers should be assessed as physical abuse. • As part of that consideration, attention should be paid to the assessment of the parental handling of babies. Paediatricians undertaking such assessments must be aware of the history and context of any prior child protection concerns. Recommendation 2 The KSCB will regularly review and seek evidence through a programme of case-audits that SCS and Partner Agencies, when assessing risk to children and leading multi-agency child protection plans, that there is a thorough assessment of parents’ or carers’ capacity to change and maintain change, using on evidence-based processes, including previous work with them. • These audits will include review of multi-disciplinary assessments of new adults who join or regularly visit the household. • The programme of multi-agency audits will also review that any new incidents, disclosures or injuries to children already subject of child protection plans are subject of a strategy discussion with the relevant agencies, as per procedure. (This should include a longer-term view of the history of the incidents and concerns as a whole and not just an assessment of single incidents as they occur.) • Within this the SCS should review how written agreements are used. Recommendation 3 The KSCB and its Partner Agencies will strengthen, through Learning and Development, the arrangements in place to consider the child’s experience and emotional development, as well as the child’s voice, within safeguarding assessments and multi-agency procedures. • This should include consideration of any barriers within systems and processes which are inhibiting the child’s needs as being seen as central. Kent Safeguarding Children Board 32 • Such assessments should include assessments of the child’s emotional state and attachment, which should be considered at Child Protection Conferences. Recommendation 4 The KSCB and its Partner Agencies will review how they equip and support frontline practitioners and supervisors/managers in engaging with challenging parents and carers, including fathers and other resident adults, to assess their capacity to change and sustain change in cases of domestic abuse. • In reviewing the effectiveness of the new arrangements for assessing domestic (abuse) incidents, Kent Police and SCS should ensure that the impact on children over repeated incidents is considered fully and prioritised according to any pattern identified, not just by single incident or by parental behaviour. • The KSCB will ask the Central Referral Unit Strategic Board to provide an Annual Report on the oversight and management of the Domestic Abuse notifications and processes, including data and outcomes. Recommendation 5 The KSCB will ask its Partners to jointly review the multi-agency and single agency guidance and training for frontline staff and their managers on understanding and working with drug and alcohol use. • The purpose of the review would be to ensure that practitioners are aware of the possible impacts of different types of parental alcohol and substance use on children and how to raise this with parents. This should include Drug and Alcohol Abuse services roles, including where the level of use may not have been assessed as ‘problematic’. This should include guidance on thresholds of when to seek or require testing of adults as part of an assessment if alcohol and/or drug use as part of child protection procedures and when there are grounds to believe that there is misuse which is impacting on children’s welfare. Recommendation 6 The KSCB will require its Partners to confirm the effectiveness of the arrangements for frontline practitioners to have informed and constructive reflective supervision or consultation, including group supervision for joint workers. • The KSCB should consider that, in the commissioning of regular audits of the quality of frontline safeguarding practice (as at Recommendation 2), the provision and quality of advice, consultation or supervision is also reviewed. Recommendation 7 The KSCB will ask the Kent Housing Group and the Joint Policy and Planning Board (Housing) with Children and Young People’s Services to review the arrangements in the Kent Agency Assessment process for (priority) nomination to housing. • The purpose of this review would be to ensure that the housing needs of children subject of child protection plans, where the housing circumstances contribute to ongoing neglect, can be properly considered. Recommendation 8 The KSCB will ask the Commissioners and Providers of Health Services to review and report back on the policies for children who are not brought for medical appointments, health assessments or required treatment, with clarity about when the failure to bring a child may be considered to be neglect. Recommendation 9 The KSCB, with the responsible Partnerships, will review how communities in Kent are made aware of the impact of child abuse and neglect, including how domestic abuse and drug misuse can impact on children, and how members of communities can report these. Kent Safeguarding Children Board 33 Recommendation 10 Kent Police and SCS should review their guidance on communication with non-family members who refer safeguarding concerns about children or who support families to ensure that concerns are assessed over time and so that community members who support families can be appropriately involved in child protection assessments and plans for family support, subject to confidentiality and consent. |
NC044744 | Summary of a review into the death of an 11-month-old boy in March 2011, as the result of a serious head injury. Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY's death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the existence of EY from members of her family and later concealed his existence to GP and children centre staff. Injuries to EY were observed by social workers, children centre staff, GP and Health Visitor in the weeks prior to his death. Issues identified include: insufficient recognition of the risks associated with concealed pregnancy; inadequate assessment; superficial engagement with family; underestimation of the risks associated with re-unification following a considerable period of separation; insufficient understanding of role of father and extended family; and non-compliance with child protection procedures in relation to reporting suspicious injuries. Identifies key lessons for practice, including: better coordination of health care for children who are discharged from being looked after; investigation in cases of concealed pregnancy, including the psychological and psychiatric status of parents; and recording in health records that takes account of the needs of other health professionals. Makes various interagency and single agency recommendations, covering: social care, health services and family support services.
| Title: Serious case review: executive summary: services provided for OY and EY and members of their families during the period January 2008 - February 2011. LSCB: Windsor and Maidenhead Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1Serious Case ReviewEXECUTIVE SUMMARYServices provided for OY and EY and members oftheir families during the periodJanuary 2008 - February 2011Windsor and Maidenhead LSCBIndependent Chair and Serious CaseReview Panel Independent ChairDonald McPhailSerious Case ReviewOverview Report AuthorKeith Ibbetson21Background to the SCR and the reasons for carrying it out1.1BetweenAprilandNovember2011WindsorandMaidenheadSafeguarding Children Board (LSCB) conducted a Serious CaseReview (SCR) of the services provided to two children who arereferred to as OY and EY. When he died in March 2011 EY was aged11 months and his brother OY was nearly two. EY died as a result ofheadinjurieswhicharecurrentlythesubjectofacriminalinvestigation. OY is the subject of care proceedings.1.2The SCR was carried out in order to fulfil the requirements ofChapter 8 of the statutory guidance Working Together to SafeguardChildren1 and the Berkshire Local Safeguarding Children BoardsProcedures. 2 The LSCB is required to conduct a SCR when a childhas died and abuse or neglect are suspected to be a factor in thedeath. Initial medical opinion indicated that this was the case andthefindingsofthepost-mortemenquiryconfirmedthis.Thecircumstances required a SCR. The children normally lived withtheirmotherintheboroughofWindsorandMaidenhead.Ittherefore fell to the Windsor and Maidenhead Safeguarding ChildrenBoard to undertake the SCR.1.3The decision to hold the SCR was made by the Independent Chair ofthe LSCB on 30 March 2011. The review covers the period fromJanuary 2008 until the death of EY. This review period was chosento include all of the significant involvement of agencies with childprotection responsibilities in the lives of the children. The decisionto conduct a SCR was also taken in the light of the followingknowledge:a number of agencies and professionals with child protectionresponsibilitieshadprovidedservicesforthechildrenandfamilyEY had been looked after by the local authority until the age ofseven months although the case was closed by the localauthority three months before his deathEY’s parents had initially indicated that they wished him to beadopted1 HM Government, Working Together to Safeguard Children – 2010.2 http://berks.proceduresonline.com/chapters/p_ser_case_rev.html3a number of professionals had noticed bruising and scratchesto EY in the weeks before his death.EY’s older sibling OY had not been looked after. Neither of thechildren had been the subject of a child protection plan at anypoint.1.4The findings of the SCR and the multi-agency action plan wereaccepted by the LSCB at its meeting on 16 November 2011. This isthe Executive Summary of the findings of the SCR. The SCRoverview report has also been published. Information that is judgedto be considered potentially harmful to the surviving brother of EYhas been removed from the published version of the full report.2Arrangements for the SCR2.1The SCR reviewed the work of the following agencies who wereinvolved with the family during the period up to and including 2008.All are based in Windsor and Maidenhead or are members of theLSCB because they provide a significant range of services tochildren and young people in the borough:Berkshire East Community Health Services (which provided thehealth visiting service)Primary Care (covering the services provided by three GPpractices)Heatherwood and Wexham Park Hospitals NHS FoundationTrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 3 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionsChildren’s Centre services and other family services)2.2Under the SCR arrangements all of these agencies were asked toreview their records, produce an internal chronology of theirinvolvement, interview key staff and provide an individualmanagement review. The authors of individual managementreviews were senior staff with expertise in children’s safeguardingor independent authors.3 This service is referred to as ‘children’s social care’ in the body of the report42.3Additional information was also provided to the SCR by thefollowing agencies which had only brief or limited involvement:South Central Ambulance ServiceCombined Legal Services (which provides legal advice to socialcare staff in Windsor and Maidenhead and is hosted by ReadingBorough Council)Themother’sschoolrecordscontainedsomeverylimitedinformation which was taken into account by the SCR. No faith,voluntary or community groups were identified as having beeninvolved.2.4The review was conducted by a SCR panel which included seniorrepresentatives of participating agencies with expertise insafeguarding children and detailed working knowledge of theprofessional standards relevant to all of the services involved. TheSCR panel was chaired by the independent chair of the LSCB. TheSCR overview report was prepared on behalf of the LSCB by KeithIbbetson. Both the SCR panel chair and the report author areindependent of the agencies involved and have expertise inchildren’s safeguarding and substantial experience in conductingSerious Case Reviews. The other members of the SCR panel were:OrganisationDesignationNHS Berkshire EastDesignated PaediatricianRoyal Borough of Windsorand Maidenhead CouncilHead of Services to Childrenand Young PeopleRoyal Borough of Windsorand Maidenhead CouncilHead of Safeguarding andSpecialist ServicesThames Valley PoliceDetective Chief InspectorThames Valley ProbationTrustSenior Probation Officer,Berks East Community HealthServiceAssistant Director (Children)The work of the SCR panel was supported by the Windsor andMaidenhead Safeguarding Children Board Manager and the LSCBSecretary. A health overview report was prepared by theDesignated Nurse for Safeguarding on behalf of NHS Berkshirewhich commissions the health services involved with the family.52.5The purpose of the SCR is set out in Working Together as follows:to draw together a full picture of the services provided for thechildren and their familyto establish what lessons are to be learned from the case aboutthe way in which local professionals and organisations workindividually and together to safeguard and promote the welfare ofchildrento identify clearly what those lessons are both within and betweenagencies, how and within what timescales they will be acted on,and what is expected to change as a resultto improve intra-agency and inter-agency working and bettersafeguard and promote the welfare of children2.6Given the specific circumstances of the case the terms of referenceof the SCR asked it to consider whether lessons could be learnt inthe following areas:historical information on the family members about factors thatmay have impacted on the parenting capacity of the mother orthe fatherthe quality of assessment of circumstance relating to thechildren and their familyfactors that helped or hindered the engagement with thefamily;how well agencies identified and responded to children’sinjuries and other indicators of harmthe extent of, and professional understanding of, the supportfrom the extended familythe advice that was given and the services offered to theparents concerning adoption issuesrisk factors in the family known to agencies during the periodunder reviewwhether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to thecircumstances presented by the familywhether sufficient attention was given to issues relating thereunification of EY and his mother following the period when hewas in foster care6Given the circumstances of the death of EY the terms of referenceasked the SCR to consider whether his death could have beenprevented.3Family involvement in the SCR3.1The SCR panel agreed that because of the concurrent criminalinvestigation into the death of EY it would not be possible to involvethe mother or the children or other family members because of therisk of prejudicing the criminal investigation and trial. The LSCB willkeep this decision under review and will seek to obtain the views offamily members about the services that were provided to the familywhen it is possible to do so. Any further learning arising from this willbe considered by the LSCB.4Key events in the case history4.1Only very limited information about the family history of the motherand father was obtained by agencies. There is no information in anyagency record to indicate any concern about abuse or poor parentingof children in the family history of either of the parents. The motherand the father were in a relationship. There was a considerable agedifference between them. The father stated that there was nointention for the relationship to be permanent or for the couple tohave children.4.2The mother gave birth to the first child in the family at the father’shome, with no medical or nursing attention. She was aged 21. Shehad received no antenatal care and stated that she did not know thatshe was pregnant. She has no recorded history of mental illness,learning disability or drug misuse. The mother said that she hadsuspected that she was pregnant about a week before the birth, butdid not tell anyone or do anything about it. The child’s maternalgrandparents were notified about the birth of OY by the hospital soonafter the birth. Initially the parents considered relinquishing OY to beadopted but they very quickly changed their minds and took himhome.4.3Despitetheunusualcircumstancesofthepregnancyandtheconcerning circumstances of the birth only very limited assessmentswere undertaken by midwives, health visitors and the local authority7socialworker.Therewereneversubsequentlyanysignificantconcerns about the care provided to OY.4.4EY was born in similar circumstances to his brother almost a yearlater. By this time the mother lived in her own flat. On this occasionthe mother admitted suspecting that she was pregnant but she didnot tell anyone or seek any medical attention. The father said laterthat he suspected that the mother was pregnant, but that she deniedthis. EY’s parents wanted him to be accommodated by the localauthority and said that they wanted him to be adopted. His fathermaintained this view consistently. Members of the mother’s familywere not informed about the birth of EY until he was nearly sevenmonths old.4.5The mother stated that she was ambivalent about relinquishing EYfor adoption. He lived with foster carers for nearly seven monthsduring which time he was noted to be a healthy child who developednormally. During this period the mother had adoption counsellingwith the aim of enabling her to come to a properly considereddecision about EY’s future. Little progress was made by the localauthority in implementing the planned adoption. EY’s father only sawhim once during this period, at a meeting to plan his placement. EY’smother saw him twice during the first five weeks of his life, on bothoccasions this was linked to planning and review meetings held abouthim. During the next month she visited him on seven occasions. Thiswas the only time when there was any significant contact betweenthe mother and EY prior to her decision to look after him. In thefollowing 18 weeks she visited him only twice, with gaps of almost 10weeks between the visits.4.6When EY was 28 weeks old the social worker informed the mother’sfamily about the birth of EY. The aim of this was to assist inprogressing the proposed adoption, but the local authority alsobelieved that the mother and her family could provide a suitablehome for EY. At this point the mother and her family decided thatshe should look after him. After a short series of visits by the motherto his foster home, EY was placed in his mother’s care. The visitswere only observed by the foster carer.84.7There were no grounds for the local authority to prevent themother from assuming care of EY, but the complexity of thebackground and the evidence that the mother had shown verylittlepositiveinterestinEYindicatedtheneedforcarefulmonitoring of his health and development and the care that hewas provided after his placement with his mother. At this pointthere should have been a coordinated child in need plan linked toa similar plan for his health needs. The local authority closed thecase after two visits and the health visiting service offered only itscore service i.e. the mother was left to take EY to health clinicsand to seek advice from her health visitor or GP if she wished.4.8Four weeks after he moved to live with his mother, on her finalvisit, the social worker noted scratches on EY’s face. The socialworker accepted the mother’s explanation that these scratcheshadbeencausedbyEY’sbrother.Thiswasaconcerningpresentationwhichmighthavebeenanindicationofpoorparenting or abuse.4.9Four weeks after this EY’s GP noted bruises on his face and headwhile he was undertaking a developmental check. When EY’smother was asked about this she stated that these had beencaused by his older brother. At this point it was also noted thatEY’s weight had not increased since he had last been to a childhealth clinic. The GP did not realise that this coincided with theperiod when he had been in the care of his mother because he didnot have access to his medical records and he did not notice thereferences to this in EY’s Personal Child Health Record.4.10Over the following eight weeks staff at a children’s centre notedscratches and bruises on several more occasions. The mother haddeceived the staff and other parents at the centre by giving him afalse surname and telling them that EY was in fact the child of hercousin. She claimed the bruises were caused by his four year oldsister, a child who did not exist. Other parents pointed out thebruises and also expressed concern about EY. Professionals foundthe injuries concerning, but they did not refer them to the localauthority to investigate.94.11When the children’s centre sought advice from the local authoritythe centre coordinator spoke to an unqualified member of staffwithout realising this. She was unhappy with the advice given, butdid not challenge it. The systems in place in the local authority forscreening calls were not clear to other professionals.4.12The day before he was admitted to hospital with the very seriousinjury that caused his death, EY was seen by a health visitor in achild health clinic. She had not met EY or his mother before. Thehealth visitor noticed bruises on his face which the mother saidhad been caused by a fall the previous day. The health visitor wasconcerned about EY and noted her intention to speak to hisallocated health visitor. Despite the very limited time that she hadwith EY the health visitor had enough information to have madethe decision to refer EY to the local authority. At the veryminimum she should have sought the advice of the health trust’snamed nurse for safeguarding or another senior colleague.4.13When he was brought to hospital EY had bruises on his face, head,chest, back and legs. Doctors recognised that he had suffered avery serious head injury. The post-mortem findings show that EY’sdeath was caused by this injury. They also revealed that EY hadsuffered a number of fractures that predate his death by at leasttwo weeks. It is not possible to date these injuries more preciselyso some or all of them may be older than this.4.14However, taking only the two week period before he suffered theinjuriesthatcausedhisdeaththeagencyrecordslistthreeepisodes in which bruising was noted or discussed. None of theseincidents was reported to the local authority. If that had happenedor EY had been referred for a paediatric assessment the bruiseswould have been investigated. Given EY’s age and vulnerability itis very likely that a full child protection medical examination wouldhave been undertaken. In the circumstances this would very likelyhave included a skeletal survey (an x-ray of the whole body). Thiswould in turn have very likely identified the older fracture injuriesand this would have led to action being taken to protect EY.5Conclusions of the SCR and key lessons learnt5.1The conclusions of the SCR are that 1) over the long term the10potential risks to EY were underestimated 2) when he moved to livewith his mother he should have been closely monitored because ofthe concerns about the circumstances of his birth, and his mother’sfailure to visit him for long periods when he had been looked after3)inthetwoweeksbeforehisdeathprofessionalsmissedopportunities to intervene which, if they had been taken, are verylikely to have led to the detection of serious injuries and are verylikely to have prevented his death.5.2There were a number of missed opportunities to identify and assessthe bruising observed on EY. These presentations were highlysuspicious. EY’s age and circumstances marked him out as beingextremelyvulnerable.Theprofessionalsinvolvedshouldhaveresponded differently and the bruises should have been reported tothe local authority so that child protection enquiries could beundertaken. At the very least professionals should have takenadvice from a member of staff or a professional advisor withexpertiseinchildprotectionorreferredEYforapaediatricassessment.5.3Taking the case history as a whole there are important lessons forthe work of organisations work to safeguard and promote thewelfare of children. These relate to 1) the training, skills andknowledge of individual professionals and teams of staff who wereinvolved 2) the wider organisational arrangements that existedwithin agencies and 3) working arrangements between agenciesand the sharing of information.Concealed and denied pregnancy5.4Staffandprofessionalsinalltheagenciesinvolvedfailedtorecognise the significance of concealed or denied pregnancy. Whenthere has been a concealed or denied pregnancy the circumstancessurrounding it need to be recorded and investigated in detail bymidwives, health visitors, GPs and social workers and all otherprofessionals who come into contact with the children and parents.This should always include consideration of the psychological andpsychiatric status of the parents.5.5When a pregnancy is denied or concealed or a woman presents at avery late point in her pregnancy for antenatal care it is usually the11result of parental learning difficulty, drug misuse or mental illness.These were not features that were present in this case and this isone of the reasons why there was less concern than there shouldhave been. In these unusual circumstances a detailed assessmentshould still have taken place.5.6Communications between midwifery services and health staff suchasGPsandhealthvisitorswerenotsufficientlydetailedandspecific. They did not consistently make clear the concealed natureof the pregnancies and the lack of antenatal care that the motherhad received. This contributed to the fact that GPs and healthvisitors did not recognise the significance of the history.5.7In this case the mother had two concealed pregnancies and thisshould have further served to alert the professionals involved to thepotential concern. Information about the circumstances of the twopregnancies was not linked together consistently. This reduced thecapacity of some professionals to recognise the added significanceof a second episode.Initial and new birth assessments5.8The new birth health assessment in relation to OY was very limitedand failed to seek out information about the concealed pregnancyor wider family factors that might have impacted on his health.5.9The initial social care assessments of OY were of limited value. Theyalso failed to seek out information about the concealed pregnancyorwiderfamilyfactors.The complexityofEY’scircumstancesmerited a social work core assessment. Although there was noproceduretorequirethisoncehewasalookedafterchild,professionaljudgementshouldhaveidentifiedthecaseasacomplex one which merited a fuller assessment.5.10Professionals failed to involve the children’s father and members ofthe extended family fully. Better engagement would have improvedthe assessment of risk and need.Re-unification of children5.11Professionalsunderestimatedtherisksassociatedwiththere-unification of a child with parents after a considerable period ofsubstitute care (or as in this case when a parent has never had12responsibilityforthechild).Thedevelopmentalneedsoftheindividual child, the meaning for the parents of the individual childand the child’s history of attachment need to be evaluated in detaileven when there is no obvious indication of risk. There is a valuablebody of research which shows that the reunification of children withtheir parent or parents after a prolonged separation is complexwork which needs to be carefully planned and monitored.The ability of professionals to recognise abuse and comply withchild protection procedures and guidance5.12There was a lack of curiosity about scratches on the face of aninfant.Thisshouldhavebeenrecognisedasanunusualandpotentiallyconcerningpresentation.Thebruisesobservedbyprofessionals should have been considered as highly suspicious andconcerning given the age and vulnerability of the child.5.13Professionals in three different settings – the GP practice, thechildren’s centre and a child health clinic – did not comply with thechild protection procedures and the training that they had receivedand did not report suspicious injuries to the local authority socialcare service. They were faced with a confident and convincingparent who denied having harmed her child and gave explanationsthat professionals found plausible to different degrees. Professionalsneed to have the skill and confidence to take the action required toprotect children when faced with such circumstances.5.14If professionals in the health service are not sure that a referral tothe local authority is required then they must consider alternativessuch making as referral for an urgent paediatric opinion or takingadvice from a named professional or another more experiencedcolleague.5.15Key information about EY was held in his Personal Child HealthRecord. This included significant history that might have affectedthe way in which professionals responded, including the fact that EYhad been a looked after child for the first few months of his life. Thedesign of that document and the way in which some importantinformation about his history was recorded in it meant that it wasnot obviously noticeable to staff referring quickly to the record.Arrangements for transferring and sharing information135.16There were delays in transferring and summarising the GP recordson some family members. This may have impacted in a significantwayonthedecisionsandactionsofprofessionals.Currentarrangements for the transfer of GP records are not fit for purposein relation to the needs of vulnerable children. The delays that arecommonplacemeanthattheserviceofferedbyGPsmaybeseriously impaired and some children may be placed at risk. Thereare also often delays in summarising records once they arrive at GPpractices.CurrentarrangementsmakeGPsprofessionallyvulnerable.5.17The health visitors who were involved with EY prior to and after hisdischarge from care did not share all of the relevant informationabout him with one another and did not ensure that his GP knewthat he had been a looked after child. The health care of childrenwho are discharged from being looked after needs to be bettercoordinated. All of the health professionals who will be involvedwith a child and its family need to be informed about the relevanthistory and know which other professionals are involved with thechild. The role of the looked after children health team should bereviewed to take this into account.Capacity of organisations and other organisational arrangements5.18The caseloads of health visitors in East Berkshire exceeded nationalrecommended levels and the review found that this limited the timethat staff had to make visits, to undertake assessments and topracticeinareflectiveway.Healthvisitingteamsarealsoresponsibleforprovidingchildhealthclinicsinarangeofcommunity settings. These are popular and very busy and staff mayhave only a very limited contact time with each child. Staff workingin these clinics have limited access to records about the childrenthey see and rely on the information contained in the Personal ChildHealth Record.5.19Children’s centres have been developed rapidly in order to make arange of services accessible to children and their families. The staffworking in the children’s centre attended by EY and his motherlacked experience in running and managing a service used by largenumbersofchildrenandhadreceivedinsufficienttrainingon14safeguarding children.5.20Services such as child health clinics and children’s centres havebeen developed with a view to maximising the accessibility ofservices to families. This is an important and positive objective ofpolicy and service development. As a result of the SCR it has beenrecognised that the setting in which staff work can enhance orimpair the ability of professionals to recognise risks to and meet theneeds of vulnerable children. The same applies to the clinicalrecords and other information systems that are available to staff.5.21The social worker who was primarily responsible for EY’s case wasnewly qualified and inexperienced. She was allocated this casebecause it was believed to be a straightforward piece of work. Thisunderestimated its potential complexity, given the concealment oftwo pregnancies. Newly qualified social work staff dealing withchildren’s cases require a high level of supervision tailored to theirindividuallevel ofcompetence, skillandknowledge. Thiswasabsent in this case.Learning the lessons of the SCR and the implementation ofrecommendations6.1The findings of the SCR and the recommendations that flow fromthem have been adopted by Windsor and Maidenhead LSCB. TheLSCB has produced an action plan that sets out the actions needed,who is to be responsible for taking them and the timescales forcompletion. Many of these recommendations have already beenfully or partly implemented. The LSCB will oversee implementationover the coming months to ensure that lessons are learnt andpractice improves. The full detail of these recommendations is setout in the action plan that accompanies this document. |
NC50851 | Death of a 16-year-old-boy by suicide in October 2016. X was known to local health services and had been receiving intermittent psychological support for his anxiety from the age of 8. X had generally good school attendance and was expected to do well in his exams. His parents were seen as supportive by the school. X told his parents that he had taken an overdose and was taken to hospital; he was treated and released to return home with his parents with a safety plan the next day. His parents checked on him regularly through the night, when they went to wake him at 11 he was found to be lifeless. An ambulance was called that verified he was dead. Ethnicity or nationality is not stated. Learning includes: more preventive approaches are needed to support young people who are anxious and help prevent them acting on suicidal thoughts; more support should be available for young people to talk to others if they are feeling anxious or depressed. Recommendations include: raise awareness about the use of and impact of illegal drug use by young people; consider the role of drug and alcohol use in mental health assessments of suicidal young people; schools should ensure that a child's vulnerabilities including mental health issues should be passed onto a new school when a child transfers; hospitals should ensure that there is enough provision for adolescent and child mental health services at night and weekends.
| Title: Multi-agency case review: ‘X’. LSCB: City and Hackney Safeguarding Children Board Author: Malcolm Ward Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Multi-Agency Case Review ‘X’ March 2019 Malcolm Ward Independent Reviewer 1 Contents page Background Summary 2 X’s death and the immediate antecedents 4 Family views about services received, what may have helped X, lessons learned and possible actions 8 Practitioners’ Views 11 Findings 14 Recommendations 27 Appendixes: The City & Hackney Safeguarding Children Board response to X’s death 30 Xanax 32 Relevant findings from research into suicide by children and young people 34 Reading 38 Useful Organisations / Resources 39 2 This multi-agency review seeks to learn from the tragic death of X who took his life in October 2016. He had just had his sixteenth birthday and was in Year 11 at school, preparing for GCSEs. X lived with his mother and father. His older sister had just moved away from home to university, outside London. With other local multi-agency reviews into recent suicides by young people in Hackney it will inform local awareness, practice and strategic responses with a view to improve work to prevent self-harm and suicides. The City and Hackney Safeguarding Children Board thanks X’s family and the practitioners who worked with X for their involvement and contribution to the review. 1. Background Summary 1.1. X had experienced (social) anxiety for some time and had received intermittent psychological support for this from age 8 years. From January to May 2009 he was seen at First Steps, a local NHS psychological service for children and young people. Between January and May 2009, he was seen by a psychologist for adapted Cognitive Behavioural Therapy (CBT) to help him manage the triggers of anxiety and to help him cope. After seven sessions X and his mother reported improvement and it was agreed that the sessions would cease but that if concerns re-emerged they could self-refer to the service or ask their GP to re-refer them. 1.2. In December 2009, aged nine, X was re-referred to First Steps by his GP as he had a persistent cough which was thought to be anxiety related. The First Steps re-assessment noted that X had problems with managing his anger. 1.3. In July 2012, aged 11, X’s GP re-referred him to First Steps as he was anxious about his SATs exams and about some street dance performances which he was taking part in. His anxiety had prevented him from completing his SATs exams at the end of Year 6. This was followed up in the new term when X had started at secondary school. Advice was given by telephone in October. X’s parents were seen by the service at the beginning of December 2012 and two weeks later X, aged 12, was seen by a psychologist for an assessment; and some adapted CBT approaches were suggested for him. 1.4. Further sessions were offered for January 2013 but X and the family declined these as there had been an improvement. It was agreed with X’s father that the service would be held open for X and the family to see how X managed upcoming exams and then the family and First Steps could review if there was a need for a service. 3 1.5. X was seen by the First Steps service twice in September 2013 (approaching 13 years) for adapted CBT to assist him with managing his anxiety; he was also offered mindfulness techniques to assist him. It was agreed to cease sessions as X and his father reported improvements. They were advised about self-referral or re-referral via the GP if X needed further assistance. There was no further contact with the First Steps service after this. The service noted that the parents were very supportive of X and his therapy. 1.6. In early April 2016 X, aged 15 and six months, was seen by his GP. He was worried about excessive blushing; said to be something he had experienced “all his life”. X found it uncomfortable and embarrassing and was acutely distressed about it. He could not identify a specific trigger to the blushing. X had undertaken internet research on the issue and did not want medication but wished to be referred for endoscopic thoracic sympathectomy (ETS) surgery1. The GP agreed to look further into possible treatment options. A few days later, after seeking additional clinical advice, the GP spoke again with X. A conservative approach was recommended with the possibility of a referral to the dermatology service. X was keen to be referred to dermatology. He was advised that he would probably grow out of the problem, but it was agreed that a referral to the dermatology service would be made. The GP also invited X to speak with him further if he wished. The referral to Dermatology was made two days later. 1.7. In June 2016 X was seen in the Dermatology Department of the local hospital. It was noted that the flushing was triggered by emotion and exercise. X reported that it was having an impact on his confidence as he approached his GCSEs. X was keen to have surgery for this. The consultant discussed the complications of surgery. X’s mother has told this review that X was unhappy with the dermatologist’s reluctance to refer him for surgery. A gel was prescribed and X and his parents were advised to discuss the possible treatments with the GP. It was also suggested that CBT may be useful. He was not seen again in the Dermatology Department. 1.8. X saw the GP again in mid-July. He said that the gel had not worked. X was still keen for surgery. The GP discussed the risks of this, about which X and his father were already aware. Alternative approaches of CBT or beta blockers were suggested, and it was agreed that X would trial increasing doses of beta blockers first as he was reluctant to take up CBT. CBT or a re-referral for surgery would be considered if this did not work. 1.9. X (15 years and 11 months) was seen again by the GP in early September. The excessive 1 https://www.nhs.uk/conditions/blushing/treatment/ 4 blushing was continuing and X also now complained of excessive sweating. The beta blockers were reported to have had no effect. X only wanted surgery; he was clear that he did not want to be referred for CBT or to have longer acting beta blockers. The GP agreed to refer him. The GP discussed the matter with colleagues before referring X to be considered for thoracic surgery, at a different hospital, in mid-September. The GP re-referred X to a third hospital to be considered for surgery a few days before X died. (This review has been advised that the second hospital – to which X was referred in September – would not have considered X for surgery for this matter until he was 18). 1.10. At secondary school (Sept 2012 to October 2016) there were no concerns about X. He was excluded for a few days in Year 9 (November 2014) for possession of a small amount of cannabis; it was thought that he was holding this for another student, rather than for his own use. It was noted that in December 2014 X had had some authorised absences to attend his GP – but the school did not know what these attendances were for. (This review has noted that there is no record that X attended his GP in 2014.) His school record was normal apart from a period of poor attendance in Year 10. At the end of Year 10 X was assessed to be a little behind in some subjects, but this was not seen by staff as a problem. 1.11. X’s attendance at school in the Autumn term 2016 was 100%. X was seen as an able student, predicted to get A and A* grades across the board. He was well liked by staff and was popular with his large group of peers (boys and girls). Both his parents were appropriately involved with the school and seen as supportive of X. 1.12. X was never seen, by the school, as vulnerable or in need of additional support. The school was unaware of his history of social anxiety or worries about blushing. The school had not noted any physical aspects of X’s blushing. 1.13. After his death the school learned that X had been involved in what peers alleged as ‘recreational drug use’. This had not been known at the time as an issue for X, but the school had been raising the general issue of drug use with parents more widely. 2. X’s death and the immediate antecedents 2.1 On the last Friday of October 2016, shortly after his 16th birthday X attended a party with some of his friends. They later reported that X had seemed to be ‘very down’. In the early hours of the Saturday morning X texted his mother to ask for a lift home. His mother was away from home that weekend and replied reminding him of that and advising him to get a 5 cab. An hour later he sent her a further text apologising for troubling her and saying he loved her. 2.2 In the middle of the Saturday X texted his father (and mother, who was still away) to tell them that he had taken an overdose. X’s father called an ambulance saying that X had told him that he had taken an overdose of paracetamol, Xanax2 and whisky. The ambulance took X and his father to the local Emergency Department. He was triaged by a paediatric nurse. It was assessed that there was no need to admit him to a children’s ward for assessment or treatment at that point; he was taken to the Adult Emergency Department for assessment. 2.3 X disclosed that he had taken 13 paracetamol (6.5 mg) and 25 Xanax (50 mg); he said that he had also drunk whisky the previous evening. On arrival X was alert and cohesive. His blood levels for paracetamol showed that he was below levels for medical treatment. He was not tested for Xanax levels as he showed no symptoms and a urine test would not have shown levels of Xanax in his body. He was referred to Psychological Medicine for assessment for self-harm, as per the agreed guidelines. 2.4 X’s mother returned to London and was present with X, at hospital later that day. 2.5 X was assessed, initially alone, by the hospital on-call Senior House Officer (SHO) for Psychological Medicine. X stated that after returning home in the early hours he had continued drinking whisky alone and then decided to take an overdose. He had woken after midday and no longer wanted to end his life and so texted his father (and mother3). X said that the primary cause for his action was anxiety. He said that he had been experiencing anxiety for about a year (from Year 10) and more recently had had some suicidal thoughts, although he had not acted on them or planned to act on them. The overdose was described by him, as an impulsive act, it was not pre-planned. He had been ‘self-medicating’ from February 2016, initially with Diazepam4 and later with Xanax. X changed to Xanax as he was worried about becoming addicted to Diazepam. X denied using the drug daily, saying that he took it only occasionally. He had sourced the drugs illegally, through a local dealer. X was also very troubled about excessive facial flushing and wished to have surgery, then ‘everything would be perfect’. The SHO also spoke with X’s mother. 2 Xanax - A benzodiazepine used to treat anxiety, not recommended for under 18s and not available in UK, except by Private Prescription. It is addictive. See appendix. 3 X’s mother has told this review that X had vomited at home before texting his father and her. It is not clear if the hospital were aware that X had vomited or when he vomited. This may have had implications for the amount of drugs in his body. 4 Diazepam - A benzodiazepine used for the treatment of anxiety, muscle spasms and convulsions (fits). It is addictive. 6 2.6 The assessing SHO and on-call (off-site) Child and Adolescent Mental Health (CAMHS) Psychiatric Registrar discussed the assessment on two occasions. It was agreed that X was no longer suicidal or at risk of self-harm and did not meet criteria for admission. X wished to return home and his mother was happy for him to be discharged. 2.7 It was agreed that X could be discharged home with a Safety Plan. X was to take a few days off school, his mother would take a few days off work to be with him, his mother was to remove all remaining pills (although X said that there were none left), the SHO was to refer X to CAMHS for an urgent appointment, X was to tell his parents if he was feeling ‘down’ or suicidal and his mother was to check in with him regularly, X could come back to the Emergency Department alone or with his parents and they were given the Mental Health Crisis Line and CAMHS telephone numbers. X and his mother went home at 8.30 pm. 2.8 The assessing SHO sent the referral to CAMHS the same evening. An Emergency Department nurse sent a referral to Children’s Social Care (X and his family were not known to CSC.) 2.9 Through the night X’s parents checked on X regularly. His mother was disturbed about 6.30 am by X who had been looking for a bag. When she asked about it, he said that he may go to football in the morning, the bag was for his kit, and she said that they could talk about it when he gets up. His father checked on him about 9:00 am and he appeared to be sleeping. 2.10 At 11:00 am X’s mother went to wake him and found him to be lifeless. He had pulled his hoodie up over his head, his face to the wall, hiding that he had suffocated himself. (X sometimes slept in his hoodie with the hood up.) X’s mother rang for an ambulance and started CPR. The ambulance crew examined X and noted that he was pulseless, his heart had stopped, and rigor mortis was evident. His death was verified. 2.11 A multi-disciplinary Rapid Response Meeting5 was convened in the first week of November to review the circumstances of X’s unexpected death and plan what actions should be taken. It was noted that X had written a suicide note relating to his overdose on the Friday night/Saturday morning which he had not shared with his parents until his return from the Emergency Department on Saturday evening. (The assessing SHO was not aware that X 5 A Rapid Response Meeting or process is part of the Working Together to Safeguard Children, 2015, Chapter 5 and London Child Protection Procedures relating to Unexpected Child Deaths. The purpose of the meeting is to bring key professionals together as quickly as possible to consider the unexpected death and plan bereavement support, any safeguarding that is required, information gathering to inquire into the death and to plan to learn lessons as part of the child death overview process. http://www.londoncp.co.uk/chapters/unexpected_death.html 7 had written a suicide note). In that note X had stated that he felt that he was suffering from addiction to Xanax, which he thought was causing depression, anxiety, and paranoia. The Police took X’s phone and Xbox for forensic examination. It was confirmed that arrangements were in place for bereavement support for X’s family, close friends, and for students and staff at X’s school. It was noted that the CAMHS had noted a new trend of young people using Xanax in conjunction with alcohol to achieve a “buzz” or to use benzodiazepines to self-medicate anxiety. The CHSCB chair was also to be consulted about commissioning a review to learn from X’s death. 2.12 A further Rapid Response Meeting was held two weeks later. It was noted that in the Emergency Department assessment after the overdose X did not display the typical symptoms that would be expected from the reported levels of overdose of paracetamol, Xanax and whisky. Possible reasons for this are that he may have built up a tolerance to Xanax, given his previous use; X may have over-estimated the number of tablets taken; or the Xanax may not have been pure Xanax. It was also confirmed that a urine test for Xanax cannot show the levels in the body. There was no information available to this meeting about whether there was relevant information on X’s phone or Xbox. 2.13 At the inquest the Police gave evidence that they had examined X’s phone, reviewing emails and texts for a month prior to his death. There were no emails or texts about suicide or X’s intention to harm himself, prior to the texts that X had sent his parents on the day after his overdose. The search history of the web browser showed that during the early hours after X had returned home from hospital after the overdose, he had made numerous searches about suicide and one site in particular had shown methods. 2.14 The Coroner noted that there had been no prior known history of self-harm or suicidal thinking but that X had a history of anxiety related to the extreme facial blushing. The GP had sought to help X find a solution to the facial blushing. His family was supportive and loving and he had positive elements in his life with friends and lots of activities. The risk assessment in the Emergency Department showed no physical risk to X from the overdose and the psychological assessment showed a lower short-term risk of suicidal thinking or action but that in the longer-term X needed support with his anxiety. He was discharged with an appropriate Safety Plan. The evidence from X’s phone, about the web searches he had made of suicide websites, showed that X had intended to take his life. As a result, the Coroner decided that X’s death was as a result of suicide. 8 3. Family views about services received, what may have helped X, lessons learned and possible actions 3.1 X’s family were advised of the review and invited to contribute. X’s mother met with the Independent Reviewer to represent the family. 3.2 X’s mother had reflected a lot on what had happened and had thought a great deal about adolescent suicide since X’s death. She and the mother of another young person from X’s school who took her life a few months after X have done a lot of work with the school in thinking about how to support young people under stress. 3.3 X’s mother described X as ‘full of life’, at times fidgety; ‘he lived life at 100 mph’. He was adventurous, funny and quirky. He could be determined about what he wanted and could not wait until he was old enough to do what he wanted. X was very bright. He was also very popular. He could be imaginative. He was sporty, enjoying football and street dance, when younger. He partied hard in his GCSE year and gave up football on Sundays as it was hard to get up. He was altruistic and worried about issues of inequality, such as Black Lives Matter. 3.4 However, X was also anxious. He had tics when he was younger and developed a persistent cough, both as a result of anxiety. He had CBT for that. He had social anxiety and developed problems with blushing. He had researched blushing on the internet and wanted surgery to deal with it. He challenged the consultant who said that surgery was not available on the NHS showing him that it was. The family thought that the GP had ‘lost’ the follow up referral for surgery (this review had confirmed that this was not the case). X’s appointment for the thoracic surgeons arrived after X died. It has been noted as part of this review that X would not have been considered for surgery (endoscopic thoracic sympathectomy ETS)6 until he was 18; and only after considering the possible psychiatric impact. 3.5 X’s parents had not known, until his overdose, that X had been self-medicating with Xanax. X’s mother has learned that Xanax can cause suicidal ideation. X said he felt depressed at 6 NHS: Treatment - Blushing https://www.nhs.uk/conditions/blushing/treatment/ 9 his addiction to Xanax which he had got ‘through the internet’ and he thought he was a ‘victim’ to it. (X told the psychiatrist that the drugs were sourced from a dealer.) “Like all parents”, X’s parents had wondered about X possibly using drugs (particularly cannabis/skunk) and alcohol but in their view, these had not been a problem for X. 3.6 On the way home after the overdose X’s mother wondered if the drugs were still influencing or clouding X’s thinking. He spoke passionately about Black Lives Matter, but this seemed to be out of context, given what had just happened. They talked about the risks of him self-medicating and he agreed that he would no longer do it. 3.7 When they got home, X showed his mother and father the suicide note he had written, which they had not seen before he went to hospital. 3.8 X’s parents watched X at times through the night, as mother was advised to do by the hospital. 3.9 X’s mothers’ reflections after X’s death included not being surprised that this happened at the end of the half-term break as she thought X was anxious about going back to school. He had been going in to school during the holiday as he was trying to catch up with the course work for his GCSEs, although, at the Parents’ Evening prior to his death the staff had been very positive about X and his progress. She also wondered whether X was missing his older sister. They were very close, and she had just gone off to university. 3.10 She had come to wonder, in hindsight, if X had been determined to take his life. X’s friends said that he had been ‘really down’ on the Friday night. He had changed the screen-saver on his phone to read ‘I love you all’, surrounded by angels and emojis with a message to say that his girlfriend would know the access code number to his phone. It was discovered from his phone that X had accessed a specialised suicide website, which discussed possible methods. 3.11 In terms of lessons that could be learned from X’s death X’s mother felt that the agencies who responded to X’s overdose and then suicide were thorough. She had understood that if he had been under 16 he would have been kept in hospital. (This was not the case. If he had required treatment for the overdose, such as a drip, consideration would have been given to whether he should be admitted to a children’s ward, given his age. As the psychological assessment showed that X had mental capacity and was no longer suicidal and did not require observation or treatment he was discharged; this would have been the case if he was under 16.) 10 3.12 For X’s mother the key issues were the need for preventative approaches to support young people who are anxious and help and prevent them acting on suicidal thoughts. Since X’s death there have been talks about drugs at school. The school, with a charity set up by X’s mother and another mother have asked young people about their worries. One of the students’ worries was knife crime and where young people can go for safety if they are feeling under threat. 3.13 Another key issue is ‘Who do young people talk to if they are feeling anxious or depressed’? Young people will not necessarily go to a counsellor. X’s mother wondered whether there could be staff mentors – perhaps younger teachers or the sports teachers, who are more approachable? How can young people be helped or encouraged to talk to each other? One of X’s friends regretted that although they were good friends they had not talked to each other about their worries. X’s mother wondered whether there is a role for peer mentors perhaps from the 6th Form or Year 11 who are looked up to; but she also wondered if that would be effective – would students speak to those peers? Could issues about stress or anxiety be raised in tutor groups? Is there a need for separate boys’ and girls’ groups? 3.14 She thought that Helplines can be useful but can also be slow to answer - would young people wait? Also, it is important that Helpline numbers are kept up to date. Some of the information about helplines on noticeboards at school was not accurate. 11 4. Practitioners’ Views 4.1 As part of the systemic approach to this review practitioners who were directly involved with X and his family were asked to meet with the Independent Reviewer and some Review Panel Members to share their thoughts about their contact with and provision of services to X. Such an approach also allows this group of frontline practitioners and their managers to think beyond the individual child and family being considered to the wider systemic context of cohorts of children or need locally and to think about patterns of response. The group was also asked to consider the analysis and emerging themes identified by the Review Panel. The group met jointly, except for the Headteacher, who was unable to attend and was seen alone. The Deputy Headteacher was present in the group discussion. 4.2 The school had been unaware of X’s history of social anxiety going back to primary school days or that he had been supported from time to time by First Steps, the psychological service. It was questioned whether there should have been a formal note of this from his primary school on transfer to secondary school. The group thought that this raised questions about proportionality and the ‘need to know’, and of how parents may have concerns about schools making prior judgements about students at admission. It was also suggested that the transfer of information from primary schools generally was not always of good quality. It was suggested that parents generally (not X’s parents specifically) are reluctant to share information about a student’s mental health for fear of how a school (not specifically X’s school) may respond to this. Experience from mental health practitioners suggested that parents may hold views about how a school will respond, including whether attendance at health or counselling therapy appointments are deemed to be authorised or unauthorised absences. There may be a need for myth-busting information and education from schools to dispel such beliefs. 4.3 No service, or practitioner, was aware that X had experienced suicidal thoughts before the overdose or that he was ‘self-medicating’ to help him manage this. 4.4 For the GP service the priority was to support X with his facial flushing, which was causing him a great deal of anxiety. At the time X was clear that the flushing was the only problem that he had; and he was adamant that surgery, rather than the less interventional approaches offered, was what he wanted. The GP service has considered, after X’s death, whether it would have been possible to explore further whether X was experiencing wider anxiety and whether a more assertive approach to recommending CBT should have been tried. These are hindsight thoughts but raise an important point; namely that when a young person is very troubled by one issue it will be important to consider whether this is a symptom 12 of a wider issue rather than the cause. 4.5 In relation to the mental health assessment after X’s overdose, the SHO has noted that at that time, in late 2016, less was known about Xanax and its use or effects, including from withdrawal, if addicted. X had said that he had not been taking Xanax every day. If such an assessment were being undertaken now more consideration should be given to the risk of withdrawal and its possible impact on emotions and thinking. 4.6 Reflection on X’s death had raised the question for medical practitioners about whether there is sufficient education about drug misuse for doctors in training; and how this can be kept up-to-date. There may be a need to review the CAMHS Crisis Pathway in relation to drug use as a factor in mental health assessments in young people. Related to this was the issue that drug or alcohol use may increase impulsive behaviour and irrational thinking. (The post mortem showed that there was still a significant amount of Xanax in his blood which could have influenced his thinking.) 4.7 There is a question about whether an adult focussed mental health service in the Emergency Department, out of hours, when CAMHS practitioners are unavailable on-site, meets the specific needs of young people. There is no doubt that the assessment of X was thorough (see section 5) and it was supported and overseen, at a distance, by the CAMHS Registrar; who would have come in to the hospital to see X, if necessary. CAMHS has increased its direct service to the Emergency Department into the evenings, Monday to Friday, since the suicides of X, and another child. The practitioners’ and managers’ group noted that there were still times at night and at weekends when CAMHS was not available, however. At those times, an older young person would be seen by an adult specialist, unless it was identified that a child and adolescent specialist should be called in. 4.8 An additional consideration raised by the practitioners in relation to mental health assessments, particularly in relation to risk of self-harm or suicide, is how to consider a young person’s use of the internet or social media as influencers (positive or negative) on risk-taking behaviour; and to know or advise young people about which are useful and neutral sites to visit for support and advice or how to be aware of issues to consider in case a website is advocating risky behaviour. 4.9 More widely, X’s death had raised for practitioners the challenges of working with young people in the field of drug and alcohol awareness and prevention. The school had developed sessions for students and information for parents before X’s death and has further refined them since. For this group of practitioners, there were questions and soft 13 intelligence about possible ‘pockets’ or areas of drug use by young people in some parts of the borough with patterns of behaviour and a culture of how young people access drugs through dealers, through the web or support each other to access drugs, without parents’ knowledge, by use of bank cards. Peer pressure and increasing independence away from adult supervision for older young people and gatherings of young people where alcohol and drugs may be available may lead young people into risk taking behaviour which they are ill-equipped to manage. Soft intelligence suggest that drugs are sometimes available at young people’s parties. Some young people spoke about this after X’s death. In X’s school there is a system for young people to anonymously share their worries about the welfare of a peer (this system is wider than drug use). 4.10 The practitioners thought that it should be noted that cannabis is probably stronger and more damaging than many parents realise and that young people, who can be impulsive and risk-taking may be experimenting with a range of other substances. Local information suggests that young people experiment with cocktails of mixed drugs and alcohol; which may have given names; but as the cocktails change so do the names. It is hard for practitioners who are not drugs specialists (and for parents) to know about or keep up with this more hidden world of young people. There are also questions about the authenticity or contamination of drugs available through dealers or the web. 4.11 It was thought that young people (and parents) need accurate information about drugs, including the short and longer-term possible side-effects. Young Hackney7 works in this field and can support young people and practitioners with this. The practitioner group thought that it would be useful to have a local multi-agency strategic approach led by the Safety Partnership and Health and Wellbeing Board to lead this issue; including how to raise drug and alcohol awareness in schools through PSHE (personal, social, health and economic education). 4.12 A related question was how services respond to awareness that a young person is in possession of or may be using drugs. The practitioners thought that there is a need to consider a more public health / safeguarding approach to drug use rather than an investigative / criminal approach. It is also important to destigmatise ways for young people to ask for help (drugs or mental health issues). 4.13 Is enough known about risk and anxiety in the wider community and among young people following a young person taking their life? Shortly after X’s death there were questions about 7 Young Hackney is a Council service which provides a range of resources for children and young people; including activities, advice and community involvement. This includes advice about drugs and alcohol. https://www.hackney.gov.uk/young-hackney 14 whether his death would encourage other young people to harm themselves. There was no evidence of such ‘contagion’ locally. At the time, First Steps reviewed the vulnerability and service to a number of identified young people in its service who it was thought may be disturbed by X’s death. It was noted that generally there may have been an increase in reports of self-harm; but it is not possible to say that this came about because of X’s death. 4.14 The practice group noted that the internet and specifically social media in a variety of forms are now central to young people’s lives and are very important influences in their behaviour and decision-making. It was suggested that the CHSCB should review its guidance on Online Safety8 to ensure that it covers advice and safeguarding in relation to internet and social media use when young people may be looking for advice about drugs, self-harming behaviour and suicide. 4.15 In addition to these considerations the practitioners responded to and were in agreement with the emerging lessons suggested by the Review Panel, drawn from the analysis of the agency reports to this review. These are discussed further in the next section. 5. Findings 5.1 Prior to X’s overdose and subsequent suicide no practitioners, from any service, who met or worked with him, in the preceding twelve months, were aware of his chronic anxiety. The school staff, who knew X well, were unaware and had had no concerns about him with regard to anxiety or flushing, or any worries about his emotional health based on his behaviour. The possibility of drug use (cannabis) and alcohol use was considered by the school, but not thought to be a serious risk. His worry about flushing (and excessive sweating) was known to the GP and local Hospital Dermatology Department, but it was not seen as being of such a level to require referral to CAMHS or that X was at risk of self-harm because of it. The GP had recommended CBT as an approach to the flushing but X had been clear that he did not want this. X had not shared with any practitioner or his family that he had had suicidal thoughts until the assessment after his overdose. It was not known until then, by anyone, including family, that he had been ‘self-medicating’ with illicit drugs for approximately nine months (by X’s own report). 5.2 It can be concluded from this that there were no missed opportunities by any professional staff to recognise that X was a risk to himself prior to the critical weekend at the end of 8 http://www.chscb.org.uk/wp-content/uploads/2017/09/CHSCB-Safeguarding-in-the-Context-of-Access-to-Technology-and-Use-of-Social-Media-Handbook-digital-version.pdf 15 October 2016. 5.3 X’s parents were supportive and involved appropriately with the school and the GP in relation to X. They were both seen at hospital and appropriately concerned in relation to the overdose. No agency had any concerns about X at home. Response to X’s overdose 5.4 The key work with X about possible risk is the crisis assessment in hospital, after the overdose. The confidential Health Trusts’ Serious Untoward Incident Inquiry (SUI) undertaken jointly between the Mental Health Trust and Hospital Trust after X’s death concluded that the assessment and discharge plan were appropriate; there was a low level of risk, X was remorseful, expressed no further suicidal intent (at that time) and was looking to the future. Plans were in place to supervise X over the next few days and for timely follow up support. The SUI’s view is that X’s suicide could not have been predicted. 5.5 This review has raised one area of practice which may have required greater exploration, however, namely X’s use of illicit medication and access to it and whether he was addicted. At the time the possible impacts of physical or psychological withdrawal from Xanax generally, or from an overdose of 25 Xanax (as stated by X) do not appear to have been explored fully. Risks of withdrawal may include “effects such as headaches, muscle pain, extreme anxiety, tension, restlessness, confusion, mood changes, difficulty sleeping and irritability”. (See the Appendix to this review for more information about Xanax.) 5.6 It is recognised, in hindsight, that X’s state of mind may have deteriorated overnight – including possible access to and influence by a suicide website, which was not known at the time of the Health Trusts’ SUI. X’s family have queried, however, whether X may have been determined – which raises a question about whether X may have concealed his state of mind during the mental health assessment. At the time of the assessment he may also still have been under the influence of the drugs in his system – however, it is clear that he gave the staff the impression that he was rational, open and honest and understood what was happening. 5.7 Regarding multi-agency co-operation and information sharing in relation to the overdose, it is evident that there was good co-operation and consultation between the hospital SHO and the CAMHS Registrar during the assessment while X was an in-patient and appropriate follow up with immediate referrals to CAMHS and to Children’s Social Care. The Ambulance Service also made a timely referral to CSC, with X’s father’s consent. The work in this short 16 period followed protocols and agency guidelines; although it has been noted, in addition, that it would have been appropriate to consider that X should also have been referred to substance misuse services. A practice question is whether this is best done in a crisis assessment or in the follow up after the event with a fuller assessment, such as would have been done by CAMHS. 5.8 No systemic or organisational issues were identified that impacted on the work done or decisions made. A question has been raised about the hospital policy for children over 16 being assessed and treated in an adult focussed Emergency Department. This review has been advised that this is not hard and fast. The Trust’s SUI review did not see this as a negative factor. X was seen initially by a paediatric nurse. He did not need to be admitted to a ward. If he had shown signs of sedation or had been unconscious, he would have been admitted. Following X’s death, the Hospital Trust has agreed that vulnerable 16 and 17-year olds who are seen in the Emergency Department with significant safeguarding or self-harm concerns can be given the choice to be admitted to a paediatric ward, if deemed suitable by the senior paediatric team, and that admission is required for treatment or observation. More generally – support to X prior to the overdose 5.9 One systemic issue which may have influenced X’s mental state given his high anxiety over flushing was what the family thought might have been a delay in re-referral to the Thoracic Team for assessment for ETS surgery and X not knowing that this had happened. The GP did refer X again in the September, as agreed. However, the September referral to the first hospital was not accepted and a second referral was then made. X and his parents did not appear to know about this. This review has also been told that he would not have been considered for such surgery until he was 18 years old and that a psychological assessment in relation to the impact of such surgery would have been required. 5.10 The School has raised the question of whether they should have been informed about X’s prior history of anxiety and occasional treatment by First Steps. This would have enabled them to keep a watchful eye on him or to have a greater understanding if he showed any anxious behaviour – which he did not. They have also raised a wider systemic question about the quality of information about students which transfers from primary to secondary schools – it is sometimes insufficient. That wider question is not the remit of this review. The Hackney Learning Trust, with Headteachers, may wish to explore that separately, if it is a common theme in secondary schools locally. The view formed here is that this is a proportionate issue and that there needs to be a judgement about what information is shared 17 between services. There is also the issue of consent. For a Year 7 student on transfer that is likely to be parental consent but for older children the young person may need to be consulted. The practitioners’ discussion suggested that there is soft information in the wider system that parents are reluctant to share information about children’s mental health with schools for fear that schools may make (unfair) judgements which may impact on decisions about admission or about student’s behaviour. 5.11 In relation to X’s use of drugs the school has said that, in hindsight, it has learned that it should have explored more fully the possibility of X’s own drug use when he was found with cannabis in school, rather than accepting that it belonged to someone else. He was suspended for a few days. This does raise the methodology of dealing with such issues and whether a safeguarding / preventive and exploratory approach is used or whether a firmer authoritative approach is used. A question is that while the law must be followed, and schools must be able to ensure order; young people may not open up about drug use if they see it as a ‘punishable’ issue. 5.12 This review has found that practitioners who met with X and his family were open and sensitive to his needs. He was able to express himself well and it is clear that practitioners heard and noted his thoughts and wishes. In the critical assessments after the overdose X’s experiences and problems were ascertained and considered appropriately based on his own account and some corroboration from parents. It is possible to question, in hindsight, whether he concealed some information – but he appeared open. The work done by all agencies met X’s ethnic and cultural needs, as white British. Information which has come to light after X’s death from which we can learn about local systems and responses and learning following an unexpected child death 5.13 We must be careful not to make judgements about the professional practice at the time based on hindsight, however there may be important lessons to be learned for the way in which services are designed and offered for young people like X and their families. 5.14 Local services responded appropriately to X’s unexpected death using the agreed processes set out in Working Together to Safeguard Children 2015 (now 2018)9, the London Child Protection Procedures and local processes. Two Rapid Response Meetings10 were convened; the first, to set in place support arrangements for family, peers and 9 Working Together 2018 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 10 London Child Protection Procedures Section 9.5 Rapid response service for unexpected child deaths http://www.londoncp.co.uk/chapters/unexpected_death.html#twelve_five 18 professionals and to agree what investigation and wider learning would be required. The second was a follow up to that. 5.15 It was noted in the first meeting that the police had taken X’s phone and Xbox for examination. However, there was no formal feedback through the local multi-agency child death review processes about what examination was done on them and what, if anything of significance, was found to understanding the antecedents to X’s suicide. The police did not attend the second Rapid Response meeting and no information was given to the Child Death Overview Panel when seeking to learn public health lessons from X’s death about what was found, or whether there was any other information which may have been of value for safeguarding other identifiable young people. The police advised the Inquest that they had searched X’s phone and discovered information about searches of suicide websites in the hours just before X’s death. As noted in a parallel Learning Review (Child Y), when a child takes their life there may be a need to review their digital footprint immediately to identify if any other young people may need to be safeguarded because of associated behaviour or ‘contagion’. Also, from a Child Death Review, public health and learning perspective, valuable wider lessons may be learned from understanding if a person who takes their life has accessed specific websites or social media, which may have influenced them. The CHSCB or Child Death Review Partners may wish to explore this issue further. 5.16 Another lesson from the Rapid Response process was that it was not routine practice to test for the presence of benzodiazepines (Xanax) following an overdose. It was not done for X as he was not displaying any negative symptoms and he had admitted to taking Xanax, which a test may have confirmed, but the test would have had limited value and would not have assisted with treatment as it cannot show the levels of benzodiazepines in the body, only that they are present. 5.17 Appropriate arrangements were put in place to provide support for the family, peers and the school. The school was supported by education psychologists in the immediate period after X’s death. A lesson that has been learned from this is that the Hackney schools’ critical incident plan did not specifically cover organisation responses to suicide. The Hackney Learning Trust may wish to review this. Such a response should consider risks of ‘contagion’ and increases in self-harm by other young people; although there is no clear evidence that this was the case following X’s death. 5.18 It is noted that First Steps, the local child and adolescent psychological service, reviewed their current patient caseload to risk assess any impact of learning of X’s death on young people known to the service, with a plan to increase vigilance and support where 19 necessary. This was good practice. Initiatives to support young people’s mental health in schools 5.19 Following X’s death and the later death of another child in the school, Child Y, the school with the local CAMHS and a charity set up in memory of both young people has introduced a range of initiatives to improve understanding about risks of drug-taking and to improve the opportunity to talk about stress and mental health. It is important that these lessons and approaches are shared across Hackney schools in a preventive way. 5.20 This review has been advised that the local CAMHS is progressing the Wellbeing and Mental Health in Schools initiative (WAHMS). This provides sessions from a CAMHS clinician in participating schools to develop closer links between the school and CAMHS, with training, consultation, support, signposting and liaison. The aim is to build capacity in the participating schools and to assist in increasing understanding of students’ mental health needs, assisting referrals to CAMHS of identified students and developing strategies for the school to help students in the school setting. These activities are part of each school’s Wellbeing Action Plan. This is an early intervention service to support students who may have a mental health need. There is also a Crisis Workstream which has identified additional resources for staffing by CAMHS, such as availability into evenings and at weekends, including at local hospitals. It is hoped that the crisis service will provide a more suitable service for young people who may otherwise go to Emergency Departments. There will also be additional sessions by CAMHS within Emergency Departments. It is understood that Hackney CCG and Council were unsuccessful in their bid to be a ‘trailblazer authority’ in response to Government initiatives to roll out the plans for improving the mental health of young people in schools with closer liaison, initiatives and resources between CAMHS and schools11. Drug use and alcohol use amongst young people 5.21 After X’s death intelligence came forward confidentially from bereaved peers who had been shocked by the tragedy. They spoke of patterns of drug taking and access to drugs by young people. It is clear that this is hidden from parents and teachers, for understandable reasons. From this softer information, which is hard to evidence, and from information from Young Hackney for this review it would appear that there are sub-cultures of drug taking 11 Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps; Dept for Health and Social Care and Dept for Education; July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf 20 amongst young people in the borough which will require a public health approach alongside a policing approach. 5.22 Young Hackney provides a Substance Misuse Service, commissioned by Hackney Public Health, which aims to prevent and or delay first drug use, or provide harm reduction information where required. This includes one to one support for young people, with two main functions: One-to-one Treatment (for those who present with experimental, recreational and functional use); and Prevention in the form of raising understanding and awareness around drug and alcohol use / misuse and reducing harm (with young people, professionals and parents). In relation to prevention activities before X’s death, schools were offered drop-in sessions for young people. X’s school had used this service. It is understood that X attended one of those sessions with a friend. 5.23 Since X’s death the service has provided sessions in X’s school within the PSHE curriculum and confidential drop-in sessions for students. It has also assisted the school in reviewing its Drugs Policy. The Service also supported a workshop for parents at X’s school covering YouTube music culture and the misuse of prescription drugs, such as Xanax. 5.24 With regard to a wider understanding of drug use by young people in the borough the Young Hackney Substance Misuse Service has provided this review with data showing an increase in known use of Xanax from a very low number in 2016/17 with a small but significant increase in 2017/18, including use by children aged 14 and 15. In 2016, Xanax was on the periphery of presentations to the service; in 2017 presentations increased to show an emerging (all be it a small) trend. Information provided by partner agencies to the Substance Misuse Service shows few services were seeing many presentations of Xanax misuse use within their respective services; but there is evidence that it has been a factor in a small number of recent cases. 5.25 The Service has used Facebook & Twitter to promote messages to young people and regularly raises issues about risk of Xanax use in drug and alcohol awareness classes (reaching 680 students in the academic year 2017/18). 5.26 As well as its own services the Young Hackney Service also promotes Talk to Frank12 a website which provides good information and advice about drug use. 5.27 Young Hackney, the Hackney Learning Trust and the CHSCB may wish to seek a formal report on the take up of drug awareness services in all schools in the Borough and promote 12 https://www.talktofrank.com/ 21 the lessons that have arisen from the responses in X’s school. 5.28 Information from the practitioners who attended the Focus Group for this review suggests that practitioners are not confident in terms of up-to-date knowledge of jargon and use of drugs by young people or of how to discuss drug use with young people. This is a wider systems issue relating to staff awareness, competence and confidence. Learning from the wider context of research and data about adolescent self-harm and suicide 5.29 A review into one young person’s death can give a picture of how local services may be operating and whether any improvements may be required. Lessons from X’s death will be considered locally alongside the reviews into the deaths of two other young people. However, the CHSCB and its partners must also seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services; as well as ensuring up-to-date knowledge and skills for practitioners at the front line. Appendix 3 of this report summarises some key research and data on Suicide by Children and Young People published in July 201713 and the NCISH Annual Report for 201814 which provides additional data. 5.30 The 2017 report sets out a number of key factors which can influence suicide in young people, alone or in combination. The report refers to ten common themes previously found in a previous study of suicide by children and young people up to 20 years of age. These are family factors, e.g. mental illness; abuse and neglect; bereavement and previous experience of suicide; bullying; suicide-related internet use; academic pressures especially related to exams; social isolation or withdrawal; physical health conditions that may have a social impact; alcohol and illicit drugs and mental ill health; self-harm and suicidal ideas. Of the suicides studied 51% of the young people were in education (school or college) and of those 43% were experiencing academic pressures (32% exam pressures). Another important factor in suicide was prior self-harm, 52% had a history of self-harm; cutting or overdose were the most common. 58% had previously expressed suicidal thoughts or hopelessness. 7% had had an episode of self-harm in the week prior to the suicide. 41% had a diagnosis of a mental disorder – most commonly an affective disorder such as bipolar or depression. 16% of the young people were receiving anti-depressants. The presence of one of these factors is not an indication that a young person will take their life but that they 13 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) Manchester: University of Manchester 2017 See section 9 of this report. 14 The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report. October 2018 University of Manchester See section 9 of this learning review for a summary of key issues. 22 may be in need of support and intervention. It will be seen that X does not meet all of these antecedents – although he had been experiencing anxiety and suicidal ideation but had not shared it with family or professionals, except anxiety, in relation to his distress at flushing and sweating. The national data serves to signpost indicators for risk assessment, treatment and commissioning options which should be considered in service planning and delivery. 5.31 The research notes that illicit drug use and no prior contact with services with regard to self-harm or suicidal thinking were common in young males (but also seen in young females to a lesser degree). This is the case with X. 5.32 It is not clear that X was experiencing acute academic pressures, one of the stressors/antecedents highlighted by the study. The school had no concerns and were not aware that he was worried about his studies; he was predicted to do well. His mother wondered whether the timing of his overdose and suicide may have been influenced by worries about his school work. 5.33 Another dynamic mentioned in the research as an antecedent is suicide related internet use. X’s mother has told this review that X accessed a suicide website; police reported on this to the Inquest. This was in the early hours after he had returned from hospital after the overdose. It appears to have been in crisis and as noted above, there are questions about X’s state of mind and emotional state at this time and whether his judgement might have been impaired from the drugs he had taken or whether he was affected by withdrawal symptoms or an increase in anxiety. It is understood from the police evidence to the Inquest that the forensic review of X’s phone searches, for the month prior to his death, did not show that he had been using the web to seek information about suicide (or other self-harm or mental health websites) in that period, before the fatal night. He told hospital staff that he had had suicidal thoughts for some months and it is known that he researched his physical ailment (flushing) to inform himself about causes and options. Use of the internet and social media in self-harm and suicide 5.34 Understanding this issue is important in a wider context than X to increase practitioners’ understanding of the importance of internet use in self-harm and suicide to see if there are opportunities to help young people make informed judgements about what they access and prevent a young person acting on what they have read or understood from the web. Recent media interest in this issue about a young person being influenced by self-harm images on Instagram15 is relevant here. It raises questions about how schools 15 https://www.theguardian.com/technology/2019/feb/04/instagram-to-launch-sensitivity-screens-after-molly-russell-death 23 and other services advise young people on safe internet use and risk, particularly in relation to self-harm, suicidal ideation and other mental health issues, such as eating disorders, where ‘advice’ provided by a website may not be neutral. 5.35 The Practitioners’ Group noted the importance of social media and digital media to young people and that their use cannot be ignored. They are an important influence in young people’s lives and a source of information (fake or real) on which young people base decisions. Young people increasingly have a relationship with and relationships through digital media. 5.36 Research published by Bristol University in May 201816 on using the internet for suicide-related purposes notes the following findings. “… This study explored the suicide-related online behaviour of two contrasting samples of distressed users, focusing on their purpose, methods and the main content viewed. In-depth interviews were conducted in the UK between 2014–2016 with i) young people in the community; and ii) self-harm patients presenting to hospital emergency departments. Data were analysed using methods of constant comparison. Suicide-related internet use varied according to the severity of suicidal feelings. In the young people sample, where severity was lower, use was characterised by disorganised browsing without clear purpose. A range of content was ‘stumbled upon’ including information about suicide methods. They also pursued opportunities to interact with others and explore online help. Self-harm patients were a higher severity group with a history of suicidal behaviour. Their use was purposeful and strategic, focused around ‘researching’ suicide methods to maximise effectiveness. They made specific choices about content viewed; many consulting factual content in preference to user generated accounts, while help content and communication was avoided. Findings indicate further action is necessary to improve online safety. Also, novel online help approaches are needed to engage individuals experiencing suicidal crisis. Awareness of the nature of suicide-related internet use and how this may reflect the status of an individual’s suicidal thinking could be beneficial to clinicians to promote safety and indicate risk.” 5.37 The NSPCC Report: On the edge; ChildLine spotlight: suicide17 provides useful information about what young people say to and seek from ChildLine when thinking about suicide or self-harm. Chapter 2 covers: The role of the internet. It notes that young 16 Using the internet for suicide-related purposes: Contrasting findings from young people in the community and self-harm patients admitted to hospital; Biddle et al, University of Bristol, 24 May 2018 https://research-information.bristol.ac.uk/en/publications/using-the-internet-for-suiciderelated-purposes(e2b9be6a-89b7-4a12-ad8d-226fa4426048).html 17 On the edge; ChildLine spotlight: suicide; NSPCC, 2014; https://library.nspcc.org.uk/HeritageScripts/Hapi.dll/search2?CookieCheck=43416.5807625926&searchTerm0=C5246 24 people seeking advice about suicide prefer to do so over the internet rather than by phone and often use other websites and/or join in suicide and self-harm discussion fora and chat-rooms. The young people feel that they can make relationships with other young people experiencing similar problems to them; and so do not feel so alone. Some had used other websites to research painless methods or where to buy products, if considering overdosing. Some reported being triggered by harmful content that they had seen online ‘normalising’ suicidal behaviour. Some gave examples of seeking support through social media but experiencing bullying and hate messages which actively encouraged them to self-harm or kill themselves. The report advocates the need for social media sites to have a duty of care to young people to protect young people from harmful content. The report makes a number of recommendations about actions to support young people. These include actions to promote peer to peer support, advice for parents and carers, advice for professionals, and recommendations for government and service providers. 5.38 X’s mother told this review of the site that X had accessed just before his death. It is a well-constructed and attractive site; created by a person who has considered suicide in their own right. It has a warning that it is only for those over 18, but that is easily dismissed. While encouraging hope and advising that users seek help it also has a drop-down list of methods and analyses research into their efficacy and techniques. A troubled person can easily skip the help section and click straight on to detailed instructions on how to take your life effectively. The site has links to other sites. Another site that this author trialled did have a pop-up chat window asking if I ‘needed help’. I declined the chat not wanting to explore what kind of help – dissuasive or persuasive - that might be. Both sites looked as professional as other sites that we use all the time for information. 5.39 A key public health question is to consider how do we help young people distinguish between different types of site offering advice and support in the fields of self-harm and suicide? The SCR ‘Child J’, Lambeth SCB, 2016 raised this issue with regard to sites aimed at eating disorders – so-called ‘Pro-Anna’ sites aimed at advocating anorexia. How do we help troubled young people understand that such sites may not be neutral? How can we increase knowledge about the use of these sites? 5.40 There is also a role to understand more fully the young person’s digital footprint after death (or serious self-harm) – not only to protect identifiable others in social groups, who may also be at risk, but to increase understanding of how troubled young people use such sites in order to provide public health and educative responses. 5.41 A final question is: how well informed are frontline practitioners about such sites, to enable 25 them to provide guidance to troubled young people or to consider asking questions about access to such sites in assessments (this was raised in the practitioners’ group)? 5.42 Local suicide and self-harm prevention strategies should consider the importance of the internet and social media as a dynamic or influencer in young people’s behaviours and from this what public health approaches can be devised to mitigate their more negative aspects. Supporting Peers’ Awareness and Peers as Supporters 5.43 X’s mother has thought about what may have helped X. She wondered if he would have spoken more easily with peers about his anxieties. She thought that he and boys like him (more-so than girls) would not easily go to staff or counsellors. She raised a question about peer mentors or advisors as a possibility. It is clear, in hindsight, that X’s peers had noted some issues about his behaviour but this was not shared until after his death; and there was no information that they had thought him to be self-harming or suicidal. One friend does seem to have taken him to a drop-in session on drug use. 5.44 The NSPCC/ChildLine report: On the edge, 2014 notes the importance of peers (and family members). ChildLine had seen a year on year increase in the number of young people seeking advice about a friend or family member where they had concerns about suicide. Being worried about a peer can be a burden in several ways – anxiety, constant focus on the friend, not feeling equipped to help, feeling that if they sought help it might lead to suicidal acts, and other impacts. If that vulnerable friend is then successful in suicide (or serious self-harm) it can leave the peer feeling guilt that they have not been able to prevent it. 5.45 The NSPCC/ ChildLine report has a section on Encouraging peer to peer support. This includes increasing understanding of mental health, helping young people understand how they can support their peers, teaching active listening skills and where the peer supporter can get help. This does not necessarily mean establishing organised peer support or mentoring schemes but supporting young people who are already trying to help their friends; behaviour which is going on all the time informally. 5.46 The Anna Freud Centre is trialling approaches to organised peer support schemes in schools and community organisations18, on behalf of the Government, to promote young 18 Peer Support for Children and Young People’s Mental Health and Emotional Wellbeing Programme https://www.annafreud.org/what-we-do/schools-in-mind/our-work-with-schools/peer-support-for-CYP-s-MH-programme/ 26 people’s mental health and emotional wellbeing. The approach is to be evaluated through independent research. It may be premature, therefore, to seek to introduce formalised peer support schemes or mentoring, except through these trials, until more is tested about the methods, outcomes and pro and contra-indications. This is something that could be considered and planned for, however. 5.47 Informing and advising cohorts of young people through general mental health awareness and wellbeing programmes in schools is an approach that can raise awareness and help students in looking out for and supporting their friends; or in a worst-case scenario knowing when to report worrying behaviour, even anonymously. Schools or other services will then need a safe process for following up such reports. Boys / young men, anxiety and seeking or providing help 5.48 X’s mother raised a question about how young men can be encouraged to seek help. X had had brief episodes of therapeutic help when he was younger and they were reported to have been successful. He declined referral for CBT in relation to his chronic and excessive blushing. Was the reluctance to talk about his worries and suicidal thoughts with his mother and father or friends a gender issue, an adolescence issue or an anxiety issue? Possibly all. In the work that X’s mother has done in the school she has seen it as a gender issue and suggested that boys may find it easier to talk in boys’ groups rather than mixed groups. She also thought that going to a counsellor was seen as something that boys are reluctant to do. 5.49 The NCISH 2017 report on Suicide by Children and Young People noted gender in-balances. Fewer males under 20 had been known to local authority services or CAMHS prior to suicide. 5.50 This may be a public health education issue. It is hoped that the initiatives to increase understanding about and responses to mental health and wellbeing in schools will help address such a gender-cultural issue, if it exists. It may be useful to offer gender specific tutor groups or support groups and ensure that there is access to male tutors or counsellors as well as to undertake work on feelings and well-being for young men. 27 6. Recommendations A number of the recommendations made in the parallel review for Child Y are relevant to this review of X and are included here from 6.6. New recommendations arising from this review are 6.1 to 6.5 and part of 6.6. 6.1 The Hackney Public Health Service, with local Police and Young Hackney should review the need for and availability of local public health programmes, including awareness raising for young people, parents and professional staff about the acquisition, use of and impact of illegal drug use by young people. (See paragraphs 5.21 – 5.28) 6.2 Local primary, acute and mental health services should review guidance and training for practitioners (including adult focussed practitioners) who undertake mental health assessments of young people to equip assessors to consider the role of drug and alcohol use in mental health, self-harm and suicidal thinking. This should include how to access information about the risks of withdrawal on cognitive and affective ability and impulsivity in risk assessments. (See paragraphs 5.21 – 5.28) 6.3 The Hackney Learning Trust should review with schools how information about a child’s vulnerability, including issues of emotional or mental health can be passed on to the new school when a child transfers, to ensure that the new school is able to support the child. This should include reassurance to parents that such information will be without prejudice. The Learning Trust should consider providing a specimen draft Mental Health Policy for use within schools which will include an explanation to parents on terminology in mental health and the school’s approach to young people taking time out from lessons to attend mental health services. Such a draft Mental Health Policy should seek to learn from the national trail blazers, trialling the approaches from the Green Paper on Children’s Mental Health in Schools. (See paragraph 5.10 and paragraphs 5.19 – 5.20 and the DfE announcement on the work of the trailblazers19) 6.4 The City and Hackney Safeguarding Children Board should review its Internet Safety Policy and guidance to local agencies to ensure that they cover risk from social media sites which purport to give advice about mental health, drug use, eating disorders, self-harm and suicide and how parents and professionals can be assisted to help young people recognise such risks. The policy should also consider the issue of culture and ‘contagion’ among young people sharing information which may be harmful to them. (See paragraphs 5.35 – 5.41) 19 https://www.gov.uk/government/news/one-of-the-largest-mental-health-trials-launches-in-schools 28 6.5 The Hackney Clinical Commissioning Group should review the provision of Child and Adolescent Mental Health specialists in Emergency Departments of local acute hospitals to ensure that there is sufficient cover at night and at weekends. This should include an audit of the numbers of young people requiring a mental health assessment and the percentage of those seen by an adult focussed practitioner. 6.6 The Health and Wellbeing Board should expedite the completion and publication of a Local Strategy for Prevention of Suicide by Young People and consider whether this should be a Strategy to prevent self-harm and suicide by young people. The Board should set a timescale for completion and set out how the strategy will be implemented, monitored and reviewed; what key indicators should be collected regularly about young people’s mental health, self-harm, attempted suicide and suicide; and what the local resources are. A Head Teacher representative should be co-opted to the Steering Group. (Child Y Recommendation) That strategy should include local approaches and actions on how to support children and young people in assessing the content of websites which purport to give advice about mental health, self-harm or suicidal thinking. (See paragraphs 5.34 – 5.42) (See also 6.4 above) 6.7 The Clinical Commissioning Group, Local Authority (including the Director of Public Health and Director of Education) and the East London Foundation Trust Child and Adolescent Mental Health Service with local Head Teachers and Chairs of Governing Bodies (or their equivalents) should build on the positive links between schools and CAMHS started in the WAHMS project. A strategy and action plan should be devised to set out steps for this and be presented to the CHSCB and the Health and Wellbeing Board. (Child Y Recommendation) 6.8 The CHSCB should consider convening a conference for Head Teachers and Chairs of Governors (and their equivalents) or working with their local representative bodies to promote the lessons from this review and the parallel reviews of young people’s deaths by suicide. The purpose of such a conference / liaison would be to raise awareness and learning between schools about children’s mental health and risk. This should include the national picture with regard to increasing understanding about children’s mental health in schools and the local lessons from this and other reviews; including study and exam stress, bullying, impact of social media and peer pressure. Such an event would build strong links to the WAHMS project. It could promote a review of whole school mental health approaches or policies, including a specimen approach. It could also provide guidance and develop mentors on Immediate School Recovery and Support Programmes in relation to child 29 deaths, by suicide. The CHSCB should consider inviting the charity created by X’s mother and the mother of Y, another young person to assist with such a conference or wider liaison in order to promote the lessons from one school more widely. (See the revised guidance Mental health and behaviour in schools, November 2018 published by the Department for Education20.) (Child Y Recommendation) 6.9 The CHSCB should seek reassurance from partners that there is in place, a robust and coordinated response to suicide by a young person, in the context of identifying and mitigating the impact on other children and young people. This is likely to be as part of the revised Rapid Review process following a critical incident, as set out in Working Together to Safeguard Children 2018, chapter 4. This should include if and how a young person’s digital footprint will be assessed to see if there are indications that others may be at risk of harm. (Child Y Recommendation) 6.10 The CHSCB should ask the Director of Education to review the generic guidance to schools on responding to critical incidents and its accessibility to ensure that it covers child deaths and support to peers and schools, including where a student takes their life. (Child Y Recommendation) 6.11 The CHSCB or successor Child Death Review Partners21 (when they come into place) with the Child Death Overview Panel should consult with the Metropolitan Police and the Local Coroner about the investigation of child deaths by suicide in relation to access to electronic equipment used by the young person which may give a greater understanding of influences on the young person and their state of mind, over time. This will enable the Child Death Review Process to build up a clearer public health picture of the possible use of specialist websites, online advice services, social media and other important influencers on young people’s decision-making and impulsivity. (Child Y recommendation) 6.12 The CHSCB should provide an anonymised summary report of the key lessons from this review for frontline practitioners and first line managers across the multi-agency network. The CHSCB should also consider providing bespoke briefings and materials for key designated and named leads in local services to enable them to cascade the lessons from this report and the parallel reports to frontline practitioners. 20 https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2 21 Working Together to Safeguard Children 2018; Chapter 4: Improving child protection and safeguarding practice; & Chapter 5: Child death reviews 30 7. Appendix 1 The City & Hackney Safeguarding Children Board response to X’s death 7.1 Following notification of X’s death, Rapid Response meetings were convened in line with the City and Hackney Safeguarding Children Board’s process for managing unexpected child deaths22. 7.2 The Independent Chair of the CHSCB decided not to initiate a SCR. The National Panel of Independent Experts23 concurred with his view that the case did not meet the criteria as defined in 5(2)(a) and (b)(i) and (b)(ii) of the Local Safeguarding Children Board Regulations 2006. There was no evidence noted that abuse or neglect were either known or suspected factors in X’s death. 7.3 The Independent Chair agreed that a multi-agency case review should be undertaken to analyse what happened, why, and to identify any practice improvements that should be made by organisations to safeguard and promote the welfare of children and young people. 7.4 The multi-agency review was to be line with the principles for learning and improvement set out within Working Together 2015 (4:11) and conducted in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 7.5 Agencies were asked to comment specifically on: a) Were practitioners aware of and sensitive to X’s needs? Was risk identified and was planning effective to ensure X’s needs were met appropriately? 22 The Child Death Overview Panel 23 The Serious Case Review Panel 31 b) When, and in what way, were X’s experiences ascertained and taken into account when making decisions about the provision of services? Was this information recorded? c) When, and in what way, were the parent’s experiences ascertained and taken account of when making decisions about the provision of services? Was this information recorded? d) What were the key relevant points/opportunities for assessment and decision making in relation to X and his family? Did assessments and decisions appear to have been reached in a timely, informed and professional way? Did the agency liaise/engage appropriately with other agencies? e) Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments and was the family signposted to appropriate support? f) Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services? g) Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of X and family, and were they explored and recorded? h) Were senior managers or other organisations and professionals involved at points in the case where they should have been? i) Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? j) Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? k) Was there sufficient management accountability for decision making? 32 Appendix 2 Xanax https://www.medicines.org.uk/emc/files/pil.1657.pdf Extracts from the Medicines leaflet supplied with Xanax: What Xanax is and what it is used for? Xanax is a tranquilliser containing the active ingredient alprazolam. Alprazolam belongs to one of a group of medicines called benzodiazepines. Benzodiazepines affect chemical activity in the brain to promote sleep and to reduce anxiety and worry. Xanax tablets are only used to treat severe anxiety and severe anxiety associated with depression. Xanax is not recommended for the treatment of depression. Xanax tablets should only be used for short-term treatment of anxiety. The overall duration of treatment should not be more than 12 weeks including a period where the dose is gradually reduced (this is called dose ‘tapering’). Children and adolescents Do not give this medicine to children and adolescents below the age of 18 years because safety and efficacy have not been established. Xanax with food, drink and alcohol It is important not to drink any alcohol while you are taking Xanax, as alcohol increases the effects of the medicine. If you stop taking Xanax Always see your doctor before you stop taking Xanax tablets as the dose needs to be reduced gradually. If you stop taking the tablets or reduce the dose suddenly you can get ‘rebound’ effects which might cause you to become temporarily more anxious or restless or to have difficulty sleeping. These symptoms will go away as your body re-adjusts. If you are worried, your doctor can tell you more about this. Dependence and withdrawal symptoms It is possible to become dependent on medicines like Xanax while you are taking them which increases the likelihood of getting withdrawal symptoms when you stop treatment. 33 Withdrawal symptoms are more common if you: - stop treatment suddenly - have been taking high doses - have been taking this medicine for long time - have a history of alcohol or drug abuse. This can cause effects such as headaches, muscle pain, extreme anxiety, tension, restlessness, confusion, mood changes, difficulty sleeping and irritability. In severe cases of withdrawal you can also get the following symptoms: nausea (feeling sick), vomiting, sweating, stomach cramps, muscle cramps, a feeling of unreality or detachment, being unusually sensitive to sound, light or physical contact, numbness and tingling of the feet and hands, hallucinations (seeing or hearing things which are not there while you are awake), tremor or epileptic fits. Other side effects that may occur are: Very common: may affect more than 1 in 10 people - Depression - Sleepiness and drowsiness - Jerky, uncoordinated movements - Inability to remember bits of information - Slurred speech - Dizziness, light-headedness - Headaches - Constipation - Dry mouth - Tiredness - Irritability Common: may affect up to 1 in 10 people - Loss of appetite - Confusion and disorientation - Increased sex drive (men and women) and erectile dysfunction - Nervousness or feeling anxious or agitated - Insomnia (inability to sleep or disturbed sleep) - Problems with balance, and unsteadiness (similar to feeling drunk) especially during the day - Loss of alertness or concentration - Inability to stay awake, feeling sluggish - Shakiness or trembling - Double or blurred vision - Feeling sick - Skin reactions - Change in your weight Uncommon: may affect up to 1 in 100 people - Feeling elated or over-excited, which causes unusual behaviour - Hallucination (seeing or hearing things that do not exist) - Feeling agitated or angry - Incontinence - Cramping pain in the lower back and thighs, which may indicate menstrual disorder - Muscle spasms or weakness Concern about young people using Xanax as a recreational drug In the last two years there has been an increase in concern about young people using Xanax as a recreational drug and sourcing it through the ‘dark web’ or dealers, with increasing risk to themselves of harm or death – see for example: http://www.bbc.co.uk/newsbeat/article/39870899/what-you-need-to-know-about-xanax https://www.theguardian.com/society/2018/feb/05/xanax-misuse-uk-dark-web-sales-health 34 8. Appendix 3 Relevant findings from research into suicide by children and young people 8.1 Understanding that there may be other young people like X gives impetus to learning and improvement, to seek to develop local preventive responses and public health approaches when there may be earlier signs in a young person’s life. There are two relevant research studies led by The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness. The first is a review of suicide by young people under 25. The second is the Annual Report 2018, covering a wider field and age range but with additional relevant findings to this review. Not all the antecedents and themes identified in the cohort studied were applicable to Y, but some similarities can be seen. The full analysis from the research is too detailed to be included here but should be examined when considering local suicide prevention strategies for young people. 8.2 Findings from Research Report: Suicide by Children and Young People; The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness: July 201724. The research report gives a view of suicide by children and young people under 25 in England and Wales in 2014 and 2015. 8.3 The Key Messages from the 2017 Research are: Suicide in children and young people is rarely caused by one thing; it usually follows a combination of previous vulnerability and recent events. The stresses that we (the research) have identified in young people before suicide are common in young people; most come through them without harm. Important themes for suicide prevention are support for or management of family factors (e.g. mental illness, physical illness, or substance misuse), childhood abuse, bullying, physical health, social isolation, mental ill-health, and alcohol or drug use. Specific actions are needed on groups (we have) highlighted: (1) support for young people who are bereaved, especially by suicide (2) greater priority for mental health in colleges and universities (3) housing and mental health for looked after children (4) mental health support for LGBT young people. 24 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017. https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf 35 Further efforts are needed to remove information on suicide methods from the internet; and to encourage online safety; especially for under 20s. Suicide prevention in children and young people is a role shared front-line agencies; they need to improve access, collaboration and risk management skills. A later, more flexible transition to adult services would be more consistent with our findings of antecedents across the age range. Services which respond to self-harm are key to suicide prevention in children and young people and should work with services for alcohol and drug misuse, factors that are linked to subsequent suicide. 8.4 Common themes identified in the research were: Family factors (such as mental illness) Abuse and neglect Bereavement and experience of suicide (by others) Bullying Suicide-related internet use Academic pressures, especially related to exams Social isolation or withdrawal Physical health conditions that may have social impact Alcohol and illicit drugs Mental ill health, self-harm and suicidal ideas 8.5 The research sought to identify common antecedents for the young people in the cohort who were aged below 20, by gender. The common antecedents were: Previous contact with social care/local authority services (at any time) A history of self-harm Contact with CAMHS (at any time) Self-harm by cutting Psychiatric diagnosis (Being or having been) a looked after child Bereaved Experienced abuse 36 Bullied Self-harm by self-poisoning Contact with youth justice/police (at any time) Excessive alcohol use All of these antecedents were found to have been more prevalent for females – but were also present for males. Illicit drug use No prior contact with services These two antecedents were more prevalent in males under 20 – but were also present for females. 8.6 What the research findings say about prevention: “The circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversity and high-risk behaviours in adolescence and early adulthood, and a ‘final straw’ event.” The significant event may not seem severe to others and thus risk may be hard to recognise by family or professionals unless the history of past and present problems is also taken into account. 8.7 A model for prevention is suggested for use at different ages and stages (see Figure 12 in the study for more detail of the model). The possible interventions include: supporting vulnerable young children and their families promoting mental health in schools to address bullying and online safety services for self-harm and alcohol and drug misuse in young people healthy workplace and campus initiatives, and crisis services. 8.8 Other dynamics to be noted in considering support and preventive services for particularly vulnerable young people are: Bereavement services, especially when young people have been impacted by suicide 37 of another person Internet safety (particularly for under 20s) in relation to websites which give information about suicide methods Greater staff awareness in front line services of suicide awareness and better multi-agency co-operation Self-harm should be seen as a crucial indicator of risk suicide and should be taken seriously – even if it appears minor. This may be the most important area for local development with regard to suicide prevention for young people; including psycho-social assessment, prompt access to psychological therapies and services for co-occurring problems such as alcohol or drug misuse. Additional Findings from the NCISH Annual Report October 201825 8.9 For children and young people under 20 who took their lives: 41% had been in contact with services (mainly CAMHS – 34%) in the previous three months. Mental illness was reported in 40%. The most common primary diagnoses were affective disorders, especially depression. Academic pressures overall were noted in 63%; with exam pressures being 27%. Previous self-harm was found in 49% and suicidal ideas (at any time) was 59%. 8.10 In 29% of all cases (any age) there had been a recent history of self-harm in the preceding three months. For under 25s this was 39%, with a higher proportion for females (51%). Patients with a history of self-harm more often had a diagnosis of personality disorder compared to other patients. 8.11 For patients who died as a result of suicide who had a recent history of self-harm (within three months) immediate risk of suicide at the professional last contact was judged to be low or not present in 76% (all ages) – lower than the risk for patients with no recent history of self-harm. Risk was also assessed as lower in this group when seen a week prior to death; or in the longer-term risk assessments. Author note: The research does not seek to explain this lower scoring in risk assessments for those with a recent history of self-harm. It would appear to be a dynamic to be considered in depth when undertaking such risk assessments where self-harm has been present. 25 National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk 38 8.12 What could have reduced the risk (all ages)? Clinicians views were: Closer supervision, closer contact with the patient’s family, improved compliance with treatment, a decrease in caseloads and access to psychological treatment. (See paragraph 170 of the report.) 9. Appendix 4 Reading National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017. https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf Transforming children and young people’s mental health provision, December 2017 A Green Paper https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: A Green Paper and Next Steps, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf Mental health and wellbeing provision in schools; Review of published policies and information Research report; October 2018 Rebecca Brown; Department for Education https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/747709/Mental_health_and_wellbeing_provision_in_schools.pdf Young Minds Report on: A&E Attendance by young people with psychiatric conditions almost doubled in five years – new figures October 2018 https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/ Mental health and behaviour in schools – revised guidance November 2018, Department for Education https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2 39 10. Useful Organisations / Resources Talk to Frank https://www.talktofrank.com/ Provides good information and advice Young Hackney Substance Misuse, Advice and Referral Line 0208 356 7377 available 9am to 9pm Monday to Friday Kooth from XenZone, is an online counselling and emotional well-being platform for children and young people, accessible through mobile, tablet and desktop and free at the point of use. https://www.kooth.com/ ChildLine https://www.childline.org.uk/ Papyrus https://papyrus-uk.org/ Charity/campaigning organisation to promote awareness and research to prevent suicide by young people Papyrus-Hopeline UK https://papyrus-uk.org/hopelineuk/ Helpline and website for young people – and others who are worried about them Samaritans https://www.samaritans.org/ Young Minds https://youngminds.org.uk/resources/ |
NC049392 | Sexual assault of a 4-year-old girl in December 2015. Molly was sexually abused by her mother's partner who was convicted of rape and other sexual offences involving Molly and others. Sentenced to 18 years in prison in 2016. Family previously known to police, health services and children's social care. Mother had a history of depression and abusive relationships. Mother's partner known to police for previous offences. Molly presented at GP with a genital rash and bleeding on previous occasions. Section 47 investigations launched twice in 2015. Mother's partner arrested following allegation of grooming, but released on the same day. Molly and sibling moved to live with maternal grandparents. Molly reportedly acted fearful in mother's partners' presence. Disclosed sexual abuse during second forensic medical. Molly and sibling moved to live with foster carers and made subject of care orders. Ethnicity of family not stated. Methodology used: Significant Incident Learning Process (SIL) model. Learning includes: GPs should consider sexual abuse when presented with unexplained genital bleeding; in assessments, sufficient consideration should be taken of historical information and not only presenting issues; relying on conviction rates as an indicator of a person's offending, or seriousness of the risk they pose, leads to a significant underestimation of potential risk. Recommendations include: assessments of families with children at risk should consider historical background information about parents and carers; assessments of individuals with a history of domestic abuse should consider the current relationship may also become abusive; social care staff should have sufficient information to challenge unsafe assumptions about the level of risk based on previous offending for adults who pose a risk to children.
| NORTHUMBERLAND SAFEGUARDING CHILDRENS BOARD SERIOUS CASE REVIEW USING THE SIGNIFICANT INCIDENT LEARNING PROCESS MOLLY INDEPENDENT REVIEWERS: Mark Dalton Nicki Pettitt February 2017 Confidentiality statement This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with the NSCB/SCR chair. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved CONFIDENTIAL March 2017 Page 2 of 29 INDEX INDEX ............................................................................................................................. 2 1. INTRODUCTION .................................................................................................... 3 The Key Principles of the Significant Incident Learning Process (SILP) ............. 4 THE PROCESS ............................................................................................................. 4 2. KEY EPISODES ....................................................................................................... 8 KEY EPISODE 1 - Liaison between Police Scotland and Northumbria Police June 2014 ............................................................................................................................ 8 KEY EPISODE 2 - Injury to Molly 27th April 2015 ........................................................ 9 KEY EPISODE 3 – S47 Assessment April 2015 .......................................................... 12 KEY EPISODE 4 - Liaison between Police Scotland and Northumbria Police April 2015 .......................................................................................................................... 15 KEY EPISODE 5 - 2nd Referral to Children’s Social Care 9th December 2015. Allegation of Child Sexual Abuse .......................................................................... 16 3. ANALYSIS ............................................................................................................ 17 4. EMERGING THEMES ........................................................................................... 18 5. EXAMPLES OF POSITIVE PRACTICE ................................................................... 25 6. RECOMMENDATIONS ....................................................................................... 27 7. TERMS OF REFERENCE…………………………………………………………….…29 CONFIDENTIAL March 2017 Page 3 of 29 1. INTRODUCTION Introduction to the Serious Case Review 1.1 Molly was 4-years-old when it became known that she was the victim of sexual assault by her mother’s partner. In December 2015 Molly told her mother and social workers during a child protection enquiry that mother’s partner had taken her into a room and hurt her. At the time of the disclosure mother and her partner were living apart. 1.2 Mother’s partner was convicted on numerous counts of rape and other sexual offences involving Molly and others. He was sentenced to 18 years in prison in April 2016. The Decision-Making Process 1.3 The circumstances were considered against the criteria set out in Chapter 4 of Working Together to Safeguard Children 2015: 1.4 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCB’s. This includes the requirement for LSCB’s to undertake reviews of serious cases in specified circumstances. Regulation 5(1) I and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. Where a case is being considered under regulation 5(2)(b)(ii), unless there are no concerns about inter-agency working, the LSCB must commission an SCR. 1.5 In this case a child had been seriously harmed and abused. There was also some concern about the quality of interagency working between different agencies. CONFIDENTIAL March 2017 Page 4 of 29 The Key Principles of the Significant Incident Learning Process (SILP) 1.6 The key principle of SILP is the engagement of frontline staff and first line managers as active participants in the review process, alongside members of the Children Safeguarding Board Serious Case Review Panel, and Designated and Specialist Safeguarding staff. The engagement of frontline staff and first line managers enables a higher level of involvement in the review process and therefore a much greater commitment to learning and dissemination of the lessons from the review. 1.7 The process focuses on understanding why individuals acted in a certain way. It highlights the factors in the system that influenced their decision making at the time. The review process is separate from any potential grievance process or disciplinary action, but seeks to promote open and transparent learning from practice and improve inter-agency working. It also highlights what is working well and examples of good practice. 1.8 This engagement comprises: • Independent Management Reports (IMR’s) being commissioned from all the agencies/providers engaged with the subject of the review during the period under review. This identifies the single agency learning and any recommendations for improvement. • Learning Events involving many of the practitioners, managers involved directly in the case, along with Safeguarding Lead Professionals coming together for a day to discuss the case. • All the IMR’s being shared with the participants at the Learning Events, • A draft Overview Report which critically reflects the management reviews and includes the comments and perceptions of the participants in the Learning Event, • A second Learning Event at which the first draft of the Overview Report is debated. THE PROCESS Terms of Reference See appendix 1 CONFIDENTIAL March 2017 Page 5 of 29 Engagement with the family 1.9 Molly’s mother met with one of the independent reviewers and a representative from Northumberland Safeguarding Children Board during this review and discussed the events leading to the discovery of the abuse of her daughter. The final version presented to the Northumberland LSCB will be made available to her prior to publication. Background information 1.10 Molly’s family first moved to Northumberland in February 2014, at that time the family comprised, Molly, her mother, and mother’s partner. The relationship with Molly’s birth father had ended and the relationship between Molly’s mother and her new partner was relatively new; they had only been in a relationship since January 2014. 1.11 The family registered with two separate GP practices in a relatively short period; the change of practice being the result of a change of address. They became known to Northumberland Health Visiting Services in February 2014. A Tynedale Health Needs Assessment1 was completed which recorded that Mothers previous relationship with Molly’s father had been abusive. Mother also shared that she had been distressed by some text messages from her ex-partner and was worried he now knew where she lived. The Health Visitor provided advice which included the contact details of agencies which could offer additional support. The usual screening questions about any current issues of domestic abuse were not asked as mother’s partner was present at the interview. Molly’s mother was the younger of two siblings and had a history of depressive illnesses and other health problems. The most important relationship was with her own mother, who was seen as a source of support at the time, but someone who could also dominate Molly’s mother and has significant health needs of her own. 1.12 The family transferred to a second Health Visitor in March 2014 because of their change of address. A second health needs assessment was completed, but again questions about any current domestic abuse were not asked as the partner was present during the interviews. There were no other concerns raised by the assessment. 1.13 In July 2014 Molly was taken to the GP with a rash and soreness to her genital area, a problem which had lasted intermittently for two weeks. 1 Tynedale Health Needs Assessment Tool (THNAT) is a structured assessment tool which covers nine specific areas, including socio-economic factors, parental health, substance abuse and domestic violence, previous children, parents’ experience of childhood and family life, support, coping mechanism, and interests. CONFIDENTIAL March 2017 Page 6 of 29 The GP prescribed medication for thrush. This was the first presentation of a symptom that would re-occur several times in the next year. 1.14 The first contact with Northumberland Children’s Services occurred in August 2014 following a referral from the Crisis Resolution and Home Treatment Team2 relaying concerns about maternal grandmother. The Crisis Team reported that maternal grandmother had full time care of Molly and they were concerned about her state of mind. Maternal grandmother also stated that her relationship with her partner was under stress. A referral was made to Children’s Services who contacted Molly’s mother, she told Social Workers that Molly lived fulltime with her and her partner and only stayed occasionally with maternal grandmother. 1.15 Mother and her partner were invited to the office to discuss the Crisis Teams’ concerns. The couple were offered advice about how witnessing abusive behaviour could impact on children but no further role for Children’s Services was identified. This intervention was recorded on an information and advice record; which meant that no home visit or direct assessment of Molly undertaken. The Health Visitor was still marginally involved and discussed the case with Children’s Services on several occasions. 1.16 In November 2014 Moly was seen again by the GP with a recurrent rash on her inner thighs and ‘clicking’ hips. An irregular rash was noted over her thigh and buttocks. No explanation was discussed regarding this and the GP was more concerned about the reported ‘clicky’ hip. The hip problem was later assessed by the health visitor in the home environment. Although Molly’s mother and her partner reported that Molly cried with pain if she walked any distance and complained of soreness, the Health Visitor observed Molly running, walking, and climbing with ease. 1.17 Molly’s sibling was born in November 2014. The pregnancy had been uneventful and all anti natal appointments were kept. However, by the six weeks’ post-natal check, Molly’s mother admitted to feeling low and stated she had suffered post-natal depression following her previous pregnancy (Molly). The family had moved home two days prior to the birth which had been stressful. 1.18 The Health Visitor arranged an appointment with the GP in January 2015. The GP consultation did not explore in any depth why Molly’s mother was depressed. There is nothing documented in the GP records to demonstrate how mother’s low mood/depression impacted on her parenting skills and ability to cope with two very small children at home. The GP records noted that the ‘husband’ was helping with house chores 2 The Crisis Resolution and Home Treatment Team is a team which offers assessment and home treatment for people experiencing a mental health crisis. CONFIDENTIAL March 2017 Page 7 of 29 and prescribed anti-depressants for Mother. Other options were also explored such as counselling and further Health Visitor support. The GP agreed to see her again in two weeks, however there was no follow up appointment and mother was not seen again for over three months. 1.19 There was some family support from the maternal grandmother who lived close by, although this was not without its own difficulties as she was contending with her own personal challenges. In February 2015, the Health Visitor began fortnightly ‘listening visits’ and became concerned as mother was quiet, not eating much, difficult to engage and had run out of anti-depressant medication. Practice Messages – Background information 1.20 The lack of an accurate record of the status of mother’s partner by both GP practices is an important oversight; he was variously referred to as “father”, “husband”, “boyfriend” and “partner”. The first practice also assumed that he was Molly’s birth father. If accurate baseline information is not collected at the point when patients register, then inaccuracies can assume the status of “facts”. 1.21 Neither the GP or Health Visitor considered the history of the rash in July 2014 followed by presentation with rash to inner thighs and buttocks in November 2014 as being a possible cause of her soreness. It is possible that that the second GP was unaware or the earlier presentation. The focus was on Molly’s hip pain as being the main cause for concern; this is understandable because joint symptoms in young children can potentially be serous and need to be investigated. 1.22 In the light of subsequent events, the significance of the individual and family histories of Molly’s parents became more apparent. It subsequently became known that Molly’s mother’s partner was the oldest of 4 children, and there had been previous concerns about him displaying sexually harmful behaviour and alleged sexual assaults on other young females. The victims in all cases withdrew their complaints. Records indicate that he had a learning difficulty, and was known to have problems controlling his temper when he was growing up. Although this did not prevent him working, it would seem he had difficulty in establishing personal relationships and was something of a loner. CONFIDENTIAL March 2017 Page 8 of 29 2. KEY EPISODES 2.1 The SILP methodology has adapted the term “key episodes” from the systems approach to Serious Case Reviews developed by the Social Care Institute of Excellence (SCIE). A key episode can be a single event or a series of events over time where there were key changes in the circumstances of the case which require further analysis. 2.2 A key episode can be good or problematic and the use of the word “key” emphasises that this is not a list of every event in a person’s life; rather it is intended to shine a light on those professional involvements which seem significant in understanding the decisions made at the time. 2.3 Inevitably there is some overlap between key episodes, due to the complex interface between different services. KEY EPISODE 1 - Liaison between Police Scotland and Northumbria Police June 2014 1st occasion - June 2014 2.4 An email contact from Police Scotland in June 2014 was the first-time Northumbria Police were aware of mother’s partner living in the area. The initial email request was for assistance in tracing mother’s partner regarding ongoing enquiries into sexual offences. 2.5 The request was straightforward; confirmation of his current address and to obtain contact details for him. The Northumbria Police Inspector made direct contact with his Scottish counterpart who confirmed that they believed mother’s partner was in a relationship with her. There was no expectation that he should be arrested at this point. 2.6 The emails between the Detective Constable in Scotland and the Inspector in Northumbria on 4th June 2014 show that the full extent of mother’s partner’s sexual offending, (which included two charges of rape, one attempted rape and a sexual assault against a child) was shared with Northumbria Police. However, this information was not given to the Police Officer sent to the family home to check whether he lived at that address. 2.7 The visit was somewhat routine, Molly’s mother stated she was fully aware of the allegations against her partner, but believed that they were untrue, and motivated by an ex-girlfriend trying to get him into trouble. At the time of the enquiry, the Police Officer was not aware of Molly and no mention of her was made to the Officer during his conversation with Molly’s mother. CONFIDENTIAL March 2017 Page 9 of 29 2.8 Following confirmation of the address Police Scotland (with the assistance of Northumbria Police) arrested mother’s partner on 12th June 2014 on suspicion of rape of a female aged 16 or over. He was taken back to Scotland and charged with rape and released on bail without conditions or residency monitoring. Practice Messages – Key Episode 1 2.9 The quality of the liaison between Police Scotland and Northumbria Police was significant because it concerned the transfer of information regarding the potential risk Molly’s mother’s partner may pose to children. The context of the information exchange was an attempt by Police Scotland to ascertain mother’s partner’s whereabouts to investigate alleged sexual offences in Scotland. 2.10 However, during the exchanges neither Police Force appears to have considered that mother’s partner may pose a risk to Molly or her unborn sibling. His previous history of abuse and offences against children appears to have been overlooked in assessing risk. 2.11 The system for exchanging emails at “Force level” is one where emails are sent to a Force-wide hub and then distributed to the relevant district and subsequently allocated to an officer who is then responsible for that piece of work. Once work has been delegated through the chain of command, individual officers communicate freely between Police Forces to clarify information and report progress. Although important details were shared, the information was not subject to any analytical discussion that might have led to a strategy to manage the risks posed by mother’s partner. On this occasion, important details concerning mother’s partners offending history were not passed down the chain of command, and the primary task of locating him subsumed any wider concerns about the potential risk he might pose. 2.12 Because Molly’s mother was neither a complainant or witness there was no formal mechanism for informing her of the outcome of the court hearing in Scotland. Furthermore, there is no system in place for passing on court disposals between Police Forces; an individual officer needs to be actively monitoring a person to know what their current status is. Because of this Northumbria Police were not informed of the outcome of the hearing in Scotland, or that Mother’s Partner had returned to Northumberland without any bail restrictions or residency monitoring. KEY EPISODE 2 - Injury to Molly 27th April 2015 2.13 Molly was taken to the GP by her mother on the morning of 27th April with symptoms of a genital bleed. There was no obvious injury and after CONFIDENTIAL March 2017 Page 10 of 29 telephone consultation with a paediatric SHO, a decision was made to refer Molly to the Children’s Assessment Suite at the local hospital A&E department. It subsequently transpired that Molly should have been sent to the Paediatric assessment unit at the local general hospital which is where the Paediatricians were based who would review Molly. Molly was later referred to the Paediatric Forensic Network (PFN), a specialist service located at the Regional Hospital some distance from the original hospital. 2.14 The reason for the bleeding could not be conclusively established. On examination, there was some evidence of bruising and a possible injury. Molly also said to the doctor that she may have hurt herself by falling on her shoe, although her speech was indistinct and the doctor could not be sure she had understood Molly correctly. While this may seem unusual, such injuries have been documented previously in other girls, and so this seemed a possible explanation for the cause of the injury. The explanation was also partly confirmed by Molly’s mother who said Molly had sandals with a rim around the sole and she had seen blood on them. 2.15 What was unknown to the doctors in different hospitals were the differing descriptions of the discovery of Molly’s injury. 2.16 Initially the GP had been told that mother and partner were together with Molly as her nappy was being changed. Mother had gone downstairs for a moment and on her return noticed a “gush” of blood from Molly’s vagina. Therefore, in this account it suggests that mothers partner was left alone with Molly for a short time and the blood noticed during a nappy change. 2.17 Later, the nursing and medical assessments at the referring hospital recorded that Mother’s partner had gone upstairs and found Molly lying on her changing mat with blood on her hands and bleeding from her vagina. 2.18 Finally, the Paediatric Consultant recorded a third version of events; that mother was downstairs and has heard Molly cry out. She found Molly with blood on her hands. In this version, her partner was out at the shops at the time of the incident. Although the Consultant paediatrician had the referring information from the hospital she did not have the original account given to the GP. 2.19 From these differing accounts, it is impossible to establish whether mother’s partner was part of the nappy changing event, or even in the house at the time. It would also seem that none of the adults were aware of the possible injury caused by the sandal until Molly mentioned it to the paediatrician at the PFN. CONFIDENTIAL March 2017 Page 11 of 29 2.20 Further tests were undertaken, including swabs for STI’s which were all negative. 2.21 The doctor then contacted Children’s Social Care to inform them that she had seen Molly and on balance, she felt that this was probably an accidental injury caused by Molly falling on her sandal. Social Care requested that Molly be admitted overnight as it was not entirely clear what had happened. The initial medical opinion was that this was disproportionately cautious given the presentation of a happy child with a likely medical explanation for the injury. However Social Care had obtained some information from the Police regarding the history of sexual offending by mother’s partner and took the view that they would prefer Molly to be admitted overnight to enable further assessments to be made. 2.22 The doctor discussed the information about her partner with Molly’s mother, who acknowledged that she was aware of the allegations, but they were made by an ex-girlfriend and motivated by jealousy. Molly was transferred back to a local Hospital (this was to enable Molly’s sibling to be brought to the hospital to be with mother) and admitted overnight with the agreement of Molly’s Mother. 2.23 The doctor’s findings were documented and written up the same evening and a follow up appointment booked for one week later. The following week Molly attended a review appointment on 6th May 2015 with the doctor in the Children and Young People’s Clinic. Molly was observed to be a “chatty and confident little girl. She remembered the toys from the previous week and played appropriately for her age”. Her injuries were seen to be healing satisfactorily. 2.24 The specialist nurse supporting the doctor liased with the allocated Social Worker and was informed that Molly’s mother had suggested a further possible cause of the injury; a toy car with a broken and sharp edge. The social worker also provided further information regarding the extent of mother’s partners sexual offending. 2.25 The Consultant Paediatrician’s considered opinion was that, based on the available evidence the injury was on balance an accidental injury. However, the doctor included various caveats that “other causes of genital injury including abusive causes cannot be fully ruled out” and “further assessment is needed to understand the risks that mother’s partner poses to the family and the degree of protection that mother can provide”. CONFIDENTIAL March 2017 Page 12 of 29 Practice Messages – Key Episode 2. 2.26 Molly had been seen by 4 different doctors in 3 different hospitals, from the initial appointment with the GP at 10 o’clock in the morning. She did not have her final medical examination until 9 o’clock that evening. 2.27 Each successive doctor was unaware of all the accounts given previously regarding the circumstances of how the injury had initially being identified. (the Consultant Paediatrician had the information from the referring Hospital but not the information from the GP.) 2.28 As a general observation, for a family dependent upon public transport or ambulance, the journeys between hospitals can add significantly to the delay in examining an injured child and potentially increase levels of stress for the child and her parent, although this was not an issue in this case. 2.29 The Consultant Paediatrician and Social Care Team Manager discussed their different perceptions of the risk posed to Molly and agreed a change of plan, which protected her overnight – this was good practice. 2.30 The conclusions of the Consultant Paediatrician who examined Molly were accepted as virtual “proof” that the injury sustained on 27th April was accidental. A close reading of the doctor’s report shows that given the position of the injury, general presentation, and lack of discomfort the doctors’ opinion was that on balance this was likely to be an accidental injury caused by falling on her sandal. However, the report also noted that the possibility of an abusive cause could not be fully ruled out, and would need to be re-visited in the light of further information. 2.31 This was another occasion where a face-to-face strategy discussion would have been extremely useful for all the professionals working with the family to share information, and most importantly the limits to the medical opinion that the injury was accidental. KEY EPISODE 3 – S47 Assessment April 2015 2.32 The section 47 investigation3 commenced on 28th April, the day mother and her two children returned home from hospital. 2.33 Important information was obtained through Northumbria Police regarding criminal behaviour by mother’s partner in Scotland. While he had no previous convictions, there were 12 pending prosecutions, 3 of 3 Under Section 47 of the Children Act 1989, if a child is taken into Police Protection, is the subject of an Emergency Protection Order or there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm, a Section 47 Enquiry is initiated. This is to enable the local authority to decide whether they need to take any further action to safeguard and promote the child’s welfare. CONFIDENTIAL March 2017 Page 13 of 29 which were for rape of a person over the age of 16 and 1 rape, which was stated to be ‘domestic related’. There was no information relating to offences against children. Because there was no reported history of offences against children and because the medical view was that the injury to Molly were most likely to be accidental, the police played no active part in the section 47 enquiry.4 2.34 As part of this investigation mother’s partner was asked to leave the home while the enquiry was undertaken. A written working agreement was put in place to clarify the expectation that he would not reside in the family home and would not have unsupervised contact with the children for the duration of the enquiry. As an additional safeguarding measure the Social Worker arranged for unannounced visit to the family from the Children’s Support Team and, out of hours, by the Emergency Duty Team. 2.35 Mother and partner agreed to these stipulations under duress and now stated that mother’s partner had not been in the family home when the injury took place (this was different from the 2 earlier accounts which were given to the GP and Hospital). 2.36 The working agreement was subsequently modified to allow mother’s partner to visit the home for 1 ½ hours each day, with the stipulation that his contact with the children was supervised by mother. Despite the family’s reluctance all the evidence is that they complied with this agreement. 2.37 During the section 47 enquiry mother maintained that her partner was not present when the injury was caused and she believed it had been caused accidentally by Molly falling on either her sandal or a toy car. 2.38 The section 47 investigation raised concerns about Molly’s school attendance and speech and language delay, although at 3 years old she was below statutory school age. There was limited information regarding Molly’s health, but nothing that raised any concerns. 2.39 There was little background information obtained about Molly’s mother, or her partner, and what was known was self-reported and not verified by contact with health agencies or Social Care in Scotland. Also, there was no attempt to contact Molly’s birth father. 2.40 Both the Health Visitor and the GP had contact with the family during the time Children’s Social Care were undertaking the section 47 investigation. The Health Visitor undertook a home visit on the 13th May as part of a monthly review of the family. The following day Molly was taken to the GP 4 Section 47 enquiries are either “joint” involving the Police and Social Care or “single agency” and undertaken by Police or Social Care alone. The decision should be made through a strategy discussion and not decided unilaterally. CONFIDENTIAL March 2017 Page 14 of 29 with a recurrence of the genital itching problem first recorded in July 2014. This visit had been prompted by the school who noticed Molly passing urine frequently and showing signs of discomfort. 2.41 During the section 47 enquiry all the presenting risk factors regarding parenting were addressed to some extent; the information from the Scottish Police concerning the allegations against mother’s partner was that the offences were against adults, he was not on bail for the offences and further decisions about how the case against him would proceed would not be made until later in the year. School attendance issues were also addressed during the enquiry and significantly improved following a meeting between the school and parents in mid-May. The Consultant Paediatrician’s opinion was that the injury to Molly was most likely accidental and there were no other health or other concerns which challenged this view. 2.42 The conclusion of the section 47 enquiry was that there was insufficient evidence to initiate a child protection conference, but the case would remain open and a more comprehensive child and family assessment would be undertaken within the recommended 45 days. 2.43 The extended assessment period also provided a rationale for remaining involved with the family after mother’s partner had been allowed back in the home. He returned to the family on 8th June and the case remained open until 22nd July as no further concerns had emerged at this time. The fact that Molly’s mother, and the maternal grandmother were fully aware of her partner’s criminal history was considered an additional safety factor and would make them more alert to risky situations in the future. 2.44 The conclusions of the assessment were based on direct observation, interviews with the parents and maternal grandmother and limited input from School and the Health Visitor. The observations of parenting by social work staff (including out of hours and unannounced visits) were positive and seemed to show a warm and loving relationship. The parents consistently denied any problems or difficulties either in their relationship or with parenting their children. 2.45 A further unresolved event occurred on 20th July 2015 when Molly’s maternal grandmother rang the surgery for an urgent appointment. She described Molly as curled up in pain and screaming (which the receptionist could hear). As there were no appointments available, she was advised to dial 999 or take the child to A&E, she agreed to do the latter. However, there is no record that Molly was seen by any doctor, or taken to Hospital following this incident. CONFIDENTIAL March 2017 Page 15 of 29 Practice messages Key Episode 3 2.46 The decision to undertake further assessments following the conclusion of the section 47 enquiry was taken because both the social worker and team manager were uneasy and did not feel they properly understood what was happening in the family. 2.47 While further exploration of the issues within the family was an appropriate response to the concerns raised but not addressed by the section 47 enquiry, again it would have been useful to convene a multi-agency strategy meeting to share perceptions and pool knowledge of the family at this point. 2.48 The workers involved have acknowledged that intuitively they felt that they did not have a full picture of what was happening in the family. This underlines the importance of background and historical information in providing a context for current behaviour and have the knowledge to be able to challenge and probe parental patterns of behaviour where necessary. The failure to obtain this important history meant that the assessment could not be fully completed. 2.49 It would seem that the GP who saw Molly in mid-May was not aware the previous history of genital rashes. Although the discharge letter from the Hospital had already been received regarding the genital injury, there is no evidence the GP saw it. and if so, whether sexual abuse was considered a possible cause of her symptoms. It should also be noted that this was a different GP from the one who had seen Molly in 2014. KEY EPISODE 4 - Liaison between Police Scotland and Northumbria Police April 2015 2nd occasion – 28th April 2015 2.50 As part of the section 47 enquiry Northumbria Police contacted Police Scotland in the early hours of the 28th April for information regarding Molly’s parents. Within 2 ½ hours Police Scotland were able to provide two intelligence reports regarding sexual offences in Scotland (the attached reports concerned mother’s partners offending against his previous partner and did not contain any information on his history of sexual offending and specifically no involvement of a child or concerns about any child). However, the email went on to state that: “as there are no safeguarding issues” further information would need to be requested during office hours from the relevant area. The email gave a named Officer, fully conversant with mother’s partners offending, who could be contacted. However no further contact was made by Northumbria Police to follow up this information. CONFIDENTIAL March 2017 Page 16 of 29 2.51 The failure to identify the offence history as a “safeguarding issue” is puzzling, but Northumbria Police were not reliant on Police Scotland to inform them of mother’s partners offending; a PNC (Police National Computer) check revealed that he had 12 pending prosecutions, including 2 alleged rapes of females over the age of 16 and one other count of rape. The email exchanges 9 months earlier also detailed his offending history including risks to children. KEY EPISODE 5 - 2nd Referral to Children’s Social Care 9th December 2015. Allegation of Child Sexual Abuse 2.52 A second referral was made to the Social Care Emergency Duty Team by the Police on 9th December 2015. They had arrested mother’s partner in relation to grooming allegations involving a 14-year-old female. He was released on bail the same day and the decision was subsequently made by the Crown Prosecution Service not to charge.5 A Child Concern Notification (CCN) was sent from Northumbria Police to Children’s Social Care, but this did not initially identify mother’s partner as living in a home with children. This important link was made by the Social Workers receiving the CCN. 2.53 Northumbria Police were contacted on 10th December by mother after her partner had arrived at the home address, as he had no conditions on his bail he believed he was entitled to live there. Given he was on bail for grooming offences Molly’s mother was concerned whether the children would be safe around him. At this point, Molly’s mother decided to move the children to their grandmother’s address. The Police advised mother’s partner to leave the family home and made a referral to Children’s Social Care. 2.54 Molly’s mother and grandmother gave an undertaking that Molly and her sibling would remain at the grandparent’s home and that her partner would have no contact with the children. 2.55 Social Care began a second section 47 enquiry and visited the family on the 11th December 2015 and found that Molly’s mother had moved the family to their grandparents home due to her fear of her partner. Molly’s step grandfather informed Social Care that Molly was afraid of her mother’s partner and became distressed in his presence. He described that she was fearful and would cower and scream when her mother’s partner came into the room. Maternal grandmother also reported that 5 The CPS would have charged Mother’s Partner with this offence as the evidential threshold was met. However, in view of his substantial custodial sentence any subsequent trial was deemed not be in the public interest as this would not affect his current sentence. CONFIDENTIAL March 2017 Page 17 of 29 Molly was sore in her genital area, and recently had an infection that could have been thrush and was always complaining of stomach pains. 2.56 It had been agreed that this section 47 enquiry would be a joint investigation by police and social workers. A Strategy Meeting was held and Molly had her second forensic medical on 11th December. Molly was spoken to, and she disclosed that she had been sexually abused by her mother’s partner. 2.57 Molly and her sibling remained in the care of her mother and grandparents for a while and subsequently moved to live with foster carers and both were made the subject of Care Orders. 3. ANALYSIS 3.1 Safeguarding Molly was a complex multiagency task, and within the practice described in this review there are some examples of decisive, analytical, and child-centred multiagency practice. 3.2 However, close examination of the details of the case also show that sometimes the lack of collaboration and exchange of information led to prolonging the time Molly was at risk from her abuser and delayed its final discovery. It is ironic that mother’s partner’s arrest for a crime he did not commit led to the discovery of his abuse of Molly. Despite her grandparents alleged concerns, they had not shared these with any agency, and thus Molly may have continued to be at risk. 3.3 It should be noted that domestic abuse had not featured in the assessments by any agency of the relationship between Molly’s mother and her partner, quite the opposite in fact; as the family were seen to have a loving and warm relationship. Also, no information had been provided in the routine screening questions that had been asked by the Health Visitor or Midwife. Therefore, the extent to which her partner could exercise coercive control over Molly’s mother and apparently convince her that previous allegations of sexual assault were the invention of a jealous ex-partner was not explored. 3.4 The lack of assessment and focus on Molly’s mother’s partner would seem to be a further example of the lack of assessment of significant males in families; where the workers became over-reliant on Molly’s mother for information about her partner.6 It was known that his previous relationships have been violent, yet Molly’s mother was rarely seen without him and there were few opportunities to talk to her alone about their relationship. 6 A lack of assessment of significant males is a recurrent them in Serious Case Reviews. See for example: Hidden men: learning from case reviews and New learning from serious case reviews: a two year report for 2009 - 2011 CONFIDENTIAL March 2017 Page 18 of 29 The full extent of his previous offending was not known to professionals in Northumberland at the time because of the problems in obtaining information from Scotland 3.5 This case is also notable in respect of the Social Worker’s reluctance and unease in terminating their involvement at the conclusion of the section 47 investigation in April 2015. In the face of some convincing arguments that the injury was explicable and probably accidental and lacking any hard information about concerns about the adults, the Social Worker nonetheless felt that the risks in the family were not properly understood. 3.6 A more comprehensive child and family assessment was commenced, but unfortunately ran out of steam, partly because of the difficulty in obtaining historic information from the GP and Police Scotland. The lack of a multiagency meeting compounded the isolation of the Social Worker and an opportunity was lost to consider the findings of the Social Work investigation alongside information from the school, GP, and Health Visitor. 3.7 It would have been helpful to produce a Child in Need plan, which would have formed the framework for multiagency meetings and facilitated exchanges of information between professionals (but not all professionals as it wouldn’t have included police in the same way a strategy meeting or Child Protection conference would have). While some agencies believed that Molly was a ‘child in need’, it would have been easy to verify whether this was the case; the fact that no meetings were held to review the plan clearly demonstrated that no such plan was in place. 4. EMERGING THEMES Failure to consider child sexual abuse 4.1 Following Molly’s visit to the GP in April 2015 due to the unexplained genital bleed, the possibility of sexual abuse was not recorded by any doctor until the paediatric forensic examination by the last of 4 doctors who saw her that day. 4.2 There are no records to indicate that the GP considered sexual abuse as part of a differential diagnosis, although the available guidance7 would have advised him to do so, and equally importantly, accurately record those concerns. If the GP had been considering the possibility of sexual abuse the correct course of action would be to notify Children’s Social Care. 7 Protecting children and young people. The responsibilities of all doctors p13 CONFIDENTIAL March 2017 Page 19 of 29 Lack of a Strategy Discussion and Initial Child Protection Case Conference 4.3 During the events which unfolded on the night of 27th April 2015, there was little time for anything that could be considered a strategy discussion. However, the case did raise some difficult questions which would have benefited from face-to-face collaboration and challenge between the relevant agencies. Other than providing information from Police Scotland, Northumbria Police had no further involvement in this case, although as an agency they were in possession of relevant information concerning the potential risk posed by mother’s partner in the light of his previous offending history. 4.4 The decision that this section 47 enquiry should be a single agency was contrary to the multiagency guidance8 for investigating alleged sexual abuse. The decision appears to have been made primarily by the police, based on the partial information they had received from Police Scotland about mother’s partners offending history. The possibility that he may pose a risk to children does not seem to be actively considered or discussed between agencies. 4.5 It is clear from the paediatric assessment of the injury to Molly, that the doctor’s opinion was that, on the balance of probability it was caused accidentally. However, the Paediatrician was not aware of the changes to the story of how the injury was caused, nor the offending history of mother’s partner. This information may have affected the doctor’s conclusion regarding the cause of the injury. 4.6 Finally, the intuition of the social worker and team manager responsible for the section 47 enquiry was that, despite the conclusion of the medical examination, they did not fully understand the scenario of how Molly was injured and they were uneasy in accepting that it had been caused accidentally. 4.7 Paradoxically, the lack of hard facts seems to have inhibited the process of seeking a multiagency discussion. The criteria for convening an initial child protection conference are twofold; firstly, that child protection concerns are substantiated, and secondly that the child continues to be at risk of significant harm. Based on these criteria it is clear that Molly did not reach the threshold, which is why children Social Care took the decision to undertake a further child and family assessment. However, the lack of a multiagency discussion at this stage may represent something of a missed opportunity to test professional opinions, and seek further information. 8 Northumberland LSCB Procedures Manual - Section 47 Enquiries section 7 CONFIDENTIAL March 2017 Page 20 of 29 4.8 A further issue concerns the recording of the investigation process. Northumbria Police have no record that they participated in any strategy discussion. However, because of the limitations of the Social Care recording system, the contact between the agencies was recorded as if a strategy discussion had taken place. This was not an attempt to deceive, but there is a clear risk in a recording system which does not accurately reflect what has happened. Communication between Police Forces 4.9 The exchanges between Police Scotland and Northumbria Police were key in the perception of risk posed by mother’s partner. Information was sought on 2 distinct occasions; in June 2014 when Police Scotland requested the assistance of Northumbria Police in locating mother’s partner, and subsequently assisting with his arrest. The second occasion occurred in April 2015 when Northumbria Police requested background information on mother’s partner from Police Scotland. 4.10 The first exchange involved contact between a Detective Constable in Scotland and a neighbourhood Police Inspector in Northumbria in June 2014. The purpose of this contact was to ascertain the correct address for mother’s partner to enable him to be interviewed as part of the investigation into alleged sexual offences. Once it had been confirmed that he was living in the area, the Detective Constable in Scotland gave brief details of mother’s partners alleged sexual offences. 4.11 The Inspector from Northumbria Police immediately queried whether they should be concerned about his presence in the area, and specifically asked whether mother’s partner should be considered a risk to children. While the response from the Detective Constable in Scotland, does not specifically answer this question, he provides sufficient detail of the alleged offences (which include allegations of child sexual abuse) to raise concerns about the risk mother’s partner posed towards children. 4.12 Crucially, this information was not shared with the Police Constable sent to visit the address; he was only informed that Police Scotland were investigating an allegation made by a former girlfriend of mother’s partner. This limited remit was inadvertently confirmed by Molly’s mother, who stated she was aware of the allegations and believed they were made by his ex-partner to cause trouble. 4.13 Further emails were exchanged to arrange support for the arrest interview, and transport of mother’s partner back to Scotland to be formally charged on 13th June 2014. However, Police Scotland did not subsequently inform Northumbria Police that mother’s partner had been released on bail without any conditions or further monitoring. The Police Scotland policy is to inform victims when a suspect is released, because CONFIDENTIAL March 2017 Page 21 of 29 Molly’s mother had not made a complaint, she was not considered a victim and therefore there was no procedure in place for informing Northumbria Police, or any other agency in England of the decision. 4.14 The second exchange of emails occurred on 27th April as part of the section 47 enquiry with a request for information from Northumbria Police to Police Scotland. By the time the request was made, the Police had logged that Molly had been examined by the Paediatrician and there was a plausible explanation for her injury. Police Scotland received the request just after midnight. Due to it being received outside of the usual office hours the Police Scotland response only contained limited details of 2 intelligence reports concerning mother’s partner’s sexual offending in Scotland, which only referred to his offending against an ex-partner. The full extent of his offending, including allegations made relating to children does not seem to have been available to the respondent from Police Scotland at that time. Clear details were provided of the relevant Officer who could provide further information regarding mother’s partners offending history and the status of any ongoing investigation, however, these were not followed up by Northumbria Police. 4.15 It would have been helpful if the outcome of mother’s partners Court appearances in Scotland had been reported back to Northumbria Police. At this point, there was still active communication between the two Police Forces; in fact, the Detective Constable in Scotland thanked his English colleagues for their help on the same day mother’s partner was released by the court without any bail conditions. The actions of Police Scotland suggest that they did not consider mother’s partner, despite his offending history to be a risk towards children. This resulted in a 10-month period; between June 2014 and April 2015 when Northumbria Police were unaware that mother’s partner was residing in the area on bail and facing charges for sexual offences. Assessment 4.16 If there is a common theme in the assessments undertaken regarding Molly, it is that they have tended to focus on presenting issues without sufficient consideration of historical information. 4.17 The child and family assessment undertaken by Children’s Social Care following the section 47 enquiry in April 2015 did not obtain information from Social Care in Scotland. It would have been good practice to contact Molly’s natural father, and to obtain information regarding her mother’s current partner’s previous offending history. The assessment was also thwarted by the lack of information from the GP surgery who did not respond to requests for information. CONFIDENTIAL March 2017 Page 22 of 29 4.18 However, it is to the credit of the Social Worker and Team Manager involved that they kept the case open in an attempt to complete the assessment and build a working relationship with the family. At the time. Molly’s mother, maintained that her partner was not in the home when the injury occurred (in contradiction to the story given at the time of the incident) and it was therefore unfair of Social Care to insist that her partner live elsewhere. 4.19 The passage of time tends to play a part in the assessment of risk; by the time the case was closed there appeared to be a tacit acceptance of the following “facts”: a) mother’s partner was not at home at the time of the injury, b) that the cause of the injury was accidental was accepted by all agencies, c) there were no indications of any problems in the relationship between the adults, d) the family were believed to be compliant in keeping to the working agreement, e) family were working positively in some areas and there had been a significant improvement in Molly’s school attendance. 4.20 The family appeared to be stable and the quality of the relationship and home conditions were thought to be good. For Social Care to insist that mother’s partner remained outside of the home, would have seemed contrary to the evidence of their assessment. 4.21 Northumberland LSCB has produced useful guidance on undertaking assessments9 which would have been a useful checklist and guide for a complex assessment. In addition, the NSPCC guide: Ten pitfalls and how to avoid them10 provides a research based critique of mistakes commonly made in assessments. Lack of risk assessment regarding sexual offending 4.22 There does not appear to ever have been an assessment of mother’s partner in relation to his sexual offending as an adolescent. Undue emphasis and inappropriate reassurance was placed on his known history of sexual offending against adults - the fact that he was not known to have recent child victims should not have been interpreted as him posing no risk to children. The assessment of risk appears to have been primarily focused on the criminal definitions of his offending to the extent he was only considered a risk if he had been convicted of an offence. 9 Single Assessment Framework - Pre-birth to 18 years 10 Ten pitfalls and how to avoid them. NSPCC 2010 CONFIDENTIAL March 2017 Page 23 of 29 4.23 It is widely accepted that to rely on conviction rates as an indicator of the extent of a person’s offending, or the seriousness of the risk they pose, would lead to a significant underestimation of potential risk. 4.24 In assessing the risk Molly’s mother’s partner posed undue emphasis was placed on his offences being against older females. This conclusion is not supported by the research into sexual offending; equal, if not more, emphasis could have been placed on the relationship between an abuser (particularly relevant given his history of sexually harmful behaviour), and victim and the opportunity posed by living as part of a family with a child. 4.25 The child and family assessment undertaken by Children’s Social Care did not successfully seek out historical information regarding his previous offending history. The available background information would have supplied information about previous attempts to work with the family by Social Services and details of sexual abuse. 4.26 However, Northumberland Children’s Social Care did try in vain to get clarity about his offending history from Police Scotland; several attempts were made to get information from different sources but at no point did any of the available information suggest he had been accused of offences against children. Significance of wider family 4.27 Molly’s maternal grandmother played an important role in Molly’s childhood. She was clearly an important support for Molly and played a significant role in supporting Molly’s mother, both emotionally and practically. More importantly, she offered refuge and respite to Molly and her sibling when Molly became frightened of her mother’s partner. 4.28 While she may have been perceived as a protective factor. It is also the case that she did not report Molly’s apparent, fearful reaction against her abuser to the Police or Children’s Social Care. It is possible to imagine that she had divided loyalties between her daughter and granddaughter, but in the light of the previous concerns there is no doubt that she had a responsibility to report these appropriately. Professional curiosity. 4.29 The authors of the independent management reports (IMR’S) commissioned for this review were asked to note, specific evidence of professional curiosity shown by their staff when engaging with this family. Without exception, all agencies could identify where this was CONFIDENTIAL March 2017 Page 24 of 29 demonstrated, but they were also able to recognise that its use was inconsistent and on some occasions, it was notably absent. 4.30 It is important therefore to establish a shared definition of professional curiosity and it meaning across a multiagency audience. Expectations of competence in this area vary between agencies; one expects the Police, with their training in investigation to be more practiced than other professionals. However, this review demonstrates that it is equally important for GP’s, Social Worker’s and Health Visitors to have skills in challenging and probing information. 4.31 The Munro Review of Child Protection recognised that professional curiosity needs to be embedded in the practice mindset of those working with families and is, in part, how a worker exercises the “respectful uncertainty” advocated by Lord Laming following his review into the death of Victoria Climbie in the 1980s. 4.32 “Respectful Uncertainty” is generally recognised to mean the process of corroborating and validating information provided by a service user to establish that it is truthful and has been correctly understood. Laming was directing his comments specifically as Social Workers, but the principle applies equally to other professions: “The concept of “respectful uncertainty” should lie at the heart of the relationship between the social worker and the family. It does not require social workers constantly to interrogate their clients, but it does involve the critical evaluation of information that they are given. People who abuse their children are unlikely to inform social workers of the fact. For this reason at least, social workers must keep an open mind.”11 4.33 The need to develop skills in professional curiosity has arisen alongside an increased awareness of issues such as disguised compliance where cooperation is superficial and follows the line of least resistance, but without a meaningful engagement. Consequently, the desired change is not achieved, and seemingly cooperative parents continue to place their children at risk. 4.34 Professional curiosity may describe the tenor of the relationship with service user, but to develop the necessary skills and develop an open and questioning mindset, workers need regular effective supervision to test out the strength of their assessments and highly developed interpersonal skills to challenge families and other service users in a way which does not lead to a breakdown in the working relationship with a family. 11 The Victoria Climbie Inquiry p205 CONFIDENTIAL March 2017 Page 25 of 29 4.35 Very few LSCB’s provide separate training on the topic of “professional curiosity”12, for most LSCB’s however, it would be more effective to include it in the context of other multi-agency child protection training. This also give the opportunity for its importance to be reinforced on different training courses. It should also form part of training offered to supervisors by their respective agency. 5. EXAMPLES OF POSITIVE PRACTICE 5.1 As part of the process of completing their Individual Management Reports (IMR’s) agencies were asked to identify examples of good practice as well as areas for improvement. Inevitably Reviews will concentrate on organisational, systemic, and individual failings. However, this should not deny the opportunity to also learn from examples of practice that was competent, sensitive and based on sound professional judgement. a) The discussion between Consultant Paediatrician and Social Care Team Manager out of hours on 27th of April 2015. This was an example of professionals being able to challenge decisions, share information and agree a different course of action to promote effective safeguarding. b) The Health Visitors practice of offering “listening visits”; recognising Molly’s mothers’ vulnerability particularly in relation to domestic abuse and offering practical advice and support about how to report concerns to the Police and details of local support groups. c) The Social workers’ and Team Managers’ professional judgement leading to the decision to keep the case open following the section 47 enquiry. The Social Worker made tenacious efforts to obtain background information about offending. Although the efforts did not produce results at the time, the effort and creativity put into this should be recognised. d) Written agreements were well used to manage the case and underpin a safety plan. They were clear and explicit about the safeguarding concerns and expectations. The family did not agree about the need for restrictions on contact but they did appear to be compliant. The Children’s Support Team were used appropriately to monitor the family circumstances and ensure that mother’s partner was not spending time in the family home when he was not supposed to. In terms of 12 Brighton and Hove LSCB and Wakefield and District LSCB are two Boards which provide information on professional curiosity. CONFIDENTIAL March 2017 Page 26 of 29 effective practice. It is important to note that proactive and regular social work visits reinforced the written agreements. e) The quality of the out of hours’ response - despite being reliant on staff working full-time during the day. Information was obtained, analysed, and subsequently used to raise concerns about the cause of the injury and garner agreement for keeping Molly in Hospital overnight. There is no evidence to suggest that the safeguarding and protection of Molly was adversely effected by the incident occurring out of hours. f) The identification of Mother’s partner from the grooming allegation and linking him with the family where there were vulnerable children. It should be recognised that it was the individual action of the allocated worker which made the connection between the person named in the grooming investigation as Molly’s mother’s partner. Although the link would have been made eventually, this realisation allowed steps to be taken to safeguard Molly and her sibling immediately. CONFIDENTIAL March 2017 Page 27 of 29 6. RECOMMENDATIONS Recommendations arising from the review. 1. Strategy Meetings/discussions should always be held in cases of suspected Child Sexual Abuse and recorded as such. 2. Face to face multi-agency strategy meetings should be held in complex cases13. Northumberland LSCB should review local multi-agency threshold guidance to ensure that it provides adequate guidance regarding strategy meetings. 3. Northumberland Children’s Social Care should seek to improve the quality of its assessments in three specific areas: a) They must ensure that Assessments of families where children are at risk should consider historical information about the background of parents and carers. Wherever possible, this information should be corroborated and self-reported information should be treated with a degree of caution. b) Assessments of individuals with a history of domestic abuse should always consider the possibility that the current relationship may also become abusive. Assessments should also consider that an abusive relationship need not be overtly violent; and may also include coercive control and intimidation. c) Adults who pose a risk to children may require additional or forensic assessment, however from the evidence of this review it is important that social care staff have sufficient information to challenge unsafe assumptions about the level of risk based on previous offending. 4. All agencies should accept that while the key responsibility for obtaining and analysing this information rests with Social Care, they also have a key responsibility in supporting the assessment process by providing information, specialist knowledge, explanation, and interpretation where necessary. 5. Northumberland LSCB should seek assurance from constituent agencies that the constraints of their recording systems do not inhibit information sharing or lead to inaccurate records. 13 It is accepted that there is no overarching definition of what constitutes a complex case; the term is differently used to denote complex health needs, organised abuse, and cases where there are different perceptions between professionals. However, an argument can be made for providing a framework and leaving it to professional judgement, in this case, for example, the complexity arose from the difficulty in constructively engaging the family and difficulty in obtaining information. CONFIDENTIAL March 2017 Page 28 of 29 6. Northumberland LSCB should brief all GP practices on the specific learning from this review; that they should consider the possibility of sexual abuse in all cases where there is a genital injury. 7. All agencies should review their participation and engagement in strategy meetings to ensure: a) decisions about single/joint agency investigations should be made following consultation with Social Care b) there are effective systems to ensure that there is full and comprehensive sharing of information 8. Northumberland LSCB should seek assurance form Northumbria Police that the issues raised regarding their processes for recording and sharing information have been independently investigated and the lessons learned shared within the force area. 9. Northumberland LSCB should review its training provision to ensure that “professional curiosity” is adequately addressed in multi-agency training. 10. Northumberland LSCB should review its current Child Sexual Abuse training provision to ensure that it considers recent learning and research. 11. Northumberland LSCB should review its inter-agency guidance on Child Sexual Abuse to ensure easily accessible advice is available regarding the recognition of abuse and recording and reporting requirements. CONFIDENTIAL March 2017 Page 29 of 29 APPENDIX 1 TERMS OF REFERENCE Molly Terms of Reference.doc |
NC042874 | Death of a 10 month old baby who was the subject of a child in need plan, from a non-accidental head injury. The mother's boyfriend was convicted of manslaughter. The mother was 16 and living in a hostel. Considers issues around supporting young mothers and assessing the needs of the mother and the baby; disguised compliance, neglect; parenting capacity; assessing unknown men in the family; optimistic thinking; failure to take up support services offered; adolescent behaviour; substance misuse; capacity to challenge families and professional colleagues. Makes interagency and various single agency recommendations covering children's social care, housing, early childhood services; GPs and NHS Trusts and the police.
| Title: Overview report on the serious case review relating to Child G - redacted version LSCB: West Sussex Safeguarding Children Board Author: Fiona Johnson Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 West Sussex Local Safeguarding Children Board Overview Report on The SERIOUS CASE REVIEW relating to CHILD G – Redacted version 2 1 INTRODUCTION 1.1 Background to the review 1.1.1 CHILD G information redacted was in the sole care of information redacted mother’s partner, Chris B, information redacted. On the morning information redacted he called the ambulance service as CHILD G information redacted was not breathing; following intensive medical treatment information redacted CHILD G was declared dead information redacted. Chris B was arrested and there were medical and police investigations into the circumstances surrounding the cause of information redacted death. Initial medical findings indicated that information redacted CHILD G sustained a catastrophic head injury. Police information on the known medical findings is that information redacted CHILD G had not experienced any injuries prior to being in the care of Chris B; that the injuries found were not considered accidental; and that it was believed that the use of force must have been significant. Chris B was charged with murder but was convicted of manslaughter for which he was sentenced to 8 years in prison. 1.1.2 Following a meeting of West Sussex LSCB Serious Case Review (SCR) sub group information redacted; it was decided that the case met the criteria under para 8.9: ‘The LSCB should always undertake a serious case review when a child dies, and abuse is known or suspected to be a factor in the child’s death’ and it was recommended that a serious case review should be held. information redacted the Chair of the West Sussex Local Safeguarding Children Board made the decision to accept this recommendation and to carry out a Serious Case Review (SCR). Ofsted was notified of this decision information redacted. The Care Quality Commission and SHA were informed in writing by the Designated Nurse on information redacted. 1.2 The Terms of Reference 1.2.1 It was agreed that all agencies would address the following specific terms of reference when undertaking their reviews:- • The key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Specifically: o Were the decisions made at the Child Protection Conference reasonable o In light of the Conference recommendation was the full extent of the role and responsibilities of mother’s partner in information redacted CHILD G’s life, and his ability to care information redacted assessed appropriately? o Were there any indications of potential risk at any point during the period of review, and if so were they shared or acted upon appropriately and in a timely manner? • The actions taken following assessments and decisions and whether appropriate services were offered/provided or relevant enquiries made, in the light of assessments? Specifically: o Did the Children in Need plans and services provided effectively meet the child’s needs? 3 • The degree to which the child’s needs were taken into account when making decisions about the provision of children’s services, and whether this was accurately recorded? • The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and information redacted family, and whether this was explored and recorded? • Was there sufficient management accountability for decision making and the involvement of managers at key points in the case? • The adequacy of training and supervision of staff to carry out their role? • The consistency of work with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? • Any organisational difficulties being experienced within or between agencies and whether there was a lack of capacity or resources in one or more organisations? • Any examples of good practice or lessons to be learned about single and multi-agency working? • Any recommendations you would make to the West Sussex Local Safeguarding Children Board regarding training, practice or procedures? 1.2.2 Initially it was agreed that the review spanned the agency involvements during the period from the information redacted; this being from the date that the Health Visitor raised concerns which led to the Initial Child Protection Conference until the date of information redacted death. Following discussion at the first SCR panel meeting it was agreed that additionally all agencies were asked to review documentation from the information redacted, when mother became pregnant and to include any relevant information in their report as well as reporting on any other relevant information outside of the time period; the time frame for the chronology was not extended. 1.2.3 Further into the review process additional information was provided by the police which became available via their criminal investigation. This information indicated that information redacted CHILD G was exposed to drugs over a period of time. As a result information redacted all agencies were contacted and asked to further review their involvement with the family to consider ‘to what extent did they consider substance misuse by any adults involved with information redacted CHILD G to be a factor – if so what actions were taken by the agency’. Agencies were asked to submit an addendum report addressing this issue and as a result the overall time-scales for the review were extended. 1.3 Review Process 1.3.1 Individual Management Review (IMR) reports were received from the following sources: • West Sussex County Council Children Social Care (including the Child Protection Unit), • West Sussex County Council Early Childhood (Children and Family Centre and outreach) • Sussex Police, • information redacted Hostel, • Sussex Community NHS Trust 4 (Health Visiting), • NHS Sussex Cluster (West Sussex) (GP) • Western Sussex Hospitals Trust (A&E, Midwifery and Child Development Centre) 1.3.2 IMR authors were provided with a briefing session and also asked to attend the serious case review panel in order that feedback could be provided on the reports and the panel could ask questions in order to clarify any issues. 1.3.3 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: - • information redacted Hospital London • South East Coast Ambulance NHS Trust • information redacted Borough Council • information redacted (domestic violence victims advisory service) Checks were also undertaken with Connexions and the Youth Service with regard to any involvement that they may have had. Carly attended youth clubs and received support from the Connexions service however all of this involvement was prior to the period of the review therefore it was not felt necessary for them to complete an IMR. 1.3.4 A health overview report was also produced in order to review and evaluate the practice of all involved health professionals, including GPs and providers commissioned by the PCT area. 1.4 Family Input to the Review 1.4.1 Consideration was given to involving the parents in the review process however this was not immediately possible because of the risk of compromising the criminal investigation. Mother was a witness in the criminal process. Father was thought to have had limited contact with CHILD G during the period of the review and therefore it was felt inappropriate to involve him. The parents were informed of the serious case review process and when the criminal trial was completed contact was made with mother and maternal grandmother and maternal grandfather. The independent overview author met with mother and maternal grandmother and their views are included later in the report. Numerous unsuccessful attempts were made to arrange a meeting with maternal grandfather however this was not achieved. The father was offered to see a copy of the report prior to full publication. 1.5 The Review Panel 1.5.1 The review group membership was as follows: - • Jane Browne, Surrey and Sussex Probation Trust: Chair • Lorraine Smith, Designated Nurse • Marilyn Barton, Early Childhood WSCC • Debbie Bath, LSCB Business Manager • Edmund Hick/Jonathan Gross, Sussex Police • Susan Ellery/Siobhan Burns/Mark Frankland, Children Social Care 5 Additionally Fiona Johnson, the Independent Overview Writer attended review Panel Meetings. 1.5.2 Dates of review Panel meetings were as follows: - information redacted 1.5.3 The Chair (Jane Browne, Surrey and Sussex Probation Trust) is from an agency that had no involvement with the family and is therefore independent with regard to this case. The independent chair of the LSCB from January 2012 is Jimmy Doyle. 1.5.4 The independent overview writer is Fiona Johnson, an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s services since 1997 contributing to the development of strategy and operational services with a particular focus on safeguarding and child protection. She is GSCC registered and has previously written overview reports for East Sussex, Brighton & Hove, Portsmouth, Southampton, Kent, West Sussex, Wandsworth, Surrey, Slough and Bracknell Forest LSCBs. 1.5.5 The overview report was completed based on information provided in the IMRs and the additional reports. The overview author also saw the notes of the initial child protection conference; the child in need plan and the strategy discussion notes. 1.5.6 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. Full publication of the findings of the review will follow on from the completion of the criminal process. 2 THE FACTS 2.1 The Family background Name1 Gender Relationship Date of birth Ethnicity information redacted CHILD G information redacted Subject information redacted White British Carly G Female Mother information redacted White British Russell S Male Father information redacted White British Chris B Male Mother’s Partner information redacted 2 Dual heritage white British/black Caribbean 1 information redacted CHILD G, Carly, Chris B etc are the names given by West Sussex LSCB to provide anonymity 2 There was some discrepancy with the police and social care recording of the dates of birth for Chris. As the GP held records for Chris from birth this was believed to be the most accurate. 6 Maureen G Female Maternal Grandmother Unknown White British Mark G Male Maternal Grandfather Unknown White British Pam B Female Chris B’s mother information redacted White British A genogram and a full chronology covering the period the information redacted November information redacted to information redacted May information redacted 2.1.1 information redacted CHILD G and information redacted parents are white British and their first language is English; religious affiliations are unknown. Chris B is dual heritage, white British/black Caribbean, his first language is English and his religious affiliation is unknown. information redacted was the first child of Carly and Russell. Their relationship began in May information redacted and ended in August information redacted, when information redacted CHILD G was two months old, following an incident of domestic abuse. Carly started her relationship with Chris B in October information redacted when information redacted CHILD G was four months old. information redacted CHILD G and Carly were living in a hostel as a result of Carly becoming homeless during her pregnancy, following a disagreement with her mother. Prior to being pregnant Carly worked as a hairdresser; however, for the period of the review she was in receipt of benefits. 2.1.2 Chris B was said to be working as a labourer but was also receiving benefits; he had separate accommodation from Carly and during the period of the review lived at two separate addresses, both being rooms in shared houses. Chris B was reported to have a child, with whom he did not have contact, but nothing further was known about this; police investigations since the death indicate that Chris B did not have a child. Chris B has a criminal record for possession of cannabis (two counts) and has been arrested for other matters. 2.1.3 There is little information about Russell S as he was not involved for the significant period of this review however he is known to Sussex Police for matters including harassment of a female and is also known to have Attention Deficit Hyperactive Disorder (ADHD). 2.1.4 There was limited involvement by agencies with this family prior to the period of the review. Carly’s older sister was accommodated in her teens because of problems in her relationship with her parents; she became pregnant when she was 16. There had been police involvement with Carly and her sisters because of minor criminal matters and Carly was reported missing to the police on one occasion when she was fifteen. At that time she was reported by her father to be mixing with inappropriate older men. Carly’s parents’ relationship ended in 2009. 2.1.5 Carly became pregnant when she was sixteen and was made homeless by her mother in February information redacted following arguments about maternal grandmother’s boyfriend. It would appear that relations between Carly and her mother were acrimonious from December information redacted and Carly presented as homeless on two occasions in January information redacted and February information redacted prior to her being housed in the information redacted Hostel. 7 Throughout the period of the review the maternal grandmother provided little support; however, Carly and information redacted were supported by the maternal grandfather and his new partner. Chris B and Carly were also supported by Chris B’s mother, information redacted. 2.2 Agency Involvement with family 2.2.1 Carly reported her pregnancy first to her GP on 4th November information redacted and then booked with midwifery for her confinement on 27th November information redacted. At this stage Carly advised the midwife and GP that she was well supported by her mother and boyfriend. Carly was allocated to the teenage pregnancy midwife and on 9th February information redacted a routine safeguarding alert was raised to alert maternity staff regarding her young age as a parent. 2.2.2 In February information redacted an initial assessment was undertaken by an assistant care manager (ACM) of Carly’s needs. At that stage she was a homeless sixteen year-old who was pregnant with very limited support from her family. The outcome of this assessment was that Carly was housed at the information redacted Hostel and from March information redacted she was paid a subsistence allowance of £50.00 per week which she collected from the social work office. Social care staff did not visit the information redacted Hostel and there was no further support or assessment of her needs as a vulnerable teenager or any risk assessment of her capacity to be a parent. 2.2.3 When Carly moved to the information redacted hostel she advised the midwife on 19th February information redacted of her change of address. The midwife visited within a few days and discussed what additional support she needed. This midwife made a referral to Connexions for additional support and also updated social care and the labour ward as to the changes in Carly’s circumstances. The midwife visited on six further occasions during the pregnancy but these visits were routine and the only significant matter was a record in April information redacted that Carly had attempted to attend parent craft classes but had not continued as her partner did not like big groups. The health visiting service became involved in May information redacted and undertook an ante-natal assessment which deemed Carly to be vulnerable because of her youth, her strained relations with her extended family and Russell S’s ADHD. 2.2.4 information redacted CHILD G was born via an emergency caesarean section; following her mother experiencing an eclamptic fit information redacted 3. Carly received treatment in intensive care for the eclamptic fit but returned to the postnatal ward on information redacted; information redacted CHILD G did not need any additional care following the delivery. information redacted CHILD G and Carly were discharged from hospital on information redacted and went to stay with paternal grandmother. Following discharge Carly and information redacted CHILD G were visited by community midwives on four occasions and all clinical checks were found to be satisfactory and no concerns were raised about the baby. Care was discharged to the health visitors on information redacted. 3 An eclamptic fit is seizures which can occur in pregnancy usually at any time form the 2nd trimester until up to 5 days post delivery. It can be caused by several factors, including: reduced blood flow to the brain, caused by a combination of small clots and spasm of the small arteries; swelling in the brain (cerebral oedema), possibly as a complication of excessive fluid retention; bleeding from small arteries ruptured by the intensity of the blood pressure. Early indications of the risk can be one, all or several symptoms including: High blood pressure, Proteinuria, generalised oedema, Epigastric pain, headaches and visual disturbances’ 8 2.2.5 Carly had her post-natal check information redacted when she self-reported that she was tired but not depressed; her physical health was seen to be normal. Carly was then seen at the hospital on information redacted for a post natal appointment because of the eclampsia. It was noted at that time that she was ‘low’ and anti-depressants were prescribed. The hospital sent the GP a letter informing of the clinic appointment on information redacted however this was not found in the GP records. Carly did not attend the GP again and received no follow-up with regard to her depression. 2.2.6 In August information redacted there was a domestic abuse incident between Carly and Russell S. The incident involved verbal and physical abuse of Carly by Russell S and also included ‘threats to kill’ being made by text. The Police were not advised by Carly of the physical abuse or ‘threats to kill’ but these were disclosed to information redacted domestic abuse victim support Services Team. They were also raised when the incident was discussed at a Multi-agency Risk Assessment Conference (MARAC) for domestic violence. Carly ended her relationship with Russell S following this incident and was provided practical and emotional support at this time by the information redacted domestic abuse victim support Services Team. 2.2.7 From information redacted Carly and information redacted CHILD G were seen regularly by the health visitor who reviewed information redacted CHILD G’s health and development and provided advice and guidance. There were no problems with information redacted CHILD G’s health or development however Carly was repeatedly reminded regarding leaving information redacted CHILD G unattended on the bed. During this time Carly was also being supported by staff within the information redacted hostel who offered sessions aimed at improving practical skills such as cookery and money management. Carly did not engage in these support services. Carly’s physical care of information redacted CHILD G was seen to be good and information redacted CHILD G was always clean and well-dressed. There were some concerns that Carly’s verbal interaction with information redacted CHILD G was limited and that occasionally information redacted CHILD G was left unsupervised in the bedroom without all potential hazards being removed. These issues were discussed with Carly and staff considered that the issues were similar to many other tenants within this age-group. At this stage Carly was also receiving limited support from social care. Early in October 2010 Carly began a relationship with Chris B. 2.2.8 On information redacted the health visitor received a call from information redacted who reported that Carly was not coping, was feeling low and had no milk for information redacted CHILD G. The health visitor visited the hostel later that day and found Carly with ‘made-up’ feeds that were not refrigerated and no further formula; she also said she had few clothes for information redacted CHILD G that fitted. Carly seemed low but said that she had more formula at her boyfriend’s flat which she visited regularly. information redacted CHILD G was seen and seemed well and had gained a little weight. The health visitor was concerned about the poor management of money and the lack of appropriate care regarding information redacted formula and reported these concerns to the assistant care manager (ACM), on the information redacted The ACM advised the health visitor that case responsibility was likely to move to a social worker and that consideration was being given to calling an Initial Child Protection Conference. As there is little 9 recording it is unclear why a conference was being considered. The ACM also informed the health visitor that the information redacted was in fact Chris B’s mother, Pam B. 2.2.9 Following the contact from the health visitor the ACM visited Carly and information redacted at the hostel; Pam B was also present and offered practical support to Carly around budgeting. The visit confirmed the health visitor’s concerns regarding finances. After this visit the ACM discussed the concerns with her supervisor who recommended a visit be undertaken with a Senior Practitioner. This visit took place on the information redacted and was undertaken at Chris B’s house because Carly and information redacted CHILD G were staying there. This visit raised further concerns regarding the care being provided to information redacted CHILD G as the conditions within the shared house were poor. There was evidence of cannabis use in the bedroom and it became apparent that information redacted CHILD G had spent the night in a bouncy chair as there was no travel cot despite Carly having previously told the ACM that this was where information redacted CHILD G slept when they stayed over at the house. 2.2.10 Following this visit a decision was made to convene an Initial Child Protection Conference. The process of decision-making is confused and does not appear to be reflected in the recording. There was a formal strategy discussion held on information redacted involving police and social care which identified the risks as being chronic neglect, Carly failing to prioritise information redacted CHILD G’s needs and Carly associating with people involved in drug-use. The outcome of the strategy meeting was that social care would undertake a single agency section 47 investigation and that a child protection conference would be convened. The evidence for most of the risk factors seemed limited and based mainly on the information from the health visitor and the two recent visits. Carly was formally told about the conference on information redacted when the ACM visited her at maternal grandfather’s address. 2.2.11 information redacted Carly and information redacted CHILD G were seen by the health visitor at maternal grandfather’s home. Carly said that she had moved to stay with him because she was unhappy with aspects of the regime at the information redacted hostel including cleanliness, availability of support staff and security of the home. These issues were fully discussed with hostel staff and Carly returned to the hostel on information redacted. On information redacted Carly approached the Children and Family Centre seeking support in parenting skills she was accompanied by Chis B and his mother on this visit. 2.2.12 The child protection conference was held on information redacted. Carly attended supported by her father’s partner. Staff from the information redacted hostel did not go because there was a pre-planned regional training event that they had to attend; they did send a report. The GP was also not present as he was not sent an invitation although he was aware of it happening from another source; he did not send a report. All other agencies were represented at the meeting. The decision of the conference was that there would not be a child protection plan but that Carly and information redacted CHILD G would be supported via a child in need plan. This decision was recorded as being unanimous but the record of the conference indicated that five of the eight professionals present initially recommended a child protection plan; however, the record of the final decision of the conference did not include any dissenting views. The recommendations from the conference included 10 that the core assessment should be updated and an assessment of Chris B undertaken; that Carly should attend all appointments and engage in support offered by the Children and Family Centre including a parenting course and independent life skills course; that Carly should be supported regarding housing difficulties and any recurring difficulties regarding domestic abuse from Russell; that a family group conference be considered; and finally that a contract of expectations should be drawn up which would specify the need to have a further child protection conference if Carly did not co-operate with services provided. Following the conference key worker responsibility transferred to a student social worker supervised by a qualified social worker. 2.2.13 Following the child protection conference Carly and information redacted CHILD G were seen by information redacted hostel staff on information redacted CHILD G received her third set of immunisations at the GP surgery. On the information redacted there was a child in need planning meeting attended by Carly, the social work student a Children and Family Centre outreach worker and the information redacted hostel support worker. The health visitor was unable to attend. Carly was very positive at this meeting and committed to attending ‘Solihull’ parenting classes as well as a ‘Parenting with Prospects’ course run by Connexions. Following this meeting Carly spent much of the next month away from the information redacted hostel staying with Chris B and other friends over the Christmas period. information redacted CHILD G was seen by information redacted hostel staff on information redacted however no other agency had contact with her until the information redacted The health visitor attempted three visits during the period before Christmas and received no response to messages left. information redacted the health visitor spoke on the telephone to Carly who said that she was staying at Chris B’s flat but was unwilling to give the address or to see the health visitor. The care of the health visitor transferred at the end of December information redacted. The new health visitor attempted visits in early January information redacted but was unable to see information redacted CHILD G until information redacted. 2.2.14 On information redacted, following a review of the police file by a supervising officer, Sussex Police determined that there should be an unannounced visit to Chris B’s accommodation to check regarding possible substance misuse. Sussex Police then contacted the senior practitioner involved in the earlier assessment to arrange this visit. The senior practitioner spoke to the student social worker who advised that Chris B was moving on the information redacted but that his new address was unknown. Attempts were made by the student social worker to obtain Chris B’s new address from Carly but she did not disclose it until information redacted. 2.2.15 During January information redacted Carly and information redacted CHILD G were seen at two home visits by the student social worker and she failed to engage with the Solihull parenting course being offered by the Children and Family centre. At this time Carly was thought to be spending most of her time at Chris B’s accommodation which was not seen by the student social worker as Carly was resistant to a visit being made to the home. Carly was also in arrears with her service payment on her hostel accommodation and was given a warning letter from the information redacted hostel for the arrears and because she was not residing in the hostel (there was a requirement that residents should sleep five days a week at the hostel). Carly’s explanations for her lack of co-operation were that there were mice at the hostel and that her phone had been malfunctioning. 11 2.2.16 On information redacted the health visitor visited the family at the hostel and undertook a health assessment of information redacted CHILD G who was found to have age appropriate development but could not maintain sitting position without support. Advice was provided to Carly about how she could enable information redacted CHILD G to build up information redacted upper body strength. On information redacted there was some confusion about the ‘child in need’ review meeting as the health visitor attended but was told the meeting was cancelled; shortly after the social work student arrived and the meeting took place. This was the second child in need meeting that did not have input from the health visitor. At this meeting Carly agreed ‘to fully engage with the health visitor’ but was reluctant to attend parenting classes. Following this the health visitor was requested by the social worker to provide an update health report on information redacted CHILD G. This was provided and detailed information redacted health from birth including the difficulties recently identified with maintaining a sitting position. 2.2.17 Following discussions between the social work student and Sussex Police about obtaining Chris B’s address a joint visit was eventually undertaken on information redacted. Unfortunately this visit was not unannounced because of confusion between the staff arranging the visit. The accommodation when visited was seen to be newly decorated and clean and tidy; there was no evidence of substance misuse and no smell of cannabis. Chris B appeared to be co-operative with the police and seemed to be trying to do his best for Carly and information redacted CHILD G. 2.2.18 During information redacted there was limited contact by agencies with information redacted CHILD G and Carly. The social work student visited on information redacted and undertook a budgeting exercise with Carly. She advised Carly that she would be away most of the month and advised her to contact her supervisor in her absence. The social work student also noted that information redacted CHILD G appeared to experience some distress when passing a bowel movement. Following this visit the social work student liaised with the health visitor and advised her of the date of the next child in need planning meeting and informed her about information redacted CHILD G being constipated. 2.2.19 The health visitor visited Carly information redacted at the hostel on information redacted. At that meeting Carly presented as ‘anxious’ and having a ‘low mood’; she was reluctant to see her GP as she did not want to ‘become addicted to anti-depressants’. information redacted CHILD G was seen to be ‘getting into the crawling position and weight bearing but was not pulling to stand or sitting beyond one minute’; because of concerns regarding this development the health visitor referred information redacted CHILD G to the Child Development Centre at the hospital. 2.2.20 Carly also had limited involvement with hostel staff during information redacted. Carly was very unhappy that she had not received a move-on letter and that other residents who had lived at the hostel for shorter periods had moved on. It was explained to Carly that whilst she was in arrears with her service payment; was not attending support sessions with hostel staff; and was not staying regularly at the hostel; she would not be offered further accommodation. Carly attended four support sessions with hostel staff; but did not pay off her arrears; and her residence at the hostel continued to be sporadic. As a result further warning letters were issued which advised Carly of the possibility of legal action for eviction. During information redacted CHILD G was not seen by hostel staff at all. 12 2.2.21 The CIN planning meeting held on information redacted was attended by the student social worker, the family outreach worker, the health visitor, the support worker from the information redacted hostel and Carly and Chris B. This meeting was challenging, as Carly was very angry about her accommodation situation, and walked out of the meeting. There are no minutes from this meeting, but case records indicate that Carly had failed to attend the Solihull Parenting Course and had missed appointments regarding her housing application; she still had arrears on her service payments but had done some budgeting work with the student social worker. It was noted at this meeting that information redacted CHILD G had been registered with a new doctor and that information redacted CHILD G was unwell with a gastric illness. The outcome of the meeting was to recommend continued work on assisting Carly to access permanent accommodation. Following this meeting it was agreed that as Carly would not attend the parenting group the student social worker would undertake work about child development issues on a one-to-one basis. 2.2.22 During information redacted hostel staff had contact with Carly on ten occasions and information redacted CHILD G was seen eight times; however they were not thought to be staying at the hostel and a further warning letter was sent regarding non-occupation. Carly and information redacted CHILD G were thought to be staying with her father; and on information redacted the service arrears were cleared; it is thought that maternal grandfather paid off this debt. Carly continued to make complaints about the standards in the house; complaining about mice infestation and lack of support. On information redacted there was a telephone conversation between the maternal grandfather and hostel staff where the circumstances around the decision not to provide Carly a move-on letter were fully explained. 2.2.23 The student social worker saw Carly information redacted on two occasions in information redacted; the first visit was on information redacted when Carly requested counselling as she found the experience of eclampsia to have been traumatic; she also expressed some anxiety about Russell S who has been in contact with her sister and was talking about wanting contact with information redacted. The Solihull parenting group was discussed and it was agreed that at a future session they would discuss ‘relationships, communication and atunement’. Carly also identified that information redacted CHILD G was not sleeping well and the student social worker agreed to contact the health visitor to ask for advice for Carly. The second visit was a week later when there was a discussion from the parenting programme about ‘attachment, containment and reciprocity’. This visit was followed by the student social worker and Carly visiting the Housing Office to establish her status with regard to the housing waiting list. 2.2.24 The health visitor’s only contact with Carly information redacted at this time was a telephone conversation information redacted to offer support regarding information redacted sleep problems. Carly advised the health visitor that these problems were resolved and was advised to make direct contact if there were any further problems. 2.2.25 During information redacted the only agency to have direct contact with information redacted CHILD G was the information redacted hostel. Carly’s engagement with the hostel support services improved significantly; she attended fourteen times at Life Skills sessions and information redacted CHILD G was seen by the support worker on nine occasions and always seemed well. Carly also paid her service rent and seemed to be staying at the hostel more consistently. One explanation for this may 13 have been that she had reported to the social work student at the end of information redacted that she and Chris B had been arguing but it is also possible that Carly was being encouraged by her father to co-operate with the services in order to access permanent accommodation. By the end of the month the hostel support staff were positive that Carly would soon be receiving a move-on letter enabling her to obtain permanent accommodation from the Housing Department. 2.2.26 The CIN planning meeting on information redacted was attended by the student social worker, an hostel support worker, the health visitor, a family outreach worker and Carly and Chris B. All at the meeting were very positive about the progress that Carly was seen to have made; she had paid off her arrears and was engaging well with the hostel and so would be receiving a move-on letter. information redacted CHILD G was thought to be developing well and Carly and information redacted CHILD G were said to be attending a ‘music and play’ group. Carly was also saying that she would attend the next Solihull Parenting Group. From this meeting it was agreed that the family outreach worker would assist Carly with her housing application and that the student social worker would be recommending that the case be closed and that therefore another agency should take over as lead professional for any on-going work; this to be agreed at the next child in need planning meeting which was arranged for information redacted. 2.2.27 information redacted CHILD G was seen at the Child Development Centre on information redacted for a joint motor assessment. The outcome of this visit was that she was making ‘age-appropriate developmental progress, with motor milestones being a little slow but with no evidence of underlying disorder’. On information redacted Carly was provided with a move-on letter by the hostel staff. On information redacted Carly was seen to be very drunk at her mother’s house prior to going out with her mother and older sister. This information was provided in a child protection referral that was made regarding Carly’s younger half-siblings (there is no reference to information redacted CHILD G being present) and the link with Carly was not identified until after information redacted CHILD G death. 2.2.28 On the information redacted Carly and information redacted CHILD G were seen by the student social worker; information redacted CHILD G was seen sitting with toys and seemed happy and well. Carly referred to her mother having been the subject of a malicious allegation and that social services were involved. Carly also said that information redacted CHILD G had recently been cared for by maternal grandfather in order to allow her to have time with Chris B. Carly referred to information redacted CHILD G having hit information redacted head on the bed headboard five days previously. information redacted CHILD G cried at the time so Carly took her to the GP however the surgery was closed. The student social worker looked at information redacted CHILD G but could find no signs of an injury. This was a positive visit and the student social worker was looking to close the case later that month. 2.2.29 Later that day the health visitor also visited Carly and information redacted CHILD G and observed positive interaction between the mother and child. The health visitor noted that information redacted CHILD G had attended the Child Development centre and no problems had been found. information redacted was seen to be ‘babbling, smiling, sitting, crawling, weight-bearing and exploring her environment’; information redacted CHILD G’s height and weight were normal and no problems were identified. There is no record that the health visitor saw a bruise and no evidence that Carly reported this incident to the health visitor. 14 2.2.30 On information redacted the student social worker sent an email to all members of the child in need planning group distributing the minutes of the previous meeting and indicating her intention to close the case to social work with a view to another member of the child in need planning group, probably from the Children and Family Centre, picking up lead professional responsibility. 2.2.31 Carly and information redacted CHILD G spent time on information redacted at Chris B’s house and at 10pm Carly left information redacted CHILD G in Chris B’s care and returned alone to the hostel. It had been agreed that he would care for information redacted CHILD G to enable Carly to sleep as she was very tired. At some point that night information redacted CHILD G experienced a life-threatening injury that eventually lead to information redacted death on information redacted. The exact circumstances of the injury are unclear and are currently the subject of police investigation so cannot be described in more detail. (correct at time of report writing) 2.2.32 Chris B contacted the ambulance service information redacted saying that he was caring for a 10 month old child who was not breathing. An ambulance was dispatched and arrived within five minutes, resuscitation was attempted and eventually information redacted CHILD G was taken to the local hospital within an hour. Sussex Police attended the scene and spoke to Carly (who was by then at the scene) and Chris B and then accompanied information redacted CHILD G to hospital where they were joined by Child Protection Team (CPT) officers. 2.2.33 An emergency strategy meeting was held on information redacted involving police and social care the outcome of this meeting was that information redacted CHILD G was to remain in hospital for further tests and that the police should be informed if either Carly or Chris B attempted to remove information redacted CHILD G from hospital. At this stage the police perspective was that there were no suspicious circumstances associated with the death and as a result when information redacted CHILD G was transferred from the West Sussex hospital to the London hospital information redacted CHILD G was not accompanied by a police officer. 2.2.34 information redacted CHILD G’s injuries were so severe that information redacted needed to be transferred to a specialist London hospital. Carly accompanied information redacted CHILD G in the ambulance and Chris B and other family members went to London by train; no professionals accompanied the family to London. Hospital staff in London were provided with some background information from social care and took a full social history from the family which included Chris B, Carly, maternal grandfather and his partner and Chris B’s mother. There was some confusion regarding information redacted CHILD G’s status as inaccurate information was provided indicating that information redacted CHILD G was the subject of a child protection plan; this misinformation was rectified the next day. Hospital staff advised Carly that it was unlikely that information redacted CHILD G would survive. 2.2.35 The hospital provided intensive treatment for information redacted CHILD G however information redacted injuries were too severe and at 8.00am information redacted hospital staff contacted the emergency duty service (Social Work) to advise that doctors were aiming on withdrawing care; they also expressed concern that there had been no police contact with the hospital. Withdrawal of treatment was discussed with Carly and the family at 8.40am. 15 2.2.36 On information redacted at 10.39am an EDT social worker informed the police that the London hospital had advised that information redacted CHILD G was not expected to live and had suffered a major retinal haemorrhage which would be consistent with severe shaking or a heavy fall or blow. Sussex Police then liaised with the London Police and arranged for officers to attend the London Hospital. Sussex Police then attended the London Hospital. Eventually information redacted CHILD G died at 1.10pm4 after withdrawal of ventilator support. Chris B was then arrested and escorted to West Sussex. Chris B was charged with murder and is now in prison. 3. VIEWS OF FAMILY MEMBERS 3.1 Carly was clear that in her view there was nothing that could have been done to prevent information redacted CHILD G dying, as no-one knew that Chris B would harm information redacted CHILD G; and, since information redacted the death nothing further had been identified that would have indicated that he posed a threat to information redacted safety. 3.2 Carly was also very clear that she had never seen Chris B taking drugs apart from occasionally smoking cannabis which he always did outside, away from information redacted CHILD G. Carly said that she never took any drugs, even cannabis, and would not have remained with Chris B if she knew that he was taking other drugs. 3.3 Carly was asked about the support that was provided to her, before and after information redacted CHILD G s birth. She indicated that prior to the birth she was assisted by the midwife, although she was surprised that the input was an enhanced service. After the birth she felt everything was acceptable until information redacted contacted the health visitor and made untrue allegations about her care of information redacted CHILD G. Carly said that the child protection conference held after this was a difficult meeting; and did not enable her to express her point of view, or to tell people the truth. Particular inaccuracies were that information redacted CHILD G had not slept overnight in a bouncy chair, but in a carry-seat that was part of information redacted push-chair and was meant to be used as a travel cot for babies. Also there were plenty of toys and clothes available information redacted. 3.4 Carly agreed that after the conference she was not very co-operative with professionals as she was angry that they had not listened to her. She was also unhappy that other girls had been re-housed from the hostel ahead of her. Carly said that she did not like it at the hostel as there were mouse droppings in her room and on her bed. Carly said that this was the reason that she did not pay her rent rather than because she did not have money. Although she also said that Chris B was often short of money and that she used to feed him. Carly paid off her rent arrears independently without any assistance from her father and said that the staff at the hostel did not offer any support in enabling her to learn to manage her money. 3.5 Carly confirmed that she were unaware that there was a child in need plan and had not signed any written agreement and felt that while the social worker was visiting 4 This is the time of death as recorded by the hospital – there is a discrepancy with the time recorded in the police IMR which is thought to probably be the time that the death was reported to Sussex police not the time of death. 16 she received very little support but had to go to a lot of meetings which was sometimes unhelpful. 3.6 The maternal grandmother was able to offer little in addition to Carly’s views. She said that she had never met Chris B and had no contact with Carly for the period of the review. Maternal grandmother’s major concerns were about the effect that publication of the case review would have upon Carly who was emotionally vulnerable. 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS 4.1 Skills in engaging families 4.1.1 A significant issue identified in this review was the extent to which any professional was able to engage and build a positive working relationship with Carly. With the possible exception of the midwife it does not appear that any professional found it easy to engage Carly and there is some evidence that she avoided contact and could be deceptive in her responses. 4.1.2 This ambivalence and unwillingness to engage was however not clearly understood by the agency system as Carly was also very adept at diverting professional attention by being critical of other professionals. This is most overt in her relations with staff at the hostel but could also be seen in some of her responses to the student social worker and health visitor. For instance there were a number of occasions when the student social worker contacted the health visitor on Carly’s behalf rather than encouraging her to take responsibility for resolving matters with the health visitor directly. Carly was also very adept at appearing to be positive about future involvement in support services which she then failed to attend. This behaviour was apparent with regard to attendance at the parenting groups and involvement with the sessions offered by the hostel. 4.1.3 Adolescents are often difficult to engage and a pattern of partial co-operation is not unusual from teenager mothers. There were aspects however of Carly’s behaviour, particularly after she became involved with Chris B, that were more representative of a pattern of behaviour observed in other serious case reviews where families show disguised compliance. This is described in research as being ‘where parents defused professionals’ attempts to take a more authoritative stance by making pre-emptive shows of cooperation… The family’s compliance was only temporary but it was sufficient to persuade workers of their apparent willingness to be more open and therefore kept them at bay.’ 5 Ostensibly the family seemed to co-operate with the professionals but in fact this was illusory and the pattern of engagement included ‘deliberate deception, disguised compliance and “telling workers what they want to hear”, selective engagement and sporadic, passive or desultory compliance.’6 4.1.4 Whilst there was significant involvement by agencies with Carly information redacted and much time was invested in helping her improve their circumstances; it was clear from the IMRs that very little was known about their day-to-day life. In particular it was very unclear to what degree Chris B was involved in direct care of information 5 Reder et al (1993), 6 P 76 Understanding Serious Case Reviews and their Impact – Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren and Black, DCSF 2009 17 redacted CHILD G and whether it was intended that when Carly moved into independent living that Chris B would be living with her. 4.1.5 As a result of meeting with Carly and receiving her contribution to the review process the overview author considered that Carly’s lack of compliance was mainly a product of her youth. It was clear that no professional was able to engage her however this was not because she was deliberately manipulative but was a feature of her inexperience. It is possible that a greater understanding of her adolescent ambivalence by professionals might have enabled better partnership working. 4.2 Quality of supervision 4.2.1 It is clear that all staff were receiving regular supervision; however, there is some concern as to the quality of the supervision provided; in particular whether it sufficiently challenged professionals in their attitudinal perspectives. Reder and Duncan argue that front-line staff need to develop ‘a dialectic mind-set’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. 7 Similarly in ‘Working together to safeguard children’ it is suggested that professionals ask themselves: • Would I react differently if these reports had come from a different source? • What were my assumptions about this family and what, if any, is the hard evidence supporting them?8 4.2.2 The absence of clear analysis of the major risk factors in the core assessment initially undertaken by the ACM would argue that the supervision and oversight provided to her work did not provide her with sufficient challenge and scrutiny. Similarly the supervision provided to the student social worker was practically oriented and there was little evidence that it questioned the developing optimism about the apparent change that was being achieved. The role of the supervisor should be to provide independent and objective challenge and if that had been available it seems unlikely that the drift in child care planning and failure to effectively engage with Carly would have remained hidden. Despite discussion in supervision about agreeing a contract of expectations there was apparently no consideration of actions that should be taken if the contract was breached. 4.2.3 There was some evidence of challenge provided in the police oversight however the delay in arranging the follow-up visit and the move to a pre-arranged appointment would indicate that this was not sufficiently robust. 4.2.4 The health visitor was clearly receiving regular supervision and there was a child centred approach as indicated by the decision to maintain health visitor continuity when the GP changed. The supervision seemed however to be led by the health visitor and there was no evidence that the supervisor queried whether there was sufficient improvement or enabled the health visitor to challenge the student social worker perspective about the effectiveness of the child in need plan. 7 Reder & Duncan Lost Innocents 1999, p98 8 Department of Health, Home Office, Department for Education and Employment, 2006: p113 18 4.2.5 Overall the extent to which the supervision provided to professionals gave the opportunity for critical reflection is dubious given the failure by any agency to critically analyse the purpose and functioning of the child in need planning process. The exception to this would be the police supervision of the initial section 47 investigation; unfortunately the follow-up to this intervention was less effective and the delay in action influenced the outcome. 4.3 Significance of substance misuse 4.3.1 Substance misuse was never identified as a key issue in the assessment of this family despite there being some evidence that Chris B used drugs and at one time lived in a house where it was suspected that there was drug-dealing. The significance of this issue was not recognised at the initial strategy discussion as it should have resulted in a joint section 47 investigation. This error was however identified during supervising police officer review of the work and rectified. 4.3.2 It is clear that the state of Chris B’s first flat was a significant factor in the ACM’s perspective that an initial child protection conference should be held. This issue however then became absorbed into a general concern about Carly’s neglect of information redacted CHILD G rather than focussing on what could have been the reason for the neglect. No professional linked the neglectful parenting with possible substance misuse. 4.3.3 One reason for this may well have been that there was very little evidence that Carly was involved in drug-use. She was never seen to be intoxicated by professionals and there was only one referral alleging alcohol abuse which was received after information redacted CHILD G’s death. The evidence of drug use may have been hidden as professionals had very limited access to Chris B’s accommodation and it is probable that he was the source of any drugs. 4.3.4 Since information redacted CHILD G’s death there have been two allegations by family members that information redacted CHILD G was given alcohol by adults however there is no other evidence to support these assertions and the matter is under on-going police investigation. (Correct at time of report writing). Neither of these alleged incidents were known about by professionals prior to information redacted CHILD G’s death. 5 ANALYSIS 5.1 Did assessments and decisions appear to have been reached in an informed and professional way? • Were the decisions made at the CP Conference reasonable? • Was the ability of mother’s partner to care for information redacted assessed appropriately? • Were there indications of potential risk, were they shared or acted upon appropriately and in a timely manner? 5.1.1 A range of assessments were undertaken with this family; and, whilst some were reached in an informed and professional way, there were others that seemed less consistent. Carly was initially assessed as a vulnerable homeless young person; this assessment identified her immediate needs for accommodation but did not address 19 her wider needs as a vulnerable young person and did not meet the requirements of the Southwark Judgement (May 2009)9. This is acknowledged in the Children’s Services IMR which is rightly critical of the initial assessment and identifies that a core assessment should have been undertaken at this time. 5.1.2 Carly was then assessed as a pregnant young woman by both the midwifery service and health visitor. These assessments were competent and addressed her needs acknowledging that she would need additional support because of her youth. The assessments were kept under review; and when Carly’s circumstances changed because of her homelessness, consideration was given to the additional support that might be required. Later when Carly experienced a difficult birth because of eclampsia she was provided with an additional follow-up at the hospital which ensured that any physical health problems were monitored. The assessment of Carly’s emotional needs following this event was less satisfactory and there is no evidence that the GP, midwife or health visitor considered the impact of the eclamptic fit on a vulnerable teenage mother and assessed whether she might need specific support or counselling. Later Carly mentioned this to the student social worker and asked for counselling but this should have been considered at an earlier point. Awareness of mental health needs is a theme in previous West Sussex Serious Case Reviews10 and it is concerning that this still remains an area of vulnerability in service provision. 5.1.3 Later assessments by the health visitor of Carly’s emotional well-being are also less effective and although there were a number of indicators that Carly was experiencing low moods there was no attempt to use formal assessment tools to establish the nature and degree of her depression. This was addressed fully in the Community NHS Trust IMR. The health visitor did however use the Brearley Risk Assessment tool to identify that Carly needed additional support as a parent. The health visitor was also fully involved in the MARAC risk assessment that identified the risks posed to information redacted CHILD G from Russell S and led to a safety plan that enabled Carly to protect her information redacted effectively. 5.1.4 The continued enhanced health visiting service input enabled the health visitor to contribute to the assessment undertaken by the ACM that resulted in the Initial Child Protection Conference held in information redacted. This assessment was limited in that it was based on very little direct contact and did not include appropriate consultation with all relevant agencies; the GP was not consulted and there was limited contact with the information redacted hostel. These issues are fully explored in the Children’s Services IMR which is rightly critical of the core assessment that was undertaken. The process was also very confusing as the strategy discussion seemed to follow from the decision to call a conference rather than initiating the process to plan the section 47 investigation. Furthermore the strategy discussion did not involve the health visitor who was the referring agency and should have been included. As the Health Overview Report identifies ensuring the right people are involved in strategy discussions and Section 47 Investigations is a theme for West Sussex LSCB that was identified in the Ofsted Report on Safeguarding.11 Another weakness 9 The Southwark Judgement, made by the Law Lords in May 2009, is a piece of case law that obliges children's services to provide accommodation and support to homeless 16- and 17-year-olds. 10 SCR Family E West Sussex LSCB August 2010 11 Ofsted, Care Quality Commission (December 2010) Inspection of Safeguarding and Looked After Services in West Sussex. Ofsted. 20 in the assessment process was the decision by Sussex Police to allow a single agency assessment which led to the issue of Chris B’s possible substance misuse being inadequately investigated. Whilst this matter was picked up later by supervising officer oversight the immediate opportunity to examine this issue in more depth was lost and was never fully explored. 5.1.5 The decisions of the conference reflected the poor assessment undertaken prior to the meeting being held. It is very difficult for a chair of a child protection conference to achieve an effective outcome if the core assessment underpinning the conference process is flawed or substandard. It is clear that Carly needed to be assisted to care for information redacted CHILD G appropriately but it was less clear whether that needed to be via a child protection plan or a child in need plan; as there was insufficient evidence about Carly’s willingness or ability to co-operate without the additional challenge that a child protection plan would provide. The Children’s Services IMR clearly identified the weaknesses in the assessment that preceded the conference and concluded that the decision reached by the conference to work via a child in need plan was appropriate. 5.1.6 It is not apparent from the record of the conference how and why there was no formal dissent from this decision; given that the majority of agencies initially wanted a child protection plan. It is noteworthy that the professionals who wanted a child protection plan were largely those who had direct contact with Carly; and, it would have been good practice for the chair of the conference to have recorded more fully why those people later thought there was no need for a child protection plan. It is also unclear as to whether the chair formally invited people to record that they were dissenting from the decision. The Social Care IMR indicates that following discussion professionals’ views changed. It is certainly not positive to have such a shift in professionals’ judgement without recording why the decision was made and gives the impression that their perspective was not valued. The outline child in need plan that was formulated by the conference was however sound; and, if effectively implemented, could have provided a solid structure for working with Carly and protecting information redacted CHILD G. 5.1.7 The ability of mother’s partner to care for information redacted CHILD G was not assessed appropriately and there is very little evidence of any assessment having been undertaken. The direct contact by any professionals with Chris B was limited and was mainly concentrated in the last three months of information redacted CHILD G’s life when he attended the CIN planning meetings. There was only one visit made to his second address and that was pre-arranged and may have been deliberately organised by him to impress professionals. Certainly it affected police officer and social worker perceptions of him; and thus was viewed by the information redacted hostel staff as an endorsement that it was acceptable for Carly and information redacted CHILD G to stay there overnight. 5.1.8 In reality very little was known about Chris B and there was limited attempt made by any professional to explore further issues that could be viewed of concern. Specifically it was thought that he had a child by an earlier relationship with which he had no contact; but this was not explored more fully. There were concerns about his possible drug misuse; but these were not investigated beyond the one, pre-arranged visit. Furthermore, if there had been appropriate contact made with the GP, there 21 was some evidence of previous mental health problems as well as information that might have raised concerns about information redacted. 5.1.9 This review has identified a pattern previously recorded in serious case reviews of agencies failing to take account of the role of male carers within the family process. ‘There were instances of ‘unknown’ males in some households at the time the child was killed. There appeared to be a minimalist “need to know” attitude to sharing information about the appearance of new men in a household....these men became invisible to practitioners working with the family or child.’12 This reflects a wider issue about the lack of involvement by health and welfare professionals with men despite their significant involvement in children’s lives. The need therefore is for all agencies to ensure that relevant information about men is collected during assessment processes and to ensure that their assessment processes are adapted accordingly. In this case Russell S was seen as a negative influence and there was almost an assumption made that Chris B would be a supportive and positive factor. Certainly there was inadequate investigation of possible concerns about him. Professionals may also have been influenced in this perspective by his mother’s role as a information redacted as this may have given them a false sense of security about him. 5.1.10 There were clear examples of professionals working well together to identify and respond to indications of potential risk to information redacted CHILD G. Specifically there was sound inter-agency working to assist Carly as a vulnerable young pregnant woman and later there was effective support provided when she was the victim of domestic violence with the MARAC process providing an effective support plan. There was also good awareness of potential risks identified at the child protection conference where all agencies were clear about the need to provide an effective care plan for information redacted CHILD G even if there was dissent about the best mechanism to be used. 5.1.11 A significant flaw in this process however was the failure to explore with Chris B the issue of substance misuse; and this was never fully addressed as it was later accepted that the opportunity had been missed. There was no assessment of whether Carly was also involved in using drugs. In particular a statement made by Carly ‘that if Chris B smoked cannabis he never did it in front of information redacted CHILD G’ was one that warranted further assessment as it could be seen as an indication that Carly knew Chris B was smoking cannabis. The failure to fully address the issues of drug-use was further compounded by the child in need planning process which did not provide a framework for further assessment of the family or effective work with the family to achieve change. The professionals working with the family then became over-optimistic with regard to Carly’s capacity for change. 5.1.12 The strategy discussion initiated after information redacted CHILD G suffered information redacted injuries did not immediately identify Chris B as a possible perpetrator. On the information redacted it was known that information redacted CHILD G had experienced a life threatening event while in the sole care of Chris B however the reasons for the event were not clear. He was therefore allowed to attend the London hospital with Carly and her family. There was limited communication with the hospital about how to manage his contact however information redacted CHILD G’s medical condition meant that it was unlikely he would have unsupervised contact 12 P52 Understanding Serious Case Reviews and their Impact: Brandon et al DCSF 2009 22 with the child. The process of managing parental contact after a life threatening event, and where exact cause is not known, is always difficult; the strategy discussion allowed the contact on the basis of the medical information available at the time. 5.2 Were the actions taken following assessments appropriate? Did the children in need plans and services provided meet the child’s needs? 5.2.1 Services provided following the earlier assessments were in the main appropriate and proportionate. Accommodation was provided for Carly that was suitable for her needs as a young and vulnerable person who was soon to be a mother. There was suitable support and advice available and a range of support systems were established to provide her with skills required to move towards fully independent living. Carly’s willingness to take up the services offered was limited however this ambivalence was within the normal range of responses by adolescents of her age. Consideration was not given in the assessment as to whether Carly was emotionally and socially vulnerable and therefore should have been accommodated as a ‘looked after child’ in accordance with the Southwark judgement. It is probable however that even if that assessment had given greater consideration to these factors the accommodation that would have been provided in those circumstances might well have been similar. It is clear that Carly was very eager to move into fully independent accommodation and it is unlikely that she would have wished to have been placed in foster-care or supported lodgings. 5.2.2 Similarly the support provided by the health visitor was broadly appropriate in that she provided enhanced support and information redacted CHILD G was visited fairly frequently. The only area were there could have been greater consideration to support needs was regarding provision of counselling or similar services with regard to the birth experience which appears to have been a difficult and traumatic period for Carly and which she later identified as a need. 5.2.3 Service provision after the child protection conference was mixed. A clear ‘outline child in need plan’ was developed at the child protection conference; however, there was some delay before key components of this plan were established. In part this was because the conference was just before Christmas. It was also because Carly was not co-operative with the student social worker; and was very adept at avoiding other professionals. Another factor that may have influenced Carly’s engagement with services is the range of options that was being discussed and the lack of clarity about how they related to proposed outcomes. The initial conference identified neglect as a key issue and indicated that Carly was failing to prepare feeds for information redacted CHILD G appropriately; and was not budgeting effectively. As the early childhood service IMR indicates these issues would most appropriately be met by the Parents with Prospects course; which whilst offered to Carly was not pressed strongly. The course that was emphasised was the Solihull Parenting course which focussed on ‘containment, reciprocity and behaviour management’; and which did not obviously address issues identified in the core assessment. Neither of these courses addressed the significant factor which was identified in the conference, which was the role that was being played in information redacted CHILD G’s life by Chris B nor did they consider substance misuse or its possible impact on the child. 23 5.2.4 During the five months after the child protection conference there was significant evidence that Carly was not co-operating with the child in need plan. She failed to attend the Solihull Parenting Group; refused to provide Chris B’s address where she and information redacted CHILD G were regularly staying; failed to budget effectively and remained in arrears for most of the period; and often avoided contact with professionals. It is probable that her eventual co-operation in information redacted was purely driven by the desire to access permanent accommodation and it is possible that the apparent improvements would not be sustained. There was no evidence that any of the professionals involved with Carly and information redacted CHILD G at this time identified that her ambivalence was an indication of possible risk to information redacted CHILD G and a rule of optimism seemed to predominate in the latter stage of the CIN plan. 5.2.5 Although there is mention of a contract of expectations in the social care IMR, it is not clear when this was developed; and if so, it was not shared with other agencies. It was decided that the Family Group Conference should not be taken forward which meant that an opportunity to establish the full nature and type of support provided by both Chris B’s mother and Carly’s father and his partner was missed. There was a lack of a clear outcome focus in the implementation and practical administration of the plan that subsequently led to drift. This process was compounded by poorly chaired and administered meetings and it is clear that no agency had full records from the meetings or a copy of the child in need plan or contract of expectations. 5.2.6 There was however, no evidence that any agency requested these documents, or raised concerns about the planning. The main responsibility for ensuring a child in need plan is effective lies with the key worker however, it is a multi-agency responsibility; and, if it is clear that the plan is not being successfully implemented, all agencies have a responsibility to take action. The outline ‘child in need’ plan agreed at the initial child protection conference clearly stated that if Carly did not co-operate, or there were further concerns, that a further child protection conference should be convened. This could have been requested by any of the professionals. That it was not called would imply that none of the other professionals was more concerned than the key worker about the failure of Carly to co-operate with the ‘child in need’ plan and the potential risk this posed to information redacted CHILD G. This would suggest that all the professionals involved with the family became committed to a perspective that there was improvement despite limited evidence to support that view. ‘The vulnerability lies not in the initial assessment, but in whether or not the revision process breaks down and practitioners become stuck in one mind-set or even become fixated on an erroneous assessment, thus missing, discounting or re-interpreting discrepant evidence’.13 5.3 Were the child’s needs taken into account when making decisions about the provision of children’s services, and was this was accurately recorded? 5.3.1 During the period of the review information redacted CHILD G was a very young baby with very limited capacity and ability to make information redacted needs known. Recording by agencies about information redacted CHILD G that could identify information redacted possible wishes and feelings was limited. There is recording to indicate that information redacted CHILD G was usually very clean and well-dressed. 13 (Woods and Hollnagel, 2006: 75) (Munro 2008): 53 quoted in Piloting the SCIE ‘systems’ model for case reviews: learning from the North Westhttp://www.scie.org.uk/children/learningtogether/files/NWPIlotsReport_a.pdf 24 There is also recording about the physical risks that information redacted CHILD G could be exposed to, such as, being left unsupervised on the bed. information redacted physical health and development was also documented and indications of delay in sitting were identified. There is less recording about the nature of the relationship between Carly and information redacted CHILD G and the extent to which Carly was able to develop a fulfilling relationship with information redacted; although the health visitor did report good bonding. The recording from the information redacted hostel indicated vulnerabilities in this area but there is limited evidence from the other IMRs. There is some evidence in the information redacted hostel IMR that this was not the only time that Chris B had sole care of information redacted CHILD G and that report indicates other occasions when Carly put her own needs ahead of those of her information redacted. This may be nothing more than a teenager mother coming to terms with the challenge of caring for a dependent child. It could however also be an indication of an absence of a strong bond between Carly and information redacted CHILD G which may be relevant in that it may have influenced Carly’s decision to leave information redacted CHILD G in Chris B’s care. A mother with a limited or ambivalent attachment to her child may be more likely to leave information redacted with risky carers. 5.3.2 The failure to fully assess Chris B or know or understand his role in information redacted CHILD G’s life was very significant when considering information redacted needs. It is now clear that he was significantly involved and on occasions provided unsupervised care for information redacted CHILD G. It is apparent that this was not fully known to all the professionals working with Carly however if they were taking information redacted CHILD G’s needs into account this should have been considered. There is no evidence that Carly was withholding this information as there is little evidence that she was ever asked. This is particularly important in view of information redacted CHILD G’s age and vulnerability; very small children cannot tell professionals about the adults in their lives so it behoves involved professionals to ask the questions. 5.3.3 A factor that has been identified in a number of serious case reviews is the extreme vulnerability of very young babies who because of their total dependency on their carers are at greatest risk of abuse, particularly physical assault. In the most recent research on serious case reviews just under half of all serious case reviews concern a baby under one year of age. That research identified that ‘there were three main ways in which the youngest babies aged under six months died or were harmed. These were primarily physical assault.’14 All professionals working with young babies should establish early who is involved in the care being provided to the child in order that appropriate assessments can be made as to whether they are suitable carers. 5.4 The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and her family, and whether this was explored and recorded. 5.4.1 The professionals involved with the family identified that information redacted CHILD G’s parents were white British and that their first language was English. None of the professionals recorded their religious affiliation. Chris B’s ethnicity was poorly 14 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009 Marian Brandon, Sue Bailey and Pippa Belderson 25 recorded by most agencies however the GP noted that he described himself as ‘mixed white and black Caribbean’. There is no recording of his religious affiliations and no evidence that any agency considered his ethnic origins and background in their assessments. information redacted CHILD G was the first child of Carly, who was 16. Her boyfriend Chris B was nine years older. This was not highlighted as an issue; although all professionals did identify Carly’s youth as a risk factor and provided her with additional support. 5.4.2 Both information redacted CHILD G s parents were unemployed at the time of information redacted CHILD G’s death. Carly had previously worked as a hairdresser and Chris B had worked as a labourer. Carly had problems managing her finances throughout the period of the review and was regularly in arrears with her rent. It is unclear whether these financial difficulties were associated with drug-use and whilst she was offered support with managing her money there is no evidence that any professional discussed why she was finding this difficult. 5.4.3 Russell S was known to have ADHD and this was considered by the health visitor when assessing the family’s needs. A number of professionals discussed with Carly her emotional needs, and she was prescribed anti-depressants post-natally by hospital staff; however, this was not followed up in the community and further assessment could have been undertaken. Chris B was not identified as having mental health difficulties during the period of the review but had experienced emotional difficulties earlier. Neither Carly nor Chris B were identified as having any communication difficulties. 5.4.4 Comparatively little was recorded about the social background of the extended family of either parent. Carly was seen to have intermittent support from her family. information redacted. It is apparent that there was some confusion by professionals about the role played by Chris B’s mother information redacted. This was particularly apparent in her contacts with the health visitor prior to the initial child protection conference. It is clear however that staff at the Children and Family Centre were very clear that when she attended there with Carly information redacted she was not attending as a professional. It is not known if this confusion about role affected how professionals responded to Chris B but there is no explicit evidence that there was a serious intention to deceive. 5.5 The management accountability for decision making and involvement of managers at key points in the case. 5.5.1 All of the IMRs are clear that there was appropriate management involvement and accountability throughout the period of the review. There is certainly evidence that practice was reviewed and that actions were taken when there were concerns that appropriate interventions had not been undertaken. An example of this would be the police management oversight of the child protection investigation which led to a joint visit by police and social workers to Chris B’s home address. 5.5.2 The Sussex Community NHS IMR identified that the child in need plan was not fully discussed in supervision and that practice regarding child in need plans had now changed with awareness of the raised thresholds and increased vulnerability of children subject to such plans. 26 5.5.3 There were however limitations in the management input as much of it was reactive and dependent on upward reporting by frontline practitioners. This may have been why the management scrutiny did not identify the drift in the child in need planning and was not robust in challenging practitioners about Carly’s capacity to improve. Clearly this is linked to the quality of the supervision provided to professionals as discussed earlier. ‘Child protection ….. managers need to establish the systems, ethos and context in which constant testing and revision of hypotheses and assumptions can underpin practice, as well as creating a working environment where professionals are actively encouraged to question their judgements and to invite alternative opinion – one in which it is acceptable and safe to simply change their mind.’15 5.6 The adequacy of training and supervision of staff to carry out their role. 5.6.1 Most of the professionals from the agencies who were permanently employed had received appropriate child protection training and most were considered to be experienced staff with relevant safeguarding knowledge. Within social care the ACM although undertaking work beyond that which is usual for unqualified staff had undertaken appropriate training and was considered to have sufficient experience and knowledge to undertake the work. The quality of the assessment undertaken would raise questions about the validity of that assumption and it is noted that unqualified staff no longer carry out initial or core assessments in West Sussex. 5.6.2 The social work student who was key worker for a significant period was supervised by a qualified social worker who was in the process of completing her specialist award; it being a requirement of this training that student supervision is undertaken. Similarly the social work student was in the last year of training and was undertaking a final placement and there is the expectation that this should include some experience of statutory work. The nature of the case was not such that it would be inappropriate for a student social worker to act as key worker. It must be acknowledged however that this worker’s personal experience of this case will have been very difficult. 5.6.3 As has been indicated earlier in the report the quality of the supervision provided to staff was variable and did not provide sufficient challenge and opportunity for professionals to re-evaluate their assessment of this family. There was an assumption that Chris B was an acceptable partner because ostensibly he appeared more suitable than Carly’s previous boyfriend however this was not based on a robust or assertive assessment. Many of Carly’s actions were considered to be usual adolescent behaviour and there was insufficient consideration of other causes for her financial problems and inability to co-operate with hostel staff. There was not a thorough exploration of the issues of substance misuse despite some indications of this as a risk factor early in the assessment process. The assumption that progress was being made was not questioned in supervision and managers and supervisors did not challenge the plan to ‘step-down’ the child in need plan. 5.7 The consistency of work with policy and procedures for safeguarding and with wider professional standards. 15 Munro, E. (1999) ‘Common errors of reasoning in child protection work’, Child abuse and neglect, 23, 8, 745–758. 27 5.7.1 During the period of the review the multi-agency Sussex Child Protection and Safeguarding Children Procedures (2006) were in place and available to staff, either as a hard copy or electronically. The main areas where there were questions of consistency with procedures were around the organisation and administration of the child protection conference and the systems and processes around section 47 inquiries, particularly strategy discussions. 5.7.2 A number of the IMRs discussed the issue of dissent at child protection conferences and it would appear that some professionals were not clear about their responsibilities to identify formally when they are not in agreement with the conference decision. The recording of the conference should also indicate where there is dissent; and, if it is resolved, how that resolution has been achieved. A number of agencies also indicated there were concerns about the mechanisms for distribution of invitations and reports for child protection conferences and it is clear that these were not in accordance with the standards as detailed in the procedures. 5.7.3 The processes around joint and single agency investigations by police and social care are issues that were highlighted in the Ofsted inspections and have been subject to significant levels of scrutiny since then. As a result of audits of these systems major changes in practice have been achieved. 5.7.4 There is no specific information in the procedures about the management of child in need plans or agencies’ responsibility within this integrated model. It is clear, however, that there were aspects of the inter-agency child in need planning that were not consistent with good professional practice. Any such joint working requires all agencies to be fully involved and to have access to joint documentation such as the child in need plan and contract of expectations. 5.8 Organisational difficulties experienced within or between agencies and any lack of capacity or resources in one or more organisations. 5.8.1 The IMR from Sussex Community NHS Trust identifies throughout the report the significant organisational and structural changes that were occurring during the period of this review. The IMR also identifies that health visitor caseloads were high and that the health visiting team was 0.65 down due to long term sickness. It was felt however that this would not have impacted on the care that information redacted CHILD G and Carly received as they were receiving an enhanced health visiting service and were prioritised. The GP report does suggest that work pressures for health visitors meant that there was less opportunity for joint working but this was not evidenced specifically with regard to work with Carly and information redacted CHILD G. The Health Overview report does not support it as a significant issue and in fact states that it was clear that supervision and training for health visiting staff were maintained despite these changes. 5.8.2 The social care IMR identifies that there were organisational changes within the service in March information redacted and that the Ofsted Safeguarding Inspection took place between information redacted. Whilst it would be expected that these events could be seen to be pressures that could have affected practice in fact the staff interviewed did not identify this to be a problem. None of the staff interviewed considered that they were working beyond capacity and they were clear that this 28 case was allocated to the social work student because it was felt to be appropriate to her learning rather than because of allocation pressures. 5.9 Examples of good practice. 5.9.1 Commentary about good practice has been provided throughout the report but it is noteworthy that in general there was good communication between agencies and there was significant evidence of professionals working closely together within the child protection and child in need planning process. There were however no examples of practice within this case that were significantly better than the norm which require specific mention. 5.10 Recommendations regarding training, practice or procedures. 5.10.1 Any specific recommendations regarding training, practice or procedures are included in Section 7 and then followed through to Section 9. 5.10.2 The specific recommendation from the Sussex Community Trust regarding the provision of multi-agency training on Child in Need planning was incorporated into recommendation 9.3. Similarly the recommendations from the Health Overview Report regarding involvement of professionals in child protection conferences and notification and distribution of conference minutes are included in recommendation 9.7. 5.10.3 The information redacted hostel made a number of recommendations for the LSCB; two of them are incorporated into 9.3 and 9.7; one of them will be acknowledged within the next review of child protection procedures; and one, ‘Request a report from Adult Social care and Supporting People Commissioners on whether general service specifications in contracts involving services to households including children make sufficient provision for adequate direct support time to be spent on dealing with Safeguarding issues.’ was felt to fall outside of the remit of the LSCB. 6 ASSESSMENT OF AGENCY MANAGEMENT REVIEWS All of the IMRs were considered by the panel to be of an adequate standard and provided useful descriptions of events as they occurred. There was less focus on the explanations as to why things happened in the first drafts and in the main this was the area that required further elaboration when IMR authors were interviewed by the panel. The Serious Case Review Panel reviewed all of the recommendations and the action plans. A number of agencies’ recommendations were not sufficiently smart, measurable, achievable, relevant or time-bounded and so the agencies were asked to re-draft them. 6.1 West Sussex County Council Children’s Social Care 6.1.1 This report addresses the key terms of reference and clearly identifies the failures in the assessment processes undertaken by the ACM. The report identifies that the conference provided a sound ‘child in need’ plan but is possibly too positive that this was the only possible outcome. The report is also less critical of the ‘child in need’ planning processes and fails to identify drift as a key factor in the failure to progress the plan. 6.1.2 This IMR was reviewed by the panel three times and some amendments were suggested. The panel considered that the authorship was sufficiently independent; 29 the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.2 West Sussex County Council Early Childhood (Children and Family Centre and outreach) 6.2.1 This IMR reported on the comparatively limited involvement that the service had with the family. It appropriately identifies that the services suggested for Carly and information redacted CHILD G may not have been most appropriate but seemed to have been offered largely because they were available. It also raises legitimate questions about the nature of the child in need planning and the absence of any commissioned work regarding Chris B. 6.2.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.3 Sussex Police 6.3.1 This IMR identified the key points when the police were involved with the family; specifically around the joint working around domestic abuse prior to the initial child protection conference; the limitations in the assessment regarding substance misuse by father; and the joint intervention after information redacted CHILD G sustained information redacted injuries. 6.3.2 This IMR was reviewed by the panel twice and some amendments were suggested. The panel also noted the discrepancy in the time of death as recorded within police records as opposed to the hospital report. The panel considered that the authorship was sufficiently independent; the recommendation was appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.4 information redacted Hostel, 6.4.1 This IMR examined the intervention by staff from the information redacted hostel and identified weaknesses in administrative arrangements associated with the conference process. The report also identified improvements that could be implemented with regard to the safeguarding arrangements within the hostel around recording and management systems. 6.4.2 This IMR was reviewed by the panel who considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. This was particularly noteworthy given that this organisation is not often involved in work of this nature. 6.5 Sussex Community NHS Trust (Health Visiting), 6.5.1 The community trust had significant involvement with information redacted and information redacted family and the IMR clearly identifies areas of good practice that included the intervention during pregnancy; the support after information redacted birth and the positive response after the incident of domestic violence. The report highlights the issues around the conference and the multi-agency working around the child in need plan. The report is legitimately critical of the administrative arrangements around the conference and child in need meetings but also 30 acknowledges that the health visitor had a responsibility to challenge when practice did not meet expected standards. 6.5.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.6 NHS Sussex Cluster (West Sussex) (GP) 6.6.1 GP involvement with this family was limited and the contact was with a number of surgeries as information redacted CHILD G’s doctor was changed half way through the period of the review. The IMR details the contacts with the family and highlights the weaknesses in the assessment prior to the child protection conference when no formal contact was made with the GP. The GP also raises some concerns regarding the inter-disciplinary working between GP and health–visiting services that are addressed in the Health Overview report. 6.6.2 This IMR was reviewed by the panel twice and some amendments were suggested. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.7 Western Sussex Hospitals Trust (A and E, Child Development Centre) 6.7.1 The hospitals trust had limited involvement during the period of the review however the IMR provided useful information regarding the assessment and support provided to Carly during her pregnancy and after information redacted CHILD G’s birth. 6.7.2 This IMR was reviewed by the panel and some minor adjustments were suggested but broadly the report was unchanged. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 6.8 Health Overview Report 6.8.1 This very comprehensive and detailed report appropriately reviewed the key themes from the health IMRs and identified any relevant matters of concern for commissioners. These were the problems regarding administrative arrangements for conferences, the difficulties in engaging adolescent mothers; the importance of effective child in need planning; and positively improved recording and communication between agencies. The panel considered that the authorship was sufficiently independent; the recommendations were appropriate and reflected the issues that were raised in the report and that the action plan was sufficiently robust. 7 LESSONS LEARNED FROM THE REVIEW 7.1 The importance of effective engagement of families and the need for assertive and inquiring interventions that include all adults, particularly men in the assessment process. Alongside this the review identified the difficulty of working with teenaged mothers; and the problems of distinguishing between ‘usual’ adolescent behaviour, and more problematic, ‘passive resistance’. A key factor for professionals working with families is their capacity to challenge and confront when outcomes are not achieved; regardless of the underlying causes. 31 7.2 The need for challenging and empowering supervision that enables professionals to review their work effectively. This needs to engender sceptical review and the capacity to re-evaluate existing presumptions. The challenge for supervisors is to be sufficiently aware of progress in work with families whilst still maintaining a degree of independence and scrutiny. It is crucial that supervisors do not solely rely on the supervisee to raise issues. 7.3 The need for improved child in need planning processes. These systems need to have multi-agency involvement and ownership and must ensure that there is sufficient capacity and capability to review the effectiveness of the child in need plan. This evaluation needs to include an on-going consideration of the assessment process which allows for re-assessment as time progresses and enables an evidence–based approach to casework planning. 7.4 The importance of greater awareness and consideration of substance misuse and the ways in which it may influence and affect parents and carers’ abilities to provide safe and consistent care for children particularly the more vulnerable babies. This understanding requires that professionals move beyond outward signs such as direct use of drugs and alcohol and consider other factors such as money management and availability as other indicators of possible substance misuse. 7.5 The importance of ensuring that all appropriate persons are invited to conferences and receive minutes within reasonable time frames. 8 CONCLUSIONS 8.1 Even with the benefit of hindsight there has been no evidence identified that Chris B presented a risk of physical harm to information redacted CHILD G. It must be acknowledged however that very little was known about him or about the level and nature of care that he was providing to information redacted CHILD G. If the work undertaken with agencies had been significantly different there would be no guarantee that information redacted CHILD G’s death could have been avoided. The reality is that there was limited information held by any agency to indicate that Chris B posed a risk to information redacted CHILD G and the review has not been able to identify any information that could have been accessed that would have shown that he was unsuitable to be caring for information redacted CHILD G. 8.2 With hindsight it is clear that information redacted CHILD G was exposed to drugs during information redacted life. The issue of substance misuse was not fully addressed in any professional assessment of information redacted mother. It is possible that if there had been a more thorough investigation of this issue when it was first raised then the risks to information redacted CHILD G might have been identified. 8.3 It is possible that if an effective assessment had been undertaken investigating the concerns regarding substance misuse that this would have identified further information about Chris B but it is equally possible that this would not have provided any additional knowledge. It is therefore not clear how this death could have been prevented. 32 9 RECOMMENDATIONS LSCB 9.1 That the West Sussex LSCB ensures that the learning is shared with all relevant staff. 9.2 That the West Sussex LSCB ensures that the recommendations in all of the completed IMRs are implemented by regular review of individual action plans. 9.3 That the LSCB ensures that all relevant member agencies are engaged with and fully understand the child in need planning processes including the use of ‘contracts of expectation’. 9.4 That all relevant agencies should satisfy the West Sussex LSCB that assessment processes include due consideration of the involvement of fathers and/or partners in the child's life. Where possible this should include their effective involvement in the process. 9.5 That the LSCB request all agencies examine their supervision of professionals who work with children in need. Agencies to report on whether supervision arrangements are sufficiently robust and capable of challenging and sceptical review. 9.6 That the LSCB undertake a review of multi-agency working with families where substance misuse is considered; following the launch of the ‘Think Family’ protocols 9.7 That the LSCB requests the Children’s Safeguarding Unit to review the processes regarding invitations to and distribution of minutes from child protection conferences. see Integrated Action Plan WSCC CHILDREN’S SOCIAL CARE 9.8 To ensure agency checks are completed and recorded on Framework I within all Section 47 enquiries (7.5.9) 9.9 A review of the quality of Child in Need Plans arising from an Initial Child Protection Conference (7.5.4) 9.10 Improve the quality of assessment in relation to the following; • children alleged to be suffering from neglect. (7.2), • parenting capacity of teenage parents (7.1) • the role and impact of new partners in relation to the child (7.5.2) • ensure all CIN plans include a contract of expectations (7.5.4). 9.11 Improve the quality of student supervision in relation to casework practice, analysis and planning, allocation of cases and understanding of working in a multi-professional context. 9.12 Raise awareness of the value of Family Group Conferences or family meetings in Children in Need plans. (7.5.7) SUSSEX POLICE 33 9.13 That any changes to the existing Police processes for the way information is shared and recorded are subject of post implementation audit and review. WSCC EARLY CHILDHOOD 9.14 Establish a single strategic oversight for Safeguarding and Family Support activities within ECS - - (reference paragraph 10.1 in Section 10 ‘Learning Points’.) 9.15 The implementation of a case file structure for Family Outreach Worker Service – to ensure consistent practice across the service - (reference paragraph 10.2 in Section 10 ‘Learning Points’). 9.16 Ensure consistent practice for casework supervision with related record keeping – (reference paragraph 10.3 in Section 10 ‘Learning Points’.) 9.17 Family Outreach Service to have clear and consistent care planning requirements which ensure focus on children’s needs and related improved outcomes - reference paragraph 10.4, 10.5 and 10.6 in Section 10 ‘Learning Points’. 9.18 To ensure that diversity issues are routinely considered in all contacts with children and their families – (reference paragraph 10.7 in Section 10 ‘Learning Points’.) information redacted HOSTEL, 9.19 Improve record keeping. 9.20 Align Hostel ISP and CIN Plan reviews and Safeguarding processes. 9.21 Review Visitor Time procedures to ensure robust risk assessment of visitors to vulnerable tenants. 9.22 Revise Hostel Safeguarding policy and procedures to make more comprehensive. 9.23 Revise Confidentiality and Data Protection policies. 9.24 Develop Trustees understanding of Safeguarding. 9.25 Improve management and sharing of key information. 9.26 Increase manager involvement in Safeguarding cases. 9.27 Review all Safeguarding cases. SUSSEX COMMUNITY NHS TRUST (HEALTH VISITING), 9.28 Sussex Community Trust to ensure that HV assessments meet the required Core Service Standard. 9.29 Sussex Community Trust to ensure that practitioners who attend child protection conferences are fully conversant with the process. 34 9.30 Sussex Community NHS Trust Child Protection and Safeguarding Children Procedures to include clear guidance on the roles and responsibilities of health professionals within integrated working on a CIN plan. WESTERN SUSSEX HOSPITALS TRUST 9.31 Where there are vulnerabilities recognized at clinic consultations, letters should be copied to relevant parties such as the health visitor, with the consent of the individual 9.32 Although the A & E visit information redacted appears to imply a minor illness, it is unclear that there was any regard taken of her social situation. This should be reviewed using the new paediatric A&E flow chart to trigger the assessment of vulnerabilities. 9.33 Although safeguarding training and the hospital procedures provide clarity on how the safeguarding team can be accessed to support staff and help with progressing safeguarding concerns, this should be strengthened. 9.34 There are not any copies of the PICU retrieval documentation in the notes; this should be remedied by the provision of an HDU/PICU retrieval pathway, or copies of PICU documentation should be added to the medical notes. NHS SUSSEX CLUSTER (WEST SUSSEX) (GP) 9.35 That NHS Sussex Cluster (West Sussex) advise all GPs in West Sussex that when the GP hears of a child protection conference being scheduled, they ensure that they have been invited and if they are unable to attend they send a report and also advise GPs that the GP contacts the social worker if they do not receive a report after the conference. 9.36 That the NHS Sussex Cluster (West Sussex) advises GP surgeries in West Sussex to ensure that their practice nurses document which adult attends with a child for vaccinations and whether they have parental responsibility and they document why a vaccination has been given later than advised if this has happened. 9.37 NHS Sussex Cluster (West Sussex) requests that the Acute Trusts that are commissioned by them ensure that their Accident and Emergency Discharge Summaries are legible so that GPs and Health Visitors and others are able to identify any concerns from the records. 9.38 NHS Sussex Cluster (West Sussex) commission future midwifery services to include a requirement for midwives to document antenatal and postnatal consultations within the GP medical notes. 9.39 Recommendation that NHS Sussex Cluster (West Sussex) carry out an audit of all West Sussex GP Surgeries to discover which GP surgeries hold a regular multi-disciplinary child safeguarding meeting (to include GPs, practice staff, health visitors (HV), school nurses (SN) etc) and to encourage those surgeries that do not hold such meetings to introduce them. 35 SUSSEX COMMUNITY NHS TRUST & WESTERN SUSSEX HOSPITALS NHS TRUST 9.40 Sussex Community NHS Trust and Western Sussex Hospitals NHS Trust to review the system for receiving and processing Child Protection Conference invites and documentation, to ensure there is a clear audit trail of receipt of information and that non receipt of expected documentation is followed up appropriately. Fiona Johnson January 2013 36 Appendix one Genogram information redacted |
NC047816 | Death of 3-month old child in 2015 due to medical causes. A child protection plan had been in place one year before the death for child BW and siblings, who lived with their mother, due to concerns of neglect. In 2013 there had been concerns about neglect when family lived in a different area, which resulted in a common assessment framework process being started to support the family. A 'Getting it Right Assessment' was completed in 2014 due to increasing concerns about the family. Issues identified include: views on a good enough home environment can be subjective and is complicated by working in a deprived area; safe sleep advice had been provided but was not followed; mother's disguised compliance may have added to the optimistic view of her intentions and capacity to change. Good practice identified: robust information sharing processes and good local professional relationships. Recommendations include: wider promotion and clarification for staff of the Graded Care Profile 2, and any other agreed neglect assessment tool for the multi-agency partnership; audit on how expected outcomes are recorded on Children's Services' documentation particularly Child Protection Plans, to clearly highlight what difference is expected to be made, and the consequences should positive change not occur; audit of pre-birth child protection processes to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately; review the Multi-Agency Pre-birth protocol; review of position of progress of the recommendation regarding safe sleep assessment from an earlier serious case review ; develop training on non- engagement and disguised compliance.
| Title: Serious case review: Child BW. LSCB: Blackpool Safeguarding Children Board Author: Amanda Clarke and Kathy Webster Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 BSCB Child BW SCR FINAL 02.02.2017 Blackpool Safeguarding Children Board Serious Case Review CHILD BW Review Process This serious case review (SCR) was commissioned by the Independent Chair of Blackpool Safeguarding Children Board (BSCB) after a referral from the Pan-Lancashire Child Death Overview Panel (CDOP). It was agreed after consideration of the recommendation from the BSCB Case Review Sub Group that the circumstances surrounding the death of a child met the criteria for a serious case review. Subject of the review: Child BW aged 3 months (deceased) Child BW was aged three months at the time of death. BW was born in the local area and had lived with Mother and two siblings. Other close family members involved in BW’s life included BW’s Father, maternal Grandmother and maternal Grandmother’s Partner. Circumstances resulting in the review Child BW had lived locally with birth Mother (Mother) and two older primary school aged half-siblings prior to the death. Within the report the eldest sibling will be referred to as Sibling 1 and the youngest as Sibling 2. The family had recently moved into a different property within the area at the time of the death and were settling into their new home. There were issues at the previous address around the state of the property, including cleanliness, tidiness and household risks. Due to the home environment and other circumstances, the two Siblings and the unborn Child BW had been placed on Child Protection Plans in the autumn of 2014 under the category of neglect. The process around the Child Protection Plans will be explored in detail later in the report. BW’s birth Father (Father) had had some contact with the child but had not been involved in the daily care. He was not the father of BW’s siblings but had been involved briefly in their lives during the short relationship with the children’s Mother. Mother and children were regularly supported by maternal Grandmother (Grandmother) and her partner (Grandmother’s Partner) who lived in the same area. Mother was known to have a number of friends locally who she would visit with the children. BW was seen by a number of professionals on different occasions during the child’s short life, and was described as a happy looking baby, appropriately dressed and warm. Sadly, BW was found at home, unresponsive by Mother during a morning in early 2015. Mother reported feeding BW at 5am then both slept downstairs, Mother on the sofa and BW in a baby swing chair in the same room. The Siblings were at Grandmother’s overnight. Mother awoke at 11am and on seeing BW an ambulance was called. Unfortunately despite everyone’s best efforts BW was pronounced dead at hospital. The cause of death was considered as natural causes due to infection. The Police have conducted enquiries regarding the sudden death and there are no criminal proceedings as a result. 2 BSCB Child BW SCR FINAL 02.02.2017 History and significant events leading to the review Mother and the two Siblings had previously lived with the Siblings’ birth father (Siblings’ Father) in another part of the country. Mother and the Siblings moved in the autumn of 2013 to Blackpool to be closer to Mother’s own family, and in particular Grandmother. The relationship between Mother and Siblings’ Father had ended around two years prior to the move and Mother became the main carer for the Siblings after the separation. Local services in the area had had some involvement with Mother and the children after the break-up, and Children’s Social Care from the previous area have contributed information to the review. Children’s Social Care in the previous area, were involved in early 2013 regarding the poor state of the family home, and an initial assessment led to a Common Assessment Framework process (CAF) being commenced to support the family. The Common Assessment Framework (CAF) is a shared assessment tool used across agencies in England. It can help professionals develop a shared understanding of a child's needs, so they can be met more effectively through a multiagency plan. CAF is an important tool for early intervention which requires the engagement of parents and carers, Pan Lancashire Safeguarding Children Procedures, 1.5. Soon after the initial assessment took place, unexplained bruising to Sibling 1 was noted at school where the child was also known to have had poor attendance. Mother had not engaged fully with the CAF process and was described as “low in mood”. The bruising was unexplained with no perpetrator identified by Sibling 1. A core assessment by a social worker resulted in an agreement to support the family by universal services and a continuing CAF plan. Later that year (2013) the family moved to Blackpool. Sibling 1 was admitted to a Blackpool school in Autumn 2013 and information was shared verbally with the school by the previous Local Authority. School health records were also transferred and reviewed in line with cross border transfer arrangements. Sibling 2 joined the nursery provision in the same school setting in early 2014. The family were living in a rented house but conditions were poor with no cooker connected, no carpets and the property was mostly undecorated. The children were often brought to school late, looking unkempt and in early 2014 Sibling 1 told a teaching assistant they had not washed, showered or cleaned teeth for three days. The family were known to be staying at other properties with friends due to the condition of their own home, and school and health professionals visited various local addresses to try to engage and offer support to the family. Many pre-arranged visits made by professionals were unsuccessful and Mother and the children were not always seen. During early 2014 school health and education professionals met and decided to complete a Getting it Right (GIR) assessment due to the accumulation of concerns for the family. GIR was a new process implemented in the local area in October 2013. The early intervention strategy, the ‘Getting It Right’ (GIR) framework, is designed to support partner agencies in helping families with more complex needs, thus reducing the likelihood that they will require support from statutory services. The professionals involved categorised the concerns as Level 3: complex: this category identifies children whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or development, Blackpool Thresholds for Intervention, November 2013. The health visitor visited the family home soon after the GIR assessment had commenced and conditions had not improved; all rooms were described as dirty with food on the floor, toilet facilities were unclean and the children had no bedding on mattresses which had been placed on bare floorboards. Mother said she had been prescribed anti-depressants by the GP. The health visitor shared her additional concerns with the school and it was agreed that the new information would be added to the GIR assessment tool. As the 3 BSCB Child BW SCR FINAL 02.02.2017 GIR process was quite new checks were required about the process to complete the task of adding additional concerns to the assessment, but the extra concerns and information was submitted. After three weeks, and several requests for updates by the school, they were informed that the case had been sent by the Early Assessment Team to the Families in Need Team (FIN) for allocation. The FIN team is a family intervention service operated through a multi- disciplinary team providing intensive support in homes. FIN was previously known locally as ‘Springboard’ and is often still referred to as ‘Springboard’ by families. In Spring 2014 less than a month after the initial concerns were raised, the health visitor, being so worried about the continuing poor home conditions, made a child protection referral to Children’s Social Care (CSC). The concerns in her professional opinion had now escalated to Level 4: acute: children at risk of significant harm / or has suffered abuse and for whom there is continued risk, Blackpool Thresholds for Intervention, November 2013. As a result a CSC and Police Public Protection joint visit was made and the children were placed in the care of Grandmother whilst Mother was required to attend to the poor home conditions. The children returned two days later and at this time a Child in Need plan was developed. A child is defined as a child in need in law, if he or she is unlikely to achieve or maintain or to have the opportunity to achieve or maintain a reasonable standard of health or development without provision of services from the local authority; his or her health is likely to be significantly impaired, or further impaired, without the provision of services from the local authority; he or she has a disability, Section 17 Children Act 1989. Mother was informed that should standards fail to improve an Initial Child Protection Conference would be initiated. The purpose of an Initial Child Protection Conference is to bring together family members, the child (where appropriate), supporters/ advocates and those professionals most involved with the child and family to share information, assess risks and to formulate an agreed plan of management and services, with the child's safety and welfare as its paramount aim; Pan Lancashire Safeguarding Children Procedures, 3.5. During this period BW’s Father and Mother had commenced their relationship. Father was subject to a Suspended Sentence Order at the time (for an offence unconnected to the family) and there was some liaison about the relationship between professionals from the Probation Trust and CSC. There were concerns historically about Father’s behaviour, including domestic abuse, and his use of alcohol and drugs. At the first Child in Need meeting Mother confirmed the relationship and that she was in the early stages of pregnancy with Father’s child. The unborn child was BW. Throughout the Spring and Summer of 2014 there was regular involvement by professionals with the family. Concerns noted in agency records included the children described as dirty and unkempt at school, at times smelling of urine. Both Siblings had head lice, which was not immediately treated. The Pupil Welfare Service was involved regarding school non-attendance. The home conditions were regularly described as poor with only occasional improvement, the house was recorded to be dirty and cluttered, particularly the kitchen, and the toilet was unclean. Sometimes the home smelt heavily of cigarettes and occasionally of cannabis. There were concerns that the children were often caring for themselves, there were no routines, and they were sometimes out late into the evening with Mother at other addresses. Engagement with Mother was regularly un-successful, there were no access visits when Mother and the children were not seen, and the home was not entered. However Mother did regularly attend the Child in Need meetings which took place monthly. As there was no significant improvement in the living conditions and lifestyle of the family they were referred to FIN for additional support. This was towards the middle of the Summer 2014 and at that time there were difficulties with Mother and Father’s relationship and a possible break-up. 4 BSCB Child BW SCR FINAL 02.02.2017 FIN commenced involvement mid to late Summer 2014 with home visits made at all times of the day and evening to try to better engage the family. However, records show in the first month of FIN involvement there were 14 no access visits. On 10 occasions the family were seen (either at home or when found to be at Grandmother’s address). At the Child in Need review it was agreed that, overall, circumstances had not improved and there were concerns for the unborn child (BW). A strategy meeting took place immediately which led to a decision in early Autumn to step up the case to an Initial Child Protection Conference (ICPC). At this time Mother was 24 weeks pregnant. At the ICPC Sibling 1 and Sibling 2, and the unborn child (BW) were placed on Child Protection Plans under the category of neglect. A number of concerns were explored at the conference including Father of unborn BW’s involvement in the family and associated risks. Consequently a written agreement was signed by Mother for there to be no contact between unborn BW’s Father and her children, Sibling 1 and 2, until a risk assessment was completed. FIN continued their intensive involvement but there was little change to the home conditions and limited improvement in terms of access to the premises, with 11 no access visits across the month after the children had been made subject to Child Protection Plans. The family were seen 10 times but half of these were at Grandmother’s home. The view of FIN professionals at this time was that the home conditions were scoring very high on the FIN neglect tool, which was a tool internally developed in FIN to provide some consistency to workers when managing neglect. The home was scored at 9 out of 10, with a score of 10 categorised as requiring immediate action to be taken. On one visit the conditions were recorded as “uninhabitable” with rubbish and dog faeces on the floor, and the children’s beds were wet with urine. On that occasion the children were placed with Grandmother by the Social Worker, being able to return home after four days once improvements had been made. In late Autumn 2014 a new Social Worker was allocated due to maternity leave. There had been a slight improvement to the home setting but leading up to the Review Child Protection Conference other concerns were noted. These included the children and Mother being located at the home of Mother’s friend one evening which smelt strongly of cannabis, an unexplained bruise to Sibling 1’s arm, and untreated head lice for Sibling 1. There was also a lack of preparation for the new baby (BW). The new Social Worker discussed obtaining legal advice with her Manager. At the Review Child Protection Conference, which took place one week before the birth of BW, the decision was made that the two Siblings and the unborn Child BW were to remain on Child Protection Plans. After BW was born a discharge planning meeting was held at the hospital with discharge of Mother and BW delayed due to lack of preparation of baby equipment by Mother at home. BW was seen by FIN professionals in the first week after the birth but the Midwife was unable to gain access and was therefore unable to monitor the health of the new baby. BW was finally seen by the Midwife for the first time at school as this was a place that Mother was expected to visit to collect Siblings 1 and 2, therefore access to Mother and BW could be reasonably guaranteed. There were concerns once BW was born that Mother was allowing Father to have contact with the baby, which was against the agreement made with CSC until a full assessment of Father had been completed. Other concerns at the home related to safety hazards including insufficient lighting upstairs, no loft door and a dog which was considered as a possible risk if left alone with Child BW and the Siblings. A strong smell of smoke and cannabis had also been recorded as noticed in the house. On a positive note the property was said to be warm on visits, BW was appropriately dressed and there was good attachment seen between BW and Mother. Professionals did see the family on 15 occasions, but there were 12 no access visits. Safe sleep advice is recorded as having been provided by the Health Visitor, and records show this was also given to Mother before the birth. 5 BSCB Child BW SCR FINAL 02.02.2017 Early in the new year 2015 Police were called to an argument outside Mother’s address which involved Mother and Father of BW. Mother said Father was upset at not being allowed to see BW but no offences were reported in the incident. The Police took no further action other than to remove Father to a different location. Soon after Mother reported to the Health Visitor that the relationship between the two had ended. When BW was nearly two months old the family (Mother, BW and the Siblings) moved house to a different property in the local area. Home conditions at the first address had been noted as poor by the Social Worker just prior to the move. Unfortunately during this period Sibling 1 was required to have 5 teeth removed due to dental decay following poor dental hygiene. In the first month at the new property Mother acted appropriately by taking BW to the GP for routine appointments. There were a further three appointments with the GP for BW for treatment of a viral upper respiratory tract infection. Home conditions were described as better, the children were all seen by the Social Worker and appeared well, and Mother’s emotional state seemed to have improved. On occasion BW was felt to be too warm and professionals advised a coat and blanket should be removed. After one month in their new home, as described earlier in the report, BW was found unresponsive at home and was later pronounced dead at hospital. Following BW’s death Sibling 1 and 2 moved out of the area and into the care of their own father (Sibling’s Father) who had become involved formally as the child protection process evolved in the autumn of 2014. Siblings have subsequently returned to live with Mother, following an assessment by Children’s Social Care. Legal Context: A serious case review was commissioned by Blackpool Safeguarding Children Board, following agreement at Blackpool Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2013). Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely: 5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. The methodology used was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Children Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the 6 BSCB Child BW SCR FINAL 02.02.2017 learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final report or in the action plan as appropriate. The decision to conduct the serious case review in this way was considered and agreed by the Blackpool Safeguarding Children Board after the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011. Munro suggests that Local Safeguarding Children Boards should use any learning model which is consistent with the principles in the Working Together to Safeguarded Children Guidance: Learning and Improving, HM Government 2015. Methodology: Following notification of the tragic death of Child BW in this case, and agreement by the chair of the Blackpool Safeguarding Children Board to undertake a serious case review, a review panel was established in accordance with guidance. This was chaired by Dr Rob Wheatley, the Designated Doctor and Consultant Paediatrician, Blackpool Teaching Hospitals NHS Foundation Trust and included representation from relevant organisations within Health, Education, the Police, Probation and Social Care. Amanda Clarke, an independent reviewer from Derbyshire was commissioned to work with the panel and to undertake the review. Kathy Webster, Consultant/Designated Nurse for Safeguarding Children in Derbyshire was commissioned as a second reviewer due to the children being on child protection plans at the time of the death, to provide additional scrutiny regarding the child protection processes. Review timeframe The timeframe for this review was from 19th November 2013 until 1st March 2015. However, any significant events relevant to the case but prior to the start date of the timeframe were reflected in the information submission and analysis completed by each agency. The timeframe starting point was to reflect the time at which Mother and the Siblings were known to have moved to Blackpool from another part of the country to live permanently. Information provided by services in the previous area has provided some historical context for the review but the interventions in the other area have not been analysed in detail as they were outside the review’s timeframe. This was the joint decision of the review panel. There is evidence of information sharing and follow up between professionals across borders. The end date of the review reflects the time around the death of BW. Full terms of reference for the review are included in Annex 1. All relevant agencies reviewed their records and provided timelines of significant events and analysis of their involvement. These were considered by the panel and provided opportunity for panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer and second Reviewer with the panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case. Family involvement The Reviewer attempted to meet with the Mother of Child BW in July 2016 but initially Mother decided that she did not wish to contribute to the review process. Fortunately in October 2016 Mother agreed to speak to the Reviewer by telephone. Father was seen in person by the Reviewer in July 2016 and was able to participate in brief to the review. The Siblings’ Father (Siblings’ Father), who resides away from the local area, was spoken to by telephone in September 2016. Grandmother was also spoken to by telephone in October 2016. 7 BSCB Child BW SCR FINAL 02.02.2017 The involvement of family members in the review has provided valuable insight into their own experiences, knowledge of the services offered to the family and overall some useful context. The thoughts of the family are included where appropriate and account was taken of the views of the different family members when writing the report and recommendations. The Reviewer is grateful for their contribution. The learning event The learning event was held in September 2016 and was attended by 6 professionals who had had direct involvement with Child BW and/or significant family members, in addition to the Reviewer who facilitated the session, the Second Reviewer, the Chair of the panel and the Board Manager of BSCB. The learning event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) and notes were recorded of the event. With the support of panel members and the Blackpool Safeguarding Children Board team, further enquiries were made with professionals who were unable to attend the learning event, and this information is included in the report. Following the learning event, the Reviewer collated and analysed the learning to date for discussion with the panel. Practice issues originally identified by the panel were re-examined in the light of the findings of the review. This provided opportunity to identify issues requiring further clarification with practitioners or managers. In reviewing the findings, the panel gave consideration to what could be done differently to further improve future practice. A draft report was provided to the panel in advance of the panel meeting in November 2016. Learning from the full report will be made publically available after consideration by the Blackpool Safeguarding Children Board Case Review Sub Group and the Board. ANALYSIS: Practice & Organisational Issues Identified Child BW and the identified significant family members, were engaged with a number of services during the timeframe of this review, including Midwifery and Health Visiting Services, Education, the GP, Children’s Social Care, Families in Need, the Police, the local Probation Trust and it’s successor Community Rehabilitation Company and Pupil Welfare Service . Scrutiny of the timeline, information shared and reflections at the panel meetings and the learning event have highlighted areas of good practice and also provided an opportunity for wider learning to emerge about the ways in which services work together. The following is an analysis of the issues identified: 1. Management of Neglect 1(a) Thresholds for neglect “The extent and significance of neglect in children’s lives has been a key and recurring theme throughout the previous biennial reviews of serious case reviews”. In the latest review for 2011-2014 from the 175 SCR final reports available, neglect was apparent in the lives of over half (52%) of the children who died, and nearly two thirds (62%) of the children who suffered non-fatal harm, Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection: Final Report May 2016, Peter Sidebotham, Marian Brandon et al. There is evidence in this case to suggest that Sibling 1 and Sibling 2 suffered neglect during the timeframe of the review, as did the unborn child, BW. Descriptions in case recording by a number of different professionals, which are only summarised above, help to illustrate what living conditions were like for the two young children (the siblings of BW), their Mother, and for BW both pre and post-natal. Furthermore there is some information of the lived experience of Siblings 1 and 2, including how they presented; dirty, with head lice and tooth decay, and how they felt: frightened having no upstairs lighting or loft hatch door, and unclean by not brushing teeth for 3 days. There is considerable information on record to suggest that the children were often seen caring for themselves and that they were not having their basic needs met. 8 BSCB Child BW SCR FINAL 02.02.2017 Professionals visited the home frequently, recorded their concerns and regularly challenged Mother. However it appears that a sense of acceptance on the behalf of professionals was prevalent regarding the conditions in which Sibling 1 and 2, and the unborn BW lived. For a period of at least 5 months in 2014, the siblings were viewed as Child in Need but it appears limited action was taken during this time other than advice and support given to Mother to make improvements. Records, particularly of the Initial Child Protection Conference and Review Conference show some professionals were optimistic about Mother’s capacity to change especially in terms of the state of the house. There appeared to be some acceptance that no change to, or slight improvement of, the conditions was satisfactory. No change to very poor home conditions (therefore no improvement) means conditions remain very poor. Slight improvement to very poor home conditions means they are still poor. Neither is acceptable when this is the home where young children and an unborn child are expected to live. The understanding of ‘what is good enough’ in terms of home environment is subjective in that what is good enough for one group of professionals or a family, is not for another. Subjectivity can also affect judgements of the type of area and housing where people live. In areas where there is known deprivation the threshold for intervention for neglect can be higher. When Mother and the Siblings moved to the area Blackpool ranked 12th highest in England for the proportion of children in low income families, compared to all authorities in the country and to the English average, Department for Education 2013. Furthermore Blackpool has a high level of child poverty, at 29.5%, a level which varies across the area rising to over 50% in some wards, Together on Poverty: Blackpool’s Child Poverty Framework 2012-2015. Professionals at the learning event working in the area where BW and family lived were in agreement that there were other families with children, in the same local area, living in similar circumstances. The definition for neglect includes the phrase “persistent and severe failure to meet a child needs”. This does not mean circumstances and the environment have to get progressively worse; the threshold for neglect can be met by the concerns not getting any better, despite as in this case extensive professional intervention. The environment in which BW’s family lived and level of basic care to the children did not show any sustained improvement until the family moved house in the last weeks of BW’s life. Supervision of the professionals involved is explored later but supervision is a key place for the beliefs of professionals to be challenged about apparent changes, good or bad, within families and for managers to seek evidence of actual progress through management oversight of cases. The impact of neglect on children should not be underestimated. In Children’s Social Care supervision records for the case the Siblings were described as “resilient, developing independence and the ability to self-care”. The Siblings were nursery and early primary school age at the time therefore such life skills should not be reasonably expected. Furthermore, no child should be expected to be resilient to neglect. This professional view could again be linked to the subjectivity of identifying levels of neglect or working routinely in circumstances where neglect is common and children “learn to live with it”. It is positive that Blackpool Safeguarding Children Board has adopted a suite of neglect assessment tools to help support professionals facing the challenges associated with the subjective nature in agreeing the severity of neglect in families. One example is the neglect assessment tool known as the Graded Care Profile 2 (GCP2). The Graded Care Profile (GCP) scale was developed in 1995 as a practical tool to give an objective measure of the care of children across all areas of need where there are concerns about neglect. The second version of the tool, known as ‘GCP2’ was developed to improve on GCP with the core principles of GCP remaining the same. GCP2 is a reliable and valid assessment tool in aiding practitioners in the assessment of child neglect: Testing the Reliability and Validity of the Graded Care Profile version 2. National Evaluation of the Graded Care Profile: NSPCC, Robyn Johnson, Emma Smith and Helen Fisher, NSPCC October 2015 9 BSCB Child BW SCR FINAL 02.02.2017 Full implementation of GCP2 in Blackpool is said to be planned to occur during the Winter of 2016/ 2017 and should allow the threshold for neglect and emotional abuse to be promoted and used consistently. Professionals at the learning event were at times confused about which neglect tool had been formally agreed for use across the area, particularly during the timeframe of the review. This may have been due to the different tools and initiatives regarding responses to neglect which have been introduced and tested over a period of time. The Blackpool Safeguarding Children Board multi agency training programme includes a course on Neglect Tool Training with objectives which include to become licensed to use the GCP2 and to consolidate knowledge in relation to neglect. The Board should consider wider promotion and clarification for staff of the GCP2 and any other agreed neglect assessment tool for the multi- agency partnership, to ensure all staff are aware of its implementation and how to use it effectively. 1(b) The Toxic Trio The term “toxic trio” is often used to describe the issues of domestic abuse, mental ill-health and substance misuse which have been identified as common features of families where harm to children can occur. Issues highlighted during the timeframe of the review include the mental health of Mother, her concerning relationship with Father who had some history of domestic abuse in a previous relationship, and the use of cannabis by adults in the environments in which the children lived and visited. Mother at times presented as low in mood, and sought support from the GP regarding this. Historical information shared regarding Mother indicates she had showed signs of similar low level mental health issues previously whilst residing in the other area of the country. Mother herself, in conversations with the Reviewer, confirmed she had sometimes thought that she “felt depressed” and had taken prescribed medication for how she felt, prior to the pregnancy with BW. She praised FIN workers who she said would ask her about how she was feeling at different times. In contrast she said she felt the Social Workers involved asked how she felt, wrote down her response but didn’t support her to find solutions. The relationship between Mother and Father (of BW) was relatively short but Father was identified as a risk to the children due to previous offending. It was positive that professionals from the Probation Trust/ Community Rehabilitation Company (there was no change of staff despite organisational changes) maintained good lines of communication with others involved with the family to share information and consider risks. Action was taken in that an agreement was required regarding Father’s involvement with Mother’s children and with BW, and an assessment was planned. When Father was seen as part of the serious case review process he shared that he felt unfairly treated by some professionals who he said viewed him as the only problem in the children’s lives because of one prior incident from his past. The Police did attend a dispute between Father and Mother early in 2015 and this indicates there was some hostility and aggression within that relationship. The incident was not recorded by Police as domestic abuse and therefore no Protecting Vulnerable Persons (PVP) form was submitted. Lancashire Constabulary has a Protecting Vulnerable Persons (PVP) form that is used for the submission of a referral around vulnerability. The PVP has three vulnerability categories of vulnerable child, vulnerable adult or domestic abuse. In addition the referral form also allows officers to risk assess the particular referral using the following classification of risk – standard, medium and high. Lancashire Constabulary was inspected in 2015 as part of Her Majesty’s Inspectorate of Constabulary’s (HMIC) effectiveness programme. The programme was to assess how well police forces keep people safe and reduce crime. Within the programme, HMIC’s vulnerability inspection examined the overall question, ‘How effective are forces at protecting from harm those who are vulnerable, and supporting victims?’ Overall Lancashire Constabulary’s operational procedures to protect vulnerable people and support victims were judged as good. In addition it was noted the quality of risk assessments was seen as improved since domestic abuse was inspected in 2014, Police effectiveness (HMIC) 2015 (Vulnerability): 10 BSCB Child BW SCR FINAL 02.02.2017 An inspection of Lancashire Constabulary, December 2015 The incident above, between BW’s parents, which occurred in early 2015, highlights a possible domestic abuse episode where appropriate risk assessment of vulnerability did not take place. In view of the judgement from the HMIC Vulnerability Inspection in the same year this was hopefully an individual oversight which fortunately had no serious related consequences. Lancashire Constabulary may wish to reassure itself that all frontline staff, officers or civilians, coming into contact with vulnerable children and adults are aware, and fully understand the requirements of the PVP process and the importance of sharing information about risk. It was suggested by some professionals at the learning event and by Grandmother in her contribution to the review, that there was suspected controlling behaviour by Father against Mother during the review timeframe. On speaking to the Reviewer Mother said, in her opinion, that no domestic abuse took place. She was aware of the incident in Father’s previous relationship, but claimed she had felt at no risk from him whilst they were together and that her children were safe, in her view, when in BW’s Father’s presence. Records in the timeframe suggest Father was a regular user of cannabis, and in the summer of 2014 he received a police cannabis warning after being found in possession of the drug. Mother was regularly challenged about her acceptance of cannabis use by her friends and Father, particularly when Siblings 1 and 2, and unborn BW were with her in environments where cannabis was obviously being used. It is noted that 3 weeks prior to BW’s birth, Mother and the children were located at a friend’s address where cannabis was openly being used. There is no record of Mother using cannabis or other controlled substances in Blackpool, and she denies any drug use herself. However her lifestyle choices are known to have brought her and the children into regular close contact with adults using cannabis. Risks from this lifestyle are recorded as being discussed frequently at professionals meetings including core groups and the Initial Child Protection Conference. In the Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection: Final Report May 2016, Peter Sidebotham, Marian Brandon et al, a wide range of factors in the parents’ backgrounds were highlighted as raising potential risks to children. These include domestic abuse, parental mental health problems, and drug and alcohol misuse. The timeframe for the review regarding BW’s death contains numerous entries of concerns relating to these issues, commonly referred to as the “toxic trio”. Others factors identified in the Triennial Analysis of Serious Case Reviews are a history of criminality (particularly violent crime) and acrimonious separation. These were also features in the lives of Father and Mother, and therefore in the lives of BW and the Siblings. In March 2015 BSCB identified the “toxic trio” as a priority theme for the Board, as well as neglect and early help. The toxic trio has also been a common priority for the Blackpool Safeguarding Adults Board. A course is currently available through the BSCB multi agency training programme titled “Hidden Harm-Toxic Trio”, with further training available on each individual element of the toxic trio. Half-day neglect briefings have also been externally commissioned by the BSCB since the start of 2016. Due to the highlighting of these risks and their potential links to children known to be subjects of serious case reviews nationally through the Triennial Analysis, BSCB should lead an evaluation of the Hidden Harm-Toxic Trio training. The evaluation should focus on overall attendees, which professional staff groups and agencies have attended, and whether from a Safeguarding Adult or Children background. What difference the training has made to those professionals, regarding their approach to neglect and identification of risk factors since attending, should be examined. 1(c) Making a difference for children Families in Need (FIN) had considerable involvement in the lives of BW’s family. FIN is currently positioned within the early help section of Children’s Social Care and is co-located in a Blackpool Police Station 11 BSCB Child BW SCR FINAL 02.02.2017 setting. Extensive visiting and intervention took place by FIN particularly in the period when Mother was pregnant with BW, but the question could be asked as to what difference this intensive service provision made to BW and the Siblings. Unfortunately FIN representatives were unable to attend the learning event but the Service Manager of FIN has provided valuable context of the service then, and now. The FIN Service Manager explained in March 2016 a decision was taken to audit cases that had been open to FIN for over 12 months. The audit was expected to show clear evidence of direct work with children and adults to address the needs that had already been identified. However some case audits showed a clear pattern of multiple visits (largely ‘welfare check-type visits’) but little evidence of direct work. There was limited evidence of any change in risk for the children, particularly in the cases involving the most complex and chaotic families. It appeared that increasing the frequency of visits to a family had become the default option when FIN were attempting to support a family in chaos or crisis, with some families receiving numerous visits, but this was not effecting real change. After consultation across FIN the approach of increased welfare check visiting was discouraged. Instead all practitioners were tasked to reflect and consider “So what?” in every aspect of their work, the main focus being to ask themselves to consider what they could do to make the most difference for children at each contact. This immediately led to a reduction in welfare visits and an increase in productive and effective direct work with children and their families. The FIN Service Manager reported ‘So what?’ is now a commonly used phrase across the team and hoped this change helped to demonstrate ongoing improvement in practice across FIN in relation to achieving better outcomes for children and families. The proactive approach to try to affect change in services for children is encouraging. Blackpool Safeguarding Children Board should request FIN undertake a further audit of complex cases and report findings to the Board. The audit should focus on cases open for over 9 months, as was the position in the family of BW, with particular scrutiny of frequency and reason for visits undertaken, and to explore specific outcomes for children as a result of FIN intervention. In the Children’s Social Care interventions with the family there was limited evidence of the outcomes for the children being explored or scrutinised in any depth. The case was discussed regularly in supervision once the Siblings had been identified and categorised as Child In Need for three months. Unfortunately there was no recorded supervision in the early stages of Children’s Social Care involvement. This is the time when expected outcomes should have been explored, what the expected outcomes were specifically and what early progress was being made. Supervision is explored later. Multi-disciplinary conversations did take place during the Child in Need and Child Protection processes. However, the “So what?” question does not always appear to have been clearly answered, in that there is no obvious outcome or improvement for the children to demonstrate what difference a specific intervention or action had made. On the Conference Outline Plan, which is a document with details of an Initial Child Protection or Child in Need Plan, there is a column with the heading “desired outcome”. In this case the Outline Child Protection Plan agreed in early Autumn 2014 includes some generic outcomes but these are brief and non- specific to the actual circumstances of unborn BW and the Siblings. Therefore professionals working with the plan may not have had complete clarity of exactly what was trying to be achieved and what difference this would make to the children. Furthermore the first core group notes and actions, from a week after the Child Protection Plan was instigated, has no reference or reminder to the desired outcomes as agreed on the plan. Detailed plans were completed after the initial outline plans, and these do focus more clearly on what is expected to change for BW and the Siblings. However the circumstances for the family and the unfounded optimism that change would happen demonstrate that whatever the detail in records of outcomes and what difference these would make, in this case little or no positive change occurred. 12 BSCB Child BW SCR FINAL 02.02.2017 Finally a further gap regarding outcomes in this case was an agreed plan, or consequences, for professionals to put in place should outcomes not be achieved and no positive difference be identified. This would have helped to avoid drift in the case creating focus on the expected outcomes for the children. Blackpool Safeguarding Children Board conducted a multi-agency ‘deep dive’ case audit in the Autumn of 2014 with a specific focus on neglect. A conclusion from the audit was despite high levels of agency involvement and resources being in place, there appeared to be no positive impact on the children. The BSCB should consider a further audit focussed simply on how expected outcomes are recorded on Children’s Services’ documentation particularly Child Protection Plans, to ensure detail is specific to an individual child and/or family’s circumstances and clearly highlights what difference is expected to be made, and what consequences are planned should no positive change occur. 2. Voice of the Child BW at 3 months old did not yet have a voice but records demonstrate there was some focus on the child, once born, in terms of observation of BW’s presentation by professionals working with the family. As stated earlier how the child was dressed, positioned and attachment with Mother was noted. Before BW was born but whilst the pregnancy was known to services there was only intermittent focus on BW as a child in their own right. The majority of case discussion and activity focussed on Sibling 1 and 2 and Mother, and this is evidenced by the lack of a pre-birth assessment of BW’s needs. Pre-birth protocols are examined later. There were a number of occasions during the review period when the Siblings would speak about their concerns to a member of staff in school. Sibling 1 reported there was no heating in the home during the winter and that they (Sibling 1) had been sleeping in a “baby cot”. Sibling 1 was also concerned that their hygiene needs were not being met including not being able to clean teeth. Unfortunately despite these concerns being raised eventually Sibling 1 had five teeth removed as a result of tooth decay. Records at school evidence that Sibling 1 and 2 were listened to by members of staff and this resulted in the concerns being raised more formally by the school, jointly with Health professionals. However there was limited evidence that the voices of the siblings of BW were properly listened to by all professionals, or that they were given every opportunity for their wishes and feelings to be fully heard. The poor, and at times shocking, state of the property where the family lived resulted in some professionals focussing more attention on Mother in trying to find ways to support her to improve the home. If such efforts had been effective, and conditions had got better, the outcome for Siblings 1 and 2, and subsequently BW, would have been positive. Unfortunately, despite the best efforts of professionals, who made numerous daily visits and revisits to the home, improvement was minimal. Therefore what could be described as the ‘indirect focus on the children via their Mother’ was of no benefit to them. It is positive that the bedroom where Sibling 1 and 2 slept was examined by those involved on a number of occasions, what they wore was noted and professionals obviously attempted to build a rapport with the children. Unfortunately acknowledging the presence of children and noting how they are dressed does not equate to giving them a real opportunity, and safe space, to share what their life is really like. Messages from children on their experience of the child protection system were submitted to the Munro review. Children voiced the importance of being heard separately from their parents and being listened to…. They made a plea for better information, honesty and emotional support throughout the process: The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011, Chapter 2.9. Professionals visiting families known or suspected to be living in neglectful environments should ensure children are regularly spoken to alone, and for this to occur away from the home setting when practicable. It is known that the Siblings were occasionally spoken to by the Social Worker within school, but what was discussed and how this information was used is not clear. Interventions with children in a safe, neutral environment will enable them to speak of their lived experience and more importantly how they feel, which can inform assessments and service provision. 13 BSCB Child BW SCR FINAL 02.02.2017 From early Autumn 2014 Sibling 1 and 2, and the unborn BW were all made subject to Child Protection Plans. The children did contribute to the Social Worker’s report to Conference by completing the standard children’s questionnaires which is the norm for the Blackpool area. The Siblings did not attend the conference and this is acceptable due to their young age. Their contribution to the process was therefore very brief and it is not clear, for example, what their thoughts were on Mother having another child and how this might affect their daily lives. Once the Child Protection Plans were in place the Siblings were seen by the Social Worker on statutory visits, but it is unclear if they were seen alone and for how long, or what type of intervention took place with them other than observation. The experiences of the Siblings, if explored in depth throughout the whole Children’s Social Care involvement, would have provided valuable insight into both the pre-birth experience of BW and how life was for the family once BW was born. It is known from Education professionals attending the learning event, and from records, that the Siblings were capable of sharing some information about their lives and home conditions. Blackpool Safeguarding Children Board reported it is standard practice in all case audits to examine whether the voice of the child was evident. This was part of the neglect case audit which took place in late 2014, see above. BSCB may wish to consider undertaking a specific audit regarding focus on all children, including unborns, and what this actually involves for the child being heard. Such an audit would be in in addition to child focus being an area considered in all multi agency audits as happens now. 3. Pre-birth protocols Research and experience indicate that very young babies are extremely vulnerable. According to The Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection the largest proportion of cases leading to serious case reviews related to children who were aged under one year. 120 of the 293 children (41%) were aged under one year at the time of their death, or incident of serious harm; and nearly half of these babies (43%) were under three months. “The high number of serious case reviews conducted with regard to babies under one year of age reflects the intrinsic vulnerability of the youngest babies who are dependent on their parents for care and survival”. Work carried out in the antenatal period to assess risk and to plan intervention will help to minimise harm. A Multi-Agency Pre-birth Protocol exists in the Pan Lancashire Safeguarding Children Procedures, October 2012. The protocol is to ensure that a clear system is in place to develop robust plans addressing the need for early support and services and to identify any risks to unborn children. A pre-birth assessment for BW was not considered or undertaken but several concerns relating to the Mother and Father of unborn BW and their parenting capacity indicate that, according to the Protocol, an assessment of identified risk factors should have taken place. It is obvious that considerable multi-disciplinary involvement was taking place with unborn BW’s immediate family and that statutory child protection processes were ongoing. A birth plan was developed by the Social Worker which included conditions regarding Father’s presence at hospital and contact after BW’s birth. This was discussed in supervision. However the lack of completion of a pre-birth assessment for BW meant that the risks to BW were not considered exclusively even though a number of concerns were known. Although it is widely accepted that BW, whilst unborn, was placed on a Child Protection Plan in early Autumn at the same time as the Siblings, there is no formal record of this, as the outline plan names the Siblings only. Subsequent records relating to the Child Protection Plan, including the Review Conference continue to exclude unborn BW as a subject in their own right. This may be a recording error or oversight as BW is certainly mentioned and considered in the body of documents relating to the Child Protection Plans for the Siblings. However if a pre-birth assessment had 14 BSCB Child BW SCR FINAL 02.02.2017 taken place this may have resulted in a continued focus on unborn BW’s own needs rather than these being added to, and possibly being overtaken by the needs of the Siblings and Mother. The Reviewer raised an additional concern that if BW was not recorded individually on some Child Protection Plan documentation would BW have been traced on any records search or management information data collection, and have been formally identified, and counted, as a child on a Child Protection Plan, whether unborn or not. Blackpool Safeguarding Children Board should audit pre-birth child protection processes, including the effectiveness of assessments completed, to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately, and the impact of the new baby on the mother’s/care giver’s ability to meet the needs of the other children is understood. The Multi-Agency Pre-birth Protocol in the Pan Lancashire Safeguarding Children Procedures should be reviewed by the relevant sub group with oversight of the Pan Lancashire Procedures. The version available for use currently states due for review in 2014, but this review has not yet been completed. Once reviewed and re-issued the new Protocol should be promoted and highlighted to all relevant professionals. 4. Embedding new processes Working Together 2015 is very clear that local agencies should work closely to provide early help assessment and effective services for children who may benefit from them. Blackpool’s strategy of support for children and families is called the “Getting it Right” (GIR) framework, as mentioned earlier. The strategy is designed to assist everyone who works with children and families in Blackpool in their work, and to ensure families get the right support at the right time. The key principle is to offer help to children and families who need it at the earliest possible stage. GIR processes were launched in Blackpool in October 2013. This was a few months prior to the GIR assessment which commenced as a result of school and Health Level 3 concerns for Siblings 1 and 2. When the concerns were first raised Mother was not yet pregnant with BW. Professionals at the learning event who were involved in the initial GIR assessment spoke of confusion at that time regarding the new process, including completion of required GIR documentation. There was acceptance that training had been provided regarding the GIR framework but using the new process was described as challenging and time consuming. It was fortunate that the professionals persevered with the process and eventually the case was allocated in FIN. Blackpool Safeguarding Children Board reported that there was a considerable amount of support available for the launch of the new GIR process including practitioner training and a GIR champions’ network established for help in individual agencies. Literature including leaflets was and still is available across the partnership. The experience of professionals in using new systems and processes should not be ignored. Introducing and embedding new frameworks, processes and assessment tools, across a workforce takes time, see management of neglect section above. For implementation to be a success key messages for the new system need to be widespread and consistent, with support available when difficulties arise. Despite all the best efforts of Blackpool Safeguarding Children Board and Blackpool Council regarding the smooth introduction of GIR, experienced members of staff struggled with its implementation. The Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection: Final Report May 2016, Peter Sidebotham, Marian Brandon et al, 8.3.2 explored the lack of clarity of processes concluding that “professionals’ familiarity and comfort using processes is integral to their effectiveness”. Whilst no recommendation is made regarding the testing of GIR’s continued implementation and use across Blackpool, the Safeguarding Children Board and the Early Help Steering Group should note the 15 BSCB Child BW SCR FINAL 02.02.2017 views and experience of practitioners in this case, and the learning from the Triennial Analysis of Serious Case Reviews (above), to inform plans for successful implementation of new processes and pathways. 5. Safe sleep support Due to the circumstances of how BW was found immediately prior to being taken to hospital safe sleep processes have been scrutinised by the Panel and by professionals at the learning event. Safe sleep materials are shared by the three Pan-Lancashire Local Safeguarding Children Boards and were re-launched in late August 2015. The Pan-Lancashire Child Death Overview Panel commissioned the Lullaby Trust to facilitate training to raise awareness of the need to promote safe sleeping arrangements for infants and toddlers. The multi-agency training has been ongoing and is complimented by local safe sleeping awareness campaigns. It is clear that Health professionals involved with the Mother of BW provided appropriate safe sleep advice and guidance to Mother both pre and post-natally. The Pan-Lancashire Safer Sleeping Guidance for Children, updated July 2015, gives clear information to the multi-disciplinary workforce who have contact with parents and carers of babies, “to discuss baby sleeping arrangements, in order to support parents to make informed choices regarding safer sleep”. Within Lancashire it is recommended that the safest place for a baby to sleep is in a cot in a room with the baby's carer for the first six months, and this refers to any time the baby is asleep, during the day or night. The guidance includes information on car seats, pushchairs, and other baby sleep and carrying devices where babies should not spend longer than is necessary. Mother did confirm that she received safe sleep advice from the Midwife, as well as other advice for new babies, but it is not known what she had retained regarding the safe sleep information that was given. Professionals visiting the home had recorded that BW had been seen on the sofa and in the baby swing chair. It is not clear how much challenge was made around this observation. There were also two occasions, as mentioned earlier when BW was found to be too warm and the baby’s coat and blanket was required to be removed. Sadly on the morning of the death BW was found to have been sleeping overnight in a baby swing chair, not a cot or moses basket. There is no evidence in this specific case that the sleeping position and equipment used contributed to the death but the safe sleep advice provided consistently by professionals to Mother of BW was not being followed. In a serious case review in the local area in 2015, BSCB Case BV, a recommendation was made that BSCB should explore the introduction of a safe sleep assessment process for all new babies in the Pan Lancashire area. The process is designed to promote more robust safe sleep practices in gathering as much information about a baby’s sleeping situation, including location and equipment available, in order that appropriate advice is given. There is additional scrutiny as part of the assessment in that the Health professional actually sees where the baby is sleeping in order to promote safer sleeping routines and give appropriate advice which is relevant to the circumstances of each family. The timing of BW’s death was prior to the recommendation regarding the introduction of the safe sleep assessment being agreed, which means Mother of BW would not have been subject to the new assessment. Furthermore the provision of safe sleep support and an assessment of parents and carers will only result in positive outcomes for babies and infants if those responsible for settling them to sleep remember and act on the advice provided. It is evident that safe sleep information for parents was, and is still being provided consistently in the area, and the issue is whether parents and carers choose to act on the information and support. BSCB should request the current position in terms of progress of the recommendation from the serious case review BV, including data of how many assessments have been completed compared to numbers of local births, as the intended outcome was that use of the new assessment could assist in embedding safe sleep 16 BSCB Child BW SCR FINAL 02.02.2017 messages in families. Professionals at the learning event noted that colleagues other than Health professionals were also well placed to highlight and reinforce safe sleep messages due to the high frequency of contact with some families as in BW’s case. BSCB should continue to ensure that the safe sleep awareness materials through local initiatives such as the Safer Sleep for Baby Campaign are available, accessible and embedded across relevant partner agencies in order that consistent advice can be shared with families at every opportunity. 6. Non engagement Records demonstrate that non engagement was a feature in this case with extensive efforts and resources required by many professionals to maintain contact with the children and Mother. Examples include the numerous visits undertake by FIN staff to gain access to the home, and after BW was born, the Midwife having to pursue Mother and BW to the Siblings’ school as all other attempts to see the new baby had failed. However, there is also evidence of Mother’s attendance and participation at core groups and other multi-disciplinary meetings which would indicate some compliance with safeguarding processes. Disguised compliance involves parents giving the appearance of co-operating with agencies to avoid raising suspicions and allay concerns. Although there were many instances of professionals not gaining access to the home of BW and the Siblings, by complying on some occasions when visits took place and by attending formal safeguarding meetings Mother gave an impression of cooperating with agencies, therefore showing disguised compliance. This appears to have added to the optimistic view of Mother’s intention and capacity to change and thus to improve the lives of the children. Furthermore disguised compliance can lead to a focus on adults, in this case Mother, and their engagement with services, rather than on achieving safer outcomes for children. Issues relating to engagement or lack of it, and disguised compliance, by parents and carers must be a standard area for discussion in supervision of professionals. For all professionals, disengagement, resistance and disguised compliance should be included as a key area of concern when assessing risk to a child, and therefore be included in supervision discussions about decisions and risk analysis. If issues of non- engagement and hostility in families are not brought to the attention of Managers or if Managers do not include engagement as a supervision agenda item, then the impact of non- engagement and subsequent risks will not be addressed. A learning point from a Serious Case Review January 2016 into the Death of Child A in Milton Keynes highlighted a similar theme that “supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement”. Supervision is discussed later in the report. Professionals attending the learning event spoke generally about the challenges of dealing with non- engagement by families. In some Local Safeguarding Children Boards multi agency training programmes include specific training courses on dealing with hostile and uncooperative families. It was shared that BSCB do incorporate non engagement and resistance as a theme running through much of their safeguarding training. The Board should explore the development of training focussed on the issue of non- engagement and the impact on children, particularly in cases of chronic neglect, to better equip professionals to respond to such behaviour and the associated risks. In BW’s case non engagement of Mother and gaining access to the family home was a routine problem for all those involved. In these cases particularly when Child Protection Plans are in place and there are known risks to an unborn child and/or young children the content of the Plan should include clear consequences for parents and carers should engagement remain an issue. Quick and robust action must be taken if improvements regarding access and contact with the children are not made. 17 BSCB Child BW SCR FINAL 02.02.2017 7. Concerns Resolution At Panel meetings and at the learning event for this review the overall view of partnership working in the area is positive. Strong links are said to exist between agencies, there is some co-location of professionals and there are multi-disciplinary teams. Meaningful information sharing is said to take place. Professionals at the learning event held the view that much of this is due to longstanding working relationships and a small geographical area which assists in sound professional relationships being developed. Even in areas where good working relationships exist, professionals across all safeguarding organisations must be aware of, and have the confidence to use, the local Resolving Professional Disagreements Guidance 8.1 Pan Lancashire Safeguarding Children Procedures 8.1 in conjunction with the Blackpool Children’s Services Concerns Resolution Protocol which covers all services that operate within Blackpool Children’s Services Department. In this case there were apparent delays in the initial referral after the GIR assessment was actioned and records show professionals were proactively requesting updates on progress. The use of the Resolving Professional Disagreements Guidance was not required at this stage but there was no common knowledge amongst professionals at the learning event of the guidance should circumstances have developed differently. Managing expectations and differing viewpoints of professionals in complex cases such as BW and family is difficult. Raising awareness of the guidance to resolve disagreements will enable problem solving between professionals which is transparent and non-confrontational, and which retains a focus on the needs of the child. As guidance is already in place in the local area the Blackpool Safeguarding Children Board should ensure, as a practice issue, that the Resolving Professional Disagreements Guidance is highlighted and re-promoted as necessary across all partner agencies. 8. Supervision and management oversight In referring to reflective practice and the role of social workers and managers Lord Laming stated “supervision should be open and supportive, focusing on the quality of decisions, good risk analysis, and improving outcomes for children”, The Protection of Children in England: A Progress Report, March 2009 3.15. In the Ofsted Inspection of Blackpool Services for Children in Need of Help and Protection, Children Looked After and Care Leavers, July 2014 inspectors highlighted that social workers did not consistently receive regular reflective supervision to support and challenge their practice. There is no record of supervision taking place for the first three months when the Siblings were categorised as Child in Need with social work involvement. This period was just prior to the Ofsted inspection. Supervision of the Social Workers involved did take place regularly over the nine month period leading up to BW’s death. There was consistent case management for that period of the serious case review timeframe with just two Social Worker/Manager partnerships involved. Recording of these supervision discussions was detailed. However the period of social care intervention where there was no recorded formal supervision is a missed opportunity for informed and specific management oversight, which is especially pertinent in the early stages of any case. Furthermore as mentioned above there was limited focus throughout interventions on the needs of BW as an individual before BW was born. This was a similar position in case supervision where unborn BW was not a focus. There was an element of optimism of Managers that Mother was capable of change without an assessment to evidence this was actually happening, but eventually legal advice was sought by the local 18 BSCB Child BW SCR FINAL 02.02.2017 authority in late 2014. This was as a result of supervision discussions. At one point a joint visit of the Social Worker accompanied by the Manager was discussed in supervision but there is no record of this taking place. Whilst accepted that Managers are supervising high numbers of staff and demands on time are challenging, joint visits to families and homes can provide an opportunity for supervision “on the ground”. Furthermore, joint visits can help with illustration of family circumstances particularly when neglect is suspected, to enable effective and joined up analysis of risk and to better effect change. The review panel was told that ‘live supervision’ when managers and workers are able to discuss cases whilst being operational is being considered within the authority. The Service manager of Families in Need (FIN) reported that managers across FIN are trained in safeguarding supervision and provided reassurance that supervision of FIN staff is taken seriously and does regularly take place. FIN Managers should also consider undertaking joint visits with their staff where practicable and particularly in cases open to the service for longer than 9 months. Recording of FIN supervision is now on the same recording system as used by Children’s Social Care. Joint supervision between FIN and Children’s Social Care for cases with both departments’ involvement does not routinely take place, but resource panels attended by both FIN and Children’s Social Care regularly occur. The panels provide a good opportunity for progress, any challenges and forward plans in open cases to be discussed. 9. Involvement of fathers A number of local and national reviews have highlighted the importance of professional communication with both parents even when they become estranged. In Blackpool the serious case review regarding Child BT (BSCB May 2015) considered this issue, and the NSPCC have produced a summary (March 2015) of the learning from national reviews with regard to “Hidden” Men (see below). In this case BW’s Father was not hidden but as he was required to have no contact with the Siblings, and BW once born, due to identified risks, this meant that some professionals did not see or involve him. Father did attend some health appointments with Mother early in the pregnancy and in his brief contribution to the review he spoke warmly of the midwives who took time to ask him how he felt about becoming a parent. On the other hand, Father said he felt excluded by some professionals, particularly towards the end of the pregnancy, and he was aggrieved by the perception, which he felt, professionals had formed of him. Officers from the Probation Trust/ Community Rehabilitation Company were closely involved with Father throughout the timeframe of the review due to his offending and were proactive in sharing safeguarding information with others. Licence conditions for Father, after prison release for an unconnected matter in the Autumn of 2014, included non- contact with the Siblings and a condition of residence to live at an address other than with Mother. Records show contact issues and identified risks, including the impending birth of BW, were regularly discussed by Probation staff with other professionals. There is also some evidence that the concerns and rationale for restrictions were discussed with Father which shows transparency and involvement of fathers, even though Father disagreed with the professional judgements formed of him. Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015 highlights that professionals do not always talk enough to other people involved in a child’s life, such as the mother’s estranged partner, or other extended family. This can result in important information being missed and sometimes failure to examine another perspective or realise inconsistencies in a mother’s account. In the Reviewer’s brief contact with Father, and through the contact subsequently with Mother and Grandmother differing viewpoints were shared about the family. Whereas this is normal particularly when relationships have ended, opportunities for involved professionals to gather as much information from significant adults must not be overlooked to build a more rounded picture of what life is said to be like for the children concerned. The pre-birth plan for BW, which was agreed one month before the birth, shows a risk assessment was 19 BSCB Child BW SCR FINAL 02.02.2017 required for Father before his contact with BW could occur. Unfortunately the process was not completed due to Father’s lack of engagement with the assessment and then the death of BW. This meant the support which could have been provided to Father by professionals, and the window this could have given on the family from another perspective (Father’s) was never developed. Father was described as difficult and challenging to manage by a number of professionals particularly towards the end of the pregnancy. The Social Worker was subject of an aggressive episode by Father against her. Whilst aggression and threatening behaviour should not be tolerated, and the Social Worker rightly reported this to a Manager, there are many reasons why this type of behaviour may be displayed. A lack of rapport and feeling of not being listened to are just two reasons given by Father of BW as to why he failed to engage with services, which may reinforce the research regarding fathers above. Siblings’ Father contributed to the review to provide some useful context, albeit he had no involvement with Child BW. He said his relationship with Mother ended soon after Sibling 2 was born and there was limited contact after that, and once Mother and Sibling 1 and 2 moved areas to Blackpool. Father did look after the Siblings overnight in the summer of 2014 whilst he was visiting Blackpool, which is when, as he recalls, for the first time he was informed of the Children’s Social Care involvement with the Siblings (his children). At this point they were categorised as Child in Need (see above) and Child in Need meetings had been taking place regularly throughout the spring/summer of 2014, which Mother attended. He recalls he was involved by services after that overnight stay and he was able to attend the Review Child Protection Conference for all the children, just before BW was born. In Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015 it is noted that “failing to identify and/or engage with fathers ignores their fundamental importance in a child’s emotional and psychological development. When a vulnerable child’s needs are not being met by their mother, an estranged father may be able to provide the protection and stability that the child needs”. For BW’s Siblings there had been intermittent contact with their Father (Siblings’ Father), however this was not explored as an option on the occasions when the Siblings were required to spend time away from their home due to worsening conditions. Whilst accepted that the Siblings’ Father did not live locally there were concerns which developed over time regarding Grandmother’s home including sleeping arrangements and other environmental factors, but still the Grandmother was the first and only option considered. In contrast almost immediately after the death of BW the Siblings were returned to the Siblings’ Father’s care. How fathers can be better engaged, and therefore also used as a source of information, whatever their current position is within a family, can be a challenge. Those involved need to remain professionally inquisitive with fathers, and to identify any additional support and guidance which may be required to get the best from them. A recommendation was made regarding the death in Blackpool of Child BV (published by BSCB January 2016) to explore new opportunities of better engaging all expectant and new fathers and work is continuing to complete that action. Practice issues Practice issues were highlighted for individual organisations as a result of the learning review. These issues are not subject to separate recommendations as practice improvement is already in place, or relevant policy and procedures exist. The organisation’s own governance arrangements will need to monitor that issues continue to be resolved; Lancashire Constabulary should continue to ensure that all frontline staff, officers or civilians, coming into contact with vulnerable children and adults are aware, and fully understand the requirements of the PVP process and the importance of sharing information about risk. 20 BSCB Child BW SCR FINAL 02.02.2017 Safe sleep awareness materials through the local Safer Sleep for Baby Campaign continue to be available and are embedded across relevant partner agencies in order that consistent advice can be shared with families at every opportunity. Blackpool Safeguarding Children Board should ensure that the Resolving Professional Disagreements Guidance within the Pan-Lancashire Safeguarding Children Procedures is highlighted and re-promoted as necessary across all partner agencies. Supervision for all safeguarding professionals must take place to the prescribed individual agency frequency and be recorded accordingly. Good Practice Identified Good practice was identified during the review, by the panel and by professionals at the learning event as follows: Robust information sharing processes and the existence of good professional relationships locally between all partners were highlighted, including agencies where safeguarding is not seen as the core daily business such as within the Community Rehabilitation Company. Conclusion The outcomes for all three children in this family before the sad death of BW could have been improved more promptly. There was some lack of understanding around Mother’s parenting capacity and ability to change which resulted in prolonged inadequate parenting of the children. All professionals should have challenged Mother more consistently and effectively using prescribed thresholds for neglect whilst working to detailed and specific outcomes for BW and the Siblings. However the findings of this serious case review do not indicate that inter-agency practice or the practice of any individual or organisation could have altered the outcome of this case. The death of Child BW, which was due to natural causes, could not have been predicted or prevented. Within the review good practice was noted. Scrutiny of practice, however, always provides an opportunity to consider ways in which services may be improved and therefore the following recommendations, based on the learning from this case, have been made: Recommendations In order to promote the learning from this case the review identified the following actions for Blackpool Safeguarding Children Board and its member agencies: 1. Blackpool Safeguarding Children Board should consider wider promotion and clarification for staff of the Graded Care Profile 2, and any other agreed neglect assessment tool for the multi- agency partnership, to ensure all staff are aware of its implementation and how to use it effectively. Intended outcome: Thresholds and criteria for neglect are consistently applied and understood by all professionals ensuring children living with neglect are identified and supported at the earliest opportunity. 2. Blackpool Safeguarding Children Board should lead an evaluation of the Hidden Harm-Toxic Trio training. The evaluation should focus on which professionals and agencies have attended, including which professionals from an Adult Safeguarding background as responding to Hidden Harm-Toxic Trio has been a common priority across both the Safeguarding Children and Adult Boards in 21 BSCB Child BW SCR FINAL 02.02.2017 Blackpool. What difference the training has made to the professionals who attended, regarding their approach to neglect and identification of risk factors since the training, should be examined. Intended outcome: The current training programme is evaluated and as a result may be developed or amended as necessary to capture the findings of this serious case review. The evaluation should provide evidence of which relevant professionals are attending, from both Adult and Children Safeguarding backgrounds, and whether training has transferred into practice which will provide improved outcomes for children affected by neglect. 3. Blackpool Safeguarding Children Board should consider an audit focussed simply on how expected outcomes are recorded on Children’s Services’ documentation particularly Child Protection Plans, to ensure detail is specific to an individual child and/or family’s circumstances and clearly highlights what difference is expected to be made, and the consequences should positive change not occur. Intended outcome: All professionals working with children subject to Child Protection Plans are clear about the specific outcomes and expectations for individual children, enabling focussed intervention on the needs of each child. 4. Blackpool Safeguarding Children Board should audit pre-birth child protection processes, including the effectiveness of assessments completed, to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately, and the impact of a new baby on the mother’s/care giver’s ability to meet the needs of the other children is understood. Intended outcome: Unborn children are afforded the focus and protection required when concerns have been identified either for the unborn child or any siblings. 5. The Multi-Agency Pre-birth Protocol in the Pan Lancashire Safeguarding Children Procedures should be reviewed by the relevant sub group with oversight of the Pan Lancashire Procedures. Once reviewed and re-issued the new Protocol should be highlighted to all relevant professionals. Intended outcome: The Multi-Agency Pre-birth Protocol is updated and its use promoted, to provide robust and up to date guidance to professionals involved in offering support and managing risk to unborn children, improving the focus on and protection of these vulnerable subjects. 6. Blackpool Safeguarding Children Board should request the current position of progress of the recommendation regarding safe sleep assessment from the serious case review BV. The progress report should include data of how many assessments have been completed compared to numbers of local births, as the intended outcome was that use of the new assessment could assist in embedding safe sleep messages in families. Intended outcome: The use of the safe sleep assessment is confirmed as being routinely used by professionals in order to assist in embedding safe sleep messages in families. If data suggests the assessment is not frequently used this position can be addressed. 7. Blackpool Safeguarding Children Board should explore the development of training focussed on the issue of non- engagement and disguised compliance, and the impact on children, particularly in cases of chronic neglect, to better equip professionals to respond to such behaviour and the associated risks. Intended outcome: Professionals are provided with an opportunity to improve their knowledge and practical skills in managing families where persistent non-engagement and disguised compliance is a concern, to ensure the issues are confronted, access to children and homes is increased, and meaningful engagement with families takes place. References Working Together to Safeguard Children H M Government March 2013 and 2015 Pan Lancashire Safeguarding Children Procedures The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011 22 BSCB Child BW SCR FINAL 02.02.2017 Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection: Final Report May 2016, Peter Sidebotham, Marian Brandon et al Together on Poverty: Blackpool’s Child Poverty Framework 2012-2015 Testing the Reliability and Validity of the Graded Care Profile version 2. National Evaluation of the Graded Care Profile: NSPCC, Robyn Johnson, Emma Smith and Helen Fisher, NSPCC October 2015 Police effectiveness (HMIC) 2015 (Vulnerability): An inspection of Lancashire Constabulary, December 2011 Multi-Agency Pre-birth Protocol, Pan Lancashire Safeguarding Children Procedures, October 2012 Pan-Lancashire Safer Sleeping Guidance for Children, updated July 2015 Serious Case Review into the death of Child BV 2015 in Blackpool, BSCB Serious Case Review into the death of Child A 2016 in Milton Keynes, MKSCB Resolving Professional Disagreements Guidance, Pan Lancashire Safeguarding Children Procedures Blackpool Children’s Services Concerns Resolution Protocol The Protection of Children in England: A Progress Report, Lord Laming, March 2009 Ofsted Inspection of Blackpool Services for Children in Need of Help and Protection, Children Looked After and Care Leavers, July 2014 Serious Case Review into the death of Child BT 2015 in Blackpool, BSCB Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015. 23 BSCB Child BW SCR FINAL 02.02.2017 Statement by Reviewer REVIEWER Amanda Clarke (Independent) Statement of independence from the case Quality Assurance statement of qualification I make the following statement that prior to my involvement with this learning review:- I have not been directly concerned with the child or family, or have given professional advice on the case. I have had no immediate line management of the practitioner(s) involved. I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review. The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer (Signature) Amanda Clarke Date 20th December 2016 Second Reviewer (Signature) Kathy Webster Date 5th January 2017 Chair of Review Panel (Signature) Rob Wheatley Date 2nd February 2017 |
NC52218 | Death of a 10-year-old boy in August 2020. James died because of restricted airways after his mother gave him an excess does of Melatonin, prescribed to help him settle at night, and put him to bed with a sponge in his mouth. Mother reported to police that she had killed her son and subsequently pleaded guilty to manslaughter with diminished responsibility. James was a boy with severe learning disabilities and a complex range of disorders. James had a degenerative visual impairment and hearing loss. In March 2020 Mother decided to keep James at home due to health risks posed by the Covid-19 pandemic. Mother was concerned about stress related to finances and her divorce; she was diagnosed with depression in 2018. Mother and Father divorced in 2017, and Father moved to Spain. Mother was a Russian national, Father English. Learning includes: there was a significant level of contact between the family and agencies, services were maintained and there was multi-agency oversight; during this contact James's mother was inconsistent in her presentation; James's mother refused offers of support through Children in Need services; there was no contact between agencies and James's father. Recommendations include: collaborate and co-produce with disabled children and their parents, information about and service delivery of child in need services; review information provided to parents about the Direct Payment System and their responsibilities to inform funders of situations where family members or partners are employed; review the approach to engagement of fathers as single agencies and as a partnership.
| Title: Child safeguarding practice review: Child ‘James’: 3 January 2010 – 16 August 2020. LSCB: Ealing Safeguarding Children Partnership Author: Rachel Dickinson Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Ealing Safeguarding Children Partnership Child Safeguarding Practice Review Child ‘James’ 3 January 2010 – 16 August 2020 Report Author: Rachel Dickinson Date completed: 9 March 2021 This report is produced on behalf of the Ealing Safeguarding Children Partnership to support learning and should not be disclosed or copied either as a whole or as extracts without the agreement of the Independent person. 1 Contents Page Section One A Picture of the Child 02 Section Two Background and Context 03 Section Three Methodology 04 Section Four Participating Agencies 05 Section Five Summary of the Case 06 The child’s death 06 The child’s history 06 The events of 2020 08 Mother’s mental health 11 Section Six Key Issues and Practice Episodes 12 Covid-19 Pandemic and timeline 13 Picture of James 13 Supporting the family 15 Mental health care of mother 17 Offers of Children in Need Support 18 Missed appointments in 2017 18 Engagement of fathers 19 Section Seven Overall Learning 20 Section Eight Analysis 21 Section Nine Conclusions 23 Section Ten Recommendations 24 Appendix One Terms of Reference of the Review 25 Appendix Two Foot note – additional information 27 2 Section One A Picture of the Child This Child Safeguarding Practice Review report begins by drawing in words a picture of the child who is subject to the review. It is important to understand as much about the child and his lived experience in the months before his death, in order to put him at the centre of the review process (1). For the purposes of the review the child is known as James. James was a 10-year-old boy who lived at home with his mother (a Russian national) in a ground floor flat in the London Borough of Ealing. His father (an English national) lives in Spain. He was a Year 6 pupil who attended an Ealing Special School. James would go to his mother when she collected him, and they were observed to have a close relationship. The school provides education for children aged 2 to 11 years who have profound and severe learning difficulties. James had a complex range of disorders; autism, significant learning disability, neutropenia (low white blood cell count) and Cohen syndrome. He had a degenerative visual impairment and was registered as severely sight impaired. He also had hearing loss. He wore corrective glasses and adapted special footwear. In 2020, James attended school regularly until March when his mother decided to keep him at home due to the health risks posed by the Covid-19 pandemic. At school, James was described as a happy, likeable boy who often caused staff to smile. He used Makaton to communicate knowing about 20 signs. He used photos and symbols and was able to differentiate around 50 photos. He used a communication book and speech sounds to ask for things. He had a range of speech sounds and these altered in relation to how he was feeling. James heard English at school; Russian, English and Ukrainian at home. He used big resources in school because of his visual impairment which was deteriorating. It was expected that as a relatively young man he would have lost his sight completely. James was at an early stage of development, he was ‘toddler-like’. He had limited functional skills and difficulty retaining information. His body tone was low, as was his fine motor skill level. James would gain adults’ attention by tapping them, he made eye contact and would take adults by the hand and lead them if he wanted something. James enjoyed the company of his peers at school, but he would not initiate contact. James enjoyed being outside, he really liked spinning objects, and focused on wheels on bikes in the playground. He enjoyed books particularly books with sound especially animal sounds and he also liked classical music. James was being encouraged to explore different kinds of play and the school were providing a curriculum for life, supporting his independence. He regularly went out with school staff on visits. There were no behaviour management risk concerns for these visits. If James became frustrated or did not want to do something, he may have thrown an object, hit out or hit himself. At school, this behaviour was infrequent (no more than weekly). If he was insecure or scared, he would cling to a trusted adult. He sometimes bit his clothes and needed to be reminded to stop. James was able to feed himself, he managed main meals by himself at school and was helped with them at home. He could drink from a normal cup. He wore nappies (day and night), responded well to personal care and was learning to use the toilet. James could pull his trousers up and down when wearing joggers, he was also learning to tolerate having his teeth brushed. James followed simple instructions from adults very well. (1) This picture is drawn from information provided by the professionals who knew him. James’s mother and father felt unable to contribute to the review – see section 3. 3 Section Two Background and Context This Child Safeguarding Practice Review has been commissioned by the Ealing Safeguarding Children Partnership in response to the requirements of statutory guidance issued by HM Government; “Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children.” (July 2018). This guidance recognises that child protection in England is a complex multi-agency system involving many different organisations and individuals. The guidance states that reflecting on how well the system is working is an important part of the collective endeavour to improve the public service response to children and families. The guidance recognises that sometimes a child suffers serious injury or death and that when this occurs it is important to understand what happened and why so that improvements can be made in the public service response to children and their families at both local and national levels. Child Safeguarding Practice Reviews are the means through which this can be achieved. On receiving the notification from the police of the death of the child known as James the London Borough of Ealing carried out its legal duty to report the incident to the National Child Safeguarding Review Panel (16C (1) of the Children Act 2004 (as amended by the Children and Social Work Act 2017). In accordance with statutory guidance, local safeguarding partners met to hold a Rapid Review Meeting on the 20th August 2020. As required by the guidance, the partners gathered the facts as far as they were known at that point; considered the potential for identifying immediate improvements and whether to hold a practice review. The statutory criteria for undertaking a review were taken into account, namely whether such a review may highlight: • Improvements needed to safeguard and promote the welfare of children • Recurrent themes in the safeguarding and promotion of the welfare of children • Concerns regarding two or more organisations or agencies working together effectively to safeguard and promote the welfare of children. It was decided at the Rapid Review meeting that a local child safeguarding practice review should be undertaken. At this point it was known that a severely disabled child had been killed by his mother, and this tragic event took place during the pandemic of Covid-19. It was believed that the criteria for undertaking a review were met in that a review might identify important learning about improvements needed to safeguard and promote the welfare of children. The National Child Safeguarding Panel was notified on the 9th September 2020. Following consideration, the National Panel agreed with the Ealing Safeguarding Children Partnership decision and communicated this in a letter dated 25th September 2020 The Ealing Safeguarding Children Partnership identified an independent person to undertake the review whose professional background met the requirements of statutory guidance. The reviewer has a professional background in social work, well over thirty years’ experience of the public sector and a national reputation for partnership working and service improvement. The terms of reference for the review were drawn up from the main findings of the Rapid Review Meeting (Appendix One). 4 Section Three Methodology The purpose of the Child Safeguarding Practice Review is to understand for James what happened and why, so that learning can be identified to support future improvements to safeguard and promote the welfare of children, and this includes the identification of good practice. The overall aim is to learn from what happened to prevent or reduce the risk of similar incidents. It is not undertaken to hold individuals or organisations to account. The methodology adopted for the review is informed by both the statutory guidance contained in Working Together to Safeguard Children (2018) and The Munro Review of Child Protection: Final Report – A Child-centred System (2011) which requires that systems methodology be adopted. This means understanding and analysing the practice in the case through securing the insights of front-line professionals and managers and understanding and analysing the context in which the practice occurred. The methodology used for the review is proportionate to the circumstances and reflective of the guidance. The review has sought to reflect the child’s perspective and the family context. It has been shaped to understand and analyse the front-line practice as well as organisational structure and learning. Importantly, it has sought to understand the implications and impact of the Covid-19 pandemic on the family, front-line practice, and organisations. The information drawn upon for the review has been taken from the agency reports provided to the Rapid Review Meeting on 20 August 2020, and the note of that meeting. The review has not had access to medical assessment reports of James’s mother completed after 16 August 2020. Individual discussions have been held with school staff, the community paediatrician, a senior leader for children’s social care and the police Senior Investigating Officer. An individual discussion has also been held with a member of the family’s local community who helpfully came forward to share their insights. All the information arising from the written material and individual discussions were considered and analysed and emerging themes were explored at a Practice Insight Event. This event engaged front line practitioners and leaders in an in-depth exploration of those themes. The practice insights and overall learning have been considered and analysed. Conclusions are drawn from the analysis and recommendations made. The child’s mother and father have been approached individually and invited to contribute to the review on two occasions. They have declined to contribute, and it is appreciated that both parents are grieving the loss of their child. There is no doubt that their contributions would be beneficial to the review and of great value to the learning that could be achieved. 5 Section Four Participating Agencies The following agencies participated in the Child Safeguarding Practice Review: Central London Community Health Care NHS Trust James’s and his mother’s GP practice Great Ormond Street Hospital London Borough of Ealing Council An Ealing Special School Metropolitan Police Service London Ambulance Service NHS Ealing CCG London North West University Health Care NHS Trust West London NHS Trust 6 Section Five Summary of the Case A summary of the child’s development and service response has been collated to begin to understand the practice in this case. This supports the understanding of what happened. It begins by describing the circumstances of James’s death as it is these circumstances that have resulted in the review being undertaken, and then relays the case history. A summary has been drawn up of what was known about mother’s mental health prior to James’s death. The child’s death James died on the evening of the 15 August 2020. His mother gave him an excess dose of Melatonin (a medication prescribed to help him settle at night). She put him into bed with his toys and placed a sponge in his mouth, he died because of restricted airways. James’s mother then called a friend (the person who had been providing care under the Direct Payments system), for help and who came to the family home. Both adults subsequently walked to Acton Police Station in the early hours of 16 August 2020 where James’s mother reported to police that she had “killed her son”. Police attended the home and found James unresponsive; officers attempted to resuscitate him and paramedics were called. James was pronounced dead at the scene. James’s mother pleaded guilty to manslaughter with diminished responsibility on 25 January 2021, this plea was accepted by the Crown Prosecution Service. She was sentenced to an indeterminate hospital order on 11 February 2021. A Coroner’s Inquiry is ongoing. The child’s history James was born on the third of January 2010. He was the first and only child of his parents, and they shared legal parental responsibility for him. No problems were detected at his birth. However, by October, James’s parents had concerns and his development was identified as delayed by his health visitor. Referrals were made to the Child Development Team (CDT) and Physiotherapy, a service which he received throughout his life. From this point onwards James and his family were in receipt of additional and specialist health services. A home portage service was provided to James and his parents; this is an early years’ service for children with special educational needs and it focuses on play, communication, and relationships. In December 2010, at eleven months old he was seen by the CDT for floppiness (a condition caused by neuromuscular and central nervous system disorders) and microcephaly (a condition where a baby’s head is much smaller than expected). James’s mother was known to be understandably anxious about her son’s progress and she carried out her own internet research. She believed he had Cohen Syndrome and he was subsequently investigated by the geneticist at Great Ormond Street Hospital for Cohen Syndrome. Testing at this point did not find this to be the case. Cohen is a rare syndrome, and it is not usually detected in children under the age of 5 years. In 2011, James had occupational therapy services and this service continued to support him for the rest of his life. He also started to receive speech and language therapy, and this continued until 2015. In 2011, at the age of eighteen months James was referred by his health visitor for additional needs childcare funding. Ealing Borough Council Early Years Services reviewed this request, and he was allocated a place at the local Children’s Centre and nursery. He started to attend the following year in February 2012 at the age of two years. As this age, he was showing signs of autistic features and had been diagnosed with optic atrophy and retinal dystrophy (this can be progressive, leading to blindness). James attended the visual clinic at 7 Great Ormond Street Hospital and remained under their care for the rest of his life. He was also found to have intermittent neutropenia (reduced white blood cells) which meant that he may be more susceptible to infection. James was now receiving speech and language therapy services, occupational therapy services, as well as physiotherapy services and childcare services to support his development. From 2012 onwards he received the continual care of the same community paediatrician. James received audiology support during 2012 and 2013. In 2012 James’s mother told community paediatric services that she and James’s father were divorcing. In 2013, after his third birthday James was privately diagnosed at Great Ormond Street Hospital as having autistic spectrum disorder. He continued to attend nursery taking up around 80% of allocated time until December 2012 when he travelled to Russia with his mother for an extended holiday to visit relatives. He returned to nursery in March 2013. Thereafter his attendance was low and by August 2013 at the age of three years seven months, James’s mother stopped taking him to nursery altogether, choosing to support his education at home. During 2013 (July) she contacted Ealing Council for support, and this led to a recommendation for multi-agency support which was given. This came through a multi-agency service run by the NHS and Ealing Council that gives both families and professionals a single point of contact for information, referrals, assessments and help for children and young people with special educational needs and disabilities living in the London Borough of Ealing. In February 2014, when James was four, his mother contacted Ealing Council’s Children with Disabilities Service (CWDS) and asked for a social work assessment for home support. She later decided not to go ahead with this request. In the same year James was registered as severely sight impaired and he had a statutory assessment of his educational needs which resulted in a statutory Statement of Educational Needs. The Statement was later transferred to an Education Health and Care Plan (EHCP) following the implementation of the Children and Families Act 2014 and this Plan was subject to annual review. The Special School was identified as an appropriate placement to meet his needs and James started attending in February 2015 just after his fifth birthday. He attended this school until his death and staff there along with the whole school community knew him very well. In October 2015, over 18 months after her first request, James’s mother once again contacted Ealing Council’s CWDS and asked for a social work assessment for home support. On this occasion she did not withdraw her request and an assessment was completed. This led to an agreement with James’s mother to support him as a Child in Need (The Children Act, 1989) and a support plan was drawn up which largely focussed on service co-ordination. From this point onwards James and his mother were in receipt of practical support from Ealing Council Children’s Services and this support continued until James’s death. In July 2016 at the age of six years and six months James was confirmed genetically as having Cohen Syndrome. A few months later in December, at his mother’s request, the help she received from Ealing Council CWDS transferred from being provided under the Children Act to the Chronically Sick and Disabled Persons Act, 1970 (CSDPA). A Resource Panel decision was made to support the family with holiday provision (12 hours a week), after school provision (7 hours a week in term time) and home care support (6 hours a week). This meant that James and his mother received practical support without social work support and co-ordination, as James’s mother did not want James to be treated as a child in need. 8 James’s mother subsequently declined the agency-provided home care support, having refused the services of a care worker on faith grounds. During 2017, when James was seven years old there were several missed hospital outpatient appointments between June and November. These all related to concerns that his mother had raised about his middle ear and nasal congestion. Although it was mother’s concern that resulted in appointments being made for her son, she did not take him, and he was subsequently discharged. James’s parents’ divorce was finalised in 2017, and at some point, in this year his father moved to live in Barcelona, Spain. In January 2018, James’s mother and James moved from a large house in Acton to their flat, initially the flat was rented and then it was purchased. Later in 2018, James’s mother decided to manage his home care package herself through the Direct Payments system. This meant that she was able to make decisions about who to employ to provide care and when that care would be provided. James’s mother directly employed the carer, and the funding was provided by Ealing Council. In October 2018 James’s mother contacted CWDS and said she had found her own carer and had been paying them for 12 hours a week since March 2018. At this point the agreed package included 6 hours of home care support a week. Support was provided with the completion of the necessary administration requirements, the additional home care hours that James’s mother had put in place were agreed, and funding provided from 19 October backdated to March 2018. At this point the family were again offered support from a social worker, and this was once again declined. Ealing Council continued to support the family under CSDPA. In May 2019, at James’s mother’s request the support package was again revised as she reported that she was under considerable pressure, suffering headaches and depression. Two weekly sessions at The Log Cabin (an out of school Specialist Centre) were agreed and Direct Payments to fund 12 hours care a week continued. She told the social worker that she was receiving less support from James’s father. The nature of the reduction in support is not known. The events of 2020 In January 2020, James was ten years old. In the same month, a review of the CSDPA support package was completed at a meeting in the family home. The care package remained in place and James’s mother was once again offered support through the Child in Need services and this again was declined. In January, James’s mother asked her GP for more bespoke care, the practice linked her to another parent of a disabled child for peer support. It is not known if she followed this up. In March 2020, the CSDPA support package was revised following completion of a child and family assessment and further review. By agreement, the two weekly sessions at Log Cabin were increased to three weekly sessions (although this support had not previously been taken up) and home care support through Direct Payments was increased from 12 to 16 hours a week. In March 2020, and before the government’s decision to close schools and place the country into lockdown in response to the Covid-19 pandemic, James’s mother contacted her GP and asked for him to be included on the shielding list, and this was agreed. James had not been originally included on the list because he had not been a child deemed to be at risk. Although James had no significant history of physical illness, his mum was concerned about the potential for him to be immunocompromised because of Cohen Syndrome. She decided that James should not attend school because of the risk and he never resumed attendance. Schools closed in March, remaining open for the children of key workers and vulnerable 9 children where attendance at school could be safely managed. There was weekly contact from the school following the closure of schools in March. This contact was initially between the class teacher and James’s mother and was mainly by telephone as this is what James’s mother said she preferred. In March, James’s mother also contacted Ealing Children with Disabilities Service to discuss support. She asked for help with the costs of outdoor play equipment and an iPad that she had purchased. On a separate occasion in March, she asked for support with shopping and other practical support for single parents. She also talked with social care staff what would happen to James if she became ill and respite care was discussed. The following day James’s mother was linked to ‘Ealing Together’ for practical support, this is a collaborative support network set up by Ealing Council and local voluntary organisations in response to Covid-19. In the third week in March, the direct payment carer had to self-isolate and mum was managing James’s care alone, although the direct payments continued. After the carer completed the period of self-isolation and was able to resume caring for James, his mother asked her not to come because she was concerned about the risk of infection. From April, there was weekly direct contact between the teacher and James. It is known from school contact and neighbour reports that mum and James went out regularly to play in the garden of their home and to visit the park. In April, the GP contacted James’s mother as a Covid-19 response to see how she was. James’s mother described herself as ‘coping’ to the GP. She was also contacted by a CWDS manager to see how she was doing (6 April). James’s mother said she was managing okay; she was on the government list for priority on-line food shopping. She told the CWDS manager that she would only be using her carer in emergencies and discussed an additional request for funding toys and equipment. In the same month (17 April) James’s mother contacted Ealing Children’s Integrated Response Service with a health concern about her knee which she felt was exacerbated by caring for James. She had consulted her GP. She asked for financial support to help make adaptations to her kitchen to fit a dishwasher. The service asked about support from the carer and James’s mother said that she had asked her not to visit due to Covid concerns. The service passed the request to CWDS who contacted her the same day. James’s mother’s concerns about shielding and support from the carer were discussed, the use of personal protective equipment (PPE) was raised. James’s mother also mentioned making the home care support package more attractive to the carer by increasing the hours. A few days later (20 April) James’s mother was again contacted by CWDS to see how she was doing, James’s mother was upbeat, not wanting to increase the care package and she asked for the school to be contacted for the teacher to telephone James, and this was done. In the third week of April (21 April), the community paediatrician contacted James’s mother, also as part of the Covid-19 response, to discuss the balance of shielding and attending school. The safety of receiving support from the direct payment carer was discussed and it was agreed that the family should receive support from the carer if personal protective equipment (PPE) was worn. It is not clear exactly when the support of the carer was re-instated by James’s mother, but it is known that from 26 May the carer was providing support 30 hours a week and that this care was continually in place until James died. In early May (05), James’s mother asked the OT (who had contacted her to discuss a report for James’s annual EHCP review) to borrow a scooter and tricycle from school. The OT arranged this for two days later and James’s mother collected them from her in the school car park. 10 Towards the end of May and into June the family had building work completed in the kitchen to fit a dishwasher which was stressful. The works resulted in a difficult dispute with a neighbour for which mum sought legal advice. In May (half-term) a planned holiday (James and mum) in Spain to visit father did not go ahead: there are two alternate reasons put forward for this: one is the impact of the pandemic on travel and a second is that James did not have enough time on his passport before it expired - six months is required. Mum told school at the end of term in July that she and James were going to Spain. School thought James was in Spain with his mother and father over the summer until they heard that he had died in London. It is not known what level of contact James had with his father during 2020 and by what means. James’s mother made a request for James to return to school towards the end of May. she wanted James to be taught in a room on his own with his teacher wearing full PPE. This was not in line with national guidance issued to schools. The school could not provide education for James in the isolated conditions that mum requested. An offer was made that he could have attended a small class. James’s mother’s request was discussed with her and she decided to continue shielding at home with support from school. Mum emphasised her view that James needed training, Applied Behaviour Analysis (ABA) work sessions or a member of staff to come into the home to teach James. School staff did not believe that ABA (an approach sometimes used for teaching children with autism) was appropriate for James and they were unable to provide home tuition. At the end of June (26 June), James’s mother contacted CWDS by email and described ongoing stress and asked for financial support from children’s social care for expenditure incurred for toys, the increase in carer support that she had put in place and the kitchen refurbishment. On 03 July CWDS contacted James’s mother by email; the request for help with toys was declined, but mother had received some equipment from school on loan, the request for support with additional care was being progressed and advice was being sought over help with the kitchen. On the same day James’s mother contacted her GP about James’s ear; he was seen on the same day. In the consultation James’s mother said she needed more support managing James as she was exhausted because of disturbed nights. The GP wrote to CWDS on the same day and his letter was immediately acknowledged. On 06 July, the social worker from CWDS telephoned James’s mother to say that a review of the support package would be undertaken. On 07 July, the manager from CWDS telephoned James’s mother and confirmed that a review would be held under CSDPA. James’s mother said that she was under significant pressure and so stressed that she was not functioning mentally. She wanted funding for the additional hours that she had put in place. On the 08 July, the social worker updated James’s mother about the review, the request for the increase in hours would be presented to the Resource Panel for a decision by the 08 August. On 10 July, the Community Paediatrician telephoned mum to see how she was doing. James’s mother said that she was struggling. The Community Paediatrician offered to end the shielding status and resume James’s attendance at school. This was turned down by mum who felt that the end of the school year was near. James’s mother was aware that the school was running a three-week play scheme over the summer; she did not take up the offer. The next contact was planned for 25 August to help James to return to school in September. The Community Paediatrician followed up with CWDS the request for financial support for care on the same day. 11 On 07 August, James’s mother contacted the GP about James’s teeth, the GP asked how James’s mother was doing and mum reported that she is ‘surprisingly fine’. She said that she has not heard about her request for support from children’s social care for the care package and this was followed up by the GP on the same day. On the 10 August James’s mother met a neighbour in the communal garden of their home, they had a friendly conversation in which they shared a joke and laugh together. James’s mother said James had not gone to Spain for the summer as he had for the past two years because he had insufficient time on his passport before it expired. Mother’s mental health In the autumn before James’s birth (during the ante-natal period in 2009) his mother consulted her GP and said she was concerned about stress which related to finances. She said that she was receiving private counselling and the following month when reviewed by the GP, no concerns were raised about mental health. Following James’s birth his mother reported to her GP that she felt empowered, she was sleeping and eating well. She spoke about the private treatment she had received for depression and mood swings. Post-natal depression was discussed. A month later she declined the health visitor’s offer of a maternal mood assessment. In May (three months later) her mood was assessed on the low side and she was referred to psychotherapeutic services for cognitive behaviour therapy which she did not take up. In July 2011, James’s mother consulted her GP with stress related problems, she was again referred to psychotherapeutic services and it is understood that she attended and was assessed on this occasion. In March 2012, the GP records show that James’s mother was receiving cognitive behaviour therapy privately. The following month (April 2012) the GP records show that James’s mother has been prescribed an anti-depressant by a private physician with follow up in the private sector. There are no further references to mental health care until January 2018. In January 2018, The GP notes record that James’s mother was stressed having recently divorced from James’s father. She was referred to a specialist to follow up a physical health condition and that specialist recorded that she was stressed, and she was advised about sources of support. In the following August (2018) in a GP consultation for a physical health concern, James’s mother reported she was under a specialist in Spain for her mental health and had been prescribed medication. The GP assessed James’s mother’s mental health and diagnosed depression. An alternative medication was prescribed in line with the GP prescribing practice. James’s mother was directed to support networks through psychotherapeutic services. There was a review in September 2018 when James’s mother reported that she was in a much better place and the prescription dosage was decreased. In February 2019 there was a further review, James’s mother reported that her mental health was stable, that her stresses would not go away and that she was coping. She questioned whether she still needed medication and was advised to continue with it. From August 2019 this was prescribed at three monthly intervals, the latest being July 2020 at which point the prescription was further reduced. It is understood from information reported at the practitioner insight session that in the days just before James’s death, his mother had suffered a severe depressive episode with acute psychotic symptoms. Sleep deprivation and stress have been identified as factors contributing to the onset of this episode of mental illness. 12 Section Six Key Issues and Practice Episodes The review has adopted a systemic approach to achieve a comprehensive understanding of what happened and why with the aim of reflecting on how well the system worked, to identify learning and recommendations for any improvements to the public service response to children and families. The previous section helps with the understanding of what happened in this case, and the question of why remains. A review of the material provided, and individual discussions led to the identification of key issues and practice episodes for further enquiry to develop an understanding of why James died. In summary the key issues and practice episodes are: 1. The Covid-19 pandemic and timeline It is important to consider the context in which the family were living and in which multi-agency front line practice occurred. The timeline of the national response to the pandemic is important as this affected both the family’s experience and the agency response. 2. The picture of James in 2020 It is important to place James at the heart of this review and to understand what life was like for him in the months before his death. He died during the pandemic of Covid-19, an exceptional time for the family as it was for everyone living in England. The factor of Covid-19 is an integral part of the family’s experience of life during 2020 and cannot be separated out. It is important to consider the implications of this. 3. The support provided to the family in 2020 It is important to understand the support received by James and his mother during 2020 and to consider how responsive the front-line practice was to identified need, and the potential for learning. It is equally important to be curious and consider whether with the benefit of hindsight there were indications of additional need, and the potential for learning. The factor of Covid-19 also applies to organisations and the support that was provided to the family. 4. Mental health care of mother It is now known that mother’s mental illness was a very significant factor in James’s death. It is important to review what was known about mother’s mental health by practitioners and consider how responsive the practice was to identified need. Here too, it is important to be curious and consider whether with the benefit of hindsight there were indications of additional need, and the potential for learning. Mother received a mix of NHS and private provision and the implications of this need to be understood. 5. Offers of Children in Need Support Support was offered to support James and his mother through the Children in Need process. His mother rejected this service on three occasions. It is important to consider why she made these decisions, how this service might have benefited James and his mother. Alongside this it is important to consider whether there are implications arising from the way in which his mother chose to manage the care package, namely through the Direct Payments system. Again, the purpose of this consideration is to identify the potential for learning. 6. Missed appointments in 2017 There were several missed hospital appointments in 2017. It is important to understand this as a practice episode, to consider whether there was a missed opportunity to support James and his mother, to identify learning. 13 7. Engagement of fathers James’s father shared parental responsibility for him with his mother. The combined chronology illustrates that there was little to no direct communication between education, health and care agencies and James’s father. It is important to understand why this was the case, what the implications of this were for the family and what can be learned. These issues were considered in depth at a well-attended Practice Insight Event. A combined chronology and outline picture of the child were drawn up to support the event. The approach of practitioners, managers and service leaders was one of reflective and open enquiry with the aim of identifying areas of learning and the potential for practice improvement. 1. The Covid-19 pandemic and timeline By March 2020 England was in the throes of the national and global Covid-19 pandemic, infection rates were rising as were the rates of hospitalisation and death. Schools were closed on Friday 20 March but remained open for vulnerable children and the children of key workers, where they could be safely educated. A ‘national lockdown’ was announced on 23 March 2020. The following day the prime minister referred to a ‘moment of national emergency’. All non-essential shops and services closed on 26 March 2020. All non-essential travel was banned, citizens were required to work at home unless they were key workers and the nature of their work required working outside the home. Citizens were asked to go out for ‘one form of exercise a day’, to shop only for ‘basic necessities’. The public were told to stay at home, support the NHS and save lives. Life completely changed for families across the country. Lockdown began to ease on 15 June 2020 with the opening of non-essential shops, parks, and zoos. The national alert level reduced from four to three on 19 June. On 4 July, cafes and restaurants re-opened with social distancing rules and with this the lockdown ended. Restrictions on citizens behaviour remained in place with requirements to socially distance, wear face marks on public transport and maintain handwashing hygiene. The country was opening up again, but home working continued. James died after the first ‘national lockdown’ ended. Schools in Ealing remained open throughout the lockdown period. They actively engaged with parents who were key workers and with parents of vulnerable children to continue to offer education safely. 2. The picture of James in 2020 The Practice Insight Event considered the implications of the pandemic for James, and his mother and concluded it meant a significant change in routine. It is known that the family had a limited close friendship network, no extended family living close by, and James’s father was abroad. There was regular social contact with residents of the other four flats in the converted house where the family’s flat was located, and there were offers of support from neighbours. In addition, James’s mother had the support of Ealing Together who dropped food parcels. James’s mother had decided earlier in March to keep James at home from school. She was concerned that he was more susceptible to infection because of Cohen Syndrome and wanted to keep him safe. The desire to keep children safe from the pandemic 14 Practice Insights “James’s mother was a powerful advocate for him, she was always concerned to do her best for him. Her decision to keep him at home and stop attending school was the action of a “good and concerned parent.” “All children find a change in routine difficult; this is more so for children with autism. It is likely that the change in routine was frustrating for James. As a child he was less emotional and affectionate. He was close to his mother but not physically close.” and reduce infection rates prompted the government’s decision to close schools a week or so later when all parents were asked to keep children at home if they could possibly do so. James’s mother was the sole carer for him from the third week in March (when the carer had to self-isolate) until the end of May, and this must have been a challenging time. James’s routine was disrupted, and it is likely that he found this difficult. His mother was managing all the practical aspects of his care. This meant helping him to wash, dress, eat, play, and learn and to settle at night. It also meant attending to his personal care at night and disrupted sleep for them both. Disrupted nights were nothing new but there were no breaks for James’s mother during the day as James was no longer attending school. His learning at home was supported by school and there was weekly contact. Despite the challenges this situation must have presented, James’s mother took a decision not to allow the carer to resume care following the required period of self-isolation, this decision was motivated by her concern to keep James and herself safe from infection. This decision meant that she cared for James without the support of the carer for a period of about ten weeks until 26 May. Following contact from health professionals James’s mother decided to accept the support of the carer once again at the end of May. From this point she had the help of a carer for 30 hours a week. She took the decision herself to increase the hours of support from 16 hours a week. She was directly managing the care package and could make decisions about when and what care was provided. The pressures of caring for James would have eased. A month later she contacted CWDS to ask for support with equipment and the increased cost of the care she had commissioned. In May around half term time (25 – 29 May) James and his mother were due to go to Spain on holiday. This was cancelled and although the reasons are not completely clear it was felt by practitioners that foreign travel did not accord with James’s mother’s decision to keep him at home from school. UK residents were officially welcomed back to Spain by the Spanish Government on 26 June 2020. The cancelled holiday meant that James’s mother and James missed a break and direct contact with his father. It is known that there was ongoing contact with his father, and that James’s mother shared with him how difficult things were for her. James’s father knew that James’s mother was in regular contact with health and care agencies. 15 At the end of May, James’s mother re-considered her decision not to let James attend school and having discussed the options with school staff, she decided to continue to keep him at home. She commissioned building work to her kitchen which was started in May and ended in June, so a dishwasher could be fitted. The work was largely completed by a builder who was also a flat tenant in her ‘block’. This is proved to be stressful and resulted in a dispute with a neighbour, a source of further stress. It is evident that James’s mother sought to enrich James’s experience at home with the purchase and loan of play equipment and that she asked for help with this. It is known that she and James regularly went out to play in the communal garden of their home and they went to the park. She and James were often seen by her neighbours in the garden and James played alongside other children. After the easing of lockdown on 15 June with the opening of non-essential shops, they went shopping regularly. James’s mother received Ealing Together food parcels every few weeks and shared food surplus to her requirements with neighbours, this provided another source of social contact. She also bought groceries on-line which were delivered, she was on the priority list as her child was being shielded. James’s mother continued to keep James at home from school and term ended on the 24 July 2020. In the two previous years (2018 and 2019) James had spent the long school summer holiday in Spain. It is understood that James’s mother took him to Spain, returned home to take a break and then collected him. This did not happen in 2020 because there was insufficient time on James’s passport before it expired. As a result, James missed the opportunity to see his father and James’s mother did not have the opportunity for an extended break. It is not known whether James’s father considered coming to London. 3. The support provided to the family The family benefited from continuity of support from James’s school, their GP and community paediatrician, and children’s social care over many years. The family had regular contact with them, and these professionals knew them well. There were no pre-existing concerns about James’s care or his safety. Education At school, James’s teacher had known him since the start of his school life, and he benefitted from 1-2-1 support from a teaching assistant. His mother’s powerful advocacy ensured that his needs were being met as far as the school was able. The School remained open to small numbers of children during lockdown and contact was maintained with all pupils and their families whether children were attending school or not. The nature and frequency of contact was agreed with parents. James’s mother decided to keep James at home, he could have attended along with a small group of children from April, but this arrangement was not acceptable to James’s mother who wanted him to be educated in a room on his own by a teacher wearing full PPE. This was neither an appropriate education environment for a child nor was it practically achievable. The school supported his learning through the provision of learning plans and tools as well as the loan of equipment. He had at least weekly telephone contact with his teacher and the school maintained frequent contact with James’s mother through email, in line with her wishes. The school operates a three-week play scheme over the summer which mum was aware of. She did not approach school for a place following the cancelled August holiday in Spain. Mum saw school as a place for learning, not play. Throughout the contact the school had with James and his mother there were no indications of additional need, and school staff had no concerns about James’s welfare. 16 Health Care From March to August there were 11 separate contacts with health professionals. Some were initiated by James’s mother; some were initiated by health professionals concerned to support the family during the challenges of the pandemic. Health care was provided to the family as needed. The GP responded to James’s mother’s concerns about James’s susceptibility to infection and he was placed on the shielding list. There were two proactive discussions initiated by the community paediatrician which supported James’s mother to think firstly about the safe use of carer support, and on a second occasion about school attendance. There was a planned further contact about school attendance to take place at the end of August. There was also regular contact with the school nurse and contact with the OT. It is evident that a regular line of communication was open and in use. On some occasions James’s mother reported that she was stressed and on others she said that she was coping. Health practitioners did not feel with the benefit of hindsight that the reports of stress were unusual or in any way different to the levels of stress of families in similar circumstances. There was nothing that made the family stand out. Children’s Social Care (CWDS) The latest child and family assessment was completed under CSDPA in March 2020 and the package of care increased in line with need. James’s mother managed James’s care herself, through the Direct Payments System and employed her own carer. During the lockdown period CWDS maintained contact with and responded to requests for support from James’s mother; there were 14 separate contacts. Practical and financial support was discussed, James’s mother was linked to community sources of support and on two occasions she had the opportunity to talk through what would happen to James if she became ill. One decision was outstanding, that relating to funding the additional hours of care that James’s mother had already put in place. Again, it is evident that a regular line of communication was open and in use. On some occasions James’s mother reported that she was coping on others she reported that she was stressed. She did not make requests for more support than the 30 hours of home care that she had put in place. There were no indications of additional need. Multi-agency practice In addition to the regular and open communication to and from health professionals, school staff, CWDS, and James’s mother, there was regular contact and exchange of information between professionals from different agencies. There was a multi-agency discussion in May Practice Insights “James’s mother challenged school staff over the years about the progress James was making. She was frustrated about this and put it down to of a lack of teaching skill rather than her child’s ability. She had unrealistic expectations of James and what his development would be. More recently she had been more accepting of who James was. School staff felt they were working more in partnership with her.” “James’s mother saw school as a place of learning not play or learning through play. Her non-acceptance of the school’s summer play scheme for him needs to be seen in this light.” 17 about the possibility of a return to school for James. The potential to have missed risk factors was explored at the Practice Insight Event. In all this contact it was known that as a single parent caring for a severely disabled child not attending school (in the context of a national pandemic) the family would be under pressure. As stated at different times James’s mother reported being stressed and she also reported that she was coping. She was clear about the support that she needed and communicated appropriately across the children’s education, health, and care system. James’s mother made clear decisions and managed the family’s care package. 4. Mental health care of mother James’s mother was known to have depression which was managed through the care of her GP and subject to regular review. Whilst treating James’s mother there was no indication of a more severe level of need that would have required more specialist care via a referral for consultation with a psychiatrist. This conclusion held with the scrutiny that the benefit of hindsight brings. The picture that her GP had about James’s mother’s mental health history was incomplete. She was known to have had care for her mental health whilst abroad in both Russia and Spain. Difficulties arising from the use of private alongside NHS resources was explored at the Practice Insight Event. The reports James’s mother made about feeling stressed were considered in a discussion about her mental health. The presentation of stress did not suggest that any change was needed to treatment and nor was this requested by James’s mother. There were no signs or symptoms of the severe depressive illness and psychosis that she subsequently experienced. 5. Offers of Children in Need Support Offers to support the family through the child in need process were rejected by James’s mother on three separate occasions, the most recent offer and rejection being in March 2020. This meant that there was not a child in need plan in place that focussed on meeting Practice Insight “It is not uncommon for patient to take up a ‘mix of treatment’. Ealing has a diverse community, and many residents take up medical care whilst travelling abroad. Health practitioners are alert to the implications of this. Private health practitioners are required under regulating body rules to report any safeguarding concerns, this does not apply to medics practising abroad”. “There were no signs of symptoms of mental ill health that raised a red flag.” Practice Insight Practitioners thought very carefully and deeply about whether any signs of potential risk of harm were missed and concluded that they were not. “There were no Red Flags, this was not the case with all children and families in Ealing during this time, some children needed child safeguarding services.” There were no concerns raised about James and his care, and professionals were both extremely surprised and deeply shocked when they learned of his death. 18 the needs of James and the family did not benefit from a key worker role. A key worker is a professional who can support the co-ordination of other professionals providing services within a plan agreed with the parent. The Practice Insight Event reflected on this. James’s mother was very proactive, she acted as James’s champion wanting the best for him. There was also consideration of whether James’s mother’s nationality, class and culture impacted on her decision not to accept a child in need support service at the Practice Insight Event. As children in need services were rejected these issues were never explored and assessed. It has not been possible to pursue this line of enquiry with James’s mother during this review. 6. Missed appointments in 2017 There were a number of historical missed hospital appointments for James. These were originally instigated by concerns that James’s mother had about his middle ear and nasal congestion. The appointments were in 2017, the year in which James’s mother and father were divorced. The hospital’s response to the missed appointments was to discharge James following several unsuccessful attempts to contact his mother. Current child safeguarding practice is to regard events where a child did not attend a medical appointment as an event where a child “Was not Brought”. The professional response needs to be based on both an understanding that children cannot take themselves Practice Insight Ealing Safeguarding Partners now have a “Was Not Brought” policy in place. The events of 2017 pre-date this. However, James’s health and wellbeing were overseen by ESCAN and he remained under the care of the community paediatrician with regular oversight of ESCAN health services. He did not become a forgotten child following the hospital appointment non-attendances. Practice Insight James’s mother needed to feel in control of the support she received, and she did not see any value in the children in need service. This is why when she realised that she could have the package of care without the children in need service, she transferred to accessing support through CSDPA and then to the Direct Payments (DP) system. She wanted the flexibility and autonomy that the DP system brings. She acted as her own co-ordinator. Parents of disabled children have the right to manage their own care through the Direct Payments system, this is a national government policy initiative. His mother chose to manage James’s care directly and in effect act as his key worker. “Children in Need services are voluntary and James’s mother had the right as his parent to refuse this support if she did not want it. No professional ever identified a concern about James and/or his mother’s care that could have led to the imposition of the non-voluntary child protection process. On the contrary, James was observed to be a well-loved and well cared for child.” 19 to hospital appointments, and a consideration of whether non-attendance gives rise to a concern for the health and welfare of the child. The continual care James received from ESCAN services meant that there was no missed opportunity to intervene and support him; that support was already in place. A clinical decision was made not to pursue his mother’s concerns about James’s middle ear and nasal congestion further at that point in time. 7. Engagement of fathers There was minimal engagement between agencies and James’s father following his birth, and no engagement following his move to Spain in 2017. James’s father did not seek information directly from agencies about James and neither was he provided with any. This meant that all the information James’s father received about James’ health and his progress was from James’s mother. As his legal guardian, James’s father was entitled to receive reports from the annual review of his son’s Education, Health and Care Plan, attend health appointments, engage in discussions about diagnoses, and be involved in the child and family assessments and reviews that were completed under CSDPA. The fact that he was not, means that agencies have no clear information about the support he provided to James’s mother and James nor did they have the opportunity to engage him in discussions about the support he might offer in the present and in the future, as James grew older and his needs changed alongside both his development and the physical conditions he had progressed. It is often, but not exclusively, the case that agencies delivering services to disabled children and their families engage only with the main care provider, and this is often the child’s mother. In the experience of front-line practitioners, it is mothers who bring children to medical appointments and mothers who engage in assessments and reviews of children’s needs, fathers rarely attend appointments. Practice Insight “Men, fathers, men disappear from professional view. This is likely to be the case when they work and is certainly the case where they live abroad.” 20 Section Seven Overall Learning The Practice Insight Event identified several learning points. Firstly, that there was a significant level of contact between the family and agencies from March onwards, services were maintained and there was multi-agency oversight. The nature of contact was different because of public health safety requirements arising from the pandemic. James did not attend school because his mother did not believe it was safe for him to do so. The school supported James at home and there was regular contact with both James and James’s mother. Services had no mandate to insist James went to school and to override his mother’s wishes. Secondly, during this contact James’s mother was inconsistent in her presentation. She said different things to professionals at different times. In March, the family were in receipt of home care support which was assessed at 16 hours a week. When care resumed at the end of May James’s mother independently commissioned 30 hours a week and wanted reimbursing for this increased level of care through the direct payments system. There were a number of contacts in which James’s mother reported stress alongside a request for financial support for the increase in hours. At the last contact with professionals before James’s death, James’s mother said that “Despite all that is going on in the world I am surprisingly fine.” Thirdly, James’s mother refused offers of support through Children in Need services. She was entitled to do so, just as she was entitled to receive support for home care through the Direct Payment System. There would have been an opportunity through child in need services to have support with co-ordination of the agencies supporting James, and there were many of these, and to receive support as a parent. Parents caring for disabled children can benefit from the opportunity to express their feelings; to think through the support they and their child need, and how the services they receive support their child and family to live a good life. Children in need services are accepted by parents on a voluntary basis, they cannot be imposed on families. There were never any concerns about James wellbeing or safety that would have warranted compulsory intervention. Fourthly, there was no contact between agencies and James’s father. This meant that he missed out on receiving direct information about the progress his son was making, diagnosis and the prognosis of his health conditions over time. It was James’s mother who engaged with agencies about James’s education, health, and care needs. James’s father lived abroad, and he did not have a daily presence in James’s life. 21 Section Eight The Analysis James was a ten-year-old boy with severe learning disabilities and a complex range of disorders. From an early age he received a wide range of health, education, and care services. For the last few years of his life, he was in the sole care of his mother and they had a close relationship, it is understood he had limited contact with his father. James’s mother was a powerful advocate and champion for him; school had regular contact with her on all aspects of his education and care, including discussion on issues that she had researched. The school was confident that his needs were met with the appropriate level of service provision. James’s mother was an experienced and effective navigator of the children’s health and welfare system. She evidently understood the contribution individual agencies could make to James’s life and to supporting her and James as a family. It is clear that she knew where and how to request services and how to seek support from professionals for the help she felt that James and she needed. It is also clear that she knew which services she did not want to accept; for example, children in need services and agency-provided home care. Unlike most cases that are the subject of Child Safeguarding Practice Reviews, in this case no concern was ever raised about the nature of James’s mother’s relationship with her son and no concern was ever raised about the nature of her care of James. There were no ‘red flags’ that triggered a professional discussion based on a concern about James’s welfare in the care of his mother, nor about any potential risk of harm. There was no history of severe depression or psychosis. The family were well within the ‘line of sight of agencies’ and there was no information that would have given rise to concerns about James’s mother’s mental health and prior to James’s death there was never any question that her mental health or level of stress impacted on her ability to care for James or placed him at risk. This continued to be the case when the family’s life changed because of the pandemic. James’s mother took a number of decisions in response to the pandemic that were motivated by her concern for James’s safety; she decided that he would not attend school and that she would not accept the services of the home support carer for a period of about 10 weeks. James’s mother decided that home care would resume at the end of May, James’s mother had been under more pressure than usual and was tired. It is also likely that this motivated her decision to increase the hours of care from 16 to 30 each week. There was a high level of multi-agency contact with James and his mother throughout his life and this continued to be the case during the Covid-19 pandemic although the method of contact was different. The family benefitted from the fact that professionals providing education, health and care services knew them well, they remained well within the ‘line of sight’. This is the case despite the fact that the Covid-19 pandemic meant that education, health, and care agencies across the country were operating under extraordinary and unprecedented conditions. There was significant national guidance and services were frequently adapting their approaches to deliver services safely. This meant that working practices changed, there was less physical interpersonal contact, services were generally provided through digital means. The pandemic also meant that organisational resilience was affected as staff attendance reduced because of illness, caring responsibilities, and requirements to self-isolate. Over time this affected both professional and personal resilience. Supply of important equipment (PPE) was restricted and working practices were adjusted and readjusted in response to progressively developing government guidance and 22 shifting priorities. Organisations and their workforce were operating within a national climate of grave concern as the number of hospitalisations and deaths rose. Education, health, and care agencies in Ealing identified those citizens who might need support and worked hard to maintain contact with them despite reduced resilience. The Council worked with local voluntary organisations to establish a network of support. Set against this context, the level of multi-agency contacts with James and particularly his mother from March to August was significant and good practice. One request for support from James’s mother did not result in a decision before James died. This relates to the request for financial support for the additional care hours that she had commissioned independently. The request was under review and a decision was due by the 8 August and this was delayed. This needs to be seen in the context of organisational pressure because of the pandemic. It is notable here, that at the end of April James’s mother had said that she would only use the home care support in an emergency, that she did not want to increase the home care support package and mentioned that an increase in the care hours might make the role more attractive to a carer. A month later James’s mother had both re-instated the care and increased the hours that the carer was working from 16 to 30 hours each week, and this level of support was in place when James died. A further month later (at the end of June) she asked for financial support for this increase. Evidently, the care James’s mother felt she needed was in place, she had previous experience in 2018 of deciding to increase home care hours and securing retrospective agreement from Ealing Council to fund these hours. This cannot therefore be regarded as a contributory factor to James’s death. James’s mother received direct payments to manage the family’s home care needs, and she was entitled to do so. This meant that she manged the employment and tasking of the carer herself. In contrast to home care workers who are employed by care agencies, direct payment carers are isolated and have no wider organisational support, access to advice and guidance. If direct payment carers have concerns, and it is not known whether this was the case here, it may be more difficult for them to know how to raise them. Following James’s death, it emerged that James’s mother had employed a carer with whom she had previously had a personal relationship. The Direct Payment guidance requires that carers who are family members and do not live in the family’s home can be employed with the agreement of the funding body (in this case Ealing Council). Whilst the carer was not a family member, this situation presented a sensitivity that Ealing Council should have been made aware of and could only have been aware of if James’s mother had told them. However, whilst this is a learning point this cannot be regarded as a contributory factor in James’s death. Child in need services were offered to James’s mother on three occasions, she had received the service from October 2015 to December 2016. Thereafter she chose to receive services through CSDPA and then to manage care herself through direct payments. She was entitled to make this choice. Children in need services are provided on a voluntary basis and they are accepted by parents where they feel they add value. They provide an opportunity to place the child at the heart of assessment and planning to ensure their welfare is promoted through appropriate support. In so doing they give parents an opportunity to think through their child’s needs and support in a more holistic way and this includes impact of caring. James’s mother evidently did not find the child in need service helpful in 2016, and whilst this is a learning point it was not a contributory factor in James’s death. James’s father lived abroad and did not have frequent personal contact with his son as a result. The information he received about James’s progress and wellbeing came from 23 James’s mother. He did not have direct contact with the education, health and care services that were so involved with James and his mother. The information that James’s father had about his son was limited as a result. For James, this meant he had one parent rather than two parents acting as his advocate and making fully informed parental responses to his needs. Whilst this is a learning point, it cannot be seen as a contributory factor in James’s death. James and his mother were due to go to Spain over the half term break in May because of the risks associated with the pandemic and James did not spend the long summer holiday with his father in Spain as he had done over the previous two years. This was because he did not have sufficient time left on his passport before it expired. This meant that James didn’t get to spend time with his father, James’s mother did not benefit from a break and the pressure that she was under did not ease. However, the fact that a holiday did not take place cannot be seen as a contributory factor in James’s death and this is not a learning point for the public service response to children and families. Section Nine Conclusions The review adopted systems methodology and as a result has clearly identified the multi-agency practice in this case. It has helped to understand from a multi-agency perspective, what this practice was and why. Questions remain however, about why James died. The factors that precipitated the rapid onset of a severe depressive illness with an associated psychosis that was so acute a loving mother killed her son, are not known to those engaged in the review, with any level of certainty. What is certain is that there was regular contact with this family from all the agencies involved in James’s life. The method of contact was different because of the Covid-19 pandemic, it was generally not in person and through digital means. Nevertheless, the levels of contact were significant, services were in place in August 2020, and there was timely and appropriate information sharing between professionals. In all this contact, there were no indications that James was at risk of harm. It was known that his mother was stressed, but the level of stress was not new. Given the context of the Covid-19 pandemic, the conclusion is drawn that the child welfare system worked well in this case. It is appreciated that this is a conclusion that may be difficult to receive in a case where a child has been killed by his mother. Society looks to the child welfare system to work effectively to keep children safe and prevent tragic events such as the death of James. However, service providers could not know what was not there to know; they could not know the unknown. There were no signs that James’s mother was suffering a severe mental illness in the GP contact on 07 August 2020 and the observation that there was nothing unusual in her behaviour, was shared by a member of her local community who met her a few days later on 10 August 2020. There were therefore no failings in this case. Agencies could not have predicted that James’s mother was going suffer an episode of mental illness so severe that it led to killing her son, and they could not therefore have prevented her from doing so. 24 Section Ten Recommendations The overall purpose of a Child Safeguarding Practice Review is to identify areas of improvement in the public service response to children and their families at both local and national levels. This review has identified three areas of improvement for the Ealing Safeguarding Children Partnership. 1. Child in Need Services – collaborate and co-produce with disabled children and young people and the parents of children with disabilities, information about and service delivery of child in need services. 2. Direct Payment Carers – review the information provided to parents about the Direct Payment System which helps them to make good choices about who to employ and of their responsibilities to inform funders of situations where family members or partners are employed. 3. Engagement of fathers – review the approach to engagement of fathers as single agencies and as a partnership. 25 Appendix 1 Terms of Reference for a Local Child Safeguarding Practice Review in respect of James Background James was a ten-year-old boy with disabilities who resided with his mother in the Borough of Ealing. On the 16th August his mother attended a local police station and stated that she had murdered her son who was found at the family home. Despite attempt to resuscitate he was pronounced dead at the scene. James’s mother has subsequently been charged with murder. A Rapid Review has been completed. This incident occurred during the national Covid Pandemic. We are concerned to understand a number of issues and to ensure that any learning is effectively embedded in the local system for safeguarding. We are also concerned to identify any good practice and to ensure that this is consolidated. We seek to understand the following • The circumstances and lived experience of James immediately prior to his death • The support afforded to the family, including care and financial support sourced and paid for by James’s mother and his father, alongside support paid for by local services including health and the LA • The impact of James’s disability on all family members • The impact of the pandemic on all family members • Missed opportunities to intervene The period to be covered We are keen to understand the engagement of all agencies in this case. We are keen to understand the period immediately following James’s birth and, in the involvement, up to the point of his death. We are of the view that this gives a good sense of the lived experience of the family and will help us to understand the issues and challenges they faced. Methodology In accordance with the arrangements in Working Together 2018, we seek to use this review as an opportunity not to apportion blame but to support learning any lessons. The LCSPR will include the following elements 1. An opportunity for all agencies to share the reports completed for the Rapid Review and Joint Agency Response meeting and to engage in structured dialogue with the Review author 26 2. The data and material gathered from individual agencies will be collated into a single report highlighting a number of learning points and or hypotheses to be explored further in discussion 3. At this stage we anticipate two learning sessions will be conducted to discuss the case-based shared material. This will include: • A discussion with some front-line practitioners • A discussion with key managers and other interested staff members nominated by agencies. 4. A discussion with family members, including James’s mother and his father to ascertain their view and contribution to this learning exercise (subject to their agreement and cooperation and in line with the views of their advisors) 5. An overview report will be drafted to include the information gleaned from the above 6. A recall session with practitioners to share learning 7. Production of a final report to be agreed with the Ealing Independent Person. With discussion to include issues relating to potential anonymised publication and the response to the national panel. 8. We aim to complete all activities by 31st January 2021; and publish the final report thereafter. Information Sharing This report is being produced in accordance with Working Together 2018. The information supplied in respect of James and his family, is shared for the purposes of safeguarding. It is to assist the agencies in Ealing to learn and to ensure that practitioners have the necessary skills, knowledge and experience to operate safely. 27 Appendix 2 Footnote, added 27th April 2021, after completion of the report: At the point of the report being shared with James’s father and the solicitors acting for James’s mother, James’s father apprised the Chair of the ESCP of the correct facts relating to the passport issue – referred to on pages 10, 11, 15 & 23 above: Although professionals may have been of the view that there was insufficient time left on James’s passport, in fact the passport had expired. Mr Freeman sought to make the Passport Office aware of the circumstances, and was in discussion with them, however, a new passport was not granted, with the result that James was unable to travel. |
NC52391 | Sexual abuse of two children by a carer whilst in a long-term kinship care placement. An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed Mother and then the Police. Carer received a custodial sentence for the sexual abuse of Child A and Child B. Prior to entering care, Child A, Child B and Sibling 1 witnessed extensive and serious domestic abuse between their Mother and Father. Initially, the children were placed with Mother under an Interim Care Order, and later placed with Carer 1 and Carer 2 as kinship carers. The carers were subsequently approved as foster carers, and the placement became permanent for the children for 12 years. Learning includes: importance of robust exploration during the approval process for kinship foster carers; placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met to avoid children remaining long term in inadequate accommodation; without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged. Uses the Welsh Child Practice Review model. Recommendations include: ensure that social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives; ensure that social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children.
| Serious Case Review No: 2020/C8452 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Local Safeguarding Children Board Serious Case Review Child A and Child B Final Report June 2020 2 Contents Page Introduction 3 Process 3 The Family and background information 3 Agency Involvement 4 Analysis 7 Organisational Context 23 Good Practice 23 Conclusion Learning and recommendations 23 3 1 Introduction 1.1 In May 2019, the Local Safeguarding Children Board decided to undertake an SCR1 in relation to the serious harm suffered by two children, who were sexually abused by a carer whilst in a long-term kinship care placement. An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed Mother and then the Police. The carer is currently serving a custodial sentence for the sexual abuse of Child A and Child B. 1.2 It was recognised that there was potential learning from this case in the way that agencies worked together to support children in kinship care. The National Panel was informed of the decision to undertake a review. 2 Process 2.1 This report has been written with the intention that it will be published, and only contains information about Child A, Child B and their family that is required to identify the learning from this case. The review2 was guided by the terms of reference agreed by the steering group and followed the Welsh Child Practice Review model. 2.2 An independent author worked alongside the SCR panel to complete the review. The review considered single agency timeline reports and chronologies. Practitioners involved at the time participated in a learning event to discuss the case and identify practice improvements. The panel contributed to the learning and recommendations resulting from this review. The review considered multi agency practice during the two years prior to the disclosure by Child A that she had been sexually abused by Carer 1. Relevant information beyond this timescale also contributed to practice learning. 2.3 The author and a representative from the LSCB met separately with Child A, Child B and Mother to obtain their views about the support and intervention provided by agencies. Their contributions are included within this report and informed the findings and recommendations. The final report will be shared with Child A, Child B and Mother prior to publication. The second carer who will be referred to as Carer 2 was informed about the review and did not participate. An older sibling (Sibling 1) who witnessed the abuse spoke about his experience when the outcomes of the review were shared and his comments have been included. 3 The Family and background information 3.1 Prior to entering care, Child A, Child B and Sibling 1 witnessed extensive and serious domestic abuse between their Mother and Father. Initially, the children were placed with Mother under an Interim Care Order. Following further violence between the parents and a deterioration in Mother’s mental health, they were placed with Carer 1 and Carer 2 as kinship carers. The carers were subsequently approved as foster carers. 1 SCR’s have been replaced by child safeguarding practice reviews which should be considered for serious child safeguarding cases where: abuse or neglect of a child is known or suspected, and a child has died or been seriously harmed. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 It was the aim of the review to be compliant with Working Together 2015 which states SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. 4 3.2 The children were very young when fostered by Carer 1 and Carer 2 (Child A was 18 months; Child B was 4 years and Sibling 1 was 5 years old). The kinship care foster placement became the permanent living arrangement for the children for 12 years until the disclosure by Child A of sexual abuse by Carer 1. Child A and Child B were subsequently placed in alternative foster placements and Sibling 1 moved into semi-independent living. 3.3 Health visitor (HV) records noted that there were concerns about the behaviour of Child B when initially placed in kinship care and Carer 2 attended a behaviour management course. Health records reflected ongoing concerns regarding the behaviour and emotional wellbeing of Child B throughout the time in foster care. A Family Support Worker (FSW) provided support to Child B and Carer 2. 3.4 Records of the Looked After Children (LAC) nurse, dated 2013, detailed information shared by a social worker following a home visit to the carers. It was noted that the family home was chaotic, and there were concerns that the children were left alone at home during the day. Also, it was thought that another child may be sleeping over which may have an impact on the behaviour of the children. Child B was 12 years old at the time. 3.5 Carer 1 supported Child B to report an alleged sexual assault by a teenage male to the Police when Child B was 14 years. The carers did not inform Children’s Social Care (CSC) until two months after the incident3. There was no evidence that the Carers were challenged about the delay in information sharing. 4 Agency Involvement The following agencies/services were involved with the family during the period considered by this review: Children’s Social Care, CSC School/College Health Visitor Service LAC Nurse School Nurse Police The table below details the involvement of professionals with the family during the period considered by this review. This is not an exhaustive list and includes activity relevant to multi agency learning. 2016 to 2018 Event Agency/Service Statutory LAC review CSC Review Health Assessment (was due in October) LAC Nurse 3 Police informed the LAC service and Carer 2 confirmed the allegation. 5 Social worker (SW) completed one statutory visit during this period Child A and Child B requested to have time with Mother alone at her home Child B was involved in an alleged physical assault LAC review A management audit of Child B’s file concluded that improvements were required and noted some good SW practice. Independent oversight by the Independent Reviewing Office (IRO) was recommended. Stable and positive living arrangements were highlighted Permanence Planning Meeting, minutes noted that the carers were considering an application for Special Guardianship Orders (SGO) CSC CSC CSC CSC CSC CSC CSC PEP review completed LAC review SW visited on three occasions during this period, Child A and Child B were seen alone on one occasion Placement with parents agreed. Child A and Child B to have individual time with their mother at her home as they requested SW supervision record noted that carers do not wish to pursue the SGO application Support was provided to improve Child B’s attendance at college Education CSC CSC CSC CSC School/college LAC review - IRO raised a concern due to the lack of statutory visits by the social worker Pathway assessment concluded for Child B and Personal Advisor (PA) allocated. PA changed one month later Education records noted that LAC health assessments and LAC reviews could be held in school to reduce absences Parents evenings were attended by carers and concerns re. Child B were discussed. Child A was reported to be doing well in school. Concerns regarding Child B underachieving and having poor behaviour and attendance were raised at PEP and LAC meetings and with the carers CSC CSC School/college 6 Child B attended the GP and disclosed self-harm Child A informed school that she was going to Birmingham for the weekend with a friend and her mother. School shared information and concerns with CSC Child B attended A & E with a minor head injury following an alleged assault by boys on a bus GP School/college LAC Nurse LAC review records indicated that the placement continued to be assessed as safe and appropriately meeting the needs of Child A and Child B . Duty SW completed a statutory visit with Child A and Child B. New SW was allocated Child B was allocated a new 16+ Personal Advisor Supervising SW reported in supervision that that the carers were highly rated, self-sufficient, and provided a range of opportunities for the children with minimal support needs The annual review of Foster Carers was overdue following a change in process. No significant concerns were raised and continued approval of Carer 1 and Carer 2 as kinship carers for Child A and Child B was agreed SW supervision notes recorded a discussion between the SW and team manager regarding Child B having outgrown the placement with Carer 1 and Carer 2 Child A was not taken to ophthalmology outpatients’ appointments in July and Sept and was discharged from the clinic Child B argued with some boys at school as Child A had been crying all night and said that she was going to kill herself due to bullying by the boys. Form tutor was informed and followed up with boys and Child A Review Health Assessment- 10 months overdue Pathway review for Child B, the IRO added an amber alert on the file to enable a closer oversight around unmet health and education needs Child A LAC review - visits have not progressed as expected due to a change in the allocated SW CSC CSC CSC CSC CSC CSC NHS Trust School/college LAC Nurse CSC CSC 7 and the previous SW being absent from work due to illness Report by Sibling 1 that Child A had been sexually assaulted by Carer 1 Child B attended the GP alone on three occasions and was referred to CAMHS for a triage assessment. Police GP CAMHS 5 Analysis 5.1 The context in which Child A, Child B and Sibling 1 came to be placed with the carers will have influenced the assessment and decision-making process of professionals at the time. Care proceedings were initiated due to the violent and volatile relationship between the parents, and a placement was required for the children. The Children Act 1989 placed a duty on local authorities to explore family and friends’ placements when a child could not be looked after by their own parents. The Carers expressed a willingness to commit to the children long term and were subsequently approved as foster carers. The placement with the Carers provided a viable opportunity to keep the children together, and within the family unit. 5.2 Guided by the Terms of Reference for this Review, specific themes emerged following analysis of the available information. Exploration of each theme enabled rigorous examination of practice and identification of opportunities to improve the systems to safeguard children in care in the local authority, specifically those living in kinship care placements. 5.3 The themes identified were: (i) Kinship Foster Carers - Approval and annual review - Accommodation - Supervision of the kinship foster carers (ii) Statutory procedures to safeguard looked after children in kinship care placements - Statutory social work visits - Personal Education Plan and Review Health Assessment - Looked After Child reviews (iii) Voice of the child and professional understanding of the lived experience of the children (iv) Multi-agency information sharing 5.4 Whilst the themes will be discussed separately, it is important to note that each theme had an impact on the others, and learning identified in one area has the potential to influence practice in all. For example, the frequent change in social worker impacted on the development of a trusting relationship with Child A and Child B and professional understanding of their lived experience. In addition, shortcomings in the review process 8 for the foster carers meant that there was limited understanding about the capacity of the Carers to meet the physical and emotional needs of Child A and Child B and enable them to reach their potential. (i) Kinship Foster Carers 5.5 The carers were approved as foster carers prior to the period considered by this review. However, some concerns which emerged during the initial approval process remained unresolved and were evident during this review. Whilst practice has since changed, the SCR panel identified that there was an opportunity for learning regarding the approval, review, and supervision of kinship carers. Approval and annual review 5.6 Child A and Child B had been in the placement for 22 months before the carers were approved as long-term kinship foster carers. The delay in obtaining approval was due to concerns about the suitability of the accommodation and the ability of the Carers to implement positive behaviour management strategies. 5.7 It was noted in the LAC review dated 2007 that; the long-term plans for the children were still not formulated as the couple were struggling to manage the demands placed by the children. The kinship SW was not able to recommend to the Panel a long-term matching between the children and the carers due to concerns regarding their responses and their limited ability to use consistent behaviour management strategies. 5.8 There were specific concerns about the strategies used by Carer 1 to manage the behaviour of the children, and these were discussed with the safeguarding unit at the time. It was decided to address the concerns as a practice issue and advice was provided about appropriate sanctions. It was recorded that the carers were to be offered additional support around parenting and Carer 2 attended a parenting course. It was noted by the SCR Panel that processes are now more robust, and similar concerns would be referred to the Local Authority Designated Officer (LADO). 5.9 It is highlighted within statutory guidance that family and friends foster carers must be able to meet the child’s assessed needs, bearing in mind that those needs will often be greater than for other non-looked after children of a similar age4. Central to the assessment of a relative or friend to be a foster carer, will be consideration of the carer’s capacity to provide a level of parenting to meet the child’s needs within the requirements of the care plan and placement plan. 5.10 The local authority’s information leaflet for foster kinship carers describes the assessment process, which includes: the availability of carers and capacity to understand and respond to the child’s needs; the ability to put the child’s needs at the centre and safeguard children; understanding of child protection and development; and home environment and space in the home. Information provided to this review evidenced that there were concerns in each of these areas during the period that Child A and Child B lived with the Carers. 5.11 A statutory review of the placement took place annually and no concerns were raised during the 12 years that Child A and Child B were placed with the Carers. Continued approval was granted, and a strong narrative emerged amongst professionals and within agency records which stated that the placement was stable and family relationships were good. 4 Family and Friends Care: Statutory Guidance for Local Authorities, DfE (2011) p39. 9 5.12 The stable and positive arrangements were also highlighted in an audit report of Child B’s file dated 2017. At the time of the audit, concerns about Child B’s behaviour, emotional wellbeing and lack of attainment were contained in agency records, although not addressed within the care plan. The audit process to quality assure practice did not identify the discrepancy between the positive view of the placement and recorded concerns, specifically with regard to Child B. Whilst the consistent view presented by the Carers, family and professionals was that the placement was stable and positive arrangements were in place, there was information available to support an alternative narrative. The audit process lacked rigour and there was limited interrogation of information within records that were available at the time. 5.13 There was an opportunity within the foster carer’s annual review (required under regulation 28 of the 2011 Regulations) to identify any support required to assist the carers to meet the child’s needs. Whilst some support was identified, this was mainly to assist with the behavioural management of Child B and focussed on the changes that she needed to make. There does not appear to have been any discussion with carers about whether they required support to change their approach or further exploration to understand what may have been influencing Child B’s behaviour. 5.14 The Carers initially said that they were keen to progress an application for a Special Guardianship Order (SGO) which would have given them parental responsibility and increased permanence for Child A and Child B, however, this was not progressed. The SSW and SW shared the view that whilst the behaviour of Child A and Child B was not particularly challenging, the parenting capacity of the carers was basic5. It was the view of professionals at the time that the carers would require on-going support to meet the needs of growing teenagers and it would not be in the best interests of the children to pursue an SGO. It was recorded that the Carers were reluctant to pursue the SGO because they required ongoing assistance from the local authority to help them manage the behaviour of Child B. This view was supported by practitioners at the Learning Event. Sibling 1 said that every week he had to pay loan sharks, the family were always in debt. He felt like an item and that he was only being looked after so the carers could get their money. 5.15 Sibling 1 informed the review that the carers were always talking about money and he felt that money was the key motivation for them becoming kinship carers. Sibling 1 said that the carers spoke about losing money if they had an SGO and that is why they didn't agree to it in the end. This view was supported by Mother who said that the carers were only looking after the children for the money they could gain. 5.16 It was acknowledged by professionals involved with this review that the limitations of the Carers and the support they required to enable them to meet the needs of Child A and Child B was not explored or reflected in the statutory reviews or care plans. In the majority of cases, kinship care provides children with a good home environment, although for some (5-17%) the experience is not positive. The 2020 triennial analysis of SCR’s6 highlighted a study by Hunt, Waterhouse & Lutman 20087 which identified the need for careful assessment of the parenting capacity of potential caring relatives and the support they may require to enable them to look after the children most effectively. 5 This was identified as a concern during the initial assessment to approve the carers as kinship foster carers. 6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869586/TRIENNIAL_SCR_REPORT_2014_to_2017.pdf P70 7 Hunt, J., Waterhouse, S. and Lutman, E. (2008) Keeping them in the family: outcomes for children placed in kinship care through care proceedings. London: British Association for Adoption and Fostering. 10 5.17 Placement of the three siblings with the carers appeared to address safety issues, keep the children together and within the family. The SCR review group considered that the efforts by professionals to keep the children together and within the family was an influencing factor during the approval process and possibly contributed to a lowering of the expected standards with regard to the assessment and review of the Carers. 5.18 The statutory process to approve the carers appears to have taken place without reference to the needs of the children or the review of the placement and care plans. 5.19 Practitioners at the learning event noted that practice has since changed, and the assessment and reviews of foster carers are now more robust and thorough. This view was supported by the SCR Panel who advised that since 2019 a Fostering Independent Reviewing Officer has had independent oversight over the foster care assessment and approval process. It is important that assurance is sought that practice improvement has had a positive impact on the lived experience of children in kinship foster care and this will be addressed in the recommendations. Accommodation 5.20 The carers were approved as Foster Carers in 2007 on the basis that more appropriate accommodation would be found. The Carers’ home was too small to accommodate Child A, Child B and Sibling 1 and it was acknowledged within the minutes of the fostering panel that the accommodation did not meet the National Minimum Standards (NMS) in place at the time8 specifically, Standard 6: • 6.2 The foster home can comfortably accommodate all who live there. It is inspected annually to make sure that it meets the needs of foster children. • 6.4 Each child placed has her/his own bed and accommodation arrangements reflect the child’s assessed need for privacy and space or for any specific need resulting from a disability. 5.21 It would have been acceptable for Child A and Child B to share a bedroom initially, however the girls shared a bedroom with Sibling 1 until they were teenagers and with the carers when the house was very overcrowded. It was noted in the LAC Review in 2007 that: The pressure of the housing situation was high as the adults and children were sharing a bedroom. 5.22 It was reported that the housing situation became extreme when the son of Carer 1 and his family regularly visited and eventually moved into the house. At one time there were up to 10 people in a two-bedroom house including twin babies. At the learning event practitioners stated that the SSW and SW challenged the carers about the sleeping arrangements and concerns were escalated to service manager level. Support was provided to rehouse the son and his family however the Carers persistently refused to move into larger, more suitable accommodation. Practitioners acknowledged that the house must have been very chaotic with large numbers of people living there. 5.23 Records from the Fostering Service indicated that efforts were made over the years to support the Carers to obtain accommodation with adequate space for the children. It was evident that professionals consistently discussed concerns about housing with the Carers, however, there was limited challenge regarding the lack of commitment by the 8https://bettercarenetwork.org/sites/default/files/Fostering%20Services%20National%20Minimum%20Standards.pdf 11 Carers to move to larger accommodation. There was no evidence that the Carers accepted the concerns of professionals about the limited space for the children, or that they were actively committed to improving the situation. This remained an issue for the 12 years that Child A and Child B were in the placement and NMS 6 was not met. 5.24 In interview with the independent reviewer Mother stated, I was fine with Child A and Child B going to the carers. I knew that Carer 2 wouldn’t move to a bigger house. I didn’t like them sharing a bedroom with Sibling 1, but the social workers didn’t say anything about it. 5.25 The inadequate accommodation and lack of personal space had a significant impact on the quality of life and emotional wellbeing of Child A and Child B. In interview both spoke about the large number of people in the house, noise, lack of privacy and lack of a place to sleep. Child A: The house was very small, there were always lots of people. I used to give up my bed for my cousins. There were two bunks, we used to top and tail. I just used to get on with it, I didn’t have a choice. There was too much noise and too many people in the house. Social workers never used to ask how we were or how we felt that the house was so busy. It would have been better if all the rest of the family – uncle, aunts, and children were not there. The social workers knew how many people were in the house, they knew where we were sleeping. Child B: I felt I had no privacy and couldn’t tell anyone but at the same time I didn’t want to move from my family. There was no door on the bedroom, we had no privacy. We used to shove it in the frame. I had anger issues and barricaded myself in the room once. It was very crowded in the house, two bedrooms and there were baby twins as well. The house was chaos, I was fighting for attention. People should have looked further and asked; why is it so overcrowded, why are there an extra 8 people? Every time the uncle aunt and their children came round, I was asked to sleep out. I used to sleep in the park, drink, get high. There was a lack of supervision, I fought with Child A, used to throw things, photo frame, phone. I had a support worker for anger issues. 5.26 Overcrowding had a significant impact on both Child A and Child B. Child A spoke about having no choice but to put up with it. As a child in the placement it was evident that she felt powerless to do anything as she knew that adults were aware of the situation. Child B highlighted the lack of critical questioning by professionals and described feeling torn between telling someone about the overcrowding, and the fear of potential separation from their siblings. It appeared that the fear of separation from siblings and family was a significant factor which prevented Child B from speaking out. 5.27 The accommodation arrangements for Child A and Child B were inadequate throughout the placement. There was a lack of effective challenge by professionals involved with the family. Mother, Child A and Child B stated that SW’s were aware that the accommodation was too small and overcrowded and, in the words of Child A, nothing was done. As time progressed there was a general acceptance amongst professionals that the accommodation was crowded, there was no evidence that the impact of lack of space and privacy on the children was considered. 5.28 Child A or Child B were not asked directly how they felt about lack of privacy, limited space and overcrowding. Whilst it is not appropriate to speculate about what they may have said, it is evident that not asking for their views was a missed opportunity. From 12 their perspective they had no choice but to put up with the situation. Child A and Child B were old enough to express their views and may have done so if the housing situation had been explored with them in a respectful way by a professional whom they trusted. 5.29 The panel for this Review questioned whether standards may have been lower for the kinship carer placement and the value of keeping the children within the family was given priority even when there was clear evidence that statutory minimum standards were not met. Whilst some compromise may be necessary when children are placed with kinship carers, it is important that professionals remain focussed on the needs of the child and that the lived experience of the child is fully considered when statutory minimum standards are not met. Supervision of the Kinship Foster Carers 5.30 National Minimum Standards were revised in 2011 and Regulation 21 focussed on the provision of supervision and support for Foster Carers: The fostering service supports their foster carers to ensure they provide foster children with care that reasonably meets those children’s needs, takes the children’s wishes and feelings into account, actively promotes individual care and supports the children’s safety, health, enjoyment, education and preparation for the future9 p 42. 5.31 The report prepared by CSC for this review noted that the placement was not appropriately supervised or monitored by the Supervising SW in line with good practice and statutory regulations. Given the strong perception of professionals that this was a stable placement, the children were settled, and carers were managing well, there were limited visits to see the carers and children during the timeline considered by this review. 5.32 Alongside the statutory visits, Child A and Child B were involved with a local organisation, which delivered art activities to improve the emotional health, wellbeing, and self-efficacy of vulnerable young people. Sessions were supported by SW’s and Supervising SW’s. Practitioners at the Learning Event spoke about having observed Child A and Child B regularly during workshop sessions and in performances. It was acknowledged by Practitioners and within the SCR Panel that observation of Child A and Child B, often accompanied by the Carers within the community, would have reinforced the perception of a happy and settled placement and provided false reassurance to professionals that the needs of Child A and Child B were being met. 5.33 The CSC report prepared for this review noted that supervision records for the SSW were limited and mainly descriptive. Records which were available continued the positive narrative that the placement was established and noted that carers provided good guidance to Child A and Child B despite challenges. The visiting pattern of the SSW reflected this view. 5.34 There was absence of effective multi-agency action to improve the situation regarding the parenting capacity of the carers and overcrowded accommodation. Whilst support and oversight provided by the foster care service could have been more thorough and child focussed, it was acknowledged by professionals involved in this review that practitioners from all agencies contributed to and maintained the positive perspective of the placement. 9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/192705/NMS_Fostering_Services.pdf 13 Learning Point 1 It is important that there is robust exploration during the approval process for kinship foster carers about whether they can meet the needs of all the children in their care and any concerns are fully addressed prior to obtaining approval. Learning Point 2 Placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met, whether changes are required and within what timescale to avoid children remaining long term in inadequate accommodation. Learning Point 3 Without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged and children may remain in placements where their needs are not met. Learning Point 4 It is important that audits of a child’s file evidence critical reflection and explore whether identified concerns for looked after children are reflected appropriately within the care plan. (ii) Statutory procedures to safeguard looked after children in kinship care placements 5.35 Statutory visits by social workers and reviews for looked after children are central to practice for children in care. It is important that practice is meaningful, and all relevant plans have a positive impact on the lives of children in care to ensure that they are effectively safeguarded and reach their potential. Opportunities for multi-agency practice learning in these areas is discussed below. Statutory social work visits 5.36 It was acknowledged in the report submitted by CSC to this review, that social work practice and management oversight was, at times, inadequate, and practice standards were not met. This appears to have been exacerbated by frequent change of allocated SWs. There were lengthy delays between visits and case records were brief and repetitive. In addition, supervision records were descriptive, task focussed and contained little evidence of discussion with Child A and Child B or consideration of their life experiences. There were at times lengthy gaps between supervision of social workers by the team manager. 5.37 The Care Planning, Placement and Case Review Regulations 2010 state that when a placement is intended to last until the child is 18 visiting intervals can be extended to 3 months. Regulation 35(3) (b) requires that a record of each visit is made. The record must include the Social Workers full name, the date of the visit and the date the recording was made. A copy of the report must be sent to the Supervising Social Workers for the foster carers. 5.38 Whilst the SW and SSW attended LAC reviews for Child A and Child B every six months there was little evidence of additional communication between the social workers 14 regarding the suitability of the placement, or the capacity of the Carers to meet the needs of the children. 5.39 During the period considered by this review, the IRO formally escalated a concern due to a six-month delay between statutory visits by the social worker. Repetition of a similar significant delay shortly afterwards indicated that the escalation by the IRO had minimal impact and did not result in sustained improvements to practice. 5.40 The change in social workers and long gaps between visits impacted on Child A and Child B who described their experience as follows: Child A: there were too many social workers. Workers need to be more aware of children’s wishes and feelings. Child B: I didn’t feel the SW was relevant to me. I was asked the same questions and gave the same answers. Then they wouldn’t show up for another 6 months. After the abuse, my behaviour got worse. I was 13/14 used to climb out of the window onto the roof. There were too many social workers to know what was happening. One person may have noticed it and worked it out from my behaviour. It would have helped to be seen on my own, even go for a walk in the park. I think a social worker should get on my level, share themselves, not focus on the process stuff and don’t treat me like an item. 5.41 Child A and Child B were seen alone by a SW at times, however, it was frequently recorded in case notes that Child A and Child B refused to be seen alone. This appears to have been accepted by social workers with little reflection in supervision. Child A and Child B explained that it was difficult for them to agree to be seen alone, especially when asked in front of the carers. Child A: We used to have to be so careful as the family were in the room. We never got offered to be seen alone – maybe we should just have been taken. Social workers could have taken us out, they just used to sit us down at home. I would have loved to have gone out without my siblings. Everything you said to the social worker got repeated back to the Carers anyway. Child B: There was too much chaos, I refused to be seen on my own in case I slipped up and they (professionals) got the carers involved. The Carers used to make us tell them what was said if we were seen alone. 5.42 It is not possible to say whether Child A and Child B would have agreed to speak with the SW if the SW had been more directive about taking them out from the placement. Child A and Child B said that it was very difficult for them to see the social worker alone. In addition, they felt unable to speak privately without things being repeated back to the Carers. 5.43 The frequent change of social worker together with infrequent statutory visits will have impacted on the development of a trusting relationship, quality of discussion and the willingness of Child A and Child B to see the SW alone. It is important that social workers have the confidence to be pro-active and assertive in their work with children in care regarding seeing children alone and away from their Carers. Requests to see children alone should be made in a child focussed and creative way and case notes should include the reasons given if a child refuses to see a social worker away from their Carer. 5.44 It was evident that the frequent change of social worker, during the 12 year placement with the Carers, had a significant impact on the quality of social work with Child A and 15 Child B. Each newly allocated social worker was presented with a positive narrative regarding the placement. It would have taken time and confidence for social workers to adopt a critically questioning approach to the care plan and within the looked after children reviews. In the absence of robust supervision to support this approach the positive discourse about the placement continued. Personal Education Plan and Review Health Assessment Personal Education Plan (PEP) 5.45 The PEP forms an integral part of the care plan and provides essential information to ensure that appropriate support is in place to enable the child to achieve the targets set. The PEP is used in school to make sure the child’s progress towards education targets are monitored, with the Virtual School Head having a quality assurance role. 5.46 Prior to the timeline for this review, Child B was reported to be struggling with things emotionally and received support from the school counsellor. Child B spoke about wanting to see more of her Mother and this was shared with the Social Worker at the time. Child A and Child B spoke positively about the school mentor who provided support during the period considered by this review. 5.47 Communication between school and the carers was reported to be good with updates provided by telephone and at PEP or LAC review meetings. Carer 2 attended meetings at school for Child A and Child B whenever possible and LAC Reviews were held in the home. The education representative was asked by the social worker in an email not to attend the statutory reviews due to lack of space. It was unclear why the reviews did not take place in school as the lead mentor had suggested this as an option. It was acknowledged by professionals involved with the review that it was not acceptable or appropriate that the social worker requested the education representative not to attend the statutory review due to lack of space in the family home. 5.48 Whilst it may be appropriate for some professionals not to attend LAC reviews when permanent placements are stable with no issues this was not the case for Child A and Child B. Throughout the period considered by this review there were concerns about the emotional wellbeing and achievements of Child B at school. The report prepared for this review by the school designated safeguarding lead (DSL) noted that worries with regard to the behaviour and attendance of Child B were raised at the LAC and PEP meetings and recorded in minutes held by the virtual school team. 5.49 In discussion for this review Child B acknowledged that they did not achieve their potential at school; I needed help to meet my potential, didn’t turn up at school, and was late every day. I waited until Carer 1 had left or was asleep, used not to eat or to eat in secret. It would have been better if they looked behind the smiles, no one noticed the struggles of Sibling 1. 5.50 It was a significant omission that a key professional who had substantial contact with Child A and Child B10 did not actively participate in the LAC reviews. There appeared to be acceptance of the request not to attend the LAC Reviews. There was lack of robust 10 which included oversight of the counselling and mentoring provided by school 16 multi-agency discussion to explore and address the issues which impacted on Child B reaching her potential whilst at school, this was a missed opportunity. Annual Review Health Assessment 5.51 It is a statutory requirement that looked after children have a health plan that is updated once every 12 months after the child’s fifth birthday. Statutory guidance notes that: The child’s social worker and IRO have a role to play in monitoring the implementation of the health plan, as part of the child’s wider care plan11. 5.52 The annual Review Health Assessment (RHA) provides an opportunity to focus on emotional and mental well-being as well as physical health. The RHA should inform other aspects of care planning, such as the impact of a child’s physical, emotional, and mental health on their education. Local authorities are required to use the Strength and Difficulties Questionnaire (SDQ) to assess the emotional well-being of looked after children. The SDQ score should be recorded within the annual health assessment. 5.53 The SCR Panel group noted that action to address practice improvement regarding use of the SDQ is underway across the local authority. 5.54 A LAC health representative did not regularly attend the statutory Reviews, and this has been addressed in immediate single agency learning12. The RHAs provided limited information about SDQ and the emotional wellbeing of Child A and Child B was not explored in depth. The report prepared for this review by the trust highlighted missed opportunities to explore information provided by Child A and Child B who were forthcoming to health professionals with information that may have indicated early concerns. 5.55 The opportunity to see the LAC nurse in a confidential slot was not always taken and the views of Child A and Child B about seeing professionals alone are included at 5.38. It was acknowledged in the report prepared by the trust for this review that there needs to be better documentation about why children are not utilising the confidential slot in the RHA with LAC nurses. Also, when children do not utilise the confidential slot in the RHA this information should be shared with CSC and this will be addressed in the recommendations for this Review. 5.56 There was an omission to record a physical health condition for Child A within one RHA and it was noted that recording was below expected standards. In addition, there was no RHA completed between 2016 and 2018 (after the incident which triggered this review). 5.57 Whilst there may have been some challenges within the system to request RHAs, it was agreed by all involved with this Review, that such a substantial delay when RHAs were previously attended within a reasonable time frame was unacceptable. In 2018, the RHA was ten months overdue and repeated attempts to contact Carer 2 were unsuccessful. There was an omission to escalate to the trust LAC team manager and limited consideration by professionals of potential safeguarding concerns. It was not known whether the family were deliberately avoiding the RHA and the voice of Child A and Child B were not heard. Since 2018 there is an RHA tracking list in use by the LAC team to identify outstanding RHAs. 11 Promoting the health and well-being of looked-after children. March 2015 DfE, DH, p18 12 Current practice is that LAC nurses are expected to arrange cover or send a report to all Reviews. 17 5.58 There is a clear expectation that foster carers meet the health needs of children in their care. In this case however, there appeared to be an acceptance by professionals that the Carers were busy people and there was lack of challenge regarding the importance of prioritising the health needs of Child A and Child B. Whilst the delayed health assessment was noted at the statutory LAC review, there was no effective action to progress the assessment or to ensure that the health needs of Child A and Child B were met. Child A stated: Carer 2 never sorted our appointments cos she never had time. She couldn’t take time off work as she was ill a lot. Looked After Child reviews 5.59 A key purpose of the statutory review is to ensure that appropriate plans are in place to safeguard and promote the overall welfare of the child and to ensure all plans are progressed effectively, according to local safeguarding multiagency procedures. Key plans that should be considered at the Child Looked After review are the Care Plan; Health Care Plan; Pathway Plan if applicable and the Personal Education Plan (PEP). It is important that the plans are considered together and contribute to the care plan. 5.60 When a child has been placed in a designated long-term foster placement for more than a year, consideration should be given to whether it is necessary to hold a meeting as part of each review There was no evidence of a formal decision to reduce the frequency of the LAC reviews and these continued to be held every six months. 5.61 The Reviews were attended by the IRO, Child A, Child B, the carers, Mother, the SSW and the children’s SW. Information and updates regarding health and education were shared, although representatives from these agencies did not routinely attend the reviews which took place within the family home. As noted in paragraph 5.44, the representative from school did not attend the reviews following a request by the social worker. Consequently, the care plan was reviewed by a closed professional network with no evidence of challenge or multi agency scrutiny to address whether the care plans met the needs of Child A and Child B. 5.62 The Care Matters Green Paper consultation in 2006-07 identified the following concerns regarding reviews for looked after children13 Not every statutory review was being conducted in a way that encouraged a challenging analysis of the proposals for meeting the child’s needs. Unless care plans are rigorously examined the review is no longer an opportunity for informed reflection on the child’s progress and planning for the child’s future; These concerns were evident in the review process for Child A and Child B. 5.63 Review records reflected that Child A and Child B were happy with their placement and care plan and had a good relationship with the Carers and social worker. Practitioners at the learning event acknowledged that there was lack of critical questioning by all professionals involved at the time and lack of robust monitoring of the care plan and personal education plan. The LAC reviews were at times repetitive and tokenistic and 13Subsequently addressed in statutory guidance: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/326311/Care_Matters_-_Time_for_Change.pdf 18 served to progress the positive view of a settled placement. Whilst Child A and Child B chaired their own reviews, they had a clear view about the value of these meetings and Mother appeared unaware about the care plan. Child A: I knew about the care plan I understood what was said in the meetings. The review booklets are all the same, I wrote the same thing every time whether I was happy or not. Holidays were good I had my own space then. Child B: The care plan is all about what we can’t do – there’s nothing in it about nurturing us. Often, I didn’t have money on my food card, and I used to steal for food. Mother: I didn’t know what the care plan was and can’t recall what was in them. 5.64 Child A and Child B noted that the care plan was more about restrictions and was not aspirational in a way that assisted them to reach their potential. The views of Child A and Child B indicated that from their perspective the reviews had little value and the care plan lacked relevance and was restrictive. 5.65 Given the lack of an up to date assessment it was not possible for professionals to have confidence that the care plan met the needs of Child A and Child B. The assessments undertaken at the time the children were placed with the carers were not reviewed or updated for many years. The physical and emotional needs of the children would have changed over the years however the care plan was not amended to ensure that additional needs were identified and met. It was noted by the author of the CSC report that: Updated assessments would have given the opportunity to gain additional understanding of the needs and circumstances of Child A and Child B and ensure that plans were relevant and potentially more aspirational. 5.66 There was limited evidence that the statutory reviews had a positive impact on the lives of Child A and Child B. The narrative that the placement was stable and the children settled persisted, although there was information available to suggest otherwise. There was lack of critical exploration by multi agency partners of key issues and incidents which will have impacted on the wellbeing of Child A and Child B, specifically: • There was a significant difference in the way that Child A and Child B were treated by carers in the placement. The behaviour of Child B was described as challenging within agency reports and professionals expressed concerns about her emotional wellbeing. Child B did not fulfil their potential at school and generally had poorer outcomes than Child A. Child A and Child B were consistent when explaining that they were treated differently by the carers. Mother stated that: Child B was treated differently and never really got on with Carer 2. Child B got blamed for everything that Child A did. I always felt that Child A got more. If Child B asked for anything, she was told we’ll see if we can afford it. • There was a reference in each statutory LAC Review to Child B understanding why she was in kinship care and it was noted that the Carers were supporting her with this. Absence of life story work, specifically for Child B, was highlighted in the trust report for this Review. Given the limitations of the Carers it is likely that Child B would have benefitted from formal life story work. There was no 19 evidence that multi-agency partners considered this as a potential unmet need for Child B. • Concerns regarding lack of supervision for the children were identified at the beginning of the placement. During the period considered by this review there was an incident which resulted in School reporting potential safeguarding concerns to CSC14. There were unresolved concerns about the quality of supervision provided by the Carers. 5.67 Agency reports submitted for this review noted that there was lack of professional curiosity by practitioners involved with the family, the implication being that if professionals had been ‘more curious’ information may have emerged that would have prevented harm. Burton V and Revell L (2018) explored the organisational factors that may inhibit professional curiosity in practice and act as potential barriers to invoking curiosity. They argued that for a practitioner to exercise curiosity they require confidence that tension and uncertainty will be managed within reflective practice and supervisory processes. Whilst it is appropriate that professionals take responsibility for their own practice it is important to note that there were organisational factors which impacted on the ability of practitioners at the time to demonstrate curiosity. Opportunities for critical reflection and rigorous supervision were limited during the timeline considered by this review. 5.68 In addition, frequent change of social worker impacted on the quality of support provided. Child A and Child B lacked the opportunity to develop a relationship with a trusted professional whom they may have been able to talk with about their experiences in foster care. It is important to note that whilst there was consistency in the professional contacts at school and college it appeared that Child A and Child B wished to keep their home life separate from school. Anxiety and fear about possible separation from each other and sibling 1 was a powerful deterrent which contributed to the reluctance of Child A and Child B to share openly with any professional about their experience in foster care. 5.69 The statutory review process lacked rigour and focused on the immediate or short-term future. There was a lack of professional challenge, in part, due to the small group of practitioners alongside the family at the reviews. The quality of the care plan was poor and lacked clarity about actions required to improve the circumstances of Child A and Child B and there was little evidence of aspirational planning for longer term successful, happy, rewarding adult life experiences. Learning point 5 Supervision of social workers should include the critical appraisal of the care plan for looked after children particularly when the social worker is newly allocated. This should provide an opportunity to identify gaps, consider unmet needs and challenge incorrect assumptions. Learning Point 6 Frequent change in social worker and lengthy gaps between visits to looked after children reduces the opportunity for children in care to develop a relationship with a trusted professional outside of their family whom they can talk to about their experiences in care. Learning Point 7 14 Child A had said she was going away for the weekend with a friend and her mother. School had concerns regarding the family and the carers did not know who Child A was going away with. 20 It is important that all relevant professionals attend Reviews for looked after children and there is robust scrutiny of all plans to promote the wellbeing and development of children in care and support to assist them to achieve their potential. Learning Point 8 There may be many reasons why children in care decline to meet with professionals without their carers present. If children are not seen alone it may be difficult for professionals to have an informed understanding of their lived experience. (iii) Voice of the child and professional understanding of the lived experience of the children 5.70 There was a lack of direct work by any professional with Child A or Child B and their verbalised wishes and feelings were accepted without question. Child A and Child B were described by practitioners at the learning event as ‘vocal’ at their respective LAC reviews and there were examples of direct statements from Child A and Child B within LAC health review reports. Professionals from all agencies accepted their views, often expressed in front of the foster carers, without further exploration. 5.71 Both Child A and Child B consistently stated that they were happy in the placement and felt that they could talk to the Carers or a teacher if they had any concerns. Opportunities to understand the lived experience of the children were missed by practitioners in health, education and social care. It was acknowledged at the Learning Event that Child A and Child B were not as happy as they reported and professionals acknowledged that they could have adopted a more critical and child focussed approach in their support of Child A and Child B. 5.72 Child B was abused by Carer 1 prior to the allegation made by Child A and spoke to the independent reviewer about how her behaviour changed when the abuse started. Child B said that no one noticed that she was in distress or asked what was going on in her life: Child B I felt I had no privacy and couldn’t tell anyone, but at the same time I didn’t want to move from my family. I used to put on a happy face to hide my problems. I didn’t want people to know. I told Mum about the sexual abuse, but I didn’t make it clear what had happened. I told Sibling 1, but he didn’t believe me cos I’d told so many lies. I totally changed (after the abuse started), they never asked about the change in the way I dressed, changed in my eating, I started to self-harm. No one looked between the lines. No one took me away from the house, I had counselling for self-harm, and I kept myself to myself. 5.73 Mother said that at that time Child B had told her about the abuse the social worker whom she could trust had left. Mother said that she did not share this information with professionals as Child B did not explain fully what had happened and she thought Child B had made it up. Mother: Child B told me about the abuse on the phone, she was supposed to come around and talk about it – I thought it was inappropriate touching. She didn’t come round to talk; it never came up again. Child B had been caught shoplifting and I thought she’d made it up so she could come and live with me quicker. Because I didn’t tell the SW at the time, I couldn’t talk to her. I could have told JM (previous SW) and asked her to explore it with Child B. 21 5.74 It was not possible to have confidence that that the initial disclosure by Child B would have been explored appropriately had the SW remained in post. Furthermore, it was not known that Mother had also been abused by Carer 1 until the police investigation following the disclosure by Child A. However, the CSC report prepared for this review noted that the frequent changes in SW and light touch in professional practice may have impacted on the ability of Child A and Child B to form relationships with their SW’s and limited the opportunity for the children to share any worries or concerns with a trusted adult outside of their immediate family. Whilst it is important to avoid hindsight bias, the disclosure by Mother that she had been the victim of abuse by Carer 1 is significant. It is important that the experiences of adult children of prospective kinship foster carers are fully assessed prior to approval being granted and this will be addressed in the recommendations. 5.75 When describing life with the foster carers Child A and Child B stated: Child A: Most of the time I was in my room, they (carers) used to be on the play station or watching horror films downstairs. I’d go to sleep early, there was no TV in the room. Child B dropped off with her behaviour in year 7. I got love and attention from my siblings even though we argued. I was closest to Carer 2, had been home a lot and my behaviour was better than Child B’s. The carers made us cook our own food from year 7 they couldn’t be bothered, they used to fight with Child B and Sibling 1 – we all had to share a room. Child B had bruises – 1 or 2 a month. Child B: I used to cry for attention so they would have to ring the SW’s, sometimes I wasn’t reported as missing from home – once I was out until 4 am. I stole from Carer 2, I told them Carer 2 was hitting me, SW came up to the bedroom and I told them about the threats to throw me out – nothing got done. All the reports said we were settled. 5.76 Professionals did not have a clear understanding of Child B’s wishes and feelings and without an opportunity to understand the context of the behaviour at the time and external influencing factors it is not possible to state with confidence what Child B was attempting to communicate by her behaviour. Challenging behaviour is often the way a child tries to communicate their distress or process their emotions. It is important that consideration is given to what children may be trying to communicate by their behaviour as well as verbally. 5.77 It is known from research that children’s behaviour may be a signal of sexual abuse even when there is no verbal disclosure. Information provided by the Centre of Expertise on Child Sexual Abuse noted that many children do not ‘tell’ in a straightforward way; rather, their behaviour and demeanour or the characteristics or behaviour of caregivers indicates that something is wrong15. It is important that practitioners are enabled to prioritise listening to the voice of children in care in a meaningful way and are alert to what children may be communicating by their behaviours. 5.78 Listening to the voice of the child has emerged as key learning in SCR’s16 which have highlighted the importance of recognising behaviour as a means of communication and the implications of doing so for practice. (Ofsted 2011 p 18; Sidebotham P. Brandon M. 2016 p118). Understanding the lived experience of the child is a complex process and the importance of professionals having a child centred approach is well recognised. 15 https://www.csacentre.org.uk/resources/key-messages/intra-familial-csa/ 16 The voice of the child: learning lessons from serious case reviews. Ofsted 2010 22 5.79 Understanding the lived experience of the child was a key theme identified in audits. It was acknowledged that there is a need to improve on obtaining children’s views as well understanding their lived experience. The audits highlighted the importance of putting together what children say and fully understanding their circumstances. Learning and recommendations from this review will complement current action plans to improve professional understanding about and response to the lived experience of the child. Learning Point 9 Understanding the lived experience of the child is central to protective safeguarding work. It is important that children are provided with different ways to get their voice heard, and that professionals critically reflect on what is said and what children may be trying to communicate by their behaviour. (iv) Multi-agency communication and information sharing 5.80 This review has identified some gaps in communication between agencies which include: • GP records in 2013 indicated that the GP was unaware that Father was not supposed to have unsupervised contact with Child A. The potential risk of Child A having unsupervised contact with Father was not assessed and this information was not shared with the SW. This episode was 7 years ago, and it is possible that systems for information sharing have improved, however assurance is required. • Non-attendance of health and education professionals at the LAC review resulted in missed opportunities to share information effectively and contributed to the unmet needs of Child A and Child B not being recognised or addressed. • Child B disclosed self-harm to the GP in 2018. There was no evidence that the GP shared information with the LAC nurse or the SW. There was a missed opportunity for the LAC nurse and/or SW to explore potential causes for the distress and self-harm with Child B. • Child B attended three appointments with the same GP during the week that Child A disclosed sexual abuse by Carer 1 and a referral was made to CAMHS. There was no evidence of information sharing between the GP and the SW regarding this referral and no evidence of liaison between CAMHS and the SW. It was a significant omission that CAMHS were not aware of the disclosure by Child A and therefore unable to explore this with Child B. • In early 2017 Child B was involved in an alleged physical assault of teenage girls and whilst Carer 2 informed the Duty SW there was no communication directly or indirectly by the Duty SW to explore this incident with Child B. Records indicated that the allocated SW may have been on leave at this time and the incident was discussed with Child A and Child B one month following the event. There was no evidence of follow up discussion with the Police or discussion about the incident at the LAC review. 5.81 Information sharing is central to effective safeguarding practice and particularly important when working with looked after children who are likely to have additional vulnerabilities. Omission to share information effectively during the period considered by this review was a contributory factor which impacted on missed opportunities to effectively safeguard Child A and Child B and ensure their needs were met. 23 Learning Point 10 It is important that practitioners use available systems and processes within and between agencies to share information about the wellbeing of looked after children. Missed opportunities to share information can impact on the ability of practitioners to safeguard looked after children 6 Context 6.1 During the period considered by this review, Children’s Social Care in the local authority experienced a period of significant change. 6.2 At the learning event practitioners acknowledged that practice at the time was process driven, non-compliance with agency procedures was an issue and practice standards were not always met. Implementation of a comprehensive improvement plan is in progress and the learning and recommendations from this review aim to strengthen and complement the improvement journey. 7 Good Practice • Professionals from CSC and School supported the work of the local organisation that Child A and Child B attended and had contact in the community with Child A and Child B. • A consistent group of professionals at school provided mentoring to Child A and Child B. • In 2018, the LAC nurse was proactive and contacted Carer 2 to discuss an assault on Child A by boys at school. • GP records reflected detailed child focussed consultations with Child B and clear exploration of potential risks and support. 8 Conclusion, learning and recommendations 8.1 This review was triggered following the disclosure by Child A that she had been sexually abused by Carer 1. The review has found that there whilst there was no obvious missed opportunity to identify the sexual abuse of Child A and also Child B, it is possible that the shortcomings in multi-agency systems and processes identified by this review contributed to conditions which allowed the abuse to progress undetected. 8.2 Carer 1 and Carer 2 did not fulfil the responsibilities expected of kinship carers, however there was lack of challenge and the Carers had minimal involvement with the local authority. The motivation of the carers for taking Child A, Child B and Sibling 1 into their home was not fully assessed. The limited capacity of the Carers to parent was acknowledged but not effectively addressed. The benefit of keeping the children within the family and together appeared to have prevented consideration about whether this was the best placement for the children. The powerful perception that this was a strong stable placement persisted over many years and was supported by Child A, Child B and Mother who shared anxieties and concerns that if they were not with the Carers they may be separated from their siblings. From information provided to this review it was evident that Child A and Child B did not have their needs met and agencies were aware of some of the issues highlighted in this Review when the placement started. 8.3 Learning from this review has highlighted practice shortcomings that in isolation may not present a significant problem. However, when combined, they resulted in serious weaknesses in the systems and processes to safeguard looked after children in a kinship care placement. Practice shortcomings were identified in regard to: assessment, monitoring and supervision of kinship carers; voice of the child; the review process for 24 looked after children; effectiveness of statutory plans for looked after children including the RHA and the PEP; professional challenge of carers; escalation of concerns and multi-agency information sharing. 8.4 When assessing whether professionals were overly optimistic in their practice and decision-making processes it is important to consider the structures and contexts within which practitioners worked. Practice which may be assessed as overly optimistic and unquestioning can flourish when there is limited supervision and support to promote reflection, challenge, and critical thinking. As was the case in this review. 8.5 The 2016 Triennial Review describes authoritative practice as the ability to negotiate the complexity and ambiguity of child protection work with confidence and competence. It enables ‘professionals to be curious and exercise their professional judgement in the light of the circumstances of particular cases (Sidebotham et al, 2016)17. Professionals involved in this review accepted the necessity to improve multi agency authoritative practice. 8.6 Whilst it is not possible to change the past, senior managers involved with this review stated that there is a sincere commitment and enduring responsibility to provide ongoing support to Child A and Child B. It was acknowledged by the SCR panel that services for looked after children in kinship care have significantly improved since the time period considered by this review. In addition to systemic changes to improve multi-agency practice there is a bespoke kinship care service and an advocacy service for looked after children. It is important that these changes reduce the risk of repetition of practice shortcomings identified by this review and have a positive impact on the lived experience of looked after children. 8.7 This review has benefited from the generous participation and reflection of practitioners from all agencies. It was a challenge for professionals who had been involved with the family over many years to critically review their practice and identify opportunities for multi-agency practice learning. There was acknowledgement by practitioners who attended the learning event of the powerful personal learning from participation in this review, specifically with regard to exercising respectful uncertainty when working with families and maintaining focus on the needs of the child. 8.8 The review also benefitted from the views of Child A, Child B and Mother who shared their experiences with courage to inform the learning and influence change in practice. The review will be shared with the family prior to publication. In discussion with the independent author Child A and Child B said they would be willing to consider involvement in the development of resources for children in care to raise awareness about sexual abuse and available support. Learning and Recommendations Learning Point 1 It is important that there is robust exploration during the approval process for kinship foster carers about whether they can meet the needs of all the children in their care and any concerns are fully addressed prior to obtaining approval. Recommendation 1 Safeguarding Partners seek assurance that the approval and review process for kinship foster carers requires: 17 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. Sidebotham, Peter et al. Department for Education, 2016 p201. 25 • Rigorous exploration of the parenting capacity of all carers • Identification of any support (practical, emotional, financial) required to the enable the carers meet the needs of children in their care • Monitor the capacity of carers to respond to changing needs of children as they age and develop • Consideration of specific exploration with adult children of potential kinship foster carers about whether they experienced abuse of any nature as children Learning Point 2 Placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met, whether changes are required and within what timescale, to avoid children remaining long term in inadequate accommodation. Recommendation 2 When placements do not meet the National Minimum Standards, a referral is made to the Fostering Panel for further consideration Learning Point 3 Without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged and children may remain in placements where their needs are not met. Recommendation 3 Safeguarding Partners seek assurance that: • Supervising social workers support kinship foster carers to meet the needs of children in their care and provide effective challenge when required • Supervising social workers have access to regular supervision which provides opportunities for reflection and critical challenge Learning Point 4 It is important that audits of a child’s file evidence critical reflection and explore whether identified concerns for looked after children are reflected appropriately within the care plan. Recommendation 4 Safeguarding Partners seek assurance that: Audits for looked after children in kinship care (single and multi-agency) are robust and have specific regard to: • Identification of unmet need • The effectiveness of multi-agency arrangements to implement the care plan Learning point 5 Supervision of social workers should include the critical appraisal of the care plan for looked after children, particularly when the social worker is newly allocated. This should provide an opportunity to identify gaps, consider unmet needs and challenge incorrect assumptions. Recommendation 5 Safeguarding Partners seek assurance that: 26 • Social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children Learning Point 6 Frequent change in social worker and lengthy gaps between visits to looked after children reduces the opportunity for children in care to develop a relationship with a trusted professional outside of their family whom they can talk to about their experiences in care. Recommendation 6 Safeguarding Partners seek assurance that: • Children in kinship care receive statutory visits from social worker within timescales • Social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives Learning Point 7 It is important that all relevant professionals attend Reviews for looked after children and there is robust scrutiny of all plans to promote the wellbeing and development of children in care and support to assist them to achieve their potential. Recommendation 7 Safeguarding Partners seek assurance that learning from this review informs the system and process for looked after child reviews regarding: • Proactive attendance of all relevant professionals at the LAC review • Robust monitoring of the quality of all care plans including the PEP and HRAs • Effective multi-agency challenge and escalation of concerns when the needs of the children are not met Learning Point 8 There may be many reasons why children in care decline to meet with professionals without their carers present. If children are not seen alone it may be difficult for professionals to have an informed understanding of their lived experience. Learning Point 9 Understanding the lived experience of the child is central to protective safeguarding work. It is important that children are provided with different ways to get their voice heard, and that professionals critically reflect on what is said and what children may be trying to communicate by their behaviour. Recommendation 8 Learning from this review informs and contributes to the action plan currently in place to improve multi agency practice to understand the lived experience of the child, and assurance is provided that: • Professionals are proactive when encouraging children in care to meet with them and provide appropriate assurance that what is said will not be reported back to the carers 27 • Professionals explore and record why children may refuse to meet with them 1-1 and this is monitored • Consideration is given to what children may be trying to communicate by their behaviour and whether what may be described as challenging behaviour is an indication of unmet needs • The voice of children in care is evidenced within care plans and informs the provision of services and support • Learning Point 10 It is important that practitioners use available systems and processes within and between agencies to share information about the wellbeing of looked after children. Missed opportunities to share information can impact on the ability of practitioners to safeguard looked after children Recommendation 9 Multi-agency safeguarding partners are reminded of: • Their responsibilities to share information both between and within their organisations • The potential impact of practitioners to safeguard looked after children when these opportunities are missed |
NC50803 | Neglect of four siblings over a period of several years. Matthew admitted to hospital with a non-accidental head injury in November 2016, diagnosed as a fractured skull. Lincolnshire police investigated but case has now closed. Mother known to childrens social care since 1997. Mother had a history of heroin use and offending behaviour. Several referrals to Childrens Social Care from 2006-2013 related to parental drug misuse and family violence. Catherine taken to A&E for bumps and bruises believed to be related to poor parental supervision. Concerns about mothers heroin use whilst pregnant with Andrew. Twins born prematurely and diagnosed with Neo Natal Abstinence Syndrome. All siblings subject of child protection plans, stepped down to Children in Need in June 2016. Ethnicity of the family not specified. Learning includes: when professionals do not have an understanding of the family history, relationships and functioning it is difficult to have a clear picture about what daily life is like for the children; significant decisions should be informed through key assessments being completed, including pre-birth parenting assessment and risk assessments. Recommendations include: seek assurance that the model used in assessing risk within conferences is being used effectively; seek assurance in the practice of Independent Child Protection Chairs and their management of conferences; consider establishing a practice by which CP plans should not be removed at the first review unless there are evidenced circumstances; seek assurance that the professional resolution and escalation procedure is understood and effectively applied in all partner organisations.
| Title: SCR G. LSCB: Lincolnshire Safeguarding Children Board Author: Sue Gregory Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review G V1.2 LINCOLNSHIRE SAFEGUARDING CHILDREN BOARD SCR G SUE GREGORY DECEMBER 2018 2 Contents 1. Introduction 2. Methodology 3. Parallel Processes 4. Narrative / Summary 5. The experience of children 6. Analysis i) October 2015 Transfer to Lincolnshire ii) Move to a different Lincolnshire town iii) Agency understanding and impact of Mother's problematic drug use on her parenting ability iv) Pre birth assessment v) Immediate post natal period 2/6/16-11/7/16 vi) Review Case conference and decision to step down vii) Delivery of discharge plan from hospital and ongoing CIN plan 7. Changes in Practice and Actions 8. Summary and Conclusions 9. Recommendations Note: This Overview Report has been anonymised throughout. 3 1.Introduction 1.1 This Serious Case Review (SCR) concerns four children: Matthew and Sarah Catherine Andrew There are two other siblings who are adults living independently and therefore not subject to this review. The four children were living with their mother until 23rd November 2016, the day after Matthew was admitted to hospital with a head injury which was subsequently diagnosed as a fractured skull. 1.2 The family have been known to Childrens Social Care since 1997 when mother was pregnant with her oldest child and there were concerns about her drug use and related issues. Both of the older siblings were subject of CP Plans under the category of neglect and by 2002 were living with their respective fathers. There were a number of referrals to Childrens Social Care between 2006, when mother was pregnant with Catherine, and 2013 which were mainly in respect of concerns about parental drug use and domestic abuse. While some assessments were completed, the children did not remain an open case for any substantial periods of time. The family, at that time mother, her partner (father of Andrew), Catherine and Andrew, lived outside of Lincolnshire from 2013 where the two children were made subject to Child Protection (CP) Plans on 4th July 2014. Mother and the two children returned to Lincolnshire in September 2015 informing workers that she had left father of Andrew and her property. A transfer in conference was held on 9th October 2015 and the children remained on CP plans under the category of Neglect. An Initial Child Protection Conference (ICPC) was held on 5th May 2016 to consider the unborn twins resulting in a decision that they be made subject to CP plans at birth. The first CP Review Conference for the twins (and third in respect of Catherine and Andrew) was held on 24th June 2016 at which the decision was made to remove the CP plans and manage all four children as Children in Need. 1.3 The Lincolnshire Safeguarding Children Board (LSCB) commissioned a SCR in accordance with ‘Working Together to Safeguard Children’ 2015 and the ‘Local Safeguarding Children Board Regulations’ 2006. The Terms of Reference (TOR) for this review are set out in S1.5 below. The SCR was commissioned in June 2017 and the delay is due to a change in the Independent Author. 1.4 The LSCB appointed Sue Gregory as independent overview report author of this review. Ms Gregory is a HCPC registered social worker with over 30 years experience, predominantly in childrens services, and in particular safeguarding as a front line worker, child protection co-ordinator, head of safeguarding and a director. She has worked independently as Matthew Thomas Associates since 2009 and has experience of undertaking reviews in childrens and adult services. 1.5 This review seeks to provide an analysis of what happened, what could be done differently and what has already changed. The LSCB identified 7 key factors to be addressed: - transfer in to Lincolnshire - move to a different Lincolnshire town 4 - agency understanding and impact of mothers problematic drug use on her parenting ability - pre-birth assessment - immediate post natal period - Review Conference and decision to step down to Children in Need - delivery of the Discharge Plan and Children in Need plan 1.6 The review also gives consideration to: - management oversight and accountability - policy and procedures - domestic abuse - overarching safeguarding issues - the role and involvement of the fathers - voice of the child 2. Methodology 2.1 All agencies to whom one or more children and their family were known have participated in the review. Agency submissions were provided by: Lincolnshire County Council GP’s United Lincolnshire Hospital Trusts (ULHT) Lincolnshire Community Health Services NHS Trust (LCHS) Addaction National Probation Service (NPS) Schools 2.2 All agencies provided a chronology of involvement during the scoping period of the review along with a precis of knowledge/involvement at the time of transfer conference. They also provided an analysis of their involvement during the scoping period of October 2015 to Matthew's hospital admission on 22/11/16 using an agreed template addressing the key factors identified in para.1.5. 2.3 Summary reports were also provided by East Midlands Ambulance Service (EMAS), North Lincs and Goole (Scunthorpe) A&E, and Lincolnshire Police. 2.4 Each agency has identified relevant actions taken as a result of examining this case and the action plans can be found in Appendix 1. 2.5 The childrens fathers have been written to twice and mothers' sister, all were invited to participate in the SCR. Mothers' sister met with the Independent Author and was able to make valuable contributions to this review which have been incorporated into this report. There was an inquest into mothers death on 11th April 2018 and the coroner conclusion was open verdict. 3.Parallel processes and Investigations 3.1 Determination for completion of this SCR has been mindful of other processes. 5 3.2 Lincolnshire Police conducted an investigation following the injury to Matthew. While medical opinion is clear that the injury was as a result of significant trauma there was no forensic evidence or witnesses to assist the investigation. A decision was made that there was unlikely to be a realistic prospect of securing a conviction against any of the potential suspects and did not meet the threshold for submission to the Crown Prosecution Service. A decision to not proceed was made within the Force and the investigation closed. 3.3 The details of mother's death were notified to the Lincolnshire Police Professional Standards Unit and the Independent Police Complaints Commission under the category of ‘death or serious injury of a person after police contact’. The case has been finalised with no further action. 4. Narrative Summary 4.1 The childrens mother has been known to social care since 1997 when 17 years old, homeless and expecting her first child. It is known that she was already using heroin at that time. Her first child was born in September 1997 with her second in November 1998. There were concerns about drug use, lifestyle and offending behavior including a short prison sentence for theft in 2001. Both children were subject to CP plans under the category of neglect and by 2002 were living with their respective fathers. 4.2 In 2004 she was in a relationship with father of Andrew who had a child (with one of mothers' sisters) who was in care and subsequently placed for adoption. During this year and again in 2006 concerns were also raised with social care about the safety of the mothers' two children during contact due to the drug and alcohol use of both mother and father of Andrew. 4.3 The midwife made a referral to social care when mother was pregnant with her third child, Catherine, due to concerns the history of drug use by mother and father of Andrew. Whilst there is evidence of an assessment the case was closed. A further referral was made in 2008 by a drug agency concerned about standards of parenting by both mother and father of Andrew. Catherine was known to have been taken to A and E on 5 occasions with bumps and bruises believed to be as a result of poor parental supervision. Again there was an assessment and the case was closed by the end of December 2008. 4.4 The next contact was in 2010 when a midwife raised concerns about mothers heroin use and she was pregnant with her fourth child. At the time it was believed that mother was engaging with services and it was initially agreed that the case could be managed by Team Around the Child (TAC) rather than being open to Social Care, however following additional concerns with respect to mothers heroin use a Core Assessment was started in respect of Catherine and the unborn baby. Andrew was born on 7/8/10, remaining in the neo-natal unit until 23/9/10 as showing symptoms of drug withdrawal. The case remained open as Children in Need under s17 of the Children Act until 9/6/11 by which time mother was believed to have reduced her drug use and ended her relationship with father of Andrew. 4.5 In July 2011 father of Andrew told a worker at Lincoln Prison that the mother of his children injects heroin and that a male, later confirmed to be her brother, was visiting the house. The case was again closed after an initial assessment. Further concerns were raised in August 2011 when the police attended an incident of violence between father of 6 Andrew and mother. Two days later Addaction called social care to advise that mother had missed her last two appointments and that they had been informed that she had recently taken an overdose and tried to cut her wrists. Again an initial assessment was completed that resulted in the case being closed less than a month later. A further Initial Assessment was carried out in August 2012 after an anonymous referral via the RSPCA and evidence of drug paraphernalia found in the house. Again the case was closed within a few weeks. 4.6 It is believed that the family, at that time consisting of mother, father of Andrew, Catherine and Andrew, moved outside of Lincolnshire in 2013. The children were made subject to CP plans due to concerns about parental drug use and domestic abuse in July 2014. 4.7 The period in scope for this SCR starts when the family became known to Lincolnshire again after mother presented herself to a Social Care office in September 2015 advising that she had left father of Andrew and her property outside of Lincolnshire to stay with her family in Lincolnshire. This was followed by a notification from outside of Lincolnshire that the family had moved and that the children were subject to CP plans. A transferring in ICPC was held on 9/10/15 by which time mother was known to be in a relationship with her cousin, father of Matthew and Sarah. The decision was made that Catherine and Andrew should remain on CP plans under the category of Neglect. In November 2015 mothers oldest daughter, who was 17years old at the time, accused her of physical assault and Catherine and Andrew, who had been present, were placed with family friends while the police investigated the allegation. Mother, who at this point was known to be 12 weeks pregnant with the twins, was released without charge. By December 2015, mother and children had moved to a different Lincolnshire town and she had informed Addaction that she had been injecting heroin for the previous 3 weeks and was pregnant. In January 2016, mother made an allegation that she had been abused as a child by her stepfather who continued to provide support for her by caring for the children including assisting in transporting the older two to school. 4.8 During the pregnancy mother was informed that there was a high probability that one of the twins (Matthew) would be born with significant disabilities resulting in mother facing a real challenge about whether to terminate the one twin. The prognosis improved and mother made the decision to continue with the pregnancy for both twins. An ICPC was held in respect of the unborn twins on 5th May 2016 where the decision was made to make them subject to CP plans under the category of Neglect at birth. 4.9 The twins were born prematurely on 31st May 2016 and were diagnosed as having Neo Natal Abstinence Syndrome, described as a group of problems that occur in a newborn exposed to addictive opiates while in the womb. They received appropriate treatment, including use of morphine. Mother had discharged herself from hospital the day after the birth and continued to visit the twins on the ward. During this period the first Review CP Conference on 24th June 2016 made the decision to remove all four childrens names from CP plans and step down to Children in Need. 4.10 On 11th July 2016 the twins were discharged to the family home to live with mother and their two siblings. The discharge plan outlined the required pattern of visiting by agencies including an Early Help worker to support mother in the home and with practical tasks. Mother's brother and her adult son were regarded as playing a significant role in supporting mother in caring for 4 children. In August the family were found to have 7 temporarily left their home due to problems with drug dealers in the area. Mother and the twins stayed with one of her sisters while Catherine and Andrew stayed with father of Andrew at his father's house. In September 2016, and again in October 2016, concerns were raised when mother left the twins in the care of others who were regarded by agencies as unsuitable carers. It also became known in October 2016 that mother was again using heroin and had been taken to hospital on one occasion with an infected injection site in her groin. She was accompanied to the minor injuries unit by her stepfather, and it is unknown who was caring for the children. She subsequently visited the hospital on advice. Around the same time, mothers' brother and her adult daughter raised concerns about her drug use and shared information about one of the twins falling from her knee while she was injecting. The descriptions of mothers' wound fitted with that seen by the health professionals. 4.11 On 22nd November 2016 Matthew was taken to hospital with a wound to his head. It is known that 5 people had or potentially had care of him in the previous 24 hours. The other children were removed following medical opinion that the injury was a Non Accidental Injury. Subsequently, following Matthew discharge from hospital, he joined his 3 siblings who have remained in the care of a family member. 5.The Experience of the Children 5.1 Catherine, Andrew, Matthew and Sarah are the younger children of mother with their two older siblings living with their respective fathers from a young age. The nature of the relationship between these four and the older siblings, particularly relevant for Catherine and Andrew, is unclear although it is known that there was contact as the daughter raised concerns about her mother's drug use and the son was included as part of the support package for mother when the twins were discharged from hospital. 5.2 The four children remained in the care of mother until November 2016. It would appear that father of Andrew lived with Catherine and Andrew for the majority of their life until mother and the children returned to live in Lincolnshire in 2015. It is clear that father of Andrew remained a significant part of their lives, even after it emerged that he wasn’t the father of Catherine, for instance they stayed with him when the family had to temporarily move out of their house due to problems with neighbours. The nature of any relationship or contact between Catherine and her father, father of Catherine, is unclear. The relationship between mother and the twins father, father of Matthew and Sarah, had ended before their birth. It is unclear as to whether he ever lived in the same house as mother, Catherine and Andrew. 5.3 Catherine and Andrew are described very positively by their teachers who have known them since February 2016. Both children have been clearly effected by the death of their mother though are making good progress socially and academically. 5.4 Whilst it is hard to know what life at home really looked like for these children, it is known that during the time within the scope of this SCR they experienced significant change both in terms of where they lived and who was living with them. They changed school and had a significant periods of time out of school due to mother moving house. It is known that they had been exposed to domestic abuse and had lived with adults, including their mother, with problematic drug use. There is information to suggest that they had seen their mother injecting. 8 5.5 Matthew and Sarah spent the first 6 weeks of their lives in the neonatal unit where it was clear that they were suffering from the effects of mother's drug use while pregnant. During the four months they lived with their mother there were at least 2 occasions when they were left with unsuitable carers and significant evidence that mother was injecting heroin. It is unclear who was in the home throughout this period of time. 5.6 There is much information to suggest that mother loved her children and intended to provide a warm, caring environment for the four children subject to this review. Although unable to care for her two older children she had clearly managed to maintain contact and establish a relationship with them both. However, she had a long history of drug and alcohol abuse and had a history of self harm. She had experience of life in a large family with complicated networks of relationships and, as an adult, disclosed childhood sexual abuse by her stepfather who she continued to be dependent on for support. Mother had experienced a number of abusive relationships, including physical assaults, with a number of those significant to her being involved in drugs and/or criminality. Mother herself had a long criminal record, with her first recorded offence at the age of 15 years, including offences against the person and property. From 2000 until her death her pattern of offending included thefts, fraud and breaches of police and court orders all clearly linked to the need to provide herself with drugs. 5.7 All three of the fathers of the children have a history of criminal behaviour and drug use, although only father of Andrew appearing to have played a significant role in their lives. father of Matthew and Sarah is in prison at the time of this review. Mother's brother, and his partner, were also part of the childrens lives including the provision of support and care, during the scoping period of this review. Both have a history of drug abuse with mother's brother having a significant criminal record which included violent offences. 5.8 Information available to this review indicates that mother, along with other adults who at times had responsibility for the care of Catherine, Andrew, Matthew and Sarah, found it difficult and at times impossible to prioritise the needs of the children. 6. Analysis 6.1 This section of the report seeks to analyse the evidence gathered to address each of the key factors identified in the ToR and is therefore structured accordingly. 6.2 October 2015 and transfer to Lincolnshire 6.2.1 Childrens Social Care had initially been informed that the family had returned to Lincolnshire when mother visited the social work area office. At the time she was staying with family and was seeking help to find accommodation and settle in the county. This was followed by an appropriate notification from another Local Authority Social Care that children subject to CP plans had moved into the area. A transfer in conference was arranged within the required timescales where the decision made was that Catherine and Andrew would remain subject to CP plans and that this would be under the category of Neglect. All of this activity was in accordance with Child Protection Procedures. 9 6.2.2 The report presented to the conference from another Local Authority Social Care indicated that there had been little progress in the case since the children were made subject to CP plans and that consideration was given to progressing to Public Law Outline before the family decided to move. There was however some incongruity between the report and information shared by the presenting Social Worker who had only known the case for 2 weeks and attention appeared to be focused on how well mother was doing and that she had left a violent relationship. There is no evidence that this was challenged within the meeting. Neither mother or father of Andrew were at the meeting and there is little evidence of curiosity about the causation, circumstances or timing of the ending of their relationship. There was a decision that contact between father of Andrew and the children should be supervised until an assessment of him had been completed although it is not clear how this was to be arranged with the responsibility for supervising contact left with mother. There is no evidence of consideration of the impact on the children of this assessment or the move to Lincolnshire. It was subsequently discovered that mother would have already been pregnant with the twins as a result of a relationship with her cousin. 6.2.3 Although mother did not attend the conference there is evidence of professionals contact with her prior to the meeting. There is no evidence that professionals sought the views of father of Andrew who the children had lived with all their life and who, it is now clear, continues to play a significant role in their lives. It is important for professionals to retain an open minded curiosity when conducting assessments and they should include fathers even where there is a concern that they are perpetrators of Domestic Abuse. 6.3 Move to Lincolnshire Town 6.3.1 By November 2015 mother had found a property in a Lincolnshire Town and was planning to move there with Catherine and Andrew. By this time the children had moved home 3 times in 3 years. They were not enrolled in a local school until late December 2015. In the same month mother referred herself to Addaction and informed them that she had been injecting heroin for the previous 3 weeks. There is no clear picture of who was living in the house with mother during this period. At times she indicated she was again in a relationship with father of Matthew and Sarah and he would be moving in. She had also informed workers that she had resumed her relationship with father of Andrew. There is no real clarity regarding her relationships during this period. 6.3.2 There is evidence that Core Groups met within procedural expectations and that required CP visits did happen. Information was appropriately transferred between health professionals when the family moved towns and there is evidence of managerial oversight and in particular, case supervision in Childrens Social Care. A significant outcome of the move was that two children already subject to CP plans were out of school for a number of weeks with their educational needs not being met and the opportunity to monitor their safety on a daily basis also missed. There were already indicators that mother was struggling to put her childrens needs first e.g. knowledge that she was injecting heroin. 6.3.3 Even more concerning is an incident in November 2015, when mother, who was drunk at the time, was alleged to have physically assaulted her 17 year old daughter. Whilst the alleged crime was investigated by the police and a notification of a domestic abuse incident was sent to social care there is no evidence that consideration, either by police or social care, was given to fulfilling the requirements of s47 of The Children Act i.e. 10 to make enquiries where there are concerns that a child under 18 years may be experiencing abuse or neglect. There were a number of children in the household at the time including two who were already subject to CP plans. It is also unclear as to whether consideration was given to the sufficiency of these CP plans, in light of this insight into mothers alcohol use following this incident, and resulting behaviour. 6.4 Agency understanding and impact of mothers problematic drug use on her parenting ability 6.4.1 Mother's history of drug use since at least 17 years old was well known to all agencies. However, there continued to be an optimistic view by some professionals at the times mother stated her intention to stop and on the basis of her achieving short periods of apparent abstinence. This positive view by professionals significantly impacted on decisions and planning for the children. Whilst she sought help including self- referral to Addaction following her move to a different Lincolnshire town, it should be noted that she failed to engage with work to support sustainable change. She attended only 50% of Break the Cycle sessions, 1 of 5 psychosocial counselling sessions and failed to keep any outreach appointments compared to attending 22 of 23 appointments for drug testing. Many of the significant people in her life also continued to use drugs and therefore it is hard to see where she would find the necessary support to put her intent into action. 6.4.2 There is no doubt that mother stated her intent to act in the best interests of her children and did in the main continue to meet their basic needs. However, her need for drugs and the lifestyle that was associated with their acquisition continued to get in the way of her meeting her children’s needs e.g. 3 house moves plus temporary stays in 3 years, 3 partners (including one whose identity appears not to be known to agencies though for a short time she stated her intent to move to another Lincolnshire town with him), children not being enrolled at school for an unacceptable period of time. There is evidence that at times it placed the children at risk of harm e.g known violence sometimes from partners but on at least one occasion by mother, leaving the twins with unsuitable carers, one twin falling off her knee while she was injecting. 6.4.3 On the basis of information available to this review it appears that mothers periods of ‘being clean’ were ‘blips’ rather than evidence of sustainable change. Apart from the opportunity to engage in sessions with Addaction there is little evidence of support for mother to remain drug free or to recognise the impact of stress, e.g worries about one twin being born with significant health needs, being in a position of choosing whether to abort one of the twins, caring for four children etc, or her ability to do so. 6.4.4 Mother was described as likable and it is clear that she was able to engage with staff. It is admirable that workers were able to establish a relationship with her and wanted her to do well, however, it is suggested that this resulted in an overly optimistic view of her ability to change and to prioritise the needs of her children. Consideration should have been given as to the real level of mother's ability and/ or willingness to engage with professionals and the plans in a meaningful way. It is suggested that mother was complying with plans when she was able but that there is little evidence of engagement in interventions which were aimed at achieving change in her drug and alcohol use and, therefore, the level of care and protection afforded to her children. 11 6.5 Pre birth assessments 6.5.1 A Protective Carers and pre Birth Assessment was commenced by childrens Social Care although mother did not attend all of the planned sessions. This appears to have been mainly concerned about her ability to care for a child with disabilities in light of the concerns at the time about one of the twins. Whilst there is no question that this was a difficult situation it is suggested that this and the resulting sympathy for mother distracted the attention from the wider concerns about her ability to care for, let alone, protect 4 children. There is little evidence of focus on the risks and yet by that time Catherine and Andrew had been subject to CP plans for almost two years with very little evidence of change in their circumstances, apart from their address, since being identified as at risk in 2014. 6.5.2 During this period mother had made the disclosure of child sexual abuse by her stepfather resulting in her being asked to sign a written agreement not to allow Catherine and Andrew to have unsupervised contact with him until a risk assessment was completed. There is no evidence of consideration of the impact of the abuse on her emotional and psychological wellbeing or her ability to protect herself and her children from her abuser. Furthermore, she continued to depend on him to support her in transporting the children to school. There is no evidence that a risk assessment in respect of her stepfather was ever completed. 6.5.3 There is no evidence that the pre- birth assessment included any consideration as to the risks that other adults may present for example father of Andrew and mothers brother. 6.5.4 The proposal to arrange a Family Group Conference as part of clarifying and establishing support for mother was positive, however mother did not attend appointments and the referral was closed. There always seemed to be a good reason for none attendance with no evidence of appropriate challenge by workers. It is suggested that this is an example of disguised compliance and potentially of avoidant behaviour. 6.5.5 Mother attended the ICPC on 5th May 2016 with her brother mother's brother and it was well attended by relevant professionals. The discussions appear to have focused on the medical issues relating to the unborn twins and the difficult decisions that mother had faced. It is noted that the chair of the conference stated to mother that “the issues around her seem to be shrinking and professionals are so proud of you for it” although little evidence was provided to support this perceived progress. It is suggested that this over optimistic view and lack of focus on the actual risks led to what was initially a split decision as to whether the twins should be made subject to a CP plan. Any doubt as to the need for CP plans is hard to understand given the circumstances already set out in paragraph 6.5.1 6.6 Immediate post natal period 6.6.1 The twins were born at Queens Medical Centre on 31st May 2016 and transferred to Lincoln County Hospital on 2nd June 2016. There is no evidence of exploration with mother of why she discharged herself from hospital on 1st June 2016 although staff at the QMC did inform ULHT of her discharge and her need for a Community Midwife. 6.6.2 It was good practice for the nursing staff to arrange a pre discharge meeting in respect of the twins which took place on 13th June 2016 although it is suggested that 12 meeting could have also served as a Core Group meeting which would have provided a focus on the potential risks as well as the health needs of the twins. The twins remained on oral morphine and it was noted that mother was not staying overnight. Two days later the Consultant Paediatrician expressed concern about twin’s additional needs and questions the adequacy of the discharge plan. There is some evidence of concerns about mother's behaviour on the ward but no real evidence of appropriate challenge or recognition of this as part of the ongoing assessment. Further discharge meetings take place on 17th and 21st June 2016 where the frequency of visiting post discharge were increased to address the concerns about the level of care the twins would need. A decision had already been made within social care to provide Early Help support as soon as the twins were discharged. 6.6.3 There is evidence of managerial oversight and case supervision however there is no evidence of appropriate challenge of the social worker’s view that the threshold of significant harm was no longer met. It is difficult to see how this position could be reached when the parenting assessment had not yet been completed, risk assessments in respect of significant other adults remained outstanding and the ability of mother to care for four children had not yet been tested, particularly in light of the Paediatrician's concerns about the additional needs of the twins. 6.7. Review Conference 6.7.1The Review conference held on 24th June 2016 was the first in respect of the twins and third for Catherine and Andrew since the transfer in conference. Mother attended the conference and was supported her brother, mother's brother and her 19 year old son. Father of Andrew was not at the conference. The meeting was also well attended by those agencies who would have ongoing involvement but it is of concern that there was no representative from the neo natal team in light of the level of the concerns expressed to the social worker prior to the conference. 6.7.2 The Social workers report to conference appropriately outlined the difficulties the twins had faced since birth as a result of Neo Natal Abstinence Syndrome and yet the safety goal was for them to continue to make progress rather than address the issues that had caused them to be in that situation. The report also recognised the pressures that mother would face in caring for two babies but indicated that support would be provided through the Discharge Plan and recommended that the CP plans be removed and that all 4 children are stepped down to Children in Need. Minutes of the meeting indicate that the discussions focused on how well mother had engaged with agencies and the evidence of some negative drugs tests. The concerns of the Paediatrician and ward staff which were expressed to the social worker do not appear to have been acknowledged or discussed. 6.7.3 Mother's brother was accepted as suitable to provide support based on a belief that he had stopped using drugs. There is no evidence of discussion about his history of violence or previous decisions about his own child. 6.7.4 It appears that the focus of the meeting was on mother's support needs and not on whether the risks to all 4 children had been reduced or their vulnerabilities. There is no evidence of consideration of the impact of the twins return home, and resulting demands on mother, or the safety and well- being of Catherine and Andrew. 13 6.7.5 The decision of the conference appears to have been solely based on the use of the Scaling Tool with all but one participant scaling the risks to the twins as low. It can only be assumed that this was based on an over optimisitic view of mothers ability and on the twins at that moment in time which was safe on the neo natal unit. Mother's capacity to care for all four children and the efficacy of the support identified should have been tested before removal of CP plans was considered. 6.7.6 It is therefore suggested that the evidence available at the meeting did not support the decision to remove the CP plans and step down to CinN at that stage. 6.8. Delivery of the Discharge Plan and Children in Need Plan. 6.8.1There were indicators that the plan may not be sufficiently robust prior to discharge with concerns about mothers lack of contact with the twins and her behaviour when she did visit the hospital. There is no evidence of questioning whether she was using drugs or challenging her behaviour. It is suggested that the plan should have been reviewed prior the twins being discharged on 11th July 2016. 6.8.2 There appeared to be lack of clarity about which discharge plan was being followed and it is of concern that the twins went home without social care being informed before the day of discharge. There is evidence of good practice by the Early Help worker who made a visit within the hour when informed by mother that the twins were home. Appropriate practical and material support was provided by the Early Help worker. There is evidence that the Discharge Plan, which was part of the Children in Need Plan, was not implemented and home visits by agencies did not happen in accordance with the plan leaving the twins unseen by professionals for a number of days. The plan was also heavily dependent on support from mother's brother and her son, neither of which materialised. Mother's sister described how mother would telephone her describing how tired she felt and believes that mother needed more support than she received. 6.8.3 Subsequently, there were a series of events between July and November that indicated that plan was not effective: Mother had left the twins with a neighbour. The Early Help worker was concerned that the neighbour smelled of alcohol and disclosed that she did not have care of her own children. Mother presented at the hospital with Matthew who she could not stop crying. She left before he could be seen. It is of concern that Childrens Social Care were not informed. Mother and twins were found at her sisters. She explained that she had gone there to get away from trouble in the street thought to be linked with drug dealers. Mother disclosed that she was using her sister’s methadone which she was topping up with street heroin. Catherine and Andrew were found to be staying with father of Andrew and his father. Mother was talking about moving to another Lincolnshire town with a new partner It was known that the twins were left with neighbours. Mother presented at the minor injuries unit with an infected wound in her groin. She was accompanied by her stepfather who was present throughout the investigation Further concerns about the twins being left with carers whose own children are on CP plans Sarah was in hospital with a viral infection 14 Information is passed to Social Care that mothers adult daughter has voiced concern about the safety of the children as a result of mother injecting drugs. Mother informs the Early Help worker that she is having difficulty walking Mother's brother informs social care that he saw one of the twins roll off her knee while she was injecting heroin 6.8.4 It is suggested that the information in respect of the twins being left with unsuitable carers on at least 3 occasions and one of the twins falling while mother was injecting met the criteria for enquiries to be made under s47 of The Children Act. There is no evidence that this was considered or that the totality of this information was addressed in management supervision or the Children in Need meetings held on 21st July and 17th November. 6.8.5 The Children in Need meeting on 17th November was attended by mother, Catherine, Andrew, social worker and professionals working with the older children. Despite mother talking about her infected wound and drug use while at her sisters the meeting appeared to view this as a blip and minutes indicate that consideration would be given to step down to TAC if both mother and father of Andrew continued to be drug free. It was also noted Catherine and Andrew enjoyed visiting father of Andrew and sometimes stayed overnight. It is of concern that the risk assessment in respect father of Andrew, identified as necessary at the transfer in conference, had not been completed and it is unclear when the position changed about the need for contact to be supervised. 6.8.6 On 22nd November 2016 Matthew was taken by his mother to the A&E department at Scunthorpe General Hospital and later transferred to Sheffield Children’s hospital. Information shared by mother with the hospital staff indicated that her brother, his partner and a neighbour had also had care of Matthew during that day. 7. Changes in Practice and Actions 7.1 Section 2 of this report sets out how agencies have examined their own practice as part of this Serious Case Review. Appendix 1 provides a table of actions identified and changes made as a result of this activity. 8. Summary and Conclusions 8.1 It is clear that Catherine, Andrew, Matthew and Sarah had experienced living in a family where there was a significant amount of problematic drug use, offending behaviour and on occasions violence. The potential impact of this had been recognised when Catherine and Andrew were made subject to CP plans in another county in 2014, and subsequently continued when they moved to Lincolnshire. Matthew and Sarah were made subject to CP plans at birth. 8.2 There is evidence that mother, who was believed to be their sole carer throughout the time within scope of this review, was committed to caring for her children and intended to do her best. It appears that for the majority of the time she was able to provide for their basic needs with no concerns about their appearance or the behaviour of the older children. However, she had a history of problematic drug use that had led to her first two children being brought up by their respective fathers, and which continued to get in the way of her being able to afford the level and consistency of care that these four children 15 needed. She also had a complicated set of relationships with partners and some family members who themselves had problematic drug use and/or offending behaviour. Information gathered through consultation with the family supports this conclusion. 8.3 It appears that professionals did not have an understanding of the family history, relationships and functioning and, as a consequence, there was no clear picture about what daily life was like for these children. 8.4 Although outside of the scoping period for this review it remains hard to understand why assessments concerning Catherine and Andrew had not resulted in more robust action prior to their move to outside of the Local Authority. 8.5 There was an opportunity to manage the case more effectively on the family’s return to Lincolnshire. However, it is of concern that significant decisions were made without key assessments being completed, including the pre- birth parenting assessment and risk assessments of father of Andrew and mother’s stepfather. It is suggested that the removal of the CP plans prior to the twins being discharged from hospital was not evidence based. 8.6 It is evident that the Discharge plan and Children in Need plan were not implemented and there were a number of incidents between the decision to remove the CP plans and the injury to Matthew that should have prompted a review of the plans and, on some occasions, enquiries being made under s 47 of The Children Act. There is no evidence that the professional resolution and escalation procedure was used by any agency. 8.7 In conclusion, the information available to this review suggests that there were missed opportunities to intervene which may have impacted on the level of care afforded to these children and which may have prevented the injury to Matthew. 8.8 It should be noted that all four children are now doing well and Matthew has recovered from his injury. 9. Recommendations 9.1 It is recommended that the LSCB: seeks assurance that the model used in assessing risk within conferences is being used effectively and in particular that: o the Scaling tool is used as part of a wider assessment of perceived future risks. o ‘Danger statements’ and ‘safety goals’ are translated into effective plans that seek to both effect necessary change to protect children and to monitor their safety and well -being. Seeks assurance in the practice of Independent Child Protection Chairs and their management of conferences. consider establishing a practice by which CP plans should not be removed at the first review unless there are evidenced circumstances seeks assurance that the professional resolution and escalation procedure is understood and effectively applied in all partner organisations. 16 Assures itself that the actions and recommendations in section 7 and Appendix 1 are completed. Produces a practice learning brief for circulation to all partners. |
NC52689 | Death of an infant in 2020 while in a mother and baby unit of a psychiatric hospital. The mother admitted she had caused Baby RD's injuries and was subsequently charged, convicted, and sentenced. Learning themes include: the potential impact of a parent's significant mental ill-health on their children and in particular the challenge of assessing risk when the illness is of a cyclical nature; the role of early help for vulnerable parents, making a referral and planning an intervention; the benefits of the "think family" message; the response to emergency situations, for example suicidal behaviour or attempts to harm a child when the adult concerned is a parent. Recommendations for the Partnership include: consider how best to promote and embed the "think family" agenda and seek information from each agency about how they evaluate the effectiveness of the initiative; seek assurance that all agencies, including adult services, are fully engaged with the use of early help assessment; engage in discussion with commissioners of service about developing and strengthening the team working on the mother and baby unit in order to ensure a multi-disciplinary approach to risk assessment and that the voice of the child is not lost in the midst of a parent's mental health crisis and medical treatment; seek assurance from the local Healthcare Trust that an effective protocol is in place which addresses the response to a medical emergency and that all staff are familiar with the content and its application within their working environment.
| Title: Child safeguarding practice review: Baby RD. LSCB: Derby and Derbyshire Safeguarding Children Partnership Author: Karen Tudor Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD SAFEGUARDING PRACTICE REVIEW BABY RD INDEPENDENT REVIEWER Karen Tudor FINAL 15/11/22 FINAL 15/11/22 2 CONTENTS Introduction Significant Events Key Lines of Inquiry Analysis and Learning Pregnancy and Birth Think Family Early help and Multi Agency Intervention Risk Assessment – The Voice of the Child Parental Responsibility Assessing Parenting Capacity Response to Emergency Situations Impact of Covid 19 Conclusions Summary of Learning Recommendations Page number 3 4 5 5 5 8 9 11 12 12 12 13 13 14 15 16 FINAL 15/11/22 3 INTRODUCTION 1. In the Summer of 2020, the police received a call that a woman was missing from home. She had recently given birth to a baby, known to this review known as Baby RD. 2. Baby RD’s mother was known to have a history of mental ill-health and some years earlier had been diagnosed with bipolar affected disorder1. Both her children had been safely left with a relative and the family were very concerned for her safety 3. To protect identity, the mother is known as Ms RDS and the child’s father as Mr RDS. The older child in the family is known as O-RD. 4. A few hours after the call, the police located Ms RDS in a precarious public place, she told the officers she was feeling suicidal. 5. Having made some enquiries, the police officers took Ms RDS to a local psychiatric hospital where she had been treated before. Ms RDS was admitted as a voluntary patient, the hospital has a mother and baby unit (MBU) and a few days later Ms RDS’ baby was admitted to be with her. The older child remained at home with their father, Mr RD. 6. The MBU knew Ms RDS, Baby RD and the family from previous admissions and were observant as she settled into the daily routine and was receiving treatment. Within the context of her diagnosis, nothing particularly unusual or unexpected was noted in her demeanour. 7. Two weeks after the admission, Ms RDS was discovered holding Baby RD who was unresponsive; an ambulance was called but sadly, Baby RD died. 8. Ms RDS admitted she had caused Baby RD’s injuries and was subsequently charged, convicted, and sentenced. 9. When these events were reported to the Safeguarding Children Partnership, a Rapid Review 2 was instigated and the outcome was to commission a Child Safeguarding Practice Review. (CSPR) 1 Bipolar Affected Disorder, this is a mental illness characterised by episodes of disturbed mood which may be of depression or elation and which can vary in duration. Episodes of depression are usually more common. There can be long periods of stability of mood between episodes. 2 Rapid Review and CSPR FINAL 15/11/22 4 SUMMARY OF SIGNIFICANT EVENTS As a teenager Ms RDS was diagnosed with bipolar affective disorder. 2018 Ms RDS older child (O-RD) was born, and Ms RDS was admitted to the MBU with post-natal psychosis.3 2019 Ms RDS was pregnant with Baby RD. A referral was made by her GP to the peri-natal mental health team. Ms RDS’s medication and well-being were monitored and the pregnancy continued without incident. 2020 Baby RD was born, delivery was normal and the baby was healthy. Ms RDS spent 2 weeks in the MBU as a precautionary measure. This was a planned admission and was uneventful. Two weeks after discharge Ms RDS’ symptoms worsened and she was re-admitted with Baby RD. They remained in the MBU for 7 weeks. At the same time… Covid 19 During Ms RDS’ stay, the COVID 19 pandemic led to severe restrictions. Six weeks after discharge Ms RDS self-reported her mental health was deteriorating and asked for an urgent appointment with the psychiatric consultant. A video call was arranged. 10 days after the consultation Ms RDS was missing from home and suicidal. The police found her and facilitated admission to the MBU. Two weeks after admission Baby RD was found unresponsive and died. 3 Post-natal psychosis also known as postpartum psychosis, or puerperal psychosis, it is a rare but serious and potentially life-threatening mental health issue. It takes the form of severe depression or mania or both. FINAL 15/11/22 5 KEY LINES OF INQUIRY 10. The Rapid Review gathered detailed information about the events and professional interventions with the family, from the notification of Ms RDS’ second pregnancy to the date of Baby RD’s death, a period of 12 months. 11. The relevant family history, particularly Ms RDS’ diagnosis and depression when her first child was born, was also considered. 12. A complaint had been made by Ms RDS’ family about the standard of care during her first pregnancy. The subsequent investigation found serious failures and the NHS Foundation Trust issued an apology to the family. The outcome of this complaint was also considered as part of this review, in particular by exploring the standard of care during Ms RDS’ second pregnancy with Baby RD. 13. From the Rapid Review the following lines of inquiry were identified as providing opportunities for learning: The potential impact of a parent’s significant mental ill-health on their children and in particular the challenge of assessing risk when the illness is of a cyclical nature The role of Early Help for vulnerable parents, making a referral and planning intervention The response to emergency situations, for example suicidal behaviour or attempts to harm a child when the adult concerned is a parent, how embedded is the “think family” message Learning from the response to the Covid 19 pandemic 14. The findings from the Review are for some, new learning, and for others may stimulate thinking and be reminders of good practice. 15. A comprehensive review has also been carried out by Derbyshire Healthcare NHS Foundation Trust (DHCFT). The report is not published but has been seen by the Safeguarding Children Partnership, the findings are consistent with those of this review.4 ANALYSIS AND LEARNING Pregnancy and Birth 16. Ms RDS’ older child had been born about 3 years before Baby RD’s death. The birth had been traumatic and Ms RDS’ family felt that the care she received throughout the 4 This report is not published but is available to members of Baby RD’s family and will form the basis of learning and any agreed policy changes within the DHCFT. FINAL 15/11/22 6 pregnancy had had been inadequate. They made a complaint which was investigated by the NHS Foundation Trust which provides midwifery and obstetric care. 17. The findings indicated that Ms RDS had not been referred (by the midwife) to the peri-natal mental health service, despite her significant mental health history. The investigation concluded that this was a significant omission which impacted on subsequent experience as she became unwell post-natally after the birth of O-RD. 18. Ten days after giving birth to O-RD, Ms RDS had been admitted to the MBU with post-natal psychosis, she received appropriate treatment and recovered. The adult mental health service and the peri-natal consultant reviewed Ms RDS’ progress a year after she had given birth and reported that her mental health was stable. 19. When she became pregnant again, Ms RDS contacted her GP early in the pregnancy and the GP, who was aware of Ms RDS’ history, made an urgent referral to the peri-natal mental health service. This led to immediate and appropriate intervention from the peri-natal team. 20. Midwifery records are specific to each pregnancy and are not transferred or carried forward, and the midwife was dependent on Ms RDS to share details of her previous pregnancy. Reports suggest that Ms RDS had good insight into her mental health and was generally open with professionals about her medical history, although they also suggest she was not always forthcoming about how she felt on any particular day, tending to minimise any difficulties. 21. During this pregnancy, Ms RDS’ health was carefully monitored by the peri-natal service, her medication was kept under review, nothing of significance was noted. This was a very different response from that to Ms RDS’ first pregnancy and Ms RDS’ family report that they felt the standard of care was good. 22. There were no indications of a need for a pre-birth assessment as Ms RDS had engaged well with the services, had good family support and there were no safeguarding concerns. 23. Baby RD was born just as the Covid pandemic hit the UK and lockdown restrictions were imposed. Ms RDS and Baby RD were admitted to the MBU as a precautionary measure because of Ms RDS’ diagnosis, previous history of post-partum psychosis and the high chance of relapse.5 Health Visiting 5 We know from research that about 50% of women with bipolar are likely to have some sort of episode during pregnancy or postnatally. 20-25% of women with bipolar will experience postpartum psychosis (PP), which is more severe and requires emergency treatment usually a stay in hospital. Bipolar and pregnancy: decision, decisions... | Bipolar UK FINAL 15/11/22 7 24. Health Visiting would normally carry out an ante-natal visit but this didn’t happen because of an administrative error by midwifery, which incorrectly recorded Baby RD’s due date. It was after the birth that a Health Visitor was allocated and the new birth visit was undertaken when Baby RD was two weeks old. 25. Although there is evidence of discussion, Health Visiting did not utilise any of the tools designed to assess a new mother’s mental health because Ms RDS was already receiving care from the specialist in-patient unit. 26. Both children were under the care of the Health Visitor with O-RD continuing to be offered the universal Health Visiting service. Baby RD was assessed and offered a targeted service which was Universal Plus, this acknowledges that the further support, assessment of need and intervention is required. On reflection the service has suggested that considering the family as a whole, a more targeted approach, Universal Partnership Plus Health Visiting6 would have been more appropriate. 27. Two weeks after returning home, Ms RDS was re-admitted to the MBU with Baby RD and spent seven weeks receiving treatment. Ms RDS reported that she particularly struggled with her mental health when she was sleep deprived and reports suggest that she struggled to care for the new baby and the older child, who was still a toddler. It is not uncommon for patients on the ward to go home during the day and return to the MBU at night and this was the plan for Ms RDS. 28. Health Visiting were kept informed by the MBU and visited again when Baby RD was 12 weeks old. By this time the Covid restrictions had been imposed. 29. Discussion with the practitioners indicate that it is likely that the restrictions would have had a significantly negative impact on Ms RDS. Family support became limited and community resources had closed down. Ms RDS reported that she was unable to participate in many of her usual activities, she missed physical exercise and spending time with friends and other parents. 30. There is no record of a discussion between health visiting and Ms RDS about the change in circumstances or any indication of how this might be mitigated. Her recent discharge from the MBU and the safety plan if she were to experience further symptoms or suffer a relapse, were not discussed with the Health Visitor. 31. The discharge summary from the MBU noted that Ms RDS had good family support and was compliant with taking prescribed medication, showed insight into her illness, and had made good progress. 6 Universal Partnership Plus provides ongoing support from the health visiting team and a range of local services to deal with more complex issues over a period of time. These include services from Sure Start Children’s Centres, other community services including charities and, where appropriate, the Family Nurse Partnership The service will be available in convenient local settings, including Sure Start Children’s Centres, and health centres, as well as through home visits. FINAL 15/11/22 8 32. A few weeks after discharge Ms RDS was in contact with community health visiting through a telephone advice service, Single Point of Access (SPA), when she sought advice on feeding and weaning. During these calls she described finding lockdown difficult but said she felt well. 33. Eight weeks after her discharge Ms RDS told the MBU that her health was deteriorating and requested an urgent consultation with the psychiatrist. In the midst of the Covid restrictions, a video call was arranged and Ms RDS was prescribed additional medication, support from the peri-natal nurse would continue and a follow up would take place in two weeks. 34. Two weeks later Ms RDS was reported missing by her family and subsequently admitted to the MBU. Think Family 35. The Think Family agenda has been promoted consistently over the past few years, the Safeguarding Adults Board provides key reminders and states: “Think Family means securing better outcomes for adults, children and families by coordinating the support and delivery of services from all organisations. Neither adults or children exist in isolation and Think Family aims to promote the importance of a whole-family approach. Contact with any service offers an open door into a system of joined-up support and coordination between adult and children's services. Services working with both adults and children should take into account family circumstances and responsibilities.”7 36. The Safeguarding Children Partnership has “Think Family” embedded within multi-agency training materials and the local safeguarding children procedures. The Early 7 Think Family - Derbyshire Safeguarding Adults Board (derbyshiresab.org.uk) Learning • When a parent is admitted to hospital, it is important that practitioners working in the community are up to date with care and discharge planning. In-patient and community health services are equally valuable and effective communication is key to ensuring in-patient and community-based services work together to provide continuity of care. FINAL 15/11/22 9 Help guidance8 integrates “Think Family” principles consistently promoting awareness of the whole family approach such as the use of the “Team around the Family”. 37. Despite consistent efforts by all agencies to promote this message, a number of practitioners highlighted the lack of consideration of the principles of “Think Family” and the benefits of giving consideration to others in the family when a parent is unwell. The evidence indicated that the Think Family message is not yet fully embedded in practice. 38. This was particularly evident when the police took Ms RDS to the MBU in response to the incident when she had been missing from home. 39. The police are required to send a notification to other agencies, known as Public Protection Notices, PPNs. Their purpose is to alert relevant agencies of an incident and prompt a multi-agency risk assessment and response. It would have been expected that the police would have sent the PPN to Children’s Social Care to assess whether there was a need for their involvement. 40. A PPN was completed by the attending officer and recommended referral to “relevant agencies.” At the time the police report that an “informal agreement” was in place that if a parent was admitted to the MBU, the MBU would make a referral to Children’s Social Care. However, neither agency made a referral and an opportunity to share information and consider whether there was a role for Children’s Social Care, was lost. Early Help and Multi-Agency Intervention 41. Working Together to Safeguard Children 2018 (DfE, 2020b) states that 8 Guidance for completing a Family Early Help Assessment Learning • All agencies working with parents, especially at a time of crisis, need to be alert to “Think Family” and the benefits of multi-agency working. Staff must be clear about when and how to refer a family to Children’s Social Care and if more than one agency becomes involved with a family, practitioners must agree and confirm who will make the referral. FINAL 15/11/22 10 “Providing Early Help is more effective in promoting the welfare of children than reacting later. Early help means providing support as soon as a problem emerges, at any point in a child’s life”. 42. Whilst there is no legislative basis for Early Help, this guidance outlines duties for all partners in identifying, assessing and providing a comprehensive range of Early Help services as part of a continuum of support.”9 43. The Derbyshire County Council website describes the purpose, “Where they (the family) would benefit from co-ordinated support from more than one agency there should be an Early Help Assessment.”10 44. In this case, there was no Early Help assessment or referral to Children’s Services prior to Baby RD’s death; case records and conversations with practitioners and managers indicate that the work done with Ms RDS and her family was entirely led by Ms RDS’ medical needs. 45. This meant that opportunities for any form of multi-agency assessment of need was lost, access and referral to community support and resources was not considered and the benefit of a multi-agency risk assessment when Baby RD was in his mother’s care in the MBU, was missed. 46. During Ms RDS’ pregnancy and Baby RD’s life, there were several occasions when a referral to the Early Help Service or Children’s Social Care might have been considered, however, at no point did health professionals or the police consider this. 47. Practitioners and managers have suggested some reasons why a referral was not considered including that: • The assumption that the threshold for intervention was not met • Ms RDS had good family support • An assumption that another professional would make a referral if they felt it necessary • Ms RDS had long periods when her mental health was stable • There was a reliance on the MBU, who knew Ms RDS very well, to meet all of the family’s needs 48. The reasons suggested for the lack of referral indicate that, within Derbyshire, the concept of Early Help is not always well understood. The common misunderstanding, 9 The current framework for the inspections of local authority children’s services (Ofsted, 2018) provides evaluation criteria for early help as “Children, young people and families are offered help when needs and/or concerns are first identified. The early help improves the child’s situation and supports sustainable progress. The interface between early help and statutory work is clearly and effectively differentiated”. Research Report SAFEGUARDING PRESSURES PHASE 7 February 2021 The Association of Directors of Children’s Services Ltd Home | ADCS 10 https://www.derby.gov.uk/.../children-and-family-care/early-help-assessment FINAL 15/11/22 11 described in a number of national Serious Case Reviews, is that Early Help is often seen as an additional service and the benefit of coordination of help is overlooked. Risk Assessment – The Voice of the Child 49. Having been brought to MBU by the police, in order to be admitted, Ms RDS needed to have Baby RD with her. Had Baby RD remained at home with Mr RDS, Ms RDS would have been admitted to a different ward in the same Trust, to an acute psychiatric ward and believed it was in Ms RDS’s best interests not to do this. 50. Ms RDS (and her family) was well known to the psychiatric team who had cared for her during and after the birth of both her children. When, with suicidal feelings, she was admitted again, the team’s assessment was that she could safely care for her baby. 51. The risk to Baby RD was assessed as part of a “safety assessment” in line with the unit’s practice guidance. At the time the assessment was recorded in a standard “tick box” format, which focuses on the mother’s presentation. If there are concerns about the safety of a child, a more detailed summary is required. The ward did not have any concerns that Ms RDS posed a risk to Baby RD. 52. The unit describes the assessment as “multi-disciplinary “in practice it involves doctors, nurses, and nursery nurses, all of whom work closely together on the ward. There is no involvement from others, for example a psychologist, community services or Children’s Social Care. Learning • Practitioners should remain mindful of all the children in a family and what support other family members may need. Early Help and the “Think Family” approach set out the benefits of “joined up support” and working toward better outcomes. • The Association of Directors of Children’s Services document, “Safeguarding Pressures, 2021”1 includes a review of Early Help services and offers guidance on what works well. Practitioners and Managers should ensure they are clear that an Early Help assessment can assess need and coordinate existing services. FINAL 15/11/22 12 53. Discussion with practitioners highlighted the challenge of balancing the medical needs of a mother with safety of the baby placed with her. In this situation, this was Ms RDS’ fifth admission, staff had treated Ms RDS over a number of years, and each time had witnessed her recovery; they were completely confident that her needs were best met by their unit and based on Ms RDS’ presentation, they had no concerns about Baby RD’s safety. Parental Responsibility11 54. While Baby RD was with his mother on the ward, the baby’s status was that of “visitor” and although supported by ward staff, responsibility for his care rested entirely with his mother. The assessment of Ms RDS’ parental capacity was carried out by the medical team and was based on their knowledge of her history and how she presented on the ward, which was a safe and supportive environment. 55. The baby’s maternal family were consulted and the MBU noted that they agreed that admission was the best option. On reflection, the MBU staff acknowledge that the family views were not thoroughly explored. Mr RDS reports that he was against the idea of the baby remaining with Ms RDS and concerned about safety, but felt his views were ignored by the MBU. Assessing Parenting Capacity 56. Despite the restrictions imposed by the pandemic, one person from Ms RDS’ family was able to visit her and Baby RD almost daily. For them, the frustration was that they felt kept at arms-length from the psychiatric team and were not able to discuss Ms RDS’ demeanour and progress in the same way they had in previous admissions. 57. Ms RDS’ parents were conscious that Ms RDS’ health didn’t seem to be improving. Because of restrictions Ms RDS was spending significant amounts of time alone in her room with Baby RD and they were concerned that she tended to “push herself” to care for the baby and was not open with staff about the depth of her struggles. 58. Ms RDS’ family and the ward staff were aware that she was having difficulty forming a relationship with Baby RD (which was very different from her experience of parenting O-RD) and work to promote attachment was part of her treatment. In discussion as part of this review, Ms RDS’ family indicated that they felt that more attention should have been given to the nature of the mother and baby relationship. 11 Parental Responsibility is a legal term which defines all the rights, duties, powers, and authority that by law a parent has in relation to his or her child. If a man and woman are married, they automatically both have parental responsibility. FINAL 15/11/22 13 Response to Emergency Situations 59. When Baby RD was found to be unresponsive, clinical staff began CPR and an ambulance was called. The ambulance arrived within the recommended response time but sadly, Baby RD died. 60. The Rapid Review identified a number of communication difficulties in the period between the ambulance being called and Baby RD being attended to by the ambulance crew. Whilst it seems likely that by this time Baby RD’s life could not have been saved, a separate review has examined the process and made a number of recommendations which will improve the response to an emergency in the event of a similar situation occurring. 61. In summary, the learning identified the need for a minimum number of people present at the scene, with the right skill mix and clearly ascribed roles; for example, one person on the scene takes responsibility for communicating with the ambulance service call handler, another remains with the patient and priority is given to relaying pertinent information to the ambulance crew to allow for full assessment, treatment and transfer. All staff should know where emergency equipment is stored, and it should be easily and quickly accessible. Impact of Covid 19 62. It is clear from the information gathered in this review that the Covid 19 pandemic and the subsequent restrictions impacted greatly on both Ms RDS and her family and on the practitioners who continued to provide services. One of the practitioners described the impact as “catastrophic” when relating how service delivery was forced to change and face to face meetings were stopped or severely limited. Learning • Whilst the benefits of strong leadership and effective team working is well recognised, it is important that the system remains open to other information, skills and experience. A multi-agency risk assessment would be enhanced with the addition of other disciplines, to allow the voice of the child to be clearly heard and avoid fixed thinking or over-optimism. • When a parent is in the midst of a mental health crisis and staff are considering risk to a child, the view of the other parent and close family members must be part of the risk assessment and clearly recorded. This ensures that the “voice of the family” is included along with the voice of the child. FINAL 15/11/22 14 63. Certainly, during Ms RDS’ last admission, her family felt communication between them and the ward staff was very different from her previous admissions. They considered that the Covid restrictions kept everyone separate and lack of opportunity to share information hindered the risk assessment. CONCLUSIONS 64. Although the death of a child in these circumstances is rare, the challenges faced by the staff are those common in safeguarding practice. 65. For mothers with acute mental health diagnosis who are admitted to an MBU with their babies, the question remains how the team treating the parent can ensure the that the risk assessment is robust and that the safety of the baby is paramount and is given priority over the parents’ medical needs. 66. The role of community health and community services should not be underestimated. Practitioners can provide valuable insight into the strengths and needs of the whole family, ensure referrals are made when appropriate and that there is a continuity of care. The “Think Family” message applies to everyone. 67. Whilst the key finding of this Review is to highlight the benefit of multi-agency assessment, planning and intervention, there is no way of knowing if there was anything which could have been done to prevent Baby RD’s death. Resources are finite and it may be that is not practical or appropriate for every parent who is admitted with a baby to be referred to Children’s Social Care; however there a number of ways in which social workers and other specialist practitioners can work with medical services with the overall aim of strengthening safeguarding systems. 68. The Derbyshire Health Care Foundation Trust (DHCFT) Review examined in detail the service provided by the medical team and has made a number of recommendations for management and operational development. The report is not published but has been made available to the Safeguarding Children Partnership who will consider the recommendations, alongside those from this review, and will closely monitor progress. FINAL 15/11/22 15 SUMMARY OF LEARNING • When a parent is admitted to hospital, it is important that practitioners working in the community are up to date with care and discharge planning. In-patient and community health services are equally valuable and effective communication is key to ensuring in-patient and community-based services work together to provide continuity of care. • All agencies working with parents, especially at a time of crisis, need to be alert to “Think Family” and the benefits of multi-agency working. Staff must be clear about when and how to refer a family to Children’s Social Care and if more than one agency becomes involved with a family, practitioners must agree and confirm who will make the referral. • Practitioners should remain mindful of all the children in a family and what support other family members may need. Early Help and the Think Family approach sets out the benefits of “joined up support” and working toward better outcomes. • The Association of Directors of Children’s Services document, “Safeguarding Pressures, 2021” includes a review of Early Help services and offers guidance on what works well. Practitioners and Managers should ensure they are clear that an Early Help assessment can assess need and coordinate existing services. • Whilst the benefits of strong leadership and effective team working is well recognised, it is important that the system remains open to other information, skills and experience. A multi-agency risk assessment would be enhanced with the addition of other disciplines, to allow the voice of the child to be clearly heard and avoid fixed thinking or over-optimism. • When a parent is in the midst of a mental health crisis and staff are considering risk to a child, the view of the other parent and close family members must be part of the risk assessment and clearly recorded. This ensures that the “Voice of the family” is included along with the voice of the child. FINAL 15/11/22 16 RECOMMENDATIONS FOR THE SAFEGUARDING CHILDREN PARTNERSHIP 69. In order to disseminate and consolidate the learning from this review the following actions are recommended: A. The practice of creating and sharing of PPNs did not work in this case and led to a missed opportunity for a referral to Children’s Social Care. A review of the process is underway by the police and the Partnership should satisfy itself that the review is concluded and the outcome is clearly communicated to all relevant agencies. B. That the Safeguarding Children Partnership considers how best to promote and embed the Think Family agenda and seeks information from each agency about how they evaluate the effectiveness of the initiative. C. This Review indicates that the value of an Early Help assessment was not well understood by the agencies working with this family. The Partnership should obtain assurance that all agencies, including adult services, are fully engaged with the use of Early Help assessment. D. In order to ensure the voice of the child is not lost in the midst of parent’s mental health crisis and medical treatment, the Partnership should engage in discussion with commissioners of service about developing and strengthening the team working on the mother and baby unit. The introduction of different skills and experience will help to ensure a multi-disciplinary approach to risk assessment. E. That the Safeguarding Children Partnership seeks assurance from the Derbyshire Healthcare Foundation Trust that an effective protocol is in place which addresses the response to a medical emergency. All staff must be familiar with the content and its application within their working environment. |
NC048436 | Death by suicide of a 17-year-old boy in January 2016 who was found lying on a railway track. 'A's' mother had mental health problems and 'A' had been exposed to physical and emotional abuse and witnessed domestic violence from an early age. Over 19 foster care break-downs led to placements in therapeutic units at age eight and age 12. Throughout his life 'A' displayed challenging behaviour including aggression and violence, self harm and regularly going missing from placement. In 2006 he reported historic child sexual abuse. Later he was identified as being at risk for child sexual exploitation and expressed fears that he may sexually harm other children. In 2015, plans had been made to transfer A to a foster home, in preparation for independence, and a proposed moving date was set for January 2016. Identifies learning under three headings: choice and initiation of placement; issues arising during placement, such as identifying the need for additional therapeutic support; and transition towards greater independence including help with coping with change and his move from therapeutic care. Recommendations include the need for training around the vulnerability of care leavers for Brighton and Hove Children's Social Care; all care and placement plans should include a contingency position; and the therapeutic unit should review organisational capacity to challenge care plans if they deem it necessary.
| Title: Serious case review: ‘A’. LSCB: Brighton and Hove Local Safeguarding Children Board Author: Fergus Smith Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. BRIGHTON & HOVE SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW ‘A’ FERGUS SMITH 04.05.17 Contents 1 INTRODUCTION 1 1.1 Event triggering a serious case review & family background 1 1.2 Purpose & conduct of the serious case review 2 2 FAMILY HISTORY: EARLY EXPERIENCES OF ‘A’ IN FOSTER CARE & FIRST THERAPEUTIC UNIT 6 2.1 Introduction 6 2.2 Original entry to care & early foster placements 6 3 KEY EVENTS AFTER PLACEMENT AT SECOND THERAPEUTIC UNIT 8 3.1 Introduction 8 3.2 2010 8 3.3 2011 10 3.4 2012 14 3.5 2013 15 3.6 2014 19 3.7 2015 / 16 22 4 RESPONDING TO THE TERMS OF REFERENCE 31 4.1 Quality & timeliness of care planning 31 4.2 Effectiveness of inter-agency co-operation 33 4.3 Extent to which ‘A’s ‘voice’ was heard 34 4.4 Self-harming episodes 35 4.5 Any issues relating to family contact 36 4.6 Violent & aggressive outbursts 37 4.7 Sexualised behavior 37 4.8 Sufficiency & quality of psychiatric / psychological support 39 4.9 Formally ‘notifiable’ incidents & any additional issues of relevance 39 5 FINDINGS & CONCLUSIONS 40 5.1 Good & sub-optimal professional practice 40 6 RECOMMENDATIONS 42 6.1 Introduction 42 6.2 Action required of agencies 42 7 GLOSSARY: ABBREVIATIONS / PROFESSIONALS 43 8 BIBLIOGRAPHY 44 CAE 1 1 INTRODUCTION 1.1 EVENT TRIGGERING A SERIOUS CASE REVIEW & FAMILY BACKGROUND 1.1.1 On New Year’s Day 2016 a 999 call was made and an ambulance was called to attend an unknown person lying on a railway track in West Sussex. The individual who was pronounced deceased at the scene, was later identified as ‘A’ (a White British male aged 17) who had been in the care of Brighton & Hove Children’s Social Care since 2004 and who was a part-time student at a College of Further Education. 1.1.2 In A’s early childhood, he had been exposed to significant levels of physical and emotional abuse and neglect in the context of chronic domestic violence. In more recent years, ‘A’ had made allegations of historical sexual abuse by a named family member. 1.1.3 Following his entry to care, several foster homes had been unable to manage his behaviours and ‘A’ (aged 8) had been placed in a therapeutic Unit in Kent. After further unsuccessful attempts to find a foster family that could manage his behaviour, he was (aged 12) placed in a therapeutic Unit in West Sussex and remained resident there until his death. There had been ongoing concerns about ‘A’s sometimes aggressive and denigrating behaviour, his fears and fantasies about a potential for committing sexual offences and (largely historical) concerns about self-harming. 1.1.4 Plans had been formulated during 2015 to transfer ‘A’ to a foster home. In November of that year, introductions had begun and what was intended to be a permanent transfer had been scheduled for a date in early January 2016. CONSIDERATION OF A SERIOUS CASE REVIEW 1.1.5 In accordance with the Local Safeguarding Children Board Regulations 2006 and local agreed procedures, ‘A’s death was reviewed at a ‘serious case review sub-group’. It was concluded that the primary criterion for initiating a ‘serious case review’ (reproduced in paragraph 1.2.1) was satisfied and a recommendation made to the independent chairperson of Brighton & Hove Safeguarding Children Board (Mr Graham Bartlett) that a serious case review be commissioned. Following further consideration and consultation, the chairperson ratified that recommendation and the Department for Education. Regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE) were then informed. 1.1.6 This serious case review was undertaken between July 2016 and January 2017. A Coroner’s Inquest has been initiated and is currently adjourned awaiting further evidence. CAE 2 1.2 PURPOSE & CONDUCT OF THE SERIOUS CASE REVIEW PURPOSE 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died [as in this case] or been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 In this case, the original abuse and neglect occurred in ‘A’s earlier childhood but there were also more recent allegations of abuse and/or some indications of sexual exploitation. 1.2.3 The purpose of this review is to inform and facilitate learning and to identify required improvements in service design, policy, systems or practice amongst local or national services. Establishing the cause of death remains the responsibility of the Coroner. CONDUCT OF REVIEW 1.2.4 The primary focus of the review was determined to be from the date in June 2010 when ‘A’ was transferred to his therapeutic community until his death. A summary of the period in which he had been resident there, was also sought from the former therapeutic unit. An independent report was commissioned from www.caeuk.org and it was agreed that the lead reviewer Fergus Smith would: Collate and evaluate material submitted Conduct any required supplementary enquiries Develop for consideration by the review ‘steering group’ a narrative of agencies’ involvement, an evaluation of its quality and conclusions and recommendations for action by Brighton & Hove Safeguarding Children Board 1.2.5 The review steering group consisted of the: Lead Reviewer (chairperson) Head of Performance & Safeguarding Brighton & Hove Children’s Social Care Interim Head of Safeguarding Children West Sussex County Council Representative of Sussex Police Therapeutic Unit Operational & Developmental Adviser Clinical Lead for Child & Adolescent Mental Health Services (CAMHS) & Safeguarding Representative Sussex Partnership NHS Foundation Trust Business Manager Brighton & Hove Safeguarding Children Board CAE 3 1.2.6 The following agencies submitted material: Brighton & Hove Children’s Social Care West Sussex County Council Children’s Social Care Sussex Police Service ‘A’s Previous Therapeutic Community ‘A’s Current Therapeutic Community 1.2.7 Though the modest size of the second therapeutic community rendered it impossible to identify an author without some contact with ‘A’ in his 5 years of residence, the report submitted was developed by a sufficiently independent experienced professional and was comprehensive, sensitive and enquiring. Remaining reports were written by highly experienced individuals who had had no direct involvement with A or with the supervision or management of his case. INVOLVEMENT OF RELEVANT PROFESSIONALS 1.2.8 So as to better understand judgements formed and actions taken by those with responsibility for ‘A’, an initial consultation event / briefing was undertaken. The purpose and approach to the serious case review was explained. Individual interview/s were subsequently completed with the following individuals: Brighton & Hove Children’s Social Care ‘A’s first allocated ‘social work resource officer’ (SWRO) who had worked with ‘A’ and his family from 2010 to 2014 ‘A’s allocated social worker who was case-accountable from May 2014 onwards The supervisor and manager of ‘A’s social worker The independent reviewing officer (IRO) with case- planning oversight responsibilities since ‘A’s placement Service manager for agency placements Assistant director (responsibility for looked after children) Therapeutic Community ‘A’s link-worker An ex head-teacher Psychotherapist Service manager Director 1.2.9 It later proved possible to complete a discussion by phone with the ‘supervising social worker’ of ‘A’s potential foster carers and a face to face meeting with the current manager of the relevant independent fostering agency (IFA). All those individuals, in spite of their personal feelings, were open and willing to consider lessons that might be learned from ‘A’s death so as to improve services for such extremely vulnerable young people. Sincere thanks are owed them all. CAE 4 INVOLVEMENT OF BIRTH & POTENTIAL FOSTER FAMILY MEMBERS Birth mother / grandmother 1.2.10 ‘A’s mother was informed that her son’s death required a serious case review and she responded promptly to an invitation to contribute. A meeting with her (supported by her own mother) was held. They provided a great many valuable memories of a young man to whom they remained committed in spite of extremely adverse circumstances. 1.2.11 At the family’s request, consideration was given to the extent and quality of ‘A’s early developmental and educational assessments, the challenge of meeting the needs of a mother with significant mental health difficulties who had experienced extensive domestic abuse and the events that resulted over 12 years in 20 placements (representing 31 moves, many prompted by respective carers’ need for respite). 1.2.12 The more historical issues identified by the family were explored by means of sourcing and considering records that described why and how ‘A’ and siblings were committed to care by the Family Court. Those documents also described the attempts made at that time to address mother’s ongoing mental health difficulties. The lead reviewer and review steering group are satisfied that the issues referred to above had been adequately addressed already and that the focus on the period since ‘A’s placement at the Unit in which he spent the last 5 years of this life was appropriate. The lead reviewer also met ‘A’s mother and grandmother to share with them ahead of the Inquest, the results of this serious case review. Potential foster carers 1.2.13 The female carer with whom (together with her husband) it had been hoped ‘A’ would live also contributed to the review. The author explored what background information had been provided prior to the placement decision being made, how introductions were being managed and how the carers were made aware of ‘A’s death. 1.2.14 The detail of the experiences and views of birth family and the selected foster carers is provided in the following report and the learning emerging from these contributions summarised in section 5. PEN PICTURE OF ‘A’ 1.2.15 As well as his mother and grandmother who clearly loved and remained committed to ‘A’, and in spite of his troubled and troublesome behaviours, ‘A’ was very popular with those who worked with him. His charm, good looks, sporting prowess and dry sense of humour was commented upon by several of those who contributed to this review. ‘A’ himself appears to have been making great efforts not to become the sort of person whose sexually abusive behaviours had caused him lifelong distress. CAE 5 FAMILY STRUCTURE Birth father Mother Sib.2 Born 1997 Sib.1 Born 1992 ‘A’ Born 1998 Birth father Sib.3 Born 2000 CAE 6 2 FAMILY HISTORY: EARLY EXPERIENCES OF ‘A’ IN FOSTER CARE & FIRST THERAPEUTIC UNIT 2.1 INTRODUCTION 2.1.1 Though the focus of this review is from 2010 to ‘A’s death, section 2 offers some explanation about when and why he first entered care and how his complex and extensive needs required specialist responses. 2.2 ORIGINAL ENTRY TO CARE & EARLY FOSTER PLACEMENTS 2.2.1 As a result of his mother’s inability to provide safe, stable and suitable care (itself a consequence of long-term mental health difficulties and an associated susceptibility to violent partners) ‘A’ was voluntarily accommodated twice in 2004 under s.20 Children Act 1989. Care Proceedings were initiated in August 2005 and a final Care Order made in May 2006 by which time ‘A’ was 8 years of age. 2.2.2 Between 2002-05 there had been 3 referrals to Child and Adolescent Mental Health Services (CAMHS) (by health visitor, GP and social worker respectively). Mother failed to follow up offers of help in the first 2 instances and the subsequent conduct of Care Proceedings meant that no direct work was undertaken nor a definitive diagnosis determined, prior to ‘A’s placement described below. PLACEMENT IN FIRST THERAPEUTIC UNIT 2.2.3 After over a dozen disrupted foster placements, it was determined on psychiatric advice that a ‘non-familial’ setting was required. ‘A’ was placed in a junior ‘therapeutic community’ in Kent and received education on-site until February 2008 when he began to attend a local mainstream Primary School. Planned contact with mother and siblings was maintained and, in spite of the anxiety and challenging behaviours associated with it, was seen by all to be of benefit to ‘A’. 2.2.4 An investigation of ‘A’s disclosure in 2006 of historical sexual abuse whilst at home, could not be progressed because he was unwilling or unable to complete an ‘Achieving Best Evidence (ABE) interview. The Unit reported ‘A’s frequent expressions of low self-esteem e.g. ‘I am ugly; I am stupid; nobody wants me’. ‘A’ could though be comforted and reassured by those staff to whom he related well and his confidence level was regarded as having risen during his time at this Unit. Incidents of self-harm were minor and required no medical response e.g. hitting his head on the wall, scratching himself with his nails or (more rarely) with a broken cup or clothes hanger. 2.2.5 ‘A’ also manifested aggression and violence which because of his age and size could be managed. They were usually in response to the imposition of boundaries and had all but disappeared by the end of his placement (with some re-emergence attributed to anxiety about a planned move to a foster home in early 2009). CAE 7 FURTHER FAMILY PLACEMENTS 2.2.6 Fostering was raised as a possibility in September 2008, a suitable family identified by December and a transition plan developed and agreed by the Unit and Brighton & Hove Children’s Social Care. ‘A’ met the selected family in January and, after several more visits moved to them in February 2009. This placement has been calculated to be his 17th (though there had been many more ‘respite’ placements required in order to offer carers a break, and inevitably meant for ‘A’, further discontinuity of care). 2.2.7 The 17th placement endured 13 months and was followed by an 18th in Kent lasting 3 months and a more local 19th emergency placement, after which residential care was again used as described below. DECISION TO PLACE ‘A’ AT A SECOND THERAPEUTIC UNIT 2.2.8 In November 2009 a social worker referral had been made to the then provider of the local Child & Adolescent Mental Health Service – CAMHS (currently provided by the Sussex Partnership Foundation NHS Trust - SPFT). This sought therapy of a directive nature as recommended by ‘A’s first therapeutic community. 2.2.9 The plan being formulated was for some direct work with ‘A’ following consultation meetings with the carer. The clinical recording is poor and not of the standard expected by the Trust. The plan was not progressed as a result of the placement disrupting and ‘A’ being moved on as described below. No evidence with respect to the standards discharge process has been found. Comment: thus the need for CAMHS expertise had been discerned since ‘A’ was under 4 years of age. No diagnostic or therapeutic work had proved possible (though CAMHS had accepted and allocated referrals made and offered therapeutic intervention). 2.2.10 The events that followed the wholly understandable and justifiable decision to identify a further appropriate therapeutic Unit, the issues arising from its use and plans for ‘A’s transition to greater independence are described and commented upon in section 3 below. CAE 8 3 KEY EVENTS AFTER PLACEMENT AT SECOND THERAPEUTIC UNIT 3.1 INTRODUCTION 3.1.1 From amongst a very large volume of records generated across the review period, key events or milestones are considered below, year by year. Italicised comments about professional practice within and between involved agencies are included. 3.2 2010 3.2.1 There were no pre-placement enquiries made by the ‘responsible local authority’ (Brighton & Hove) of the ‘area authority’ (West Sussex County Council) in terms of the latter agency’s ability and willingness to be commissioned to offer services such as reviews of special educational needs or child and adolescent mental health services (CAMHS). Interviews have confirmed that there was an assumption that the new placement could provide for all ‘A’s care, educational and therapeutic needs. 3.2.2 In June 2010 ‘A’ was placed at his new ‘Therapeutic Community Unit’. His allocated worker completed an initial visit to him (as required by regulation) within a week. Comment: ‘A’s complex case was allocated to a ‘social work resource officer’ (SWRO) rather than a registered social worker as best practice (and by 2011, regulations) required. UN-AUTHORISED ABSENCES 3.2.3 On 02.08.10 the Unit notified the placing authority of an un-authorised 3 hour absence over the weekend. Records indicate that there were several other such occasions in 2010 though on all of them, ‘A’ returned without incident when found by staff or police officers. The report submitted by Police provides clear confirmation that the first episode in late July and all others were responded to efficiently and took full account of ‘A’s reported vulnerabilities. BEHAVIOURS & FAMILY CONTACT 3.2.4 Though ‘A’ appeared to be relatively settled, there were incidents that illustrated his ongoing levels of distress e.g. on 09.08.10 staff were obliged to restrain him for about 10 minutes when he had lost control and was throwing objects and hitting out. 3.2.5 Contact with mother and siblings had been agreed at the point of placement and was further debated at the initial review. At a planned contact on 24.08.10 ‘A’ proved unable to sustain a full 2 hours with mother and other family members and his allocated worker later discussed the implications of this with mother and staff. CAE 9 STATUTORY REVIEW 1: AUGUST 2010 3.2.6 A sensitive and comprehensive report was provided and debated at S’s first s.26 statutory review1 on 12.08.10. Mother though invited, reportedly felt unable to be present. She was later offered an opportunity to be taken through the discussion held at the meeting. It has been confirmed that mother was always invited to reviews. A SIGNIFICANT ‘MISSING’ EPISODE 3.2.7 On 10.09.10 ‘A’ again ran away. On this occasion, the event seems to carry more meaning than the more simple and frequent ‘absent without authority’ episodes. ‘A’ had climbed out of a first floor window and was missing for about an hour. He later reported that he was trying to undermine his placement so that he would have to move on. 3.2.8 Because the independent therapeutic Unit is situated in West Sussex, the response to the report of ‘A’ being missing had been handled by Children’s Social Care and Police in that County. Records of responses included some concern that staff had failed to notice the boy’s departure, that the Home was ‘untidy’ and that ‘A’ was sleeping on the floor of his bedroom. Comment: these reports do not make it clear whether ‘A’ actually had a bed which he could have used (Unit staff have confirmed that he did). 3.2.9 The allocated worker’s response was prompt. She discussed the incident with the Unit and her own supervisor and visited 2 days later. STATUTORY REVIEW 2: NOVEMBER 2010 3.2.10 In accordance with the relevant regulations, a second independently chaired review was held within 3 months on 25.11.10. ‘A’s mother was not present on this occasion though ‘A’ was and contributed. The allocated worker noted that ‘A’ struggled to accept that his difficult behaviours made it hard for others, especially foster carers to manage him – hence necessitating a residential placement. 3.2.11 Contact arrangements with ‘A’s mother and other relevant family members were discussed and clear plans agreed. ‘A’ confirmed that he had a copy of his ‘Care Plan’2 and understood it. His allocated worker had visited him on 7 occasions since his placement in late June. Comment: the frequency of visits was well over the regulatory minimum. 1 S.26 Children Act 1989 and associated regulations / guidance requires independently chaired reviews of those entering the care system to be completed after 20 working days, within 3 months of that date and thereafter at intervals not exceeding 6 months. 2 Regulations require that normally before a child is placed and anyway within 10 working days, a ‘Care Plan’ must be developed; this plan reflects the intentions of the placing authority and the sort of information it must contain is also described in regulations. CAE 10 3.2.12 Amongst the sensitive issues of concern during this period was that of ‘A’s birth father with whom there had been no contact since his very early years. It was unclear whether it would be safe to allow contact and that possibility was not pursued. 3.2.13 Before and for days after each planned contact with his mother, ‘A’ became very agitated and his behaviour more challenging. The allocated worker continued to make frequent visits to ‘A’. Contact with (and in ‘A’s mind, the possibility of a return to), his last pair of foster carers was being considered. The carers were of the view though that resumed contact would offer false hope of a return to them. Comment: though not apparent from the review paperwork, supervision notes at this period refer to an intention to find ‘A’ a further foster home. 3.3 2011 MANIFESTATIONS OF ANXIETY 3.3.1 On 04.02.11 an outburst by ‘A’ prompted a physical restraint by 2 female staff. Staff concluded that ‘A’ had been feeling ‘uncontained’ and was testing the extent to which females would be able to overpower him. Comment: ‘A’s apparent need to assert control rather than be a victim of it characterised and explained many of his behaviours at this stage and as he moved into adolescence. 3.3.2 During this time, ‘A’, though embarrassed by having to acknowledge it, was referring to some sensitive medical symptoms about which he did not want his family to be made aware. FURTHER EPISODE OF RESTRAINT 3.3.3 On 22.02.11 the Unit reported an attack by ‘A’ on his then link-worker. The view was that he had been serious in his attempt to hurt him. Staff had restrained ‘A’ who was by then speaking more openly of his confused feelings toward his mother. DISCLOSURE OF HISTORICAL SEXUAL ABUSE 3.3.4 ‘A’ was interviewed on 10.03.11 about allegations made about a month earlier to a member of staff. The allegations centred on the sexual abuse of ‘A’ and others, by a man described by ‘A’ as his ‘father’. Comment: the allegations had been shared immediately with the placing authority and appropriately triggered a strategy discussion with Police. CAE 11 3.3.5 During March 2011 there was further liaison between ‘A’s allocated SWRO and Police. ‘A’s maternal grandmother (MGM) and mother were made aware of the allegations. MGM stated that she had no knowledge of such events. Comment: it is clear that in spite of her inability to cope with ‘A’s high level of need, mother was consistently supportive of the care provided to her son by the Therapeutic Unit and has also acknowledged the support it extended to her. 3.3.6 Mother and MGM provided names of 2 men who had had opportunities to abuse ‘A’ and others. Mother thought that one was more likely to be the perpetrator. In the event, and in spite of efforts by all concerned, ‘A’ felt unable to attempt an ABE interview until about a year later and Police investigations were delayed until then. FURTHER EPISODE OF RESTRAINT / MINOR SELF-HARM & COMPLEXITIES OF FAMILY CONTACT 3.3.7 Reportedly because of his anxiety about a scheduled Police visit, ‘A’s behaviours on 08.03.11 prompted physical restraint lasting 2 hours. He had been very destructive and had cut his arm with a broken lightbulb. 3.3.8 MGM was unwell during March 2011 and there was considerable debate about the need and benefit of ‘A’ meeting older half-sister (sib.1) without his grandmother being present. ‘A’s feelings of anger coupled with protectiveness toward his mother made contacts with her challenging. 3.3.9 Reports from the Unit were of increasing levels of violence, an obsessional need for his link-worker to spend time with him rather than other residents and his growing awareness and jealousy of the more harmonious family relationships enjoyed by many others. 3.3.10 By April 2011 planned contact arrangements were rendered uncertain because of tensions between siblings and were finally postponed by staff and sib. 2’s carers. ‘A’ was reported to be pre-occupied with medical difficulties for which he was awaiting surgery. 3.3.11 A Brighton & Hove social worker SW1 completed some direct work with mother at this time and established that she had herself experienced some early childhood trauma. CAE 12 STATUTORY REVIEW 3: MAY 2011 & THREATS OF SELF-HARM / VIOLENCE 3.3.12 On 09.05.11 a 3rd review was completed. ‘A’ attended and contributed his views. Records indicate a consensus amongst those present that his placement remained the best option for the foreseeable future. ‘A’. expressed a preference to remain rather than be found a foster family, though that possibility was recognised by the professionals at the meeting. 3.3.13 ‘A’ appeared unsettled after the May review e.g. he punched his female link-worker in the face. The report supplied by the Unit refers to other serious assaults during the year including spraying boiling water at a female staff member and several occasions on which he kicked and punched staff. The Unit also reported threats of self-harm. At this time ‘A’ was also exposing himself to other young people. 3.3.14 On 19.05.11 a one-off consultation with an independent psychotherapist, focused on ‘A’s anxiety about his medical problem (a need for minor surgery was later confirmed). 3.3.15 The allocated worker continued her high level of visits to ‘A’ who was still considering whether to complete an ‘Achieving Best Evidence’ (ABE) interview with Police. A detective constable (DC1) made an arrangement to familiarise ‘A’ with the interview suite in advance of a formal interview and a joint visit at which the formal interview process was explained was completed by DC1 and ‘A’s allocated worker. 3.3.16 The Unit was considered to be managing ‘A’s anxieties and challenging behaviours and the focus of the allocated worker was making contacts with significant family members as constructive as possible. Staff were at this time seeking to assist ‘A’ to distinguish sexually exploitative relationships from those based on love and commitment. At about his time, his first link-worker informed ‘A’ that she would be leaving. ANNUAL HEALTH ASSESSMENT 3.3.17 On 24.08.11 ‘A’s first annual health assessment (a regulatory requirement) was completed. It noted (not wholly accurately) that he was in receipt of ‘various forms of therapy’. ‘A’ had declined to discuss the ‘growing up’ section of the pro-forma used for these annual assessments (which would have offered an opportunity to explore issues of puberty / understanding of sex / sexuality). CAE 13 MISSING EPISODE 3 3.3.18 On 24.09.11 ‘A’ was reported as missing with £400 taken from the Unit’s petty cash. He was found next day by Police and returned, when he assaulted head-teacher HT1 causing a ‘black eye’. This was the only episode of ‘A’ being missing during 2011. 3.3.19 In September 2011 the needs for ‘A’ to have 1:1 therapy from an external source was recognised and (according to records) agreed. Comment: this ‘agreement’ is the first of several that illustrate a difference between practical time-focused expectations of Brighton & Hove (the responsible authority which commissioned the placement) and the therapeutically-minded provider Unit where implementation of any plan critically depended upon there being a consensus that the timing was optimal. Both perspectives were legitimate but the continuing failure to wholly resolve differing expectations represented a joint weakness of service delivery. PERSONAL EDUCATION PLAN (PEP) REVIEW 3.3.20 On 31.10.11, ‘A’s PEP was reviewed again. 2 previous such reviews had been completed (October 2010 and May 2011and had included the hope that ‘A’ might return to mainstream education, perhaps in 2 years). The records of this review noted that ‘A’s special educational needs (SEN) statement had been reviewed in July 2011 by the ‘area authority’ (West Sussex) and remained unchanged. The content of this latter PEP review focused (as had earlier such reviews) on behaviour and contained little educational material. COMPLETION OF ELECTIVE SURGERY / SELF-HARM EPISODE 3.3.21 ‘A’ underwent a successful minor operation, the nature of which though, evoked memories of previous traumas. ’A’ claimed at this time to have self-harmed by drinking some fish tank cleaning fluid and went on a few days later to cut his forehead, arms and legs, also it was thought in reaction to the experience of the medical intervention. 3.3.22 Reports of ‘A’s behaviour at this time note his difficulties if anyone got too emotionally close to him. He appeared to be especially threatening and abusive to female staff. ‘A’ was also expressing anxiety about the heritability of his mother’s mental health difficulties. Comment: it would have been helpful for ‘A’ to have been offered an informed view by a psychiatrist or clinical psychologist on the probability of him or his siblings experiencing mental ill-health. CAE 14 STATUTORY REVIEW 4: NOVEMBER 2011 3.3.23 At his 4th review which was attended by ‘A’ though not his mother, an improved ability to manage his own routines was acknowledged. ‘A’ confirmed at this meeting that he felt unready to undertake the required ABE interview. Efforts by Police to gather basic information e.g. when either of the 2 potential suspects were in contact with ‘A’ and his siblings continued but the investigation inevitably remained incomplete awaiting ‘A’s development of sufficient confidence to participate. 3.3.24 ‘A’s mother was supportive of the Police investigation and of the arrangements being formulated by her son’s allocated worker for ongoing contact with family members (mother, siblings, grandmother and maternal great-grandmother). 3.3.25 The allocated worker continued to maintain a high level of contact and her notes reflect a sensitive understanding of ‘A’s aggression. 3.4 2012 ASSAULTS BY ‘A’ 3.4.1 What had been physically destructive behaviour before Christmas 2011 escalated to significant violence in January of the New Year. On 09.01.12 ‘A’ assaulted 2 female staff members punching both in the head and face. ‘A’ ceased his attack when male staff arrived. The incident was attributed to anxiety over the loss of his valued first link-worker. The SWRO disagreed with the decision made by the victims not to press charges (the Unit policy was to allow staff discretion with respect to their response and to support the decision made). The search for suitable off-site psychotherapy had not at this point produced a suitable provider Comment: ‘A’s conduct represented a significant risk of harm to staff and would have been (in many other contexts) considered criminal. The contrasting attitudes toward the behaviour offers a further example of a philosophical difference of approach which would later underpin and complicate the transition to greater independence. STATUTORY REVIEW 5: APRIL 2012 & SUBSEQUENT TRANSFER TO UNIT FOR OLDER BOYS 3.4.2 By April 2012 ‘A’ was reportedly keen to transfer to a linked Unit for older boys. He was also pressing for more unsupervised family contact. Records of contact by his allocated worker and by Unit staff for the following few months seem largely focused on the intended transfer which was completed in September 2012. CAE 15 STATUTORY REVIEW 6: OCTOBER 2012 3.4.3 On 12.10.12 ‘A’s 6th review was completed, again chaired by the same reviewing officer (IRO1). ‘A’ attended as did his allocated worker and care and educational staff from the Unit (director, HT1 & virtual school representative VS1). 3.4.4 The meeting learned that there had been no recent outburst of violence and that ‘A’ was improving his ability to relate to others. Though the agreed plan was for ongoing residential placement with some possibility of a foster home, a later exchange between his allocated worker and the director noted ‘A’s wish to resume living with his mother when he became 16 years of age and his stated belief that she could look after him adequately. 3.4.5 Subsequent conversations failed to entirely shift mother from a well-meaning and certainly mistaken view that she might be able to cope with her son’s return. Meantime an annual plan for contact during the following year with each family member was drawn up. Comment: contact arrangements, though complex, were typically clear and always rooted in ‘A’s best interests. MISSING EPISODE 3.4.6 ‘A’ was reported missing only once during 2012 (in November). He had left accompanied by another resident and returned just after midnight having he reported, given up an attempt to walk along the beach to a nearby town. The number of times ‘A’ went missing increased sharply in the following year and the most significant episodes are described below. 3.4.7 Individual therapy had still not begun. Enquiries during the course of this serious case review suggests that the elapsed time was in part due to the challenge of identifying the best provider and in part a measure of ‘A’s perceived readiness (within the Unit) in the view of staff. The psychotherapist herself expressed her opinion to the author that ‘A’ would not have been ready sooner for what had been envisioned as twice-weekly, but instead became weekly therapy. 3.5 2013 3.5.1 Early in the New Year a social worker from East Sussex reported that ‘A’ had left a message on the phone of a former foster carer. The message appeared innocuous though the female carer had been upset because of ‘A’s previous (unspecified) behaviours. Days later after an unauthorised absence, ‘A’ phoned his mother and shared with her a list of concerns and anxieties about schooling, his placement and of a girl with whom he was ‘in love’. CAE 16 REVIEW HEALTH ASSESSMENT & INCIDENT OF SEXUAL EXPLOITATION 3.5.2 On 09.01.13 ‘A’ was seen by a different nurse. A ‘strengths and difficulties’ (SDQ) questionnaire (a standardised instrument for recording needs) was given to his link-worker for completion ‘if deemed appropriate at this present time’. It remains unknown whether this SDQ was completed. The nurse anyway recorded that ‘A’s emotional needs were being met within his residential Unit. 3.5.3 On the same day (it is presumed after completion of the health assessment, since its report makes no mention of the event) ‘A’ admitted that he had planned to meet a man whose number he had seen on a toilet wall alongside the message ‘call for sex’. All relevant agencies were informed, a strategy meeting convened and a criminal investigation initiated with respect to a man whom ‘A’ indicated was middle-aged (the basis ‘A’ on which believed that, is uncertain). In spite of extensive enquiries, this man was not traced. INCREASED FREQUENCY OF MISSING EPISODES 3.5.4 In response to the events of 09.01.13 the Unit recognised the heightened risk and required staff to immediately inform Police if ‘A’ ran away or was absent without authority. 3.5.5 At her supervision toward the end of January 2013, the allocated worker noted that ‘A’ was continuing to run away, mostly for short periods during which he met a variety of individuals. ‘A’s further response to his contact with the potential abuser was a mixture of fear and excitement which at times required staff to physically prevent him from leaving the Unit. 3.5.6 The agreed safety plan was that ‘A’ should not be out alone, though it was acknowledged that he was not complying with that expectation. 3.5.7 The report provided by the Unit refers to a decision made by ‘A’s allocated worker to allow unsupervised family contact from this point on. This is not confirmed in the records maintained by Brighton & Hove nor included in its report to this serious case review. Any such change should be the subject of planned multi-agency debate that includes child and parent. 3.5.8 A ‘care planning meeting’ was convened on 20.02.13 and ‘A’ and his mother attended. ‘A’ was reported to be in a pleasant and positive mood contributing well and showing ‘great self-awareness’. He expressed a wish to return home but his mother was able to say that she thought he ought to remain at the Unit until he was 18. 3.5.9 Less than a month later the allocated worker learned at a visit that there had been a decline in ‘A’s engagement with school and that he was manifesting a misplaced confidence in his ability to manage (though there remained amongst those who knew him well, a belief that he knew really, that he was not ready for more independence). CAE 17 3.5.10 In mid-March 2013 ‘A’ learned from his birth mother that he had been the product of her rape. At this time he was saying to his family that he was bi-sexual, later gay. ‘A’ was said by his mother to have ‘found his ‘brother’ via FaceBook’ [the person in question was actually the son of sib.1’s father]. Apparently as a further consequence of tracing this individual, ‘A’s birth father contacted his mother. She asked and he agreed, that he would initiate no further contact. STATUTORY REVIEW 7: APRIL 2013 3.5.11 The 7th review which was attended by mother and ‘A’ generated no new issues. Discussions in Spring 2013 included thoughts of sourcing a family which might provide ‘A’ with a short-break from his residential care and offer some experience of a more age-appropriate level of independence. ‘A’ supported the idea but after further debate within the Unit, he was deemed unready for such an arrangement. Comment: contact with family members continued to be highly prescribed though increasingly and age-appropriately, less restrictive. MISSING FROM PLACEMENT EPISODES & FAMILY CONTACT 3.5.12 During May 2013 ‘A’ was recorded as missing on 3 occasions (for over 4 hours, 3 hours and 40 minutes respectively). Contact with his family continued to be of importance. Some sessions remained supervised and others e.g. with his grandmother (MGM) were unsupervised. A proposal from mother’s Adults’ Services support worker that ‘A’ could visit his mother in her flat was considered and rejected though the reasons for that decision were not located in records. 3.5.13 ‘A’ was anyway spending time after school with a friend who (apparently by chance) lived next door to his mother. Inevitably, levels of contact with her well exceeded the formally agreed arrangement. ‘A’s last episode of being missing during 2013 was in June. There had been 16 to that date, most associated with him meeting friends locally and all resolved by him returning to the Unit of his own accord. REVIEW OF PERSONAL EDUCATION PLAN (PEP); DELAYED PSYCHOTHERAPY 3.5.14 At a further annual review of his PEP on 12.06.13 ‘A’ expressed anxiety when the possibility of a college placement was discussed. He did though agree to visit a college when a suitable one was identified. 3.5.15 By September 2013 an external psychotherapist had been identified though sessions had still not started. Discussions between Unit director and allocated worker referred to a hope that ‘A’ would be ready to be fostered by the time he was 16 or 17. Comment: this option had been mentioned but not yet explored at a care planning or statutory review meeting involving ‘A’ or his mother. CAE 18 STATUTORY REVIEW 8: SEPTEMBER 2013 3.5.16 ‘A’ attended his 8th review and had submitted his written comments to the independent chairperson (IRO1). Mother was also present and contributed. The worker’s report contained the following entry….’It is felt this foster placement within a therapeutic residential home continues to be the most appropriate placement for ‘A’ at this time, the department shall be exploring the possibility of a foster placement as respite initially over the next review period’. Comment: the meaning of the first part of the sentence is very unclear; no respite family was anyway, ever identified. 3.5.17 Records of 31.10.13 refer to concerns expressed by sib.1 about ‘A’s interest in the recent drowning of a young man of similar age. ‘A’, who had not known the victim visited the site and laid a rose there. Comment: this incident offers the first and arguably only example of any ‘morbid preoccupation’. 3.5.18 The allocated worker’s supervision record for this period reflect a growing sense of frustration that the planned psychotherapy had not begun, a recognition that actual contact with his mother was nearer daily than the formally agreed once per month, and that a foster placement might be an overly ambitious plan given ‘A’s ambivalence. SELF-HARM EPISODE 3.5.19 On 13.12.13 A required the insertion of stiches at a hospital A&E Department having (staff believed) deliberately cut his forearm. A room search revealed other blades hidden his room, as well as a mutilated baby doll that ‘A’ had been using for the purpose of sexual gratification. In a conversation between the director and the allocated worker, the former expressed concern that some of ‘A’s conduct was ‘becoming dangerous’ (a reference to these events and ‘A’s previously shared fears and fantasies). Comment: this was an early illustration of the greater level of concern felt by those within the Unit when compared with Brighton & Hove staff; at interview the director recalled feeling that ‘A’s profound disturbance was only being ‘contained’. SWRO and to a greater extent successor SW2, focused on what ‘A’ could and (given his age) would increasingly be expected by society to be able to do. 3.5.20 ‘A’ was allowed an overnight stay with his mother at Christmas which was carefully planned and incident-free. The allocated worker visited ‘A’ on 24.01.14 and met with staff. Her account does not refer to any more behaviours that might reasonably be considered ‘dangerous’. CAE 19 3.6 2014 MISSING EPISODES & VIOLENCE REQUIRING RESTRAINT 3.6.1 ‘A’ was absent without authority on 6 brief periods in January 2014 (and once thereafter that year). On the first and most significant occasion his violence required 3 staff to hold him. Later, having been abusive and threatening ‘A’ and a fellow resident left the Unit. After several further disruptive returns to the outside of the Unit during the night, ‘A’ reported he had been assaulted by a peer and was collected. The incident was reported to local Police and Children’s Social Care. 3.6.2 Of the other 5 occasions of unauthorised absences in January 2014 records confirm that 3 were reported to Police. His link-worker in a subsequent conversation with the allocated worker referred to ‘A’s loneliness. In February mother reported that she had traced the children of her ex-partner and had to be dissuaded from pursuing revenge for what she regarded as him having ruined all their lives. The risk of ‘A’ getting embroiled with his mother’s grievances was recognised. REVIEW HEALTH ASSESSMENT 3.6.3 On 30.01.14 the same nurse as in 2013 completed the routine health assessment. She noted that a ‘strengths and difficulties questionnaire’ (SDQ) had been completed and her completed form referred to stress, getting on with peers and behavioural difficulties. On this occasion sexual health was discussed though there is no indication that ‘A’ shared any fears about his developing sexual preferences. FURTHER EXAMPLE OF SEXUAL EXPLOITATION 3.6.4 On 08.02.14 ‘A’ revealed he had been speaking to a man and exchanging intimate self-images via Facebook / Snapchat. The man claimed to have raped a child, sent some apparently sadistic images and made threats to ‘A’. Police responded and because the man lived abroad, involved Interpol. Exchanges between Police and link-worker acknowledged their concern about the possibility of ‘A’ becoming a perpetrator. FURTHER ALLEGATION OF HISTORIC SEXUAL ABUSE & A REFERENCE TO SUICIDE 3.6.5 On 11.02.14 ‘A’ wrote extensively about memories of childhood sexual abuse. His mother later acknowledged the fact of his abuse, though named an alternative perpetrator to the one identified by her son. A strategy meeting was held. Tensions within the family were heightened during February when ‘A’ alleged that his siblings had been selling drugs during one of the unsupervised contacts. His mother acknowledged needing supervised contact. ‘A’ apparently spoke to her about suicide at around the time of a successful supervised ‘Mother’s Day’ contact, claiming he knew someone who had jumped to their death whilst Police were present. CAE 20 STATUTORY REVIEW 9: MARCH 2014 3.6.6 On 13.04.14 ‘A’s 9th review was held. ‘A’ attended and contributed. Mother was not present. The record again includes the mis-leading response (possibly ‘copied and pasted’) to the question ‘what is the chosen care plan for this child?’- ‘long term foster placement until independence - It is felt this foster placement within a therapeutic residential home continues to be the most appropriate placement for ‘A’ at this time and his mother’. 3.6.7 By April ‘A’s claims that he was bi-sexual3 had become more assertive and he included this contention on FaceBook. The outstanding ABE interview was scheduled for a date in April but cancelled when ‘A’ (actually en-route to the event) felt unable to manage it. ALLOCATION OF A SOCIAL WORKER 3.6.8 With effect from 13.05.14 a social worker SW2 from the ‘Looked After Children LAC Team’ was allocated. SWRO had made her farewell visit in mid-April and provided a useful summary of relevant issues. Aside from the still outstanding psychotherapy (according to Brighton & Hove, to be twice weekly) her summary offered no hint of the differing perspectives described below. 3.6.9 What emerged from interviews during the course of the review is that when SW2 subsequently obtained a post in the newly-formed ‘Adolescent Pod’, it was agreed that she should (for the sake of continuity) retain ‘A’s case. Similarly as later described, an element in the planning for a transfer to a foster home prior to ‘A’ being 18 was that it would ensure ongoing involvement by SW2 and IRO1 with whom ‘A’ was very familiar. Comment: the wish to minimise change for a young man who had already endured so much of it, was commendable. 3.6.10 The first supervision record of 22.05.14 of SW2 notes that the Care Plan was for ‘residential placement’. Records of reviews and supervision notes of both allocated workers are not wholly consistent in how they describe desired and anticipated future placements. 3.6.11 The analysis section of SW2’s supervision record of 22.05.14 recorded …‘current concerns about lack of education at current placement for ‘A’. This is historical and Unit has not responded to decisions made at last PEP (Personal Education Plan). Provision by the school is inappropriate, school reports required. SW2 to follow up with the Unit to send school reports and evidence of work done with ‘A’. BTEC application requested in October, still not done by school. SW2 to discuss with school for completion and submission of application. SW2 will visit ‘A’ on return from leave’. 3 According to the Office for National Statistics (ONS) 1 in 30 young people (aged 16-24) in Britain identify themselves as lesbian, gay or bisexual. This is an increase from 1 in 38 4 years previously. The national average for all ages is 1 in 60 Release: Sexual Identity by Age Group [email protected] CAE 21 Comment: interviews have confirmed a fundamental difference of expectations; Brighton & Hove’s Virtual School4 (in particular newly appointed VS2) expecting clear educational targets and measured progress whilst the Unit’s priorities were mood or behaviour-related ones, on the basis that only when self-esteem or motivation were sufficient could a pupil make educational progress. RE-CONVENED PEP REVIEW 3.6.12 What had apparently been a contentious PEP review in early May promoted a re-convened meeting on 30.06.14. The psychotherapy that had been agreed in September 2011 to be necessary had begun (nearly 3 years later). Recognition of the need for or availability of, other psychological or psychiatric perspectives does not appear in records at this time or subsequently. 3.6.13 ‘A’ declined a planned contact with an unidentified family member in mid-July and was noted to have a lowered mood state. He was reported missing (for the final time that year) on an occasion in August when he chose to stay out at a friend’s party. ‘A’ remained in constant contact throughout his absence and a return interview was completed by a duty officer from SW2’s team and no concerns were identified. Comment: this episode and others like it also highlighted a difference of perspective and priority; SW2 regarding such conduct as typically adolescent and not of itself, necessarily indicative of the high level of emotional disturbance ‘A’ was enduring. STATUTORY REVIEW 10: SEPTEMBER 2014 3.6.14 ‘A’ and his mother were present at his 10th review, the records of which added little to previous accounts of events and proposed responses. SW2’s records dated 01.10.14 implied a more rigorous evaluation of progress. They referred to a ‘lack of a coherent plan for ‘A’ to move on into less support’ and the option of a further foster home was specified. At a supervision session with supervisor 2, there is increased emphasis on the need for ‘A’ to develop the ability to be more independent and upon his educational deficits. 3.6.15 As part of a corporate review in November of high cost placements IRO1 contributed his clear view that ‘A’ should remain at his Unit until he was 18 when a planned move to more independent setting would be justified. The case was debated at a ‘Care Planning Panel’ on 02.12.14 and a target date of 2015 was set for there to be further discussions with the Unit about ‘A’ moving to an alternative placement. Comment: panel records and reported experiences of operational staff provide sufficient reassurance that case planning was not being ‘cost-led’. 4 Each local authority is obliged to maintain a ‘virtual school’ for its looked after children and the teacher/s who fulfil that function will support, promote and monitor educational progress for pupils who may be placed in a wide variety of educational settings within and outside of the responsible local authority. CAE 22 3.7 2015 / 16 3.7.1 In early 2015 the Unit described ‘A’s behaviours as ‘pretty horrid at the moment’. ‘A’ was still attending a local college 2 days per week. Staff referred to him feeling very sad and experiencing lots of loss. As a result of an incident around Christmas at his mother’s home ‘A’ was feeling hostile toward her and there was very limited contact for 3 months. HT1 had met with a ‘youth employability adviser’ and options for educational and training needs were addressed. A SIGNIFICANT CASE DISCUSSION: JANUARY 2015 3.7.2 On 30.01.15 a meeting was held involving SW2, IRO1 and supervisor 2. A meeting with the Unit was planned and a ‘pathway to independence’ contemplated. This was thought likely to involve increasing time without Unit staff support at the college for some 6 months, unaccompanied trips to meet his mother, joining groups / clubs and being referred to a local youth organisation for lesbian, gay, bisexual and transgender (LGBT) young people. 3.7.3 The planned meeting was held on 09.02.15 and involved HT1 and the service co-ordinator (and author of the report to the SCR). Its record cited the possibility of a planned move to a foster home by the time ‘A’ was 17 and a move to supported lodgings by his 18th birthday. It was agreed that ‘A’ would need a resilient, enquiring carer because some of his ‘denigrating’ behaviours could leave carers feeling wretched. 3.7.4 Records also captured a consensus that ‘A’ doesn't need another family, he is quite clear he already has a family’. The notes reflect a collective concern that ...’ if we leave it much longer, he will be too old & would instead be referred to “supported accommodation” which is less likely to meet his needs’. 3.7.5 Interviews completed during this review clarified the intentions of the case planners viz: if ‘A’ was in a family ahead of his 18th birthday he would eligible for ‘staying put’ (post 18 support). A further and helpful element of planning was that his former allocated worker (SWRO) would be re-allocated to become his ‘personal adviser’ (PA) (a role required by the Leaving Care Act 2000 and associated Regulations). CONTENTIOUS REVIEW HEALTH ASSESSMENT 3.7.6 At a consultation on 12.02.15 with a third nurse, ‘A’ raised a concern he might be dyslexic. According to Unit records, ‘A’ also reportedly discussed having had unprotected sex and (as well as taking a sample for Chlamydia testing) the nurse provided him with 3 condoms. Unit staff who dealt afterwards with a very confused and anxious ‘A’ thought the nurse had insufficient awareness of the young man’s special circumstances or needs. The records made by the nurse refer only to a ‘discussion on sexual health’, did not capture with whom ‘A’ had had intercourse (e.g. age / age differential or gender) and there is no indication that she had been briefed in advance about his specific anxieties or needs. CAE 23 3.7.7 HT1 believed that the risk of unacceptable behaviour had been increased by the way the health appointment had been handled. Comment: there was clearly scope for more effective liaison between health and care professionals so as to offer relevant health care / advice without adding to ‘A’s already high anxiety levels. Of the several Unit staff interviewed by the author, HT1 expressed the greatest level of fear about ‘A’s potential for harming more vulnerable individuals (and for his sexual exploitation). 3.7.8 ‘A’ was maintaining a consistently high level of college attendance though was challenging within the Unit. Staff described him as talking about the future a lot. Whilst still in phone contact with his mother, there had been only 1 face to face meeting since Christmas. DIFFERING VIEWS ABOUT ‘A’S LONGER-TERM NEEDS 3.7.9 During a conversation between SW2 and service & operations co-ordinator about ‘A’s Pathway Plan, the latter indicated that the Unit did not support the idea of a move to foster care. Staff had not (as had been agreed at the February meeting) discussed the plan with ‘A’. This was followed up by an email on 09.02.15 in which it was argued that ‘A’ was ‘too intense for 1 person to manage; there was an ever-present threat of violence and that the proposed timescales left insufficient time to prepare him for such a radical move. Comment: the Unit had been represented at the February meeting and received notes of it; their response indicates that their objections had not been convincingly argued or anyway completely resolved on 09.02.15; interviews during the course of this review indicate that the Unit was a reluctant (though in the final analysis, willing) partner in the plan for a foster placement. STATUTORY REVIEW 11: MARCH 2015 3.7.10 A ‘Pathway Plan Review’ meeting (a formal review of those of 16+) was held and included SW2, IRO1 (chairperson and note-taker) and 2 Unit directors. Differences of opinion about ‘A’s readiness for greater independence / placement in a non-residential environment were debated. The record of SW2’s supervision a week later by supervisor 2 acknowledged doubts amongst residential staff but reflected an even more explicit and determined stance viz: that ‘A’ would move by his 17th birthday to a suitably matched foster home. On 23.03.15 a report was submitted to Brighton & Hove’s Placement Panel which acknowledged remaining differences of opinion but approved the plan to which Brighton & Hove Children’s Social Care was still committed. 3.7.11 ‘A’s reported understanding of a meeting with SW2 on 25.03.15 was that the advantage of being fostered before he was 18 was that he might remain there until he was 24. If he stayed at the Unit, he would need to leave when 18 and subsequent options would be less clear. Comment: the debate between commissioner and provider seems to have resulted in more polarised positions rather than a negotiated consensus; ‘A’ himself appeared unhelpfully confused by the apparent choices. CAE 24 3.7.12 On 13.04.15 IRO1 (who chaired all ‘A’s reviews and knew him well) emailed SW2 to state that the Unit would need to retain and offer a level of continuity after a transfer to alternative care. At interview, he confirmed (as did others) that such continuity was contemplated by means of continuing his college attendance, post-discharge weekly psychotherapy and regular contacts with ‘A’s link-worker. FURTHER REVIEW OF PEP / EDUCATION & HEALTH CARE PLAN 3.7.13 The annual review of ‘A’s special educational needs (SEN) statement (now called Education & Health Care Plan (EHCP) suggested the Unit was perhaps still confused and not wholly behind the authority’s plan. A further ‘professionals’ meeting’ sought to address remaining differences. It was attended by all relevant parties (in February the Unit has been represented by HT1 and service manager only) including a representative of Brighton & Hove’s ‘Children’s Placement Team’ CPT1. Notes (written by supervisor 2) indicate that: …’it was clear throughout the meeting there are still concerns about the proposed move for ‘A’ when he is 17. Clearly his behaviours can be difficult to manage once he has moved out of his comfort zone and this would be difficult for one foster carer to manage alone. Agreed the placement would need a lot of additional support. ‘A’ has engaged well at the Unit and it was agreed it would be ideal if he could continue with the same therapist when he moves. CPT1 advised that the right match needs to be found and they would recommend a referral be put forward for a foster placement in August to start a search. The move would be done in a planned way around his 17th birthday, with Unit remaining involved and supportive Comment: fostering has been spoken of as a possibility in late 2014 and records of February and March joint agency meetings in 2015 include references to that aspiration, albeit without precise timescales. 3.7.14 A director offered a succinct and challenging view stating that… ’the fact is that ‘A’s deep disturbances around ordinary family life cannot be worked out within it’. In response to a request for her views, ‘A’s psychotherapist wrote: ‘My clinical opinion is that ‘A’ is still greatly in need of the containing function the work of the Unit provides through daily, ongoing and intensive therapeutic care. ‘A’ is at risk of regressing to his highly disturbed past behaviours. He needs a very well thought out plan and preparation for his introduction and integration to specialist foster care. Even with this, I believe that the intensity of his needs and ways of relating, which can be extremely denigrating and threatening, will remain a challenge to meet in a foster placement. This is more likely to succeed with careful preparation and with Unit staff providing support, continuity and outreach services….’ CAE 25 3.7.15 At interview, the psychotherapist expressed surprise that what was determined to be a suitable foster home had been identified so soon. She highlighted the not unusual contrast between ‘A’s assurances to his social worker that he did wish to be fostered, with comments to trusted staff that he did not. Comment: the psychotherapist’s surprise is shared by the author; for ‘A’ to be safely contained within a family was a very substantial challenge; that said the options for a young man such as ‘A’ who would inevitably require ongoing support but had no diagnosed condition, were extremely few in number. 3.7.16 The psychotherapist had expected a longer introductory period. ‘A’ had been aware of the plan for some months and had been introduced to and visited the family on 2 subsequent occasions, but (as described below) he was told only a week before Christmas of the final move scheduled for the New Year. 3.7.17 The psychotherapist’s weekly sessions with ‘A’ had not identified any grounds to fear intentional self-harm or suicide. Her anxiety had been about an ongoing risk of sexual exploitation and of the young man being unable to resist acting out some of his violent sexual fantasies. ALLEGATION OF SEXUAL ABUSE BY MEMBER OF STAFF 3.7.18 On 15.07.15 the Unit reported an allegation from a resident that a member of staff was having a sexual relationship with ‘A’. The staff member had been suspended and an appropriate referral made to the relevant West Sussex ‘local authority designated officer’ (LADO). 3.7.19 A discussion between director and SW2 indicated that ‘A’ had made no allegations but spoken of ‘fancying’ the member of staff concerned. A strategy meeting was convened and subsequent joint investigations involving ‘A’ revealed no allegations of abuse and confirmation of some ‘flirting’ on his part. The end result of this investigation was that the member of staff was wholly exonerated and reinstated. 3.7.20 On 14.08.15 ‘A’ went missing briefly whilst on a holiday caravan site. Staff were concerned that he was with younger children whom he had met. Police were notified but ‘A’ returned of his own accord just after midnight and no offences were alleged or disclosed. 3.7.21 At this period, ‘A’ reported in a phone conversation with his previously allocated Brighton & Hove worker (with whom for unknown reasons he was speaking) a preference to move into foster care as soon as possible. In early September SW2 was told by a Unit manager of the still fragile mother-son relationship. Comment: though it varied across time, the underlying quality (attachment / confidence) of ‘A’s relationship with mother / sibs. appeared little changed. CAE 26 REFERRAL FOR A LONG-TERM FOSTER HOME 3.7.22 In early October 2015 SW2 had completed a referral form (which was approved by her manager) and submitted it to the local authority’s ‘Children’s Placement Team’ (CPT). The referral included a reference to, though offered little detail about, the anxiety felt by ‘A’ concerning thoughts of harming females and a possible sexual interest in children. 3.7.23 References within the referral to self-harming were only to scratching / cutting of his arms and (understandably in view of the history of more recent years) no ongoing risk of such behaviour or anything more serious was identified. 3.7.24 The referral form indicated that sexualised conduct had not been an issue since 2007 and that physical violence toward carers was not an acknowledged risk. These assertions were at odds with sexually concerning behaviours and overt violence (inflicting actual bodily harm) toward female staff during 2011 as well as the risks articulated by Unit staff in meetings during early 2015. Comment: for a referral of an individual with such complex needs, the request to identify a suitable placement by November was very ambitious; the extent to which, in seeking a suitable match, an in-house team or (as in this case) an independent fostering agency (IFA) provider ensure that they share all available information with the selected carers is of vital importance in terms of the prospects of the placement sustaining across time. 3.7.25 The referral by SW2 recognised and spelled out the agreed need to sustain the therapeutic weekly input to which child ‘A’ was said to be committed. On 29.10.15 IRO1 completed a visit to ‘A’ who spoke of the proposed move and his wish that it not be rushed. ‘A’ had not seen his mother for a few weeks and was having no contact with siblings at this time. STATUTORY REVIEW 12: NOVEMBER 2015 3.7.26 On 02.11.15 ‘A’s last formal review was convened. Mother and ‘A’ were present (the latter for only the second half) and contributed fully. Both expressed some uncertainty about the planned transfer to a foster home which was contemplated ‘in the New Year’. Neither gave any indication that it represented sufficient threat to trigger self-harm. 3.7.27 A query from the Unit director of what would happen if a suitable placement was not located was left unresolved i.e. records do not describe a contingency position (a plan B) understood and agreed by all parties. CAE 27 INTRODUCTIONS TO POTENTIAL FOSTER CARERS 3.7.28 The Independent Fostering Agency (IFA) that identified a foster home submitted a description of the recommended carers (a mature married couple) to Placement Team staff CPT1 and CPT2. They used an established matching system and evaluated the placement as ‘suitable’ on 02.11.15. Comment: information provided about the carers included reassurances about experience and ability to deal with those at risk of sexual exploitation; it did not refer to their knowledge of or likely ability to withstand, still-evident denigratory conduct nor (even more critically in the context of possibly frequent physical contacts by grandchildren) ‘A’s fears and fantasies about sexual abuse of children. 3.7.29 The couple having been made known to SW2 on 02.11.15, she visited on 17.11.15. SW2 was initially uncertain of their suitability but an opportunity for ‘A’ to meet them was arranged for 01.12.15. In response to a request by the carers for relevant information, a list of examples of ‘A’s denigrating comments / conduct had (after a delay) been emailed on 23.11.15 by the Unit to SW2. 3.7.30 The author has seen an email thread indicating that 2 days later SW2 forwarded the above list to the IFA’s supervising social worker SSW1. She in turn confirmed to SW2 that she had forwarded it to the carers, and has provided evidence of so doing. The safe receipt of that email by the carers remains unconfirmed (the carer has no memory of seeing it). It is though accepted by all parties that the issue of ‘A’s capacity to be denigrating had been discussed with the carers. Comment: though useful in their own right, the examples of ‘denigrating conduct’ represented only a proportion of the information that should have been provided in advance of ‘A’s move. 3.7.31 The introduction on 01.12.15 is reported to have gone well and further short visits were planned – the next being on 07.12.15. ‘A’s link- worker was present at the initial meetings with the carers and noted that they had been unaware of the large number of previously disrupted placements (‘A’ himself shared that information). 3.7.32 SW2 asked the Unit to formulate and provide dates for further introductory visits and required a final move by 08.01.16. A ‘Transition Plan’ was supplied by the Unit on 11.12.15 or 14.12.15 [reports vary]. It confirmed its commitment to ongoing support after ‘A’ moved on. ‘A’ was at that time making positive comments about his potential carers. 3.7.33 Further visits were planned with a view to transfer on 08.01.16. On 18.12.15 ‘A’ spent a whole day with the intended carers. He was told that evening during the course of a ‘farewell’ meal for HT1 (with whom ‘A’ had been close) of the agreed transfer date (previously agreed by SW2 and link-worker in early December). CAE 28 Comment: ‘A’ should preferably have been informed at an earlier and less emotionally-charged period of the previously agreed date of his transfer; Christmas is not generally an auspicious time to effect major changes. 3.7.34 At the author’s meeting with the female carer as well as in a later phone conversation, she could not recall being been told of ‘A’s attacks on female staff at the residential Unit. She was aware of and untroubled by ‘A’s thoughts of being gay or bi-sexual. She reported that she remained unaware of the risks of sexual exploitation or ‘A’s fears of becoming a paedophile. The latter issue had though been included in the referral form submitted by SW2 to her Children’s Placements Team and (as recalled by both social workers) been raised with the carers. 3.7.35 The author undertook investigation of information flow with respect to: What (aside from the referral) had been passed by SW2 to her department’s Children’s Placement Team (CPT) How much of the information provided was subsequently shared by that team and/or by SW2 with the selected independent fostering agency (IFA) What had been shared by the IFA with its nominated carers in advance of the introductory meeting or later Alerting the carers to ‘A’s persistent anxiety that he might be capable of sexually abusing children Formulation of any written risk assessment that recognised and sought to mitigate identified risks 3.7.36 The ‘IFA’s ‘supervising social worker’ SSW1 had been unwell during the course of this serious case review and unavailable to confirm or amend the extent of briefing with respect to the planned placement. On her return to work SSW1 was able to: Report that the agency’s normal practice in response to a potential ‘match’ is to read out the entire referral form to a carer (in her opinion a colleague would have done so and confirmation that this is now standard recorded practice was provided by the registered manager during his meeting with the author) Confirm that in a meeting with the carer (SW2 had not been present) that she had discussed the potential risk with respect to the children of the carer’s daughter. So as to reduce risk, contact between grandparents and children was contemplated at the latter’s’ home rather than at the grandparents’ house 3.7.37 SSW1 accepted that a copy of the referral form had not been left with the carers, nor any risk assessment committed to paper. She was un-surprised to learn that Brighton & Hove had not provided written material ahead of the transfer, indicating that this was a frequent experience across local authorities. CAE 29 3.7.38 In spite of information latterly supplied by SW2 and SSW1 (including a record of the visit made on 17.11.15 by the former), it remains the carers’ perception that they remained unaware about ‘A’s persistent anxiety about sexual predilections. and had been given no written material from either Brighton & Hove or their IFA. 3.7.39 An interview with ‘A’s link-worker confirmed a discussion also recalled by the carer (and contained in a handwritten ‘running record / diary’ of introductions, completed and returned following ‘A’s’ death). It had referred to ‘A’ joining her whole extended family (i.e. including the carer’s daughter and her 3 children) at a ‘Center Parcs’ half-term break. Comment: amongst those involved, there were differing levels of understanding and acceptance of the potential risks that ‘A’ might represent; there was a need to complete a clear risk assessment spelling out precautions needed to minimise the risks that ‘A’ potentially represented. 3.7.40 ‘A’ had, after his introduction to the carers expressed anxiety to his link-worker about what he surmised they had not been told about him. Quite understandably, he lacked the confidence and had not wished to undermine the possibility of acceptance by sharing all his fears and fantasies. Comment: whilst SSW1’s recollection is that the carers had been made aware of the potential risk that A represented; ‘A’ would not have known that and would inevitably have assumed that his potential carers had been denied this important information. It is important that those being placed are clear about what information has been / is being shared with carers. EVENTS ON DAY ‘A’ DIED 3.7.41 The Police report submitted provided a succinct account of the events immediately preceding ‘A’s death on New Year’s Day 2016 when he and other residents were out with staff at a local fast food restaurant. In the author’s view it is unnecessary to provide detail in a document that is to be made public. It does though seem possible that an incident involving ‘A’ and a younger fellow resident reminded ‘A’, of his fear of committing sexual offences against younger children. 3.7.42 ‘A’ immediately left the scene and his responses to texts sent by staff implied a clear intent to self-harm. The last such message was at 18.02 and within a further 10 minutes Sussex Police was notified of a person (later identified as ‘A’) under a train at a level crossing. 3.7.43 Meanwhile, at 18.00 the West Sussex Emergency Duty Team had been alerted to ‘A’ being ‘missing’. 1 hour later the team was informed that Police had attended and reported with 99% certainty that a person killed by a train near a local station was ‘A’. Mother and the on-call manager for Brighton & Hove Children’s Social Care were informed. Mother and sib.2 confirmed receipt of a text from ‘A’ at about 17.30 though its content was not shared at that time. CAE 30 3.7.44 ‘A’ had been due to be taken by his link-worker for his first overnight stay with the carers on Sunday 03.01.16. When he failed to arrive, they were disappointed and assumed he had changed his mind. They did not call the residential Unit (SSW1 believes that they did not have the phone number) and instead awaited clarification of ‘next steps’. Comment: ‘A’s tragic death occurred on a Public Holiday and SW2 did not learn of the event until Monday 04.01.16; she immediately informed the involved IFA and the potential carers were made aware of ‘A’s death when SSW1 made an urgent visit later that morning. 3.7.45 The carers were also disappointed that they were not informed of or invited to, ‘A’s funeral which they would have wished to attend. Comment: the author has subsequently learned that the birth family insisted on nobody outside of the family attending the funeral. That understandable stance should not have prevented the carers being informed about the familial view (which they report they would have respected and accepted). CAE 31 4 RESPONDING TO THE TERMS OF REFERENCE 4.1 QUALITY & TIMELINESS OF CARE PLANNING PREPARATION & PLACEMENT AT ‘A’S THERAPEUTIC UNIT 4.1.1 At the time of ‘A’s placement at his therapeutic Unit, the Care Planning, Placement and Case Review (England) Regulations 2010 had been published, though came into force only in April the following year. 4.1.2 The above regulations reflected established best practice and thus sought to maximise the opportunities for rehabilitation or where that was not possible, a local family-based placement. 4.1.3 The justification for the use of specialist residential care for ‘A’ was overwhelming. ‘A’ was, and arguably remained, incapable of coping with the intensity of emotional demands that prevails in most families. 4.1.4 Though his ‘out-of area’ placement pre-dated the ‘Care Planning Regulations’ requirement for approval of a ‘nominated officer’, the reviewer has no doubts that the decision-making with respect to ‘A’s need and authorisation of expenditure were properly completed. 4.1.5 The fact that the independent placement at the Unit in West Sussex endured for 5 years offers sound evidence that the choice of placement was a well-informed one. The safe consistent care and unconditional commitment shown him by staff enabled him to make (notwithstanding his un-timely death) substantive developmental progress. 4.1.6 Whilst acknowledging the justification for and effectiveness of the placement at his Therapeutic Unit, no evidence has been presented to confirm any preparatory enquiries of the ‘area authority’ in terms of educational or psychological / psychiatric support. SUPPORT & OVERSIGHT OF PLACEMENT 4.1.7 Though the allocated ‘social work resource officer’ SWRO was clearly very committed and competent in meeting the many and varied needs of ‘A’ and his family, such a complex case should have been allocated to a registered social worker. A check of published reports has confirmed that Ofsted in its inspections of Brighton & Hove in 2011 and 20135 had also identified and challenged this issue. The author has been assured (and a more recent Ofsted report confirms) that all looked after children are now allocated a registered social worker. 4.1.8 Setting aside the issue of her qualification, the continuity of support from SWRO coupled with the consistency of his independent reviewing officer (IRO) were helpful to ‘A’. 5 See reports at www.ofsted.gov.uk/ CAE 32 4.1.9 IRO1 developed and maintained a constructive professional relationship with ‘A’ and records confirm that ‘A’ (and to the extent possible by her level of functioning at any one time) his mother were invited to contribute to all statutory reviews. 4.1.10 IRO1 also fulfilled a less obvious and more informal role particularly during the planning of ‘A’s move to a foster home. IRO1 and Unit director met and undertook broader (unrecorded) discussions about the challenge ‘A’s needs and insufficiency of resources posed. 4.1.11 Paradoxically, the reflective and considered approach of these highly experienced professionals may have further reduced the possibility of an explicit challenge by the Unit of Brighton & Hove’s plan. TRANSITION PLANNING 4.1.12 A retrospective examination of records and the reflections of involved professionals highlights the anxiety felt by ‘A’ himself and a proportion of adults seeking to work in his best interests. 4.1.13 Most residential staff, ‘A’s psychotherapist and to a lesser extent IRO1 and SW2 were initially uncertain about the prospects of ‘A’ being able to make the transition to a semi-independent life outside of the total institution in which he had spent formative years (in consequence becoming dependent and somewhat institutionalised). 4.1.14 Though the doubts of various individuals were articulated in various planning forums, they were never entirely reconciled and shaped into a clear consensus. In the mind of the reviewer, there were 2 distinct and in their own right legitimate narratives being played out in the months prior to planned discharge. 4.1.15 The commissioning local authority initially via its ‘Care Planning Allocation Panel’ addressed the ‘outer world’. It perceived an age-related need for ‘A’ to achieve a degree of independence via a route that maximised continuity of professional input (SW2 and IRO1) and would attract a right to post-18 ‘staying put’ support. 4.1.16 Those whose relationship was a close and more personal one (residential staff and his psychotherapist) developed an alternative perspective. They sought to distinguish what they interpreted with considerable anxiety to be a façade of confidence, from the continuing turmoil in ‘A’s inner world and the risks that would ensue for him (via sexual exploitation) and potentially others (if he were to act out his sexual fantasies). 4.1.17 A more robust dialogue perhaps involving formal challenge or complaint might have rendered more visible and accessible the experience over 5 years of ‘A’s characteristic responses i.e. that fear of rejection and/or loss of control typically prompted him to appear more confident or competent than he actually was. A challenge might also have prompted the commissioning of an independent opinion (see below). CAE 33 4.1.18 ‘A’s inner world was typically revealed only to those whom he knew extremely well and trusted. Unhelpfully, such trust was often made evident by aggressive or rejecting conduct. 4.1.19 The therapeutic Unit itself is accredited by the Royal College of Psychiatry and staff receive regular supervision and support from appropriately registered sources e.g. Tavistock Clinic & Portman NHS Trust . It appears that the very real professional competence and confidence within the Unit coupled with a presumption amongst Responsible Authority staff (including IRO1) that the Unit had sufficient expertise mean that the possible need to seek additional (including psychiatric) opinion about ‘A’ and his prognosis was not considered at any of the many meetings such as statutory reviews. 4.2 EFFECTIVENESS OF INTER-AGENCY CO-OPERATION Unit – Police 4.2.1 The reports from the Unit and Police refer to a total of 27 calls made to report ‘A’ as absent without authority or missing. Accounts provided offer sufficient confirmation that all episodes were handled in a sensitive and proportionate manner by both agencies. Aside from the responses of uniformed Police to reports of ‘A’ being absent / missing, the ‘Safeguarding Investigations Unit’ (SIU) collaborated well with the Therapeutic Unit and made all reasonable efforts to enable ‘A’ to complete an ABE interview about his alleged historical abuse. Unit – Responsible Authority 4.2.2 Until early 2015, records and feedback from those interviewed provide reassurance that the level of inter-agency co-operation was across time, very good. As highlighted by Brighton & Hove’s report submitted to this review, in spite of numerous dramatic incidents which had the potential to ‘split’ the adults working to safeguard and promote ‘A’s welfare, the following few were the only ones that potentially undermined that co-operation: The Unit’s stance of allowing staff who had been assaulted to determine whether they would make a formal allegation of crime An insufficiently explored or challenged delay in initiating the psychotherapy agreed in 2011 Concerns about the very limited educational offering to ‘A’ (Of greatest relevance) the differing perspectives and level of concern about the risks that ‘A’ faced and represented as he moved toward a foster placement in late 2015 CAE 34 4.2.3 Of those potential challenges, the first one might usefully have been established by commissioners prior to the placement. The dilemma of balancing the interests and rights of children and staff remains in all such placements (according to a House of Commons Committee6 and Howard League for Penal Reform, the more typical and in their view unhelpful, response to less serious conduct than that displayed by ‘A’ would be to criminalise it7). 4.2.4 The delay from 2011 to 2014 before initiation of psychotherapy (as described earlier in this report) offers an example of a discernible difference in organisational culture. From the Responsible Authority perspective, the service should have begun as soon as possible but in any case by the time of the next review. From the perspective of the residential provider, the delay not only reflected the superficial difficulty of identifying an appropriate psychotherapist but more importantly, a considered judgment about ‘A’s capacity and willingness to engage with such therapy. In the view of the psychotherapist herself , ‘A’ would not anyway have been able to make use of the therapy he received any earlier than it began in 2014. 4.3 EXTENT TO WHICH ‘A’S ‘VOICE’ WAS HEARD 4.3.1 In his early years, ‘A’s voice was relatively inaudible because the vast majority of contacts by professionals were with his mother. The psychiatric opinion which reinforced the commissioning of residential therapeutic care was a function of his behaviours and had been provided by a skilled and experienced specialist. 4.3.2 It is clear that ‘A’ was fully involved by SWRO, SW2, residential link-workers and teaching staff. This is apparent from records of regulatory visits to the Unit, everyday dialogue with link-workers, daily ‘house meetings’ and regular LAC reviews (where his wishes and feelings were sought before and during meetings). 4.3.3 The more significant challenge faced by Unit staff and the Responsible Authority was how and to what extent ‘A’s expressed and variant views should be weighed against his non-verbal wishes / feelings. ‘A’s feedback to Unit staff of a meeting in March 2015 with SW2 does suggest that ‘A’ was confused about the apparently stated advantages of a foster home over further residential care viz: a potential home until his 25th birthday versus leaving the Unit at 18 with no certainty. 4.3.4 The planned transfer date of 08.01.16 was arguably arbitrary though the author is satisfied that it was not shaped by financial concerns about the costs of 2 contemporaneous placements. ‘A’s voice (via feedback after each contact with the carers) should have been more prominent. Such opportunities were diminished by an unfortunate coincidence of Xmas and SW2’s annual leave. 6 In 2013, the House of Commons Justice Committee concluded that more effort was needed from local authorities, children’s homes and prosecutors to prevent the unnecessary criminalisation of vulnerable children in care and care leavers. 7 More recently (2016) the Howard League for Penal Reform ‘Criminal Care: ‘Children’s Homes and Criminalising Children’ has reported that ‘looked after’ children in children’s homes are being criminalised at excessively high rates compared to all other groups, including those in other types of care. CAE 35 4.4 SELF-HARMING EPISODES 4.4.1 ‘A’s self-harming was more evident in the early days of his placement e.g. 1 such episode in 2010, 6 in 2011 and a further 1 in 2013. The total of 8 episodes occurred in the following order: Self-inflicted 3 inch cut to right leg (reported by him to be a self-punishment for being open with his feelings at a ‘Children’s Meeting’ (29.09.10) An attempt (prevented by staff) to throw himself downstairs because he reported he wanted to hurt himself (22.02.11) Scratching of arm with a broken light bulb, linked by him to anxiety about the imminent interview with Police (05.03.11) Further scratching, this time of the back of his hands; on this occasion whilst staff were able to prevent his actions, ‘A’ was unable to offer an explanation of what had triggered the event (19.04.11) A threat to jump from a bannister, which action was prevented by staff (21.04.11) Reported ingestion of (fish tank and window) cleaning product and orange juice (06.10.11) Whilst in a barricaded room, superficially cut hands, arms and forehead and expressed a wish to be hospitalised (07.10.11) Used sharp blade to cut right forearm with consequent loss of blood and need for stiches (13.12.13) – thought to be linked to self-harming of a then fellow-resident 4.4.2 The report supplied by the Unit points out that self-harm for ‘A’ was typically not a private activity and may have represented a means to illustrate distress when he was unable to finds the words to describe it. 4.4.3 Over time the rate of such incidents decreased and the analysis offered by the Unit’s report suggests that the driving force for self-harm (underlying distress) was managed well and (until the prospect of leaving and re-entering a family arose) sufficiently contained. 4.4.4 Just as ‘A’s affect and conduct varied over time, there were occasional morbid thoughts: October 2013 when he laid a rose at the site where an individual unknown to him, had drowned December 2013 (the cutting episode described above) April 2014 when ‘A’ reported that he had spoken with his mother about knowing someone who had jumped to their death whilst Police were present CAE 36 4.4.5 A risk assessment dated July 2015 spelled out the anticipated rise in ‘A’s anxiety levels as his move-on drew closer and the consequent increasing risk of renewed self-harming. 4.4.6 The witness statement provided to British Transport Police by a Unit director identified (with the advantage of hindsight following the death) a number of possible indications that he had been planning to kill himself. She also cited his mother as having alerted an unidentified member of staff in Brighton & Hove to relevant references (which she recalled included stepping in front of a train). 4.4.7 The report submitted by Brighton and Hove made no reference to any such alert and a re-examination of records and renewed enquiries of SW2 and records maintained by Children’s Social Care and Adult Services (for mother’s mental health needs) have not confirmed the accuracy of the claim. 4.4.8 In contrast to the view formed by that director it seems to the author and the review steering group that ‘A’s death was more likely to be a function of the following 2 factors, of which the former was recognised and being partially managed, and the latter recognised but essentially beyond immediate containment by staff present at the time: ‘A’s generalised anxiety about the imminent transfer to a foster home (and more specifically possible exposure to the carers’ grandchildren) The impact of what went through ‘A’s anxious and fearful mind about what he may have wanted or planned to do when he and a younger resident absented themselves from staff supervision less than 1 hour before his death 4.5 ANY ISSUES RELATING TO FAMILY CONTACT 4.5.1 ‘A’s attachment to his mother was a very anxiety-laden one which posed enormous challenges to all involved professionals. 4.5.2 Records indicate and interviews have confirmed that the relevance and importance of familial contact for ‘A’ was clearly recognised and facilitated well. Arrangement for contact naturally varied over time but always seemed to be flexible according to prevailing conditions and anyway rooted in what was regarded as his best interests. 4.5.3 Though mother was not always in agreement with arrangements made, she was exceptionally well supported by the Unit and in turn had a respect for the considerable efforts that staff there expended on supporting her son’s development. CAE 37 4.6 VIOLENT & AGGRESSIVE OUTBURSTS 4.6.1 ‘A’s numerous episodes of violence (a proportion targeted toward females) seems to have been handled extremely well within the Unit. Whilst his wish to ‘test the limits’ was recognised, at no point did staff contemplate giving up on the commitment made to ‘A’ and his family. 4.6.2 As described in section 3, there existed a significant difference of view between that which is more prevalent in society and the more ‘understanding / insightful / accepting’ perspective of those within the environment in which ‘A’ spent some 5 years. 4.6.3 SWRO and SW2 (and their employing agency) whilst sympathetic to ‘A’s underlying distress, were closer to the attitude of wider society in thinking that a physical attack resulting in actual bodily harm justifies Police involvement, potential arrest and criminal charges. Comment: A significant proportion of those who enter the criminal justice system re-offend8 - there may be scope for clearer pre-placement elaboration of what being placed in a therapeutic environment may or will actually mean in the event of future conduct that would be regarded as ‘criminal’ elsewhere - the weight of evidence is though insufficient to justify any recommendation. 4.7 SEXUALISED BEHAVIOR 4.7.1 As early as November 2010 when ‘A’ was 12 he was sharing with staff some of his disturbing preoccupations with violent sex and paedophilia. The view within his Unit was that therapeutic work would need to be undertaken lest these confused anxieties become ingrained and a dominant part of his personality. 4.7.2 The following further specific references to concerning or atypical sexual behaviours emerge from the Unit’s records: ‘A’s ‘very dark, violent sexual fantasies’– perception of sex and sexual relationships remain distorted and scary for him’ (report for April 2012 review) ‘A’ referred to his swapping naked pictures with a man whose number he had seen on a toilet door; he admitted that a part of him wanted to meet the man (January 2013) A blindfolded baby doll (acknowledged to be a masturbatory toy) was found in ‘A’s room with a cord around its neck (December 2013) 8 Latest (2012/13) Ministry of Justice statistics show that of the 49,369 10- to 17-year-olds who were either cautioned, or handed a community or custodial sentence between July 2012 and June 2013, a total of 18,090 went on to reoffend within 12 months – a rate of 36.6 per cent. The re-offending rate for those released from a custodial sentence was even higher at 68.5%. CAE 38 ‘A’ contacted a paedophile via the internet; the man’s claim to have raped a 9 year old stirred up anxieties about ‘A’s own victimisation and he admitted some motivation to abuse (February 2014) ‘A’ admitted to an attitude toward females that left him fearful for what he might do to harm them (March 2014) ‘A’ (by then rising 16 years of age) reported sexual activity with a girl whilst absent without leave (August 2014) ‘A’ repeated his concern about what might happen if he made the ‘wrong’ choices in life and said that his deepest worry was being a paedophile (September 2014) ‘A’ was still preoccupied his fear of becoming an abuser at the time of his annual review report in March 2015 4.7.3 With respect to those events that required such a response, staff and subsequently his allocated worker took all appropriate safeguarding measures. 4.7.4 The trust that ‘A’ placed in staff in his Unit enabled him to verbalise his dark fears with less fear of rejection than he had experienced in all previous family placements. 4.7.5 The Unit’s report to this serious case review highlighted the importance of his individual psychotherapy that after considerable delay, began in Summer 2014. Though the March 2015 reports noted that there had been no sexualised behaviour toward peer group or adults for some time, the behaviour re-emerged in July 2015 when ‘A’ grabbed the testicles of a younger resident whilst ‘play-fighting’. SW2 was appropriately alerted to that incident. 4.7.6 The same report urged Brighton & Hove representatives to enable ‘A’ to continue to address and explore his disturbed thoughts and feelings around sex and sexuality within a planned and managed environment i.e. the current Unit. 4.7.7 The author of the report supplied to the SCR explains that ‘it was feared that if ‘A’ left the Unit prematurely it could leave him catastrophically exposed, forcing him to return to his older habitual defences as the only means of psychological survival. This would leave him out of touch and therefore out of control and regulation of his deep relational and sexual disturbances. There would invariably be an increased risk of them being dangerously enacted’. 4.7.8 A report from his psychotherapist in March 2015 includes a warning that……’although ‘A’ has made huge progress, a less intensive placement would struggle to contain him safely’. CAE 39 4.8 SUFFICIENCY & QUALITY OF PSYCHIATRIC / PSYCHOLOGICAL SUPPORT 4.8.1 Without regard to the quality and quantity (regularly monitored via reviews) of direct therapeutic care, psychotherapy and social work, there remained an unmet need for a psychiatric perspective. 4.8.2 The Royal College of Psychiatry Report CR 195 ‘When to See a Child and Adolescent Psychiatrist’ suggests a consultant CAMHS psychiatrist ‘should be involved in the care of any patient who has… the possibility of a mental disorder and there is a risk to self or others’. 4.8.3 The above report offers a non-exhaustive list of mental health conditions when psychiatric involvement with children may be useful, of which 3 relevant categories refer to those: ‘With emotional and behavioural problems, particularly when parental mental illness is a significant factor in the child’s presentation Who have experienced complex trauma (often in the context of child abuse) With emerging emotionally unstable personality disorder’ 4.8.4 The report was not published until 2014. Thus, the reference to it is made here so as to inform future, rather than criticise past professional practice. 4.9 FORMALLY ‘NOTIFIABLE’ INCIDENTS & ANY ADDITIONAL ISSUES OF RELEVANCE 4.9.1 So far as can be determined from records supplied, all events that required notification to the area or placing authority or regulatory body Ofsted were duly notified by the therapeutic Unit and no additional issues considered to be of relevance have been identified. CAE 40 5 FINDINGS & CONCLUSIONS 5.1 GOOD & SUB-OPTIMAL PROFESSIONAL PRACTICE 5.1.1 An exploration of the services provided to ‘A’ and his family over the period of review has identified effective systems and good professional practice as well as other examples of systemic weaknesses or sub-optimal practice. STRENGTHS OF SERVICE DELIVERY 5.1.2 The following organisational and/or individual achievements undoubtedly assisted an extremely troubled ‘A’: The care, commitment and skill of staff at his therapeutic placement and the consequent stability those features offered ‘A’ An unusual and welcome continuity with only 2 allocated workers, 2 Unit ‘link-workers’ and 1 independent reviewing officer (IRO) across 5 years in placement Persistence, in spite of its intrinsic complexity, in efforts by Unit & Brighton & Hove staff to involve ‘A’, his mother and siblings in maintaining contact with one another ‘A’s high level of involvement in an age and stage-appropriate manner in day to day and long-term planning OPPORTUNITIES FOR LEARNING / IMPROVEMENT 5.1.3 A retrospective evaluation of the multi-agency efforts made to care and plan for ‘A’ also inevitably identified opportunities for organisational and individual learning. These can usefully be summarised under 3 headings: choice and initiation of placement, issues arising during that placement and transition toward what was hoped would become greater independence. Choice & initiation of placement 5.1.4 On the basis of then known needs, the choice of an out-borough residential therapeutic community was justified by the evidence of many failed family-based alternatives. The evaluation by Ofsted of this particular Unit as ‘outstanding’9 may have added confidence about its potential use, but no evidence has been located of pre-placement enquiries by the Responsible Authority to determine the existence and potential availability of relevant local facilities e.g. CAMHS or of the likely (and actual) limits to the Unit’s educational offering. 9 www.ofsted.gov.uk/reports URN SC449155 ; the Unit was rated as ‘good’ at its latest 2016 inspection. CAE 41 Issues arising during placement 5.1.5 Whilst there was a high degree of compliance with elements of the Care Planning and Review Regulations (initially 2010 and later the 2015 amended equivalent) e.g. frequency of visits, independently chaired reviews, an ‘agreed’ need for additional therapeutic support was not met for 3 years and at no point was the possibility of seeking a multi-disciplinary assessment of risk to self or others, discussed. 5.1.6 There was a significantly differing perspective between those who knew ‘A’ very well and their recognition of the potential risk he represented (‘A’s ‘inner world’ was one that frightened him and triggered a significant level of concern about his potential to harm others), versus those whose actions were largely influenced by his age and a more pragmatic concern to avoid a sudden ‘step-down’ from the high level of support of the sort provided since 2010. Transition toward greater independence 5.1.7 Differences of perspective / philosophy and risk assessments required more rigorous debate and potentially escalation. Had there not (during 2015 especially) emerged mutual frustration between Unit and Responsible Authority and a distraction from shared goals, the potential for achieving the following could have been enhanced: A more extended introduction rooted in agreed interpretations (by Unit and Responsible Authority) of how ‘A’ was actually coping with incremental steps toward his move (brief visit, overnight stay, weekend, few days etc) Formulation of a contingency ‘plan B’ to anticipate a likely (in the reviewer’s judgement) disruption of placement 5.1.8 The effectiveness of transition planning was also undermined and a disruption rendered more likely by a failure: Primarily of Brighton & Hove but also of the IFA to adequately brief and provide carers with a written summary of ‘A’s background, Placement and Care Plan and other (risk management) advice (see reg. 9 and Sch.2 Care Planning Regulations 2010); its absence left them insufficiently informed and able to mitigate behaviours posing a risk to ‘A’ himself or others To make it clear to ‘A’ what personal information had actually been shared with his potential carers 5.1.9 Amongst those who knew ‘A’ well and cared greatly about him, neither professionals or family had discerned that he was thinking about self-harm. Subject to the Coroner’s Judgment, it appears that behind a ‘brave face’, anxiety about leaving the security of his home of 5 years to face the emotional pressure of normal family life, expectations of age-appropriate education and above all, an immediate panic about what sort of a person he might become, overwhelmed him. CAE 42 6 RECOMMENDATIONS 6.1 INTRODUCTION 6.1.1 Individuals who had worked with ‘A’ were prompted / encouraged by his death or this review to reflect upon alternative judgments / actions. 6.1.2 The review has sought to avoid a preoccupation with individual errors and in spite of the tragically premature end to ‘A’s life, a critical examination of the sometimes extraordinary efforts made by professionals has identified only a few systemic learning opportunities within the agencies specified below. 6.2 ACTION REQUIRED OF AGENCIES 6.2.1 In addition to the potential for internal improvements identified by some agencies (e.g. procedural changes at the therapeutic Unit, further training about the vulnerability of care leavers by Brighton & Hove), the more substantive opportunities for agency-wide improvements are as follows: BRIGHTON & HOVE CHILDREN’S SOCIAL CARE 6.2.2 Brighton & Hove should assure itself that, with respect to its looked after children: All relevant available information is being passed over (when possible ahead of placement) in accordance with Care Planning Regulations 2010, to those individuals who are be entrusted with the care of a child That the individual being placed is provided with an age-appropriate appreciation of information being passed over All Care and Placement Plans (the priority being ‘high risk’ cases) include a clear contingency position (a ‘plan B’ as per para. 2.45 Volume 2 Care Planning, Placement & Case Review Regulations Guidance 2015) SUSSEX PARTNERSHIP NHS FOUNDATION TRUST In the context of ‘Who Pays’ Commissioning guidance, the Trust should continue to progress discussions with the relevant 3 authorities (West Sussex, East Sussex and Brighton & Hove) to facilitate access for ‘looked after children’ to specialist mental health services for those placed ‘out of area’ and still remaining within Sussex THERAPEUTIC UNIT Management should review organisational capacity (knowledge and assertiveness) to challenge any Care Plan about which the Unit has insufficient confidence Overview draft report ‘A’ Brighton & Hove Safeguarding Children Board 04.05.17 CAE 43 7 GLOSSARY: ABBREVIATIONS / PROFESSIONALS Abbreviation Meaning ABE Achieving Best Evidence A&E Accident and Emergency Department CIN Child in Need EHCP Education and Health Care Plan IRO Independent Reviewing Officer LSCB Local Safeguarding Children Board NPIE National Panel of Independent Experts PA Personal Adviser SIU Safeguarding Investigation Unit (Sussex Police) SCR Serious Case Review SDQ Strengths & Difficulties Questionnaire SEN Special Educational Needs CAE 44 8 BIBLIOGRAPHY Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008 Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 Published December 2008 The Child’s World Jan Horwarth Jessica Kingsley 2008 What can we learn from a decade of reviews of child fatality and serious harm from maltreatment from the 4 UK nations? Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE Healthy Child Programme DH 2009 A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009 Getting it right for children and young people – Overcoming the cultural barriers in the NHS so as to meet their needs -Sir Ian Kennedy September 2010 Personal Communication: Dr Kwadwo Osei - Nyame, Jnr (D.Phil/PhD Oxford) Lecturer in African Literature, Cultural and Diaspora Studies Africa Department School of Oriental and African Studies (SOAS) University of London 2011 [related to previous case of proven force feeding in another area] Working Together to Safeguard Children, HM Government 2010, 2013 & 2015 Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Munro Review of Child Protection: A Child-Centred System TSO www.tsoshop.co.uk Professor Munro 2011 Learning together to safeguard children: a systems model for case reviews SCIE January 2012 New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012 Improving the Quality of Children’s Serious Case Reviews Through Support & Training@ NSPCC, Sequili, Action for Children; DfE 2013 (revised Feb. 2014) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Criminal Care: ‘Children’s Homes and Criminalising Children’ Howard League for Penal Reform 2016 |
NC52485 | Death of a 4-year-8-month-old boy in December 2020. His mother admitted to drowning him in the bath. Learning includes: recognise that children in need and who no longer require a child protection plan can potentially have long-lasting vulnerabilities or risks of harm; inaccurate or imprecise language such as 'children doing well' may not support critical thinking and can give false assurances; the importance of recognising the interaction of mental health and other risk factors such as adverse childhood experiences of the parent; the importance of responding to changing risk and need; and the importance of adult orientated issues being assessed in their own right and for their impact on the child. Recommendations include: revise guidance for assessments and reviews within the community mental health service; reinforce the Think Family approach to safeguarding and promote joint working across adult and children services; consider using an interpreter or alternative forms of communication when imparting complex medical information to a parent for whom English is a second language; information sharing when a child is given a diagnosis and a parent is known to adult mental health services; staff remain curious with regard to culture and family composition, and understand the cultural impact of diagnosis of children with additional needs; an established process for stepdown from a child in need plan to an early help plan; and the inclusion of important historical information when services make referrals to early years services or schools.
| Title: Local child safeguarding practice review [Child B]. LSCB: Greenwich Safeguarding Children Partnership Author: Colin Green Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview Report CHILD B 130721 v4 Local Child Safeguarding Practice Review Commissioned by Greenwich Safeguarding Children Partnership (SCP). 1. Introduction 1.1. This overview report was commissioned by Greenwich SCP following the death of Child B on 27th December 2020. A rapid review of the circumstances of Child B’s death was held on 7th January 2021. The rapid review agreed that the criteria for a local child safeguarding practice review were met as the abuse or neglect of Child B was known or suspected, he had died and that a review might highlight improvements needed to safeguard and promote the welfare of children. 1.2. Child B’s mother has been arrested and charged with his murder. No date has been set for her trial. An inquest into Child B’s death has been opened and adjourned. 1.3. There were no indications in the period prior to Child B’s death that his Mother’s mental health was deteriorating or that she would harm Child B. 2. Principles underpinning the review • To remember at all times that the main purpose for undertaking a Local Safeguarding Partnership Review is to learn and improve. • Recognition that safeguarding children is complex and errors are made. • It is important to understand not only who did what, but why they did what they did, the underlying reasons that led individuals and organisations to act as they did are equally important in obtaining a full understanding of what happened • The review will seek to understand practice from the viewpoint of the individuals and organisations and form a view based on what was known and what was knowable at the time rather than using hindsight. 2 Overview Report CHILD B 130721 v4 • Relevant research and case evidence will inform findings and recommendations. • To take a child-centred approach. 3. Key questions agreed for the review are: • Was information shared appropriately across agencies as well as internally? • How much of an impact did Covid-19 have on this case? • How effective was management supervision and oversight in this case? • What support was there for mother’s mental health, including around the time of Child B’s autism diagnosis? • What was the impact of mother’s mental health on her parenting capacity? • Was the family history understood by all agencies especially in relation to Child B’s Supervision Order and support following the end of the supervision order? • What impact did the culture and ethnicity of the family have? • As a result of the learning identified, what will your agency do differently? • Sharing of Child B’s diagnosis with mother and availability of support to mother. • Community support for Mother and Child B 4. Review Period The review period was agreed as 1st January 2018 to 27th December 2020. 5. Methodology The methodology used by the review was a hybrid model. Building on the information shared by the Rapid Review process each agency was asked to undertake an Individual Management review (IMR) and provide a chronology of their involvement. This allowed them to analyse their own agency practice and identify learning to contribute to the overall findings. The review panel discussed the IMRs and the draft overview report to reflect on the information provided and agree learning and recommendations. The 3 Overview Report CHILD B 130721 v4 family were given the opportunity to contribute to the review but at this stage have not felt able to do so. 6. Description of Child B Child B was 4yrs and 8mths old when he died. Child B was described as a well-cared for child. He was always neat and clean in his dress. His school described him as fun, loving and sometimes mischievous. He would sometimes grab adults to give them a big hug. His relationship with his mother was described as warm. 7. Child B’s Family Child B Subject DoB 30/04/2016 Mother 37 yrs Father age Unknown – lives in Lagos Brother 13 yrs – lives with Father in Lagos Maternal Aunt Lives in London Child B was of black African heritage. Both of his parents were from Nigeria. His Father lives in Lagos. Child B had an older brother who is 13 years and lives with their Father. Child B’s mother came to the UK in 2008 on a student visa after the birth of her older son. She has a sister living in London. 8. Significant history prior to the review period 8.1. Child B’s Mother suffered her first serious mental health breakdown in 2011/12. She was treated from 18th July 2012 by Greenwich Early Intervention in Psychosis Team. She was transferred to the Greenwich East Intensive Case Management Team – Psychosis (ICMP) on 12th April 2016. This was just before Child B’s birth. Child B’s Mother was diagnosed as 4 Overview Report CHILD B 130721 v4 suffering from an enduring mental illness, Paranoid Schizophrenia, and this needed follow up treatment in the community to support Child B’s Mother in managing her treatment and symptoms. This care and support were provided under the Care Programme Approach framework. 8.2. When Child B’s Mother became pregnant with Child B, she stopped taking her medication however her mental health deteriorated and her medication was restarted during her pregnancy. This evidenced that when Child B’s Mother was not medicated her mental health was likely to deteriorate significantly. In January 2016 Child B’s Mother was referred to Greenwich Children’s Social Care (CSC) by the Best Beginning Midwifery Service. The referral gave Child B’s Mother’s diagnosis and mental health history with other relevant background information. This led to a child and family assessment. The assessment concluded just before Child B’s birth that a robust Child in Need (CIN) plan was needed. This led to a CIN meeting in March 2016 which included Child B’s Mother, CSC, Adult Mental health Services, Best Beginning Midwifery, Specialist Health Visitor (Mental Health) and Early Help. The CIN meeting agreed a detailed package of support. The Social Worker (SW) completed a detailed risk assessment that was shared with the professionals involved and Child B’s Mother. The way services responded to Child B’s Mother’s pregnancy and her needs as a prospective parent with a serious mental illness and to Child B when he was born was good practice. 8.3. In February 2017 following a risk assessment the CIN plan ended as Child B’s Mother was accepting support and engaged well with the professionals in her network. The family were stepped down to Early Help and targeted and universal health services. No lead professional was identified in the stepdown process. 8.4. In April 2017 there were indications, which the HV identified, that Child B’s Mother’s mental health was deteriorating and Child B’s Mother and Child B were referred to CSC. There were also referrals from the Police indicating a decline in Child B’s Mother’s mental health. A Child and Family assessment 5 Overview Report CHILD B 130721 v4 was started in April. Concerns escalated further in May when a family member intervened concerned about Child B’s Mother’s mental health and the impact on Child B. Child B’s Mother was hospitalised under section 2 of the MH Act 1989 and Child B placed with his maternal aunt. Child B’s Mother at assessment, before admission on in May 2017, informed the assessing psychiatrist that she had not been taking her medication for a few months. This sequence of events and intervention showed good joint working between agencies and the Family. 8.5. Child B’s Mother subsequently disclosed to a doctor and social worker at the time of her assessment under the Mental Health Act she had held Child B under water whilst he was in the bath. The context given by Child B’s Mother was delusions about people watching her while she was in her home. This information was shared with the Police and there was a strategy meeting with CSC. The Police investigation was opened but did not proceed as there was no evidence to corroborate what B’s Mother had said. This report led to Greenwich CSC initiating care proceedings to safeguard Child B. Child B was made subject to an Interim Care Order (ICO) in August 2017. His Aunt was travelling abroad and Child B was placed with foster carers in August 2017. He remained with foster carers until January 2018. Child B’s Mother was acutely mentally ill in August 2017. She was discharged from hospital in October 2017 to her home. Child B’s Mother was asking to be reunited with Child B following her discharge from hospital. 9. Review Period 9.1. In January 2018 Child B’s Mother and Child B entered a mother and baby foster placement. Child B remained on an ICO. In March 2018 Child B and his Mother returned to live at their home. This plan was agreed with the Family Court. The Family Proceedings ended in late March 2018 with a 6 Overview Report CHILD B 130721 v4 Supervision Order made to Greenwich CSC for one year. The Court and the Children’s Guardian, appointed in the proceedings, advised a robust plan should be progressed reflecting Child B’s Mother’s frail mental health and Child B’s vulnerability. This was put in place and included funding for a childminder/nursery 3 days a week and twice weekly attendance at a Greenwich CSC children’s centre. In July 2018 Child B and his Mother attended a drop in Speech and Language Therapy session where it was identified that Children B was presenting with social communication difficulties. This is the first reference to Child B having developmental difficulties. His Mother engaged well with subsequent workshops and other appointments offered to explore Child B’s needs and to provide him with support to improve and address his communication difficulties. The supervision Order was for a year and ended in March 2019. 9.2. In March 2019 the HV contacted the SW with concern and requested Child B remain on a CIN plan until changes were seen in Child B’s development. The HV was concerned about the level of stimulation of Child B and that Child B’s Mother was not fully engaging with childminder/nursery and health care needs. The Early Years Team at the Children’s Centre highlighted concerns about Children B’s communication delays and Children Child B’s Mother’s lack of supervision at stay and play sessions. The Family were referred to Home-Start Family Support Worker (FSW) who identified Children B’s additional needs. The FSW worked with Child B’s Mother, the SW and HV as part of the CIN plan. The FSW referred to CSC but seems not to have been aware Child B and his Mother were already open to CSC as a CIN case. 9.3. After the supervision order ended CSC worked with Child B and his Mother as CIN. It was becoming clearer that Child B had additional needs. His childminder/nursery wanted him to have additional support which was provided. There was regular and good communication between all the professionals involved with Child B and his Mother. 9.4. The FSW encouraged Mother’s attendance at Parenting GYM which she attended, helped Child B be placed with a local childminder/nursery and 7 Overview Report CHILD B 130721 v4 supported an application one to one support for Child B when at childminder/nursery to help his communication skills. The Family were closed to the FSW and Home-Start in November 2019. 9.5. The concerns of the HV about Child B’s Mother not fully engaging with nursery and health care services do not seem reflected in Child B’s Mother’s engagement with services more broadly. The HV was aware of when the CIN plan ended and expressed concern about Child B being stepped down from CIN. The HV had concerns about Mother’s ability to meet Child B’s needs. These concerns were about mother’s capacity to meet her child's needs and the lack of insight into how well she was able to stimulate Child B. In supervision it was suggested the HV ask if a cognitive assessment may be required for mother as mother had acknowledged to the Paediatrician that she struggles with reading. The HV stepped down Child B to Universal Plus pathway as there was no longer a multi-agency plan in place. This meant Child B had minimal HV contact from this point onwards. 9.6. In June 2019 the final CIN meeting was held. The HV who had concerns was not able to attend the meeting and nor was a colleague able to cover the meeting. The adult mental health care coordinator did not attend but reported that Child B’s Mother’s mental state was stable and she was complying with all medication. Child B’s Mother was reported to be insightful and capable of self-medicating. Child B’s Mother had requested to change from receiving her medication by injection to oral medication. She received additional support from mental health services during this change of medication. The final CIN meeting was at the same time as Child B’s Mother’s support with the change to oral medication ceased. The meeting was attended by the SW, Home Start Family Support Worker and Child B’s Mother. Child B and his Mother stepped down to early help with the SEN service, Community Health Services, Health Visiting and Adult Mental Health services continuing to be involved. No practitioner or organisation was named as the lead and there was no early help plan. This was a significant gap as there was no 8 Overview Report CHILD B 130721 v4 person identified as a key worker for coordination of communication and information sharing or to bring the professional network and B’s Mother together to discuss her and Child B’s needs and how they could be met. 9.7. In October 2019 Child B was identified by the Community Paediatrician as having global developmental delay and social communication needs. Continuing support from Speech and Language Therapy (SALT) was recommended with an assessment for Autistic Spectrum Disorder (ASD) to be progressed. Child B’s Mother was noted in Autumn 2019 to show increased insight into Child B’s social communication difficulties and asked for additional time to help her set goals for therapy. In December 2019 Child B’s Mother contacted the Early Years Inclusion Team upset about the support Child B was receiving at childminder/nursery. Child B’s Mother wanted another placement. There were no other placements available and Child B’s Mother agreed to keep Child B at the childminder/nursery. There were further issues raised by Child B’s Mother in January 2020 which led to a meeting with the Early Years’ Service, the childminder/nursery and Child B’s Mother. When lockdown came the Early Years Special Educational Needs Coordinator (SENCO) had regular contact with Child B’s Mother. The SENCO tried to contact Child B’s Mother weekly. There was discussion about supporting B’s transition to school but the school had already met Child B’s Mother and Child B and did not feel a transition meeting was needed. 9.8. Following Child B’s Mother’s discharge from hospital in October 2018 and the end of her detention under section 3 of the MH Act her mental health service was under the Care Programme Approach (CPA) framework and she was entitled to statutory after care under section 117 of the Mental Health Act. OB’s care coordinator participated in the Supervision Order and CIN meetings. In the period 1st January 2018 to 27th December 2020 there were 13 CPA review meetings of which Child B’s Mother missed two, in July 2018 and October 2019. The contact with Child B’s Mother’s care coordinator was a combination of home visits, meetings at the Community Mental Health Team (CMHT) base and telephone contacts. The records indicate that 9 Overview Report CHILD B 130721 v4 parenting was explored regularly and no safeguarding concerns were identified. The risk assessment was last updated by the care coordinator in October 2020. The Covid 19 lockdown period led to a reduction in face-to face contact and more reliance on telephone or internet video communication. Decisions on face-to-face contact were risk assessed by practitioners within their organisation’s guidelines. 9.9. Child B’s Mother’s medication was by monthly injection up to April 2019. Child B’s Mother requested a review of her medication and following review it was changed to daily tablets with additional support and supervision of her medication which ended in July 2019. The reason Child B’s Mother requested a change to the way she received her medication was because of scarring on the site where she received her injections. It does not appear that Child B’s Mother’s mental health worker had any indications that her mental health may have been deteriorating in Autumn 2020 or that the risk Child B’s Mother might pose to her child had changed. The CMHT were not part of discussions about Child B’s developmental needs nor how his additional needs might impact on his mother’s mental health. The last face to face contact by the CMHT was on 28th August 2020 which was at Child B’s Mother’s home. Child B was present. The last contact with Child B’s Mother was on 27th November 2020 by telephone. This was with a Care Coordinator she knew but not her allocated worker who had left the service in November 2020. The summary of this contact said that Child B’s Mother was reported to be doing well. She was not experiencing any abnormal symptoms or negative thoughts to harm her son or others. She was complying with medication. The crisis plan was discussed. Child B’s Mother was waiting for allocation of a new care coordinator. There was no evidence in that telephone contact of relapse at that point or signs of concern 9.10. In August 2020 Child B’s Mother was involved in an incident with another parent. Child B’s Mother is alleged to have spat on a bench, the ground and at a child when asked by the parent of the child to keep a metre distant from her. The complainant did not wish to make a statement to the Police 10 Overview Report CHILD B 130721 v4 and the matter was not pursued by the Police. Greenwich CSC were informed of the incident but as there was no concern expressed about Child B no action was taken. In retrospect this incident might be seen as an indicator of Child B’s Mother’s mental health deteriorating. 9.11. In July 2020 Child B had an initial appointment to assess whether he may have ASD. Child B’s Mother attended a telephone interview with SLT in August 2020 and disclosed her own concerns about whether she had a learning difficulty or ASD. She was advised to discuss these issues with her GP. There were further appointments for Child B and his Mother with SLT and Occupational Therapy and for the concluding part of Child B’s ASD assessment in October and November 2020. These appointments were online including the ASD assessment which was by video communication. Child B’s Mother kept these appointments and was clearly concerned about her son and keen to ensure he got the help he needed. Child B’s Mother was given Child B’s diagnosis of ASD by the SLT during the video appointment on 30/11/20. The SLT said Child B’s Mother had mixed feelings. Child B’s Mother was upset but got over her initial reaction and asked appropriate questions. Child B’s Mother asked for support. A letter was sent by post on 3rd December 2020 confirming the diagnosis. Child B’s Mother would have been provided with an information pack and outreach information. Child B’s Mother went to the school to discuss the diagnosis the following week. 9.12. Child B started school in a reception class in September 2020. There was a handover from his nursery setting to the school which was good practice. His attendance was excellent at 97% and he was always well presented in school. Child B’s Mother was visible at drop off and pick up and she engaged well with Child B’s school. She attended meetings when requested, engaged well during these meetings and seemed appropriately concerned about Child B’s development and the difficulties he had. Child B’s Mother discussed Child B’s diagnosis with the SENCO and Child B’s class teacher in early December 2020. Child B’s Mother’s response to the diagnosis was 11 Overview Report CHILD B 130721 v4 described as appropriate and she asked questions reflecting her concerns about her child. She was keen to work with the school on strategies to support Child B at school and at home. This was the last meeting Child B’s Mother had with professionals and there was nothing to indicate that her mental health was deteriorating. 9.13. Child B’s last day in school was 14th December. The school allowed parents to decide about attendance in the last week of term. Child B’s Mother decided not to send Child B to school. 14th December appears to be the last contact Child B’s Mother and Child B had with any service. 9.14. Child B’s Mother and Child B had regular contact with Child B’s father by video call. This contact was mostly every day. They had a call on Christmas day where Child B’s Father said Child B appeared happy and showed his father his Christmas toys. Child B’s Father called again on 26th December several times and did speak to Child B’s Mother. Child B’s Father said Child B’s Mother sounded dull and tired. When he called later there was no reply but Child B’s Mother did reply to a text message saying she and Child B were fine. This was their last contact. In a telephone interview Child B’s father confirmed he had no indication Child B’s Mother’s mental health was deteriorating or that she might harm Child B. 9.15. Child B was found dead in his home after Police were called by his Mother to say she had killed Child B. He drowned in the bath. The family home was well kept and tidy. The Police attending found a quantity of B’s Mother’s prescribed medication. The medication was collected in December 2020. This suggests Child B’ Mother had stopped taking her antipsychotic medication some time before Child B’s death. 10. Responses to the key questions in the terms of reference 10.1. Was information shared appropriately across agencies as well as internally. There was consistently good information sharing within and between agencies in their work with Child B and his Mother up to the end of the CIN 12 Overview Report CHILD B 130721 v4 plan. Those working with the Family were aware of who else was involved and shared information and contacted partners when necessary. There were occasions when a professional was hard to contact or there was a delay in returning a request for contact but these were not frequent or significant. What was significant was the ending of formal key working with multi-agency meetings with Child B’s Mother when the CIN plan ended in June 2019. Up to this point throughout Child B’s life, apart from a short period in 2017 prior to his Mother’s breakdown in that year, the Family had been either CIN or Child B was on a supervision order. The decision to end CIN in June 2019 is understandable given the progress made, the apparent lack of concerns and the number of other agencies who would continue to be involved. However, no other agency then picked up a key worker role or initiated team around the family meetings. There was no organised step down from the CIN plan which would have clarified roles in the professional network supporting Child B and his Mother. This lead professional role would also have helped carry forward key knowledge about Child B and his Mother into future planning with them including when Child B started school so that his school would have been aware that he had been subject to care proceedings and a supervision order. There was no formal reassessment of Child B and his Mother’s needs together and review of their individual and joint vulnerability which reflected on the entirety of their history when the CIN plan ended and the case was closed to CSC. The Health Visiting service was concerned about aspects of Child B’s Mother’s parenting and wanted the CIN plan to continue and made this point to the SW. However, when the CIN plan ended the Health Visiting input was also reduced as Child B was moved from Universal Partnership Plus to Universal Plus level of service. This together with staff shortages within the HV service meant there would be no continuing HV involvement with B. 13 Overview Report CHILD B 130721 v4 From Summer 2019 Child B and his Mother continued to have a high level of contact with professionals from community children’s health services in relation to the assessment and provision of therapeutic advice for his special needs, from his Mother’s care coordinator for her mental health, from Early Years education services, the childminder/nursery, Home Start, the local children’s centre and from September 2020 Child B’s school. There was no one amongst these professionals who took on a lead professional role to bring together Child B’s Mother and all those working with her and Child B. This absence of key working role and leadership to the multi-professional network meant no one had a full picture of the Family’s needs from Autumn 2019. There was continuing contact with the mental health service but they did not have details of Child B’s autism diagnosis and were working in parallel to other services. 10.2. How much impact did Covid-19 have on this case? From March 2020 most of the professional contacts with Child B’s Mother and Child B, other than Child B being with his childminder/nursery and from September 2020 at school, were by telephone or video call. This included contact with Child B’s Mother’s care coordinator. There was a lot of contact. Given that a feature of Child B’s Mother’s deteriorating mental health was withdrawal from contact with others the absence of face-to-face contact made it much more difficult to know whether Child B’s Mother’s mental health was deteriorating. Covid-19 also reduced Child B’s Mother’s contacts in the community which also might have been a source of alert to deteriorating mental health. It was a combination of community and professional concerns that alerted services to the serious deterioration in Child B’s Mother’s mental health in April 2017. By 2020 her relationship with her sister had broken down and we do not think she was in contact with her sister. 14 Overview Report CHILD B 130721 v4 Covid-19 may well have increased Child B’s Mother’s isolation and made it much more difficult for professionals and community contacts to identify if her mental health was deteriorating. The Christmas period with Covid- 19 restrictions will have further reduced the likelihood of contact with others. 10.3. How effective was management supervision and oversight of this case? There was evidence that the needs of Child B’s Mother and Child B were reviewed within each agency in line with their normal arrangements for case oversight. The staff involved were managed and supervised and the IMRs did not identify any significant gaps in oversight of the case. The HV did raise her concerns about the ending of the CIN plan in safeguarding supervision. However, it is not evident that the management and supervision of practitioners at a single agency level ever took a sufficiently broad view of Child B’s Mother and Child B’s needs that would have considered their needs together and the impact on each of their vulnerabilities. 10.4. What support was there for Child B’s Mother’s mental health, including around the time of Child B’s autism diagnosis? Child B’s Mother continued to have regular contact with her care coordinator throughout Autumn 2020. This was by telephone. Child B’s Mother’s care coordinator left the service in November 2020 and the contact with Child B’s Mother in November was by another care coordinator who knew Child B’s Mother pending reallocation. The last contact was on 27th November 2020. The chronology for this contact says “CPA review and telephone call. Child B’s Mother reported to be doing well. Not experiencing any abnormal symptoms or negative thoughts to harm her son or others. Complies with medication. Crisis plan discussed.” This was based on self-report by Child B’s Mother. There was no independent check of what she was saying and without a visit there were no observations of Child B’s Mother, B and how 15 Overview Report CHILD B 130721 v4 she was with Child B or of the condition of their home. The diagnosis for Child B of ASD was given to his Mother on 30th November. The chronology says that “Diagnosis provided in session. Mother was very upset in the appointment but advised she was relieved at hearing the diagnosis.” Given the discussion with Child B’s Mother over a number of sessions about Child B’s needs and the further discussion at school on 4th December it is hard to see in Child B’s Mother’s response that there was evidence that the diagnosis or how it was given to Child B’s Mother was affecting her mental health. None of the professionals in contact with her who were all aware Child B’s Mother had significant mental health needs suggested this. Child B’s Mother’s care coordinator was not informed of the ASD diagnosis for Child B and there was therefore no opportunity to discuss with the care coordinator any implications of this for Child B’s Mother’s mental health. There is much stronger evidence for the significance for Child B’s Mother’s mental health that she almost certainly stopped taking her medication sometime in Autumn 2020. The Oxleas NHS Foundation Trust mental health service chronology sets out the history of OB’s medication and her strong desire from early 2019 to move from monthly injections to oral medication and how this was dealt with. The change in medication was made in April 2019 and supported with additional service until July 2019. The effects of ceasing Child B’s Mother’s medication delivered by injection would take 6 to 9 months to show and of ceasing oral medication 3 to 6 months. Child B’s Mother’s history showed that her stopping medication could lead to a rapid deterioration in her mental health. This happened when she stopped taking medication during her pregnancy with Child B and when she stopped taking her medication in the early part of 2017. From July 2019 the Care coordinator was reliant on Child B’s Mother’s self-report that she was complying with her medication and any observation by the care coordinator or others of Child B’s Mother’s behaviour which might indicate she had stopped taking her medication. 16 Overview Report CHILD B 130721 v4 10.5. What was the impact of Child B’s Mother’s mental health on her parenting capacity? When in an acute episode of mental illness Child B’s Mother was unable to parent Child B and was a danger to him. She had a diagnosis of a severe and enduring mental illness which required her to take medication to maintain her mental health and ability to care for Child B and herself. Child B must have been affected by his Mother’s mental health. He was separated from her when she became acutely ill in 2017 and spent May 2017 to January 2018 in the care first of his Aunt and then a foster carer. The comments of professionals who saw Child B and his Mother together were mostly positive but there were observations suggesting Child B’s Mother was not sufficiently stimulating him or always supervising him adequately. There are comments in the mental health records suggesting Child B’s Mother was struggling with Child B’s behaviour. Most comments in the chronologies are positive about Child B’s Mother’s care of Child B. The Family home was observed to be clean and cared for. Child B’s Mother was described as appreciative of support including practical support with food and clothing as she was financially struggling. It was more difficult for those observing Child B and his Mother to judge how far any issues such as Child B’s fussy eating were a care issue or related to Child B’s development or the complex interaction between the two. Child B’s Mother kept most appointments concerned with assessing and trying to address Child B’s needs. There were occasions when she pushed back against advice from professionals but such behaviour is not unusual amongst parents being faced with the news that their child may have significant developmental problems. Professionals also reflected on how far such examples of push back reflected cultural views and beliefs that Child B’s Mother might have. The chronologies do not show that cultural views were explicitly explored. 17 Overview Report CHILD B 130721 v4 When seriously ill Child B’s Mother could not parent Child B and being with her at such times was probably a confusing and frightening experience for him. 10.6. Was the family history understood by all agencies especially in relation to Child B’s supervision order and support following the end of the supervision order? While Child B was on a supervision order there was good communication between the agencies working with Child B and his Mother. Agencies sufficiently understood the history even if they may not have had a full understanding of the exact implications of a supervision order. When the supervision order ended there was a CIN plan which also had good engagement from the agencies working with Child B and his Mother. When the CIN plan ended in June 2019 there was no longer a lead professional for Child B and his Mother or any meetings to coordinate work between all professionals. Those working with Child B and his Mother for the first time from Autumn 2019 were aware of some of the history, most knew Child B had had a CIN plan but they did not know the full history and without the coordination and leadership of a lead professional there was no ready mechanism for them to know the full history. 10.7. What impact did the culture and ethnicity of the family have? This is very hard to evaluate. There is wider evidence of higher rates of mental health problems in some ethnic minority groups for example rates of detention under the mental health act in 2012/13 were 2.2 times higher for black Africans than the average for all adults1. However, this area is not well researched and a recent systematic review1 of mental health disorders among adults from minority ethnic groups found there was littler recent 1 Rees R, Stokes G, Stansfield C, Oliver E, Kneale D, Thomas J (2016) Prevalence of mental health disorders in adult minority ethnic populations in England: a systematic review. London: EPPICentre, Social Science Research Unit, UCL Institute of Education, University College London. ISBN: ISBN: 978-1-907345-84-5 18 Overview Report CHILD B 130721 v4 information on rates of mental health disorders by ethnic groups. This suggests caution in making any judgements based on ethnicity in this case. The chronologies and IMRs show that those working with the family were aware of the possible impact of issues of ethnicity and culture but there is no evidence of this in explicit discussion with Child B’s Mother. There is evidence of reflection in the NHS Oxleas CYP IMR of whether Child B’s Mother’s understanding of spoken English was sufficient to help her fully understand what she was being advised about Child B’s needs and how far she understood Child B’s diagnosis. Thought was given to whether an interpreter should be used. There has not been an opportunity to speak to Child B’s Mother about her experience or her sister which might help gain a better understanding of these issues and whether concern about how Child B’s diagnosis might be seen in her community might have played any part in how she responded to Child B and to her seeking help for herself and B. 10.8. Sharing of Child B’s diagnosis with his Mother and availability of support for his Mother. Child B’s diagnosis came after a series of assessments with the Integrated Neurodevelopmental (IND) team and with SLT and OTs, together with observations of Child B in childminder/ nursery, information from Child B’s Mother and observations of her and Child B. Child B’s Mother knew Child B was being assessed for ASD. She understood he had social and communication difficulties and wanted help for Child B. In 2020 there are examples of Child B’s 1 Ethnic Inequalities in Mental Health: Promoting Lasting Positive Change Report of findings to LankellyChase Foundation, Mind, The Afiya Trust and Centre for Mental Health February 2014 19 Overview Report CHILD B 130721 v4 Mother contacting professionals for advice and help sometimes following up meetings where she had shown some push back to what was being said about Child B or what she was being advised to do. Child B’s Mother was given the diagnosis in a telephone meeting. This was then confirmed by letter and was followed up quickly with a meeting at school. Child B’s Mother knew further support for her and Child B was planned. It would have been much better to have had the diagnosis meeting face to face but that was not possible due to COVID-19. Child B’s Mother was upset by the diagnosis as reflected in the chronology entry but her upset was seen by those working with her as appropriate for a parent receiving such information. In the circumstances informing Child B’s Mother of Child B’s diagnosis was dealt with appropriately and should not be seen as a possible pre-cursor to Child B’s death. 10.9. Community support for Child B and his Mother. Child B’s Mother did have some community links and was reported as being part of a Church. The nature and extent of these links is not evident from the IMRs and the chronologies. This issue needs to be explored with Child B’s Mother and her sister if and when this is possible. 11. Learning relevant from Triennial Reviews of Serious Case Review 2011- 2014 and 2014 -20173, the Child Safeguarding Practice Review Panel Annual report for 20204 and from assessing adult orientated issues in parents. 11.1 Key points from the Triennial Reviews of Serious Case Reviews 2011-2014 and 2014-2017 and the Child Safeguarding Practice Review Annual report for 2020: • The importance of the child’s voice which for young children like Child B means practitioners reflecting on and imagining what life was like for him. This goes beyond considering his development, responding to the concerns about this and his health and physical care which appeared good. 20 Overview Report CHILD B 130721 v4 • Poor maternal mental health was a common feature of the cases considered by the Triennial Reviews. The Triennial Analysis of SCRs for 2014-2017 found that in 47% of the cases notified the mother had mental health problems. Reflecting on this case: • How far was Child B’s Mother’s mental health considered in the assessments of her and Child B’s needs? • How well did non-specialist mental health practitioners understand the risks of relapse for Child B’s Mother and the high risk to Child B when his Mother relapsed? • Did any of those working with Child B and his Mother know that Child B’s Mother not taking her medication could lead to relapse and her presenting a serious risk to Child B? • Did the mental health specialists fully appreciate the risks of relapse? Once there was no key worker role and no regular multi-agency meetings there was nowhere for all the agencies working with Child B and his Mother to consider these issues. Professionals other than those from Child Safeguarding Practice Review Panel Annual report 2020 Annual Report 2020 Patterns in practice, key messages and 2021 work programme DfE May 2021 children’s social care can call multi-agency meetings but it is rare for them to do so. 3 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen and Complexity and challenge: a triennial analysis of SCRs 2014-2017 Final report March 2020 Marian Brandon, Peter Sidebotham, Pippa Belderson, Hedy Cleaver, Jonathan Dickens, Joanna Garstang, Julie Harris, Penny Sorensen and Russell Wate 21 Overview Report CHILD B 130721 v4 • Children in need and children who no longer require a child protection plan to keep them safe should nevertheless be recognised by agencies as having potentially long-lasting vulnerabilities and or risks of harm. This was true for Child B and his Mother. Should the multi-agency system consider how it provides long term support to families who are vulnerable such as Child B and his Mother? • Avoiding using generic phrases such as ‘children doing well’. Use of stock phrases is easy for hard pressed workers. Inaccurate or imprecise language does not support critical thinking and can give false assurances when viewed by other practitioners. How precise were practitioners about their observations of Child B with his Mother? While most observations were positive there were concerns expressed by the HV. • Were the signs of Child B’s Mother relapsing ever discussed with the multi-agency staff working with Child B and his Mother? • The importance of recognising the interaction of mental health and other risk factors e.g. childhood abuse and other adverse childhood experiences which Child B’s Mother had suffered. Who could have explored these issues of vulnerability and risk with Child B’s Mother? How could this have been done in a way that did not alienate her? • The importance of responding to changing risk and need. The Child Safeguarding Practice Review panel identified that there were weaknesses in risk assessment and not revisiting initial assessments when circumstances change or taking sufficient account of potential risks arising from known information. In this case it was known that Child B’s Mother could relapse with serious consequences for Child B and for her own mental health but this possibility does not seem to have been sufficiently considered as Child B and his Mother appeared to be managing satisfactorily and the focus was on Child B’s developmental problems. 11.2 The chapter on assessing parenting and working with adult orientated 22 Overview Report CHILD B 130721 v4 issues in The Child’s World2 raises questions about how well Child B’s Mother’s needs were understood and the impact of her mental health and emotional difficulties on her care of Child B. How far, once the care proceedings were completed, did the assessment of Child B and his Mother by adult and children’s health and social care services consider: • Child B’s Mother’s availability physically and emotionally to act in response to B’s needs? • What the impact of Child B’s Mother’s mental health was on her predictability and behaviour in relation to her response to Child B? • Recognising that for Child B his mother’s’ symptoms were more important for their subsequent impact on her parenting than a diagnostic label. • How could the assessment of Child B and his Mother have been able to understand the overlap between her mental health and her history of adverse experiences? • The importance of assessments that combine adult and child frameworks so that the adult orientated issues are assessed in their own right and for their impact on the child. Did the organisational and service arrangements make it impossible to achieve an integrated assessment of Child B and his Mother’s needs? 12. Analysis using the Pathways to Harm Framework for analysis 12.1. There is potential value for this CSPR of using the framework set out in the 2011-2014 Triennial Review of Pathways to Harm for case analysis. The Pathway is described in Figure 1. Figure 2. 2 Basarab-Horwath, J. A., & Platt, D. (Eds.). (2019). The child's world : the essential guide to assessing vulnerable children, young people and their families (Third). Jessica Kingsley. 23 Overview Report CHILD B 130721 v4 24 Overview Report CHILD B 130721 v4 12.5. These vulnerabilities for Child B and his Mother led to both preventive and following Child B’s Mother becoming seriously ill and disclosing she had tried to drown Child B protective actions by statutory agencies. These protective actions ended when the CIN plan ended. Preventive actions continued but without a lead professional and without coordination across all services including adult and children services. While the predisposing vulnerabilities of Child B and his Mother were recognised the predisposing risk Child B’s Mother might present when she ceased her medication was not adequately considered within the network of agencies who were working with her. 12.6. When Child B’s Mother’s mental health deteriorated there appeared to be no family members or community members in contact with her to identify her changed mental state as there had been in 2017. The loss of social contact due to Covid social restrictions may well have played a part in this though there is little clear evidence on this issue. The capacity for preventive action by society including family and friends was reduced just as the parent’s capacity to protect was also reduced. The level of professional contact was reduced by COVID and there was no longer a coordinated network working with Child B and his Mother. The network was focused on B’s diagnosis and response to this and the work with Child B’s Mother about her mental health was quite separate. The risk of Child B’s Mother relapsing and the danger to Child B from relapse had been lost sight of. In terms of the pathway to harm key preventive and protective areas within society, the family and the professional networks were all weakened. 12.7. Child B’s Mother’s change of medication from injection to oral made it much harder to monitor Child B’s Mother’s medication. Those treating her had to rely on self-report. Child B’s Mother had a history of relapse when she ceased taking medication. This was an important risk factor for Child B. It is likely Child B’s Mother had stopped taking or reduced her medication in the period before Child B’s death and no one was aware of this. The change of medication in itself was well handled. It is clear the treating psychiatrist was not keen to change from depot injection and when Child B’s Mother firmly chose oral medication support 25 Overview Report CHILD B 130721 v4 was provided. The recommendation in paragraph 14.3 for a lead professional is to address the need for full discussion of the risks of medication change and how such changes are monitored by the multi-agency group working with an adult with an enduring mental illness or other needs that need to be monitored. In this case the overall team around the family was not effective and part of that was the lack of a shared understanding of the risks of relapse and of the implications of the change of medication. A lead professional can help keep such risks actively managed within care plans for both parent and child. 13. Recommendations from agency reviews 13.1. Agencies identified learning and action following their reviews of work with Child B and his Mother. These recommendations included: • Revised guidance for assessments and reviews within the Community Mental Health Service • Reinforcement of the Think Family approach to safeguarding and promoting joint working across adult and children services within the health trust. This work included review of the CPA policy to integrate the principles of the Think Family approach into CPA. • When imparting complex medical information to a parent for whom English is a second language professionals should consider the benefits of using an interpreter and whether additional and alternative forms of communication e.g. visuals should be used. • Where a child is given a diagnosis and a parent is known to adult mental health services every opportunity to share this information should be sought. • Staff to remain curious in regard to culture and family composition and to include an understanding of the cultural impact of diagnosis of children with additional needs in their consideration of service responses. 26 Overview Report CHILD B 130721 v4 14. Recommendations for the partnership 14.1. The partnership needs to plan to work with families where because of adult needs, including those arising from enduring mental health needs or learning disability, and the vulnerability of a child due to age or other additional needs the family needs support extending throughout childhood. 14.2. All agencies need to reflect on the impact of Covid 19 on face-to-face contact and give weight within their risk assessments to the vulnerability of young children whose parent has an enduring long-term mental illness. 14.3. RBG and Partners have an established process for stepdown from a Child in Need Plan to Early Help Plan. The Partnership needs to ensure that all staff are aware of and understand the importance of this process and how it should be implemented in practice, including the identification of a lead professional and the routes to use to resolve disagreements about the decision to stepdown or about the Early Help Plan. 14.4. When services make referrals to early years services or schools, they should include important historical information so that this information can be carried forward when the child transitions to school or between schools. This requires referrers to recognise what information people need for the future that is key to understanding the child and family’s needs. Examples of such information will include care proceedings and the orders made at the end of proceedings, a child being looked after or a child having a child protection plan. 14.5. The partnership should develop the cultural competence of all staff so that they have the confidence and skills to ask children and families about their culture and how this may inform their experience and view of the services they are offered. 15. Next steps 15.1. Development of action plan 27 Overview Report CHILD B 130721 v4 15.2. Contact with Child B’s Mother and her sister when possible and further contact with Child B’s father. Colin Green Independent CSPR Author 27th August 2021 |
NC52686 | Serious sexual offences committed by the mother and a former partner, against Child I. These offences came to light in 2021 but took place in 2013. Concerns for the subject children and/or their siblings are recorded from 2000. There have been many changes in professional practice in all agencies over the course of time considered in the review. Learning themes include: escalation of practitioners' concerns; inter-generational abuse; management of sex offenders and risk assessments; the voice of the child in assessment and planning; timeliness of forensic testing where children are at risk of abuse. Recommendations to the partnership include: ensure planned review of the escalation policy is completed; increase awareness and confidence in using the escalation policy and monitor its effectiveness; ensure practitioners have access to training in respect of the impact of inter-generational abuse and tools to support risk assessments; ensure that, where convicted sex offenders are in contact with children appropriate and effective risk management mechanisms are in place; consider the arrangement for risk assessments and safety planning where the allegation is regarding an alleged offender rather than one with convictions; agencies should work together to ensure that potential risk from sex offenders in the family network are assessed in respect of other children with whom they have contact; ensure policies and procedures reenforce the importance of specific risk assessments, such as the 'Persons who Pose a Risk of Harm' tool, being completed pending the outcome of forensics.
| Title: Children – H and I: local safeguarding children practice review. LSCB: Cheshire East Safeguarding Children’s Partnership Author: Jane Booth Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Children – H and I Local Safeguarding Children Practice Review May 2022 Author: Jane Booth jbconsultancy 2 Contents: Page numbers Family Composition and key 3 1. Brief background and circumstances leading to the review 4 2. Terms of Reference and Methodology 5 3. Parallel Proceedings 6 4. Practice linked to Key Lines of Enquiry 7 5. Questions asked by the Panel 13 6. Analysis 18 7. Recommendations 19 8. Good Practice 23 Appendix 1 – Terms of Reference 24 3 Family Composition and key The list below is of individuals referred to in the report and the identifiers used to provide anonymity. Child H - male subject child Child I - female subject child Half-sibling 1 - eldest child of mother Half-sibling 2 - 2nd eldest child of mother Half -sibling 3 - 3rd eldest child of mother Mother - the mother of child H, child I and their three older half-siblings. Male 1 - mother’s partner prior to 2000 and father of half-sibling 1 and 2 Male 2 - mother’s partner between 2000 and 2002 and father of half- sibling 3 Male 3 - mother’s partner from 2004 to 2011 and father of the subject children Male 4 - mother’s partner in 2012/13 Male 5 - visitor to household around 2014 Male 6 - Mother’s partner in 2015/16 Male 7 - Maternal grandfather Male 8 - Maternal great uncle 4 1. Brief background and circumstances leading to the review 1.1. The children who are the focus of this report, and referred to as Child H and Child I, are the youngest of five children, their older half-siblings (referred to as half-siblings 1, 2 and 3) all being adults at the time of the review. They are members of a large extended family, many of whom have also been known to agencies for several years. Agencies have had considerable levels of engagement with the family for many years and mother herself had a history of abuse as a child. Concerns for the subject children and/or their siblings are recorded from 2000. 1.2. Concerns centred on: o emotional harm o physical injury o potential risks from sexual offenders in the extended family, o concerns about risk from mother’s partners; o general concerns about mother’s parenting ability and neglect; and o relationships and violence within the family; 1.3. Children of the family were subject to Child Protection Plans1 from August 2010 to July 2012, due to concerns re emotional harm, and were supported via Child in Need Plans2 and via a lead professional at different times. In addition, significant levels of support have been provided by the schools the children attended and by health visiting services. 1.4. This review was prompted by the discovery of serious sexual offences having been committed by the mother and a former partner, Male 4, against Child I. These offences only came to light in 2021 but took place in 2013. 1 A child protection plan is put in place following multi-agency agreement that without it there is a risk of harm. The overall aim of the child protection plan is to: ensure the child is safe and prevent them from suffering further harm; promote the child's welfare, health and development; and support the family and wider family members to protect and promote the welfare of their child provided it is in the best interests of the child. 2 The Children Act 1989 defines a Child in Need as in need if: He/she is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him/her of services by a Local Authority; His/her health or development is likely to be significantly impaired, or further impaired without the provision for him/her of such services; He/she is disabled. A plan should set out the support to be given. 5 The Partnership3 established the review in order to identify any learning from practice at that time, and to satisfy itself that any practice deficits were no longer present within current practice. It was of concern that these offences took place within the context of extensive multi-agency involvement with the family. 2. Terms of Reference and methodology 2.1. This review was commissioned by the Cheshire East Safeguarding Children’s Partnership following a Rapid Review, completed over two meetings, in June and July 2021. An independent author was appointed but subsequently had to withdraw on realising they had had prior involvement with the case. Progress was delayed pending the identification of another author, Jane Booth, in September 2021. She is self-employed and has never worked for any of the agencies in the area. 2.2. A Practice Review Panel was established comprising senior representatives from relevant agencies (see Appendix 1 for membership) and they set out the terms of reference for the review (see Appendix 2). They have been responsible for ensuring their agencies fully participate in the review and have provided oversight and quality assurance of the review process. 2.3. The review used a blended methodology including a desk-top review of data gathered via chronologies from agencies, engagement with some practitioners via a virtual learning event, and individual interviews with some practitioners. An internal police review placed some limitations on discussions with practitioners in respect of some specific matters but did not significantly impact on the review. 2.4. The review has also been informed by the outcome of two police reviews looking at internal processes, one in Cheshire and one in West Mercia. 2.5. In addition, an audit of current cases, where risks of intergenerational sexual abuse are a factor, has been carried out to test the quality of more recent practice. 2.6. The time span for the period under review runs from 2006 to 2021. The Panel identified key safeguarding practice episodes to be considered in detail together with key lines of enquiry. 3 The Cheshire East Safeguarding Children’s Partnership was established in accordance with governmental guidance - Working Together 2018. Accountability for its effective functioning sits with three lead partners – the Local Authority, the Clinical Commissioning Group and the Police. 6 2.7. It was not possible to meet with members of the family for fear of compromising their status as potential witnesses in criminal proceedings. The children H and I themselves were very young when the abuse occurred and many years have passed since then. The discovery of the offences, subsequent arrest, remand in custody and eventual conviction of their mother, and the commencement of care proceedings has been traumatic for them and the Panel decided it was not in the children’s interests to seek their engagement with the review at this time. This was kept under review as it had been hoped that it would be possible to include family contributions and learn from their experience once the trials had been completed. Unfortunately, a new line of enquiry emerged and new investigations commenced so this was still not possible. 3. Parallel Proceedings 3.1. Criminal proceedings re the 2013 offences were running in parallel with this review in connection with mother and Male 4. This process was managed by West Mercia police, not the local police force. Good communication was established with the Senior Investigating Officer and consultation arrangements established with the Crown Prosecution Service to ensure neither process compromised the other. Mother and Male 4 were convicted of serious sexual offences and are now serving substantial prison sentences. 3.2. A local police investigation was underway in connection with Male 3 and further alleged offences involving indecent images. In addition, towards the end of this review, further disclosures of alleged abuse resulted in a new investigation being commenced in Cheshire in respect of mother and Male 4. 3.3. The children were subject of Care Proceedings during the course of the Review. 3.4. Two police internal reviews were also underway. The first in the West Mercia’s force regarding the delay in completing the digital forensic analysis of phone images which showed the abuse of the children by mother and her then partner. 3.5. The second police review in Cheshire was in respect of the response to chat-room concerns re abuse of a child in 2009. 7 4. Practice linked to key lines of enquiry. 4.1. As early as 2004 there had been concerns about maternal grandfather’s contact with the older children; half-sibling 2, then aged 6 years, had been taken to the GP in 2005 following what mother believed to be blood stains in her knickers. Mother told the GP she was concerned “someone has been messing with her”. The child was referred to a paediatrician and on examination no evidence of abuse was found. NOTE: This response was compliant with the procedure in place at the time and such cases were not referred to Children’s Social Care unless concerns were confirmed. Current practice would involve a strategy discussion in any cases where the possibility of abuse was being considered. As there was no strategy meeting, any opportunity to share the wider background of concerns was lost. Mother’s expressed concerns were not explored further in terms of who she thought might have abused the child. Neither the GP nor the paediatrician were aware of the concerns re sexual offenders in the extended family. 4.2. In 2006 there were concerns regarding sexualised behaviour involving older half-siblings 1 and 2 and children from a neighbouring family. During the investigation the girls reported being hit by Male 3, and school raised concerns about the behaviour of Male 3 towards them and the children’s apparent fear of him with Children’s Social Care and the police. Male 3 had been observed to exhibit very controlling behaviour. 4.3. During the investigation the mother and Male 3 were seen first and the children not interviewed for several days, potentially increasing the risk to them and giving ample opportunity for them to be coached in their responses. No Child Protection Conference took place. Responsibility for monitoring was left with school on a single agency basis. NOTE: Practitioners reported a significant shift in culture in the intervening years and indicate they would request a Child Protection Conference took place and if still concerned would use policies now supporting agencies in escalating concerns in such circumstances. It was however suggested that these policies are better understood by some agencies than others. 4.4. In 2008 concerns re-emerged regarding the children being allowed to visit Male 7, a registered sex offender. Records evidence high levels of challenge to mother from the Health Visitor. Possibly as a result, mother requested a change of Health Visitor which was agreed. 4.5. When subsequently challenged by the social worker, mother and male 3 agreed to ensure no contact but in conversations with other professionals showed considerable ambivalence. Male 7 was subsequently found in the home alone with the children without any action being taken. Male 6, who was also a sexual offender, was also often present or found to be sitting outside the family home in his car. 8 4.6. In December 2009 the national Child Exploitation Online Protection Unit at the Home Office identified online chat-room conversations linked to a user of a phone in possession of the family. The content of messages included explicit details of sexual abuse of a child by her father. This was reported to the local police force but not actioned at the time due to an error. NOTE: At this time two separate police computer systems were in place. The information was logged on one system but, due to human error, not the other so was not visible to staff who would have followed up and ensured a referral was sent to Children’s Social Care resulting in a joint investigation. Now there is a single system which results in the need to take action being directly available to those who process these referrals. 4.7. The error outlined in 4.6 was identified five months later when a strategy meeting was convened in respect of new concerns about a potential physical assault on half-siblings 1 and 2 by Male 3, and there was a review of police records. Male 3 was cautioned for an assault on half-sibling 2. Allegations of physical abuse made by half-sibling 1 were considered to be inconsistent and were not progressed. An investigation commenced in response to the child exploitation online protection unit referral re the chat-room incident and computers and phones were seized. NOTE: The implications of the content of the chat room conversations in terms of ongoing risks to the children at this point did not result in a specific risk assessment. This is a significant cause of concern and reflects a missed opportunity to better protect the children at that time. 4.8. Not until August 2010 was a Child Protection Conference held and a Child Protection Plan was put in place and this was in respect of continuing concerns re risk of sexual abuse from extended family members. The older children had been on holiday with Male 7 despite a requirement for no contact and mother had sought to cover this up with mis-leading information. NOTE: An issue with the management of this case appears to be the tendency to focus on the issue of the moment rather than taking a wider view and keeping the range of concerns in focus. At this point there had still been no investigation of the chat-room concerns and the outcome of searches of the computer equipment seized in the previous December was not known. 4.9. In September 2011, some 21 months after the initial report from the child exploitation online protection unit referral re the chat-room content, the results of the forensic analysis of the phone and computer which had been seized were received and Male 3 was interviewed regarding the contents. The analysis had revealed several indecent images on his computer and the interview with him focussed on these. There were also numerous empty files with titles which suggested they had contained indecent material but the content 9 deleted. He admitted possession of indecent images and was cautioned for these offences. At this point he left the family home but continued to have contact with the children, supervised by church volunteers. NOTE: There is no evidence that the material from the chat-room, which had prompted the investigation, was ever put to him despite the material relating to the description of the sexual abuse of a child by her father. This matter has been included in an internal review by Cheshire Police the outcome of which is considered later in this report. 4.10. In January 2012, after Male 3 had left the family home, a decision was recorded that the category of concern in the Child Protection Plan should be changed to Emotional Harm. Records indicate that a number of issues were identified as still needing to be addressed including the following: o Assessment of male 3’s contact with the children and its supervision; o Direct work with the children re wishes and feeling; o Work with the children re keeping safe; and o Work with mother re risks posed by other convicted offenders. None-the-less the Child Protection Plan continued under the category of risk of emotional harm. NOTE: This is recorded as unanimous but practitioners recall not being happy about the change of category. Again, there was no escalation (there was no policy to support this at the time) and they describe deference to Children’s Social Care as the norm at the time. The decision, as before, reflects a focus on the immediate i.e., as Male 3 was no longer in the home, it was considered that the risk of sexual abuse was reduced – there was no consideration of the ongoing risks from the wider family. 4.11. At the conference concern was expressed regarding the amount of time that the children had been subject to Child Protection Plans without there being any discernible or sustainable improvement in the parenting they had received, therefore it was recommended that the Local Authority seek advice of a Legal Gatekeeping Meeting4 regarding any future plans, actions or assessments which needed to be undertaken to ensure the safeguarding of the five children. 4.12. The report presented to the Legal Gatekeeping Meeting majors on the fact that Male 3 is no longer living with the family and that contact is supervised. 4 The Legal Gatekeeping Meeting was an arrangement internal to Children’s Social Care whereby social workers sought legal advice when considering the possible need to take legal proceedings to protect children. 10 Although ongoing concerns re other family members is referred to, it is not seen as a significant factor and the outcome of the meeting was that the concerns were deemed not to be sufficient to initiate proceedings and it was noted that in some respects the children could be said to be better placed – i.e., attending school and appointments and clean and appropriately dressed. NOTE: Staff in Children’s Social Care report a significant change in practice in the intervening years. At the time Legal “advice” was taken to be a decision. This essentially undermined the social worker who had hoped to get support in initiating proceedings. The outcome of positive changes following the adverse Ofsted inspection is referenced in Ofsted’s follow up report in November 2021. Internal audit in Children’s Social Care also evidences practice changes in the recording of the rationale for decisions which is now a requirement and has been evidenced. 4.13. Five months later, in June 2012 the case was stepped down to a Child in Need case and then closed to Children’s Social Care in the December. Agency records subsequently report that mother had a new partner Male 4 who had moved into the household. Records contain very little detail and a lack of clarity - even his name was unclear. His presence was picked up by school as a concern but the social worker declined to do police background check as the children were no longer on a Child Protection Plan and she felt she had no authority to do it. NOTE: All incoming concerns are now managed via an “Integrated Front Door” which receives all work, not just Child Protection cases. Staff from a range of agencies sit together and work together as a team sharing multi-agency information to inform risk and an expression of concern such as this would now be subject to a routine police check. 4.14. Concerns were also being expressed about other men, and that the older children were in touch with potential offenders on-line and staying with them at times. 4.15. It is now known, but was not at the time, that in 2013 mother’s then partner, Male 4, and mother herself committed serious sexual offences against Child I. This came to light due to the discovery of video images on Male 4’s phone when he was arrested in April 2020 (seven years after the abuse had taken place). The video showed a child aged approximately four years old being sexually abused, now known to be Child I. 4.16. There has continued to be ongoing concern about the family in the intervening years. In February 2013 half-sibling 1 was observed to be distressed in school and stated “a bad thing happened last night”. She was not prepared to give details. This was shared with the school nurse who spoke to mother about it but this was not taken further. 11 4.17. Around this time school picked up that Children H and I were having unsupervised contact with Male 3 and reported this to Children’s Social Care. They were informed that the level of risk posed by him had been re-assessed and unsupervised contact could now be allowed. School was not happy and did raise concerns with this but did accept this as a matter for Children’s Social Care. There was no formal escalation policy in place at the time. 4.18. In 2014 it was noted that another known sex offender, Male 5, was in contact with the family. A disclosure of his prior offences was made to mother as he was on the sex offenders register and Children’s Social Care were notified but no further action taken. NOTE: This potential further risk to the children did not prompt any enquiries nor any risk assessment. 4.19. During 2015 mother formed a relationship with Male 6. They were not living together but she was spending much of her time at his address where he cared for his son. This resulted in her neglecting the needs of her own children with the children H and I being left in the care of their older half-siblings. They describe being hungry and on one occasion locked out of the house at night and seeking help from a neighbour. An assessment was completed by Children’s Social Care and a Child in Need Plan put in place to support the children’s “emotional stability”. At this time there were significant concerns about a relationship between half-sibling 3 (then aged 17) and an older man she was visiting in Manchester. 4.20. Records indicate that in March and June 2016 half-sibling 2 was noted to be at risk of sexual exploitation. A referral to the police noted that she was discussed in connection with Male 8, her uncle, and reference to him “providing alcohol, sending indecent images and inappropriate text messages”. Male 8 was arrested and pleaded guilty to one offence of inciting a child to engage in sexual activity. A child protection conference was held and the children H and I and two of the older half-siblings were made subject of a child protection plan on the grounds of neglect. 4.21. Through the second half of 2016 numerous concerns were recorded. Mother’s relationship with Male 6 had become volatile and mutually abusive. Mother alleged rape by Male 6, withdrew the allegation and then re-asserted her allegations and said he had threatened to hurt her if she did not withdraw. He alleged harassment and obtained a restraining order against mother. Mother breached the order resulting in a suspended prison sentence and the case was discussed in a Multi-agency Risk Assessment Conference5 (MARAC). There 5 MARAC: The Multi-Agency Risk Assessment Conference is a regular meeting where agencies discuss high risk domestic abuse cases, and together develop a safety plan for the victim and his or her children. Agencies taking part can include Police, Independent Domestic Violence Advisors (IDVAs), Children’s Social Services, Health Visitors and GPs, amongst others. 12 was no ongoing contact with the National Probation Service due to the sentence having no management requirements on it. 4.22. During 2017 mother was noted to have been drinking to excess and taking medication for both depression and anxiety. In June 2017 Mother alleged rape by a man who came home with her from a party. Half-sibling 2 was distressed in school and recounted to staff how she had feared for her mother and had chased the alleged perpetrator down the street and kicked him. He had punched her in the face causing bruising and swelling to the mouth. School made a referral for appropriate support and gave details of support for mother. Police investigated the alleged assault alongside the alleged rape. This investigation exceeded the timescale for prosecution of a common assault so could not proceed to prosecution as part of the investigation, it is however unlikely to have proceeded in any event due lack of substantiating evidence. 4.23. Home conditions appear to have deteriorated during this period and the police officer, who had attended the premises in connection with the alleged rape, made a further referral to Children’s Social Care reporting that the house was not fit for human habitation. The RSPCA were also involved during this period regarding animal welfare. 4.24. Following a review conference in November 2017 the children remained on a Child Protection Plan. It was known at this time that children H and I were staying overnight with Male 3 at times. 4.25. Around this time Child H developed epilepsy and school became heavily engaged in supporting her and her mother in managing this 4.26. In December 2017 the Child Protection Plan ceased and support was continued via the Common Assessment Framework6. 4.27. During 2018 agency records reflect concerns about the half-siblings, now adults, re their relationships and pregnancies, growing concern for child I whose presentation was poor with signs of neglect, and whose behaviour in school was becoming increasingly difficult to manage and she was referred to the Attention Deficit Hyper-Activity Disorder /Autistic Spectrum Condition clinic. 4.28. In 2020 school raised concerns with mother re Child I’s contacts with men via the internet and mother agreed to monitor her internet usage. In December 2020 signs of self-harm were noted in school and raised with mother who said she had removed all sharp instruments from the house. 6 The common assessment framework (CAF) is a process used to identify children’s unmet needs and support them. 13 4.29. Covid impacted significantly on agencies offering support to the family but there is evidence of high levels of support continuing via virtual contacts when school was closed and an Education and Health Care Plan (EHCP) was created to better support Child I. 4.30. In March 2021 police received information regarding the uploading indecent images of children involving Male 3. This did not prompt an immediate re-assessment of risk. NOTE: For three months no additional steps were taken ensure the children were protected from potential risk of sexual abuse by Male 3.. 4.31. In May 2021, West Mercia Police informed the Cheshire Police that, in the course of investigating offences involving indecent images, they had found video footage of rape and other sexual offences against a 4-year-old child, now identified as Child H. The alleged male perpetrator was one of mother’s previous partners, Male 4. Both he and mother were directly involved in the abuse, were arrested and remanded in custody pending trial. A strategy discussion took place and Children H and I were placed in foster care and care proceedings commenced. 4.32. In June 2021 school were informed by Children’s Social Care that Male 3’s contact with the children was now to be supervised. 5. Questions asked by the Panel - In the Terms of reference for this review the Panel outlined a series of questions they wished to see answered - key lines of enquiry – and these are addressed in the following section of the report. 5.1. Question 1 - The context 2012/13 and what was known at the time: 5.1.1. Agencies had been working with this family for many years and the specific risk factors were well-known. Mother was known to have been abused herself by her father and other members of the extended family were also convicted sex offenders. Mother had demonstrated an inability to maintain a consistent position on the importance of keeping her children safe and had frequently either chosen not to, or had been unable to restrict contact. 5.1.2. It was known that mother’s own relationships with men were often initially formed on-line and had involved a series of men who also posed risks to her and/or her children. Male 3 was cautioned for possession of indecent images of children. Another of her partners, Male 4 is the perpetrator of the offences which prompted this review. Little was known about him as background checks were not completed – however checks done at this time would not have exposed any concerns. 5.1.3. Chat-room discussion about abusing children had been identified suggesting ongoing risks. 14 5.1.4. Of possible relevance at this time was the situation in Children’s Social Care which had, on inspection, been found to be inadequate. Inexperienced social workers were allocated this complex case and describe chaos both in family and department with many and frequent changes of supervisors. 5.2. Question 2a - The system: how did the system respond to the available information in 2012/13, was it joined up, was it effective, did agencies understand their roles and expectations would the escalation process be used? 5.2.1. The health visiting service and schools were pro-active in sharing information with Children’s Social Care, and schools with police liaison officers. Agencies came together under arrangement for Child Protection and Children in Need but practitioners did not describe this as feeling like a team working to a single plan. They described a deference to Children’s Social Care as the lead agency and the absence of an agreed assessment of risk. They described being concerned that the children were not being effectively protected but these concerns were not escalated – no escalation procedures were in place at the time. 5.2.2. School and health visiting staff shared information and all agencies engaged in the multi-agency planning processes but practitioners reported some reluctance to reciprocate on the part of Children’s Social Care who did not share the notes of the Legal Gateway Meeting (on the grounds that this constituted legal advice) nor the risk assessment of Male 3. 5.2.3. Practitioners reflected a sense of helplessness in delivering an effective plan. Mother’s failure to ensure safe arrangements for her children was evident, with potential abusers still in contact with them, but there were no consequences and this issue was treated as if it were a matter of advice not a requirement. 5.2.4. At a review conference in 2012 there was outstanding work in relation to direct work regarding the children’s wishes and feelings and also work with them in terms of keeping themselves safe. Also, there was work yet to be completed with mother to improve her understanding of the risks that adults may pose. By this time Male 3 had left the family and it was agreed he needed to continue to reside away from the family home and both parents were confirming that their relationship had now ended. 5.2.5. A decision was made to change the category of concern to emotional abuse at this point – it is difficult to understand the change of category of risk as risk of sexual abuse had been of major concern throughout and remained so and the work on protection had not been completed. 15 5.2.6. The way the case was managed must have given very mixed messages to the children and family – e.g., social worker sought advice from Legal Panel re possibility of Care Proceedings but grounds not judged to be met and, despite this high level of concern, the case was stepped down and closed within months; sex offenders from the extended family continued to have contact with the children with no consequences. 5.2.7. There were missed opportunities to work more directly with the children and only on one occasion was action taken to directly challenge the men themselves. Generally, no thought seems to have been given to legal remedies which might have been followed up with enforcement if breached 5.2.8. The police response to the child exploitation online protection unit referral referral in respect of the chat-room activity was inadequate. It was not actioned at the time and therefore was unknown to key agencies working with the family for several months. When this was recognised some five months later, there were further delays and the focus shifted to on-line images which had been found on Male 3’s phone. The chat-room concerns were never fully investigated. 5.3. Question 2b - The system: How would the system respond to the information in 2021 – Do agencies understand their roles and expectations, would the escalation process be use? 5.3.1. Practitioners report now feeling like being part of a team when working on Child Protection or Child in Need cases. They are now aware of escalation procedures and could give examples of their use. They were not, however, confident that there was a sufficiently widespread understanding among agencies who did not routinely get involved in this work. 5.3.2. Practitioners described different processes for the stepping down of cases being in place now, with much greater multi-agency involvement and specific follow up plans being put in place. They described mechanisms for challenge and a greater confidence in the effectiveness of joint working. 5.3.3. Cheshire Police have conducted a thorough review of practice and the issues highlighted in this review. There is evidence of change for the better and many systems have been updated and improved over the years. Significant progress has been made in respect of analysis of material held on phones. The changes already implemented have resulted in the backlogs for mobile phone examinations reducing from 26 weeks to 2 weeks. All victim and witness devices are turned around within 24 hours. In January 2022 the team received 27 victim/witness devices and all were completed and returned within the set 24-hour timeframe. Computer backlogs have reduced from two and a half years and at the time of writing sit at 7 months and are expected to continue to reduce. 16 5.3.4. The recording of child exploitation online protection unit referral referrals on duplicate systems no longer exists and there are systems in place to ensure proper process is followed and outcomes are recorded. 5.3.5. In the years running up to 2013 numerous concerns about contact with sexual offenders were dealt with via advice to mother within the framework of a Child Protection Plan, advice which was not acted upon with no consequences. The risk assessments around these offenders were either not in evidence or not robust and professional concern focussed very narrowly on this household despite there being an extensive family network within which these offenders accessed numerous other children. 5.3.6. The Partnership audited two current cases involving intra-familial and multi-generational abuse. Examination of the cases evidenced an awareness of the need for detailed risk assessments to be completed and in both cases, there was a multi-agency approach to risk management. In one case a detailed assessment had been competed using the “Persons who pose a risk to children” tools and consideration of risk to other children had been included. In the second case an AIM assessment7 had been completed previously but did not directly inform the assessment of risk and was not linked until later. One case evidenced good work across most fields of enquiry. However, a number of issues emerged and actions have been agreed in response: • Professional challenge was still lacking with some decisions still being seen as single agency when they needed multi-agency input; • Strategy meetings were not held at the earliest opportunity and need to be more-timely. The delay could have impacted on the safety of the child and siblings. • Staff engaged in ABE8 process need to be appropriately trained. • Assessments were not always of good quality nor always timely. 5.3.7. Taken as a whole the outcome of the audits suggests there is further work to do. 5.3.8. Children’s Social Care have carried out a review of work across the extended family of Child H and I in parallel with this review and can evidence that risk assessments have been completed as appropriate. Further work is 7 The purpose of the AIM assessment is to offer an assessment of the young person and his or her family to assess the concerns, risks and strengths of the young person across four key domains; sexual and non-sexual behaviours, development, family and environment considering both static and dynamic factors. 8 Guidance for investigating officers and others involved in interviewing vulnerable witness is set out in ‘Achieving Best Evidence (ABE) in Criminal Proceedings”. 17 being undertaken to support the local school who work with a number of families identified as vulnerable in terms of potential sexual abuse. 5.4. What can we learn from the daily lived experience/perceptions and behaviours of these children that would help us to respond to known and perceived risks in the future? 5.4.1. It has not been possible to date to speak directly with the Children H and I or other family members about their lived experience due to ongoing criminal investigations but much can be inferred from the chronology. Children I and H were born into a family where there had been issues about the care and protection of children for many years. 5.4.2. The older girls talked relatively freely about home when at school and were often distressed; School engaged with them in sessions focussing on their wishes and feelings but this did not appear to greatly influence plans. There was violence from Male 3 towards them and violence between them; half-sibling 3, in particular, was able to voice her distress very clearly. 5.4.3. Their experiences, distress, and the concerns it exposed, paint a picture of a household where relationships often erupted into violence, where mother had poor parenting skills, where in later years neglect of the children’s physical needs became more of an issue. The lengthy chronology of concerns appears to have been treated as single issues and dealt with as such but the whole picture not brought together resulting in lengthy periods of intervention with little sustained improvement in their lived experiences. 5.4.4. At the conference in January 2012 a unanimous decision was made that all but the eldest half-sibling (now approaching adulthood) should remain subject to a Child Protection Plan under the category of Emotional Harm. A Legal Gatekeeping Meeting regarding any future plans, actions or assessments which needed to be undertaken to ensure the safeguarding of the five children was also held. The wishes and feelings of the children do not appear to have been sought or reflected in these processes. 5.4.5. The way the case was managed must have given very mixed messages to the children and family – e.g., social worker sought advice from Legal Gatekeeping Meeting re possibility of PLO/Care proceedings but grounds were not judged to be met and despite high levels of concern the case was stepped down and closed within months. 5.4.6. The older girls’ behaviour suggested a high risk of child sexual exploitation. 18 5.5 To what extent has the current Covid-19 crisis impacted either on the circumstances of the child or family or on the capacity of the services to respond to their needs? 5.5.1 The most significant impact was on the children’s face to face contacts and attendance at school. There were, however, high levels of virtual contact. 6. Analysis: 6.1. While multi-agency arrangements in respect of children in need and child protection plans were in place the processes were flawed. Plans were not based on focussed assessments and did not bring about improvement. Agencies did not have a consensus as to the level of risk but deference was given to the view of Children’s Social Care as the lead agency with no escalation. Lengthy periods of statutory involvement produced no change. 6.2. No assessment of mother’s capacity to protect her children was undertaken and the plans which relied upon her to keep the children safe were unrealistic. Repeated examples of her inability to ensure no contact between her children and known sexual offenders were tolerated without consequences. 6.3. Schools were appropriately professionally curious about home life and mother’s partners but the concerns which arose in respect of incidents involving children from other households, including children in the wider family network and the potential that the risk of sexual abuse extended beyond this specific household were not always appropriately followed up by other agencies. 6.4. Practice was largely reactive and practitioners talked about “chaos” within the family and the struggle to respond to the level of demand. During the period around the time of the offences which prompted the review (2012/13) Children’s Social Care was found to be inadequate on inspection. The social worker at that time was inexperienced and had frequent changes of supervisor – five in a 12-month period. 6.5. When mother voiced concerns re possible sexual abuse the GP made a referral to a paediatrician. This was in line with procedures at the time and, in line with these procedures, mother’s concerns were not investigated as a child protection issue and neither GP nor the paediatrician knew of the concerns about potential sex offenders in the family and in contact with the children. Had this been responded to as a child protection concern and a strategy meeting held then this information would have been shared. Why mother thought the child might have been abused would also have been explored. 6.6. The management by police of the concerns about texts in the chat-room is a significant concern. A human error resulted in no information being shared and no investigation being commenced for over five months despite the 19 circumstances suggesting a child might be actively being abused by their father. When the error was discovered and computers etc. seized, there was further delay. The investigation side-tracked to a focus on indecent images held on the computer and the chat-room incident was never investigated. 6.7. It took some time in the process of investigation of the videos of abuse in West Mercia to identify the mother and the likely victim. However once identified mother was arrested promptly and appropriate action taken. 7. Recommendations 7.1. Context: 7.1.1. There have been very many changes in professional practice in all agencies over the course of time considered in this review. Most significantly in the period 2012-13 children’s social care was judged to be inadequate in a service inspection and the social worker managing the case described “chaos in the family and chaos in the department”. She had numerous changes of manager and inconsistent supervision. At the time of the most recent service inspection in 2019 Ofsted found the service no longer inadequate but still requiring improvement to be good. A monitoring visit in November 2021 showed positive practice in many areas but also areas still requiring attention. 7.1.2. Specifically, the letter following the monitoring visit comments on number of areas of work which are relevant to this review: ” Children in Cheshire East benefit from stable and meaningful relationships with their social workers. Children have frequent opportunities to express their wishes and feelings, and social workers complete purposeful and creative direct work with children to better understand their experiences. While children’s wishes are considered in plans, written records are not always clear about whether children have the opportunity to be actively involved in meetings about them. Timely assessments of children’s needs include careful consideration of family history and children’s experiences to appropriately identify strengths and risks for children. The views and opinions of children, parents and relevant professionals are sought effectively to inform assessment conclusions. Children who need help or protection are identified as a result of effective assessments of risk and need. Thresholds for working with children are appropriately applied. However, some assessments do not fully consider children’s identities when reaching decisions, and assessments are not always updated promptly when 20 children’s circumstances change. For a small number of children, this has resulted in a delay in identifying and responding to their changing needs. Most children in need of help or protection have written plans that are regularly reviewed and updated. Most written plans are clear about what needs to happen and who is responsible. While social workers can verbally describe the positive impact their work is intended to have on children’s daily lives, some written plans still measure success by the completion of tasks rather than impact for children. Contingency arrangements in child-in-need plans are not always sufficiently well-formed or detailed. Management oversight is also not always fully responsive to children’s changing needs, and child-in-need meetings do not always lead to the identification of drift for children. This all means that, when situations deteriorate for children in need, alternative decisive action is not always taken promptly.” 7.1.3 Children’s social care have developed an action plan in response to the findings from the Ofsted visit and so specific recommendations are not made in this review where the required action is already incorporated in this action plan. Recommendation 1: CESCP should continue to receive updates from the Director of Children’s Social Care regarding the completion and effective implementation of the action plans made in response to Ofsted inspection activity. 7.2 Lack of focus 7.2.1 In the early 2000s this family comprised a mother with changing male partners, three teenage children and two very young children. There were concerns about risks from known sex offenders in the family network and the family was a cause of concern to agencies over numerous years with periods when the children were subject to child protection plans or supported via early help arrangements with school acting as lead agency. Risks of sexual abuse were the predominant concerns but mother’s parenting skills and the degree of neglect the children experienced were also issues. 7.2.2 During periods when formal Child Protection plans were in place written plans did set out actions/requirements but these were not always fulfilled and non-compliance from mother and her partner did not lead to review of plans. Social work responses were reactive to the presenting problems and did not address wider issues, for example clearly inappropriate exposure of the children to known sex offenders in the family did not always prompt concern for other children in the wider family network. 7.2.3 The social worker in the critical 2012-13 period was inexperienced and lacked effective supervision. Assessments were not holistic and did not 21 recognise or draw on the children’s lived experience. Improved supervision and management oversight can now be evidenced via audits. 7.2.4 The recent Ofsted visit presents evidence of change –they describe children who need help and protection being appropriately identified; assessments are described as timely and inclusive of the views and opinions of young people; they are described as being based on careful consideration of family history and informed by other relevant professionals; practitioners are found to be doing creative direct work with children. 7.2.5 In view of this evidence of improved practice no specific recommendations are made in respect of generic assessments and the voice of the child in assessment and planning. (See Recommendation 1) 7.3 Escalation 7.3.1 On numerous occasions agencies were concerned about decisions made by Children’s Social Care and did voice concerns but not escalate them when this produced no change. At the time there was no multi-agency escalation policy in place 7.3.2 Appropriate policies are now in place both for escalation of concerns and for challenge to outcome of a case conference. Practitioners who participated in the learning event said they were confident in using them and reported examples of effective use. However, they also felt more needed to be done to ensure wider awareness and increase confidence in professionals who may be less experienced in safeguarding work and that application is still variable. A review of the arrangements is overdue and, although use is monitored, this is not reported via any quality assurance reporting. Recommendation 2: CESCP should ensure the planned review of the escalation policy is completed. Recommendation 3: CESCP to require the escalation tracker to feed into the Learning and Improvement Group on a quarterly basis. Recommendation 4: CESCP should use the publication of this review to increase awareness and confidence in using the Escalation Policy and monitor its effectiveness. 7.4 Inter-generational abuse 7.4.1 There is a considerable body of research into inter-generational abuse and the impact on a mother of abuse in their early life and likely impact on their later life and parenting. In this case the mother’s own history of abuse was known to agencies but no assessment was done as to how this had impacted on her parenting, her relationships, and particularly her capacity to protect her children. Recommendation 5: CESCP should ensure practitioners have access to training in respect of the impact of inter-generational abuse and tools to support risk assessments. 22 7.5 Management of sex offenders and risk assessments 7.5.1 Only in respect of Male 3 was any risk assessment carried out and this was in response to indecent images being found on his phone. Assessment of sex offenders is a skilled activity. This assessment of Male 3 was completed by the social worker for the case who had not had any specialist training. The risks posed by other members of the family and mother’s various partners were not assessed as part of the child protection planning, though those family members who were registered sex offenders were monitored as required by the police. Only on one other occasion was action taken to address issues relating to this family directly with a male who posed a risk - this was Male 8 who was arrested and charged with inciting a child to engage in sexual behaviour. 7.5.2Though assurance has been given re the current position, the risks to other children in the wider family network do not appear to have always been considered or investigated on a timely basis. This suggests a gap in the professional understanding of sexual offender behaviours and the need for risk management. Recommendation 6: CESCP should ensure that, where convicted sex offenders are in contact with children appropriate and effective risk management mechanisms are in place. Recommendation 7: CESCP should consider with partners the arrangement for risk assessments and safety planning where the allegation is regarding an alleged offender rather than one with convictions. Recommendation 8: Agencies should work together to ensure that potential risk from sex offenders in the family network are assessed in respect of other children with whom they have contact. 7.6 Voice of child 7.6.1 The older children in the family frequently expressed their distress in school – this was recorded and shared with children’s social care. They described fear, physical abuse, emotional abuse and neglect. On some occasions, e.g. allegations of physical abuse by Male 3, an investigation was commenced but this did not generally prompt a wider assessment and insufficient importance was placed on the voice of the child. 7.6.2 Practitioners identified a significant shift in culture in the intervening years (also see recommendation re escalation processes) They described a multi-agency approach to protecting children which results in agency concerns being acknowledged and assessed. They described the voice of the child and their lived experience being central to assessment and planning and this is supported by the evidence from the recent Ofsted monitoring visit. 7.6.3 In view of the evidence of change no recommendation is made. 7.7 Timeliness of forensic testing where children are at risk of abuse 23 7.7.1 There were very significant delays in the processing of forensic evidence from phones and computers in both the investigations in West-Mercia and in Cheshire. This review has been provided with detailed evidence of change in Cheshire in respect of forensic analysis of phones. A report has also been received from West Mercia Police providing assurance but lacking the supporting evidence of improvement. 7.7.2 When agencies became aware of the allegations re concerning online activity, they awaited the outcome of forensic investigations without any more immediate local risk assessment. This potentially left risks to the children un-assessed and unmanaged. 7.7.3 Computer analysis remains a significant concern. This appears to have been a direct result of lack of resources. Recommendation 9: CESCP should share the concerns re forensic analysis in cases involving risks to children with the relevant safeguarding partnership in West Mercia and recommending they seek further assurance and evidence of improvement Recommendation 10: CESP should ensure policies and procedures re-enforce the importance of specific risk assessments, such as the “Persons who Pose a Risk of Harm” tool, being completed pending the outcome of forensics, and that protection from potential risk on a timely basis. 8. Good practice 8.1 The schools who were involved with this family showed real strength in capturing the lived experiences of the children and recording their voices. They showed considerable persistence in exposing their concerns and provided a safe space for the children. There are many examples of practical support to the children and to their mother. 8.2 The chronology prepared by education was particularly thorough – this was possible due to the level of detail held in their school records. 8.3 The tenacity of the health visitor in raising her concerns about potential risks from sex offenders in the extended family is to be commended. 8.4 The internal review completed by the Cheshire Police during the course of this review is of high quality, is detailed and will form the basis of further action to continue the improvements which have a been evidenced. 24 Appendix 1 – Terms of reference CHESHIRE EAST LOCAL SAFEGUARDING PRACTICE REVIEW This document contains the Terms of Reference, research questions (KLOEs) and outline timetable for the review. Each of these will be reviewed throughout the process to ensure that they are meaningful and relevant. Key contacts for the review are Alistair Jordan Business Manager Cheshire East SCP and Jane Booth, Independent Chair. 1. TERMS OF REFERENCE Operation and Governance 1. All relevant agencies in Cheshire East will be included in the review. 2. The review will be overseen by a panel of senior representatives from relevant agencies. Panel members will be responsible for ensuring their agencies fully participate in the review and for working with the author to produce a final report. 3. The review panel will agree a communications strategy 4. Administrative arrangements will be agreed and provided by the SCP Partnership Business Team. Methodology 5. The review will use blended methodologies which will involve desktop data gathering, interaction with professionals and individual accounts to inform its conclusions and recommendations 6. As appropriate the review will refer to national guidance, policy, practice and other reviews to inform its conclusions and recommendations 7. The review will make every effort to involve the subjects of the review as appropriate. The review will also give consideration to involving the families and significant others. This will be decided by the panel as the review unfolds. 8. The event itself is considered to be the catalyst for the review and will not be analysed in detail, this is the job of the criminal investigation which is ongoing. Scope and Outcomes 9. The review will focus on the Key Practice episodes of a. From 2006 concerns regarding inappropriate/sexualised behaviour involving older half siblings, the behaviour of their stepfather towards them and the children’s apparent fear of him. b. 2008 concerns regarding the children being allowed to visit their grandfather, a registered sex offender. c. December 2009 Cheshire Police received information from CEOP, regarding a mobile phone, which was linked to the mother and father, having been used in chat logs concerning child sexual abuse. d. Discovery of video images on a phone of a male arrested in April 2020, of a child aged 4 years being sexually abused dated to 2013 with the mother present. 10. The review will aim to complete by January 2022 however it is recognised that criminal proceedings and other factors may affect the timescale for completion 2. KEY LINES OF ENQUIRY 25 Question 1: The context: What is known about the key practice episodes: • specific risk factors (individual and collective) • effectiveness of responses i.e., actions being followed up Question 2a: The system: How did the system respond to the available information at the time of the key practice episodes? Was it joined up? Was it effective? Did agencies understand their roles and expectations? Was the escalation process used? Question 2b: The system: How would the system respond to the information in 2021? Would it be joined up? Do agencies understand their roles and expectations? Would the escalation process be used? • The use and quality of tools, single and multi-agency, to assess and inform risk assessment and the effectiveness of these in informing risk management plans • Information sharing by professionals. Question 3: The people: What can we learn from the daily lived experience/perceptions and behaviours of these children that would help us to respond to known and perceived risks in future? The National Child Safeguarding Practice Review Panel have specifically requested that this question is included in the review. Question 4: to what extent has the current Covid-19 crisis impacted either on the circumstances of the child or family or on the capacity of the services to respond to their needs? Outcomes: Establish if the practice evident at the times of the key practice episodes remain pertinent in 2021 and if so, make recommendations for practice improvement. 3. DRAFT TIMETABLE Date Actions First Panel Meeting 22/9/21 Stage 1: Methodology and Information Gathering • Agree timetable, TORs, KLOEs and time period • Discuss the background to the case • Agree agency information formats (desktop review, specific enquiries) • Discuss family involvement • Discuss criminal proceedings • Discuss other relevant issues Independent chair review Desk top review Practitioner interviews/workshop 2nd Panel Meeting Stage 2: Analysis Review information Identify early findings and discuss format of final report/conclusions and recommendations Review involvement of subjects/families Final Panel Meeting Independent Chair to present draft report 26 Stage 3: Findings/Final Report Discussion re findings/conclusions and recommendations Finalise involvement of subjects/families Sign off Meeting Sign Off final report |
NC52805 | Death of a child in the first weeks of their life. The cause of death has not been established at the time of the report being published. Angel and their siblings were on a child in need plan due to a history of domestic abuse, physical abuse and neglect. Learning includes: the need for agencies to recognise that children who live in the area are their responsibility, including children who have just moved into the area; the need for robust and timely information seeking and sharing when a family move into an area, without relying on a parents self-reporting; the need for improvements in practice when children on child in need plans move to another area; the need for curiosity and vigilance in identifying the impact of moves of home area on children; increase professional confidence in introducing the use of interpreting services when a family do not speak English as a first language, and where there are potential cultural differences to be explored and understood; consideration of the impact of a family coming from a minority culture on their engagement. Recommendations include: reinforce that children with a safeguarding history who move area are potentially some of the most vulnerable children, seeking assurance from partner agencies that systems acknowledge local ownership and meet the needs of these children; remind professionals of the value and importance of using interpreting services, including provision of the cultural awareness required to work in a meaningful way with families; and ensure health visitors are involved in assessments and planning for unborn children.
| Title: Child safeguarding practice review: Angel. LSCB: South Tees Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CHILD SAFEGUARDING PRACTICE REVIEW ANGEL PUBLISHED 2023 1 Child Safeguarding Practice Review Angel Contents 1 Introduction to the review Page 1 2 Process Page 2 3 Family details Page 3 4 Identification of learning Page 4 5 Conclusion and Recommendations Page 8 Agreed by the STSCP on 6th June 2023 Introduction to the review 1. This CSPR was commissioned because it was determined that learning would be identified for agencies in South Tees through the consideration of the case of a child who died in the first weeks of their life, to be referred to as Angel.1 The cause of death has not yet been established2, but Angel and their siblings3 were on a child in need plan at the time due to a history of domestic abuse, physical abuse and neglect. 2. This review will consider systems and practice within and between partner agencies in the South Tees area specifically regarding the assessment and safeguarding of children who have recently moved to the area and have additional needs, where the children have been the subject of child protection plans in the past, and where the parent’s first language is not English. 3. The learning identified is in relation to: All agencies need to recognise that children who live in the area are their full responsibility, even if they have just moved there. The need for robust and timely information seeking and sharing when a family move into the area, without relying on a parent’s self-reporting. A requirement for improvements in practice when children on child in need plans move. The need for curiosity and vigilance in identifying the impact of moves of home area on children. Increased professional confidence in sensitively introducing the use of interpreting services when a family do not speak English as a first language and where there are potentially cultural differences that need to be explored and understood. Consideration of the impact of a family coming from a minority culture on their engagement. 1 The child’s mother chose this name. She also requested that we use the English language version. 2 The inquest is pending. 3 The number and ages of the siblings are not disclosed due to concerns about this identifying the family. 2 Process 4. The review started with consideration of the detailed agency information provided for the CDOP4 and rapid review processes, where clear lines of enquiry were identified. Further information was sought from the involved partner agencies including a request for reflection on the quality of involvement with the family, and the identification of single agency learning and improvement actions, if required. 5. An independent lead reviewer5 was commissioned to work with a panel of local safeguarding professionals from the key agencies. The lead reviewer facilitated a face-to-face practitioner event, the aim of which was to consider the details of the professional involvement with the family and what learning professionals felt was apparent regarding professional practice and local systems. However due to staff leaving6, sickness or not prioritising their attendance, only one professional who had direct involvement with the family at the time attended the event. Line managers and safeguarding leads attended to represent their agencies. 6. The lead reviewer has written this report and worked together with the panel to identifying the overall learning and agree recommendations from this CSPR. 7. The lead reviewer and a representative of the partnership met with Angel’s mother, with the assistance of an interpreter, to inform her of the purpose of the review and explore if there was any additional learning from her perspective. The review panel extends its thanks to her for her reflection at a very difficult time. Meeting her reinforced the need for all professionals to recognise and acknowledge the impact of grief and loss on the families they are working with. Family details 8. After their birth, Angel returned home to live with their single parent mother and several of their older siblings who have needs of their own. The family had not lived in their accommodation for long and there were issues with the substance of the building (such as broken doors and a need for extensive redecorating) and there were limited furnishings and home comforts. One of Angel’s older siblings was living with foster carers elsewhere, and their mother found this difficult emotionally. The older siblings could be boisterous and demanding of their mother, who sometimes struggled to manage their behaviour. The care of Angel was said to be good with appropriate routines. They were breast fed and had a cot in their mother’s room. The professionals involved at the time had an understanding of Angel’s lived experience. 9. Both of Angel’s parents were originally from an eastern European country and moved to the UK in around 2005, prior to having children. Although they had previously lived in Middlesbrough in around 2017, it appears they have moved around 53 times in the 14 years that they have been parents. Mother returned to Middlesbrough with all but one of her older children in 2021, having separated from the children’s father. The children had been on a child protection plan and the subject of care proceedings in another area (to be referred to as Local Authority A) in 2019. The threshold for significant harm was met at the time as they were made the subject of interim care orders and then supervision orders. The family 4 Child Death Overview Panel – a multi-agency function to review all child deaths in the area 5 Nicki Pettitt is an experienced lead reviewer and has been undertaking serious case reviews and CSPRs since 2009. She is entirely independent of all partner agencies in South Tees. 6 This reflected significant resource issues locally, with difficulties in recruiting permanently to key positions like social workers. 3 then made an unplanned move to another area (to be referred to as Local Authority B) without informing professionals in Local Authority A. They lived in Local Authority B for around a year before again moving to Middlesbrough in 2021. 10. One of the children remained in foster care in Local Authority A. A care order had been made due to their serious disabilities and a concern that the parents could not meet their significant special needs. Local Authority A remained involved with the older siblings despite them living in Local Authority B, as they were the subject of court ordered supervision orders, that Local Authority B refused to take responsibility for. CSC in Local Authority A closed the case when the orders expired in May 2021, and the children became the subject of child in need plans, and the responsibility of CSC Local Authority B. 11. The older children had experienced domestic abuse (with their father as the perpetrator) and physical abuse from both parents. There were neglect concerns, including neglect of their health needs, lack of supervision and a history of poor engagement with services. Father was known to be intimidating and abusive to professionals. He has long term issues with alcohol misuse and has been prosecuted for drunk driving with children in the car. 12. Just prior to the move to Middlesbrough the police were called to a domestic abuse incident in Local Authority B. Mother was physically assaulted by Father, and he made threats to kill her. The children were present. Mother told the police that Father had been violent to her for 14 years. They separated following this incident and Mother and the children moved to Middlesbrough without him. 13. Around 6 weeks after arriving in Middlesborough, Mother booked her pregnancy with the midwifery service, at 20 weeks gestation. The midwives made a referral to the Middlesbrough MACH7 due to the family ‘escaping domestic abuse.’ A social work assessment was undertaken and child in need plans were made a month before Angel died. Analysis and identification of learning 14. Through the detailed consideration of the professional involvement with Angel and their family, the review has established learning in the following areas: Impact of multiple moves 15. The extent of the family’s transience was not appreciated by any agency in South Tees prior to the death of Angel. They had moved multiple times within and between at least five different local authority areas in England. There was a resulting lack of information known in Middlesbrough about the children’s history and lived experience. Those who met the family in the months following their move to Middlesbrough largely relied on the mother’s self-report of their history and involvement with agencies. Those involved were shocked to learn of the extent of the family’s transience during this review. They told the review that this was because of having limited time to seek and consider the case history, and difficulties in accessing information, particularly from other areas. 16. There was a view in Local Authority B that the difficulties in the past were due to domestic abuse and Father’s alcohol misuse, and that the mother’s separation from him reduced risk to the children. CSC in Local Authority B informed Middlesbrough of Mother’s planned move to Middlesbrough with the children 7 Multi-Agency Children’s Hub - the front door to children’s social care (CSC) 4 and that they were on child in need plans. They also shared that should they remain in Local Authority B it was likely that they would be stepped down to early help due to the parent’s separation and because Father had left the country. The Middlesbrough MACH did not accept responsibility for the children at this time as they did not yet have an address in the area and because no written information was shared by Local Authority B CSC. Information shared by Local Authority B for this review states that ‘multiple house moves have caused instability for the family and a start again scenario for services.’ This review agrees. 17. When it was confirmed to CSC in Local Authority B that the family had actually moved to Middlesbrough there is no evidence that they informed Middlesbrough CSC. They appear to have simply closed the case. This can often happen when children are on a child in need plan. There are clear nationally agreed processes that need to be followed when a child on a child protection plan moves into a different local authority area. The same is not the case for children in need. The Children Act 1989 is clear that the responsibility for safeguarding and promoting the welfare of the child lies with the local authority where the child is to be found, so when the family gave up their property in Local Authority B and moved to Middlesbrough, the responsibility for them became Middlesbrough’s. The Tees safeguarding procedures state that when a child in need moves, ‘given the child has already been identified as having particular needs or is vulnerable in some way, urgent consideration / assessment should be given as to the impact of the move for the child in respect of their vulnerability’. They also state that ‘all relevant information should be shared by the previous authority, including social work assessments, plans, minutes of the latest Child in Need Review and a summary / case report.’ 18. As well as this, there are clear processes listed that would be good practice in a case of a child in need moving, including multi-agency information sharing, consideration of a joint social work visit and a handover Child in Need Meeting, so that the issues can be fully shared with all agencies8. This would require the consent of the parent. In the case of Angel’s siblings, practice from both areas fell short of these expectations. The case was only opened for a social work assessment of all the children because of the new pregnancy, and it was then that the concerning issues for the older children became apparent and further requests were made for information from both previous Local Authorities. When reflecting on why there was a delay in considering if the children should be assessed and acknowledged as children in need, the review understands that this was in part due to the limited information accessed and available that provided a full overview of the family history, the reassurance of Father no longer being around and a general fatigue in the area in respect of the number of transient families moving to the area and the demand this creates for local services that are already stretched. 19. The review can see that the concerns included cognitive and developmental delay for at least one child, health issues for several the children, including high BMI, enuresis, vision difficulties, bow-legs due to vitamin deficiencies, anaemia and very poor dental care. These issues were exacerbated as there was a history of the children not being bought to health appointments. Very poor school attendance in the past, and clear young carer responsibilities for the older children were also apparent. During the review it was 8 However, the Data Protection Act should never be a barrier to 'sharing information where the failure to do so would result in a child or vulnerable adult being placed at risk of harm' or indeed on those occasions where seeking consent might increase the risk of harm. (from Tees child protection procedures.) 5 reflected that community health professionals do not usually check the page on System1 which shows the addresses a child has lived at. It is good practice to do so, and it only takes one click to access the information. This is where the exceptionally high number of moves of address was identified during this review, which would have been helpful knowledge for those working with the children at the time. 20. The children’s multiple moves resulted in drift and delay in accessing health assessments and interventions for the children’s health needs. There were numerous failures to hand over ongoing health interventions over the years. The number of school moves also led to the children’s education and social needs not being met. Despite this, the focus when the family were leaving Local Authority B was on the likely reduction of risk due to the father no longer living with the family, with little consideration of the evidence of long term and cumulative neglect and no clear understanding of Mother’s role in this. 21. Because the children were effectively just receiving universal services when they arrived in Middlesbrough in 2021, the opportunity to ensure that they had timely health interventions was missed. The known and shared issue at the time was that the family were fleeing domestic abuse, rather than the reality of them being a family with a history of significant neglect that had moved extensively and not had any consistency of professional oversight and intervention. This false understanding had an impact on the response of services such as school nursing, who had been contacted by their equivalent in Local Authority B and were informed of the history of poor dental care. There is a shortage of NHS dentists in Middlesbrough, so the school nurse contacted Mother and offered support to find a dentist for the children. There was no information shared by the Local Authority B school nurse about the child protection plans and care proceedings in Local Authority A, the child in need plan in Local Authority B, the history of neglect of the children’s health needs, and known concerns about management of the children’s behaviour. 22. When the case was opened to CSC in Middlesbrough during the pregnancy with Angel, the social work assessment included two planned home visits and two unannounced. All of the children were spoken to, and the written assessment includes analysis on the children’s lived experience and has used some of their words directly. Single agency learning has been identified about the need to ensure that during the period of assessment there can also be actions taken, for example making referrals for practical and emotional support for the mother and the children, which were needed. 23. There were discussions with the children’s Middlesbrough schools but not the schools the children attended fairly recently in both previous areas. The midwifery service was also consulted, but not the health visiting service. CSC in both of the previous areas were contacted and specifically asked for copies of documents including chronologies, assessments and plans. These key documents were not forwarded. Local Authority A CSC just sent an email with a brief overview of their involvement in the case, focusing mostly on the child who remained in their care. Around a month after the request was made, Local Authority B CSC redirected the social worker in Middlesbrough to their information governance team for an access request to be made. In the circumstances, this was inappropriate, as there was a clear history of child protection concerns which required sharing in a timely way. This delay and lack of cooperation means that the extent of the children’s concerning history was not known by the 6 social worker undertaking the assessment or the social worker who then took on responsibility for the child in need plans in Middlesbrough. 24. It is significant to acknowledge that the legal threshold for significant harm had been met in respect of all the older children when they lived in Local Authority A, and it is important that any new local authority has sight of the full chronology and court papers, as well as other multi-agency documents such as plans or records from child protection conferences. The social work assessment did result in all the children and the unborn baby being made the subject of a child in need plan, and a new social worker was allocated as the case moved teams. Mother said that while she understands that their moves and the systems in which social workers work lead to changes of worker, this has been hard for the family. Provision of services and responses in Middlesbrough 25. Mother attended the Emergency Department with abdominal pain shortly after the move to Middlesbrough. She was 19 weeks gestation and told staff that she was due to go to London for a termination. A scan was completed, and Mother then decided to go ahead with the pregnancy. This means that Mother was 20 weeks pregnant when she saw community midwives to book in. Mother told the midwifery service that she had been ambivalent about the pregnancy and had been considering a termination. This information was not shared with the health visitor. There was also no information sharing from midwifery services about the appointments that Mother missed in the months that followed. It is good practice for health visitors to receive information such as this from their midwife colleagues as they will be providing longer term care to a mother and child post-natally. It is not considered a ‘late booking’ in local procedures prior to 24 weeks gestation, so there was no expectation that Mother’s booking at 20 weeks would be referred on to any other agency or highlighted as a risky pregnancy. A referral was made to the Middlesbrough MACH due to the information shared by Mother in respect of domestic abuse and the involvement of social workers in the past, but it would be expected practice to also share referrals of this type with the health visitor. 26. It is good practice in Middlesbrough that health visitors visit families antenatally. This is not always happening in other areas of the UK due to capacity and issues with recruitment and retention of staff. It was clear to the health visitor allocated to unborn Angel that the family were likely to be vulnerable, even though they came through to the service as ‘universal’. She was not initially aware of the history of CSC involvement, but made enquires and found out, from speaking to one of the older children’s primary school in Local Authority A, that the children had been on a child protection plan for neglect. The health visitor stepped them up to the ‘best start pathway’ in order to provide an enhanced service. She had enquired about CSC involvement in both Local Authority B and Middlesbrough when the case was allocated to her, but on the day that she enquired both the Local Authority B MASH and Middlesbrough MACH informed her that there was no current social work involvement. The Middlesbrough MACH opened the case for an assessment just a few days later but did not contact the health visitor, who was therefore effectively working in a silo at the time. This lack of communication maybe because all the older siblings living with Mother were of school age and there could be a lack of understanding from social workers that health visitors are involved pre-birth. The opportunity should be taken to ensure that social workers are reminded that any pre-birth assessment needs to involve the health visitor allocated to the unborn child. 7 27. There is a general shortage of school places in Middlesbrough, and this appears to have had an impact on the family getting school places for all the children when they first returned. While places were available immediately for some of the children, there were particular issues with a child in year 2 and the eldest child, of secondary school age, getting a place. This resulted in them missing many months of education. It took over 6 months and an escalation by the social worker for the eldest child to be given a school place. This was due to a combination of issues at the preferred choice of school that the Local Authority are aware of, and the review was told that the school has been supported to ensure that the admission process has improved. Unfortunately, none of the schools attended by the older children in the family attended the practitioner’s event held as part of this review, and a recommendation has been made for the Partnership in respect of the need for schools to be more involved in their work, as this has been acknowledged as a wider issue. 28. There were several other gaps in the children’s schooling prior to the latest move, including during the pandemic where the family chose not to take up the offer of continued school attendance due to the children being on a child protection plan at the time. Schools had no authority to insist that children attended at the time. This case also reflected the wider issue both locally and nationally of school records not always following children who move in a timely way. The expected timeframe for pupil records to be transferred to the receiving school is five days. For any child, the lack of records is concerning, but for children with a history of safeguarding concerns and on-going challenges, robust practice is required, both from the school the children are leaving and from the receiving school in chasing records. The Middlesbrough school had no record on their system of how many and which schools the children had attended previously, so were unaware of both the level of disruption to their education or whether there were safeguarding concerns at the previous schools. The review reflected that practice needs to be improved to enable better communication about children with their previous schools, an understanding of the need for schools to consider the impact on a child’s education and wellbeing of multiple changes, and a need to challenge the apparent acceptance of children changing schools. 29. When the children were being cared for by extended family members at the time of Mother’s confinement, one of the older children was injured and there was a possibility that the injury was inflicted by a relative. A section 47 investigation was completed, and no further action was taken, although it was made clear to the children’s mother that the family member should not have care of the children again. The strategy meeting that considered this potential non-accidental injury led to an improvement in the multi-agency knowledge of the family history, although gaps remained. The alleged incident led to Mother receiving less support from her family after the birth of the baby, however. The child in need plans were ongoing however and there is evidence that the allocated social worker in the long-term team (who was allocated after the assessment agreed that child in need plans were required) worked hard to provide practical assistance with furniture and school places, along with monitoring the home conditions and supporting Mother to make the required improvements. Working with families with language and cultural differences 30. The review was told that the children’s mother didn’t always acknowledge at the time that her spoken English could limit her understanding of what professionals were saying. This is understandable and 8 common and needs to be handled sensitively by professionals9. Despite what the service user says, they need to remain open minded to whether the service user’s understanding is sufficient for the discussions that are required and revisit the need for interpreters regularly. When meeting with Mother as part of the review, it was clear that while her understanding of spoken English appears to be good, it is not always clear what she is saying. She told the lead reviewer that she gets frustrated when trying to communicate in English, and she clearly made good use of the interpreter. She agreed with the finding of this review that professionals need to be honest about whether an interpreter is required for them to understand what a service user has to say. 31. The health visitor was able to establish immediately that an interpreting service was required, and this was accepted by Mother and used on every visit. However, the midwives and CSC did not use an interpreting service and told the review that Mother had been ‘offended’ by the suggestion. This is something that they explained can often be an issue. In this case the lack of interpreting support would have limited their ability to communicate effectively with Mother and undoubtedly had an impact on gaining a full understanding of the family history and current situation. The children spoke good English and were occasionally used to clarify things with their mother, which, while common, is of concern. Good quality telephone interpreting services are reportedly available to staff and need to be promoted, but also professionals need confidence in how to approach this issue with families in a sensitive way. 32. The review was told that the health visiting service was doing a lot of core contact by phone at the time. While this might be suitable in some cases, it makes the use of an interpreting service very difficult. This is part of the reason that the health visitor in this case wanted to visit Mother face to face both before and after the birth of Angel, which is good practice. She also spoke of the need to be clear with families where there are cultural differences about expectations in the UK, for example regarding the need to use car seats, and about the need for and the provision of free antenatal care. There is also the possibility that parent’s who grew up elsewhere may be confused and concerned about professional engagement in their family, and this also requires skilled and sensitive handling. The national panel’s latest annual report on CSPRs was published in December 202210 . It states that ‘poor parental engagement by minoritised parents has been linked with fear, including fear of the power professionals wield’, and that ‘professionals need to recognise, explore and seek to allay such fear while working with the parents.’ Mother confirmed that she was extremely concerned that her children would be taken away. She can now recognise that she requires support and would want to reassure others of the need to accept help without fear. 33. Mother and the children had been the victims of violence in their home from the children’s father. Although the relationship was over, there was a need to address this with the family, for all of them to have insight into the impact of living with domestic abuse. This was needed to prevent reconciliation with the father or future abusive relationships for the mother, and a referral was made for her to attend My Sister’s Place.11 There was also a need for preventative work to be undertaken with the children, as those who experience domestic abuse as children are more likely to be in an abusive relationship 9 This may also be relevant when there are other issues that may have an impact on understanding. 10https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1123918/Annual_review_of_loca l_child_safeguarding_practice_reviews.pdf 11 A local independent specialist ‘One Stop Shop’ for women aged 16 or over and have experienced or are experiencing domestic violence 9 themselves as adults, along with consideration of their therapeutic needs because of the trauma and cumulative neglect they have experienced over time. Conclusion and recommendations 34. This CSPR was initially commissioned because of the possibility that the death of Angel was not accidental, due to comments made by her mother at the time of the child’s death. This is awaiting resolution. While the criteria for a CSPR may not have been entirely met, it has been a useful process to identify learning, particularly about safeguarding children who move within and between areas. 35. The national CSPR Panel report 2022 states that the findings of Local CSPRs need to be contextualised with other reports, inspections and audits, to get a broader understanding of practice and organisational challenges. Similar issues have been found in cases considered at the CDOP12 in the region regarding apparent barriers to the use of interpreters, which is being considered. There is a newly formed Tees-wide partnership Task and Finish Group being set up in respect of transient families, that will use the learning from this review to consider improvements. There are several cases that the Partnership are aware of where the families have moved between local authorities within the region, and learning from these cases validates the findings and recommendations of this CSPR. 36. The review has found the need for improvements to be made which will make a difference to the children of Middlesbrough, particularly those who have moved here from another area. The message that these children need to be recognised and owned locally is an important one. The review has therefore made the following recommendations for the STSCP: Recommendation 1: That the STSCP shares this report with the Safeguarding Children Partnerships in Local Authority A and B with a request that they reflect on the concerning findings and the learning identified regarding the seeking and sharing of information when children move into and out of their area. Recommendation 2: The STSCP must reinforce that children with a safeguarding history who move area are potentially some of the most vulnerable children. They must ask partner agencies to provide assurance of good practice (including information seeking and sharing) and robust and consistent systems that acknowledge local ownership and meet the needs of these children. Recommendation 3: The Partnership asks all agencies to: -Remind all professionals about the value and importance of using interpreting13 services, including provision of the cultural awareness required to work in a meaningful way with the family. -Ensure they support professionals with how they sensitively introduce the need to use these services with families.14 Recommendation 4: The STSCP asks partner agencies to promote that a health visitor must be involved in assessments and planning for unborn children. Recommendation 5: The STSCP to ensure that the schools in this case and more generally are engaged effectively in CSPR and learning processes. 12 Child death panel 13 This should include that interpreters are valuable in providing cultural understanding 14 As the health visitor did in this case 10 |
NC046595 | Suicide by a 16-year-old girl in January 2014 while she was staying at a therapeutic residential unit. Child O had a history of eating disorders, self harm and suicidal thoughts. She was in regular contact with health and social care services and spent time as a psychiatric in-patient. Child O spoke of sexual abuse/exploitation outside the family but agencies could not substantiate this nor persuade her to disclose details. Issues highlighted include a significant delay in the local authority agreeing to the family's request that Child O be admitted into their care; Child O's situation was never subject to a formal child protection investigation; and opportunities were missed to assess whether she met the threshold for compulsory detention under the Mental Health Act. Recommendations include: the Metropolitan Police Service to demonstrate that changes have been made to ensure that reports of child sexual exploitation are always followed up; the local authority to demonstrate that child protection investigations and assessments are conducted and completed without delay and meet procedural and good practice requirements; the local authority and NHS organisations to audit and report on their care planning arrangements for looked after children; and the local safeguarding children board (LSCB) to ensure that guidance is available for all partner agencies on dealing with safeguarding situations relating to social media use.
| Title: Child O: a serious case review LSCB: Haringey Local Safeguarding Children Board Author: Kevin Harrington Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Page 1 of 72 Kevin Harrington Associates Limited CHILD O A SERIOUS CASE REVIEW Kevin Harrington JP, BA, MSc, CQSW Page 2 of 72 TABLE OF CONTENTS TABLE OF CONTENTS .................................................................................. 2 1. INTRODUCTION ......................................................................................... 4 2. FAMILY BACKGROUND ............................................................................ 6 3. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW .......................... 7 4. TERMS OF REFERENCE ......................................................................... 10 5. METHODOLOGY USED TO DRAW UP THIS REPORT .......................... 11 6. KEY EVENTS ............................................................................................ 12 6.1 Introduction ........................................................................................... 12 6.2 2010 ....................................................................................................... 12 6.3 2011 ....................................................................................................... 13 6.4 2012 ....................................................................................................... 15 6.5 2013 ....................................................................................................... 18 6.6 2014 ....................................................................................................... 22 7. THE FAMILY ............................................................................................. 24 7.1 Child O .................................................................................................. 24 7.2 Child O’s parents’ views of the services provided ........................... 25 7.3 Working with the family ....................................................................... 26 7.4 The involvement of the Local Authority Designated Officer ............ 28 8. THE AGENCIES ........................................................................................ 30 8.1 London Borough of Haringey, Children’s and Young People’s Services ................................................................................................ 30 8.2 Tumblewood ......................................................................................... 35 8.3 NHS Islington Clinical Commissioning Group .................................. 40 8.4 The Priory Hospital North London Adolescent Unit ......................... 42 8.5 Whittington Health ............................................................................... 43 8.6 Child O’s education ............................................................................. 45 Page 3 of 72 8.7 Crisis Care ............................................................................................ 47 8.8 Metropolitan Police Service ................................................................ 48 8.9 British Transport Police ...................................................................... 50 8.10 The General Practitioners - London ................................................... 51 8.11 The General Practitioners – Wiltshire ................................................ 51 8.12 NHS Haringey Clinical Commissioning Group: Health Overview Report ................................................................................................... 52 8.13 Involvement by other NHS agencies .................................................. 53 9. KEY ISSUES ............................................................................................. 54 9.1 Introduction .......................................................................................... 54 9.2 The failure to use child protection arrangements ............................. 54 9.3 Child sexual exploitation ..................................................................... 55 9.4 Risk assessment and assessment under mental health legislation 57 9.5 The joint commissioning of services ................................................. 58 9.6 Escalation ............................................................................................. 59 9.7 The impact of organisational change ................................................. 60 9.8 The influence of social media ............................................................. 60 9.9 Serious Case Review Process ............................................................ 61 10. CONCLUSIONS AND KEY LEARNING POINTS ................................... 63 11. RECOMMENDATIONS TO HARINGEY LOCAL SAFEGUARDING BOARD ................................................................................................. 66 11.1 Introduction .......................................................................................... 66 11.2 Recommendations ............................................................................... 66 APPENDIX A: THE LEAD REVIEWER ......................................................... 68 APPENDIX B: TERMS OF REFERENCE ..................................................... 69 APPENDIX C: REFERENCES ..................................................................... 71 Page 4 of 72 1. INTRODUCTION 1.1 A young person took her own life in January 2014, shortly before her 17th birthday. She had been very troubled for several years and had continuing contact with health and social care services. With the agreement of her family she had been admitted to the care of their local authority, the London Borough of Haringey, and placed in a therapeutic residential setting in Wiltshire. It was near here that she died after lying under a train. 1.2 These events were considered by the Haringey Local Safeguarding Children Board (HSCB), mindful of the government’s guidance1 that “when things go wrong there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children”. The guidance requires that a Serious Case Review (SCR) should be carried out to provide that analysis and identify the necessary service improvements when a child has died and abuse or neglect are known or suspected, or more generally when it is believed that lessons can be learned from what has happened. The HSCB decided that the circumstances of Child O’s death were such that it was necessary to conduct an SCR and this is the Overview Report from that review. 1.3 The death of this young person has been the subject of considerable publicity in which she has been identified. Her parents have been clear that they do not wish her identity to be disguised in any way in this review. This was accepted by the author of this report, and in earlier drafts she was referred to by her given name. 1.4 However, when this issue was considered by the Panel steering this review, it was decided that this would not be appropriate because of, with reference to the child’s wider family, “the Board’s duty of care to protect information about individuals who could be identified and who have not given permission for that information to be shared”, and because “the Board should not set any precedent2 in relation to SCRs that deviates from their duty of care, or from standard best practice”. The subject of this SCR is therefore referred to as Child O. 1.5 Child O was, for whatever reasons, a very damaged and vulnerable girl. That could hardly have been more clear. It is notable, in considering what the various agencies have said about their involvement with her, that there was 1 Working Together to Safeguard Children (2015) – referred to in this report as “Working Together” – is the government publication containing statutory guidance on how organisations and individuals should safeguard and promote the welfare of children and young people, in accordance with the Children Act 1989 and the Children Act 2004. 2 There are national precedents – Daniel Pelka, for example, in Coventry - but HSCB has not previously identified a child at the centre of an SCR. Page 5 of 72 never a time in the period under review when any professional who knew her did not have profound concerns for her. 1.6 Her distress manifested itself most often in self-harm. People who harm themselves do not generally go on to kill themselves but, at the same time, self harm carries a significant risk of subsequent suicide3. At the very first contact with a professional in the period under review, a presentation to a GP in 2010 when Child O was thirteen years old, she spoke of having already tried to kill herself. A month later she was assessed at UCLH as being “at high risk of suicide”. The possibility of suicide remained consistent. 1.7 However, in the hours immediately before her death there was no indication that Child O might choose that time to end her life. Those around her at the time have reflected that “something quite overwhelming had taken hold of her on (that) evening”. Her suicide on that particular night could not have been anticipated. 1.8 This review has identified very serious weaknesses across the services which should have helped Child O and her family, stemming from an overall failure to use safeguarding arrangements and risk assessments effectively. But there was also clearly a significant, avoidable delay in taking a key action – agreeing to her and her family’s request that she be admitted to the public care, to live separately from her family in a therapeutic placement - which probably had the best chance of achieving enduring, positive change. 1.9 The author of this report has been involved in one previous4 SCR in Haringey. It is of concern that a number of issues raised in that review, which considered events in 2010 / 2011, re-appear in this review, across the agencies involved. These include inadequate assessments, failure to use child protection arrangements appropriately and a lack of effective management oversight. 1.10 In May 2015 the HSCB published another SCR report5. The circumstances of the children and family under review were very different to those considered here. However a number of the “critical failings” identified in that review echo some of the findings of this report. 3 NICE Guidance 2014.pdf 4 Child T Overview Report 5 Child CH Overview_Report Page 6 of 72 2. FAMILY BACKGROUND 2.1 Child O was the youngest of five children. Although in the care of the local authority when she died, she continued to spend a lot of time at home with her family, as she had done previously during long periods as an in-patient receiving psychiatric hospital care. 2.2 The family composition is as follows: Father [Parents, married] Mother (1958) (1956) Sister Brother Sister Brother Child O (1984) (1985) (1988) (1995) (1997) 2.3 Both parents are from the USA, but all the children were born in the UK. Child O’s father was one of three children and Child O’s mother one of seven. There is a large extended family in the USA. The family, including Child O except when she was unwell in 2012, travelled to the USA every year or more often than that. Page 7 of 72 3. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW 3.1 This SCR was formally initiated by the then Chair of the HSCB, Graham Badman CBE, in January 2014. Graham Badman’s term of office terminated in March 2014 and HSCB appointed a new Chair, Sir Paul Ennals, in May 2014. 3.2 Graham Badman had convened a panel of senior representatives (the Panel) from relevant agencies to lead the SCR and had personally chaired that Panel. Sir Paul Ennals initially also chaired the Panel before handing that responsibility over to Karen Baggaley. Ms Baggaley, the Vice-Chair of the HSCB, is the Assistant Director for Safeguarding and the Designated Nurse for Child Protection for the NHS Haringey Clinical Commissioning Group. 3.3 The HSCB appointed an experienced independent person – Kevin Harrington6 - to act as Lead Reviewer and to write this report. 3.4 This review has taken an unusually long time to complete. One of the reasons for that is the large number of agencies required to contribute. Many agencies and professionals, from a number of different localities, had been involved. All agencies were required to submit an Individual Management Review (IMR), either containing a narrative and an analysis of their involvement where that had been substantial, or a narrative account of events where involvement had been less significant. Those agencies are detailed in the table below, and are subsequently referred to by the acronyms / abbreviated forms provided. AGENCY NATURE OF INVOLVEMENT London Borough of Haringey, Children and Young Person’s Services (CYPS) Child O was known to this local authority from the summer of 2011, and was in care to this local authority when she died. Tumblewood Community School (Tumblewood) The therapeutic residential home where Child O was living at the time of her death School B, a state school in central London This was the last school Child O attended NHS Islington Clinical Commissioning Group (ICCG) The commissioners of Child O’s health care from April 2013 when they replaced their predecessor body, the Islington Primary Care Trust (IPCT) The Whittington Hospital NHS Trust ( The Whittington) This Trust directly provided a range of health services to Child O - accident and emergency, community and in-patient child mental health services. The Priory Hospital North London (The Priory) This private hospital provided “overflow” In-patient child mental health services, when NHS provision 6 Appendix A of this report contains brief autobiographical details, Page 8 of 72 was unavailable or inappropriate Metropolitan Police Service (MPS) Police in London were Involved in investigations and child protection processes during the period under review Keys Childcare Group (Crisis Care) Providers of short-term residential care prior to Child O’s admission to Tumblewood General Practitioners (London) Family GP services in London General Practitioners (Wiltshire) GP services to Child O in Wiltshire NHS Haringey Clinical Commissioning Group (HCCG) This agency has provided an overview of all health services contributing to this report The Cassel Hospital This hospital provided advice about managing Child O’s situation. University College London Hospitals NHS Foundation Trust (UCLH) Child O was briefly admitted to UCLH after self-harming, at the beginning of the period under review North Middlesex University Hospital NHS Trust (NMUHT) Child O was briefly admitted to NMUHT after self-harming Barnet and Chase Farm Hospital NHS Trust (BCFH) Child O was twice treated at BCFH after self-harming Royal Free London NHS Foundation Trust (Royal Free) Child O attended the Royal Free twice to discuss surgery to conceal scarring caused by self harm British Transport Police (BTP) This force was Involved in the investigations into the circumstances of Child O’s death Central London Community Healthcare NHS Trust Provided a school nursing service while Child O was at mainstream school London Ambulance Service NHS Trust Transported Child O to hospital on two occasions The Tavistock and Portman NHS Foundation Trust (Tavistock) This Trust had one routine contact when Child O became a “looked after” child. London Borough of Hackney, Children’s Social Care services (CSC) The family previously lived in Hackney and CSC had been involved in assessing their situation 3.5 The Coroner’s inquest into Child O’s death concluded in October 2014. The Coroner wrote to the Chief Executive of the London Borough of Haringey, and to the Metropolitan Police Service raising concerns and seeking comments about a number of issues (which are addressed in this report). It was agreed with the Coroner that this review should be completed, to inform Page 9 of 72 the agencies’ response, and those agencies have now corresponded directly with the Coroner in relation to the matters raised. Page 10 of 72 4. TERMS OF REFERENCE 4.1 The Terms of Reference for the review are at Appendix B. They are drawn from Working Together, amended to reflect issues specific to the circumstances of this case. 4.2 Agencies were initially asked to review their involvement with the family from January 2007, but the scope was subsequently revised to focus on the events from the summer of 2010, when Child O was first referred to therapeutic services, until her death in January 2014. Page 11 of 72 5. METHODOLOGY USED TO DRAW UP THIS REPORT 5.1 This report is based principally on the IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors and other staff. Child O’s parents were also been keen to contribute and their views and comments are reflected in section 7 of this report. 5.2 This report consists of A factual context and brief narrative chronology. Commentary on the family situation and their input to the SCR. Analysis of the part played by each agency, and of their submissions to the review. Identification and analysis of key issues arising from the review. Conclusions and recommendations. 5.3 The conduct of the review has not been determined by any particular theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together: The review “recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight7; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings”. 5.4 The government has introduced arrangements for the publication of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would not be appropriate. This report has been written in the anticipation that it will be published. That has been discussed with Child O’s parents, who have no objection to publication and indeed have acknowledged the potential wider benefits of doing so. 7 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. Page 12 of 72 6. KEY EVENTS 6.1 Introduction 6.1.1 This section of the report briefly describes the key events during the period under review and the background to those events. Further detail is then provided throughout the report. 6.1.2 The following table summarises Child O’s whereabouts during the period under review. It does not include brief hospital admissions or short periods spent at home. Dates Child O’s whereabouts December 2010 to January 2011 The Priory January 2011 to July 2011 Simmons House July 2011 to September 2011 Home, including time in the USA September 2011 to February 2012 The Priory February 2012 to April 2012 Simmons House April 2012 to mid June 2012 Home June 2012 to March 2013 The Priory March 2013 to June 2013 Crisis Care June 2013 to July 2013 Tumblewood July 2013 to September 2013 Home, including time in the USA September 2013 to January 2014 Tumblewood 6.2 2010 6.2.1 The first evidence of cause for concern in the period under review was in the summer of 2010 when Child O, aged 13, was briefly admitted to the Whittington with alcohol intoxication. Then in October 2010 Child O’s mother took her daughter to the GP. Child O had taken a mixture of painkillers before school, then called her mother. The GP spent a long time with them, together and separately. Child O said she had “tried to kill herself” a number of times previously and spoke of “personal problems”. She had talked about this with a friend but did not wish to say anything further though she agreed to see a counsellor. She spoke of using alcohol and cannabis, and denied any sexual activity. She did not want her mother to be made aware of these matters but she said that “home and school were OK”. 6.2.2 The GP made an immediate referral to Child and Adolescent Mental Health Services (CAMHS) and a home visit was made from their Adolescent Outreach Team (AOT). Child O repeated what she had told her GP and also spoke of being angry with her parents. She talked of a friend who had tried to kill herself. Child O’s mother reported concerns that Child O and her friend were involved in self-harming behaviour. CAMHS offered to see Child O every week and placed the family on a waiting list to be seen together should individual appointments not resolve the problems. Page 13 of 72 6.2.3 The family decided, in the first instance, that Child O should see a psychologist at school, rather than being seen at CAMHS. However a month later Child O and her parents went to UCLH. She was said not to have eaten for 5 days, was unable to sleep, was cutting her arms and now said that she had been having suicidal thoughts for a year. She indicated that something bad had happened a year ago but would not disclose what this was. She said the problems were at school and in her local area. She did not always get on with her parents but that was not the main problem. 6.2.4 Child O was found to be physically well but significantly depressed and at high risk of self-harm or suicide. She was admitted to UCLH and from there was transferred to the Priory, a private psychiatric hospital in North London with an adolescent unit, as no NHS beds were available. Before transfer a referral was made to the London Borough of Hackney Children’s Social Care services (CSC). 6.2.5 The admission to the Priory was funded, as a short-term arrangement, by the former Islington Primary Care Trust (ICPT). This was because the family had a GP in the London Borough of Islington, though their home was in the neighbouring borough of Hackney. The AOT remained involved in planning and working with Child O and it was judged likely that she would need to transfer to longer term NHS provision at Simmons House, again a specialist adolescent hospital in north London. IPCT had a standing arrangement – the “Tier 48 Panel” - for reviewing these funding and care arrangements. 6.2.6 Child O’s care was now to be managed under the Care Programme Approach9 (CPA). The first assessment made by the Priory was that she had an affective disorder – that is, that her mood was disordered - with some paranoid component. Her reluctance to discuss her problems made it difficult to judge whether she had indeed experienced a traumatic life event or the extent to which she did have paranoid ideas or delusions. 6.3 2011 6.3.1 At the end of January Child O transferred to Simmons House. This admission was for assessment and was expected to continue for some months. In February the Tier 4 Panel confirmed continuing funding for this arrangement and decided there should be a further referral to Hackney CSC. This was because of the safeguarding implications of Child O’s situation – she was so vulnerable that agencies needed to be satisfied that all aspects of her situation had been thoroughly assessed. 6.3.2 By the end of March the admission to Simmons House had been confirmed as a continuing arrangement rather than an assessment, but Child 8 Child and adolescent mental health services nationally are planned, commissioned and delivered in line with a four-tier strategic framework, in which Tier 4 addresses the most complex needs, often by in-patient provision. 9 The CPA is the national arrangement for planning and reviewing the mental health needs of individuals. Page 14 of 72 O had become more unsettled. She briefly absconded once and then refused food for five days, leading to an admission to UCLH where she was fed by naso-gastric tube. Her behaviour on the ward was judged unpredictable and risky so that a nurse remained with her at all times. She was in UCLH for about a week until she could return to Simmons House in April. 6.3.3 During this time Hackney CSC conducted a Core Assessment10 and decided that there was no need for their involvement in the continuing care arrangements for Child O. The assessment found no concerns about her parents’ ability to care for and protect Child O, though Child O herself refused to see the assessing social worker. The parents were judged to have taken protective action when she became unwell and, in view of the considerable input from health services, it was decided that there was no need for further input from the local authority at that time. 6.3.4 In May the Tier 4 Panel confirmed continuing funding for the placement until late July. The team at Simmons House was now exploring plans for Child O’s longer term care. She was self-harming daily and refusing to participate in meetings with her parents. At times she had to be reported as a missing person to police. She spoke of hating her father, and of fears that she would be assaulted by other men if she were to return to live at home, an option which she refused to consider. 6.3.5 By mid-June Child O’s attitude had changed and she was spending more time at home. In early July her mother contacted police as Child O had facial injuries said by her to have been caused by a man in an incident on a bus. Child O’s mother was concerned that her daughter was being mistreated by someone but Child O would not confirm this. Police enquiries could not corroborate the report. 6.3.6 Soon after this Simmons House made a further referral to Hackney CSC after an incident where Child O returned to her home, badly bruised, saying she had been attacked in a park. Hackney CSC have reported that they agreed with Simmons House that they should refer the matter to Haringey CSC as the family were imminently moving to Haringey. They remained registered with their GP in Islington. 6.3.7 Child O went to America with her family for several weeks in the summer of 2011 and there was a planned discharge from Simmons House, where staff had expressed concern about this long period away from hospital. The discharge letter to her GP referred, for the first time, to a diagnosis of post traumatic stress disorder (PTSD). 6.3.8 A referral was now made, in early August, by Simmons House to Children’s and Young People’s Services (CYPS) in Haringey. This reported that Child O had spoken of having a miscarriage when she was twelve and 10 A Core Assessment (Framework for the Assessment of Children in Need, HMSO 2000) was a detailed assessment, undertaken by CSC over a period of weeks, when it was suspected that a child was suffering, or likely to suffer, significant harm. Page 15 of 72 subsequently being assaulted by the putative father. These reports were never substantiated. 6.3.9 At the end of September Child O was re-admitted to the Priory. There was said to be an increased suicide risk and her behaviour had become more challenging. She was cutting herself daily, banging her head and using ligatures to stop her flow of blood. She was aggressive to both of her parents, feeling overwhelmed academically, having returned part-time to school, and said she was stressed by moving house. She had spoken of auditory and visual hallucinations. 6.3.10 A Haringey social worker now became involved, as a result of the referral in early August, liaising with various agencies. Child O continued to self-harm in a number of ways (though these incidents were not all recorded by the hospital and shared appropriately between agencies). On one occasion in early November she cut her head and tried to strangle herself and required treatment at A&E (BCFH). 6.3.11 The following day the Tier 4 Panel received a report that CYPS felt she did not meet the threshold for their involvement. However some two weeks later Child O’s case was allocated to a social worker for an Initial Assessment. CYPS had also made a referral to the MPS Sapphire Team, an MPS specialist unit responsible for the investigation of rape and serious sexual assault. The referral had been prompted by comments made by Child O’s mother at a meeting at the Priory. She had expressed concerns about her daughter being in a relationship with an older man and about Child O saying that she had previously been pregnant. A Sapphire officer advised that there was insufficient information for them to become involved. They asked CYPS to make further enquiries and re-refer as necessary. 6.3.12 A week later CYPS recorded that their Initial Assessment had been completed and there was no need for the local authority’s continuing involvement. Child O had refused to see the social worker during the assessment. 6.3.13 The Tier 4 Panel met just before Christmas and decided to seek a meeting of the agencies involved, to include CYPS. They also discussed whether it would be possible for the child/family to register with a GP in Haringey. Child O remained at the Priory. 6.4 2012 6.4.1 On New Year’s Day Child O told staff at the Priory that her mother had hit her. This was notified to police and CYPS under child protection arrangements but Child O would not give any further details. It was agreed that CYPS would follow up but on 17/1/12 CYPS wrote to her mother to advise that no further action would be taken. The letter contains a confusing reference to Child O moving into residential care but the local authority no longer being involved. A Tier 4 Panel in mid-January noted “difficulty” in Page 16 of 72 working with the local authority and again discussed the idea of a change of GP. 6.4.2 Later that month Child O was again taken by ambulance to hospital and admitted self-harming - ingestion of batteries, screws, washers and cleaning fluid. She was to stay in hospital for 2 days. The notes on admission refer to “severe sexual abuse in the past” though this is not clarified or evidenced further. 6.4.3 A few days later the Priory wrote to the local authority asking that they assist with the plan for Child O to move to “a therapeutic residential placement that could predominantly meet her educational needs while maintaining her safety, and offering low intensity non-directive therapy until such time as she wants to access more structured therapy”. Child O and her family were said to be in agreement with this. At the same time there was a decision that she did not need in-patient psychiatric care but would attend Simmons House as a day patient while arrangements for residential care were made. This arrangement continued until the end of April when she no longer wished to attend Simmons House and was discharged, to be followed up in the community by CAMHS. 6.4.4 During the first weeks of March CYPS had carried out a Core Assessment, in the course of which professionals increasingly took a view that Child O had been raped or sexually assaulted by men in the Finsbury Park area when she was 12 years old. That assessment concluded that there should be continuing involvement by CYPS and that Child O should be seen as a “child in need11”. 6.4.5 The Haringey Complex Care Panel – a Panel organised by the local authority to consider care arrangements which might require inter-agency funding – now met and started to consider Child O’s case, recommending initially that there be a meeting involving key professionals and Child O’s parents. In April a doctor at Simmons House noted that there had been a very useful meeting, and that there would be further discussions between the local authority and the NHS. Then Simmons House received a letter from the Chair of the Complex Care Panel, stating that “the panel accepts that Child O needs to be given the opportunity to live outside the family home. As agreed with yourselves, there may be a number of provisions that could meet her needs. We are, therefore, going to explore a range of options and will be ready to present a decision to you during the week commencing 11 June 2012.” 6.4.6 Child O was an in-patient at the Whittington for a week at the end of May after swallowing razors, hair pins, broken glass and batteries. Two weeks later she was re-admitted. She said that she had had consensual sex with an adult male and then to have drunk vodka before shooting herself in the chest 11 Section 17 of the Children Act 1989 defines a child as being in need if he or she is unlikely to achieve or maintain, or to have the opportunity to achieve or maintain, a reasonable standard of health or development without provision of services from the local authority. Page 17 of 72 with a pellet gun. She said she wanted to kill herself. Doctors considered whether she might be made subject to detention under the Mental Health Act (“sectioned”) but decided this was not appropriate. She was transferred to the Priory in mid-June. 6.4.7 In response to the matters described in the previous paragraph CYPS convened a Strategy Meeting under child protection arrangements and again invited the Sapphire Unit but not the local police Child Abuse Investigation Team. Sapphire officers attended and advised that they would not become involved because there was no specific disclosure or corroborative evidence of a sexual offence. 6.4.8 In July the local authority advised that Child O’s situation did not meet their criteria for admitting her to care, or otherwise making any financial contribution to the costs of any placement made. The local authority had also now suggested that Child O be assessed by an educational psychologist to assist in determining how her needs might best be met. Meanwhile Child O continued frequently to self harm and talk of suicide. 6.4.9 Child O stayed in the Priory during the summer while the family went to the USA. Her mother had considered cancelling her trip to the USA but did eventually go for two weeks. One of Child O’s siblings visited her during this time. 6.4.10 In August the ICCG wrote to CYPS outlining the continuing concerns of clinicians about sexual exploitation/sexual grooming of Child O. It was further said that her self-harming behaviour was extreme and could place her life at risk. The letter stated that she did not need to be a psychiatric in-patient but that it was unsafe for her to live at home or in the local area. 6.4.11 There was now a further change of position by the local authority with renewed references in correspondence to the development of a joint funding arrangement. However they were still conducting the Core Assessment initiated in March, which was not completed until August. One of the conclusions of that assessment was that there should be a further psychiatric assessment, as there were judged to be conflicting diagnoses and the local authority had concerns about Child O’s capacity for engaging with a therapeutic placement. The Cassel Hospital had been approached by the local authority to conduct this assessment. 6.4.12 October was marked by unusually positive reports from the Priory. A psychologist reported that Child O was the happiest she had been since admission. She was participating in most activities, when previously she had stayed in her room most of the time. Child O was also co-operating with medical investigations into surgery to reverse scarring caused by cutting herself. 6.4.13 However agencies were openly in dispute about the decision to seek an assessment from the Cassel Hospital. The local authority advises that Page 18 of 72 “the Cassel Hospital had been asked to undertake the review given their specialist experience and knowledge in residential therapeutic treatment of severely disturbed young people”. However this request had been made without reference to clinicians at Simmons House or the Priory, who felt that their diagnoses had been consistent throughout. Those clinicians explicitly queried whether the local authority did not have confidence in their opinions and advice. Health agencies requested that the referral to the Cassel be withdrawn or deferred but the local authority argued that they were right to request a separate clinical overview if it felt this was necessary to inform care planning. 6.4.14 The local authority also raised the issue of Child O’s education, suggesting that she might need assessment for a Statement of Special Educational Needs. Health care professionals asked that this request be formalised and its purpose clarified but in fact the issue was not pursued by the local authority. It was eventually agreed that the re-assessment by the Cassel Hospital could be based on a review of records and discussions with some staff but would not involve Child O and her family directly. 6.4.15 In late October CYPS contacted Barnet CAIT regarding an allegation that Child O had been inappropriately touched by another patient. The CAIT advised CYPS to report the incident to local police as it did not fall within the CAIT remit. There is no evidence of any further action being taken in this matter. 6.4.16 In mid-November Child O again cut herself several times and required treatment in A&E at North Middlesex Hospital. A further meeting was held towards the end of November. All relevant agencies, including the Cassel Hospital, were represented. The Cassel Hospital recommended that the “status quo was maintained” and they should continue to carry out a full assessment. This proposal was not agreed. 6.4.17 The ICCG agreed to fund an assessment of Child O in a residential placement. Just before Christmas CYPS indicated that they were in agreement with the proposal that Child O move to a jointly funded residential care placement. Clinicians felt that Child O could be discharged home from the Priory while these matters were followed up. In fact she remained an in-patient until March 2013. 6.5 2013 6.5.1 During January and February there were discussions with a potential placement. Health agencies were satisfied with this plan and were working towards a move in March, although the local authority was still exploring alternative placements, against the possibility that the first option might not be successful. At the same time the proposed establishment was itself considering a possible risk assessment by a mental health agency before committing to taking Child O. It was decided that Child O could go to an “intermediate” placement, where such an assessment could be carried out. This would be funded by the local authority. Page 19 of 72 6.5.2 In March Child O left the Priory to go to this placement – Crisis Care in Shropshire. A few days later she was formally admitted to local authority care under section 20, Children Act, 1989 – that is, she was in care with the agreement of her parents who retained parental responsibility for her. This was what her parents had originally proposed in January 2012. 6.5.3 The focus of enquiries was shifting and the placement of choice was now the Tumblewood Community, a residential resource for adolescent girls in Wiltshire. However it was not until mid-May that Child O had her first direct contact with Tumblewood. After being shown around and meeting some young people she was judged to have been positive and cheerful. Crisis Care subsequently confirmed that she was very positive about the placement. 6.5.4 It was a month later, in mid-June, that Child O moved to a long-term placement at Tumblewood. All reports indicate that she settled well and co-operated in discussions about her education, health and social needs. She had a new social worker from CYPS, who visited soon after her admission to attend a meeting which agreed the objectives of the placement. The plan set out her daily routine in detail, including her education programme. It confirmed that she would have an allocated female worker alongside her for support, and a key worker. She would be expected to participate in a structured group work programme and would attend a weekly “Art plus” group. Community Meetings were held twice daily, before and after school and she would have regular oversight from a psychiatrist. 6.5.5 The plan to go to America for the summer was discussed with social workers & the IRO in mid-June when setting up the statutory Looked After Child (LAC) review for the end of July, and it was agreed that the family would go to the USA immediately after the review. In fact the social worker argued that they should do so, in line with Child O’s wishes, even though Child O’s mother had suggested delaying departure to allow the family to attend an event at Tumblewood. 6.5.6 In a routine monthly report at the end of June Child O is recorded as saying she had “finally found somewhere where she thought she could live comfortably.” The report states that she was proving a valuable addition to the group, attended community meetings regularly and showed maturity in her interactions with both young people and adults. 6.5.7 Child O spent a weekend at home in July, reporting on return that it had gone well. The report at the end of July was again positive with staff comments similar to those made in the previous report. Her own written contribution is also positive about her time at Tumblewood. The LAC Review at the end of July was attended by Child O and her mother, and was generally encouraging, envisaging that Child O would be living at Tumblewood for the next two years. Page 20 of 72 6.5.8 Immediately after the LAC Review Child O returned to the family for the planned holiday in America. She had been in placement for seven weeks. Around the same time an Ofsted inspection of Tumblewood as a registered children’s home downgraded Tumblewood from its former “Good” rating to “Inadequate”. The formal notice to Tumblewood details the following concerns: “The home’s safeguarding policy is inadequate. This policy had not been submitted to the Local Authority Designated Officer for Child Protection (LADO) for consideration and comment. 2 allegations made by young people against members of staff have not been reported to the LADO or to Ofsted under Regulation 30, Schedule 5. Prompt action is not always taken to minimise the risk of young people going missing from the home. There is delay in reporting some missing young people to the police to secure a swift and safe return to the home. The home has not informed placing authorities of all missing episodes. Regulation 33 and Regulation 34 monitoring processes are ineffective in identifying shortfalls in care and recording practices and improving outcomes for young people. The risk reduction measures in place within the home lead to an institutional feel” 6.5.9 When CYPS were routinely informed of this, senior managers decided, without reference to the family or any other agency, that Child O should not return to Tumblewood when the family came back from holiday. The placement is described in records as “terminated”. A Team Manager within CYPS raised concerns because “alternative plans do not seem to have been considered and (because of) the impact on Child O and her family”. These concerns were not accepted by senior managers. The family was contacted by email to advise them of the decision. 6.5.10 A week later a CYPS manager decided that, in any event, Child O had already been removed from local authority care by her family, by virtue of taking her on holiday for six weeks. This was despite the local authority’s involvement in agreeing these holiday arrangements in mid-June. 6.5.11 A senior manager then queried “whether Child O did in fact need a specialised placement given her extended leave with family and having regular weekends at home.” The local authority proposed that there should be a “re-assessment”, which should take account of the Ofsted findings about Tumblewood. The Independent Reviewing Officer12 (IRO) who had chaired the LAC Review 12 This is a statutory post, established in the Children Act 1989 and strengthened in subsequent legislation. The IRO is appointed to monitor the performance by the local authority of their functions in relation to the child’s case, participate in any review of the child’s case and ensure that any ascertained wishes and feelings of the child concerning the case are given due consideration by the appropriate authority IRO guidance Page 21 of 72 complained that she had not been consulted about any of the decisions being taken by senior managers. 6.5.12 A social worker wrote to the family advising that, because of the Ofsted judgment, the placement had been “suspended” and “a reassessment would need to be undertaken before we would consider placing Child O back at Tumblewood or anywhere else”. 6.5.13 The local authority made direct contact with the family when they returned to the UK and confirmed that they would not support Child O’s return to Tumblewood. ICCG and CAMHS expressed concerns as they had not been consulted about this, despite the joint funding arrangements. Then, despite the local authority’s decision that Child O was no longer “in care”, a LAC review was held at the end of August. Child O attended and was clear that she wished to return to Tumblewood. The IRO represented this to senior managers at CYPS, indicating that she also felt Child O should return. 6.5.14 The ICCG wrote formally to the local authority stating that they did not support the decision to refuse a return to Tumblewood because of the lack of consideration of clinical risk attached to the decision the lack of any alternative arrangements in place strong and clear objections from the local clinical team CYPS responded in detail, confirming that any resumption of the placement would be subject to a re-assessment of Child O and consideration of the problems at Tumblewood. In the meantime the local authority had offered the family “daily support (9-5)” which had been declined. 6.5.15 This situation continued for another three weeks until mid-September when Tumblewood was re-inspected and judged “adequate”. Initially there was further confusion as a CYPS manager was concerned that the grading was “adequate” rather than “good”, and that this might mean Child O should not be re-admitted. However a few days later it was agreed by CYPS that Child O could return and she did so. She was noted to be happy and settle quickly. 6.5.16 Child O’s mother approached ICCG in October asking if they would fund periodic reviews of her daughter by the psychiatrist who had managed her care in the Priory. This request was refused as she was now under the care of the psychiatrist at Tumblewood. That psychiatrist subsequently sought to liaise with the clinicians previously managing Child O’s care but received no response until after Child O’s death. 6.5.17 During the first weeks of October Child O complained of a number of minor illnesses and her attendance at school declined significantly, but she was otherwise normally involved in the life of the establishment. She spent time at home during the half-term break and was noted to be more unsettled on her return, declining to join in group activities. On one occasion she was found in a trance-like state, muttering under her breath “someone is going to hurt me.” There was evidence of self-harm – marks on her hand. She spoke to staff of hearing “noises in my head” and referred to herself as “mental”, but Page 22 of 72 responded well to expressions of concern and encouragement from staff. There was mounting evidence that she was unsettled in male company and staffing arrangements were adjusted to take this into account. The monthly overview report for October noted that she had “struggled” since returning to Tumblewood. 6.5.18 Child O had seen the Consultant Child Psychiatrist at Tumblewood twice before the summer break and then attended fortnightly sessions with him from early November until a week before her death. She also started psychotherapy sessions in mid November and continued to attend weekly, save for oversleeping once and going home at Christmas. 6.5.19 The psychiatrist was contacted by Child O’s mother in November, unhappy that she had not been involved in discussions about her daughter’s treatment. She repeated these concerns to Tumblewood staff after a new incident of self-harm, and told them that Child O had rung her saying she felt near to needing admission to psychiatric hospital. 6.5.20 Child O then had to be taken to A&E, complaining of chest pains, and was diagnosed with an inflammation of the chest. Following this her risk assessment at Tumblewood was updated with clear instructions on how to respond to various presentations. 6.5.21 Early in December Child O was involved in a fight with another young woman at Tumblewood. She was told to remain on the premises but refused to do so. She was away for some hours before returning, still angry. Over the next day she would not leave her room or co-operate with staff. The situation settled but, nine days later, she was seen with a deep scratch to her face, believed to be self-inflicted. While a member of staff was assisting with these injuries Child O disclosed that when she had left the site after the fight she had gone to the railway tracks nearby. She wanted to jump under a train but did not do so because it was her brother’s birthday and she did not want her family to be angry with her. 6.5.22 A week before Christmas a review of Child O’s education was held, attended by her mother, her social worker and Tumblewood staff. The meeting did not go well and Child O left angrily complaining that she was being criticised for unsatisfactory educational progress. She then went home for Christmas. 6.6 2014 6.6.1 Child O returned early in the New Year, telling staff she was glad to be back. However, on return, she saw the psychiatrist and referred to having “PTSD episodes” related to intrusive thoughts. She would not be more specific, commenting that this might lead to her detention under the Mental Health Act. The next day staff attempted to resolve the issue of the fight in Page 23 of 72 December. Child O became very agitated and distressed and tried to choke herself with a scarf which staff had to cut from her throat. 6.6.2 A LAC Review was held a few days later. Child O and her mother attended and Child O was pleased with decisions made which amended her education programme so that she was required to attend fewer classes. Overall it was agreed that the emphasis in working with Child O should be on developing life skills to help her when she left Tumblewood at age 18. 6.6.3 In mid-January Child O’s mother contacted Tumblewood. She said that there were media reports of the inquest into the suicide of a friend of Child O. She wanted to tell Child O about this so that she did not learn of it from the media and she spoke to Child O later that day. The following day Child O spoke to a member of staff saying that her friend had committed suicide, by jumping in front of a train at King’s Cross, because she was bullied. Child O’s manner did not give any cause for concern. 6.6.4 However she left the site that evening and staff found messages indicating that she intended to commit suicide. This was reported to police who followed up without delay but she was found to have indeed taken her own life by lying in front of an express train. Page 24 of 72 7. THE FAMILY 7.1 Child O 7.1.1 Child O was an unusually troubled young person, even by the standards of the specialist agencies that worked with her throughout the period under review. A letter from one of her treating psychiatrists in 2013 described “significant risk to her personal safety, ongoing suicidal ideation…and a number of significant attempts while in the community …she was at risk of being drawn into abusive situations which often can happen as a re-enactment of previous trauma. She also was experiencing frequent nightmares, flashbacks, dissociative experiences and visual and auditory hallucinations – often resulting in self harming episodes”. 7.1.2 It is similarly unusual that we still have so little firm evidence of the matters contributing to that disorder and distress. However Child O was resolute in her determination not to reveal information about herself. She would not speak to social workers trying to assess her situation. She expressed concern that her family would access her medical records and she insisted that only limited notes be kept of meetings she attended. Tumblewood found that “The longer Child O was in residence the more she presented herself and was experienced as not just cautiously private but…highly guarded, secretive, often untrusting … and fiercely resistant to opening up about her feelings preoccupations and fears”. 7.1.3 Despite the time she spent there the reports from the Priory and Simmons House do not give a helpful picture of Child O herself. Engagement with staff at Simmons House was inconsistent and there is only one member of staff (at the Priory) judged to have had any real success in engaging with her. The attempts by CYPS to understand Child O and form a positive relationship with her were also generally unsuccessful. The CYPS IMR finds that “conversations with Child O did not reflect sufficiently on her views, wishes and feelings about what it was like to be her, what was important to her, what she was worried about, where she felt safe…and there was limited exploration and self-reflection about her behaviour”. 7.1.4 Child O’s education was hugely disturbed by her ill health and her recurring admissions to hospital. It is clear that she also actively sought to avoid some of the requirements of being educated and that this was linked in part to her lack of confidence. She spoke to teaching staff at Simmons House about her reluctance to get involved in any assessments “as she felt that she would score ‘0’.” 7.1.5 Staff at Crisis Care did succeed, perhaps more than any other agency, in engaging with Child O, respecting her antipathy to any involvement with male staff and working around a difficulty they had identified in her capacity to adjust to disruptions in patterns of activity. As discussed below this was the Page 25 of 72 only time that Child O spent an extended period away from her family and her life in London. 7.1.6 Child O absolutely refused to permit or participate in any assessment process at Tumblewood - physical, psychological, educational or social. She also used the programme of “planning for independence” as another tool to distance herself from others. Some staff were defeated by this and could not engage with her but the IMR judges that the staff most regularly involved with Child O were not daunted. They saw dealing with her determined guardedness as part of the "work in progress". 7.1.7 The Tumblewood IMR seeks to understand this presentation as more than just a truculent refusal to co-operate. It suggests a fear of being judged and a fear that if she opened up about what she felt and what had happened to her, she would be exposed as damaged and vulnerable. She might be forced to see and accept herself in the way that she believed others saw her. 7.1.8 Child O struggled to accept that others found positive and admirable qualities in her. She needed close continuing contact from staff but at the same time she resisted that contact. At Tumblewood, despite the short and interrupted time she spent there, we see evidence of Child O as forceful and strong in demanding “independence”, and intelligent (while rejecting most educational “offers”). She could display mature thought and insight, warmth, generosity, a capacity for ordinary adolescent fun and an innate sense of justice and fairness. 7.1.9 The IMR from Tumblewood describes her as displaying the following characteristics: thoughtful and caring concern for others ability to make her own decisions and choices academic brightness and ability a readiness to participate and make a positive contribution love of animals respect for her living environment and surroundings 7.1.10 Child O’s time at Tumblewood is discussed further below and presents a mixed picture of progress and setback. But it is notable that there definitely was some purposeful activity and achievement: there was evidence there and at Crisis Care that Child O could enjoy the “ordinary” aspects of life as a young person. 7.2 Child O’s parents’ views of the services provided 7.2.1 Child O’s parents have been keen to participate in this review and have met the author of this report to share their views and experiences. Only one sibling now lives at home, a young person who remains deeply distressed by Child O’s death and has not been involved in this review. 7.2.2 Child O’s parents have been generous in their comments about individual members of staff, but forceful in describing their despair at the Page 26 of 72 succession of organisational barriers they faced in seeking ways to help their daughter. They believe that it was only ultimately because they instructed solicitors and involved their MP that the situation was unblocked. They are articulate professionals and are very aware that other parents might not have the contacts and the confidence on which they drew to pursue their case. 7.2.3 Child O’s parents firmly believe that their daughter was sexually exploited when she was 11 or 12 and this was the root of her problems. Her father did not believe for some time that this had happened but now feels that it is definitely true. They report a number of comments made by Child O to her mother, especially in the summer of 2012, which support that view. They described aspects of Child O’s personality – a girl who could be vain, a “smart aleck” – which they felt left her vulnerable to exploitation. They are frustrated that police consistently advised that no further criminal investigations could be pursued. They are aware that agencies’ understanding of and responses to concerns about child sexual exploitation have changed significantly in recent years. 7.2.4 Frequent changes of personnel, especially at CYPS, were a source of frustration. Similarly they were repeatedly disappointed when the local authority responded slowly and repeatedly failed to provide any written explanation for their decisions and actions. These are significant weaknesses in basic service standards and are reflected in the recommendations from this report. 7.2.5 In their view Child O’s time at the Priory was more useful than her admissions to Simmons House – they thought that the Priory was more structured and provided a security that Child O responded to. Crisis Care turned out to be a very good experience for Child O – she achieved things and enjoyed her time there. She grew to like being outdoors and the contact with animals, there and elsewhere, was always very important to her. 7.2.6 Child O’s parents said they knew that Child O respected and had confidence in some of the staff at Tumblewood. They judged that some of the work done with Child O, especially in the early stages of the placement, was very positive, although securing Child O’s trust was always a challenge. They feel strongly that the hiatus caused by Haringey’s decision to withdraw funding and disrupt the placement significantly affected the stability of those arrangements. 7.3 Working with the family 7.3.1 Subsequent sections of this report will describe how each of the agencies approached their work with the family. Agencies are criticised for deficiencies in that work but it is right to put those concerns in context. There were aspects of the family’s interactions with the agencies which made that work more challenging. 7.3.2 Child O’s mother’s professional background was a complicating factor. She is a health professional whose duties involve working with young people. Page 27 of 72 Inevitably she will have brought some of her experience and knowledge into her discussions with those caring for Child O. Her presentation can be forceful and some staff will have found the situation unusual and intimidating. They may have had unrealistic expectations of her. Some staff in the London services knew her both professionally and personally. It will have been equally challenging for Child O’s mother herself to see that those roles and boundaries were clear and consistent, and to contribute fully to an exposition of the family’s problems with people and agencies who were at other times colleagues. 7.3.3 Tumblewood also now take the view that they did not get their working relationship with the family right. Most importantly, right at the outset, “the “rules of engagement” for the frequency of contact between mother and daughter and the collaboration and sharing of care concerns between Tumblewood and (the mother) appear not to have been sufficiently discussed and clarified”. 7.3.4 Child O’s mother came to have far more day to day contact with her daughter and with staff at Tumblewood than staff were used to. Child O had to be given the room to settle and develop in her new environment. Yet staff never challenged this level of involvement on the basis that it might conflict with their therapeutic goals. They became too “friendly” with Child O’s mother. The Tumblewood IMR describes this factor sensitively – it made the “overall “degree of difficulty” of the placement and its management that much harder”. 7.3.5 For Tumblewood “the mother and daughter relationship becomes the near exclusive focus” because father and siblings were rarely mentioned by Child O when she was at Tumblewood. On the occasions that she did talk of her siblings, during her time at Tumblewood, she did so with warmth and affection. We know that her brother’s birthday had preoccupied her when she visited the railway tracks in December. On one occasion she reacted angrily to staff having spoken to her father but she never said anything negative about him to them. 7.3.6 Agencies in London also had far more contact with Child O’s mother than her father. Given her professional background, it might be expected that she would take a lead role in communicating with agencies. However those agencies then too easily allowed themselves to be deflected from engaging with the family as a whole. 7.3.7 There were complexities in the family history. Child O’s mother had spoken of earlier difficulties in her own life which were never explored with her. Child O had at times spoken negatively to staff in the London agencies about some family members, as well as expressing affection. One of her siblings displayed insight when talking to a social worker about Child O’s self-harm and how it might demonstrate an attempt to gain control of herself and her situation. At one time Child O expressed respect for a sibling who had overcome personal difficulties and successfully pursued a challenging professional career. Similarly there is a report of Child O supporting a sibling Page 28 of 72 through emotional difficulties before that sibling went on to notable achievements in sport, representing the UK internationally. On another occasion there was a noted difference of opinion between Child O’s mother and another of Child O’s siblings as to whether the family could guarantee to keep Child O safe, the sibling feeling that this would require 24 hour supervision whereas Child O’s mother was more sanguine. 7.3.8 The agencies’ records contain passing references to information about family members, volunteered by the family, which might have been further explored but were not. One potentially significant issue – how the family could manage successfully to take long summer breaks together when Child O seemed otherwise so out of control – was never confronted. There was no comprehensive assessment which drew together and analysed all that was known about the family background in order to inform assessments of Child O’s needs, the risks to which she was exposing herself and the extent to which her family could keep her safe. 7.4 The involvement of the Local Authority Designated Officer 7.4.1 There are concerns about how and how far the fact that Child O’s mother was a health professional became inappropriately part of the discussions between agencies. Those concerns are highlighted in the involvement of the Local Authority Designated Officer (LADO). 7.4.2 The LADO is a statutory role within all local authorities, responsible for considering cases where it is alleged that a person who works with children has: behaved in a way that has harmed, or may have harmed, a child. possibly committed a criminal offence against children, or related to a child behaved towards a child or children in a way that indicates s/he is unsuitable to work with children. The location of the employment will determine which authority is responsible for providing LADO services. 7.4.3 There were two episodes in this case, almost exactly a year apart, in which a LADO became involved. In February 2011 the LADO for the area where Child O’s mother worked, Islington, was approached after a Tier 4 Panel held at Simmons House. That approach was made by a manager in Islington’s children’s services who had attended the panel. This officer told the LADO that the treating psychiatrist had reported to the Panel that Child O had made allegations of physical abuse against her parents. 7.4.4 This was inappropriate.The reported allegation of physical abuse should have been made directly to the London Borough of Hackney, where the family lived, by the psychiatrist as soon as she became aware of it. 7.4.5 The LADO contacted the psychiatrist, stressing the difference between a child protection referral to the area where a child lives and a referral to the LADO in the area where a professional works. The LADO advised that the Page 29 of 72 first step should be for the doctor to make a formal referral to the London Borough of Hackney, so that they could investigate Child O’s allegation of physical abuse. Hackney should then advise the LADO of their conclusions so that Islington could determine whether any investigations were necessary in respect of the mother’s employment. 7.4.6 It is not clear whether the psychiatrist did now make a direct referral but a Hackney social worker did carry out an assessment. Child O would not confirm to the social worker the matters raised. Consequently the case was closed by Hackney and the Islington LADO properly took no further action. 7.4.7 In February 2012 the same LADO was contacted by a Haringey social worker – by now the family had moved to Haringey - to say that Child O had complained that her mother had hit her “when she was younger”. The original source of this allegation is unclear and, similarly, it remains unclear whether it refers to anything that was not part of the earlier matter. 7.4.8 The LADO again advised that the responsible authority, now Haringey, should liaise with police and conduct their investigation, which would then inform the LADO’s decision as to any action she should take. Eventually there was an investigation by Haringey CYPS which found no evidence of physical abuse. Consequently there was again no need for any action by the LADO. 7.4.9 The potential need for a LADO to be involved did add to the complexity of the case, and the events suggest a lack of understanding of the role and responsibilities of the LADO by some of the staff involved. In fact, evidence submitted to the SCR indicates this may be an enduring problem. It continues into the analysis by Whittington Health which comments that “The LADO process for the mother seems to have been protracted over a long period of time and reliant on other agency decision making rather than providing an autonomous risk assessment”. 7.4.10 In fact the Islington LADO dealt with the matters brought to her swiftly and with clarity. She subsequently provided a briefing session for some staff from Islington agencies to explain the requirements of the role. There is a recommendation from this report that similar arrangements are made in Haringey. Page 30 of 72 8. THE AGENCIES 8.1 London Borough of Haringey, Children’s and Young People’s Services 8.1.1 The London Borough of Haringey, for the purposes of this review, was responsible for providing children’s social care services after the family moved into that locality in the summer of 2011. 8.1.2 The local authority was made aware of the family in early August 2011 but it was not until the end of October that there was a management decision that this should be a “referral” – that is, a continuing piece of work, to be dealt with in line with organisational and statutory requirements and timescales. This decision should be reached within 24 hours. There is no indication of any management oversight of the case in the early period of contact. Case recording was poor throughout (which has itself hampered the ability of CYPS now to analyse and explain the weaknesses in their responses). 8.1.3 During that period in 2011 there was no direct contact with the family. Importantly this meant that there was no attempt to gain the parents’ permission to talk to other agencies and gather information, a fundamental requirement which should form part of the routine response to service requests. Equally there is no evidence of staff talking to Child O about her consent to gathering and sharing information. 8.1.4 This early failure to contact the family and seek to establish a working relationship with them then features repeatedly and significantly throughout the case history. Assessments and decisions were not shared and explained. Within the failure to involve Child O’s parents there was a particular weakness in respect of her father. “There is no evidence that father (was) engaged within the assessment or was encouraged to have a view (so that)….vital information about how the family functioned was lost”. The IMR notes that a failure to involve fathers in assessments and continuing work with families has frequently been identified in SCRs and similar exercises. That may be explained to some extent when fathers are absent or not significantly involved in family life. That was not the case here. 8.1.5 Reports such as this often reflect a failure to hear the “voice of the child”. Child O was a difficult person to engage but there is little evidence of any well-directed efforts to do so by CYPS. The exception is the IRO, once Child O had been admitted to care, who can be seen to have advocated for Child O when the IRO disagreed with actions taken by senior managers. 8.1.6 Assessment of a family situation should be the bedrock on which continuing agency involvement is based. National guidance on how assessments should be conducted has become less prescriptive since these events but, at the time in question, there were standard requirements for CYPS assessments, with fixed timescales and quality standards. Page 31 of 72 8.1.7 Assessments carried out by CYPS in this case did not meet those requirements. They did not properly involve her family or other agencies. They were not thorough in establishing facts and analysing them. They reached unevidenced conclusions – dismissing, for example, early disclosures by Child O of sexual exploitation on the basis that they were incredible and probably a consequence of Child O’s “mental health issues”. 8.1.8 In particular “No consideration was given to undertaking a risk assessment of the known and perceived risk being posed to Child O”. That risk assessment should have analysed and addressed the many threats to Child O’s well-being – sexual exploitation, her own mental ill health, the extent to which her parents could keep her safe within and outside the home. Risk assessment was self-evidently key to working with Child O and is discussed separately below. 8.1.9 Assessment should lead to planning, action and review. Instead there was repeatedly confusion and inactivity. The first assessment concluded in December 2011 that Child O should be seen as a “child in need”, to be followed up accordingly. Just over a month later there was a decision that the case be closed. No action had been taken by CYPS in the intervening period. The case was then immediately and without explanation re-opened but without any planning for how it was to be progressed. The management of the case appears to have been in disarray. 8.1.10 The proposal that Child O be admitted to the public care was being pressed by her mother and all the other agencies involved from at least January 2012. It is clear that it was consistently resisted by the local authority but not in a consistent way that can be easily followed. 8.1.11 In April 2012 the local authority wrote to other agencies advising that they accepted that “Child O needs to be given the opportunity to live outside the family home and they would therefore) explore a range of options”. However by July 2012 the local authority’s position was that they would not admit Child O to care and that there should be a psychological assessment. There then seems to have been a change of position to an acceptance that there should be an admission to care. But, before any placement could be made, the local authority decided to seek a further opinion, from the Cassel Hospital. That opinion would be based on a full assessment which included Child O spending time at the Cassel. 8.1.12 This was a decision taken outside the normal arrangements for care planning and funding decisions. Case recording does not reflect the decision-making process but does note that the case was removed by the local authority from the agenda of the “Complex Cases” Panel. The rationale for the decision to approach the Cassel is questionable. It would produce at least a third opinion as the proposal for admission to care and a therapeutic placement was already supported by the psychiatrists at both the Priory and Page 32 of 72 at Simmons House, if not a fourth, as it was also supported by the commissioners, ICCG. 8.1.13 Child O and her family were caught in the middle of the dispute between the agencies as to whether and how this review by the Cassel should proceed. They were distrustful of the local authority’s motives but reluctant to commit to any course of action which would cause further delay. 8.1.14 Eventually the clinician tasked with carrying out the review received “a clear message (from the local authority) that the review had to proceed without the planned clinical assessment at the Cassel, or any direct contact between the patient and myself”. The Cassel therefore produced a report based only on some information provided by CYPS, and discussions with the social worker and the Consultant Psychiatrists at the Priory and Simmons House. 8.1.15 That report offers some speculative insights into Child O’s situation but concludes that “I am unable to give a clinical opinion with any degree of confidence, as to whether this young woman is currently able to make use of a therapeutic environment, possibly away from London. I may well be able to get a clearer clinical picture of her, if I could see her for a consultation, although given the degree of difference of opinions, this is by no means certain”. The report therefore suggests that the “status quo” is maintained while the various agencies involved were persuaded to work together to support the Cassell’s review. That suggestion was not accepted by the agencies. 8.1.16 At this point - it was now November 2012 - it appears that the local authority decided no longer to contest the views of the other agencies. The family say that by this time they had mobilised the support of their MP and local politicians and that it was in the face of these pressures that the local authority agreed to proceed with a residential placement. 8.1.17 It is hard to escape the conclusion that this succession of delays was at least in part fuelled by the financial implications for the local authority of an admission to a very specialised, very expensive placement. Of course it is right that the local authority and its officers should be diligent about expenditure, which in these circumstances would be considerable, and that any concerns about the effectiveness of such a placement should be fully explored. 8.1.18 But the evidence in this case suggests something more than that. The need for Child O to be admitted to the public care was demonstrable from early in 2012. The family and all the other agencies involved felt that this was appropriate at that time. Child O herself may have welcomed and certainly did not resist the proposal. This is not to say that such a step would ultimately have successfully addressed her problems, or prevented the tragic events leading to this review. But, even in situations where officers are genuinely doubtful that admission to care will be a successful step, it is still sometimes a Page 33 of 72 step that has to be taken, because there is no better alternative. This was such a situation. 8.1.19 Child O was eventually accommodated under s.20 Children Act 1989 in March 2013, some fifteen months after her family and other agencies had started to press for this. However some disorganisation in the management of the case persisted. The IRO felt it necessary to use formal processes to challenge drift and delay in organising a statutory review of the case. 8.1.20 The unsatisfactory management of the case continued when, in 2013, CYPS decided to terminate or suspend the placement at Tumblewood, firstly in response to the Ofsted findings and then because Child O was away from the placement for an extended period on holiday with her family. Attempts were made, unsuccessfully, by CYPS to speak directly to the family on holiday to inform them of the decisions but they were decisions that had already been taken, without reference to the family or any other agency, including the ICCG which was jointly funding the placement. 8.1.21 Clearly the local authority did need to respond to the Ofsted findings and consider its position. The consequences of their subsequent decisions, and the way they were managed, need to be contextualised and seen in perspective. The impact on Child O’s engagement with therapeutic processes should not be exaggerated – the strength of that engagement had been a cause for concern from an early point in the placement. In effect she ended up spending only three extra weeks away from the placement after returning from the long family holiday. 8.1.22 However the local authority’s actions are certainly likely to have further unsettled Child O and compounded her dissociation from the placement. The failure to identify and tackle that dissociation had already been evidenced in the time she was allowed to spend away from Tumblewood and her partial engagement, on her terms, with the placement’s programme. 8.1.23 The local authority’s decisions and the way they were executed displayed a lack of good judgment, achieving nothing positive. They upset Child O and her family, creating an immediately difficult and uncertain situation for them, as well as displaying a disregard of the requirement to work co-operatively with the other agencies. There was no reason why these decisions had to be taken while the family was away on holiday. There was no indication of immediate risk of harm to Child O if she were to return to Tumblewood. Indeed the local authority was in breach of statutory responsibilities in taking this action before consulting the family. Once they did meet the family Child O was insistent that she wanted to return. 8.1.24 There was at the time, and this is still the case, no formal policy in Haringey that a residential placement must have an Ofsted rating of “good” or better, at point of placement or thereafter. Even if this was an “unwritten” policy there is a distinction between not making a placement and disrupting a placement that had already been made. In the circumstances of this case one would expect that Child O would return to placement and there would be an Page 34 of 72 immediate statutory review to consider the changed situation, assess risk and plan accordingly, with the involvement of the family and all funding partners. Local authority managers did not have to take the position they adopted. They were guided by organisational and/or financial imperatives, not the best interests of this child. 8.1.25 Equally the local authority failed to consult with the IRO who, once made aware of the decision, registered her concerns. However the IRO did not formally challenge the decision using the statutory powers13 available to her. It would have been appropriate at least to initiate a formal “local dispute resolution process” which would have sought to resolve the problem within 20 days. In these circumstances, which were serious, it may have been appropriate for the IRO to exercise her power to refer the matter to CAFCASS. It would also have been right to ensure that Child O was fully informed of her rights – to seek separate legal advice and to have access to an advocate. The IRO’s response to these circumstances was well-intentioned but not sufficiently thorough and there is consequently a recommendation from this report. 8.1.26 Under its own procedures the local authority should also have organised a “disruption meeting”. Those procedures require that “Disruption Meetings should be convened in relation to children whose placement in a children’s home or foster care has ended abruptly or on an unplanned basis”. This placement had certainly been brought to an abrupt ending. There is also no evidence that the administrative requirements arising from the decision were satisfied. Even if the placement were “suspended” rather than terminated, Child O’s status as a Looked After Child could not be “suspended”. This should have sparked a number of procedures and notifications but this did not happen. 8.1.27 There is no evidence of the authority initiating any sort of re-assessment or taking any action to identify an alternative placement. Their proposal of organising a “day carer” was predictably rejected both by Child O and her family. 8.1.28 There was a continuing lack of thoroughness or consistency when the local authority decided that Child O should return to Tumblewood. If she had, “technically” or otherwise, spent a period when she was not in the care of the local authority then there should be evidence of all the formal requirements of a re-admission to care, including placement planning arrangements and the associated statutory documentation. There is no such evidence and Child O was simply allowed to return to Tumblewood. 8.1.29 Negotiations now took place for this to be a “39 week placement” – that is, a placement which broadly coincides with school terms, rather than being a 52 week commitment for the funding agencies. This was not resisted by Child O’s family. They could hardly do so when she was spending so much time at 13 https://www.gov.uk/government/publications/independent-reviewing-officers-handbook Page 35 of 72 home and away with them throughout the summer. However it is not an unusual arrangement and should have been considered when Child O initially went to Tumblewood. This is further evidence of the need for more thorough inter-agency arrangements for tackling situations such as this. 8.1.30 The report from CYPS to this review advises that, following the initiation of this SCR, their service was inspected by Ofsted. Ofsted judged that the Department “requires improvement”, concluding that there were: “…no widespread or serious failures that create or leave children being harmed or at risk of harm (but)… the authority is not yet delivering good protection and help and care for children, young people and families14” 8.1.31 CYPS has now put in place an Improvement Action Plan, which is part of the Council’s wider improvement work, currently being delivered as part of a transformation programme known as “Haringey 54,000”. The IMR advises that significant organisational changes are already underway. 8.1.32 The IMR also advises that one of the cornerstones of the improvement programme is an aim to “ensure earlier support and better outcomes for families to prevent the need for more costly services later in a young person’s life”. That is an aim with which no-one would disagree. However there are some young people who will always need these “costly services”. CYPS were slow and reluctant to identify Child O as one such person. The local authority needs to ensure that its improvement programme does not repeat or compound the failures evidenced in this review. 8.2 Tumblewood 8.2.1 Tumblewood is a residential therapeutic service for girls, aged 11 to 18, who have serious emotional and psychological problems affecting their development and life chances. It seeks to offer these young people an integrated programme of care, education and therapy, aiming to equip them to reintegrate safely into their local communities and society. It was Child O’s placement from June 2013 until her death. 8.2.2 Tumblewood recognised and did not under-estimate the level of Child O’s unhappiness and disturbance, and the complexity of her troubled relationship with her family. As with every other agency “she determinedly refused at all times to provide any details of… information that would have assisted the investigation of her allegations and her protection”. At the same time, following on from her positive time at Crisis Care, it is the information from Tumblewood that presents the best picture from any agency of Child O, including her positive qualities, her thoughtful and caring side. 8.2.3 Four key objectives for this placement were identified: 14 Ofsted 2014 report Page 36 of 72 “to give her the experience of living and being looked after as a child not a patient {Care] to support her to develop trust in and trusting relationships with others and to communicate and explore her feelings with those she comes to trust [Mental Health] to enable her to achieve her potential and progress as a student [Education] To help her both to acquire the necessary skills for living independently and to develop her capacity to manage herself safely and without fear when she returns home and to her local community [Independence]”. 8.2.4 These are sensible and comprehensive aims but the IMR notes how, over time, tensions emerged between those objectives, and in relation to how they were balanced and prioritised. “The … needs of Child O for that experience of care as a looked after child and for clear attention to strengthening her mental and emotional health often were overtaken in priority by the education and independence objectives”. 8.2.5 Child O was at Tumblewood for about seven weeks in June/July 2013 before going on holiday to America for the summer. During that initial period there is evidence that she settled, enjoyed aspects of the placement and largely responded well to the expectations that Tumblewood had of her. “Numerous comments are recorded highlighting her high level of engagement in her individual, educational and group experiences in the programme”. The response to educational input is encouraging after so long away from any educational provision. 8.2.6 However there were also early signs of a less positive engagement. Child O started a pattern of long walks on her own without complying with arrangements made for her to return by a certain time. On her return from her first weekend at home, some four weeks after placement, she took to her bed, saying that she was unwell, and missing four days at school. This marks the start of another pattern, of her saying that she was unwell in advance of and following a period at home. There was also a “resistance to any kind of “examination” – physical, educational, psychological, social care or, in her view, therapeutic – (which) will loom prominently across the whole period of her placement”. There was also some evidence now of resistance to communal living and she insisted on changing the date of a formal review so that she effectively avoided a significant communal event. 8.2.7 Soon after she went on holiday to America Tumblewood had the Ofsted inspection which resulted in Child O not returning as planned. This meant that after spending seven reasonably successful weeks at Tumblewood, she was away for an extended period. The time Child O actually spent overall at Tumblewood was too brief and was frequently disrupted by weekends and long holidays. She only spent around half of the seven months of her placement actually in residence at Tumblewood: Page 37 of 72 “ She missed many important experiences, like planned project activities, Community celebrations, regular weekend routines and the spontaneous informal interactions between and amongst staff and young people. These latter occasions contribute so much to the culture of group living and to the internalisation of that culture by newer residents”. 8.2.8 The absences also served to undermine the attempts to address Child O’s self-harming behaviour. The National Institute for Clinical Excellence15 recommends a long term approach of developing “trusting, supportive and engaging relationships” working with the young person to develop strategies to avoid such behaviour. This approach was very difficult to establish when her time at Tumblewood was so frequently interrupted. 8.2.9 At first Child O was positive about returning to Tumblewood after the summer but staff soon noted that her enthusiasm had waned. There were long periods when she reported that she was unwell but refused to see a doctor, and times when she said she was unable to participate in education and other activities but chose to take part in activities that she enjoyed. The IMR judges that her re-integration into that community could have been better planned and executed. 8.2.10 In October Child O had an argument with her house mate who, she said, had eaten some of her food. Child O’s unhappiness about this incident dragged on for some months, despite the attempts of staff to resolve it. She and the other girl stopped sharing accommodation but staff noted her determination not to let the matter rest, or be resolved. 8.2.11 A difficulty arose in relation to the psychiatric input into the management of Child O’s care. She had started seeing a psychiatrist at Tumblewood but both she and her mother asked if she could also continue to see the previous psychiatrist at the Priory. The psychiatrist from the Priory refused advising that this would be neither practical nor desirable, as psychiatric input needed to be part of the overall “package” at Tumblewood. It is disappointing to learn that the attempts of the Tumblewood psychiatrist to discuss the case with the previous psychiatrist met with no response from the Priory. 8.2.12 Later in October there was an incident in which Child O went into what she herself called “meltdown” – she became very disorientated, distressed and fearful, in a “trance-like” state, for no apparent immediate reason. Staff struggled to reassure her and “bring her back”. Child O could offer no explanation for what might have caused this. This was to happen on a number of subsequent occasions, accompanied by self-harming behaviour. 8.2.13 Despite this the psychiatrist reports evidence of Child O engaging positively and trying to explain her difficulties to him, albeit in her characteristically guarded way. From the beginning of November they met 15 NICE guidance Page 38 of 72 each fortnight, the last occasion being a week before her death. She also separately began weekly individual psychotherapy. 8.2.14 Unfortunately her overall situation was complicated when she developed a painful medical condition, an inflammation of the cartilage joining the ribs. This led to a presentation at A&E and required continuing management. The IMR comments that there is “no doubt that Child O was regularly unwell physically …(but) the real issue is whether there was a deeper source to her illnesses that often made her feel so frail”. This comment captures both how unwell this girl was, and how, even now, we have very little understanding of the causation of that ill health. 8.2.15 In December the difficulties with her previous house-mate resurfaced and culminated in Child O assaulting her. Staff at Tumblewood thought she was bullying the other girl. Child O would accept no responsibility for the incident, entirely blaming the other girl. This dispute remained an unresolved issue until the day of her death and the IMR judges that it would have been preferable to find a way of bringing it to a conclusion: “managers could have said to her that …while in their judgement her behaviour was clearly unacceptable, it was equally clear that she was neither prepared nor able to acknowledge this. Therefore they would leave the matter “on file” until some time in the future when she was likely to be more able to consider the more difficult parts of herself”. 8.2.16 It was after the assault in December that Child O went to sit by railway tracks. She disclosed this nine days later after a self-harming incident. That self-harm – a deep, bloody scratch to her face - distracted staff attention from the previous events, including the disclosure, and the more immediate concerns became their focus. 8.2.17 Consequently that episode of going to the railway tracks was never discussed with Child O and it was not taken into account when risk assessments were reviewed. Nor was it flagged up in the establishment’s routine arrangements for staff feedback and briefings. Child O may not have responded to overtures from staff about the incident but it was a missed opportunity to try to engage with her. The incident of course now takes on a particular significance in the light of the circumstances of her death. 8.2.18 Over the following weeks Child O presented essentially the same mixed picture. She contributed enthusiastically to some activities but on her own terms – so that there were many community expectations with which she consistently refused to comply. She would not participate in educational activities and completely refused to allow psychological testing, a fundamental part of the programme at Tumblewood. She cut herself repeatedly and generally refused to allow staff to see or help her in treating the wounds. Yet her psychiatrist felt that there was evidence of her trying to understand and tackle her condition. Staff also found other examples of her “opening up” and talking about her emotions. Page 39 of 72 8.2.19 There were continuing indications that Child O’s health was precarious. She took to a salad-only diet and was found to be purchasing “slimming pills” via the internet (which Tumblewood intercepted). She spoke to the psychiatrist about intrusive thoughts but refused to give any details, saying this would lead to her being detained under the Mental Health Act. Her mother also wondered, in conversation with staff, whether she might need to be in hospital. 8.2.20 The psychiatrist and staff at Tumblewood considered this and decided that there were enough positive factors for them to continue to try to work with her in the residential setting. She was co-operating with some aspects of the programme, was building strong relationships with some staff and was deeply hostile to the idea of re-admission to hospital. 8.2.21 That position was endorsed at a statutory Looked After Child review, where she was also pleased with decisions to attempt a different educational programme, with an emphasis on vocational training and animal care. The IMR judges that this decision about her education might have been taken sooner as the pressure to achieve academically was difficult for Child O to manage. However records from those days before and after that last LAC review describe her as relaxed and happy with occasional short-lived difficulties. 8.2.22 On the day of her death Child O did not behave unusually and in the evening, as she often did, she remained in her room rather than joining in any activities. However, during the evening, staff discovered that, during a 90 minute period when she was on her own, she had gone out leaving a note that she intended to take her own life. The note stated that she loved her family very much, they should not blame themselves but should carry on with their lives and be happy. She attributed her actions to the “bastards”, unidentified, who had harmed her. 8.2.23 Some broad themes emerge from the analysis of her stay at Tumblewood in the IMR, which is detailed and thoughtful. The extent of time she spent away from the placement and her consequent marginalisation from the overall approach at Tumblewood is emphasised: “Such a setting designed intentionally to embed participants in the whole experience of living and learning together, especially when the resident has been …assessed as too unwell to make use of family or community based services. The costs of the absences from the community and… the visits home were too great”. 8.2.24 Looking at the way in which the placement was set up and launched, the IMR finds that the overall goals set may have been too imprecise and that there was then a “lack of a robust process for the production and testing of desired and agreed placement objectives”. Staff were sometimes tentative about challenging Child O who, from the outset, was very selective in the activities to which she would commit herself. She was allowed from a very early stage to develop the habit of taking long, Page 40 of 72 solitary walks, without reference to the overall strategy for promoting her independence. The IMR recommends a detailed review of the establishment’s Independence Programme to clarify its structure and implementation and how these are negotiated in detail between staff and young people. 8.2.25 The IMR also comments on the way in which the home worked with Child O’s mother who was in very frequent contact with them. This degree of contact from a parent was unusual and staff, apart from the Directors of the establishment, had little experience of working with parents who actively sought to be involved. As discussed above, her mother’s own professional background may also have affected these relationships, so that the line between her as a parent and her as a professional became blurred at times. 8.2.26 The nature and extent of her mother’s involvement, which developed rather than being agreed, along with the amount of time Child O spent away from the placement, will all have inhibited the development of the supportive, trusting relationship Tumblewood sought to establish. Overall the population of residents has changed – prior to 2013 it was rare for any girl to have close contact with their family. The service accepts that it has not kept pace with this and needs to redesign aspects of their work accordingly. It is clear that there has been a rigorous self-examination of the practices at the home. 8.2.27 Staff feel that they were slowly making progress with Child O. The independent IMR author felt also that several key members of staff did grasp the complexity of Child O's condition and needs, and that she was starting to trust them. This achievement with such a deeply troubled, conflicted and suspicious young person should not be underestimated. 8.2.28 There are now very few therapeutic residential care homes which would consider looking after a child whose health and well-being were as precarious as Child O’s. One other similar service considered whether it could help Child O and decided that it could not. While it is now, with hindsight, clearer that a different, perhaps more controlling, approach might have been used, the decision to place Child O at Tumblewood was appropriate. 8.3 NHS Islington Clinical Commissioning Group 8.3.1 ICCG was the part of the NHS responsible for commissioning health services for Child O from April 2013. This was because Child O had a GP in the London Borough of Islington although the family now lived in the neighbouring borough of Haringey. Before April 2013 her health care was the responsibility of a predecessor organisation, Islington Primary Care Trust (IPCT). The staff actually dealing with the situation were unchanged throughout. This section of this report addresses the involvement of both ICCG and ICPT 8.3.2 IPCT started commissioning and funding specialist care for Child O from December 2010, when she was admitted, first to the Priory, and then to Simmons House. She was to remain technically an in-patient, apart from a few days at home in June, until the summer of 2011, when the family went on Page 41 of 72 holiday to America. Soon after their return she was readmitted to hospital. This marked the beginning of the chain of “negotiations” between health services, in both Islington and Haringey, and local authority services in Haringey about her placement needs and how they would be funded. 8.3.3 The IMR describes in detail the many meetings and discussions which took place between early 2012 and June 2013 when Child O moved to Tumblewood. The principal cause of this long delay was the position taken by the local authority which has been discussed above. A lesser but also troubling factor was the extent to which the NHS and local authorities struggled to accommodate the consequences of the family living in Haringey but having a GP in Islington. 8.3.4 The IMR explains the bureaucracies involved, which are too dense to set out in this report. Various Panels and decision-making processes became involved without adequate and sensible reference to each other. This “cross-borough” issue became a significant obstacle to planning and delivering the care that Child O needed. There were even discussions between health commissioners and practitioners about asking the family to transfer to a Haringey GP, so that Islington commissioners would no longer be involved. Some staff pointed out at the time that to suggest a change of GP merely to fall into line with the bureaucracy of funding arrangements would be quite wrong. 8.3.5 In 2012, in a different part of London, a teenage boy took his own life. This led to a SCR, in which the Overview Report16 was written by the author of this report. That report commented on the fact that the family was unable to access the most convenient and appropriate mental health services, despite the best efforts of their GP, because, again, there was a local authority boundary between them and their GP. There may be ways round this, and the IMR makes an appropriate recommendation, but it appears to be a problem which could recur elsewhere. There is consequently a broader recommendation from this report. 8.3.6 Overall the ICCG staff displayed a strong commitment to achieving the best solution for this family. As the IMR comments “both the senior commissioning manager and the commissioning manager continually chased and followed areas of concern. They took those concerns to the appropriate people and were aware of and took seriously their responsibilities. They demonstrated a clear focus upon the needs and best interests of Child O throughout”. 8.3.7 However the IMR, which is thorough, points out that formal arrangements for the escalation of cases to increasingly senior levels were not used. This is a frequent finding in SCRs, and so significant in this case that it is discussed separately below. 16 Child B report Page 42 of 72 8.4 The Priory Hospital North London Adolescent Unit 8.4.1 This is a Tier 4 service in which places are commissioned by NHS England specialist commissioning teams. The Unit accommodates up to 18 young people between 12 and 18 years of age as inpatients, and can facilitate day services where clinically appropriate. The unit is mixed gender and accepts young people both on an informal basis and when detained under the Mental Health Act. It was where Child O went when her mental health first required a hospital admission. 8.4.2 Child O was admitted to the Priory on three occasions: December 2010 to January 2011 September 2011 to February 2012 June 2012 to March 2013 Child O would normally have been admitted to Simmons House, a local NHS in-patient facility. The Priory was used as an “overspill” provision and, on her first two admissions, she was recalled to Simmons House when a bed became available there. On the third occasion Child O refused to be admitted to Simmons House and it was agreed at the outset that she would remain at the Priory until she could be discharged. 8.4.3 The IMR stresses that these overspill arrangements are fundamentally unsatisfactory for such vulnerable young people. Knowing that they are likely to be moved back from the Priory to NHS provision possibly “compounds …negative feelings, low confidence, low self-esteem and lack of stability”. The fact that Child O refused re-admission to Simmons House in June 2012 might be evidence of that. At the same time the determination of how far such a specialist resource can be immediately available must be a challenge for commissioners. The rationale for a “back up” arrangement is understandable. 8.4.4 There is evidence of incomplete recording of events and analysis by the Priory: “there are no detailed handovers regarding the family or family relationship. There are limited notes relating to Child O …it remains difficult to ascertain in any great detail an understanding of this family”. The IMR suggests that this may be because information was not shared by other agencies or by the family, though it also arises from unsatisfactory practice at the hospital. That is supported by a subsequent comment in the report that “there is no significant information known about Child O’s parents and her other family members. There is no detailed account of the family background (when)… I would expect all patients to have a comprehensive assessment … available to inform interventions, therapies or treatment, but more importantly to understand the view of the child and where they are coming from. This information is not evident in the documents reviewed”. 8.4.5 In any event this means that our understanding of the care offered by the Priory is incomplete. There is little useful information about the hospital’s use of the Care Programme Approach (CPA), the statutory arrangement Page 43 of 72 across agencies for planning the care of someone with mental health needs. It is recorded that CPA meetings took place but it is not clear that these meetings contributed to a clear and well understood approach to working with Child O. 8.4.6 It is well documented that Child O consistently failed to engage with services offered, both individually and in group settings, although many therapeutic interventions were attempted. That lack of engagement was compounded by the extent to which Child O was not actually on the wards. She spent long periods at home and otherwise away from the hospital. This lack of engagement continued and escalated throughout her time at the Priory (and, as we have seen, beyond that). 8.4.7 The IMR reports that “there are clear records of risk assessments and management plans which reflect Child O’s individual needs…The risk assessment process demonstrably informed the management of risk, and enabled the nursing and medical team to maintain Child O’s safety. Child O was heavily involved in her care plans”. In fact the most well evidenced finding is of Child O’s determination not to engage with the services offered. This was despite having spent in total over a year at the Priory, a range of interventions being attempted and the clearly evidenced commitment of the Consultant Psychiatrist leading the attempts to help her. 8.4.8 One of the interventions offered at the Priory was a programme of family therapy. Child O refused to participate, as did her only sibling still living at home. They had similarly declined when family therapy was suggested at Simmons House. Her parents had attended meetings at Simmons House but felt they had not been useful and that there was no point in going through this again at the Priory. 8.5 Whittington Health 8.5.1 This IMR considers the contact Child O and her family had with services managed by Whittington Health, namely Islington CAMHS, the Whittington Hospital and, most significantly, Simmons House, where she spent the periods from February to July, 2011, and February to June 2012. Simmons House is an in-patient and day-patient psychiatric unit for young people between 13 to 17 years of age. The unit has places for a maximum of 12 young people of whom ten can be resident. 8.5.2 It was during Child O’s first admission to Simmons House that information began to emerge suggesting that the causation of her disturbance might include some sort of sexual abuse or exploitation, probably dating from when she was aged 11 or 12 years old. Staff properly sought to explore whether she might have been abused within her family. She explicitly told staff that she had not, and consistently asserted this throughout the period under review. Page 44 of 72 8.5.3 Evidence that Child O was associating with people who might represent a threat to her was also confirmed during this first admission. In June 2011 police from Croydon contacted the hospital advising that a man detained in custody under the Mental Health Act wanted to speak to Child O. It is clearly significant that this fourteen year old child was apparently linked to someone, on the other side of London, who might represent a threat to her. Yet this was noted by an agency nurse without leading to any further action. 8.5.4 There was a similar cause for concern during Child O’s brief admission to the Whittington Hospital in June 2012. At one point it appears that Child O spoke to a student nurse about difficult relationships with family members. Again a written record of this was made but there was no further action. This junior nurse may have not understood the potential significance of highlighting this matter. 8.5.5 Once agencies became embroiled in the long dispute about placement and funding responsibility, this became the principal focus of attention. Securing a therapeutic placement seems to have become the only solution envisaged, and there is little evidence of attempts or plans for reducing the continuing risks to Child O. Senior staff felt Child O needed to be placed elsewhere and they may have become less robust in trying to sustain better engagement in education and therapy at Simmons House. 8.5.6 The management of this case by the Whittington gives cause for concern. The IMR contains no reference to CPA arrangements. There is no documented evidence of the Named Nurse for Child Protection being approached for advice or giving any advice. In-house safeguarding supervision was provided by the Simmons House Safeguarding Lead but was not formally documented. Safeguarding supervision did not lead to an escalation of concerns to members of the Safeguarding Team outside Simmons House and, overall, was not adequate to the issues this case raised. This is particularly disappointing in such a complex case where the nature and aetiology of Child O’s presentation was – and remains – unexplained. 8.5.7 An issue of concern which emerged first at Simmons House is the amount of time actually spent in placement. The apparent contradiction between Child O’s need to be away from her family and the time she then spent with her family, including extended trips abroad, was not adequately challenged. From Simmons House she appears to have spent as much time at home as she wished, and there is no indication of this being actively managed. It again demonstrates how far Child O was successful in imposing her own terms and conditions on the services she received and used. 8.5.8 Child O was an in-patient in Simmons House for, in total, nearly a year yet there is little documented evidence of staff being successful in forming relationships with her. It would not have been easy to do so - she had a well developed ability to keep her distance. But it is disappointing not to see this dynamic being recognised and challenged, as the opportunity to do so was Page 45 of 72 one of the benefits offered by in-patient care. Instead, as is repeatedly the case, what emerges is a picture of Child O “calling the shots”. 8.5.9 Once Child O was in local authority care Whittington Health took on additional responsibilities as they are responsible for input into monitoring and promoting the health of young people in care to Haringey. Child O refused to be seen for the statutory Initial Health Assessment and so these services also did not work well. The information gathered is fragmented and there was no clear plan for the oversight of Child O’s health. 8.5.10 The IMR does helpfully pick up the issue of the use of the Strength and Difficulties Questionnaire17 (SDQ). This is a brief and basic behavioural screening questionnaire for children and young people. It exists in several versions and aims to measure psychological well-being and screen for the risk of mental ill health. It is very widely used across the country. 8.5.11 When used here, in May 2013, it found a ‘risk of developing mental health difficulties’, a pointless conclusion for a child who had already had such substantial contact with mental health services. The completion of the SDQ is often built into routine procedures but, as here, it can be a waste of professional time and needs to be used in a more targeted way. 8.6 Child O’s education 8.6.1 The first information received by the review about Child O’s education was when she commenced in Year 9 at a school in central London in September 2010.Limited information was available to the review regarding the reason for a transfer of school other than needing a “fresh start”. The new school also had limited information about her previous education history and any previous contact with support services. This would have better equipped them to respond to the problems ahead. 8.6.2 The scale of Child O’s problems emerged quickly. She was on (authorised) absence for over 20% of the first term. The school sought to support her through counselling and input from the school nurse. During November Child O’s mother reported feeling that progress was being made. Before Christmas 2010 however Child O’s first admission to in-patient psychiatric care had taken place. Her school started to provide work for her to do in hospital but effectively her formal education was already coming to an end. 8.6.3 While in hospital during 2011 there were discussions about Child O’s re-integration to school but these were generally thwarted as her difficulties persisted. In early September of that year a plan was put in place to support her return to mainstream school but her attendance lasted only a few weeks before she was re-admitted to the Priory. After that she never returned to 17 Although identified in this IMR these arrangements are not commissioned by Whittington Health but by the local authority, and provided by the Tavistock and Portman NHS Foundation Trust). Page 46 of 72 mainstream education and she did not successfully engage with any educational provision until she went to Tumblewood. 8.6.4 Child O’s engagement with School B was so limited that there is little to say about the way they approached such a troubled girl. The IMR appropriately judges that “Potential benefits could have been achieved through a pre admission multiagency meeting to capture more detail about Child O’s educational history and to inform plans to support her admission to the school”. That report also notes that there is government guidance for schools when their pupils will be away for extended periods, but that this was not referred to. As is the case throughout this review the fact that there was more than one local authority involved – the family was living in Hackney while the school was in central London – compounded the challenges faced by agencies. 8.6.5 Overall this review accepted the IMR’s conclusion that “The school provided the best opportunity they could to maximise Child O’s smooth transfer into the school. However the information they had about her past educational, medical and family history was limited. Whilst this may not have had a bearing on decision making … in the longer term it could have made a difference to sustaining her engagement…”. 8.6.6 There is less evidence that Child O’s education was vigorously pursued while she was in the 2 hospitals in London. Education should form a key part of CPA planning, especially for a young person of statutory school attendance age. The hospitals have not demonstrated that it was given an adequate priority. This must have been a factor in Child O’s subsequent struggle to comply with educational provision at Tumblewood. 8.6.7 It is reported that records of educational provision made for Child O when she was in Simmons House in 2011 were considered at weekly ward rounds but these records have not been found. There are partial, disjointed notes, some of which are inaccurate, from her time there in 2012. Those notes suggest that Child O generally rejected attempts to involve her in educational activity. 8.6.8 During Child O’s time in Simmons House in 2012 there was an occasion when she was noted by teaching staff to have facial bruising which she was apparently trying to conceal with her hair. This was recorded, and it was said to have been caused by Child O banging her head but there is no evidence that it was followed up appropriately under safeguarding arrangements. 8.6.9 Similarly the Priory has provided no information on Child O’s education prior to June 2012. From that point Child O was consistently uncooperative with attempts by Priory staff to provide an education. She declined consent for the staff to contact her former school. She showed some interest in art and music but her attendance level was 30-40% at best. 8.6.10 The records kept of Child O’s education in hospital also presage some of the management issues that were evidenced at Tumblewood. She was Page 47 of 72 particular about the activities with which she was prepared to co-operate, and often reluctant to work co-operatively with teaching staff. Her insecurity is acutely captured in her shrewd response to staff asking what she had to lose by taking an exam - “my last remaining shred of self-confidence”. 8.6.11 Education has already been identified as a priority by the LSCB in its work over the coming year, but the specific issue of the education of children in hospital has not previously been highlighted. This review has not received much information about how well Child O engaged with educational provision in hospital and how well any problems were addressed. However, the Coroner found that “It is quite clear from the expert opinion evidence that I have read Child O’s educational needs in particular were not being satisfied in either Simmons House or the Priory” 8.6.12 There is consequently a recommendation from this report, which also addresses the issue of compliance with child protection requirements, in respect of the facial bruising that was not followed up. 8.7 Crisis Care 8.7.1 Crisis Care is an independent sector service offering assessments and residential placements which include the use of adventurous activities and outdoor pursuits in a very rural setting. Child O stayed at Crisis Care, in Shropshire, between March and June 2013, when she moved to Tumblewood. 8.7.2 This appears to have been an unusually calm and settled period for Child O. Apart from some minor self inflicted injuries – scratches to her face and hands – there were no incidents of concern during her time there. She engaged well with staff and participated in all activities. This included the educational services provided despite some initial reluctance on her part. She had not attended a school for some two years – but she “made significant progress in this area and achieved a number of AQA18 short course awards” The IMR notes that “Child O wrote to Crisis Care once she left and spoke to staff when they were at Tumblewood with another young person. She had very positive relationships and memories of her time at Crisis Care”. 8.7.3 It is striking that Child O settled well and was able to demonstrate real achievements here, with little evidence of self-harm. This was the longest period – 11 weeks – that Child O spent away from London and her family during the period under review. Crisis Care is in a very rural setting and young people are not allowed access to mobile phones, and to the internet only for educational purposes. They advise that 18 AQA is an independent education charity and the largest provider of academic qualifications taught in schools and colleges. Page 48 of 72 “The reason for such tight controls is due to the nature of the placement being a crisis intervention placement, often young people placed have experienced multiple placement breakdowns and their care history has been chaotic and risks are elevated”. As discussed above the view at Tumblewood now is that it would have been better to insist on a similar approach, an extended period without returning to her home, when she came to them. 8.7.4 The only unsatisfactory matter raised by Crisis Care is that the local authority did not provide all the relevant and necessary documentation to accompany a young person being admitted to care, and this was not resolved before she left the placement. This is a matter of concern for the local authority as well as the receiving placement and leads to a recommendation from this report. 8.8 Metropolitan Police Service 8.8.1 The MPS had no substantial involvement in these matters but has reported on the following episodes which are significant. 8.8.2 In the summer of 2011 Child O’s mother reported to police that Child O had returned home the previous evening with facial injuries. She had told her mother that a man had hit her but she did not want police to be involved. Her mother did make a report to police and the Initial Investigating Officer (IIO) made enquiries with CCTV from around the Finsbury Park area, but no assault/incident was seen, and there was no other corroborative evidence. The IIO submitted a report to the Borough Intelligence Unit, so that, should there be any other reports in the area, the relevant department would be made aware. As Child O did not allege any offences, refused to speak to police and would not disclose anything further to her family, the case was closed. Police spoke again with Child O’s mother who expressed her concern that her daughter was being abused and exploited by someone living in that area. Child O’s parents remain frustrated that this investigation came to nothing. They feel that there are investigative opportunities that were not fully explored but police contest this. 8.8.3 In November 2011 CYPS made a referral to the Sapphire unit of the MPS, advising that Child O’s mother had spoken of her daughter being involved with an older man. CYPS had no further detail and were advised that there was no action that could be taken on the basis of this minimal information: they should make further enquiries and re-refer as necessary This advice was appropriate at that time but the police officer dealing did not, as she should have done, complete a MERLIN – the routine recording and notification to other agencies of police involvement with a young person. Police have advised that this matter has been followed up. 8.8.4 Sapphire were again involved in January 2012 when they received a further referral from CYPS. This contained a letter written by Child O to a former fellow pupil. The IMR advises that Page 49 of 72 “Within the letter she describes an incident 3 years prior where she claims to have been abducted from a street, taken into a park, beaten and raped. It further describes how she was forced to have sex with a variety of men, drink alcohol, giving birth to a child as well as experiencing numerous pregnancies and miscarriages”. 8.8.5 This referral was not appropriately dealt with by the Sapphire officer who received it. He decided not to take any action, emailing CYPS to say that he “…would need to establish if (the child) wishes police to investigate and would be willing to speak to a sexually offences trained officer and if so what her mental state of mind is at this time”. The letter itself was not kept by police. The officer made no formal record of these matters on any MPS information systems although the content of this letter, whatever its veracity, should have led to immediate action under child protection arrangements. Police and CYPS should have had a formal, recorded strategy discussion to agree how this would be investigated and by whom. 8.8.6 This officer was unavailable during the course of the SCR, so there is no clear explanation for the action taken. It may be that the officer was unaware of formal child protection requirements, saw this solely as an unsubstantiated allegation and made a serious error of judgment. 8.8.7 However there was a further incident involving police in June 2012. Police were called to the family home after the incident where Child O had shot herself with a BB gun. While in attendance her mother repeated the concerns she had raised the previous summer, that Child O was being abused by a man or men in the Finsbury Park area. 8.8.8 Two weeks later CYPS called a Strategy Meeting under child protection procedures. Officers from the Sapphire team attended. They advised that no police action would be taken as there was no specific disclosure or evidence of a sexual offence. Again there is no police record of attendance at this strategy meeting. 8.8.9 This response from police was again inadequate especially as the meeting concluded that Child O was at risk of sexual exploitation. The weaknesses in these police responses probably have their roots in the specialist Sapphire Team being out of touch with another specialist police area, the investigation of abuse or neglect of children. Specifically, the CAIT would have been more familiar with the challenges posed when a minor is reluctant to co-operate with an investigation. This is a more complex situation than that faced by police when a competent adult makes such a decision. 8.8.10 There is also little evidence of any challenge from any other agency to the position repeatedly taken by police. None of the professionals working with Child O sought any further advice or took any further action in response to the police decisions. Page 50 of 72 8.8.11 There have subsequently been organisational changes so that the Sapphire service is now amalgamated with the Child Abuse Command. This should promote better collaboration although the IMR notes that there is no overarching system across the new service for taking referrals. The IMR has therefore identified both individual and organisational learning from these matters and makes appropriate recommendations to address these issues. This Overview Report further recommends that the MPS should demonstrate that the changes made are resulting in an improved quality of service. 8.8.12 The MPS had a number of other contacts with Child O, mostly as a result of her being missing from home or hospital, and also in situations where allegations were made that she had been hit. She consistently refused to co-operate with any police enquiries. 8.8.13 The IMR concludes that the most significant missed opportunities for the MPS lie in the insufficient responses to the parents’ general concerns that Child O was being sexually exploited. Child O’s parents feel this keenly, reporting to the inquest that “Though we were able to provide times, dates, physical evidence from computers, phones and phone records and even clothing, the police were unwilling to undertake an investigation”. This specific claim is disputed by police who report that neither items of clothing nor any other exhibits were offered to them, and that there is nothing further that they could have done to progress their investigations. 8.8.14 However, for police, as is the case for many of the agencies contributing to this review, a broader understanding of CSE has developed substantially in recent years. The review heard that the police response now would certainly be more proactive and sustained, and would be managed by the specialist CSE service established by the MPS. A better informed approach from police might have contributed to a greater understanding of the worries and fears that Child O so evidently experienced. 8.9 British Transport Police 8.9.1 The BTP were responsible for the police investigations into Child O’s death. Those investigations were thorough and their IMR is essentially a report about their general response to such situations. That is summarised here for information. 8.9.2 The force will actively develop Suicide Prevention Plans (SPP) when an individual attempts suicide but survives – which might be said of the incident when Child O went to the railway tracks in December. The SPP is a working document created by front line officers, aimed at monitoring and supporting the welfare of a vulnerable individual. It provides a framework to assess and reduce risk by applying certain actions and controls to individuals or locations that are considered to be high risk in relation to suicide and/or self harm. 8.9.3 The front-line officers dealing will usually start the SPP, completing the relevant information required about the particular incident. The SPP is then Page 51 of 72 passed to a specialist team assisted by NHS mental health staff, who will decide whether and how it should be followed up. The SPP records BTP’s liaison with the individual as well as contact made to other agencies such as Mental Health Units, GP’s or crisis teams. 8.9.4 The SPPs are reviewed on a regular basis and once it is ascertained that the risk is reduced or that no further action from BTP can or will support the individual it may be closed. It remains on file and on the intelligence system for officers’ information’ 8.9.5 The BTP is also actively developing more involvement in safeguarding generally. A lead officer has been appointed at Assistant Chief Constable level and further specialist staff are to be introduced. An overall strategy for the force’s approach to child safeguarding is being developed. The BTP now aims to liaise directly with local authorities, or Multi Agency Safeguarding Hubs, rather than doing so via territorial police. New processes and guidance for staff have been introduced, aimed at promoting a more proactive approach and a knowledge base to inform the development of the service. There has been a substantial increase in safeguarding training for all staff. 8.10 The General Practitioners - London 8.10.1 Two GP practices in London were involved with the family during the period under review though Child O was registered only with GP1. Although the GP records are predictably substantial Child O was actually seen by her GP only six times during the review period. Of those contacts only two are significant to this review. In 2010 she was seen after taking an overdose and this contact led to the initial referral to CAMHS. In March 2012 her parents brought her to the GP as she had been unable to walk for some days. The GP judged that this condition had a psychological causation, but this presentation, which was isolated and not repeated, remains unexplained. 8.10.2 When seen in 2010 it would have been appropriate to refer Child O to hospital for a paediatric review. The IMR also judges that the GPs might have kept a “watching brief” after the initial referral to CAMHS, as there was a wait of some 2-3 weeks before Child O was seen. Finally the IMR notes that records were not updated to reflect the emerging issues of post traumatic stress disorder and sexual abuse and exploitation. 8.10.3 The overall standard of care provided by the GPs, and their compliance with professional standards and expectations during these contacts was good and appropriate referrals were made: “On both occasions the documentation indicates that she was listened to and given time well in excess of the standard GP consultation. In addition she was seen with her parents and by herself”. 8.11 The General Practitioners – Wiltshire 8.11.1 On moving to Tumblewood Child O registered with local GPs, the same GPs used by all the young people at Tumblewood. She saw the GPs Page 52 of 72 only for minor or straightforward issues and the IMR judges that they provided satisfactory care. 8.11.2 However Child O also remained registered with her GP practice in Islington. Only some paper records and no electronic records were transferred. This meant that the Wiltshire practice was unaware of her documented history with the episodes of self-harming and suicidal thoughts. 8.11.3 The IMR comments that the GPs might have been more curious, given the nature of the services provided at Tumblewood, but also notes that a number of other agencies had responsibilities in this connection. She was a child in the care of the local authority so that CYPS had a responsibility to ensure that all those professionals who might have contact with her were properly informed. The establishment itself, Tumblewood, was looking after her day to day and had a responsibility to ensure that her GPs were properly informed about her medical history. 8.11.4 There is no evidence that this lack of knowledge affected the services Child O received from these GPs but this is clearly a weakness in the systems of all these agencies. There is consequently a recommendation from this report. 8.12 NHS Haringey Clinical Commissioning Group: Health Overview Report 8.12.1 The Health Overview Report (HOR) is prepared by the NHS organisation responsible for commissioning health services in the area in which the family live. Its principal purpose is to evaluate and comment on all the health services involved in the case under review, serving also as the IMR for the commissioners of health services. 8.12.2 Key observations from the HOR largely echo the principal findings of this report in relation to NHS agencies. “The commissioning process clearly failed in this case; taking far too long for differences to be resolved”. and “The escalation process was used in this case but did not result in resolution at the highest level”. 8.12.3 The HOR also comments on the fact that CAMHS professionals did not access safeguarding supervision specifically in respect of this case from the Named Nurse for Safeguarding Children. This was a case where the way in which agencies were working together and the way in which they were responding to Child O and her family had become “stuck”. Skilled supervision might have highlighted and challenged that position. 8.12.4 The recommendations from the HOR include measures to promote and increase family engagement, along with training aimed at improving staff understanding of self-harm and its treatment. Page 53 of 72 8.13 Involvement by other NHS agencies 8.13.1 A number of NHS agencies had some minor involvement. They have provided information to the review which is mentioned in the main chronology and summarised below. 8.13.2 Child O was admitted to University College Hospital London NHS Trust (UCLH) in December 2010, as described in section 6.2 above. This presentation led to her first admission to psychiatric care at the Priory. In March 2011 Child O spent a week as an in-patient at UCLH after a prolonged period of refusing food at Simmons House. 8.13.3 In 2011/ 2012 Child O was treated three times at Chase Farm Hospital for self-inflicted injuries. On the first occasion in November she was seen with injuries to her hand and wrist. Just over a month later she was brought in after attempted self-strangulation with a scarf. On the second occasion, but not the first, liaison between the two hospitals, Chase Farm and the Priory, was good. In January 2012 Child O was brought by ambulance to hospital after swallowing metal objects and cleaning fluid. On this occasion she was admitted to a children’s ward overnight but refused to see a psychiatrist or talk to any CAMHS staff. She further refused to attend follow-up appointments. 8.13.4 Towards the end of 2012 Child O was seen twice by plastic surgeons at the Royal Free Hospital to discuss treatment for the extensive scarring she had caused by self-harm. She was given advice about this intervention, which would have been complicated, and she attended one follow-up appointment. 8.13.5 The Central London Community Healthcare NHS Trust (CLCH) provided a school nursing service. While Child O remained technically in mainstream education this service was routinely informed when Child O was treated at various hospitals for self-harm. There was some liaison but no need for any action by the school nursing service. 8.13.6 Child O was treated once at North Middlesex University NHS Trust (NMUH) in late 2012. She was an in-patient at the Priory at the time and had cut herself. Medical attention was appropriate and the paediatric registrar dealing liaised appropriately with the family and the Priory. 8.13.7 The London Ambulance Service NHS Trust (LAS) transported Child O to hospital on two occasions. 8.13.8 The Tavistock and Portman NHS Foundation Trust (Tavistock) conducted the Strengths and Difficulties Questionnaire, when Child O was admitted to care, as discussed above. Page 54 of 72 9. KEY ISSUES 9.1 Introduction 9.1.1 This section of the report draws out the key learning points for the agencies, and considers matters highlighted in the Terms of Reference for the review. 9.2 The failure to use child protection arrangements 9.2.1 It is striking that, in the face of such obvious cause for concern, there was never a formal child protection investigation into Child O’s situation. There was evidence to suggest that she may have been sexually exploited and there is well -established guidance19 across the London area for addressing concerns of this nature within the overall framework of child protection arrangements. 9.2.2 That guidance does not require the immediate implementation of formal child protection procedures. That may not be the best way to approach situations where children are not judged to be at risk from family members. The guidance recognises the particular delicacy of such situations and the need to tread carefully “children concerned are often subject to significant threats, bribes and conflicted loyalties. They may feel impelled to tell their abusers what is being planned and in turn become more isolated from services. Similarly, families may be unable to promote the child’s best interests”. 9.2.3 However the guidance is clear that formal child protection arrangements may need to be implemented and that was certainly the case here, throughout the period before Child O’s admission to local authority care. Concerns were high from the outset and there was never evidence to indicate that those concerns might be eased. Even without reference to this specialist guidance one would have expected a formal child protection response in the light of Child O’s extreme behaviour and the extent to which her parents struggled to control her and protect her from the potential consequences of that behaviour. 9.2.4 Yet there is no evidence that the implementation of child protection procedures was adequately considered, either by practitioners or their managers, in any service. Agencies outside the local authority did not use formal escalation procedures to challenge this. 9.2.5 The child protection procedures are sensitive to the reality that young people, and this was particularly true of Child O, are unlikely radically to change their behaviour because they are told to do so. “Implementing effective diversionary and safeguarding and support plans for children may require professionals to be extremely persistent in continuing to 19 London Child Protection Procedures - Safeguarding children from sexual exploitation Page 55 of 72 offer support and services. It may be that a non-LA children’s social care professional may best be able to provide a direct service”. 9.2.6 In fact Child O’s problems and her consequent behaviour were so deep-rooted that it is also unlikely that she would have responded to a diversionary approach, however persistent professionals were, while she remained in London with her family. But using this guidance – to which agencies in Haringey are fully signed up – would have brought a structure to the way they assessed the situation and worked together. That may have clarified the options available and eliminated some of the delay in reaching the plan that agencies eventually agreed. 9.2.7 In any case there is no point in having detailed, tailor-made procedures if they are not used. The circumstances of Child O’s situation required a formal child protection response and, within that, a consideration of the specific guidance on children who are being sexually exploited. No agency identified this and pursued it. This is perhaps further evidence of the way in which the disagreement between agencies about admission to care diverted attention from the fundamental processes of assessment and review. 9.3 Child sexual exploitation 9.3.1 The Terms of Reference for this review properly required all agencies to consider the issue of child sexual exploitation (CSE), its significance here, and the extent to which the agencies were prepared to respond and did respond to this issue for Child O. 9.3.2 It has repeatedly been shown throughout this account that the underlying causes of Child O’s disturbance and unhappiness have not been clearly evidenced. We have seen that agencies might have done more to explore and tackle this but it is also right to emphasise that Child O consistently displayed an absolute determination not to disclose information that could be investigated, so that agencies could form targeted plans of intervention and support. 9.3.3 As Tumblewood comments, she alleged that she had been the victim of “serious and sustained sexual and physical assaults by men in and near her local community. However she determinedly refused at all times to provide any details of what, when and where, information that would have assisted the investigation of her allegations and her protection” So, at the outset, it is right to say that there is no clear, verified evidence that Child O was the subject of CSE. Having said that it is also right to recognise that, in cases of sexual abuse, the word of the child is sometimes the only evidence that can be established, and is never to be dismissed. 9.3.4 CSE is an issue which presents in various ways throughout the history. Child O herself repeatedly gave indications that she had been sexually mistreated in some way, and that this had happened, or commenced, when she was 12 years old or younger. Child O’s parents are convinced that there was some CSE of their daughter and that it is key to the problems she Page 56 of 72 experienced. Certainly while in London it came to be treated by health and social care agencies as a fact. 9.3.5 In that context there is relatively little evidence of the agencies using strategies and practical approaches that might have helped Child O to “stay safe”. The Health Overview report suggests that “It might have been helpful to have conversations with Child O explaining to her that professionals understood the sorts of threats perpetrators make to keep victims quiet, that measures could be put in place to keep her and her family safe and that the perpetrators are likely to be harming other young people as well as her”. Staff at Simmons House are reported to have tried to discuss their concerns with Child O but their overtures were characteristically rejected by her. 9.3.6 It is notable that Tumblewood, in their account of their approach to working with Child O, rarely mention CSE. They clearly recognised the difficulties experienced by Child O in working with/being cared for by men, and designed their staffing arrangements around that. Otherwise, however, their work with Child O was based more on responding to what was in front of them, and what Child O did want to talk about. That was probably the most appropriate approach for this young person. 9.3.7 The exploitation of children for the sexual gratification of adults is not new but there has been a shift in societal understanding of the issue. Until relatively recently the sexual exploitation of children was still defined as child prostitution, a disturbing social evil rather than something recognised unequivocally as child abuse. Agencies’ understanding of CSE and its prevalence, and the development of strategies to help exploited young people, have all undoubtedly grown and improved. It is probably uncommon to be confronted with a young person as resolutely resistant as Child O, but it is not unusual to be working with exploited young people who struggle to disclose what has happened to them, and agencies have got much better at doing so. 9.3.8 However the agencies in this review have generally not demonstrated in their reports that there was a background of adequate awareness to the issue of CSE, and an ability to respond effectively to such concerns. This is also an issue that was identified, while this review was being carried out, in an inspection by Ofsted of the work of the LSCB. That inspection reported20 that further work was necessary to develop the local guidance and strategy on CSE, and the Board has already completed that work. Consequently there is no separate recommendation on this issue from this report. 20 Ofsted 2014 report Page 57 of 72 9.4 Risk assessment and assessment under mental health legislation 9.4.1 Ofsted have specifically considered the protection of older children in their work21 considering the outcomes of SCRs between 2007 and 2011. A headline finding was that “Practitioners should…demonstrate that clearly risk-assessed decision-making informs all actions in relation to older children” 9.4.2 The Panel accepted that using a formal risk assessment tool can only be an adjunct to clinical judgement. However Child O’s behaviour had been extremely dangerous throughout the time that agencies knew her. Most of that risk, such as her self-harming, was self-evident. Yet there were considerable variations between the agencies’ approach to managing that risk, and some dangerous failures routinely to use formal risk assessments. 9.4.3 CYPS confirm that “No consideration was given to undertaking a risk assessment of the known or perceived risk being posed”. There is also no evidence of CYPS evaluating the way risk would be managed by Child O’s family or by the other agencies. At Simmons House there is no evidence of regular review of the risks to Child O. 9.4.4 At the Priory there was more emphasis on risk assessment: “there are clear records of risk assessments and management plans which reflect Child O’s individual needs …The risk assessment process demonstrably informed the management of risk, and enabled the nursing and medical team to maintain Child O’s safety”. 9.4.5 Risk assessment formed a fundamental part of the regime at Tumblewood. The IMR has scrutinised the assessments and their use closely, judging that “The risk assessments were very good, well focussed, circulated to and used by staff to inform their thinking”. 9.4.6 That IMR also pinpoints the one important instance when these otherwise thorough arrangements failed. There was no risk assessment in relation to the episode in December when Child O reported sitting by the railway tracks. When information about this emerged it was overshadowed by an episode of Child O self-harming and was not discussed at the next Risk Assessment meeting, the following morning. This was a “missed opportunity to escalate levels of concern internally… and externally”. 9.4.7 However the greater concerns arise from the services where no structured arrangements were used for evaluating and addressing the risks in Child O’s life. The SCR Panel heard that the LSCB’s risk management guidance had not been reviewed for some time. It is therefore recommended that the Board engage the key local organisations in Haringey in work to address this. 21 Ages of Concern (Ofsted 2011) Page 58 of 72 9.4.8 There are correspondences with the assessment of Child O’s mental health. Child O was never formally assessed under those provisions of mental health legislation which might have led to her compulsory admission to hospital. That is, she was never seen by an Approved Mental Health Professional and two doctors who were specifically tasked with carrying out such an assessment. 9.4.9 The reports to this review from the Whittington Hospital advise that the use of compulsory powers was always considered after incidents of self-harm. There is a record that, after the incident of self-harm with a pellet gun in 2012, doctors at the Whittington considered whether she might be formally assessed. Otherwise there is no documentation that this course of action was considered there. Similarly no other agency contributing to this review has reported considering the potential application of arrangements for such an assessment, or provided any evidence of doing so. 9.4.10 Child O was certainly aware of the issue. It would have been unlikely that someone who had spent so much time under psychiatric care would not be so aware. She specifically expressed concerns about being “sectioned” soon after her return to Tumblewood in January 2014 – not long before her death. 9.4.11 Child O was not someone who refused to co-operate with the treatment offered through mental health services, even if her co-operation may have been partial - she was undoubtedly capable of deciding what she would and would not co-operate with. Simmons House have advised that Child O, in her general level of self harm, her partial co-operation and manipulation of professionals, and her overall presentation while a patient, was not dissimilar to other patients. 9.4.12 That may be right but there is one respect in which Child O was consistently unusual – the extent of her determination not to “open up” about what she felt about her situation and how she came to be in such difficulties. There were also “flash points” – times when her self harm was particularly serious, and required hospital treatment over a period of days. 9.4.13 There may have been points at which the use of compulsory powers under mental health legislation should have been formally tested. It is reasonable to expect to see evidence that this course of action was considered and evaluated, and no such evidence has been presented to this review by any of the relevant agencies. 9.5 The joint commissioning of services 9.5.1 It is right that this report should explore any lessons which might be learned from these events about the ways in which agencies work together to commission specialised services. The Terms of Reference specifically ask “How well did agencies work together in jointly commissioning services?” Page 59 of 72 9.5.2 However, before doing so, it is also important to reinforce a key point already made. The failures of agencies to work well together, which led to entirely unacceptable delays in meeting this child’s needs, were not rooted in difficulties in joint commissioning. They stemmed principally from the approach taken by the local authority, which recognises in its report to this review that “Obtaining placement funding seems to have become a barrier which impacted adversely on professionals’ ability to listen to Child O or keep her needs, and risks, in focus. Decisions appear to have been dominated by placement procurement and funding considerations and tended to detract from focussing on safeguarding Child O”. 9.5.3 It is also right to be clear that this case does not really tell us much about the overall arrangements for the joint commissioning of services by public agencies in this locality. Joint commissioning refers to a cyclical process in which agencies work together to identify local need, specify what services should meet those needs, commission services in line with that specification and then evaluate how effective those services have been, to feed into a continuing identification of need. Joint commissioning arrangements have, nationally, been championed for some years as the most efficient way of delivering services which are relevant, effective and “joined up” (although some recent research22 has challenged the basic hypothesis that partnerships lead to better services and outcomes). 9.5.4 Setting aside the position taken by the local authority, there were other complications. The family had lived in two other London boroughs before moving into Haringey. Their GP was in the borough of Islington which meant that any NHS funding contribution would be the responsibility of the NHS in Islington. Although there are arrangements in place between the ICCG and the London Borough of Islington to deal with such funding issues, there is no “cross locality” protocol, between, for example, the ICCG and neighbours such as the London Borough of Haringey. 9.5.5 The lack of such a protocol may be irrelevant in this case. The review has seen no evidence to suggest that the local authority would have worked in a different way had they been dealing with the equivalent NHS teams in Haringey. However the case does highlight the potential difficulties arising from the issue of locality and, as indicated above, this is not the first SCR where this has been identified as an issue. There is consequently a recommendation from this report. 9.6 Escalation 9.6.1 The review has seen the significance of the failure to come speedily to a plan to which all agencies could sign up. There are arrangements for dealing with such situations, involving increasingly senior personnel across the 22 Eg, Joint Commissioning in Health and Social Care: An Exploration of Definitions, Processes, Services and Outcomes University of Birmingham, 2013 Page 60 of 72 agencies in discussions / negotiations. Ultimately there is an arrangement in Haringey for child protection matters to be referred to the Chair of the LSCB. 9.6.2 These processes were not adequately followed. A range of senior managers became involved in a disorganised and ineffectual way and without consistent reference to the formal arrangements. Some NHS organisations even started considering applying for judicial review - a sledgehammer for a nut, when local options remained unexplored. The focus on the child was lost, except at the ICCG. 9.6.3 Escalation is not just complaining to another agency or to a more senior colleague about another agency. It is a formal process and, when discussions are being carried out as part of that process, this must be made clear. Ideally, when agencies have good working relationships, escalation should form part of a culture where constructive challenge is seen as an essential and positive element of safeguarding practice. The application of formal escalation arrangements is a learning point for all the key London agencies in this review. 9.7 The impact of organisational change 9.7.1 Organisational change in the public sector is so commonplace that SCRs always consider whether it may have affected the course of events. In this case the most evident factor is the number of changes of personnel at all levels within the local authority. In fact there have been so many changes of personnel that only three officers remain who have been able to throw light on the detail of which managers were involved, when and why. 9.7.2 This directly affected the ability of the service to deliver clear and consistent messages, explaining any rationale for the way in which the case was managed and led. It adversely affected the capacity of other organisations to work consistently with social care services. The consequences of this instability should be recognised by the most senior managers and elected representatives who lead that local authority. 9.7.3 Otherwise organisational change was accommodated well, particularly in respect of the commissioning of NHS services. Within the NHS, as the ICCG IMR explains, “Islington PCT (became) part of the North Central Cluster and then a shadow CCG before becoming a CCG in April 2013”. These organisational changes did not lead to changes in the personnel involved and a good degree of consistency was maintained. 9.8 The influence of social media 9.8.1 When planning this review there were indications that the role of social media might be significant. There had been press interest in the subject, linked in part to the suicide of a young person known to Child O who had visited “self-harm websites”. This was the young person about whom Child O’s mother contacted Tumblewood on the day before Child O’s death. Page 61 of 72 9.8.2 As the review proceeded little evidence emerged that the use of social media was a particularly significant feature in Child O’s life. Simmons House identified no specific concerns relating to the use of social media. The Priory did have concerns, related first to a relationship Child O was believed to have formed with a “Facebook friend”, who at one point was believed to have taken an overdose, but the role of social media does not seem particularly significant in this. 9.8.3 Tumblewood cautiously judges that “it cannot be said with any certainty that… (the internet and social media) did or did not play a significant role”. but their broad conclusion is that they did not play such a role. They had a protocol for internet use by residents and “Very early in her placement she was deemed by staff to be a responsible user of computers and the internet and there were never any concerns about internet misuse during her placement”. There was a time when it was discovered that Child O had identified the password needed to access the internet at Tumblewood and had used it, but no evidence that this led to any harmful use of the internet. 9.8.4 Tumblewood note that, coincidentally, a few days after Child O died, the Department of Health issued a report23 on preventing suicide in which the authors address the “still emerging issues of the internet and e-safety”. Tumblewood has reviewed and strengthened its training, code of practice and security measures in response to this, and raised the profile of the issue in the young peoples’ education programmes. 9.8.5 Overall, while the use of social media was properly identified in the Terms of Reference for this review, it does not appear to have been a significant factor in Child O’s life or her death. Nonetheless it has brought to light the fact that neither the Priory nor Simmons House had well-developed guidance on this issue and there is accordingly a recommendation from this report. 9.9 Serious Case Review Process 9.9.1 The review has been complex. It has involved three local authorities in London and one outside London, four LSCB areas, two police forces and thirteen NHS organisations as well as the three independent sector providers that looked after Child O. As often happens, information emerged during the course of the review which led to new enquiries being necessary and new reports sought. 9.9.2 During the review process, the LSCB Manager moved to a post with another Board and there were delays and difficulties in finding a replacement. The term of office of the Chair of the Board, who had also been chairing this 23 Suicide prevention: second annual report - Publications - GOV.UK Page 62 of 72 review, came to an end. These changes again delayed the progress of the review. In those circumstances it was clear at an early stage that it would not be possible to meet the government’s expectation that SCRs should be completed within six months. 9.9.3 Agencies were required by the Terms of Reference to consider whether there was evidence of having learned lessons from previous SCRs. The only agency to respond to this squarely is CYPS whose IMR notes that “Regrettably, practice did not appear to have learnt from previous serious case reviews within Haringey, or elsewhere in the sector”. 9.9.4 That judgment needs to be put in context. Practice improvements in response to SCRs will be incremental and will need to be repeatedly reinforced. Staffing changes are frequent and it would be unusual if some deficiencies in practice did not recur. Nonetheless the Board needs to satisfy itself that the processes, findings and outcomes of SCRs are having a positive and enduring impact on practice overall and there is a recommendation to that effect from this report. Page 63 of 72 10. CONCLUSIONS AND KEY LEARNING POINTS 10.1 The child protection implications of the overall situation were not followed up. There was never a Child Protection Conference and there was no reference to the guidance agencies should use in response to the sexual exploitation of children. 10.2 Police failed to respond adequately to evidence suggestive of sexual exploitation. There were missed opportunities for a focussed investigation. The Sapphire Team became involved without input from the Child Abuse Investigation Team. These officers did not appreciate the child protection concerns arising from the matters reported to them. 10.3 Both Simmons House and the Priory failed fully to meet statutory requirements under the Care Programme Approach. Record keeping was not satisfactory. Simmons House in particular failed to ensure that Child O was purposefully involved in provision at the hospital. She was allowed by both hospitals to spend too much time away from the hospital. She was judged not to meet the threshold for assessment for compulsory detention in hospital, though this was never formally assessed under the Mental Health Act. 10.4 Arrangements for Child O’s education foundered especially after she began to be admitted to hospital. National guidance for the education of children in hospital was not followed and this was not challenged by any of the agencies involved. 10.5 Interrupting her placement is the principal example of action taken without sufficient reference to consequent risks. Before moving to Tumblewood there is also little evidence of assessment of the known and perceived risks in Child O’s life. Continuing risk assessments should have analysed and addressed the many threats to Child O’s well-being – sexual exploitation, her own mental ill health, the extent to which her parents could keep her safe within and outside their home. 10.6 Tumblewood was an appropriate placement but Child O was allowed to spend too much time away from there. This acceded to Child O’s unrelenting drive to be “in control”. It meant that the benefits of living communally away from her home were not used to best effect. The development of supportive, trusting relationships with staff was inhibited. Throughout the period under review there was a contradiction, which was never addressed, between her needing to be away from home yet continually returning there. 10.7 Being in residential care at Tumblewood offered an opportunity, building on achievements at Crisis Care, to challenge Child O’s insistence on wanting her own way, but that opportunity was not grasped. Planning drifted away from a focus on strengthening her mental and emotional health, which should have been the first priority. Instead the emphasis grew more towards practical planning for her education and independence. Child O’s avoidance of some of the home’s requirements and expectations was not squarely confronted. Page 64 of 72 10. 8 The arrangements for promoting the health of children in local authority care did not work well, with implications for all the agencies involved. The information gathered was fragmented and there was no clear plan or programme for the oversight of Child O’s health. The sharing of information between her GPs in London and the GPs responsible for her in her placement was not adequate. The use of the “Strengths and Difficulties Questionnaire” was formulaic and added nothing to the overall understanding of the situation. 10.9 This review has identified serious failings in the services which should have helped Child O and her family. The greatest cause for concern is the substantial delay in arranging for her to be cared for away from her family home. This was the step which would have given the best opportunities for establishing supportive therapeutic relationships with Child O and her family. 10.10 The need for Child O to be admitted to the public care was demonstrable from early in 2012. That is not to say that such a step would necessarily have resolved her problems, or avoided the tragic events leading to this review. But, even when agencies are genuinely doubtful that admission to care will be a successful step, it remains a step that must sometimes be taken. This was such a situation. 10.11 The review has illustrated how there may be complications in agreeing funding arrangements when a family lives in one local authority area and has a GP in a different local authority. This is a systemic issue, identified in at least one previous Serious Case Review, although it was not the principal cause of delay in Child O’s case. 10.12 There is also substantial evidence that the local authority’s professional input was of a poor standard. Assessments were slow and did not properly involve the family or other agencies. They were not thorough in establishing facts and analysing them, thus reaching unsubstantiated conclusions. Management and supervision arrangements were weak and ill-directed. By arranging a psychiatric re-assessment without reference to the other parties and in the face of explicit concerns from the clinicians treating Child O, the local authority caused further delay and disharmony. 10.13 Following the Ofsted judgment on Tumblewood the local authority decided, without consultation with Child O, her family, the Independent Reviewing Officer or any other agency, including the ICCG which was jointly funding the placement, that she should not return there. This decision, although taken at a senior level, was hasty and misjudged. It was not necessary and it achieved nothing positive. It further damaged relationships with the family and the other agencies. 10.14 The local authority was in breach of statutory requirements in taking this step without consultation with Child O and her family. The Independent Reviewing Officer objected but could have taken further steps formally to challenge the decision. Page 65 of 72 10.15 The long dispute about placement and funding responsibility detracted from the management and planning of day to day care. The discussions about admission to local authority care became the focus of agencies’ involvement, and there is little evidence of work aimed at engaging Child O and reducing the continuing risks in her life. No agency made appropriate use of formal arrangements for the resolution of such disagreements. 10.16 The issue of safeguarding implications arising from the use of social media was properly identified in the Terms of Reference for this review, but did not emerge as a significant factor during the review. Nonetheless it has brought to light the fact that neither the Priory nor Simmons House had well-developed guidance on this issue. 10.17 The possibility of Child O’s suicide was clear and consistent but, in the days and hours before her death, there was no particular indication that Child O might choose that time to end her life. Her actions on that day could not have been anticipated or consequently prevented. 10.18 The most serious gap in the findings of this review reflects the issue that was the most challenging for the agencies. We still have no clearly evidenced understanding of how Child O came to be so troubled and why she so resolutely maintained a position of never fully sharing her worries with any professional. Page 66 of 72 11. RECOMMENDATIONS TO THE HARINGEY LOCAL SAFEGUARDING BOARD 11.1 Introduction 11.1.1 These recommendations to the Board reflect the key lessons to be learned from this review. They draw on the views of the SCR Panel and the author of this report. 11.1.2 The review does not make a recommendation for every point of learning that has been identified. These recommendations are complemented by more detailed recommendations, specific to each agency, contained in the management reviews conducted by those agencies. 11.2 Recommendations 11.2.1 The Board should require the London Borough of Haringey to demonstrate that, where a child may be at risk of significant harm, investigations and consequent assessments are conducted and completed without delay and meet all procedural and good practice requirements. These will include being consistently directed and managed by an appropriate senior officer seeing and consulting the child(ren) involved consulting with those who have parental responsibility making thorough checks with other agencies drawing on specialist advice when necessary keeping appropriate records 11.2.2 The Board should require the London Borough of Haringey and the relevant NHS organisations to audit and report on their care planning arrangements for young people who are “looked after” by the local authority. This work should include consideration of compliance with requirements for documentation and record-keeping, with particular reference to arrangements on admission to and discharge from care Independent Reviewing Officer provision, to demonstrate that statutory requirements relating to the independence and authority of this role are met the arrangements for promoting the health of young people looked after by the local authority 11.2.3 The Board should arrange for the London Borough of Haringey to provide briefings and guidance to agencies on the role of the Local Authority Designated Officer. 11.2.4 The Board should require the Metropolitan Police Service to demonstrate that the organisational changes they have made will effectively address the concerns that reports of child sexual exploitation were not adequately followed up. Page 67 of 72 11.2.5 The Board should satisfy itself that, where relevant, the Care Programme Approach is used reliably and effectively for young people from Haringey. 11.2.6 The Board should review and re-issue its Risk Management Strategy to all partner agencies and require the agencies to report back on the dissemination and use of this guidance. 11.2.7 The Board should require the local authority and the relevant NHS agencies to demonstrate that they have made arrangements for taking and implementing decisions about the shared funding of provision for young people in need, and particularly those in the care of the local authority. These arrangements must take account of the issue, arising in this review, of families who have a GP outside the London Borough of Haringey. 11.2.8 The Board should incorporate into its work programme a review of the arrangements made for the education of young people from Haringey who are unable to attend school because of long periods in hospital. That review should include an evaluation of how far those educational services are alert to the safeguarding needs of children and young people in hospital. 11.2.9 The Board should require all agencies to remind staff, in the light of the matters arising from this review, of the established arrangements for escalating safeguarding concerns to more senior managers, and, if necessary, to the LSCB Chair. develop an audit programme across all agencies to evaluate the use and effectiveness of escalation arrangements 11.2.10 The Board should ensure that guidance is available to all partner agencies dealing with situations where safeguarding concerns arise from the use of social media by young people, and that the use of that guidance is audited. 11.2.11 The Board should ensure that it has continuing arrangements for evaluating the impact of Serious Case Reviews on the quality and effectiveness of safeguarding arrangements in Haringey. Page 68 of 72 APPENDIX A: THE LEAD REVIEWER Kevin Harrington Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has worked on more than 50 SCRs in respect of children and vulnerable adults. He has a particular interest in the requirement to write SCRs for publication and has been engaged by the Department for Education to re-draft high profile SCR reports so that they can be more effectively published. Mr Harrington has been involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council, and has undertaken investigations commissioned by the Local Government Ombudsman. He has served as a magistrate in the criminal courts in East London for 15 years. Page 69 of 72 APPENDIX B: TERMS OF REFERENCE The review considered the period from 2010, when Child O was first referred to therapeutic services, until her death in January 2014. The following issues were highlighted. Were practitioners aware of “what it was like to actually be that child”? Were they sensitive to the needs of the child in their work, and knowledgeable about potential indicators of abuse, specifically physical abuse or neglect, and what to do it they had concerns about a child’s welfare? What did the agency know about the history of each of the parents? Were the parents listened to? Did their professional backgrounds influence how agencies worked with them? What were the key points for assessment, decision making and effective intervention in this case? What was the quality and timeliness of decision-making? What was the quality of multi-agency risk assessments? Were Child O’s mental health needs assessed and treated appropriately? Was child sexual exploitation/abuse identified and responded to appropriately? Did professionals consider and show awareness of how social media might affect and influence young people? Did actions accord with assessments and decisions made? Were appropriate services offered? Were opportunities / requirements for intervention taken (such as Section 47 investigations, multi-agency strategy meetings, Family Group Conferences, Child Protection conferences or Looked After Child reviews)? Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards? What were the consequences of so many localities and agencies being involved? How well did education and social care agencies work together? Were the agencies’ responses to the child’s educational and social needs appropriately balanced? How well did arrangements for finding placements work? Was there sufficient management accountability for decision-making? What was the quality of supervision? Were senior managers or other organisations and professionals appropriately involved in the case particularly in responding to the impact of parental views? Were there any issues, in communication, information sharing or service delivery, within, between or across localities and services, including services commissioned jointly by the agencies? This includes those with responsibility Page 70 of 72 for working “out of hours”. Agencies should make particular reference to the arrangements for escalation of concerns within and between agencies to more senior officers. Was practice sensitive to issues of racial, cultural, linguistic and religious identity and any issues of disability of the child and family? Were any such issues appropriately explored and recorded? Evaluate the impact of any organisational change over the period covered by the review. Did practice reflect/evidence any lessons learned from previous Serious Case Reviews? If not, what were the barriers? Page 71 of 72 APPENDIX C: REFERENCES Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications Working Together to Safeguard Children,(HM Government 2015) The Victoria Climbie Inquiry (Lord Laming 2003) The Protection of Children in England: A Progress Report ( Lord Laming 2009) Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 London Safeguarding Children Board – SCR Toolkit (2010) The Munro Review of Child Protection: Final Report (HMSO May 2011) The Munro Review of Child Protection: Interim Report (HMSO February 2011) Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 Page 72 of 72 Embargoed: 12:00hrs Monday 19th October 2015 Publication of Serious Case Review: Child O Independent Chair’s Summary Statement, on behalf of Haringey Safeguarding Children Board (HSCB) In January 2014 the girl referred to in this report as “Child O” took her own life, shortly before her 17th birthday. Haringey Safeguarding Children Board deeply regrets her death, and expresses our sympathies to her family. Child O was a very troubled girl, and very many staff from a wide range of agencies sincerely did their best to help her. The Local Safeguarding Children’s Board (LSCB) is the partnership within Haringey of agencies who seek to keep children safe. Our collective role is to promote effective joint working, and to hold each agency to account. Following Child O’s death, the Board commissioned an independent author to lead the process of reviewing the work of all agencies and seeking to identify learning. The review identified episodes where agencies could have responded differently at some key periods in her young life. It does not identify a causal link between these episodes and her death in January 2014, which it concludes could not have been anticipated. But some significant issues have been raised for the agencies who had sought to help her. Through this review process, the agencies have carefully examined their practice since 2010, and have acted upon areas where they have identified the need for improvements. Collectively, we sincerely regret that there were a number of areas where we should have done better. We have accepted all the recommendations of the independent review, and have already acted upon many of them. I summarise the key issues below. Child O presented severe challenges to agencies working with her and her family. As she entered adolescence her behaviour changed significantly, and she developed eating disorders. In the summer of 2010 she first reported having tried to kill herself several times. She attended various in-patient psychiatric placements for much of the following 3 years, whilst also spending frequent home leave and long holiday periods with her family. In June 2013 she moved to her final placement; a residential therapeutic school in Wiltshire, from where she took her own life in January 2014. Over the years she harmed herself frequently and severely, and professionals who sought to establish close relationships with her encountered significant barriers. She did not normally find herself able to trust people, and perhaps the greatest sadness that staff from all agencies express is that, despite so many people working with her closely over several years, nobody can feel sure that they truly understand what was at the heart of her unhappiness. Many times Child O said that she had been subject to sexual abuse from outside the family. At no point were any of the agencies able to substantiate this, or persuade her to share any details with them, although most professionals came to believe that something of this nature had probably occurred. In today’s climate of greater understanding of the nature of child sexual exploitation, all agencies have developed more effective ways of responding to allegations of sexual abuse, and it is likely that her allegations would have been responded to differently today. There is learning for all agencies in Haringey in the way in which they did not adequately use formal child protection arrangements. Child O was a challenging young woman to work with, but it is noticeable how few staff succeeded in gaining her confidence, and assessments of her needs rarely seemed to capture her voice. The quality of assessments by Haringey agencies has been a regular concern of the HSCB, and this case underlines the importance of many of the improvements in process that we have been seeking to introduce in recent years, in response to previous reviews. Police did not consider the possibilities of sexual exploitation sufficiently rigorously; health agencies did not always use the Care Programme Approach effectively; and social care assessments were lacking in suitable risk assessment and thoroughness. Opportunities were missed to consider whether she met the threshold for compulsory detention in hospital under the Mental Health Act. The process of agreeing Child O’s placement at the private therapeutic school in June 2013 could have been much improved and expedited. The placement was very expensive – costing £124,800 over the 16 or so weeks she spent there – and no public agencies can agree such sums without very careful consideration that the placement fully meets the identified needs. But the quality of joint working between the council and the relevant health commissioning group, who were sharing in the costs of the placement, was poor, particularly from the local authority that provided two thirds of the funding. There has been clear learning for the local authority and its partners from this episode, and improvements have been introduced to the systems for jointly commissioning any future very high-intensity placements. There was also learning from August 2013 when Ofsted judged Child O’s independent school to be inadequate, as a result of significant safeguarding failings. Child O was with her family for 6 weeks at this time, initially in the USA. Whilst it was appropriate for the authority to review the placement in these circumstances, they did not engage properly with their funding partners, and did not engage successfully with the family, in this review process. Child O’s period away from the school was extended from 6 weeks to 9 weeks as a result of this review, and unhelpful uncertainty was introduced to the placement. Improved processes have been introduced to cover the review of placements in such circumstances in the future. All the agencies in Haringey involved with Child O have reviewed their own practice and are acting on lessons learnt. HSCB will monitor the delivery of those actions. Sir Paul Ennals Independent Chair Haringey Safeguarding Children Board Contact: Patricia Durr Haringey LSCB & SAB Business Manager [email protected] 020 8489 1472 or 07964119978 The Board should require the London Borough of Haringey to demonstrate that, where a child may be at risk of significant harm, investigations and consequent assessments are conducted and completed without delay and meet all procedural and good practice requirements. These will include being consistently directed and managed by an appropriate senior officer The Board is assured of: the CYPS target of 100% assessments completed within statutory timescales implementation of the Assessment Protocol (as per WT, 2015) refreshed Threshold Guidance is being followed Audit of child’s voice Q1 2015/16 includes impact on assessment and planning Chair PPO Sub-group Quarterly monitoring via the Board Performance Scorecard. Q1 2015/16 Audit Report Revised Scorecard in place by January 2016 Report to the Board November 2015 Children in need of support and protection are supported, protected and cared for at an early stage to deliver improved outcomes without delay seeing and consulting the child(ren) involved consulting with those who have parental responsibility making thorough checks with other agencies drawing on specialist advice when necessary keeping appropriate records Audit of the child’s journey includes assessments and MASH. MASH Board monitoring ensures and ensuring arrangements are in place including the development of ongoing auditing. Q4 2015/16 Audit report Quarterly MASH reporting to the Board.Report to Board July 2016 Written reports to the Board from January 2016 The Board should require the London Borough of Haringey and the relevant NHS organisations to audit and report on their care planning arrangements for young people who are “looked after” by the local authority. This work should include consideration of • compliance with requirements for Annual report to the Board on arrangements for Looked After Children in respect of care and health planning. Director CYPS & CCG Children’s Commissioner Annual report includes: - efficiency and effectiveness of placement planning and procurement, including joint commissioning arrangements and the appointment of advocates - the role of the IRO is enhanced to challenge drift and delay and escalate concerns about the quality of service provision Reporting cycle agreed January 2016 . documentation and record-keeping, with particular reference to arrangements on admission to and discharge from care • Independent Reviewing Officer provision, to demonstrate that statutory requirements relating to the independence and authority of this role are met • the arrangements for promoting the health of young people looked after by the local authority Board Performance Scorecard includes agreed targets in relation to monitoring of arrangements for LAC. Auditing cycle for 2016/17 to include care planning via the PPO Sub-group Chair PPO Sub-group Chair PPO Sub-group - arrangements for health of LAC Audit cycle agreed March 2016 The Board should require the local authority and the relevant NHS agencies to demonstrate that they have made arrangements for taking and implementing decisions about the shared funding of provision for young people in need, and particularly those in the care of the local authority. These arrangements must take Annual report to the Board Director CYPS and Children’s CCG Commissioner Annual Report on monthly Complex Care Panel for joint funding agreement in place in Haringey. The panel provides assurance around high quality care planning and agreement for joint funding arrangements. Professionals attend to present and discuss cases as required prior to placement and to update Reporting cycle agreed January 2016 account of the issue, arising in this review, of families who have a GP outside the London Borough of Haringey. Auditing process agreed through the PPO Sub-group Chair PPO Sub-group Plan in place to develop information on Haringey Clinical Commissioning Group (HCCG) website with regarding the process for applying for joint funding where responsibility for child lies with HCCG and a non-Haringey Local Authority March 2016 for 2016/17 cycleOctober 2015 The Board should require the Metropolitan Police Service to demonstrate that the organisational changes they have made will effectively address the concerns that reports of child sexual exploitation were not adequately followed up. Continued monitoring of arrangements through the Board CSE Strategy and related activity including CSE Sub-group, MASE meetings, MAP meetings and through the CSE Profile and according to the agreed Pan-London CSE Operating Protocol (May 2015) Borough Commander Effective reporting through MAP, MASE and CSE Sub-group and quarterly reporting to the Board via CSE Profile. Ongoing First CSE profile reported to the Board September 2015 Young people at risk of CSE are identified and protected and that perpetrators are prosecuted The Board should incorporate into its work programme a review of the arrangements made for the Board to commission a review and agree timetable via its Executive Sub-group delegating to PPO Sub-Board Chair and Chair PPO Sub-group Review report to the Board assuring of arrangements, highlighting gaps and making recommendations for the Review commissioned and timescale agreed by education of young people from Haringey who are unable to attend school because of long periods in hospital. That review should include an evaluation of how far those educational services are alert to the safeguarding needs of children and young people in hospital. group for implementation partnership. January 2016 The Board should satisfy itself that, where relevant, the Care Programme Approach is used reliably and effectively for young people from Haringey. Annual Report on CAMHS to be made to the Board including Transformation work and detail of the use of CPA and feedback from children, young people and families. Head of Safeguarding Whittington Hospital NHS Trust & Director of Nursing BEH-MHT Report to Board includes progress on Transformation plans and the development of the CAMHS Transformation Board. First report January 2016 Haringey CAMHS review undertaken between February & September 2015. The Board should require all agencies to remind staff, in the light of the The Escalation Policy is available on the website but should be further promoted across the partnership to Board Manager Dissemination of the policy within specific communications. Questions about dissemination of this and other key documents January 2016 review and ongoing The Board’s Escalation Policy was agreed and updated in January 2014 to ensure match with the London Child Protection matters arising from this review, of the established arrangements for escalating safeguarding concerns to more senior managers, and, if necessary, to the LSCB Chair. develop an audit programme across all agencies to evaluate the use and effectiveness of escalation arrangements practitioners. Ensure clear review timeframes to ensure policy reviewed and agreed annually by the Board. Audit to be built into partnership audit cycle Board Manager Chair of the PPO Sub-group included in Section 11 audits Evidenced through Board agendas and minutes and the revised document with clear document control January 2016 March 2016 for 2016/17 cycle Procedures Section 18.5 Professional Conflict Resolution. All practitioners are aware of the Escalation Policy and its appropriate application in their work to provide challenge and resolve problems. The Board should review and re-issue its Risk Management Strategy to all partner agencies and require the agencies to report back on the dissemination and use of this guidance. The Risk Management Policy is available on the website but needs review and promotion across the partnership to practitioners. Ensure clear review timeframes to ensure policy reviewed and agreed annually by the Board. Board Manager Board Manager Reviewed Risk Management Policy and Guidance with clear review process and timeframes. Use of Risk Management Strategy is built into agency annual reporting to the Board. January 2016 April 2016 and ongoing reporting Effective risk management across the partnership results in improved safeguarding through clear and authoritative practice The Board should ensure that guidance is available to all partner agencies dealing with situations where safeguarding concerns arise from the use of social media by young people, and that the use of that guidance is audited.Board guidance developed. PPO Sub-group to develop auditing approachBoard Manager Chair PPO Sub-group Guidance produced and disseminated. January 2016 March 2016 for 2016/17 cycle The Board should arrange for the London Borough of Haringey to provide briefings and guidance to agencies on the role of the Local Authority Designated Officer.Bi-annual reports from the LADO to the Board in place Sarah Roberts, LADO & Board Manager Reports include analysis of awareness of the role: indication of contacts, advice given, referrals and substantiated allegations Guidance and briefings on the website and analysis of website traffic 1st report July 2015 and ongoing By December 2015 Greater awareness and understanding of the role of the LADO results in timely and appropriate referrals and action to safeguard children and young people. LADO attended Board in July to update on developments including work on guidance and documentation and thresholds guidance for agencies. The Board should ensure that it has continuing arrangements for evaluating the impact of Serious Case Audit of SCRs and established tracker. Chair SCR Sub-group Full tracker in place and ongoing monitoring continues through SCR Sub-group. March 2016 and ongoing The Board is assured that learning from SCRs is meaningfully embedded in practice. Reviews on the quality and effectiveness of safeguarding arrangements in Haringey. Establish practice impact project. Report to the Board Sub-group agreed progress on audit and project in September 2015 |
NC52393 | Chronic neglect and intrafamilial child sexual abuse of male and female children, who were aged between 3-9-years-old at the time abuse was first reported. Mother and her male partner were subsequently convicted of multiple offences of sexual abuse. Family were known to multi agency services, and had period of child protection planning under the category of neglect, later stepped down to child in need plans. Concerns re-emerged and children were removed from the family home, on an interim basis, into care. Shortly after the children were removed they made disclosures about their previous home life and of being sexually abused. Ethnicity or nationality not stated. Learning includes: information exchange between professionals must be comprehensive and timely; professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored; professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process; if an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons. Uses the Significant Incident Learning Process (SILP). Recommendations include: professionals must have knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse; professionals must have knowledge of child sexual abuse, including female perpetrator behaviours; Achieving Best Evidence (ABE) interviews and medical examinations must be child centred and undertaken in a timely way; effective management and multi-agency oversight must be child focused, analytical and reflective.
| Serious Case Review No: 2020/C8469 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Final version – September 2020 1 Executive Summary – September 2020 Family G Contents Subject Page 1. Background to this Serious Case Review. 2 2. Scope of the review 2 3. The views of the family 2 4. Objectives of the review 3 5. Brief Summary of analysis related to key learning areas 3 6. Activity undertaken to date 5 7. Lessons Learned 6 8. Recommendations 8 Appendix A: Independence; methodology; key issues and bibliography 9 Final version – September 2020 2 1. Background to this Serious Case Review 1.1 This Serious Case Review (SCR) is conducted under the statutory guidance of Working Together to Safeguard Children 2015. The purpose of a serious case review is to conduct “a rigorous, objective analysis of what happened and why, so that important lessons can be learned, and services improved to reduce the risk of future harm to children,” (WTSC 2015, page 72). 1.2 This SCR concerns a family comprised of both male and female children who experienced chronic neglect and intrafamilial child sexual abuse. 1.3 The family were well known to multi agency services. The children had a lengthy period of child protection planning under the category of neglect. This was stepped down to child in need plans and the case was later closed. Concerns began to re-emerge shortly after the closure of the child in need plans. This resulted in a second period of child protection planning, again under the primary category of neglect and a secondary category of emotional abuse. Legal proceedings commenced and the children were removed, on an interim basis, into care. Shortly after the children were removed from the family home, they began to talk to care givers and professionals about their previous home life and of being sexually abused. Their mother and her male partner were subsequently convicted of multiple offences of sexual abuse relating to all the children. 2. Scope of the review The review covered a 7-year period due to: (i) the length of time the children were known to service providers (ii) the protracted criminal proceedings. 3. The views of the family Services supporting the children will work together to agree how and when to share this review’s findings with them. Relevant adults did not contribute to this review due in part to unforeseen circumstances. Continuing efforts will be made as appropriate to share the review findings and seek their feedback at this, the final stage of the review process. Final version – September 2020 3 4. Objectives of the review The terms of reference were wide ranging including an overview of systems, how agencies and organisations worked together to safeguard the children, information sharing and management oversight/supervision. The review commissioners considered that the exceptionally young ages of the children and the extensive abuse they suffered, in conjunction with the co-occurrence of abuse committed by a female perpetrator, were areas of new learning across the local authority area. The children’s ages ranged from 3-9 years at the time child sexual abuse (CSA) was first reported. The review also focussed on the extent to which indicators of CSA may have been missed prior to the children’s disclosures. The terms of reference prepared by the review commissioners also asked the independent reviewer to assess whether the support given to the children, once taken into care, was appropriate and sufficient, given the very lengthy delays in bringing the case to charge, trial and conviction. 5. Brief Summary of analysis related to key learning areas The independent review author explored the motivation of perpetrators of sexual abuse within a familial setting. Whilst it is acknowledged that extensive research into male perpetrators of CSA is in existence this is not the case for female perpetrators. There was no evidence to say that the mother, who was known to have perpetrated acts of abuse in her own right, was manipulated or targeted and “groomed” by the perpetrator. Nor could this hypothesis be discounted as she was a woman with significant vulnerabilities who lacked the capability and, at times, the capacity to adequately care for and safeguard her children. In short, the motivation for committing CSA and who was the instigator of this category of abuse remain unknown. The review author noted that indicators of child sexual abuse are known to be wide and varied and can encompass physical, behavioural and emotional indicators, including how children relate to others and parental behaviours. They are not always ‘sexual’ in their manifestation. They can be explicit or subtle, long or short term and understood in the context of a child’s development. Just because children have not verbally disclosed the abuse, does not mean they have not disclosed. Many children do not “tell” in a straightforward way; rather, their behaviour and demeanour or the characteristics or behaviour of caregivers indicates that something is wrong. There were examples of behaviour from all children, and one child in particular, which raised concerns for the Final version – September 2020 4 children’s wellbeing. These agency concerns were identified, assessed and evaluated through the multi-agency child protection and child in need planning processes; however, this did not always lead to effective assessment or clear analysis, evaluation and robust intervention. Research confirms that susceptibility to sexual abuse is known to co-exist with neglect and other forms of child abuse. Using a holistic assessment would have placed the focus on the needs of the children. A child centred approach places an emphasis on decisions being made in the child’s best interests which could otherwise be overshadowed by parental needs. Other approaches to assess sexual abuse were in use at the time, including the four preconditions to sexual abuse and the sexual behaviours traffic light tool; the latter tool was in use by staff at the children’s school. Furthermore, learning from serious case reviews from this period, highlighted risks relating to “hidden men” and the importance of hypothesising and professional judgement. Rigorously applying these approaches to sexual abuse may have led to a better focus on the children’s welfare and need for protection from possible sexual abuse. The dissonance between the children’s apparent presentation at times, the home environment and family dynamics they were living in, should have raised concerns. Staff should have displayed more professional curiosity and thought ‘what does the child mean to the parent and what does the parent mean to the child?’ This approach challenges the optimistic view that their circumstances had sufficiently improved. Professionals may also have viewed mother as a “victim” and not a perpetrator of known neglect which led to her needs overshadowing the children’s experiences and feelings. The children were medically examined in relation to sexual abuse more than two years after professionals initially discussed the need to undertake sexual abuse medical examinations. There is a difference of opinion within the professional network, as to whether the initial decision that medicals were not in the children’s best interest was (a) due to the allegations being historic and therefore unlikely to produce credible forensic evidence or (b) whether a decision was made that a medical was not needed. The written records of the meeting are ambiguous therefore the reason cannot be clarified. Professionals later challenged the need for medical examinations on the same basis – but they did eventually take place. Another possible reason for the medical examinations not taking place at the earliest opportunity was the absence of ongoing multi-agency meetings to specifically co-ordinate and plan responses (including the investigation) to the numerous ongoing disclosures. The children’s individual reviews (as children who were looked after by the local authority), rightly focused on their care needs; however, the same level of multi-agency attention to the Final version – September 2020 5 ongoing investigation into disclosures was lacking. It is possible that an earlier examination may have achieved more conclusive results: the delay meant any physical signs may have healed and the experience was likely to have been retraumatising. The independent reviewer looked at how the children were supported once taken into care. This was a complex and lengthy investigation, where the children made disclosures over a long period of time once they were removed from the mother’s and partner’s care and felt in a safe environment. The length of the investigation was due to a number of issues including, protracted disclosures by the children, delays in ability to interview the mother due to health issues, delays in disclosure of material to the criminal investigation and staff resourcing challenges. It was a long timeframe in the children’s lives given their young ages. Overall, it is likely that these delays constrained the professional network’s ability to fully safeguard and plan for the children e.g. limitations to therapeutic work until the conclusion of the criminal proceedings in case the children were required to give evidence, and the need for therapy to adhere to Crown Prosecution Service guidance. Furthermore, the delay is likely to have had a negative psychological effect on the children, some of whom wanted to see their mother during the timeframe. The children were also aware that their mother and her partner were subjects of protracted criminal law proceedings and this was also known to have impacted adversely on the children’s emotional wellbeing. The analysis noted areas of good practice; for example, the local authority worked with multiple agencies and organisations to provide appropriate co-ordinated therapeutic support by a lead psychotherapist for the children and training support for their carers. 6. Activity undertaken to date A Child Sexual Assault Referral Centre (CSARC) is operating, providing an enhanced referral pathway, and a multi-agency CSA pathway has been produced. There are regular CSARC open days and the CSARC provides CSA training including the role of a CSA medical examination. There is a video available to explain CSARC health assessments. Children’s Social Care has moved to a relationship-based social work model as part of a restructure; this change of practice also addresses some of the learning identified as needed in this SCR. This revised approach has significantly reduced transition points in the system and changes of social workers and managers along with drift and delay. Audits of social work chronologies are now part of the quarterly audit cycle. The NSPCC neglect toolkit is being rolled out across the partnership. Final version – September 2020 6 An action plan to address the 8 recommendations produced by the review author and review commissioners is under development. Further Information about the SCR process can be found at Appendix A 7. Lessons Learned 7.1 In respect of an understanding of the extent to which indicators of child sexual abuse may have been missed prior to the children’s disclosures: • Information exchanged between professionals must be comprehensive and timely so that all members of the multi-agency network have full knowledge of concerns in order to fully assess the level of risks to children. • Professionals need to recognise the different indicators of possible child sexual abuse so that potential indicators are not misunderstood, dismissed or ignored. • Professionals must equip themselves with up to date knowledge of child sexual abuse, including female perpetrators. • Professionals need to be aware of the co-occurrence of neglect and other types of significant harm including child sexual abuse. • Professionals need to use curiosity, hypothesising and a critical analytical mindset throughout the risk assessment process. • Professionals should consistently use chronologies to understand and assess the emerging pattern of risk over time. • Risk assessment should be rooted in child development. 7.2 In respect of how well agencies’ concerns were identified, assessed, evaluated and how effective was the response to these: • Professionals need to ensure that identified concerns lead to effective assessment, clear analysis, evaluation and robust interventions. • If an agency decides not to implement an important case conference recommendation, the relevant agency professional must notify the case conference chair with reasons. • Professionals must ensure that the content of written agreements effectively address the needs of children and parental compliance is closely monitored. • Professionals should produce a multi-agency chronology to inform a co-ordinated child centred response to repeated police call outs. • Risk assessment and analysis must include the role and presence of new partners. Final version – September 2020 7 7.3 In respect of the effectiveness and response of the agencies to the initial referral of child sexual abuse: • Where there are ongoing allegations and an emerging picture of child sexual abuse, review strategy meetings should be convened at timely intervals to coordinate and plan effective responses. • Where there is ongoing supervised contact, a review of contact should be held to consider the safety and welfare of children in such circumstances. • Where child sexual abuse is known to have occurred, multi-agency professionals must work together to ensure that timely, specialist medicals are undertaken to reassure children and to provide a thorough understanding of the child’s medical needs and to support criminal investigations. 7.4 In respect of how the children’s views and feelings were ascertained and responded to: • Professionals need to apply knowledge and understanding of child development, in order to recognise and be alert to issues of concern. • Professionals need to ensure that parental issues do not overshadow children’s needs within risk assessments. 7.5 In respect of the extent to which interagency / agency policy and procedures (government guidance at the time) were followed in this case: • Risk assessments must include critical analytical reflection in order to counterbalance over optimism. • Where there is a lengthy and concerning chronology of risk and harm to children, consideration should be given at an early stage to the need to issue care proceedings. • Management oversight must result in timely, effective safeguarding interventions to robustly protect children. • During departmental restructuring and times of high staff turnover, senior managers should risk assess the impact of this to ensure there are enough practice resources to keep children safe. Final version – September 2020 8 8. Recommendations 1. Professionals must be equipped with the knowledge to enable them to identify and respond effectively to children who are or who may be at risk of suffering multiple categories of abuse. 2. Professionals must be equipped with knowledge of child sexual abuse, including female perpetrator behaviours. 3. Professionals working with neglected children must identify and implement timely, effective support and interventions. 4. Professionals working with neglect must be vigilant and open minded to the potential of co-occurring and different types of harm, including sexual abuse. 5. Achieving Best Evidence (ABE) interviews and medicals must be child centred and undertaken in a timely way. ABEs must be carefully planned in order to achieve an evidentially sound interview. The lead agency should share their findings in a way that is understood by professionals working with the family. 6. When working with neglecting families, professionals must apply knowledge, understanding of child development and remain child-centred in order to identify the holistic needs of children. 7. Effective management oversight and multi-agency oversight must be child focused, analytical and reflective. The practice of management oversight by the Head of Service and Service Manager must be consistently applied in cases where children are subject to child protection plans in excess of 18 months. 8. Strategy meetings and subsequent review strategy meetings must be convened when appropriate (and include Health/SARC) and at timely, child centred intervals where there are ongoing allegations to specifically co-ordinate and plan responses (including the investigation) and to progress outstanding actions. Final version – September 2020 9 Appendix A Independence Safron Rose, child protection consultant, is the independent reviewer and lead author. She is a full-time independent child protection consultant and trainer providing a range of safeguarding services to multi-agency managers and practitioners across England and the Channel Islands. Safron Rose has thirty years’ experience in child protection social work. She has been involved in a number of serious case reviews since 2012 and has held various operational and strategic roles in Children’s Services and is a former Director at the NSPCC. Methodology The review used an adapted Significant Incident Learning Process (SILP). The approach explores practitioners’ views of the case at the time the events took place. It analyses significant events and deals not only with what happened but why it happened. Essentially the aim is to promote reflective learning and practice improvements and reduce the notion of blame. The local authority established a serious case review group, referred to as a panel, to manage the review process. The panel comprised of senior managers of the agencies providing services to children and families across the local authority area and was independently chaired. The role of the panel was to assist the independent lead reviewer in considering the evidence, considering lessons that could be learned to improve practice and formulating the recommendations of this report. The independent reviewer produced and presented a full report with detailed analysis to the Board to enable their understanding of the review author’s findings and recommendations. This Executive Summary was produced with the Safeguarding Children Board. Final version – September 2020 10 Key issues for the review: o An understanding of the extent to which indicators of child sexual abuse may have been missed prior to the children’s disclosures, o How well were agency concerns identified, assessed, evaluated and how effective was the response to these? o The extent the exchange of information was effective: within the agency and between the agency and other agencies. o Agency management oversight and supervision of this case. o The extent to which interagency / agency policy and procedures (government guidance at the time) were followed in this case. o Any other issues identified as impacting delivery of services at that time that agencies would like to comment on such as volume of work; staff turnover; sickness / leave cover; administrative support; budgetary constraints; access to legal advice, training, etc o Were there indicators of sexual abuse in relation to any of the children? If so, what was the response to this? What action was taken to address this? o How were the children’s views and feelings ascertained and responded to? o Were there any examples of good practice that can be highlighted in this case? o Any changes to practice recommended or systemic issues identified? o The effectiveness and timeliness of the response to the initial referrals of concerns of child sexual abuse. o The timeframe between the allegations being put to the mother and step-father and them being charged. Was this a reasonable timeframe? o Did the perceived delay (from charge to trial) constrain the professional network’s ability to safeguard and protect the children? Final version – September 2020 11 References (Bibliography) I. NSPCC Statistics Briefing Child Sexual Abuse 2019 – NSPCC Knowledge and Information Service II. Exploring the relationship between neglect and adult-perpetrated intra-familial child sexual abuse: Evidence Scope 2 D. Allnock. Edited by Steve Flood and Dez Holmes. Dartington – NSPCC-Research in Practice – Action for Children III. Finkelhor, D., Ormrod, R.K. and Turner, H.A. (2007) Re-victimization patterns in a national longitudinal sample of children and youth. Child abuse and neglect IV. Female Sexual Offenders: Theory, Assessment, and Treatment - An Introduction. Edited by Theresa A. Gannon and Franca Cortini. V. Toro, Jacqueline (2009) The problem of recognising and treating female sexual offenders. Seen and Heard, Vol.19, Iss.3. VI. Ford, Hannah (2006) Women who sexually abuse children. Chichester: Wiley NSPCC/Wiley VII. No one noticed, no one heard: A study of disclosures of childhood abuse. D. Allnock & P. Miller, NSPCC 2013. VIII. Things children say – Disclosure, allegations and why language matters: Transparency Project. |
NC52439 | Sexual abuse of three siblings by members of their extended family. Learning includes: the impact of neglect and adverse childhood experiences (ACEs) on children's social, emotional and cognitive development; seek to make sense of and understand the lived experience of children; seek to understand the lived experiences of parents and carers who may have experienced trauma, live with domestic abuse, substance abuse or mental health issues and the impact of this; remain mindful, when working with children and young people with special educational needs and/or disabilities (SEND), of the fact that not all disabilities are visible, and that some children may present as more able than they are; ensure effective communication between agencies; professionals must be alert to exaggerated hierarchy, whereby professional status becomes magnified and other professionals perceive themselves to have comparatively lower status; prevent closed professional systems, where one agency assumes a dominant position or view of a case and fails to pay attention to conflicting information or information that fails to support their views and hypothesis; during the planning of any assessment, it is important to determine who knows the child(ren) and family and holds information about them; consideration of the impact of domestic abuse on the child/parent relationship; consideration of the impact of parental mental health in relation to parenting and the impact this can have on the child/parent relationship; and children and young people should be carefully matched when placed in foster care, with foster carers having a clear understanding of children's lived experience, any SEND and how this impacts in terms of meeting their needs. Recommendations include: ensure information/concerns/allegations are communicated to children's social care in a timely manner; support information sharing between and within organisations, and address any barriers to information sharing, including neighbouring authorities; and ensure partner agencies are aware of the organised and complex abuse procedures and receive appropriate training and guidance.
| Title: Warrington child safeguarding practice review: executive summary – Case AB: the handling of a case involving allegations of intra-familial sexual abuse among five families. LSCB: Warrington Safeguarding Partnership Author: Warrington Safeguarding Partnership Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. CASE AB final report, agreed at WSP.5 Page 1 Warrington Child Safeguarding Practice Review Executive Summary – Case AB THE HANDLING OF A CASE INVOLVING ALLEGATIONS OF INTRA-FAMILIAL SEXUAL ABUSE AMONG FIVE FAMILIES Learning Child’s voice; ACE’s and lived experience; Understanding the impact of SEND; Inter-agency information sharing; Multi-agency working; impact of domestic abuse; Child and parental mental health; failure to access and follow extant procedures; foster care arrangements; child in need processes Summary recommendations Agencies to rethink information-sharing approaches, to rethink approaches to ABE interviewing, in terms of focus on victims and adherence to latest guidance, to champion procedures related to addressing organised and complex abuse Keywords Intra-familial Sexual Abuse, effective multi-agency working, achieving best evidence Version 1.5 final draft Date 14 October 2020 CASE AB final report, agreed at WSP.5 Page 2 Introduction This document is the Executive Summary of the Warrington child safeguarding practice review report into Case AB, conducted on behalf of Warrington Safeguarding Partnership. The review focussed on the multi-agency management of allegations of intra-familial sexual abuse involving five families who resided in the Warrington Borough Council (WBC) district and focussed on three children, all siblings. The review process involved professionals from across the range of agencies that had been involved with the main investigation as well as professionals that were working alongside the families in different capacities. The review considered what went well, where agencies could improve, and makes several recommendations so that these improvements can be embedded into practice. Summary of the case In April 2017, care proceedings commenced in respect of all three children, as a result of allegations of sexual abuse made by the eldest child in relation to a member of her extended family. The siblings were subject of Special Guardianship Orders, to the same extended family members, following earlier care proceedings conducted by a different local authority. Once the siblings become looked after children and were placed in foster care, the younger two children made extensive allegations of sexual abuse in relation to a number of adult members of the extended family living in Warrington and 3 other local authorities. These allegations, were made over a period of time and described a paedophile ring involving a significant number of adult members of the extended family. The siblings made allegations that other children in their wider family had also been abused by several adult members of their wider family – though no allegations were made by any other children who have been subject to social care involvement. Care proceedings commenced in relation to the children of the alleged perpetrators in Warrington and by the other local authorities within whose boundaries some of the children were ordinarily resident. There followed a prolonged and extensive police investigation involving Warrington Borough Council’s Children Social Care and Cheshire Constabulary. The criminal investigation involved a total of sixty-seven best evidence interviews undertaken with the three siblings. There were no criminal prosecutions following the CPS determining the criminal threshold had not been met. A fact-finding hearing was held and concluded, April 2019, that the siblings had been abused, and the originally-identified extended family members had perpetrated the abuse or had been involved to a greater or lesser extent. No findings were made against any other party, some parties were exonerated and none of the other children identified were found to have been abused or to be at risk. In terms of agency involvement, the fact-finding hearing concluded that the agencies involved had no option other than to launch litigation, found that there was a lack of familiarity with current investigatory guidelines i.e. that achieving best evidence interviews and wider investigatory practices were not consistent with best practice. It was found that there was insufficient senior leadership oversight between key agencies during the course of the investigation and that some key officers were insufficiently experienced. CASE AB final report, agreed at WSP.5 Page 3 The Warrington child safeguarding practice review sought to examine the multi-agency handling of the case in order to identify the lessons that needed to be learned from this case, and to make recommendations to Warrington Safeguarding Partnership. Lessons Learned Adverse childhood experiences (ACEs) and lived experience - The impact of neglect and adverse childhood experiences (ACE) on children’s social, emotional and cognitive development, the more ACEs a child experiences the greater the effect on their physical and psychological health. - If practitioners are to have a positive impact on the lives of abused neglected children then making sense of and understanding their lived experience, what life is like for them, is essential. - It is also important to understand the lived experiences of parents and carers who may have experienced trauma, live with domestic abuse, substance abuse or mental health issues and the impact this has, example, the parent/child relationship and attachment Understanding the impact of SEND - When working with children and young people with special educational needs and/or disability (SEND), professionals must remain mindful of the fact that not all disabilities are visible. Children/young people may present as more able than they are. In addition, SEND may be further affected as a result of the child’s lived experience and the impact of neglect on the brain’s development. It is important the skills of educational and SEND specialists are accessed, utilised and maximised. - In ABE (achieving best evidence) planning, due consideration should be given to recruiting the support of an educational psychologist to ensure a full and robust understanding of the child’s special educational needs or disability, including the best approach to facilitate disclosure. Communication, multi-agency information sharing, and multi-agency working - The NSPCC in Warrington undertook face to face work with one of the children central to this case between 2013 and 2017. The child talked about relevant factors to this case, but the review could find no evidence that this had been shared with CSC. The work undertaken was not focussed on the child’s agency, to be empowered to explore their world and lived experience. - Effective communication between agencies, which is fundamental for effective partnership working; for social workers it is a core competency be able to engage in inter-professional and inter-agency communication. - Information sharing and partnership working between the police, CSC and the local authority legal team did not always work well in this case and was sometimes very poor. This impacted on the ability of professionals to work openly and transparently with families and on occasion impeded CSC professionals undertaking risk assessments. - Social workers did not always understand the statutory duties placed on educational settings from early years to colleges and the important role they play in the identification of abuse and support for vulnerable children and young people. - Professionals must be alert to “exaggerated hierarchy”, whereby professional status becomes magnified and other professionals perceive themselves to have comparatively lower status; this was manifested when the police assumed the central role of investigator and case manager, often making decisions in isolation of CSC and were allowed to do so due to a lack of professional challenge by CSC and legal services CASE AB final report, agreed at WSP.5 Page 4 - There was a failure by professionals from all agencies to exercise timely professional challenge at the time the case was active or to implement the Pan-Cheshire escalation procedure when information was effectively being withheld - Preventing closed professional systems, where one agency assumes a dominant position or view of a case and fails to pay attention to conflicting information or information that fails to support their views and hypothesis The framework for the assessment of children in need and their families There was evidence that the assessment framework and the three domains of the child’s development, parental capacity to parent and family and environmental impact was not always effectively utilised most importantly in the following areas: Familial history - Familial history, impact and relationships between family members. During the planning of any assessment, it is important to determine who knows the child(ren) and family and holds information about them, including information held within CSC records, and by neighbouring authorities where children have moved into the area; education settings, early years provision and schools; health services (both universal and specialist e.g. mental health services); and third sector, e.g. IDVAs, drug and alcohol specialists and the NSPCC, who provide a range of services in Warrington. In this case all of these services held information about the familial history, historical and current, however information was not always shared. - The three siblings had experienced extensive neglect in the care of their birth parents and were subject of care orders to another authority and then special guardianship orders agency records held significant historical information which was not accessed - There was a limited understanding current and extended family functioning, inter-familial relationships and the impact for the children and young people, both positively and negatively - Many of the families were blended and there was a lack of information regarding the contact and inter-personal relationships of children not living in the household but having contact Impact of domestic abuse - Consideration of the impact of domestic abuse was not clearly evidenced, this was a particular concern in this case, where perpetrators assumed care of identified children during investigation and proceedings. - In addition, the impact this can have the child/parent relationship Impact of mental health - Consideration of the impact of parental mental health in relation to parenting was not clearly evidenced. There were several references to parents suffering low mood but no analysis of this especially when they were victims of abusive relationships, were faced with the complex needs of children with medical conditions or were isolated and vulnerable. - Further, one parent had significant mental health issues, the significance of which was not immediately apparent in the IMR’s nor was the impact of this explored for all the children in the family - In addition, the impact this can have the child/parent relationship Failure to access and follow extant procedures CASE AB final report, agreed at WSP.5 Page 5 - Warrington has in place ratified and agreed procedures on multi-agency escalation and on investigating organised and complex abuse, however no agency accessed or relied on the procedures that already exist and are accessible by all. Foster care arrangements - Children and young people should be carefully matched when placed in foster care; whilst this is not always possible in an emergency, foster carers should have a clear understanding of their lived experience, any SEND and how this impacts in terms of meeting their needs Child in need processes - CiN meetings and robust administration being in place to address issues were raised in this review and by agencies e.g. the rescheduling cancelled meetings, distribution of meeting notes; Further, any agency involved in a CiN meetings should have an identified role and action in any plan e.g. plans stated there was no role for the school and the rationale for stepping down from child in need was not always clearly communicated in meetings or in the notes of the meeting What worked well? Focus on needs and voice of the child - Continuity of primary school provision for the three siblings - The siblings retained the same social worker throughout - When one of the children disclosed inappropriate touching through the online counselling service, Kooth, they informed EDT1 ; the police and CSC held a strategy discussion and completed a joint visit the same night - DSL and DDSL’s2 in schools followed up events and actions when there was no immediate feedback from CSC3 - The DDSL at one of the children’s high schools appropriately challenged CSC when they were disinclined to act following an allegation of inappropriate touching made to a learning mentor, and again when they were concerned for her welfare in one of her foster placements - Cheshire Constabulary assigned a dedicated team of experienced officers that were fully trained in public protection matters - Cheshire Constabulary have adopted ‘Operation Encompass’, providing prompt notifications to schools in relation to domestic abuse incidents - A registered intermediary was appointed by police to support the three siblings in their ABE interviews - Provision of emotional support by schools, cross phase, was outstanding and included play and art therapy, counselling, LEGO®-based therapy, nurture groups, along with excellent pastoral support - Two of the siblings received support around coping strategies, arranged through RASASC4 - Two of the siblings were referred to CAMHS5 for support in respect to their emotional well-being - An appropriate referral was made to paediatrics due to faltering growth of a baby - The CCG6 has refreshed its safeguarding children standards 1 EDT - Emergency Duty Team who provide out of office hours cover for children social care 2 DSL and DDSL - Designated and Deputy safeguarding lead in schools and colleges 3 CSC - Children’s social care 4 RASASC - Rape and sexual abuse centre 5 CAMHS - Child and adolescent mental health service 6 CCG - Clinical commission group who plan and commissioning of health care services for their local area CASE AB final report, agreed at WSP.5 Page 6 - CSC reassessed contact between a parent and her children due to the negative emotional impact of the mother’s absence - A young baby remained with their mother throughout proceedings, including when the mother was voluntarily admitted to a mother and baby unit - Professionals involved undertook a range of observations of, in particular, young children and their interactions with family members during assessments and contact sessions Engagement with parents - An NNEB nurse supported a vulnerable parent around behavioural issues presented by her eldest child - The NHS7 have updated domestic abuse packs and pathways - A social worker persevered through considerable difficulty in building a relationship with the parents of one of the involved families, eventually the family agreed to CiN8 meetings being held. There was evidence of clear benefits for the family from this point, as they were, then, part of formulating a multi-agency plan to support them, which increased communication and engagement - A school nurse involved with one of the families demonstrated outstanding practice when she provided clear advice to the parents, signposting them to appropriate support, and her records provided an excellent insight into the lived experience of the children, the impact for parents of the ongoing proceedings and the voice of the child is clear - CiN meetings, where held, were beneficial for families - A vulnerable parent failed to attend a family support meeting, so professionals took the meeting to her home address Partnership working - The review found evidence of good partnership working between schools and CSC - Schools worked with IDVAS9 when a parent disclosed domestic abuse - Timely referral made for early help services as a result of ongoing allegations of domestic abuse and intimidation - Appropriate CiN meetings held to support families and their children - When the mental health of one of the parents involved in this case deteriorated and a voluntary admission to a mother and baby unit became necessary, a joint home visit was undertaken by the allocated social worker and CPN - Meetings were held with social workers and key agencies across all 4 local authorities to share information with regards to the families involved, which helped when managing risk Contact and care arrangements - Where possible, all of the children remained in the care of either their birth fathers or grandparents - Care proceedings were instigated in respect of all children involved in the case and Warrington Borough Council legal services co-ordinated the fact finding proceedings across all geographical areas - A challenge was made by a family against the amount of contact made available with a young child; increased contact was not supported by CSC and others involved in the child’s care; the matter was placed before the family court and an agreement was reached to increase contact outside court 7 NHS: National Health Service 8 CiN: Child in need – s17 Children Act 1989 9 IDVAS - Independent domestic violence advisor service CASE AB final report, agreed at WSP.5 Page 7 - A contact agreement was drawn up with a paternal grandmother of one of the children with clear consequences if broken Parenting support and assessments - Parenting assessments undertaken as part of care proceedings generally concluded positively Recommendations 1. NSPCC (Warrington) should consider adopting “my life” being rolled out by Children Social Care (CSC), which incorporates a chronology of direct work. 2. NSPCC (Warrington) should ensure information/concerns/allegations are communicated to CSC in a timely manner, whether verbally or in writing, and that a response is received from CSC as to what action is being taken; where there is no response it is recommended that this is followed up promptly, or escalated. 3. WSP should review the role it takes in supporting information sharing between and within organisations, and address any barriers to information sharing, including between neighbouring authorities. This should be supported, as necessary, by single and multi-agency training, reinforcing when and how information can be shared and in accordance with working together to safeguard children (2018) and keeping children safe in education (2019). 4. WSP should consider what further action is required and/or available to it specifically in relation to a local authority involved in this case, who failed to cooperate, share information, or properly discharge their duties when expressly requested to do so. 5. WBC CSC and Cheshire Constabulary should present a joint report to the QA group of the WSP setting out what action will be taken to address issues identified in this review; this should include social workers and police planning and undertaking joint ABE interviews; effective partnership with the involvement of an educational specialist when supporting victims who have SEND; continuous assessment of the balance between evidential thresholds; contingency planning and oversight by the CPS to ensure ABE interviews are consistent with guidance and retaining a real focus on the welfare of vulnerable children and young people. 6. WSP should consider making all Chief Executives of all agencies in Cheshire and their respective locally elected leaders aware of this case given the serious concerns raised in relation to the lack of information sharing. For the Cheshire Constabulary, specifically information sharing and ABE interviews. 7. WSP should assure itself that all partner agencies are aware of the organised and complex abuse procedures and receive appropriate training and guidance in its use and application. |
NC51819 | Death of a 3-month-old girl in March 2019. Tracy was found deceased at home. Criminal investigation commenced by police and care proceedings instigated for siblings. Tracy was the youngest of three siblings; all had recently been made subject to a Child Protection Plan for neglect. In 2018, an anonymous referral regarding malnourishment resulted in sibling made subject to Child in Need. Family history of domestic abuse; father arrested on several occasions and had restraining order not to contact mother. Concerns about parenting capacity and neglect. Maternal history of depression, alcohol and cannabis use. Several agencies tried to engage with mother and offered to provide services within the Early Help Assessment Tool (EHAT); all offers of supports were refused. Learning includes: responsibility to initiate an Early Help Assessment (EHAT) is that of any professional who is working with a child and/or family; lack of support and alternative options available to professionals when responding to a persistent refusal of services; anonymous reports of safeguarding concerns can create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidence based approach. Recommendations include: produce a pathway for professionals which details what support, processes and resources are available for engaging resistant families; agency access to policies which detail how they should respond to refusals to engage, share information and escalate concerns into statutory intervention; ensure that information is available to the public on the timeliness of reporting concerns and outcomes available to agencies in response to those concerns.
| Serious Case Review No: 2020/C8153 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Official Sensitive Government Security Classifications April 2014 1 Serious Case Review Child Tracy Overview Report – Final Version Official Sensitive Government Security Classifications April 2014 2 CONTENTS Section Page 1. Circumstance which led to a Serious Case Review. 3 2. Methodology. 4 3. Terms of reference (including review period and rationale). 5 4. Overview of what was known to agencies. 5 5. Analysis. 12 6. Conclusion. 16 7. Summary of learning and recommendations. 17 Appendix A Serious Case Reviews 19 Official Sensitive Government Security Classifications April 2014 3 1. Circumstances which led to a Serious Case Review. Key Individuals Referred to as: Tracy Child Victim Sibling Sibling 1 Sibling Sibling 2 Mother of Tracy Mother Father of Tracy Father 1.1 Pseudonyms have been used throughout the report, for key individuals and professionals who worked with Tracy and her family. 1.2 Tracy died in March 2019. At the time of her death she was 3 months old. Tracy was the youngest of three children, all of whom had recently been made subject to a Child Protection Plan for neglect. 1.3 Tracy was found unresponsive at home, an ambulance was called and despite attempts at resuscitation, she was pronounced dead. Police commenced a criminal investigation and Children’s Services commenced child care proceedings in respect of Sibling 1 and Sibling 2. 1.4 There was a history of domestic abuse within Tracy’s family, concerns had also been raised about parenting capacity, neglect of health and care needs of the children. There were allegations of substance misuse and Mother had presented as uncooperative with Professionals. 1.5 In October 2018 the case had been opened as Child in Need following concerns in an anonymous referral regarding malnourishment, and that Tracy’s siblings and their Mother had been seen in the street in the early hours. This referral was before the birth of Tracy. In January 2019, further concerns were raised regarding the health of Sibling 1 and the case was progressed to Child Protection for all three children. 1.6 Following Tracy’s death, and in accordance with procedures, a strategy meeting and Sudden Unexplained Death in Infants (SUDI) meeting were held. A decision was reached that the case reached the criteria for a Serious Case Review. Official Sensitive Government Security Classifications April 2014 4 2. Methodology. 2.1 An Independent Chair and Author were appointed who are experienced in undertaking serious case reviews. Neither the Chair nor Author had previously worked for any of the agencies engaged within the review. 2.2 A Review Panel was established, its members gathered and analysed data, agreed Key Lines of Enquiries, reviewed practice and agreed the content of drafts and the final report. The Review Panel met on three occasions, meetings were chaired by the Independent Chair, minutes and key actions were produced. Job Title Organisation Detective Chief Inspector Police Report author Independent Education Officer Local SCB Designated Nurse Safeguarding Children Clinical Commissioning Group Chair Independent Service Manager City Council Children’s Services Co-ordinator Local SCB 2.4 Written contributions and chronologies were received from all agencies involved within the review. Where additional information was requested this was provided to the Chair and Author. 2.5 The review used a systems-based approach to analyse information and key events. The findings are presented in Section 7 using recommended best practice in identifying improvement and learning. 2.6 The Independent Chair wrote to Mother informing her of the review. At the time of writing this report legal constraints prevent the review panel speaking to Mother. The review panel made the decision for the Father of Tracy not to be contacted and informed of the review. Official Sensitive Government Security Classifications April 2014 5 The panel felt that it was important to give Mother the opportunity of engaging with the SCR to see if it could be established why she was resistant to the help and support being offered by professionals. If there were specific reasons it would enhance the learning and probably assist agencies in working with non-cooperative families. Terms of Reference. 3.1 The Review Panel agreed that the period under review would be from mid November 2017 (12 months prior to birth) and up to a date in March 2019 (death of Tracy). 3.2 The Review Panel agreed not to set specific terms of reference. The combined chronology was reviewed during the first panel meeting and Key Lines of Enquiries identified to allow for a wider exploration of important events relevant to safeguarding practice and systems. 3.3 The Key Lines of Enquiries focused on: • Agencies knowledge and responses to domestic abuse. • Agencies responses to identified needs with the family. • Was the decision making and the assessed thresholds appropriate? • Was the response of agencies to third party, including anonymous, referrals appropriate? • Was escalation on the case undertaken at the right level and pace? 4. Agency Overview. 4.1 Agency involvement prior to start of review date. 4.1.1 Mother had a history of depression, alcohol and cannabis abuse. Records stated that Mother had limited support with extended family members. These vulnerabilities were identified during her pregnancy with Sibling 1, but Mother declined professionals’ offers of support and referral to specialist teams. 4.1.2 Mother engaged well with professionals during her pregnancy. Sibling 1 was born in April 2014. There were no concerns at birth, and Mother and baby were discharged early. Mother continued to engage well with professionals following the birth, and not long after, she moved into her own accommodation. 4.1.3 In July 2014, Health Visiting services attempted to see Mother and Sibling 1 to discuss weaning. There were a number of failed encounters, and on one occasion a male answered the door, he Official Sensitive Government Security Classifications April 2014 6 reported that he was the Father, but stated Mother must have forgotten the appointment as she was not in. Entry was not gained. 4.1.4 Children’s Social Care received a referral in July 2014 from a floating support worker who reported that Mother was threatening to harm herself and Sibling 1 due to rat infestation within the property. Mother had moved out of the property to live with family. Pest Control were due to attend the property. A Social Worker visited Mother and it was agreed she would continue to be supported by Health Visitor, GP and Children Centre. 4.1.5 In September 2014 Mother attended at hospital where it was confirmed that she was pregnant with Sibling 2. On 17 September 2014 Police attended a report of a verbal argument between Mother and her extended family. This incident was shared with Children’s Social Care at the beginning of October 2014. 4.1.6 Mother informed a midwife in October 2014 that she had ceased using cannabis in May 2014 and continued to deny cannabis use in further appointments. Mother declined to share details of the Father of Sibling 2. 4.1.7 On 23 December 2014 Police attended a reported domestic incident at the home address of Mother. Father was trying to gain entry to the property and had damaged a window. Mother and Sibling 1 were not at the premises. Details of the incident were shared with Children’s Social Care. 4.1.8 At the beginning of January 2015 Mother was involved in a domestic abuse incident in another area with Father. Children’s Social Care completed a single assessment which took account of both recent incidents. The case was heard at MARAC1 (Multi Agency Risk Assessment Conference) in February 2015. Mother signed a written agreement not to have contact with Father and the case was closed in March 2015. 4.1.9 In April 2015 Sibling 2 was born. Father was present during birth. Routine questions on domestic abuse were asked but Mother made no disclosures. 4.1.10 In April 2015, Health Visiting made a home visit with Mother and Sibling 2 during which she reported that Father was staying with them until the following week before he returned to where he was living. The flat was reported to be cluttered, Father was seen to be tidying up; there was no carpet in hall and on staircase. Official Sensitive Government Security Classifications April 2014 7 4.1.11 The day after this visit Police received a report of a domestic abuse incident. Mother had been head butted by Father. Sibling 1 and 2 were present during this incident. Mother attended at hospital with facial bruising, blurred vision and haematoma to left side of head. Father was arrested and charged with offences of assault occasioning actual bodily harm and threats to kill. The incident was shared with Children’s Social Care and the case referred to MARAC. Mother was referred to the IDVA (Independent Domestic Abuse Advocate) service. Mother moved to live with family until she was re-housed. 4.1.12 Children’s Social Care completed a single assessment to review the parenting capacity of Mother. A Child in Need meeting was held. Mother declined Early Help Assessment (EHAT) support, Father was in custody and Mother was seen to be engaging with professionals. Advice was given to Mother should she resume her relationship with Father that the case could be escalated to child protection processes. The case was closed. 4.1.13 In February 2016 a neighbour contacted the front door service and reported concerns regarding the care of Sibling 1 and 2. The Health Visitor informed the Social Worker that Mother did not engage and that the Health Visitor had no concerns; however; the Health Visitor did report that Mother would benefit from parenting classes. Mother was contacted and denied the concerns. The incident was closed with the agreement of a Manager. 4.1.14 In July 2016 the two-year developmental check of Sibling 1 was completed. Some concerns were noted regarding diet, dental care, Mother’s emotional warmth and ability to provide guidance and boundaries as well as environmental factors in relation to the living conditions of the property. The Nurse advised on a Speech and Language Therapy (SALT) referral but Mother declined and stated she felt the speech will improve once the child started nursery in September. 4.1.15 The identified concerns were discussed with a Team Leader and Safeguarding Nurse, who advised Health Visitor to log them with the front door service and complete an Early Help Assessment Tool (EHAT) if Mother agreed for extra support. A further home visit was undertaken and EHAT discussed with Mother and Maternal Grandmother. An information leaflet on EHAT was left for Mother to read. Mother declined the support of EHAT. Official Sensitive Government Security Classifications April 2014 8 4.1.16 Sibling 1 came to attention of several Health professionals due to dental decay. Mother did not follow up the dental appointments. 4.1.17 In March 2017 an anonymous referral was received by in relation to Sibling 1 and 2, which stated that they believed the home was being used as a ‘crack house’ and the children were constantly crying and screaming through the night. The referral was triaged with a recommendation for Early Help and forwarded to the Children’s Centre to initiate engagement with Mother. 4.1.18 The Children’s Centre were unable to contact Mother by telephone and home visits. The Children’s Centre Manager made the decision for the referrer to be informed of the outcome and the case was closed. 4.1.19 Sibling 1’s attendance at Nursery declined from May 2017 onwards. A home visit by the Community Nursery Nurse identified further concerns. Mother reported to have forgotten about Sibling 1’s dental appointment. A further referral would be made. Mother was observed speaking inappropriately to the children, appropriate advice was given. Despite a slight improvement in Sibling 1’s speech, an assessment in February had identified that the speech was significantly below the normal range. A further assessment was arranged for July 2017. 4.1.20 In July 2017 Police attended an incident during the early hours of the morning between Mother and Maternal Grandmother. Mother was reported as being drunk and threatening to ‘glass’ her Mother. Sibling 1 and 2 were present. Police Officers recorded that the children did not appear to think there was anything unusual about what was occurring despite both women screaming at each other, and that it appeared normal for them to be awake at that hour. 4.1.21 By October 2017 Sibling 1 had failed to attend further dental appointments. The Health Visitor had been unable to contact Mother on a home visit. This visit was to discuss EHAT with Mother, as well as the children’s development, attendance at Nursery and medical appointments. It was recorded that the family had not been seen by the GP since December 2016. An appointment was made for Sibling 1 to attend for pre-school booster. 4.2 Agency involvement within timescale of review. 4.2.1 Sibling 1 did not attend the pre-school booster appointment. Official Sensitive Government Security Classifications April 2014 9 4.2.2 The Health Visitor was denied access to the house by Mother during a home visit in January 2018. Mother stated that the visit was inconvenient, as she and her children were asleep. A further appointment was arranged. 4.2.3 The Health Visitor completed a home visit in February 2018. Sibling 1 was seen to be wearing a nappy and looked pale and thin, a poor diet was reported, and the child appeared tired throughout the visit. Mother stated that Sibling 1 had been referred to the Dental Team but that she did not want the child to go under anaesthetic and preferred to wait for second teeth to emerge. A referral was made with Mother to attend at the GP to review diet and iron levels. Communication skills were recorded as poor. 4.2.4 The Health Visitor recorded that Mother displayed an indifferent approach to advice regarding both children and no warm interaction was noted during the visit. Mother appeared in low mood and stated that she was unwilling to accept professional advice around parenting and would do things her way. The Health Visitor assessed the family and noted them to be at level 2. (Child has additional, or emerging, needs which may require support. Consider an Early Help Assessment EHAT.) EHAT was discussed with Mother who stated she would contact the Health Visitor if she wanted to progress. 4.2.5 In April 2018 Mother was involved with an altercation with a neighbour during which Mother was assaulted. Both children were present during this incident. 4.2.6 By May 2018 Sibling 1’s Nursery had started to identify concerns. The Inclusion Manager contacted the Health Visitor and was provided with background information in relation to the family. The Front door service advised the Inclusion Manager to gather more information and to record these on a Referral Form if appropriate. The Inclusion Manager was unable to contact Mother and obtain details for the Referral Form. 4.2.7 Mother attended hospital in May 2018 where it was confirmed that she was pregnant with Tracy. Routine enquiry was undertaken surrounding domestic abuse - no disclosures were made. Mother left the hospital before treatment finished. 4.2.8 On the afternoon of 15 May 2018 the School Inclusion Manager and Nursery Teacher completed a home visit. The house was in darkness and Mother stated that she, and the children were asleep. A discussion took place regarding lack of attendance of Sibling 1, several options Official Sensitive Government Security Classifications April 2014 10 were discussed, and Mother agreed to Sibling 1 being picked up. The following day when staff went to collect Sibling 1 Mother stated that the child was ill and would not be attending at Nursery. 4.2.9 The School Inclusion Manager discussed their concerns with the Health Visitor and were advised to open an EHAT in order to try and engage Mother with access to Early Help. 4.2.10 In June 2018 Sibling 1 attended at Nursery and was seen to be very pale, withdrawn and unsteady on their feet. The Nursery felt that the child’s shoes were too tight and raised this with Mother. The following day Sibling 1 attended in sandals. The Inclusion Manager continued to be in daily contact with Mother and supported her to complete the Primary Transfer Form (education) for Sibling 1 for September 2018. The EHAT was not progressed. 4.2.11 Towards the end of June 2018 Mother reported a breach of restraining order and assault by Father to the Police. The assault had occurred two weeks previously whilst Father had been staying at the property. Father was subsequently charged with a number of offences and the case was referred to MARAC. Details of the incident were shared with agencies, including Children’s Social Care. 4.2.12 In July 2018 the case was allocated to a Social Worker. A single assessment was commenced which concluded with a recommendation for EHAT and allocation to domestic violence worker. Mother had acknowledged the impact on the children in relation to the domestic abuse. As Mother was already engaged with an IDVA, a decision was made not to allocate to a domestic abuse worker. The EHAT was not progressed. 4.2.13 Mother attended a health appointment in August 2018 in relation to her pregnancy. Details of the pregnancy, including a referral form for the unborn child were shared with Children’s Social Care. Staff were informed that the case had recently been stepped down to EHAT, and that the Social Worker who completed the single assessment was not aware that Mother was pregnant. 4.2.14 Towards the end of August 2018 Sibling 1 and 2 witnessed a domestic abuse incident between Maternal Grandmother and her partner. Police attended this incident and shared the matter with Children’s Social Care. A decision was made to undertake a joint visit with a worker from the Children’s Centre and the domestic violence worker. Official Sensitive Government Security Classifications April 2014 11 4.2.15 In September 2018 staff from the Children’s Centre visited Mother. Mother complained that the staff had woken her up (the visit was mid-afternoon). The purpose of the visit was explained to Mother which included the offer of services and help. Mother refused to engage. Staff queried why both children were in bed, and not in school. Mother stated she could not be in two places at once. Although staff did not gain entry to the house they reported that the house appeared to smell, was messy and unkempt from what they could see through the front door. The visit was discussed with a Manager who decided to override Mother’s refusal to consent and approved contact to be made with agencies engaged with the family. 4.2.16 Two days after this visit a midwife visited Mother at home and offered her enhanced team care for the pregnancy. Mother refused and stated she wished to continue with the care from the Community midwife. 4.2.17 By October 2018 several professionals were trying to engage with Mother, these included midwifery and the Children’s Centre. Mother had failed to attend appointments with the midwife and had declined iron supplementation and influenza immunisation as recommended by her G.P. 4.2.18 In October 2018 Children’s Social Care received an anonymous referral reporting concerns that Mother and children had been seen out in the early hours of the morning and the children were dirty and malnourished. The case was allocated to a Social Worker to complete a single assessment. Contact was made with professionals involved in the family. Mother was seen by a Social Worker and denied the allegations. The children were seen and reported not to be malnourished. 4.2.19 In November 2018 Sibling 2 lost their place at Nursery due to nonattendance. Tracy was born. Home conditions were reported as poor. Mother and Tracy were discharged the following day. 4.2.20 In December 2018 a Health Visitor conducted a home visit and recorded that Mother and three children, were all sharing the same bedroom. A Manager in Children’s Social Care reviewed the single assessment and requested further information in respect of development, weight, height and registration with GP and schools. 4.2.21 In January 2019 Children’s Social Care were still engaged with the family. Concerns had been raised in relation to iron deficiency for Sibling 1. Mother was still presenting as hostile and not co-operating Official Sensitive Government Security Classifications April 2014 12 with Professionals. Mother was reported to not accept health concerns and continued to refuse support. Mum did not attend her post-natal appointment. Tracy was not taken to her 8 week check-up appointment. 4.2.22 Towards the end of January 2019 a Child in Need meeting was held in the family home. Mother was defensive and continued to refuse support. Mother was informed of the expectations of her, and that the case would be progressed to Child Protection if concerns continued. 4.2.23 Sibling 1 attended at the GP for blood tests and was referred to hospital. Sibling 1 was severely anaemic. Concerns were also noted on dental decay and poor diet, a slight heart murmur was also detected. Due to the level of concerns the case was progressed to Child Protection and Child Protection Conference convened. A home visit was undertaken with Mother who did not consider the concerns to be substantiated. 4.2.24 In February 2019 a school placement was identified for Sibling 1. The School made several attempts to meet with Mother to discuss the placement, which was initially refused as Mother stated she wanted Sibling 2 to attend the Nursery at Sibling 1’s school. 4.2.25 By the end of February 2019 Sibling 1 had started to attend school. Sibling 2 was attending a Nursery; this attendance was achieved with the help of Maternal Grandmother. Sibling 1 had visited a dentist and recent blood tests had identified that the child’s iron levels had started to increase. 4.2.25 On 6 March 2019 an Initial Child Protection Conference was held. All three children were placed on a Child Protection Plan at risk of neglect. The plan identified the concerns of domestic abuse, neglect of health, dental needs, education and nursery, concerns about parenting capacity and non engagement of Mother with services. 4.2.26 In March 2019 Tracy was found deceased at home. A criminal investigation commenced. Safeguarding processes were commenced for Sibling 1 and Sibling 2. 5. Analysis. Official Sensitive Government Security Classifications April 2014 13 5.1 The Review Panel identified several Key Lines of Enquiries. These are summarised and used within this section to analyse key themes during the time period of the review. 5.2 Agencies knowledge and responses to domestic abuse. 5.2.1 There were several domestic abuse incidents reported to the Police. These involved incidents between Mother and Father, and incidents involving Mother and her extended family. The children were present during the incidents and reports from the Police stated that the children did not appear to be affected by the nature of the incidents. This observation appears to have been based on the assumption that the children had normalised the adults’ behaviour. Father was arrested on two occasions and charged with criminal offences. He also had a Restraining Order not to contact Mother. 5.2.2 The Police shared details of the incidents with Children’s Social Care and Health Professionals. The Police process of sharing information changed during the timescale of the review and now information is shared quicker and directly with agencies following the investment in technology. Mother was referred to MARAC on three occasions. Services were continually offered to Mother; however, she did not engage with any domestic abuse services. 5.2.3 The Maternity Trust would not have been aware that Mother had been involved in domestic abuse when she attended in May 2018 in relation to the pregnancy with Tracy, as the previous incidents had occurred outside of the agreed timescales for information sharing within the current policy. 5.2.4 The assessments undertaken by Children’s Social Care recognised the risk factors associated with domestic abuse and this was made clear to Mother during the assessment in 2015, should she have resumed her relationship with Father. However; there was a lack of engagement with Father in the completion of these assessments. There are numerous research papers which identify the benefits to engaging with father’s during assessments and child protection work1. 5.2.5 Mother was seen as a protective factor within the assessments, having reported the abuse to the Police and engaged with agencies. However; there was a delay of two weeks in Mother reporting the incident in June 2018, during which Father had returned to live in the family home 1 https://www.communitycare.co.uk/2018/02/19/working-fathers-key-advice-research/ Official Sensitive Government Security Classifications April 2014 14 two weeks, despite being in breach of a civil order and a previous written agreement with Children’s Social Care. The details surrounding Mother’s delay in reporting were not identified during the assessment. 5.2.6 All agencies engaged in the review showed a detailed knowledge and awareness of domestic abuse and the impact on children. 5.3 Agencies responses to identified needs with the family. 5.3.1 The Review Panel found clear evidence that Professionals had identified the family had additional needs and attempted to progress this through the EHAT. This was the correct response to the needs that had been identified. The EHAT was explained to Mother on more than one occasion. Documented information was also given. 5.3.2 During the single assessments undertaken by Children’s Social Care the voice of Sibling 1 and Sibling 2 was captured and documented. Tracy’s voice was identified through observed interaction with Mother. There were no direct recordings of the voice of the child within the health records held by community health services. It is felt that this was possibly due to the young age of the children when they were seen and issues that had been noted around speech development. 5.3.3 There was some good examples of information sharing on the case between Universal services, but this focused on individual incidents rather than a pooling together of all information, including historical information which may have identified the need for earlier intervention. 5.3.4 Mother’s refusal to accept the offers of EHAT and additional services had to be accepted by agencies, as currently there is no policy or process which allows them to refer their concerns when the threshold for statutory intervention has not be reached, and the engagement with Mother should be undertaken with consent. This has been identified as an area of learning 5.3.5 5.3.4 Working with Mothers who are resistant or obstructive is a challenge for all professionals who should always remember the welfare of the child is paramount. To assist Professional information and resources should be available to Professionals to assist them to engage and work with resistant families. 5.4 Was the decision making and thresholds reached on the case appropriate? Official Sensitive Government Security Classifications April 2014 15 5.4.1 In terms of the threshold for Early Help it is clear despite repeated attempts Mother did not engage with Health, Education, Children’s Centre, this included the offers of access to classes and visits from a Link Worker. The difficulty that this created for Professionals is described within 5.6.2. 5.4.2 The single assessments undertaken by Children’s Social Care were appropriate and relevant to the concerns that had been raised. However; there were no specialist assessments and Mother declined services from other agencies which might have led to mental health or drug use assessments. 5.4.3 The pattern of assessments showed the need to take history and referral into account. There was little evidence of agencies coming together to pool assessment information until the Initial Child Protection Conference. 5.4.4 Although domestic abuse was frequently the reason for referral, it may have masked that the children were neglected in terms of universal health and education. Mother refusal to engage and accepted services is documented across all agency’s records. The Graded Care Neglect Profile2 could have been used to assess neglect within the family by agencies at a number of key episodes within the review timescales. However, training on the Graded Care Neglect Profile2 was still in the early stages of being delivered to Professionals during the timescales of this review. 5.4.5 By 2018 the concerns about the family were more serious, there had been the serious assault in June 2018 and an anonymous referral. There were considerable health concerns with anaemia and dental decay, and the continuing non-engagement with Early Help. There was some delay with the single assessment and Child in Need planning towards the end of 2018, and it would have been beneficial for an earlier multiagency meeting to have been held to inform the single assessment and consider the appropriateness of a pre-birth assessment in respect of Tracy. 5.4.6 By the time the threshold for Child Protection had been reached the Review Panel began to see evidence that Mother was starting to engage with Professionals. With hindsight, the Review Panel recognised that Mother’s tactics of brushing away professionals worked for her and masked what was really happening in her life; an earlier more robust approach towards her was required. Unfortunately, this engagement came a short time before the death of Tracy. Official Sensitive Government Security Classifications April 2014 16 5.5 Was the response of agencies to third party, including anonymous, referrals appropriate? 5.5.1 There were delays in the information being reported to Children’s Social Care by third party and anonymous referrers. The Review Panel were informed that it is routine practice for all late referrers to be advised of the necessity to report concerns at the time, either to Children’s Social Care or the Police. 5.5.2 The Review Panel recognised the difficulty that agencies had when responding to anonymous concerns and the ability of prioritising these incidents within an existing workload. Anonymous referrals can provide agencies with useful information, particularly if they are already dealing with concerns, but they are difficult to assess and process when there has been a delaying in reporting and the nature of the concerns are denied when contact is made with the family. 5.5.3 In this case the concerns were raised with Mother, who denied the allegations and made inferences that the referral had been malicious. There was no evidence found to substantiate the concerns that had been raised. 5.5.4 There is evidence that information was shared between the Health Visitor and Social Worker at the time of the allegations were made, a number of concerns were discussed, which were already known to agencies and being addressed. There was no direct reference in relation to any known evidence of malnourishment. 5.5.5 The reluctance of referrers to report concerns at the time is an area of learning identified within the review, including what actions professionals can undertake following reports being made, and how this is communicated to referrers. 5.6 Was escalation on the case undertaken at the right level and pace? 5.6.1 Agencies did identify that Mother and the children would have benefitted from additional support. Several agencies attempted to engage with Mother and offered to provide services within the EHAT. The EHAT was explained to Mother and written information provided, but Mother refused all offers of support. 5.6.2 In order for the EHAT to have been implemented, Mother needed to consent to the process. The Review Panel identified the difficulty that this situation created for professionals, when additional needs had been recognised, but due to a lack of consent the level of concerns did not amount to statutory intervention and escalation; however, the Official Sensitive Government Security Classifications April 2014 17 Panel did identify that a Professionals’ meeting could have been held to share information and concerns. The Review Panel identified this as an area of learning. 5.6.3 In September 2018 a Children’s Social Care manager overrode Mother’s refusal to share information with other agencies. That was an appropriate escalation of concerns. 5.6.4 Six single assessments were undertaken by Children’s Social Care between 2015 – 2019. The first two assessments dealt with the referring issue of domestic abuse. These were closed as the Perpetrator was not in the household. The assessments identified emerging issues of support needs, but Mother declined services. 5.6.5 The third assessment in 2017 was about a single issue which Mother denied. The fourth assessment took place following a serious domestic abuse incident in June 2018. This identified that Mother was having continued contact with Father, which was impacting on the children. Following identification of the issues the case was stepped down to Early Help; however there was no engagement with the plan and this was not escalated back. It was not until an anonymous referral was seen that the case was re-opened to Children’s Social Care in October 2018. 5.6.6 From October 2018 the case was opened for assessment and Child in Need as there had been clear allegations and information of neglect within the family. The Team Manager recognised the need for a fuller assessment in December 2018 and the assessment was updated in 2019 which progressed to an Initial Child Protection Conference. 5.6.7 It was appropriate to undertake a Child in Need plan first, despite Mother having already shown a longstanding reluctance to engage with agencies. The escalation to Child Protection was correct and by the time the case was heard at an Initial Child Protection Conference the health needs of Sibling 1 were starting to improve. 6. Conclusion. 6.1 The Review Panel did not identify any action, or inaction by any professional that was a critical factor in the death of Tracy. Many of the concerns within the review related to the Sibling 1 and Sibling 2, prior to the birth of Tracy. What the review established is that had the case not been progressed to Child Protection then the health and social needs of Tracy would not have been met by Mother. Official Sensitive Government Security Classifications April 2014 18 6.2 Mother was repeatedly offered help and support and it was clear to the Review Panel that Professionals were trying to engage with Mother within an Early Help setting. However; it was only when the case came into Child Protection, in January 2019, that Mother started to engage with professionals, which given the potential consequences at stake for Mother could have been seen by her as her only option. 6.3 The learning from this Serious Case Review does create a challenge for the SCB; in providing Professionals with policies and processes to engage with resistant parents and ensure that the needs of children are being met through Early Help and Universal Services. 6.4 The Review Panel acknowledges that Mother should be provided with an opportunity to contribute to the review, to inform the learning in relation to how agencies engage with resistant families and accessibility to appropriate services. Until this can be progressed the Review Panel recommend that the report is not finalised. This does not prevent the recommendations being progressed. 6.5 The Review Panel was unanimous in believing that the Tracy Serious Case Review should be published in a manner that would make identifying the children and family very difficult. The prime reason was the need to protect the children for public intrusion and identification. 7. Summary of learning and recommendations. 7.1 Resistant Families Learning 7.1.1 The responsibility to initiate an EHAT is that of any Professional who is working with a child and/or family, this is regardless of their role or agency within which they are working. The completion of an EHAT does not rest solely with Children’s Social Care. 7.1.2 Early Helps allows agencies to engage with families as soon as concerns are identified, and to work together in a co-ordinated approach to improve outcomes for children. The implementation of Early Help relies upon consent. 7.1.3 There were several examples within this review when Professionals offered an EHAT to Mother which she refused. This could have provided Professionals with an opportunity to share their concerns, Official Sensitive Government Security Classifications April 2014 19 which may have identified evidence to support escalation of the concerns and override Mother’s consent. 7.1.4 Where there is a refusal to accept Early Help agencies must have a clear understanding of the reason and rationale behind this decision. Agencies working in the field of Early Help have a responsibility to children to ensure that services are accessible to their address their needs without which there would be and adverse impact on their life experiences. 7.1.5 The review highlighted the current lack of support and alternative options available to Professionals when responding to a persistent refusal of services to ensure the needs of children are met at all levels of the threshold of need. Recommendation 1 A pathway for Professionals is produced which details what support, processes and resources are available when engaging with resistant families. Recommendation 2 The SCB ensures that agencies have access to policies which detail how they should respond to refusals to engage, share information and escalate concerns into statutory intervention. 7.2 Responding to third party and anonymous referrals Learning 7.2.1 All members of the public have a duty to report safeguarding concerns to allow for identification and where necessary intervention by agencies. How and when people do this will vary depending on individual circumstances. On occasions the reports are anonymous, for fear of identification and/or reprisals, and can be made sometime after the event that led to the original concerns. These situations create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidenced based approach. 7.2.2 There is a common myth amongst the public that once concerns are raised, Children’s Social Care will respond and undertake safeguarding processes based on that information alone. The complexity and dynamics of Early Help and Safeguarding are not routinely known to the public. In fact, it is fair to say that unless an individual has experience of safeguarding, either professionally or personally, they Official Sensitive Government Security Classifications April 2014 20 would not be expected to know the policy, processes and legislative structure that agencies work within. Recommendation 3 Reviews are carried out of the current process and information on how safeguarding concerns can be raised by the public; including how the expectations of the referrer will be met and communicated. Recommendation 4 The SCB ensure that information is available to the public detailing the importance on the timeliness of reporting concerns, as well as, the outcomes that are available to agencies in response to those concerns. Appendix A Serious Case Reviews 1. Working Together 2015 outlines specific criteria under which a Serious Case Review must always be undertaken by applying Regulation 5 of the LSCB Regulations 2006. For this Serious Case Review Regulation 5(2)(a) and 5(2)(b)(i) applied, that being that the child had died, and abuse or neglect of the child is known or suspected. 2. A Serious Case Review is one where: a) abuse or neglect of a child is known or suspected: and b) either – (i) the Child Has died; or (ii) the Child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the authority and their Board partners on lessons to be learnt’. 3. Working Together 2015 requires that Serious Case Reviews are conducted in such a way which: a) Recognises the complex circumstances in which professionals work together to safeguard children; b) Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Official Sensitive Government Security Classifications April 2014 21 c) Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; d) Is transparent about the way that data is collected and analysed; and e) Makes use of relevant research and case evidence to inform the findings. |
NC049412 | Physical and emotional harm to a 13-year-old girl whilst in care in November 2015. Child MM suffered severe neglect and had acute attachment issues; she came into care at age 7 and her extreme behaviour was identified as needing highly specialised support to aid recovery. She had a stable period in residential care and a placement with foster carers but when this broke down in 2013 she had short placements in residential settings which were unable to safely manage the risks she posed. In November 2015, she had escalating emotional and behavioural difficulties to such an extent that no secure care was available to her; she remained in crisis and required frequent restraints. She was finally placed in tier 4 secure adolescent mental health provision. Findings/lessons learned: the adults tasked with keeping MM safe found they could not do so because systems fail to adequately account for the needs of the most vulnerable children; problems identified are systemic and can only be addressed through system reform which puts the child at the heart of the response. Methodology reflects Social Care of Excellence (SCIE) guidance. Recommendations include: the Department for Education should review commissioning and placement arrangements for secure children's homes to ensure provision is available where a s.25 order has been made; identify multi-agency training and development opportunities to support professionals in learning together about how to maintain a focus upon the needs of the child at times of crisis when inter-agency relationships are most tested.
| Title: Overview report partnership learning review: Child MM. LSCB: Surrey Safeguarding Children Board Author: Ben Byrne Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 Overview report PARTNERSHIP LEARNING REVIEW Child MM Author Ben Byrne Surrey County Council, Head of Early Help and Family Services 2 1. Introduction and background to the review MM is a child in Surrey’s care. At the time of the incidents that are the subject of this review she was thirteen years old. As a result of escalating emotional and behavioural difficulties in the latter half of 2015 she reached a position where no community provision could be identified which could keep her safe and nor was there any secure care available to her. As a result, and despite the efforts of those caring for her, MM experienced emotional and physical harm. This partnership review has been commissioned as a result of a serious case review referral by Surrey Children’s Services to Surrey Safeguarding Children Board. Following advice from the National Panel it was agreed that a local partnership review would be undertaken. This review covers the period between June and November 2015 and focuses in most detail upon the week between 19-25 November when MM came to the most harm and when the system for keeping her safe was most tested. The terms of reference deliberately point the work of the review towards the systems in place and particularly the pathways into secure care for complex and vulnerable children whose needs cannot be met by non-secure community provision. The focus of this review is therefore to identify why care pathways failed to work to protect MM and to make recommendations as a result of this learning to ensure other children are better protected in the future. 2. The questions the review will consider are: What does an examination of the circumstances of this case from mid 2015 tell us about: Planning for the most complex young people where there is a need to restrict their liberty? How well the commissioning of secure placements, be that on criminal, welfare or health grounds, recognises and responds to the complexities and overlapping needs of children and young people whose liberty might need to be restricted? Whether legislation, statutory guidance and local and national policy support the best outcomes for children and young people who present with over-lapping mental health, criminal justice and welfare needs? The need to do things differently both locally and nationally? 3. The review process and methodology This review was commissioned by the Independent Chair of the Surrey Safeguarding Children Board and oversight was provided by a senior stakeholder panel drawn from relevant agencies. The review process reflects the principles set out in Working Together 2015 (DfE 2015) and aims to contribute to learning and improvement through consolidating good practice and identifying where practice could be improved. 3 The methodology for the review reflected Social Care Institute of Excellence (SCIE) guidance and included service specific chronologies, a learning event for practitioners and agency decision-makers including the senior stakeholder panel, and individual interviews with key participants and policy makers. It is good practice to involve the child and family in learning reviews. After discussion with the social work team with responsibility for MM I met with her in March 2017 at the secure forensic mental health facility where she is placed. While the meeting was extremely helpful for me as the report author in bringing together all the things I had been told and read about MM I am not sure she benefitted greatly. MM was anxious and distracted by other events during our meeting (which included her social worker who has an extremely good relationship with her) and with hindsight I don’t think this represented the best approach to capturing the child’s voice in this review. This is something that I will reflect upon for the future and may provide a lesson to others undertaking similar reviews. MM’s social worker has agreed to continue to seek opportunities to support her in learning from and addressing the experiences reflected in this review. MM is on a full care order and I took the view that approaching her family (who were not involved at any point in the period under consideration) to contribute to the review would not have added significantly to the learning. 4. Communication and learning from this review The Board has a well-developed learning and improvement framework and where appropriate the learning from this review will be incorporated into existing training. As much of the focus of the review is upon local and national systems and care pathways much of the work to learn to improve will be at a strategic level. In support of this aim the report will be presented to local, regional and national stakeholders and feed into work to address the care pathways for complex and vulnerable children and young people. The action plan stemming from this review will be monitored by the Board. 5. MM background information and overview MM was born in Surrey in 2002, the fourth oldest child in a family who have had an extensive history of involvement with Surrey Children’s Services. She is now one of ten children. MM was accommodated in 2009 following previous periods on child in need and child protection plans. A full care order was made in 2011. MM had suffered severe neglect and has been identified as having acute attachment issues. When she came into care at seven years of age her extreme behaviour already identified her as a child who would need highly specialist support to aid her recovery. She did have a therapeutic educational placement and a relatively stable and successful period in residential care followed by a placement with committed foster carers. When this broke down in 2013 she was placed in a series of out of county residential settings which were typically short-lived because of behavioural management issues and an ability to safely manage the risks she posed to herself and others. What is evident in MM’s care trajectory is that there was careful planning 4 to attempt to meet her needs but as these needs escalated over the two years prior to November 2015 the placement options became ever more limited. In the months before November 2015 Children’s Services’ attempts to place MM became increasingly desperate and rather than a process of careful matching of placement to need (as she had experienced when younger) it was much more a case of who was willing to take her. Ultimately in November 2015 no one was willing to have MM and Surrey Children’s Services were left to manage a child in a crisis with no access to any recognised placement. For a week MM’s placement consisted of a police cell, a bed and breakfast hotel, a paediatric ward and a put-me-up bed in a family centre; for much of this time she remained in crisis and required frequent restraints and up to six social care and police staff managing her at any one time. Ultimately after two days in the family centre a Mental Health Act assessment was undertaken and determined that she met the grounds for s.2 secure assessment. An arrangement was reached with a Surrey Mental Health Trust to open an un-used s136 suite, which was an adjunct to an adult ward and MM was transferred to this accommodation, which while far from ideal was at least safe and offered appropriate medical care. After a day in the s.136 suite an NHS tier 4 adolescent provider assessed MM and offered her a placement. She has been in tier 4 secure adolescent mental health provision since then. The overwhelming view of those involved in MM’s care, as expressed in the original serious case review referral, the learning event and in subsequent interviews, is that MM’s treatment was inhumane, degrading, and distressing and placed her and others at an intolerable level of risk. Staff from a range of agencies held MM (literally in many cases) through this period of acute crisis and demonstrated a huge commitment to her care, often at their own physical and emotional cost. The abiding feelings expressed are those of frustration, anger and impotence at an inability to enable MM to access the care and treatment she required. 6. Summary of events from June 2015 The following is a brief summary of events which provides the background to the analysis to enable connections to be made between these events and the learning arising from the review. By February 2015 MM was resident with a residential care unit in Kent. Remaining here until September 2015 represents an unusual degree of continuity for MM in the period following the break-down of her foster care placement in 2013. Nonetheless it is evident from the chronology provided by the residential care unit that this placement was always fragile and MM’s behaviour was extremely difficult to manage. By June 2015 MM’s behaviour had deteriorated to the point where she was being physically restrained on most days. In the final days of her placement in Kent there were a number of serious incidents which culminated in MM being taken into police protection having twice been found on the side of the M20 motorway. MM was moved to a placement in Nottinghamshire which provided 2:1 staff to child care in a solo placement but this lasted less than two weeks before MM was moved to Peterborough in a unit offering similarly intensive support. This lasted less than a week when MM was again taken into police protection having climbed on to a roof having threatened to 5 kill herself. A further non-secure placement was identified but this lasted only one day when MM again climbed on to a roof. At this point MM was detained under the Mental Health Act for assessment. MM was admitted to an adolescent psychiatric intensive care unit (PICU), within a mental health hospital in the North West of England under section 2 of the Mental Health Act on the 2nd October 2015. During her time there she was secluded on several occasions due to her aggressive behaviour and staff assessing her to be a risk to herself and others. Prior to her admission to hospital Children’s Services had experienced significant difficulties in identifying a placement for her which would be able to manage her behaviour safely. Children’s Services placement team reported on the 22nd September that they had unsuccessfully approached over 150 residential providers across the whole of the UK. MM appealed her section and a tribunal was held on 14 October 2015. Her responsible doctor at the PICU reported that MM did not have a mental health disorder and the appeal was successful. It was agreed during the tribunal that a planned move needed to be supported, however, the social worker described being put under considerable pressure to take MM with her immediately despite there being no placement for her. It was later agreed that the PICU would keep MM for a maximum of the 28 days (from admission) to enable Children’s Services to identify an alternative placement. Children’s Services attended court on 16 October and an Interim Secure Order was granted. This Order was further extended on 13 November. Children’s Services had already unsuccessfully looked for a secure bed on previous occasions with authorisation from the Assistant Director on 29 September and 14 October. No secure units were willing to accept MM as they either considered her to be too high risk or that she would not be suitable given their current mix of children in placement. After an increasingly desperate search for a placement it was agreed to move her to a residential placement (not secure) on 28 October again with the same residential care unit in Kent, with the agreement that she would be the only child in placement. The placement gave notice on 13 November following repeated violent incidents. Initially they wanted MM to be moved within a few days but after some discussions agreed to keep her for a week. On the 19th November there was an incident at the placement where MM became aggressive to staff, she also swallowed stones and pieces of pottery and was taken to hospital. The placement stated that MM could not return to placement from hospital and she was then taken from the hospital to a police cell. MM remained in a police station in Lincolnshire until 21 November. There were still no placements willing to accept her (general or secure) and it was agreed that she would return to Surrey and be placed at a bed and breakfast hotel cared for by 4 residential workers. MM assaulted the staff (breaking a worker’s nose) and absconded, later being found by police on a tramline. MM was taken to Surrey hospital 1 where a further mental health assessment was completed which concluded that there was no identifiable mental health disorder that warranted secure section under MHA. MM remained in a room on the paediatric ward of the hospital overnight with support of additional staff and police. MM had to be repeatedly restrained by police and Children’s Service staff during her time in hospital 1. She did 6 receive sedative medication in the early hours of the morning of 22 November but she had been in hospital for a significant period before this was made available. On 22 November it was clear that she could not stay in the hospital as her behaviour posed a risk to other children on the ward and so it was agreed for MM to move to a family centre (this is an office base and has no residential provision) to be cared for by social work staff. On the 24 November a Mental Health Act assessment was completed and MM was placed on a S.2, initially being moved to the un-used s.136 suite at Surrey hospital 2 and then being assessed and moved to a Norfolk hospital on the 26 November. After a period of assessment at this secure learning disability unit MM was transferred to an adolescent forensic unit where (as of February 2016) she remains. 7. Messages from the learning event Fifteen professionals who had either had direct personal involvement with MM during the period under review or had been involved in decision-making about her were invited to come together in December 2015 to share their experiences to identify learning for this review. Here key reflections are included to inform the subsequent analysis and to bring to life the thoughts and feelings of those who were involved with MM’s care during this period. What was MM like when not in crisis? “A very likeable child, big for her age, but very young emotionally.” “A bubbly, lovely, young woman, quick to want to build relationships… I enjoyed her company.” What are your reflections on the way we responded to MM? “Effectively the local authority had a secure accommodation order but could not implement it. So even though professionals worked very hard the systems are preventing them keeping children safe.” “As employers we have a duty of care to staff and attacks were severe. We weren’t able to keep staff safe or MM.” “There was enormous pressure on the social worker to take MM with her when the secure mental health placement was terminated, which was totally unfair and would have been unsafe for her to do so.” “Enhanced provision is the answer. When MM was in the PICU Hospital in she was contained and safe. However, enhanced provision is only available under s.2 [Mental Health Act] so after that we weren’t able to meet her needs.” “Welfare secure units would not be able to manage her so it wasn’t surprising that they refused to take her.” 7 What are your reflections on inter-agency working for MM in this period? “Professionals did not step out of their rigid legal framework to think what could have been done differently.” “There were issues about professionals not identifying the child’s needs. A lot of discussion about not meeting thresholds /criteria but not much about what her actual needs were.” “Everyone was wanting police to use s.136 but MM was in a hospital and then a family centre and we did not have the powers to use s.136 in those places. If she was sectionable she was in hospital and medical staff were the ones to make that judgement not police.” “We make assumptions that other professionals already understand our point of view. You learn a lot when you get to hear what was guiding other professionals’ decision-making.” What did you learn from MM’s experience? “In the residential care unit in Kent we now have a mental health nurse on site when we work with these children.” “Children’s Services now have the Extended Hope Service so we can be more effective with crisis/out of hours work. We also have mental health nurse input for residential placements.” “For me what made the difference was escalation and the fact that the crisis was in Surrey and MM was a Surrey child so ultimately it made a difference that we had the local connections we could use.” “MM is now in a medium secure unit under s.3 but she will never fit one single category.” What recommendations would you make following MM’s experience? “A recommendation for this case would be around understanding the role of other professionals besides our own.” “For me it is about escalation – leverage for the local authority to get a bed when we need it.” “Placements locally and not out of county for children with such complex needs.” “DfE and NHS England need to be able to exert more pressure on secure units to take children.” “Escalation (local and national) at earlier stage.” “Better systems and escalation when out of hours.” 8. Analysis This analysis draws on the original SCR referral, the integrated chronology, the learning event, the serious and untoward incident report (from the Surrey Mental Health Trust) and 8 individual interviews with key participants. Additional research and interviews have been undertaken in relation to the care and placement of complex and vulnerable children such as MM. The analysis follows the structure and key questions from the terms of reference for this review. What does an examination of the circumstances of this case from mid-2015 tell us about: How well we plan for the most complex young people where there is a need to restrict their liberty? Restricting a child’s liberty can result from decisions of a criminal court, a family court or as a result of a Mental Health Act assessment by a psychiatrist and approved mental health social worker (decisions which are subject to review and ratification by a mental health tribunal). MM first had her liberty restricted following a Mental Health Act assessment on 2 October 2015 with the decision that she met the grounds to be sectioned under s.2 MHA for assessment in a PICU environment. MM successfully appealed this decision on 14 October although she remained ‘voluntarily’ within the same environment for a further two weeks while an alternative placement was sought. In the course of this search for a placement the local authority successfully applied to a family court for a secure welfare order under s.25 (Children Act 1989). In order to make such an order the court needs to be convinced that a child is likely to experience significant harm or cause such harm to someone else without the provision of secure accommodation. From the point the s.25 order was obtained the focus shifted away from the mental health pathway to seeking a placement within one of the country’s secure children’s homes. No secure unit would offer a placement to MM, despite there being beds available, citing variously the risk she posed and her unsuitability based upon the existing children in placement. Department for Education and NHS England senior officials were engaged in the attempt to access a bed for MM but as every secure children’s home is locally commissioned and locally managed each is at liberty to decline any referral. A further complication was that having obtained a secure order this effectively dis-barred MM from any non-secure placements. Providers understandably shied away from the risk MM represented following the court’s determination that she should be in a secure environment and many said their insurance would not cover such a placement. In this respect the local authority was in a double-bind: no secure unit would have MM and having obtained a s.25 order no non-secure placement would take her. Ultimately on the basis of having previously known MM the residential care unit in Kent offered her a non-secure placement, “against our better judgement”, which was short-lived. In this case it is clear that the s.25 order, while formally recognising the level of risk MM posed to herself and others, was of no use in providing a means of managing this risk. In enacting s.25 Children Act 1989 it was clearly the will of parliament to provide the courts (and local authorities) with a mechanism for protecting children and the public. MM’s experience and that of those caring for her demonstrates that when it is most needed the provision to discharge the duties under s.25 cannot be reliably accessed. This appears to be in contravention of parliament’s intention in enacting s.25. 9 The recent review of secure children’s homes for the Department of Education (Hart, La Valle 2016) recognised the need to review s.25 Children Act as its use appears to differ significantly between authorities and where a child is placed in secure under s.25 its provisions are unhelpfully inflexible. The authors argue this runs counter to the therapeutic interests of children and aspirations for successful community reintegration. In addition the Minster for State has committed to reviewing the functioning of secure children’s homes in England, including their interface with other secure provision (DfE 2016) Recommendation (1): The Department for Education should review commissioning and placement arrangements for secure children’s homes to ensure that provision is available where an s.25 order has been made How well does the commissioning of secure placements, be that on criminal, welfare or health grounds, recognise and respond to the complexities and overlapping needs of children and young people whose liberty might need to be restricted? The commissioning of health, welfare and justice secure placements are relatively discrete activities. NHS England Specialist Commissioning is responsible for commissioning mental health secure beds, local authorities commission secure welfare beds and the Youth Justice Board commissions children’s criminal justice secure placements. The only place where secure placements have any integration is in the secure children’s homes which include placements commissioned by both the Youth Justice Board and local authorities and admit children from both criminal and family courts. Ordinarily mental health secure placements admit only children who have been assessed as meeting the MHA criteria for detention and the rest of the youth justice secure estate is reserved for those meeting the criminal grounds for detention. The relationship with NHS England was described by practitioners with responsibility for finding a secure placement for MM as distant and lacking in responsiveness to deal with escalating crisis of the type MM experienced. Local practitioners felt support was lacking out of hours and particularly over the critical weekend of 21-22 November. For their part NHS England recognise that there have been bed capacity issues which have impacted upon their ability to support local areas to access placements but believe that these pressures have eased somewhat since 2015. As with secure children’s homes it is individual mental health units who determine who they take and there is no national authority to direct placement decisions. In this respect local practitioners may have unrealistic expectations as to what NHS England can do on their behalf. NHS England commissioners recognise that more localised commissioning arrangements which involve clinical commissioning groups and local authorities would be likely to be more responsive to local need and work is underway to achieve this. During the period this review is considering there were no national arrangements for managing referrals to secure children’s homes in England. This meant that Surrey Children’s Services placements team had to repeatedly approach each unit during the weeks when they were searching for a secure welfare bed. A striking feature of the Children’s Service chronology is the time and energy spent referring to both secure and non-secure placements. The development of a national referral hub (hosted by Hampshire County Council) is therefore seen as a welcome development. While this does not alleviate the 10 capacity issues in relation to secure welfare placements it does at least streamline the system. This development may also assist in speeding up decisions in regard to secure placements as another feature of MM’s experience was that hopeful placement leads, which ultimately proved un-fruitful, meant she remained in inappropriate environments longer than she might otherwise and delayed decisive action on the part of those caring for her. It is of note that in the search for a secure bed for MM the Youth Justice Board made available beds in secure units which are normally reserved for children meeting the criminal threshold for detention. Despite this unusual move it did not mean MM was able to access one of these beds as discretion still remained with the individual units to decide whether to accept her. There is no doubt that from September 2015 (at the latest) MM’s needs and risks were such that she warranted a secure placement. It is also evident that because of a lack of mental health diagnosis and uncertainty in relation to her formulation – her specific needs and the best way to respond to these – the available pathways did not work for her. MM clearly has significant emotional and mental health concerns despite the fact at the time under review these had not led to a specific mental health diagnosis. In fact after over a year in a secure psychiatric environment MM still does not have any specifically diagnosed mental disorder. Without a diagnosis MM’s behaviour, as severe and dangerous as it was, did not afford her admittance to a secure mental health bed. The same behaviour has, nonetheless, meant she has been detained in a secure mental health setting since November 2015. It is worth considering why MM did not meet the threshold for detention through a criminal justice route. This is largely as a result of a framing of her behaviour as a reflection of her health and welfare needs rather than as criminal. MM has been arrested on many occasions (since the age of ten) as a result of violent behaviour both in the community and within her various placements. On almost all occasions charges were not pursued or prosecutions discontinued and as a result she has a limited history of convictions. In 2015 alone multiple charges were dropped as ‘not in the public interest’ as a result of submissions to the Crown Prosecution Service by the local authority. In this respect the local authority can be seen as being at the front edge of good practice in relation to the de-criminalisation of children in care (and was acknowledged as such by Lord Laming’s review into the subject) but ironically for MM this closed off one of the routes into secure care for her. At another time or in another place (particularly if she were an older boy with the same history and presentation) MM’s behaviour would very likely have led to her detention through a youth justice route. While it is not suggested that being secured on criminal grounds would have been the right response for MM the changing policy context is an important backdrop to this review. The move away from custodial responses has been a feature of recent youth justice history; the number of children in custody has fallen by more than two-thirds over the last decade from a peak of around 3000 to less than 1000 at any one time in 2016. Within a local and national context this means more complex and vulnerable children either being managed in the community (often in the type of fragile arrangements we have seen with MM) or vying for entry to a secure welfare or mental health bed. It does not appear that the commissioning of either secure or non-secure alternatives for these children has kept pace with the changing policy and practice context. 11 Recommendation (2) NHS England should work with CCGs and local authorities to develop joint commissioning arrangements which are more responsive to local need and better integrate tier 3 and 4 CAMHS provision. Recommendation (3) NHS England should consider how access to mental health secure provision can be improved and what arrangements can be made to assure local services that such provision will be made available in a timely way when children are in crisis. Does legislation, statutory guidance and local and national policy support the best outcomes for children and young people who present with over-lapping mental health, criminal justice and welfare needs? “Children whose needs have not been adequately met see the world as comfortless and unpredictable and they respond by either shrinking from it or doing battle with it.” Bowlby (1973) Attachment and Loss Vol. 2 It has been recognised in recent national reviews of children’s mental health services (Future in Mind 2015), justice (Taylor 2016) and care (Laming 2016, Narey 2016, Hart and La Valle 2016) that legislation, guidance and policy have un-helpfully separated children’s needs into what have become overly siloed pathways. Those who reach the apex of the mental health, justice and welfare systems have typically suffered adverse childhood experiences, which are compounded by further social and environmental stressors, leaving these children uniquely vulnerable. The following extract in relation to children requiring secure forensic care could equally apply to the majority of those who are secured on welfare or justice grounds: “their social backgrounds are often characterised by socio-economic deprivation, multiple losses and traumas, adverse life events, family discord, poor scholastic achievements, learning difficulties, substance misuse and criminality. In addition some young people are involved with multiple agencies in complex legislative frameworks.” (2013/14 NHS Standard contract for secure mental health service for young people) This description would encompass MM’s childhood experiences and “complex legislative frameworks” are certainly a feature of this case review and something those with responsibility for her care struggled to negotiate. Despite the commonality of experience between these children our responses to them can vary markedly. Depending on the pathway a child is on, and sometimes depending on the presentation and behaviour on a given day, a child with acute emotional and behavioural difficulties may find themselves subject to greatly differing regimes and types of care between the differing settings. The three pathways can be characterised as having a dominant ethos of either treatment (health), care (welfare) or control (justice). For many children and young people (Khan 2016, Little 2015) and many professionals (Children’s Commissioner 2015) this response is arbitrary and reflects organisational and system needs rather than those of children. 12 Underpinning the escalating crisis in caring for MM was a dispute as to whether she had a mental health disorder requiring treatment or behavioural disorder requiring the right type of care. This disputed territory is recognised in the recent DfE review of secure proviosion; There appears to be a particular gap in services for children with attachment, conduct, emerging personality or post-traumatic stress disorders, with these children falling between social care and health provision (Hart and La Valle 2016) Clearly MM did have significant emotional and mental health problems (if not a diagnosable disorder) as part of a range of social and behavioural needs and challenges. Responses to MM appear to have been overly binary, concerned with specific pathways to which professionals aligned themselves, working overly rigidly within governing legislative and practice frameworks. A number of practitioners commented in the course of this review that MM’s needs got lost in the dispute between who should have primary responsibility for her care. As a result by the week of 19 November she had fallen between a care system which had run out of options to meet her needs and a mental health system which was unable (in both legal and practical terms) to accept responsibility for her. MM’s experiences are far from unique. NHS England report similarly distressing cases occurring with relative frequency where children cannot be placed. Often it is police cells or adult mental health units which have to hold on to children while those with responsibility for their care desperately seek a better alternative. For MM professionals still fear that when she is discharged from her current section a new crisis will again see them fire-fighting in the face of minimal placement options. These concerns have been shared with senior health and children’s services managers and there is a commitment to retain close senior oversight of MM’s discharge and subsequent placements to ensure there is no repeat of the crisis which engulfed her and the people working with her in November 2015. Recommendation (4) NHS England, DoH, DfE, MoJ should commit to integrated responses to complex and vulnerable children which recognise their common experiences and seek to draw together services and care pathways. What do we need to do differently both locally and nationally? “The provision of mental health support should not be based solely on clinical diagnosis but on the presenting needs of the child or young person and the level of professional or family concern” Future in Mind (Department of Health 2015) Many of the systemic issues which are reflected in the crisis which unfolded for MM are articulated in Future in Mind, the report of the government’s Children and Young People’s Mental Health and Well-Being Task Force. Critically in considering care for the most vulnerable Future in Mind recognises that children who have had the most adverse childhood experiences will have varying degrees of emotional disturbance, which may or may not be identifiable through a specific mental health diagnosis. These children will often be in our care system, will frequently have special educational needs and may also appear in the youth justice system. Rather than being solely the responsibility of a commissioner / 13 provider of education, care, youth justice, or health services the requirement for our pathways for these children is to integrate services in order to join up around them. Nationally Future in Mind has contributed to the NHS’s Five Year Forward View for Mental Health within which sits the Children and Young People’s Mental Health Transformation Programme. This programme has three key workstreams all of which are relevant to this review. The first workstream is reform of the environments in which children are detained in order to equip staff with the skills and knowledge to provide psychologically informed and trauma aware care as a whole staff group within secure settings. Secondly regional forensic CAMHS teams are being rolled out to provide specialist support to professionals managing the most complex and vulnerable children who are on the cusp of secure care. Thirdly commissioning for secure care is being reviewed with partners to deliver more local joint commissioning arrangements. Future in Mind has also led to a requirement for each local authority area to produce a CAMHS whole system transformation plan and the DoH has identified dedicated resources to improve local services. Surrey’s local transformation plan identifies crisis care and inpatient commissioning as two of its priorities. Since the period looked at by this review crisis care in Surrey has been enhanced by the development of the Extended Hope Service. Established in 2016 Extended Hope provides intensive outreach and respite residential care for children at the top of CAMHS tier 3 services who are at risk of requiring tier 4 in-patient provision. This out of hours provision builds upon and integrates with the existing Hope day service. Extended Hope would usefully have added to the resources available to support MM once she had returned to Surrey in November 2015. It should, however, be noted that Extended Hope’s respite residential provision is specifically for those who should be diverted from a tier 4 setting it is not intended to take the place of that provision for those for whom it is appropriate. Clearly MM fell into the second category. The potential for local commissioning and greater integration of CAMHS tier 3 and 4 services offers the opportunity to build upon the Extended Hope developments, providing more holistic options for those with over-lapping mental health, education, and behavioural (including offending) needs. This would offer new opportunities to consider both how children in crisis could be better supported in local settings (not in a bed and breakfast or police station) and to develop local tier 4 provision, ideally in conjunction with neighbouring local authority areas. Recommendation (5) Commissioners of Surrey’s CAMHS and looked after children’s placements should work with NHS England to further develop crisis and specialist care provision in Surrey, which better meets the needs of children who require specialist placements and provides for both health and welfare needs. There are opportunities to improve Surrey’s responses to children such as MM exhibiting behavioural dis-regulation through the developing behavioural, emotional and neuro-developmental (BEN) pathway, which is a key innovation in the new CAMHS contract. This approach seeks to respond in a more holistic way to children’s needs without requiring mental health labels to access appropriate support. One example of this attempt to promote greater integration, earlier identification and intervention, and crisis support is through the development of mental health ‘safe havens’. Surrey’s first Haven for under-18’s is opening in Spring 2017 offering mental health support within a youth centre environment, with services provided by mental health practitioners and youth workers. The Haven integrates with Surrey’s existing CAMHS, Extended Hope and young people’s / youth justice services 14 with a view to providing the holistic, non-stigmatising support which children and young people have said they want. This provision has the potential to provide a platform for better crisis care and joined up support for the most complex and vulnerable young people in the future. As Future in Mind identified, and has been explored by the Social Research Unit’s participatory research with young people facing multiple disadvantage, such integrated approaches are sorely needed for this cohort of children and young people, Those with multiple needs struggle to navigate systems designed for education, mental health, social care or youth justice. A proportion rapidly drop out of view without receiving any assessment. Many fall between the cracks of the multiple referral pathways. Others bounce between systems for many years before support rapidly evaporates at the boundary of adulthood. (Little 2015) Drawing together support which can hold on to children and young people who will in Bowlby’s words either “shrink from the world…or do battle with it” is the central challenge to services which seek to effectively support children like MM. The local / national debate played out around the commissioning of secure placements and the integration of tier 3 and 4 CAMHS services has parallels and indeed interdependencies with the debates around care placements for the most complex children in local authority care. Typically for children such as MM who escalate through fostering and in-house residential options the answer has to be found in specialist out of county placements. As described previously the more challenging the needs of the child the more difficult it is to place them and ultimately this can mean poorly matched placements or no placement at all and the child being escorted back to Surrey. While it is recognised that not every child’s needs can be met in-county and there will always be times when out of county is appropriate, there are reasons to focus upon developing local provision. In ordinary times when a child is out of county it can be difficult to access the range services they require (health, justice, education etc) from a range of unfamiliar providers; in a crisis these negotiations become more fraught. As difficult as the situation was when MM returned to Surrey after 19 November it was ultimately local leverage and access to local services that led to the resolution of the crisis. Recommendation (6) Surrey County Council and Surrey CCGs with local health providers should develop provision for emergency care for children unable to access a secure mental health or welfare setting. Recommendation (7) Surrey County Council and Surrey CCGs should work with national commissioners and neighbouring authorities to develop local provision for complex and vulnerable children who would ordinarily meet the threshold for secure provision (health, welfare or justice). This provision should be integrated with tier 3 community provision and provide both secure requirements and non-secure. Importantly consideration of the development of local placements and supporting services for complex and vulnerable children should not be left to any one agency but should be jointly developed with national commissioners (NHS England, DfE, DoH, MoJ) and local partners led by CCGs and the Surrey County Council. Thus far decisions regarding commissioning and development of provision appear to take place within single government and local agencies, as MM’s experience illustrates this is greatly to the detriment of children. 15 As described above it was when MM returned to Surrey that the crisis in her care was finally resolved. Professionals involved with her care believe this local resolution could have happened sooner and that the decision to open the Surrey Hosptial 2 s.136 suite could have been taken on 19 November rather than MM having to endure five days effectively without a placement. Two conclusions were drawn by many of those involved in the course of these days; firstly that the child’s needs were obscured by overly rigid adherence to professional codes and guidance and secondly there should have been a better escalation process to the most senior officers in the health, local authority and police services in Surrey. Firstly, to the view that in the eye of the storm practitioners fell back upon rigid professional practice and policy frameworks which lost sight of the child’s needs. MM needed to be in a safe place but practice in relation to s.136 was such that police did not feel authorised to use this power. Similarly facilities existed in Surrey and were ultimately used to provide a place of safety (in adult provision) but this was contrary to NICE guidance and does not appear to have been considered until 24 November. A further example is the reliance upon mental health diagnostic criteria which distanced mental health services from responsibility for MM’s ‘behavioural’ problems. All these reflect understandable but ultimately unhelpful approaches and decision-making in the face of a child in crisis. Subsequent review by Surrey Police has confirmed the decision not to use s.136 powers but has also highlighted the police’s willingness to assist in moving MM to an alternative place of safety had they been asked or one been made available. In relation to the escalation procedures MM’s circumstances were well known to the Children’s Services Assistant Director and she was actively involved in seeking a resolution. It is not known how much involvement there was by the most senior officers in the County Council. It is also unclear how much senior decision-makers were involved in the other key agencies, although the mental health trust (who admitted MM to the s.136 suite attached to the adult ward) said that their senior management were not consulted until 24 November. When consulted they quickly made the resource available in spite of the knowledge that in doing so they would have to account for this as a ‘serious and untoward incident’. For circumstances as serious as MM’s it would appear appropriate to ensure that an inter-agency escalation protocol exists to provide the level of senior input that can bring resources and authority to bear to more quickly resolve crises. Recommendation (8) Surrey Police, health and county council chief officers should agree an inter-agency children’s escalation protocol where they or officers directly authorised on their behalf should be informed and make decisions in relation to the most serious cases. Recommendation (9) Surrey Safeguarding Children’s Board should identify multi-agency training and development opportunities to support professionals in learning together about maintaining a focus upon the needs of the child at times of crisis when inter-agency relationships are most tested. Recommendations (10) The findings of this review should feed into Surrey’s CAMHS transformation plan and the Children and Young People’s joint commissioning strategy. This review should also be shared with NHS England, Department for Education, Department of Health, the Youth Justice Board and Ministry of Justice. 16 9. Concluding remarks This review has not levelled criticism at any professional or agency. Individuals made heroic attempts to care for MM and promote her safety. That said collectively the adults tasked with keeping MM safe found they could not do so as they were hamstrung by systems which fail to adequately account for the needs of our most complex and vulnerable children. The problems identified are systemic and can only be addressed through system reform guided by a genuine desire to see the child, without needing to label or require a definitive diagnosis, and put their needs at the heart of a transformed response. 10. Recommendations (1) The Department for Education should review commissioning and placement arrangements for secure children’s homes to ensure that provision is available where a s.25 order has been made. (2) NHS England should work with CCGs and local authorities to develop joint commissioning arrangements which are more responsive to local need and better integrate tier 3 and 4 CAMHS provision. (3) NHS England should consider how access to mental health secure provision can be improved and what arrangements can be made to assure local services that such provision will be made available in a timely way when children are in crisis. (4) NHS England, DoH, DfE, MoJ should commit to integrated responses to complex and vulnerable children which recognise their common experiences and seek to draw together services and care pathways. (5) Commissioners of CAMHS and looked after children’s placements should work with NHS England to further develop crisis and specialist care provision in- local authorities, which better meets the needs of children who require specialist placements and provides for both health and welfare needs. (6) The local authority and CCGs with local health providers should develop provision for emergency care for children unable to access a secure mental health or welfare setting. (7) The local authority and CCGs should work with national commissioners and neighbouring authorities to develop local provision for complex and vulnerable children who would ordinarily meet the threshold for secure provision (health, welfare or justice). This provision should be integrated with tier 3 community provision and provide both secure requirements and non-secure. (8) Police, health and local authority chief officers should agree an inter-agency children’s escalation protocol where they or officers directly authorised on their behalf should be informed and make decisions in relation to the most serious cases. (9) Safeguarding Children’s Board should identify multi-agency training and development opportunities to support professionals in learning together about how to maintain a focus 17 upon the needs of the child at times of crisis when inter-agency relationships are most tested. (10) The findings of this review should feed into CAMHS transformation plan and the Children and Young People’s joint commissioning strategy. This review should also be shared with NHS England, Department for Education, Department of Health, the Youth Justice Board and Ministry of Justice. 18 References Bairstow, S., Fish, Sheila., Munro, E., (2012) Learning Together to safeguarding Children: a ‘systems’ model for case reviews. Social Care Institute for Excellence (SCIE), London Bowlby (1973) Attachment and Loss Vol. 2. Basic Books, USA. Department for Education, (2016) Edward Timpson – Secure Children’s home reform Department for Education. (2015): Working together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. DFE, London Department of Health (2015) Future in Mind – promoting, protecting and improving our children and young peoples mental health and wellbeing. London Hart, D., Ivana La Valle, I.,(2016) Local authority use of secure placements research report, DfE, London Khan, L., (2016) ‘Missed opportunities: a review of recent evidence into children and young people's mental health’. London, Centre for Mental Health Laming, L., (2016) In Care, out of trouble, Prison Reform Trust, London Little, M., Sandu, R., Truedale, B., (2015) ‘Bringing everything I am into one place’ Totnes, Dartington Narey, M., (2016) Children’s residential care in England. Department for Education, London NHS (2014) 2013/14 NHS Standard contract for secure forensic mental health service for young people Taylor, C., (2016) Review of the Youth Justice System in England and Wales. Ministry of Justice, London. |
NC043732 | Suicide of an adolescent boy in October 2012. David A had a history of suicide ideation and self-harm, thought by professionals to be largely related to parental conflict. In 2009 David A became the subject of a child protection plan under the category of neglect and his sister became categorised as a child in need. David A and his father were arrested for possessing chemicals used in explosives but no prosecutions were made. Family were known to a range of agencies and received a large number of services, including: child and adolescent mental health services (CAMHS), school counselling, family therapy, couple counselling, alcohol support services, parenting education, young carer support services and young offender support services. Issues identified include: focus of work on parents' relationship at the exclusion of work with David A; provision of services on a basis of availability rather than as part of a planned, coordinated approach; failure to understand the impact of mother's alcohol misuse on the children's wellbeing; and child protection meetings held in office hours inhibiting father's ability to participate. Makes recommendations, including: need for flexibility in arranging child protection meetings to support the involvement of working parents and other relevant professionals.
| Title: Serious case review: overview report in respect of David A. LSCB: Bath and North East Somerset Local Safeguarding Children Board Author: Barry Raynes Date of publication: 2013 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 | P a g e Serious case review overview report in respect of David A Barry Raynes Chief Executive Reconstruct September 2013 Bath and North East Somerset Local Safeguarding Children Board 2 | P a g e CONTENTS Introduction Page 3 Terms of reference Page 3 Summary Page 4 Race, religion, language and culture Page 5 Methodology Page 6 Independence Page 6 Panel Page 6 Parallel processes Page 7 Dissemination of learning Page 7 Timescales Page 7 Individual management reviews Page 7 Expert guidance Page 8 Narrative of events Page 9 Year 7 Page 9 Year 8 Page 9 Year 9 Page 11 Year 10 Page 12 Year 11 Page 13 Year 12 Page 15 Analysis Page 16 National context Page 16 Assessments and analysis of risk Page 17 Working with parents Page 26 Working with David A Page 29 Conclusion Page 31 Lessons learned Page 34 Recommendations Page 36 References Page 39 Appendices Page 40 3 | P a g e 1. INTRODUCTION 1.1 When children die or are harmed whilst in contact with child care agencies, the Local Safeguarding Children Board (LSCB) (a committee made up of senior representatives from health, police, social care etc.) has the responsibility to investigate the circumstances in order that any learning for professionals can be identified and acted upon. This is called a serious case review. The overview report is a summary of that serious case review. 1.2 The chair of Bath and North East Somerset’ Safeguarding Children Board, Jim Gould, agreed that a serious case review should be convened, following the death of a young person who this report calls David A. The serious case review was conducted in accordance with government guidance Working Together1 (2010). The review happened between November 2012 and July 2013. 1.3 A serious case review involves a series of meetings between independent people and senior representatives from all of the services, including voluntary agencies, who work with children. The independent people do not have working links with the local area or agencies. The result is a series of single agency reports called individual management reviews, (IMRs) a health overview report, and this report. 1.4 The whole process was overseen by a panel of senior managers, called a serious case review panel, who scrutinised and discussed all of the IMRs, ensuring that each author had thoroughly examined the role of their agency and identified where lessons could be learned and things done differently in future. The panel was chaired by another independent person Dr. Louise Goll. This report was written by Barry Raynes who is the chief executive of Reconstruct, a company which provides services to child care agencies, families and children. This report will be published on the LSCB web-site and sent to the Department for Education. 1.5 Each agency identified a senior manager, who was not involved with the family or with the management of the case, who wrote an IMR about their agency’s involvement. 1.6 The family have been involved throughout this serious case review. David A’s parents and sister were seen twice each and have contributed questions and suggestions which have informed the review. 1.7 During the course of this review, revised guidance: ‘Working Together to Safeguard Children (2013)’ has been published, which states that a Serious Case Review (SCR) ‘should result in a report which is published and readily accessible on the LSCB's website for a minimum of 12 months. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.’ This report has therefore been prepared with a view to publication in line with that requirement. Terms of reference 1.8 Terms of reference were drawn up and are included in their entirety in appendix one of this report. 1 Government guidance relating to child protection 4 | P a g e 1.9 The terms of reference included the following key questions for the individual management reviews (reports provided by each individual agency regarding their involvement with the family): 1. Were David A and his family offered appropriate services to help meet their needs throughout the time period? 2. Was information clearly and appropriately shared between organisations? 3. Was there appropriate shared assessment of the level of risk between relevant agencies throughout the time period? 4. Were actions taken by individual agencies appropriate to address the assessed risks? 5. Was there a well-informed, robust multi-agency assessment of the risks of significant harm that informed the decision to end the child protection plan in March 2010? 6. Was the decision to end the child protection plan consistent with the assessment of risk? 7. Was appropriate support offered to David A as a child in need following the end of the child protection plan? 8. Did the strategy discussion in February 2012 take appropriate account of David A’s history? 9. Following the strategy discussion in February 2012 was there appropriate information sharing between agencies? 10. In particular was there a shared assessment of the level of risk of suicide in April 2012? 11. Were there effective strategies to manage differing levels of parental engagement with services? 12. Were there effective strategies to manage differing levels of engagement from David A? 13. Did agencies work effectively across the boundaries of Bath & North East Somerset and Wiltshire? 1.10 Whilst this report does not address these questions separately all are covered in the analysis section in this report apart from questions 2 and 13. It is this report author’s view that, after careful consideration of the facts, there were no significant learning points regarding information sharing and cross boundary working as these had been well managed. Summary 1.11 David A died by his own hands in 2012. He came to the attention of Child and Adolescent Mental Health Services, (CAMHS) in 2007 and children’s social care in 2008 and there are multiple recordings of him talking about suicide and self-harm to his family and professionals. 1.12 Between July 2009 and March 2010 David was made subject to a child protection plan due to concerns about his well-being. 1.13 David A was unsettled at his first senior school but settled well into School2, attended well and achieved good GCSE results. 1.14 In early 2012 David A was arrested by police because he had bought chemicals off the internet which could be used to make explosives. He was released without any charges and no further action was taken. 1.15 David A often talked about his unhappiness and how things weren’t changing for the better. He took his own life at a time when the circumstances of his own life appeared to be improving. 5 | P a g e Race, religion, language and culture 1.16 All members of the family are English speaking White British. It is not known whether religion is a feature in their lives as this has not been noted in records. 1.17 Both parents have been in continuous employment and have been devastated by the death of their son. 6 | P a g e 2. METHODOLOGY Independence 2.1 Dr. Louise Goll, was appointed by the safeguarding children board to chair the serious case review panel. Louise has worked as an independent consultant in children's services since 2012 following a career as a senior leader in education and children's services in Somerset, Buckinghamshire, Leicester and Oxfordshire local authorities. Her most recent substantive appointments were as Director of Children's Services in Somerset and Divisional Director of Learning and Achievement in Buckinghamshire. 2.2 Louise has over 30 years’ experience working to promote the wellbeing of children and young people as an educational psychologist, teacher, adult educator and trainer, manager and leader of services. She has a first degree in psychology, a PGCE, a Master of Applied Science in Educational Psychology and a PhD in Education which focused on the inclusion of children with disabilities in mainstream schools. She has led and managed a wide range of children's services including educational psychology, specialist teaching, youth, children's centres, school improvement, and in her final role in Somerset was responsible for the delivery and quality of all children's services. 2.3 The overview author was Barry Raynes. Barry is the Chief Executive of Reconstruct, a company providing child care training and consultancy to managers and staff throughout the United Kingdom. Reconstruct also supplies advocacy, independent visiting and participation services to children in south west England. 2.4 Barry has thirty years’ experience of child protection social work. He has been involved in over 30 serious case reviews since 2007 – either overseeing the work of Reconstruct’s consultants or producing overview reports. He has written web-based child protection and child care procedures for more than 50 LSCBs and local authorities in England, Wales and Scotland. 2.5 Barry has a Masters degree in public sector management and is currently researching a PhD into common language in child protection. 2.6 Jim Gould is the independent chair of Bath & North East Somerset (B&NES) safeguarding children board. Jim Gould has professional qualifications in teaching and social work and a Masters Degree in Business Administration. He has worked in Social Care since 1975 working in Devon, Derbyshire and Cornwall before being appointed as Director of Social Services and Housing at the Royal Borough of Windsor and Maidenhead in 2003.In 2006 he was appointed by the Royal Borough to the combined role of Director of Children's Services and Director of Adult Social Services and Housing. He held this post until his retirement in 2009. 2.7 Following retirement Jim was appointed as Independent Chair of Plymouth LSCB and still holds that position. He was also appointed as a Non Executive Director of Cornwall and Isles of Scilly Primary Care Trust. In 2010 he was asked to become the Independent Chair of Bath & North East Somerset LSCB and also took on the role of Independent Chair of Plymouth Safeguarding Adults Board. Serious Case Review Panel 2.8 The serious case review panel met on nine occasions for either a half or full day between 17th December 2012 and 24th June 2013. The overview report was ratified at the Local Safeguarding Children Board meeting on 17th July 2013. 7 | P a g e 2.9 The panel comprised of: Head of Safeguarding, Assurance and Quality – Children and Young People Bath and North East Somerset Council Deputy Director for Children and Young People Bath and North East Somerset Children’s Services Deputy Designated Nurse Safeguarding Children - Nursing & Quality Directorate NHS Wiltshire Clinical Commissioning Group & NHS B&NES Clinical Commissioning Group (CCG) Detective Chief Inspector Avon and Somerset Police Children’s Services Manager Barnardos Serious Case Review Project Lead Wiltshire safeguarding children board Parallel processes 2.10 There was a Coroner’s Hearing in respect of David A during the time of this serious case review; the Coroner recorded an open verdict. This parallel process did not affect the timescale of this serious case review. Dissemination of learning 2.11 The learning from this review will be disseminated throughout safeguarding children board professionals via a series of workshops. Timescales 2.12 The serious case review took 8 months between being commissioned and presented to the Board. This is one month beyond the timescale suggested in Working Together to Safeguard Children, 2010. Production of individual management reviews (IMRs) 2.13 IMRs were received from: Bath and North East Somerset Children’s Services (CSC) Avon and Somerset police Wiltshire Education Welfare Service Sirona Care and Health School 1 School 2 Great Western Hospital (GWH) NHS Foundation Trust General Practice Relate Mid Wiltshire Child & Adolescent Mental Health Service (CAMHS): Oxford Health NHS Foundation Trust and Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) 2.14 A health overview report was produced by Sophia Swatton drawing together the issues and findings from the health IMRs. 8 | P a g e 2.15 Sophia is a qualified nurse, health visitor and practice educator. She holds a BSc in community health studies and a post graduate certificate in higher education (PGCHE). Sophia has worked in the field of safeguarding children since 1993 and has specialised in this field since 2010. She commenced employment with NHS B&NES and Wiltshire cluster primary care trust (PCT) as deputy designated nurse for safeguarding children in June 2012. On 1st April 2013, as part of the NHS reforms NHS B&NES CCG replaced NHS B&NES (PCT) as part of the NHS reforms and is no longer clustered with NHS Wiltshire. The designated nurse function continues to be provided to B&NES CCG via a service level agreement with Wiltshire CCG. Sophia also sits on the B&NES LSCB. Expert guidance 2.16 Expert guidance was sought from a consultant nurse for self-harm from South London and Maudsley NHS Foundation Trust. The panel used material produced by this person to formulate the guidance included in this report at appendix three which forms part of recommendation one. 9 | P a g e 3 NARRATIVE OF EVENTS 3.1 The terms of reference for this review covered 2007-2012. 3.2 This narrative is in chronological order but some dates have been removed to protect the anonymity of the family. Year 7 2007-2008 3.3 On October 17th 2007 Mrs A, David A and Susan A attended an appointment with CAMHS. At that appointment David A saw CAMHS Practitioner 1 and spoke of his fears about his parents arguing and his view that nothing would change. CAMHS decided that they would offer him support as well as the rest of his family. 3.4 Mrs A, Susan A and David A met with CAMHS Practitioner 1 and CAMHS Practitioner 2 for a family therapy session. Mr A had said he didn’t feel the need to come. It was recorded about David A that he “does not believe that things are ever going to change…..wanting to commit suicide,” Oxford Health NHS Foundation Trust (page 5). 3.5 Mrs A arrived at CAMHS one morning hoping to speak to someone; she was distressed. Mrs A agreed to a referral to children’s social care as she said that she wanted help. The referral was made a week later. 3.6 On 28th April 2008 social worker 1 visited the family home to complete an initial assessment2 and talked to David A who said that he was depressed and that he had tried to kill himself by putting up a rope but that it didn’t hold. Referrals were made by the social worker to: A family support project Support services for parents Alcohol services. 3.7 Social worker 2 (from the family support project) said that Mr and Mrs A needed to sort things out between themselves and concluded that further work with David A was not appropriate because the main problem was the relationship between the parents. Year 8 2008 - 2009 3.8 In January 2009 David A’s attendance at School1 started to deteriorate. He became increasingly depressed and as a result was finding it difficult to get into school. The school allocated a key worker for David A and tried various techniques for helping him to stay at school. 3.9 Mrs A and David A went to an appointment with CAMHS Psychiatrist 1. As a result a further referral was made to children’s social care in which it was noted that there had been no change in the home circumstances since the last referral made in May the previous year, that David A was still saying that he wanted to kill himself, and that he had written a number of suicide notes. - 2 This is a short assessment, usually completed within 7 days. 10 | P a g e 3.11 School1 completed a CAF3 and made referrals to children’s social care and the educational welfare service as David A’s attendance at school had dropped significantly. - 3.13 Mrs A phoned CAMHS to say that David A was desperate and needed someone to talk to. CAMHS psychiatrist 2 wrote to children’s social care with the view that David A was at risk of harming himself. 3.14 On 1st May 2009 social worker 4 visited David A at home, as social worker 3 was no longer allocated. David A said that he was feeling down. He said he heard voices arguing in his head. Children’s social care decided that they needed to allocate a social worker to the A family. 3.15 On 13th May 2009 social worker 5 became David A’s allocated social worker. 3.16 CAMHS psychiatrist 2 wrote to social care to say that one to one work with David A had been inappropriate because the cause of his distress was due to his parents’ relationship. She also said that David A was at significant risk of self-harm. 3.17 Mr and Mrs A attended an appointment with CAMHS Psychiatrist 2. It was agreed that there would be more work with them in order to change in ways which would be beneficial to the children. Later that day GP1 rang social worker 5 saying that David A was at risk of self-harm and said that David A wanted to die and that his emotional health had deteriorated and he was significantly depressed. 3.18 On 26th June 2009 social worker 5 completed a core assessment. The main issues identified included the escalation of David A’s suicidal thoughts. 3.19 The recommendations of the core assessment were couple counselling for his parents , long term therapy for David A4 and that a multi-agency approach should commence. CAMHS were to continue to work with Mrs A and Mr A. 3.20 On 17th July 2009 an initial child protection conference decided that David A would be subject to a child protection plan under the category of emotional abuse, and that Susan A would be categorised as a child in need (CIN). 3.21 The plan detailed who should do what and what the timescales were. Social work assistant 1 was assigned to offer David A 1:1 support in order to give him the opportunity to talk about any worries he might have. Social worker 5’s role was to look at Mrs A’s use of alcohol and whether there was a need for her to be referred for further support. 3 Common assessment form – for children with “additional needs”. 4 This recommendation did not appear on the plan formulated after the child protection conference on 17/07/09 11 | P a g e Year 9 2009 -2010 3.22 On 3rd September 2009 social worker 5 telephoned School1, and said that although David A had had a good summer he had “stood by the car on the first day of school and said, ’nobody understands, I can’t do it’” joint chronology (03/09/09). A meeting was held at School 1, with education welfare officer 1 and social worker 5. They decided that they would ask CAMHS to become involved again to check if David A was medically fit to attend school. 3.23 Social work assistant 1 made a home visit during which David A talked about telling his father that he was going to kill himself. Social work assistant 1 recorded that David A was angry and frustrated because nothing had really changed in his life and he still had the same worries and problems. 3.24 David A met with CAMHS Psychiatrist 2 and 3.25 Social worker 5 was told by Mrs A that she and Mr A had started a trial separation and Mr A had left the family home. 3.26 On 16th October 2009 the first child protection conference review took place. It was reported that there were no significant changes identified since the last conference. The parents’ trial separation was still in its early days. David A was at the conference and he was able to contribute with help from the local advocacy service. He submitted a statement of two pages which included “I still have the feeling that I want to die (but) I won’t try to kill myself”. David A again said he felt that nothing in his situation had changed. 3.27 David A was referred to a young people’s support service for an online learning package. 3.28 In January 2010 a core group meeting took place. Mr A wrote a letter to be read out saying that he was unable to attend due to a lack of notice and the potential loss of a day’s pay. In the letter he asked: “All in all any report puts me as the root of the problem. Now that I have been pushed out of the family I regret to inform you that nothing has changed for the better”. 3.29 David A started attending a sports academy; he continued to do this until the end of his life. 3.30 Mr A spoke to social work assistant 1, and said that David A would be willing to try another school and they were considering School2; Mr A wrote to this school to that effect. He told education welfare officer 1 that he wished to apply for David A to transfer with a view to him making a ‘fresh start’. Education welfare officer 1 liaised with the family and School2 to facilitate this and David A’s new school was confirmed. 3.31 A meeting was held at school2 with David A, Mrs A and social worker 5. School2 staff were made aware of David A’s poor attendance at School1, his low self- esteem and emotional ill-health. They were also informed that things were improving now that Mr and Mrs A had separated, and that whilst David A was still on a child protection plan he was likely to be de-registered soon. David A said he wanted to be back in school full time and did not want any support. 12 | P a g e 3.32 It was agreed that David A would remain on School Action Plus5 for the time being. School employed school nurse 1 at school2 was allocated as a support person, he was given an experienced male tutor and a student buddy. 3.33 On 26th March 2010 the second child protection conference review took place. Mr A again sent his apologies and another letter. This letter pointed out that Mr A, David A, education welfare officer 1 and her manager had been the people responsible for getting David A to School2. The letter said that this has been achieved through “giving discipline and guidance a teenage boy needs without third party interference and ‘pie in the sky’ ideas”. 3.34 The letter ended with: “One of the conditions David A asked me to make, regarding school, is that everyone involved in this case leave him alone. And, whilst I know it’s early days, may I ask you all to help me keep that promise and keep a back seat, or at least watch from a distance, and let him find his own feet in the world”. 3.35 The conference took the decision that David A no longer needed a child protection plan. 3.36 CAMHS psychiatrist 2 wrote a letter to Mrs A setting down the details of the progress made and saying that David A’s case would be closed, with the ability to reopen if needed. 3.37 David A was soon doing very well at school; his attendance was 100% and he was achieving higher grades. 3.38 On 30th June 2010 at a home visit, social worker 5 met with Mrs A and Susan A. Both reported much improvement. Mrs A was confident about coping on her own. The case was then closed by children’s social care despite the fact that David A had not been present at this meeting. 3.39 David A’s year 9 school report showed good progress and positive behaviour points. In his own personal statement for this report David A stated that he had made good friends and his time had been quite enjoyable. He felt respected. He said that his favourite subjects were History and PE. He commented that his self- confidence had increased. He put this down to joining the sports academy where he had been going for the last 5-6 months. He said his life was on the right track. Year 10 2010 – 2011 3.40 On 10th August 2010 Mr A phoned social worker 5 to say that David A was staying with him twice a week because of problems at home. 3.41 On 8th November 2010 an advocate made a referral to children’s social care because Susan A was expressing concern to her counsellor about her mother. 3.42 Social worker 6 visited the home and completed a further initial assessment. David A was said to be very unhappy. The decision was that social worker 7 would be allocated to the family for long term support. 5 A system designed to provide extra support to pupils who are finding school difficult. 13 | P a g e 3.48 One month later, 22nd August 2011, the case was closed by children’s social care on the basis that David A had said that that he didn’t want social work support. The closing summary said there were indications that David A was less socially isolated. Year 11 2011 – 2012 3.49 David A was reported by the school as starting year 11 in a positive frame of mind. 3.50 On 24th November 2011 Mrs A rang the school to say that she was concerned about David A who was buying chemicals over the internet. School senior staff 1 telephoned the police for advice; staff at the school discussed the matter; they decided that David A presented a low risk at school and therefore they did not take the option of a fixed term exclusion. 3.51 Intelligence was received by the police that David A was expressing a desire to kill people and was researching this on the internet. 3.52 Police officers went to see David A at his father’s address. The officers explained their concerns around David A’s experimenting with explosives and Mr A said that he would supervise any such use in woods on open land nearby. He said the quantities were too low to do any harm. 3.53 Police sergeant 1 recorded this visit and his observations as intelligence, which was disseminated to the police public protection unit, special branch and children’s social care. The intelligence was allocated to police constable 1 for further enquiries and he subsequently spoke with Mrs A on several occasions. She told him she was extremely worried about David A’s mental health and felt let down by various agencies. 3.54 On 6th January 2012 a strategy meeting took place attended by police officers, social work manager 1 and social worker 7 but no representatives from School 2, CAMHS or the GP Practice. 14 | P a g e 3.55 Decisions of this meeting included: Social worker 7 to complete an assessment. Refer to CAMHS. Child protection inquiries to be made. A new strategy meeting to be held in 6 weeks’ time. 3.56 Another strategy meeting was held five weeks later attended by police, children’s social care, Youth Offending Team, School 2 and representatives from Health. The focus of this strategy meeting was on the risk posed by David A’s access to bomb-making materials. It was agreed that this was a police matter and not a case for social work because David A had refused to engage with social workers, or agree to a referral to CAMHS. The outcome was no further action in relation to child protection matters and that David A would be dealt with by the police. 3.57 On 24th February 2012 Mr A and David A were arrested from their respective homes by police officers for the offence of possessing explosives with intent to cause criminal damage. Chemicals and fuse wire were seized. 3.58 They were both taken to a police station and a risk assessment was carried out as part of the booking in procedure. It recorded that David A was fit to be detained, was lucid, orientated and able to process questions and answer appropriately. He disclosed a history of past depression, self-harming a “couple of months” previously, and “attempted suicide a few years ago”. He said that at the current time he had “not thought about self-harming”. He was visited in his cell every 30 minutes. 3.59 Detective constable 2 interviewed David A in the presence of a solicitor and an appropriate adult for 90 minutes. David A admitted ordering the chemicals from the internet and said he had ensured that it was not illegal. As his mother was unhappy about having the materials at her house he took them to his father’s. They attempted to make a flare but this was not very successful so he had not used the chemicals again. David A said it was a phase that had passed. He said that at no time did he have any intention to cause explosions that would harm people or damage property. Detective constable 2 asked David A about his reluctance to engage with social workers, and David A said this was because of the way they had handled things during the separation of his parents; he did say that he would consider working with other agencies. 3.60 David A and Mr A were released on police bail. The examination of David A’s computers was fast tracked to enable him to continue his school studies. They were subsequently advised that their bail was cancelled and there would be no further action taken. 3.61 On March 29th 2012 social work manager 1 telephoned CAMHS Practitioner 1. She told her about the Police intervention and that David A’s mother had voiced concern as she had found part of a note on which David A had written the names of the people he wanted to come to his funeral. Susan A had apparently reported that she had found his dressing gown cord tied into a ligature on two occasions. David A had told Susan A that he had used it on one occasion and she did say that there was a mark on his neck. 3.62 CAMHS Practitioner 1 discussed a safety plan with social work manager 1 for her to pass on to Mrs A; they also agreed that social work manager 1 would make a joint visit with CAMHS Psychiatrist 2 and CAMHS Psychiatrist 3 to David A at the beginning of the following week. 15 | P a g e 3.63 On Friday March 30th 2012 social work manager 1 telephoned and spoke to Susan A as her mother was unavailable. Susan A said she had told her mother to take David A’s dressing gown and cord away, which she had done. Susan A did not believe that David A would go to his GP even if his mother tried to make him. There were superficial cuts on his legs and a small mark on his neck – and David A admitted that he had tried to kill himself. Social work manager 1 made phone calls to Mrs A, police, school 2, CAMHS and Mr A. A safety plan was put in place for the weekend, involving contacting out of hours, CAMHS, or taking David A to A&E. David A was also to be supervised and kept occupied. Mrs A said that she wasn’t concerned about David A’s attempt to kill himself, feeling he was attention-seeking. Mr A was having David A stay with him for the weekend; he said there was nothing wrong with David A. 3.64 The following week Mrs A telephoned social work manager 1 to say that neither she nor David A would be available for the CAMHS appointment that morning, which was therefore cancelled. She said that he wasn’t about to kill himself. 3.65 David A’s last school report was very positive, he had a place to study at College1. Year 12 2012 3.66 In August 2012 Mr A married his new partner, David A was his best man. In the photos he appeared to be happy because he was smiling a lot, which Mrs A said, in interview with this report’s author and the chair of the panel, was unusual. 3.67 According to Mrs A, in an interview with the overview author of this report and the Panel Chair, David A found the lack of structure at college difficult. School senior staff 1, recalled in her interview with her IMR author that she had received a phone call from Mr A asking if David A could return to school which he did shortly afterwards. 3.68 A few days after the beginning of term Mrs A found David A’s body. 16 | P a g e 4. ANALYSIS 4.1 The terms of reference listed thirteen questions for IMR authors to address; the answers to which provided most of the material for this part of the report. 4.2 To capture of the learning from this review they have been collated under the following themes National context Assessment and analysis of risk Working with Mr and Mrs A Working with David A NATIONAL CONTEXT 4.3 Identifying the prevalence of self-harm and suicide in society will never be exact; many factors inhibit accurate recording, including the reluctance of coroners to label a death as suicide, Durkheim et al (1897) Madge and Harvey (1999) and young people’s reluctance to admit to self-harm, NSPCC (2009). 4.4 The child and adolescent self-harm in Europe seven year study (2005) used anonymous questionnaires completed by 30,000 15-16 year olds and found that 70% admitted to self-harming. Fox and Hawton (2004) and Hawton and Harris (2008) found that girls were more than likely to self-harm than boys, by ratios between 4:1 and 6.5:1. 4.5 There are two varying approaches to links between self-harm and suicide. “While some would argue that self-harm is in fact the opposite of suicide, i.e. a way of coping with life rather than giving up on it, there is an equally compelling argument that they are part of the same continuum, both being a response to distress,” NSPCC (2009) page 6. 4.6 This report is taking the latter view; that there are links between self-harm and suicide. 4.7 Causal factors of self-harming and suicide include: alcoholism in the family, experiences of neglect, depression and low self-esteem, Makhija and Sher (2007), Colquhoun (2009). 4.8 Oxfordshire and Buckinghamshire Mental Health NHS Trust, (now known as Oxford Health NHS Foundation Trust) found in 2010 that family relationship difficulties were the most common trigger for younger adolescents to self-harm. 4.9 David A experienced his parents’ relationship difficulties as abuse despite the fact that neither of them meant him any harm. Whilst “CAMHS Psychiatrist 2 was clear that neither parent intended to be harmful to their children….clearly their arguments were having a harmful effect on him,” Oxford Health NHS Foundation Trust IMR, (page 7). 4.10 Research by Makhija and Sher found that: “Depressed individuals with a family history of alcoholism have….more suicide attempts, and a greater intent to die….than individuals without a family history of alcoholism” QJM: An International Journal of Medicine, Volume 100, Issue 5 (page 307). 4.11 Factors like this were present in David A’s life which provides further evidence that he may have been at higher risk of suicide compared to other young people of his age. 17 | P a g e ASSESSMENTS What were the key opportunities for assessment and decision making? 4.12 The following were key moments where opportunities existed to produce in-depth and multi-agency assessments of David A’s needs. An * represents opportunities where concerted action did not take place. May 2008 CAMHS refer to Children’s Social Care 19th June 2008 First visit by a social worker 13th March 2009 Second visit by social worker 17th July 2009 Initial child protection conference 16th October 2009 1st review child protection conference 26th March 2010 2nd review child protection conference *8th November 2010 Referral from the advocacy service *14th January 2011 David A’s insistence to a social worker that he would kill himself if Mrs A moved in with her new partner *21st July 2011 Contact between GPs, social workers, Mrs A and Susan A Jan & Feb 2012 Strategy meetings regarding explosives *30th March 2012 Phone call from neighbour to say David A had written a suicide note *June – Sept 2012 David A leaves (and returns to) school CAMHS refer to children’s social care 4.13 CAMHS practitioner 1 and CAMHS practitioner 3 spoke to Mrs A and gained her permission for them to make a referral to children’s social care “noting that it would not be helpful for CAMHS to see David A anymore as it implies to him that he is seen as a problem” Oxford Health NHS Foundation Trust IMR (page 6). 4.14 This was an appropriate referral because CAMHS had attempted to work with Mrs A and Mr A but had been unsuccessful and they were aware that the situation for David A had not changed. 4.15 Other than notification of a proposed social work visit to the family, there was no contact between social care and CAMHS following their referral letter, it is regrettable that an opportunity for a thorough discussion, between CAMHS staff and social worker, was not taken; CAMHS staff knew the family well and would have been able to clarify and expand their concerns more than was possible in their letter. First visit by social worker 4.16 Social worker 1 visited and completed an initial assessment. “This was a good quality assessment identifying the key issues for the family and for David A, who she described as a sensitive child,” Children’s Social Care IMR (paragraph 4.4.2). 4.17 However she failed to speak to Mr A so did not get his views. 4.18 Referrals were made to a family project, an alcohol service and a couples therapy service. None of these actions directly addressed David A’s needs; all were reliant on Mr and Mrs A’s desire and ability to change. 18 | P a g e 4.19 CAMHS had said that they were not prepared to continue to work with the family; they should nevertheless have been more involved in the assessment as they not only knew the situation within the family but had a high level of expertise in working with troubled teenagers. 4.20 Had the social worker’s recommendation been for a core assessment then there would have been an opportunity for a thorough, multi-agency approach which would have involved CAMHS. Second visit by social worker 4.22 Although described by the children’s social care IMR author as a “good assessment” the social worker again failed to speak to Mr A and did not speak to David A’s school teachers. CAMHS Psychiatrist 1 was also not contacted despite statutory guidance6 which then stated that referrers of child protection concerns should be contacted to be told the outcome of the referral. 4.23 The social worker recommended a core assessment, an appropriate recommendation given that little change had been noted within the family or in David A’s distress. Initial child protection conference 4.24 The core assessment recommended that the risks to David A and Susan A be considered at a child protection conference. 4.25 By definition7 this was a key opportunity for multi-agency decision making in relation to David A. “The social work report for conference is an excellent report. She (social worker) takes into consideration, how the family and environmental factors are affecting David A directly, estimates the level of risk presented to David A and the probability of future harm. She states on two occasions that David A does not want to live” Children’s Social Care IMR, (paragraph 4.4.6). 4.26 However the risk factors identified at the conference focused more upon the relationship between Mr and Mrs A rather than upon the need to support David A. The lack of a thread from report to action plan regarding David A’s suicidal thoughts was a missed opportunity to help David A and reinforced the focus upon his parents and away from himself. “The risk of suicide to David A is not stated in the conference minutes under risks and this is a serious omission.” Children’s Social Care IMR, (paragraph 4.4.6). 1st review child protection conference 4.27 The first review conference took place shortly after Mrs A and Mr A had separated. The decision was to keep David A on a child protection plan because of the following risk indicators. a. “David A’s situation is still very stuck. b. David A has very low self-esteem; he talks about and has admitted self-harming. c. The situation has not markedly changed since the initial conference. d. Mr and Mrs A have not been able to work together and have failed to give common boundaries to manage David A’s behaviour and give support to him. e. No one is in control. 6 Working Together to Safeguard Children (2006) (paragraph 5.35) 7 Working Together to Safeguard Children (2006) (paragraph 5.80) 19 | P a g e f. The lack of confidence about whether Mr and Mrs A have really separated and given Mrs A’s financial situation she may feel that she needs Mr A back in the home. g. David A is not accessing any form of education at the moment and the situation regarding his future education has ground to a halt”. (Minutes of meeting). 4.28 The minutes of the meeting noted the following positives. a. “Mr and Mrs A have separated. b. The basic physical care of David A is good and there have never been any significant concerns in relation to this. d. Mrs A has used advice and support from people in the past and now”. (Minutes of meeting). 4.29 There was still no mention of David A’s suicide attempts despite the fact that he submitted a statement of two pages which included “I still have the feeling that I want to die (but) I won’t try to kill myself.” 4.30 He also said that nothing in his situation had changed. 2nd review child protection conference 4.31 This time the conference took the decision that David A no longer needed a child protection plan presumably because the positives: Positives a) “There is a marked improvement in Mrs A’s confidence… b) The separation in October has continued and appears to be final for Mrs A and the children. c) David A has self-esteem issues but he has grown in confidence enough to be able to make a decision about his future. d) David A is back in education on a full time basis. e) The support for Mrs A, David A and Susan A has been taken up and used by them” (Minutes of meeting) outweighed the risks: Risks a) “Chair stated that there are a lot of "what ifs" such as: a. Concern about the way Mrs A talks about the separation and if Mr A accepts it is permanent. c. David A could have issues at school and not be able to cope”. (Minutes of meeting). 4.32 There is again an emphasis upon the importance of the separation of the parents. 4.33 The conference ended with a child in need plan which still failed to mention David A’s thoughts about suicide. It was to be reviewed in three months but there is no evidence that this took place. “A review was particularly important as the CIN Plan replaced the Child Protection Plan and therefore formal consideration of the level of David A’s needs and any evidence of on-going risk should have been considered before the case was closed…” Children’s Social Care IMR (paragraph 4.3.7). 20 | P a g e 4.34 There had been no members of staff present from the GP practice or CAMHS despite the fact that they had been key payers in David A’s care. “GP's perceive (conferences) as being at short notice during busy working days, when a full surgery may have to be cancelled to attend, thus affecting care to other patients. Those convening such conferences need to ensure that the GP practice is contacted as early as possible to ascertain dates and times when key personnel would be able to attend. Generally this does not occur” B&NES General Practice IMR, (paragraph 5). Referral from the advocacy service 4.35 Counselling practitioner 1 made a referral to children’s social care because Susan A was saying that things at home were still problematic. This resulted in a further initial assessment conducted on 16th November 2010. 4.36 In this assessment the social worker painted a picture of the family struggling. She described David A as unhappy and wanting to live with Mr A. She described an incident in which Mrs A physically and verbally attacked Susan A. The assessment made no mention of previous assessments and made no reference to previous suicide attempts. It concluded by saying that further information should be sought from Mr A and David A’s school in order to make a decision about whether a core assessment was needed. It appears though that no further enquiries were made. The children’s social care IMR author states “It is my opinion that this initial assessment should not have concluded with a recommendation that further information be sought. The information should have been acquired and added to the assessment in order to make a concrete recommendation…..It was another missed opportunity to further assess David A’s risks and needs”. Children’s Social Care IMR, (paragraph 4.4.5). 4.37 This intervention is poor. David A is so distressed that he wished to leave home and Mrs A has physically assaulted Susan A. The assessment is incomplete as family members and other professionals were not contacted. 4.38 This was a missed opportunity for a core assessment which may have led to a further child protection conference. David A’s insistence that he would kill himself if Mrs A moved in with her new partner 4.39 David A talked to social worker 7 and made threats about harming himself and Mrs A at the same time as telling her that he had bought a gun. Although social worker 7 dealt with the issue of the gun well by checking the situation with the police and advising David A and Mrs A accordingly she took no action regarding the threats. The children’s social care IMR author wrote that social work manager 1 said, “…she believes that this information should have triggered a strategy discussion, which would have been her decision. However, her supervision notes indicate she was not aware of all the facts and therefore did not convene a strategy discussion. Good practice would suggest that managers read case notes, so they are aware of the facts and able to make informed decisions” children’s social care IMR, (paragraph 4.18). 21 | P a g e Contact between GPs, social workers, Mrs A and Susan A 4.40 Contact was made by Mrs A and Susan A to two different GPs (in the same practice) expressing their concerns. These included the threat that David A would kill himself. “A home visit was requested but not carried out. General practitioner 2 felt that as knives had been mentioned, this would not be safe and the police should be called if necessary…..There is no record of follow up by the GP team. No strategy for dealing with this problem is mentioned” B&NES General Practice IMR (paragraph 4.20). 4.41 General practitioner 3 explored the possibility of offering an appointment but felt it unlikely that David A would attend as he had seen him two days earlier. 4.42 This was the last occasion on which concerns were brought to the primary care team until David A’s death. Both Susan A and Mrs A said to the author of this report and the chair of the panel that they were disappointed that a doctor did not visit the home. Strategy meetings regarding explosives 4.43 The two strategy meetings had to deal with two issues; David A’s risk to himself and his risk to others. According to the police IMR author the searches of the parents’ homes were appropriately carried out and a good assessment was made of David A’s threat to the public. There was no criticism in the police IMR about the conduct of the public safety investigations or of the decision to take no further action. 4.44 However the two meetings were not so thorough in considering David A’s risk to himself. The first meeting provided “an excellent summary of David A’s history and risk. An assessment and Section 47 enquires were requested,” children’s social care IMR (paragraph 4.4.9). This meeting also suggested that school 2 should make a referral to CAMHS. The focus shifted at the second strategy meeting to “guns and gunpowder and the conclusion was that it was a police matter and there would be no further involvement from CSC” children’s social care IMR (paragraph 4.4.9). 4.45 No representatives from School 2, CAMHS or GPs were present at the first strategy meeting. CAMHS and GPs were not invited, nor did they attend the second meeting. The reason for there being no member from school 2 may have been because it was held just after the Christmas holidays. A representative from the school was present at the second strategy meeting but was only given the minutes of the first meeting as she arrived. She was therefore “unaware of David A’s risk of suicide, as presented at the first strategy” children’s social care IMR (paragraph 4.16.4). 4.46 Furthermore the school “was not aware until then of the request for the school to make a CAMHS referral” school 2 IMR. Consequently no referral was made to CAMHS. 4.47 The second meeting focused more upon the threats that David A may pose to others as opposed to himself and the decision was that this was a matter for the police to follow up. There appeared to be a lack of a thread from one meeting to the other, “at the first strategy discussion… the summary of CSC involvement…..was of good quality. However in the reconvened Strategy Discussion… the summary was not shared with people who had not attended the initial discussion” children’s social care IMR (paragraph 4.6.7). 22 | P a g e 4.48 This was unfortunate given the extensive information that children’s social care held on David A and his family. The disconnect between the two meetings may have been further strengthened by the fact that social worker 7 “had a conversation (on the way to the second meeting) with her manager (social work manager 1) who said We’re not going to get involved’” children’s social care IMR (paragraph 4.16.7). 4.49 This was probably based upon a belief that the problem was public safety rather than David A’s well-being. It is unfortunate that professionals often see problems as a single issue rather than multi –layered; the meetings should have considered both public safety and David A’s well-being. 4.50 There was no reason to not undertake Section 47 enquiries, as agreed in the first strategy meeting, and this is a significant omission as it was an opportunity to raise the risks that David A presented to himself. 4.51 David A had also stated in interview with a police officer that he would accept help from professionals providing that they were not from children’s social care. He said “Maybe you can get a counsellor or whatever but can I ask you just don’t get the social workers involved” police IMR, (page 26). 4.52 The Police IMR author wrote that following the strategy discussion and subsequent arrest “there was very little information sharing with or from the Police. The cause of this is the absence of a mechanism, such as a strategy meeting, to ensure that it happened. Specific information that should have been shared was further detail around: David A’s mood that the police established through their enquiries The outcome of the investigation, … David A’s suggestion that he would engage with someone not from CYPS” Police IMR, (paragraph 4.17). 4.53 This was a missed opportunity to re-assess David A and plan a multi-agency approach to his needs. Phone call from neighbour to say David A had written a suicide note 4.54 Concerns were again raised by Mrs A and Susan A (following contact with them by social work manager 1 following a referral from a neighbour) about David A. He had written a list of the people who he wanted to come to his funeral and he had tied his dressing gown cord into a noose. He had superficial cuts to his legs and a mark on his neck and he had confirmed to Susan A that he was self-harming and had tried to kill himself. 4.55 The urgency of this situation was responded to by social work manager 1 who made a number of telephone calls including to Mrs A, Mr A and school 2 to inform them of these concerns. She put a safety plan in place which did not involve a social worker visiting David A. The reason given for this was that Mrs A had said that she thought David A was attention seeking and that he didn’t want to see a social worker. Mr A also said that there was nothing wrong with his son. 4.56 An appointment was made for social work manager 1, CAMHS Psychiatrist 2 and a trainee psychiatrist to visit David A at home. Mrs A phoned on the day of the appointment to cancel it saying that it was not required because David A wasn’t about to kill himself. 23 | P a g e 4.57 The decision made by social work manager 1 to cancel the visit was not challenged by CAMHS staff which was unfortunate as “it appears that the assessment of David A’s mental health and the risk that this carried was made by the social worker (sic) and not challenged by those with mental health expertise” SCR Health Overview Report, page 30. 4.58 The children’s social care IMR author identified in an interview with social work manager 1 that she had contacted school 2 to ensure that they “kept an eye” on David A but that the decision to not visit “was based on an opinion of the family’s non engagement rather than on the level of risk to David A,” children’s social care IMR, (paragraph 4.18.4). 4.59 A strategy meeting should have been convened at this point. David A leaves (and returns to) school 4.60 Two further key moments for assessment were when David A left school 2, in June 2012, to go to College and his return to school. School 2 carried out assessments on both occasions and supported David A with his application to college; they acted with speed to welcome him back when it was clear that the college course wasn’t working. 4.61 It could be that this was a key moment for David A. His mother told the author of this report and the panel chair, in their meeting with her, that David A liked the structure of school, hated the relaxed atmosphere of college and found free periods difficult to deal with in the 6th form when back at school 2. 4.62 It is very much in hindsight, and no criticism of the professionals or family members intended, but the break down in college could well have been a time of high risk for David A. Were assessments thorough and were decisions made reasonable given what was known at the time? 4.63 David A and his family received help from many professionals from a range of agencies. The IMRs describe practitioners who are, in the main, committed, caring and thorough. There are though areas of concern. 4.64 The first is the view that David A should not be seen alone as this “would be to locate the problem with him,” Oxford Health NHS Foundation Trust, (page 5). 4.65 This view was first expressed by CAMHS Practitioner 1 on October 17th 2007. It was repeated again on May 15th 2008 in a letter to Mrs A from CAMHS and a referral to Children’s Social Care. 4.66 It was reasonable to deduce that David A’s distress was exacerbated by his parents’ relationship and focusing work upon the parental relationship made sense. But this should not have been at the exclusion of work with David A. Counselling for David A could have been on the basis of helping him to cope with the situation. A further problem with this approach was that “the therapy did not sit effectively within a wider system of case or family management, so when the parents did not effectively engage, there was not an active response, particularly in a multi agency context, to the continuing dysfunction in the family,” Oxford Health NHS Foundation Trust, (page 15). 24 | P a g e 4.67 This location of the problem with his parents rather than with David A himself remained a dominant theme throughout much of the work carried out by professionals in the child protection process. The main issue focused upon was the relationship between Mr and Mrs A. This focusing in on one issue was particularly apparent during the child protection process. 4.68 The first conference made David A subject to a child protection plan because of the following risks. a) “Mr and Mrs A cannot agree about the way forward. b) The chronic situation with little change despite the plans and support. c) Inappropriate discussions around the children. d) Both Mr and Mrs A’s alcohol use and the children’s concerns about the effect of this. e) The couple have admitted to a high degree of domestic abuse and arguments. f) David A’s negative relationship with his father. g) David A has very low self-esteem, is isolated and has no positive relationships. h) David A is a young person exhibiting issues of frustration, self-harm and futility about the situation he is in. i) David A is not achieving educationally and he has no positive experiences at school. j) Susan A’s role and her feelings that she can’t take it anymore”. (Conference minutes). 4.69 By the first review conference three months later it was clear that the professionals placed considerable emphasis on Mr and Mrs A separating because a listed strength is “Mr and Mrs A have separated” (Conference minutes), although David A was left subject to a child protection plan because “the parents’ trial separation was still in its early days,” - Children’s Social Care narrative (paragraph 2.3.24). 4.70 It was not until the next conference, six months later that the plan was ended when it became clear that “the separation in October has continued and appears to be final for Mrs A and the children,” Children’s Social Care Narrative (paragraph 2.3.24). 4.71 This is not to say that other problems were not being discussed but it may be that they were not given the same level of importance. 4.72 School 2 completed a “general risk assessment” when considering whether to allow David A to remain at school during the police investigation. This was a series of questions relating to What sort of harm? Who to? How likely? What can be done to reduce the risks? 4.73 This was a thorough piece of work and resulted in a good and supportive decision being made to support David A. Were David A and his family offered appropriate services to help meet their needs throughout the time period? 4.74 David A and his family were offered a range of services from different agencies. These were: a) Family therapy for all four members from CAMHS and 117 b) Couple counselling for Mr A and Mrs A from CAMHS and Southside Family Project c) Mentoring Plus for David A d) Advocacy for David A and Susan A 25 | P a g e e) Compass project which aims to engage with young people at risk of offending for David A f) BADAS, (New Highway and DHI) alcohol support for Mrs A g) Focus Counselling h) Strengthening families, Strengthening Communities, parenting support for Mrs A i) Cognitive Behaviour Therapy for David A j) Young Carers for Susan A k) Relateen for David A l) Allocation of a social work Assistant for David A 4.75 In addition there was a range of other professionals: GPs, teachers, police officers and social workers who were involved with the family. 4.76 Most IMR authors expressed the view that these services were appropriate though it is unclear how many of them were for David A and were focused upon his suicide ideation. The Children’s Social Care IMR author noted that “Mr A was not offered any additional specialist services” Children’s Social Care IMR, (paragraph 4.9.9) indicating that there may have been some omissions. 4.77 It is difficult to discover how effective these services were and how long some of them remained working with the family. Many are confidential counselling services who had nothing of import to pass onto the review. 4.78 Although there were services available and made use of by all members of the family at certain points there appeared to be no coordination or measurement of the effectiveness of the services. The primary aim of these interventions should have been to improve David A’s and Susan A’s emotional well-being, any other objectives should have been secondary. 4.79 The main opportunity for this co-ordination to have taken place was during the child protection conference process. It failed in this regard because the objectives set in the protection plan did not focus heavily enough upon David A’s well-being. 4.80 One activity not mentioned as a service in the IMRs, but according to David A an effective intervention, because it increased his self-confidence, was his membership of the sports club. 4.81 Professionals can often fail to see the value of community and universal services and this, along with the counselling services at School 2 should have formed an integral part of any child protection or child in need plans developed for David A. 4.82 CAMHS involvement with David A took place between January 2007 and October 2009. It has been well documented in this report and their IMR that their view was that David A should not be seen alone because that located the problem with him rather than with the family discord. Consequently “…there were no systematic arrangements for the assessment of David A’s mental and physical health and social care needs and the degree of risk regarding self harm and vulnerability to exploitation or accidental harm,” Oxford Health NHS Foundation Trust, (page 12). 4.83 CAMHS attempted to improve the relationship between the parents but “when this failed to reduce the risks to David A, he was felt (sic) disconnected from further systematic re-assessment and support from CAMHS,” Oxford Health NHS Foundation Trust, (paragraph 4.9). 26 | P a g e 4.84 CAMHS staff saw David A alone on four occasions and with family members a further 18 times. CAMHS staff were available for consultation with parents and professionals and were responsive when called. It was unfortunate that their expertise was not harnessed more thoughtfully as part of a multi-disciplinary approach to David A. 8 WORKING WITH MR AND MRS A 4.86 Both parents engaged with services; Mrs A was the person who most often attended meetings and sustained her involvement in parenting classes; Mr A’s involvement with specialist services was more sporadic although he consistently stayed in contact with School 2. Mrs A 4.87 It appears some services (in particular the parenting classes) may have been provided to Mrs A because they were available rather than as part of a planned and co-ordinated approach to meeting the identified needs of David A and Susan A. For example there is little evidence in the Social Care records of contact with services like BADAS, Southside Family Project and Strengthening Families, Strengthening Communities. It appears therefore that there was a lack of objective setting and monitoring of these services and it is consequently difficult to see how these services were helping Mrs A and whether, as a consequence this was helping David A and Susan A. 4.88 The Children’s Social Care IMR author considers that Mrs A may have been exhibiting disguised compliance. “Mrs A’s engagement with CSC is characterised by asking for help and seeming to engage with services; giving the impression that she is making use of advice, but not taking actions………. It is likely that Mrs A’s behaviour was ‘Disguised Compliance,’” Children’s Social Care IMR, (paragraphs 4.19.3 and 4.19.4). 4.89 The term ‘disguised compliance’ was first used by Reder, Duncan and Gray in their book Beyond Blame (1993), a study of thirty five child death inquiries. The term described situations where parents appeared to agree to plans and to co-operate with professionals, but in reality their commitment was superficial and designed to placate, obscure and disguise their lack of compliance. 4.90 Brandon and colleagues further explored the concept of disguised or partial parental compliance in their overview reports of child death inquiries (2008, 2009) where they found it often prevented or delayed understanding of the severity of harm to the child, leading to situations where professionals would tolerate a longstanding lack of progress, all the while accepting excuses from parents and losing an objective view of what was happening. -- 8 A reference to Children’s Social Care 27 | P a g e 4.92 Professionals identified two problems in Mrs A’s life that were impacting negatively upon David A: her relationship with Mr A and her drink problem. Mrs A addressed the first of these issues by being, by her and Mr A’s account, the main instigator of their separation. She was less successful in addressing the second issue though she did attend counselling sessions at BADAS, (and later at New Highway and DHI). 4.93 Labelling her behaviour as “disguised compliance” misses the fact that the problem that Mrs A failed to address was her alcohol misuse; a hugely difficult problem to overcome and one that she had first mentioned to a professional, her health visitor, in 1998 when she said she “fears that her only company is alcohol,” joint chronology, February 1998. 4.94 The problem was not that Mrs A was disguising compliance but was probably struggling to overcome her drink problem. Professionals either failed to understand the impact that her drinking was having on David A, or they failed to take action to address it. 4.95 This should have been a fundamental part of the care plan developed after the child protection conferences with measurements set, not for Mrs A’s reduction in drinking, but the impact that her drinking was having on David A’s and Susan A’s well-being. Mr A 4.96 Mr A’s interaction with professionals varied between positive and negative. School 2’s staff formed a good relationship with Mr A; their IMR pointed out that he regularly attended parent evenings. Mr A praised Education Welfare Officer 1 and her manager, Education Welfare Manager 1, in his letter to the second review conference for helping him to sort out the new school for David A saying that this has been achieved through “giving discipline and guidance a teenage boy needs without third party interference and ‘pie in the sky’ ideas”, (letter to review conference). Mr A’s interaction with children’s social care workers is described by the social care IMR author as “often resorting to hostility” children’s social care IMR, (paragraph 4.19.2). There are times when Mr A loses his temper with professionals, an example being his telephone discussion with Social Work Manager 1 which finishes with him telling her that, “if I can get any reprisal for this I will” children’s social care IMR, (paragraph 4.19.2). 4.97 There appears to be, as far as the social work records and reports are concerned, a lack of consideration about why Mr A may be behaving in this way. In particular there appears to be no acknowledgement that Mr A did not agree with the way in which social workers and CAMHS professionals were dealing with David A; he did not share their view of the problem. 4.98 Mr A’s view, as described to the panel chair and the author of this report, was that there was nothing wrong with David A mentally and that “pie in the sky” ideas weren’t the answer; instead David A needed discipline and to be made to go to school. He told us that he couldn’t understand why, for example, when David A was refusing to go to school, he was rewarded by social workers with trips to the cinema. 4.99 In conversation with the chair of the panel and the overview author of this report Mr A said that meetings were often held in office hours. Given that he was a self-employed worker on building sites this would mean that he would have to lose a day’s pay to attend. He mentioned this in his letter to the core group meeting of 24th January 2010. 28 | P a g e 4.100 The Oxford Health NHS Foundation Trust IMR author stated that “CAMHS staff tried hard to meet both parents and appointments were arranged at times to suit Mr A” Oxford Health NHS Foundation Trust (paragraph 4.19), though when asked for evidence admitted that “I know that one evening appointment was attended, but am unable to say how many were offered” e-mail to author 10/05/13. 4.101 A letter from CAMHS to Mr A on 13th March 2008 which includes: “Please can you tell us when you would be able to take a day off to come here to a daytime appointment, and we will see if we can manage that,” Joint chronology (13/03/08) appears to neither support the IMR author’s view nor be very welcoming. 4.102 The health overview report author shares this view stating that she “would question how accessible the service (CAMHS) was/is for working parents,” SCR health overview report, (page 30). 4.103 This report appears to be criticising CAMHS only for not offering services out of office hours but this is likely to be true for most service provision. It appears to be the case that all child protection, strategy and core group meetings took place in office hours; all likely to hinder the involvement of school age children and working parents. On the other hand CAMHS workers and social workers told the author of this report that they often visited the family after office hours. 4.104 In conversation with the chair of the panel and the author of this report Mr A expressed the view that the social work intervention was predicated upon getting him to leave the family and him being the problem. He wrote to a core group meeting “any report puts me as the root of the problem. Now that I have been pushed out of the family I regret to inform you that nothing has changed for the better”. 4.105 This is not to say that his view was necessarily right but that professionals needed to consider whether Mr A’s lack of engagement and aggressive behaviour might have come not from a psychological failing but have been a manifestation of his frustration about the services that were being provided to him and his family. 4.106 The children’s social care IMR author questioned the rationale behind some of the social work decision making following the referral from advocacy service in November 2010. “The question arises, whether there was an element of stereotyping that influenced social workers in their course of action. Would CSC have left David A with his father (Mr A) if he was exhibiting his mother’s behaviours…? I would suggest the answer would be that CSC would not have left David A” children’s social care IMR, (paragraph 4.7). 4.107 In an analysis of serious case reviews Brandon et al. (2009) found a tendency for professionals to adopt rigid or fixed thinking about men. Fathers were labelled as either all good or all bad, reliable and trustworthy or the opposite, with the consequence that workers did not take the views of ‘bad fathers’ seriously. 4.108 Fathers were often labelled as dangerous, sometimes without the professional having had any direct contact with them. Whilst this label was not attached to Mr A it is interesting that the narrative of this review contains many references to Mr A not being seen and his views not being included in the assessments. 4.109 Child welfare workers tend to focus on mothers, who are seen as the primary caretakers, and exclude or at least make little effort to include fathers. 29 | P a g e WORKING WITH DAVID A 4.110 It is clear from the events in the narrative that David A was a complex young man: He came to the attention of CAMHS at the age of 11; The chronology has 30 recorded examples of David A talking to his family or to professionals about killing himself or self-harming; He self-harmed by cutting his legs; He occasionally made apparent but not serious attempts to kill himself; (it is difficult to assess exactly how serious or otherwise these attempts were as he was never seen by a professional and treated medically following one of these apparent attempts); He was arrested by the police for having chemicals which could make an explosion; He was described by professionals as school phobic; having a social phobia; and having cognitive rigidity. 4.111 In contrast the deputy head teacher from School 2, in conversation with panel members, described David A as being polite, shy, enjoying school and being like many other boys of his age. 4.112 School 2 were excellent in their handling of David A; taking a child who had refused to go to a previous school for a number of months and helping him to achieve nearly 100% attendance and 9 GCSEs (in under two years) was a remarkable achievement. This appears to have been achieved by finding out what he wanted and respecting that. In particular they respected David A’s wish to attend the school, and allowed him to have the appropriate support with as little fuss as possible considered which “House” he should be in allocated him a male tutor moved him up a set in English when he asked for this supplied funding for him to attend the battlefields tour allowed him to rejoin their 6th form shortly after his request to return to them from college. 4.113 Underpinning the school’s approach was a careful listening to and respect for the views of David A and his father. 4.114 Although the children’s social care IMR described David A as being “a difficult young person to engage with” children’s social care IMR, (paragraph 4.20.4), this appeared to be the case only with social care workers and CAMHS; and after a prolonged period when he had regularly seen social workers and CAMHS staff. It is clear from the relationship that he formed with staff from School 2 that he was easy to engage providing that: his views were respected, he could see some value in the work that he was engaging in, he wasn’t being made to look “special” (hence counselling after school). 4.115 The reason for the lack of engagement with social workers appeared to be David A’s belief that “nothing would change” children’s social care IMR, (paragraph 4.2). 4.116 As far as the child protection process was concerned David A’s wishes and feelings were discovered and included in the reports. Furthermore he and Susan A were facilitated by an advocacy service to put their points across to the child protection conferences. There appeared to be less evidence, in the child protection process, that those wishes and feelings were being taken account of when decisions were being made about the provision of services. 30 | P a g e 4.117 Before the first child protection conference in 2009, David A talked to social worker 5 about not wanting to live. This was included in her report to conference but wasn’t included in the child protection plan that followed. There was thus a difference between the risks that David A was concerned about and the emphasis from professionals whose focus, during the conference and subsequent plan was on the difficulty in the parental relationship. This type of disparity has been noted in research by the office of the children’s commissioner, (2011)9. 4.118 In some respects it did appear that David A was being listened to by social workers; he said he did not want a social worker so the case was closed. The social workers should though have taken more notice of the fact that the reason that David A no longer wanted to see them appeared to be because he didn’t believe that their intervention was helpful. There appeared to be no professional reflection about why he didn’t want to see social workers when he was engaging positively with many other professionals. 4.119 In interview with the children’s social care IMR author, social worker 7 said that she took a person centred approach with David A, “looking at where she might meet David A on his own terms, letting David A lead the conversation and using ‘problem-free talk,’” children’s social care IMR, (paragraph 4.1.3). 4.120 McLeod (2000) in her study of looked after children and their social workers found that professionals and children have very different understandings of what is involved in listening. The young people in her research had an active view of listening involving action, practical support and self-determination. The social workers by contrast generally saw listening as a more receptive and passive activity involving having a respectful attitude, offering emotional support and encouraging self-expression. Her research revealed a situation where social workers felt that they were listening to young people while those same young people said they wanted to be heard but the social workers were not listening. This may well have been the case with David A and some of the professionals with whom he was communicating. 4.121 Mrs A and Susan A wanted there to be more help forthcoming from their GPs. The B&NES General Practice IMR author noted that “There is no overall strategy from the GP team to manage engagement with David A. On numerous occasions he attended the surgery, with physical or psychological problems, but no plans are described for follow up, apart from referral or contact with other agencies”, B&NES General Practice IMR, (paragraph 4.20). 4.122 The calls from Mrs A and Susan A in July 2011 were requesting a home visit by the GPs. This was refused because, “General Practitioner 2 felt that as knives had been mentioned, this would not be safe and the police should be called if necessary” B&NES General Practice IMR (paragraph 4.20). 4.123 There is little information available about this incident but it is a poor risk assessment both in terms of the doctors and the patient. If there was serious discussion about knives, either as a threat to professionals or to David A, Susan A or Mrs A, then the GP should have been more pro-active in supporting the family or protecting other professionals. It is possible that the “mention of knives” was little more than that (a mention) and was used as an excuse to not visit. 9 ‘Don’t make assumptions’: Children’s and young people’s views of the child protection system and messages for change’ 31 | P a g e 5. CONCLUSION 5.1 David A killed himself in October 2012 and this appears to be the first serious attempt to take his own life. There are certainly no records of him harming himself so seriously previously that he required urgent medical attention. Had David A made a serious suicide attempt earlier, but survived, it is likely that his threats would have been taken more seriously. 5.2 Given the fact that David A had, on a number of occasions, said that he would kill himself but had apparently made no serious attempt to do so would suggest that his death could not be predicted simply on the basis that he made (a further) threat to kill himself. These threats, taken along with his emotional state and his feelings that “nothing had changed” (and perhaps more importantly never would change) for him should have indicated that self-harm and possibly suicide was likely. However his death came at a time when it appeared that he was more settled and his life was improving; so it is understandable that family members and professionals were not more vigilant to the danger at that time. 5.3 This review has identified a range of good practice from organisations and individuals. Whilst this conclusion will focus upon areas for improvement the review has identified that no one individual person, act or omission is responsible for the overall failure to keep David A safe. 5.4 The review has also identified that, in the later stages of his life, David A wasn’t easy for social workers and CAMHS staff to work with, because he didn’t want to see them and he was old enough and competent to make that decision. His lack of engagement with these agencies should have heightened professional realisation of risk. His father Mr A also did not want social workers and counsellors involved in his son’s life and, even when there was a serious concern expressed about David A’s safety in April 2012, - once the crisis had passed - his mother, Mrs A, and Mr A, told professionals that he was not about to kill himself. 5.5 This analysis is based upon the belief that all that could have been done to keep David A safe should have been. It has not identified any especially poor practice but it has identified a number of areas where practice could have been improved. These are: Listening to children and young people Focusing on the suicide risk that David A presented Working with fathers Analysis Setting of objectives and measurements Professionals preferring to refer rather than collaborate Rigour in assessment, planning and review. 5.6 These issues will be considered separately but, combined, they point to a failing in care planning; in particular throughout the child protection process, children’s social care, CAMHS and the GP practice. Listening to children and young people 5.7 David A was listened to, and his views acted upon, by social workers and CAMHS staff when he said he no longer wanted to be involved with them. His concerns about his mother’s drinking however may not have been listened to in a way in which the young people interviewed by McLeod in 2000 wanted – not with sympathetic glances and expressions of support, but actual action. 32 | P a g e 5.8 It wasn’t that he lacked faith in professionals; in the early days he was regularly seeing social workers, social work assistant 1 and CAMHS staff. He became disillusioned by their failure to achieve the change that he wanted. Focusing on the suicide risk that David A presented 5.9 When reading case records, reports and referrals it could almost be that the word suicide had been proscribed. The professionals at the introductory meeting for David A at School 2 recorded his “poor attendance at… School, his low self- esteem and emotional ill-health……the fractious nature of relationships at home and the impact they were having on David A” School 2 IMR (Year 9 section) but nothing about suicide. 5.10 This report and the children’s social care IMR has already covered the fact that the risks and objectives listed in the child protection plans, child in need plans and minutes of conferences failed to mention suicide. 5.11 Consequently the professional’s gaze was refocused; primarily onto the parents’ relationship difficulties. Working with fathers 5.12 Mr A was viewed as being difficult and hostile without any thought about why he may be acting in that way. Parents feel a sense of powerless in situations where professionals are involving themselves in their lives; Mr A more so than Mrs A because, traditionally fathers engage less with caring and health agencies, he didn’t want this involvement, and he didn’t agree with the action that was being taken. 5.13 Meetings were mostly held in office hours, further inhibiting his ability to participate and possibly leaving him with a feeling that his contribution to the family (the breadwinner) wasn’t held in high regard by the largely female workforce that he encountered. Analysis 5.14 Analysis was often limited to a single cause view: for example David A’s problems are caused by the parent’s relationship; when they separate – problem solved. Another example is CAMHS insistence that David A should not be seen alone as this would give him the message that he is the problem. 5.15 Child care work is full of complexity and is multi-causal; not just that but the inter-play between the causes needs consideration as well; for example the role that alcohol played in the parental relationship. Setting of objectives and measurements 5.16 Allied to single cause mentality was the failure to set child and outcome focused objectives and measurements. Aside from the measurements of David A’s school attendance there is little that is measured. 5.17 This report takes a step further. The objectives, and therefore measurements for success, should have been focused upon David A’s well-being. 33 | P a g e Professionals preferring to refer rather than collaborate 5.18 Many referrals are made to other agencies by professionals, in particular; GPs to CAMHS GPs to children’s social care Children’s social care to CAMHS CAMHS to children’s social care Children’s social care to various providers of counselling and support for parents and children Children’s social care to the Police 5.19 The long list of organisations offering support to Mrs A and David A may well have been helping them but there was no co-ordination of these services or measurement of their impact on David A’s well-being. 5.20 This is not to say that it was inappropriate for professionals from different agencies to discuss but the narrative suggests that professionals were just passing the problem onto another agency for them to deal with rather than considering what they could do together. Two examples: CAMHS reference to their child protection referral to Children’s Social Care: “Concern that if we continue to see parents this will be seen as a solution and could prevent appropriate protective action being taken by SSD” Children’s Social Care referring to the 2nd strategy meeting: “We’re not going to get involved” Rigour in assessment, planning and review 5.21 All of the above issues could be jointly included under this sub-heading. To properly protect children and young people from self-harm and suicide, health and social care professionals must ensure that they are rigorous in: involving the children and young people, their parents and schools in assessments understanding that family problems are multi, not single causal setting child and needs led objectives and measurements organising services so that they complement one another involving themselves in a multi-agency responsibility for the child’s welfare monitoring progress whether or not there is direct involvement with the family and ultimately ensuring that the word suicide is used openly and is part of the plan. 5.22 Serious case reviews often consider whether the incident that led to the review could have been predicted and prevented. There are 30 references in the chronology to recordings made about David A making references to suicide and self-harm and he often said that things weren’t any better. On the other hand, at the time of his death, his life appeared to be going well, he had enjoyed being the best man at his father’s wedding, his father and he were building an extension to the house so that he could move in with him and he had achieved good grades at GCSE. 34 | P a g e 6. LESSONS LEARNED 6.1 There was good practice demonstrated by a number of individual professionals. These included: the social work assistant who kept contact with David A; The advocacy service at the initial child protection conference; the social work assessments produced by social worker 3 and social worker 5; School 2’s ability to work with David A, Mr A and Mrs A; o their risk assessment and counselling sessions; CAMHS psychiatrist 2’s continued involvement and attempts to support other staff members; the counsellors who did engage with David A; the assessments and actions carried out by the police. 6.2 School 2 described how they went about welcoming David A. “Senior Staff 1 and… Senior Staff 3 looked to provide a structure where we knew the tutor would provide clear routines, high expectations and strong support in a caring and sensitive way as a male tutor(School Staff 1) As David A was living with mum we felt it would be beneficial to have a male tutor,” email to overview author (01/05/13) 6.3 The practices that caused concern inevitably provide the many lessons contained in this serious case review; most have been identified before, poor assessment and care planning for example, and many agencies in Bath & North East Somerset have already learnt these lessons and implemented change. 6.4 CAMHS’ referral criteria are more defined and, if David A were to be referred to them now, he would be offered services via their outreach service. They now routinely use the care planning approach, (CPA). Their IMR describes the difficulties that the lack of this approach had for David A, “the lack of the CPA meant that care planning, regular review with other key professionals and having an identified care coordinator was absent…Consequently as the focus of the service quickly identified the primary need was to work to change the parental behaviours, there were no systematic arrangements for the assessment of David A’s mental and physical health and social care needs and the degree of risk regarding self harm and vulnerability to exploitation or accidental harm,” Oxford Health NHS Foundation Trust, (page 12). 6.5 Children’s social care has developed a care pathway for young people who are vulnerable to suicide, included as appendix two to this report. This details the steps that should be taken by various professionals and sets targets for how quickly children and young people should be seen. It routinely includes the phrase “Child’s wishes and feelings to be sought and recorded”. Whilst this was done in David A’s case the panel believe that more should have been done, such as really considering his views. 6.6 David A's wishes and feelings were sought and recorded at times during his engagement with services but not consistently so. There were critical times when the implications of his wishes and feelings were not properly considered e.g. the ending of the child protection plan when he was reported to be feeling no differently despite the changes at home. More should have been done to fully consider and seek to understand why he thought and felt the way he did. Professionals often seemed to rely on others' reports of David A's views rather than exploring with him how he saw his situation. 35 | P a g e 6.7 The child protection process may need changing if it is to remain the primary avenue for co-ordinating the care of young people who are threatening suicide and are considered to be at risk of significant harm. It will need to realise that as children get older, they become increasingly vulnerable to a broader range of risks, (Gorin and Jobe 2012) and chairs will need to develop skills in including and focusing upon the young person in a way which is different to the younger children who they are more routinely discussing. All child protection plans should include measurements that are focused upon outcome, not process as was the case with David A. 6.8 Services sometimes see fathers as ‘all good’ or ‘all bad’ and do not always give due consideration to why fathers may appear to be hostile or disengaged, when they have a crucial role in their children’s lives. 36 | P a g e 7 RECOMMENDATIONS 7.1 The IMRs produced for this review have identified a number of single agency improvements that can be made, many of which have been implemented already. 7.2 This report has the task of identifying recommendations that may have been missed by single agencies and recommendations that relate to multi-agency working. 7.3 The overview author believes that a small number of recommendations aimed at a high level achieve more change than a large number of detailed recommendations. This report therefore makes just six. 7.4 The care pathway designed for use with young people who are talking of suicide contains four references to the following action: “Childs wishes and feelings to be sought and recorded”. David A’s wishes and feelings were sought and recorded: however the plans that were identified did not effectively address his concerns. Therefore Recommendation One (a): Further words be added to the four references to child’s wishes and feelings in Bath and North East Somerset’s care pathway for identifying children and young people vulnerable to suicide. This will therefore read: “Child’s wishes and feelings to be sought, understood, genuinely considered, recorded and, as appropriate, acted upon”. 7.5 The Care Pathway may not emphasise the risk that young people face. Therefore Recommendation One (b): That the following be added to the right of the Pathway: “At any stage refer to children’s social care if child at risk of significant harm through their own behaviour or if no parental engagement/agreement re treatment plan.” 7.6 This review has identified further guidance for working with young people who are threatening suicide and this is included as appendix three. Recommendation One (c): That the LSCB Review and strengthen the care pathway for children and young people vulnerable to suicide using the specialist advice (appendix three) that has informed this review. 7.7 Social workers at the feedback meeting with the author of this report and the chair of the review reported that neither they, nor their manager were aware of the care pathway. Recommendation One (d): That the LSCB ensure that the reworded care pathway be made available to all staff throughout LSCB agencies and that a review be carried out, three months later, to monitor the awareness of the Pathway and its usage. 7.8 This report recognises that it is less common for young people to be protected via the child protection process and accepts that chairs of conferences may lack skills in this area. Recommendation One (e): All child protection chairs should be supported to develop their knowledge of risks and needs of young people talking about suicide and how to appropriately address these in the child protection process. 37 | P a g e 7.9 This review has recognised that talking with a young person expressing suicidal thoughts requires particular skills. Recommendation One (f): That the LSCB develop an on-going, child-focussed, core training program to equip professionals to respond appropriately to young people who are talking about suicide and that this should be targeted at particular front-line groups (e.g. health visitors, social workers, chairs of conferences) and that this training be based around the updated care pathway for identifying children and young people vulnerable to suicide. 7.10 This review has identified that the action plan set during the child protection process did not address David A’s suicidal threats or his emotional well-being and that an emphasis was placed upon the parents’ separating. This report has identified that the objectives, and therefore the measurements set at the review, were not child focused and needs led. The LSCB sign off meeting in July 2013 confirmed that this issue has already been recognised and is not exclusive to this case Recommendation Two: The LSCB to commission work to ensure that staff are trained in outcome led thinking and child protection and child in need plans are written with needs led outcomes and measurements. 7.11 This report has identified that staff appeared rarely to speak directly with David A about his threats of suicide. The author of this report recognises that this is not easy and understands that professionals may need support in this matter. A series of training courses for key members of the LSCB agencies may therefore help to address this providing that the participants become ambassadors for supporting staff in working with young people who are threatening suicide. Recommendation Three: That the LSCB targets training for senior or experienced members of staff chosen to represent a cross section of workplaces and agencies and supports those members of staff in being a resource or in becoming leading practitioners in their agencies to assist other staff in working with young people who are talking about suicide. 7.12 This review has identified that child protection meetings, review meetings and core groups took place during school and work hours thereby reducing the opportunity for David A and his father to attend. It also identified that GPs were never present and that this was because of the fact that the meetings are held at such a time that a whole clinic would have to be cancelled for a GP to attend. Recommendation Four: That child protection conferences, reviews and core group meetings take place: a) out of school hours if it would be useful for children and young people to be present, b) flexibly and therefore not rigidly between the hours of 9am – 5pm if working parents are involved in the family c) at times and places that maximise the potential for GPs to be present in cases where they are key members. 7.13 This review has identified that Mr A felt disassociated from the social work, CAMHS and child protection processes. Recommendation Five: Social care and health staff need to develop skills in working with fathers, finding approaches which accommodate the different ways in which men respond to problems compared to women. These should include times of formal meetings in which working parents are seen, assessments not being signed off as completed by managers until fathers have been seen and their views considered and included and the positive impact that fathers have on their children’s lives being added to a review. 38 | P a g e 7.14 Mrs A and Susan A identified their GPs as being key professionals, but the GPs were not particularly involved in the child protection process. Recommendation Six: That the LSCB commission or complete internally a review identifying the extent to which GPs attend child protection conferences, and if appropriate, the reason why the attendance is low with a view to identifying a plan to improve the representation of GPs at conferences. In particular the review should compare GP attendance at child protection and vulnerable adult conferences. 39 | P a g e REFERENCES BASPCAN (2012) A Study of Family Involvement in Case Reviews: Messages for Policy and Practice Bayley, J., Wallace, L.M. & Choudhry, K. (2009) Fathers and parenting programmes: barriers and best practice. Community Practitioner, 82 (4), 28–31. Berlyn, C., Wise, S. & Soriano, G. (2008) Engaging fathers in child and family services. Participation, perceptions and good practice. National Evaluation Consortium, Social Policy Research Centre, at the University of New South Wales, and the Australian Institute of Family Studies, Australia. Brandon, M., Belderson, P., Warren, C., Gardner, R., Howe, D., Dodsworth, J., and Black, J., (2008) Analysing child death and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003‐5, Department for Children Schools and Families, Research Report Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J. et al. (2009) Understanding Serious Case Reviews and Their Impact: A Biennial Analysis of Serious Case Reviews 2005–2007. Research report DCSF-RR129, London, DCFS. . Colquhoun, F; (2009) The relationship between child maltreatment, sexual abuse and subsequent suicide attempts NSPCC Cossar, J. and Long, C. (2008) Children and Young People’s Involvement in Child Protection Processes in Cambridgeshire, CWDC Practitioner-Led Research project. Durkheim, E., Spaulding, J., Simpson, G. Suicide (1897) Simon & Schuster Fox and Hawton (2004) Deliberate Self-Harm in Adolescents Jessica Kingsley Publishers Gorin, S. and Jobe, A. Young People Who Have Been Maltreated: Different Needs—Different Responses? British Journal of social work (2012) Hawton K, Harris L (2008) Deliberate self-harm by under 15-year-olds: characteristics, trends and outcomes. Journal of Child Psychology and Psychiatry. 49, 4, 441-448. Madge, N & Harvey, J (1999); Suicide among the young: the size of the problem. Journal of Adolescence, 22, 145-155 Makhija and Sher (2007), Childhood abuse, adult alcohol use disorders and suicidal behaviour QJM An International Journal of Medicine Volume 100 Issue 5 Pages 305-309 McLeod, A. J. (2000) Listening but not Hearing: Barriers to Effective Communication Between Young People in Public Care and their social workers, Lancaster: University of Lancaster. Ph.D. Thesis. NSPCC (2009) Young people who self-harm:Implications for public health practitioners NSPCC Inform Office of the Children’s Commissioner: ‘Don’t make assumptions’: Children’s and young people’s views of the child protection system and messages for change’ March 2011 Reder, P; Duncan, S & Gray, M; (1993) Beyond Blame: Child abuse tragedies revisited Routledge Rees, G., Gorin, S., Jobe, A.., Stein, M., Medforth, R. and Goswami, H. (2010) Safeguarding Young People: Responding to young people aged 11 to 17 who are maltreated, London, The Children’s Society. Department of Children, Schools and Families (2006) Working Together to Safeguard Children TSO Woolfson, R.C., Hefferman, E., Paul, M. and Brown, M. (2009) Young People’s Views of the Child protection System in Scotland, British Journal of social work 40 | P a g e APPENDIX ONE Bath and North East Somerset Local Safeguarding Children Board Serious Case Review November 2012 TERMS OF REFERENCE The core purpose of the Serious Case Review is for agencies and individuals to learn lessons to improve the way they work both individually and collectively to safeguard and promote the welfare of children. In this serious case review the following questions will be particularly explored to assist in this learning. (This will not limit the exploration of further relevant questions that arise as a result of review activities.) The Serious Case Review was initiated as a result of David A’s death in October 2012 and needs to consider the circumstances leading up to his death and how agencies worked together but also needs to consider an earlier period when agencies were actively involved with David A and his family, including when he was subject of a child protection plan. The panel have determined that agencies should in their IMR’s cover the period from January 2007 until October 2012. However agencies should look also at events/involvement prior to 2007 and include these in their chronologies. Where relevant they should reflect on these in their narrative and final reports. For some agencies there has been significant involvement (or little but nonetheless of significance) with this child/family prior to 2007 and it is important that these are included and inform the IMR. 1. Were David A and his family offered appropriate services to help meet their needs throughout the time period? 2. Was information clearly and appropriately shared between organisations? 3. Was there appropriate shared assessment of the level of risk between relevant agencies throughout the time period? 4. Were actions taken by individual agencies appropriate to address the assessed risks? 5. Was there a well-informed, robust multi-agency assessment of the risks of significant harm that informed the decision to end the child protection plan in March 2010? 6. Was the decision to end the child protection plan consistent with the assessment of risk? 7. Was appropriate support offered to David A as a child in need following the end of the child protection plan? 41 | P a g e 8. Did the strategy discussion in February 2012 take appropriate account of David A’s history? 9. Following the strategy discussion in February 2012 was there appropriate information sharing between agencies? 10. In particular was there a shared assessment of the level of risk of suicide in April 2012? 11. Were there effective strategies to manage differing levels of parental engagement with services? 12. Were there effective strategies to manage differing levels of engagement from David A? 13. Did agencies work effectively across the boundaries of Bath & North East Somerset and Wiltshire? 42 | P a g e APPENDIX TWO Care Pathway for identifying children and young people vulnerable to suicide working together for health & well-being Early Identification Early Support/ Identification and Assessment Schools- discuss with Designated Teacher and school nurse and agree next steps School nurse to monitor and may liaise with or refer to GP/CAMHS School Nurse to check child receiving appropriate support Agencies – consult/refer to school nurse/GP/CAMHS Prevention/Health Promotion Identification and specialist consultation School staff; school nurse; Connexion Advisors; CAMHS; YP services; adult services; substance misuse services; DV services; A&E; Foster Carers, Social Workers, parents, GP, Health Visitor, LAC nurse, early years Consult CAMHS or GP. If; Low Concerns – agency to refer back to school nurse or GP continue monitoring at practice High Concerns – GP/CAMHS undertake immediate assessment Preventative programmes i.e. Seal programme, FRIENDS, school nursing, PSHE, early years Childs wishes and feelings to be sought and recorded At any stage refer to Social Care as child at risk or significant harm if no parental engagement or agreement re treatment plan. Stage of pathway Childs wishes and feelings to be sought and recorded 43 | P a g e Longer term support Treatment Referral and Specialist Assessment Emergency referrals – seen within 24 hours Tel. 01173604040 Urgent referrals to be seen within 7 working days by core CAMHS team for assessment Treatment by CAMHS and consultation with social care re support/intervention with family Work with all agencies to address issues arising within the family, child and environment Consider outpatient/inpatient treatment And best course of treatment in each case Childs wishes and feelings to be sought and recorded Childs wishes and feelings to be sought and recorded 44 | P a g e APPENDIX THREE Risk Assessment The initial encounter with a young person who is expressing suicidal thought is critical, and the formation of a therapeutic relationship requires that it be conducted in a calm, confident, empathetic, and patient manner. A thorough history must include psychiatric history, previous suicide attempts, and history of familial suicide; this paper contains a series of questions that will assist. Discussing suicidal ideation and plans, including actual plans, access to the means and lethality of the plan is imperative. It is recognised that someone who has self-harmed is at greater risk of suicide than the general population. However, this does not mean that everybody that has self-harmed is an immediate suicide risk. One of the factors that should influence any risk assessment is whether the young person, and where relevant their parents/carers, is willing to engage with support services. If not this will potentially increase the level of risk. Where a family is referred for support by another agency but refuse to engage that agency should be contacting social care to discuss how best to respond to this. Agencies will need to consider all available options to manage such circumstances. Suicidal intent has been found to be a good predictor of subsequent attempts. A 15-year prospective study of 80 formerly psychiatrically hospitalised adolescents who had had several suicide attempts showed that highest intent and lethality (i.e. potential to cause death) were better predictors of future attempts than intent and lethality of the most recent attempt10. Put another way: the better means of prediction for suicide in the future is by looking at the most severe previous attempt in terms of possibility of death and seriousness of wish, as opposed to these factors in the most recent suicide attempt. For example if someone had made a dozen attempts with minor overdoses and always sought help at A&E in the last year they could be considered not to be too risky, but if they had also 18 months ago tried to cut their throat and needed a transfusion as they lost so much blood, their risk would be seen to be considerably higher due to higher intent and lethality although historical. Protective factors are as important as risk factors, such as family cohesion, religious beliefs, significant relationships, supportive environments and core values. What to do if a young person expresses suicidal ideation Form a good relationship, be empathetic and reassure regarding confidentiality Assess current mental health - determine symptoms (including duration and mode of onset) and associated disturbances e.g. sleep, school performance and friendships, family structure, appearance, behaviour, speech, phobias, obsessions, mental state examination, emotional symptoms, somatic symptoms, disturbance in relationships, speech and language, thinking, motor, antisocial and defiant behaviour Determine any support networks available to the young person Determine risk of further harm or suicide, using the questions below. 10 Sapyta J, Goldston DB, Erkanli A, et al; Evaluating the predictive validity of suicidal intent and medical lethality in youth. J Consult Clin Psychol. 2012 Apr;80(2):222-31. 45 | P a g e 1.2 The following should be covered in a risk assessment Violence and aggression Has the young person a history of violence? Does the young person misuse drugs/alcohol? Is the young person experiencing delusions of persecution? Has the young person made specific threats to harm others? Has the young person expressed thoughts/fantasies of harm to others? Does the young person have a history of antisocial behaviour? Is the young person impulsive/displays emotional liability? Does the young person have a history of rootlessness/social restlessness? Does the young person have a history of problems maintaining stability in relationships? Does the young person have a history of non-compliance/disengaging/DNA's with aftercare? Has the young person recently been under significant stress? Does the young person deny or minimise previous incidents of violence? Is there any evidence of violence within the young person social network (family/peers)? Have significant others expressed concern about the young person's risk(s)? Suicide Does the young person have a history of suicide attempts? If so, did (s)he use a violent/perceived lethal method? Has the young person made a plan to end their life? Is the young person expressing suicidal ideation? Is the young person expressing feelings of hopelessness? Does the young person expressing high levels of subjective distress(from psychotic symptoms/situation)? Does the young person express feelings of having no control over their life? Does the young person misuse drugs/alcohol? Does the young person display impulsively? Does the young person live alone? Does the young person have poor physical health? Has the young person recently suffered significant loss/threat of loss? Has the young person recently disengaged with care/stopped medication? Has the young person recently been discharged from hospital? Is there a family history of suicide/self harm? If Yes, please give details. Self neglect Does the young person have a history of previous self-neglect? Is the young person failing to eat or drink properly? Does the young person have difficulty managing their physical health? Is the young person unable to look after his/her own hygiene? Does the young person have difficulty communicating their needs? Does the family have significant debt due to regular difficulties, managing their finances? Is the family/individuals accommodation inadequate to meet their needs? Is there a threat of eviction? Does the young person deny problems perceived by others? Other risks Is there any evidence from the young person's history or current presentation of: Risk of wandering? (give details) Risk of sexual offences/inappropriate sexual behaviour? 46 | P a g e Risk of deliberate fire setting? Risk of deliberate self-harm? (e.g. cutting) Risk of other self-harm? (e.g. eating disorders) Risk of abuse or exploitation from others? (sexual/financial/physical/emotional) Risk of cultural isolation? Risk of accidental injury Risk of absconding if an Inpatient? Other: Is the person a young carer? What are the young person’s support systems? What protective factors does the young person have? A number of screening tools are available and appropriate for use in the primary care setting, (see list at the end of this paper). Principles in Working with Young People that Self-harm The following core values are recommended by Truth Hurts: Report of the National Inquiry into Self-harm among Young People. MHF 2006 Full involvement and consultation with young people to ensure that service delivery is well grounded in their view A clear underpinning approach or philosophy: that is, a working definition of what self-harm means and of the reasons why young people self-harm, and services based on this thinking Clear and consistent service provision goals/objectives – including short term plans and long term goals, and a clear knowledge of what the service can offer Comprehensive training for all members of staff specifically on self-harm, with appropriate debriefing/ supervision procedures built into day-to-day work and clinical supervision where appropriate Outputs and outcomes that are collected and monitored – in other words, an ethos of action research and self-reflection. These data makes it possible to see what works and why, and modify or enhance the service Integration with a very broad range of other services that are relevant to young people and families Papyrus (Prevention of young suicide) Recommend that young people who communicate thoughts of suicide, or who have attempted to harm themselves need to be seen quickly taken seriously treated with empathy, kindness and understanding Followed by a full assessment by staff trained in suicide risk assessment and prevention methods fast track referral if deemed necessary frequent, regular contact with the same key worker or other mental health professional 47 | P a g e if required, easy access to appropriate inpatient care in accommodation suitable for their age group advice on what to do to manage their suicidality given information on how to access immediate help in a crisis, understand what has happened details of contacts and organisations that can give support, chat rooms, websites etc What Young People Want Frequent, regular contact with the same professional Access to other options Emotional support Knowledge and information about depression and anxiety Appropriate responses Readily available support People working together Action to be taken based upon their views Care plans Discuss, agree and document the aims of longer-term treatment in the care plan with the person who self-harms. These aims may be to: prevent escalation of self-harm reduce harm arising from self-harm or reduce or stop self-harm reduce or stop other risk-related behaviour improve social or occupational functioning improve quality of life improve any associated mental health conditions. Review the person's care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year. Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others. Care plans should: identify realistic and optimistic long-term goals, including education, employment and occupation identify short-term treatment goals (linked to the long-term goals) and steps to achieve them identify the roles and responsibilities of any team members and the person who self harms include a jointly prepared risk management plan be shared with the person's GP include a risk management plan and crisis plan 48 | P a g e Useful assessment tools NICE advise the following ~ “All healthcare professionals should routinely use, and record in the notes, appropriate outcome measures (such as those self-report measures used in screening for depression or generic outcome measures used by particular services, for example Health of the Nation Outcome Scale for Children and Adolescents [HoNOSCA] or Strengths and Difficulties Questionnaire [SDQ]), for the assessment and treatment of depression in children and young people”. “Children and young people of 11 years or older referred to CAMHS without a diagnosis of depression should be routinely screened with a self-report questionnaire for depression (of which the Mood and Feelings Questionnaire [MFQ] is currently the best) as part of a general assessment procedure” “Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer-based instruments (such as Kiddie-Sads [K-SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) could be used for this purpose but will require modification for regular use in busy routine CAMHS setting” Others are: Columbia Suicide Screen, the Risk of Suicide Questionnaire, the Suicidal Ideation Questionnaire (SIQ), the Suicidal Ideation Questionnaire JR (SIQ-JR), Diagnostic Predictive Scales, the Suicide Risk Screen and the Suicide Probability Scale 49 | P a g e Useful websites Multicentre Study of Self-harm in England: Outcome of self-harm, including repetition and mortality http://cebmh.warne.ox.ac.uk/csr/mcm/publications/outcomes.html Multicentre Study of Self-harm in England: Epidemiology and trends in self-harm in the study centres http://cebmh.warne.ox.ac.uk/csr/mcm/publications/outcomes.html The Keith Hawton, Karen Rodham, Emma Evans, Rosamund Weatherall, paper http://www.bmj.com/content/325/7374/1207 Paul Moran, Carolyn Coffey, Helena Romaniuk, Craig Olsson, Rohan Borschmann, John B Carlin, George C Patton http://blogs.rch.org.au/cah/files/2011/11/The-natural-history-of-self-harm-from-adolescence-to-young.pdf NICE C133 Self-harm http://www.nice.org.uk/nicemedia/live/13619/57179/57179.pdf NICE depression in children and young people CG28 http://www.nice.org.uk/guidance/CG28 Truth Hurts http://www.mentalhealth.org.uk/publications/truth-hurts-report1/ 1` PAPYRUS http://www.papyrus-uk.org/ |
NC049494 | Significant neglect of a 7-year-old child and 22-month-old sibling in 2015 because of parental substance misuse and alleged domestic abuse. The children were living with their mother in a privately rented flat where the home conditions were so poor that when professionals gained access to the accommodation it was deemed unfit for human habitation. The older child was found to have a significant disability which had not been addressed, and which means that there will be a need for lifelong medical treatment. Learning includes: failure to register a child with a GP is a risk factor for neglect; babies discharged home after birth with no professional oversight of home conditions is a risk for children born to vulnerable mothers; lack of system for 'late starters' in schools means that children who start later in the term may not see the school nurse; perception that health visitors should not make unplanned visits. Recommendations include: consider the feasibility of a system for raising alerts on children not registered with a GP for longer than three months; guidance to midwifery staff requiring that all women receive a postnatal visit at their normal address; all agencies to provide assurance that their assessment processes enable the effective involvement of fathers, partners and other men within the household.
| Title: Report of the serious case review regarding Family ‘S’. LSCB: East Sussex Local Safeguarding Children Board Author: Fiona Johnson Date of publication: 2018 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review published 13.03.18 1 REPORT OF THE SERIOUS CASE REVIEW REGARDING FAMILY ‘S’ Author: Fiona Johnson Serious Case Review published 13.03.18 2 CONTENTS 1. INTRODUCTION 1.1 Background to the review and summary of the case P 3 1.2 The Terms of Reference P 3 1.3 Review process P 3 1.4 Parallel processes P 4 1.5 Family input to the review P 4 1.6 Methodological comment and limitations P 5 2. SUMMARY OF FACTS 2.1 Family details P 6 2.2 Timeline of events P 6 2.3 Appraisal of Practice P 8 3 ANALYSIS P 16 4 CONCLUSIONS P 26 5 RECOMMENDATIONS P 27 Appendix 1 IMR recommendations P 28 Appendix 2 Terms of Reference P 31 Appendix 3 Glossary of Terms & Abbreviations P 34 Serious Case Review published 13.03.18 3 1 INTRODUCTION 1.1 Background to the serious case review and summary of the case 1.1.1 This serious case review concerns two children aged 7 years, and 22 months who experienced significant neglect, because of parental substance misuse and alleged domestic abuse. The children were living with their parents in a privately rented flat and the home conditions were so poor that when professionals gained access to the accommodation it was deemed unfit for human habitation. Additionally, the older child was found to have a significant disability which had not been addressed and therefore means there will be a need for lifelong medical treatment. 1.1.2 The situation of the children was only identified when neighbours in the flat below reported seepage of an offensive liquid through the ceiling and the landlady visited and was so concerned at the conditions in the house that she contacted children’s social care (CSC) leading to an immediate joint response by social workers and the police. The parents were immediately interviewed by the police under caution and the children were placed with their grandparents. 1.1.3 The case was referred to the LSCB by Health agencies for consideration of a possible serious case review because ‘abuse or neglect was known or suspected’ and ‘a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child’ (HM Government, 2015 p73). The Case Review Committee considered the matter on 18th January 2016 and recommended to the Chair of the Local Safeguarding Children Board that a serious case review should be commissioned. The Chair, Reg Hooke confirmed this decision on 25th January 2016. 1.2 The Terms of Reference The specific terms of reference are attached as appendix 1 but all agencies were asked to complete Individual Management Reviews (IMRs) reporting on their involvement with the family and analysing how well that input addressed the needs of the children and safeguarded their well-being. The time frame of the review was from January 2008 (soon before the birth of the older child) until 17th November 2015 when the home conditions were discovered. 1.3 Review process 1.3.1 The review was conducted in accordance with Working Together 2015 guidance that: recognises the complex circumstances in which professionals work together to safeguard children; Serious Case Review published 13.03.18 4 seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings’. (HM Government, 2015 p74) Further detail about the methodology used for the review is included in Appendix one. 1.3.2 The overview report was completed based on information provided in the IMRs. The overview author was also provided with executive summaries from previous serious case reviews held in East Sussex that were considered to be relevant. The overview author was also given access to some relevant CSC assessment reports. The author also saw education records from the school attended by the older child. 1.3.3 Frontline practitioners were also involved in a workshop at which the Lead reviewer reported on initial findings from the review. There were productive discussions between members of the review team and practitioners about whether the issues identified in the review were usual practice and how they could be best addressed. 1.3.4 The Panel considered at all stages how early learning could be shared with relevant agencies and staff. The recommendations and action plans will be shared with staff and implemented immediately where possible. 1.4 Parallel processes 1.4.1 At the time of the review there was consideration of prosecution of the parents for neglect. The police first submitted to the Crime Prosecution Service (CPS) for charging advice in February 2016 and their recommendation was that it was not in the public interest to prosecute the parents. The police appealed against this decision and eventually in June 2017 the CPS recommended that the parents were cautioned for child cruelty contrary to section 1 of the Children and Young Persons Act 1933. This had happened with both parents by July 2017. 1.5 Family input to the review As the parents were potentially facing criminal charges at the start of the review, the review team felt it to be inappropriate to involve them at that stage. Once the criminal process was ended attempts were made to contact both parents. Serious Case Review published 13.03.18 5 Unfortunately, father’s current whereabouts are unknown, so this was not possible. Contact was made with mother and she indicated that she wished to contribute to the review and two appointments were made to meet with her. The first meeting she cancelled and when it was re-arranged she was not there when the Lead Reviewer visited. It was therefore agreed with the LSCB that no further contact would be made by the Lead Reviewer. 1.6 Methodological comment and limitations 1.6.1 The main source of information for the review was IMRs produced by agencies involved with the family. These reports were sound however it was felt that the review process would be enhanced by the Lead Reviewer meeting directly with frontline health and school staff who had been involved with the family. These interviews were conducted by the Lead Reviewer supported by a member of the review team. These interviews provided significant additional information to the review; mainly regarding understanding the ‘whys’ associated with professionals’ actions. 1.6.2 Unfortunately, as most of the IMR authors had also interviewed frontline staff this meant that some people were interviewed twice which they found stressful. The review team has noted this difficulty with the current SCR process and will in the future consider whether IMRs should be written based only on written records or whether staff should be warned that there might be further interviews. Serious Case Review published 13.03.18 6 2 SUMMARY OF FACTS 2.1 Family details – all names have been changed for reasons of confidentiality Age at the time of the report of the incident Mother 42 Father 42 Child 1 8 Child 2 2 Maternal grandmother 65 Maternal grandfather 67 2.2 Timeline of key events Earlier contextual information There is very little information from any agency about the parents prior to 2008 however Father was known to have been a looked after child in his teens and to have a longstanding history of substance misuse leading to a 12-month Community Order for a Public Order Offence. Mother had also been involved in substance misuse in her twenties including intra-venous (IV) heroin use leading to a successful methadone rehabilitation programme. Date Event April 2008 Mother booked in for antenatal care disclosed previous IV drug-use father present with mother. October 2008 Probation referred couple to CSC because of expected baby when Father is subject of a community order and on a methadone programme. October 2008 Social Work assessment visit – Mother assessed as very capable -outcome of assessment is to close the case. October 2008 Child 1 born, parents living together. November 2008 - January 2009 Mother did not attend six-week baby check but was eventually seen by GP and immunisations were provided – baby doing well. February 2009 Baby seen by health visitor – large weight-gain no other issues. July 2009 – September 2009 Mother moved to new private rented flat and is awarded housing benefit but does not cash cheques, so benefit is suspended. She responds by asking for the housing benefit to be paid direct to landlord. Payments of full housing benefit were made to landlord from 20.7.09 till 23.11.15. February 2010 Health visiting records requested by Central Records – address of Serious Case Review published 13.03.18 7 child 1 is unknown. May 2010 Police record of complaint from Mother that Father is abusive at access visits and sometimes will not leave – parents have been separated for 8 months and father is reporting to the Substance Misuse worker that he is no fixed abode. Information shared with CSC who send a letter offering advice to the mother. January 2011 Child 1 seen by out of hours GP - probably at maternal grandparent’s home – no record of outcome. January 2011 Both Mother and Child 1 were removed from GP lists as they were reported to be living out of the area. June 2013 Mother attended walk-in clinic – is pregnant then registered with new GP but did not include Child 1 on registration with GP. July 2013 Mother booked in for antenatal care again disclosed previous IV drug-use - father not present. November 2013 Child 1 started school late – school staff thought the child has moved from London. Child 1 visited school with Mother prior to starting. Child 1’s disability is noted but Mother said that the child was able to do everything and did not need any specific assistance. School did not notice Child 1 to have any difficulties and the child could access all parts of the curriculum without any assistance or special adjustments. The school perceived Child 1 to be a well presented, happy, confident, emotionally stable and high achieving child during the time at the school. November 2013 Three days after Child 1 started school, the child felt unwell at lunchtime and talked through some circumstances of home life with a teaching assistant. This included Father no longer living with them, and needing to go to the Salvation Army, and friends of Father being drunk and displaying evidence of violence, including a black eye. Child 1 also volunteered information that they had left their home and had now returned to it. December 2013 Mother seen in antenatal clinic where spontaneous bruising was noted. A blood test was performed, and the results indicated that she had a high platelet count. The midwife consulted with the obstetric consultant who reviewed the blood results and reported that Mother had “mild thrombocythaemia1 since 2008 during her previous pregnancy”. 1 Essential thrombocytosis (ET; also, known as essential thrombocythemia, essential thrombocythaemia, primary thrombocytosis) is a rare chronic blood disorder characterised by the overproduction of platelets by megakaryocytes in the bone marrow. Beer, PA; Green, AR (2009). "Pathogenesis and management of essential Serious Case Review published 13.03.18 8 January 2014 Child 2 born – normal delivery no issues January 2014 Midwives visited mother at maternal grandmothers’ house – no home visit undertaken at family home. January – February 2014 Health visitor attempted to see Child 2 at home – when this was unsuccessful she wrote to GP to inform him of no contact with Mother or child. March 2014 GP saw Child 2 aged nine weeks – all normal November 2014 Mother pregnant again Feb 2015 – May 2015 Child 1’s attendance at school was poor. Education Welfare Officer (EWO) became involved – five letters were sent to Mother with no response being received. 9 June 2015 Child 1 was noted to be out of school for a ten-day period and Mother did not respond to letter from EWO so EWO made a home visit but could not gain access. 12 June 2015 EWO made further home visit - no reply. Contacted CSC as child had not been seen for 19 days and was told to contact the police. Police located family at maternal grandparents’ house. Both children were observed to be safe and well, Mother’s explanation for Child 1’s absence from school was that she and children had food poisoning and she had miscarried and so had gone to stay with maternal grandmother. Child 1 returned to school the next day. 23 June 2015 Meeting held with Mother to discuss attendance (agreed to review in three weeks) following this attendance at school by Child 1 improved significantly and remained good till November 2015. 17 November 2015 Tenants contacted landlady because of seepage through ceiling from property. Landlady contacted CSC – visit with police arranged and property was found to be unsuitable for human habitation. 2.3 Appraisal of Practice 2.3.1 A significant feature of this serious case review was the low level of contact that professionals had with the mother and the children. A detailed analysis of that contact is provided below which identifies those areas where practice could have been more robust alongside some explanation of the reasons for the less than optimum practice. thrombocythemia" (PDF). Hematology / the Education Program of the American Society of Hematology. American Society of Hematology. Education Program: 621–8. doi:10.1182/asheducation-2009.1.621. PMID 20008247. Serious Case Review published 13.03.18 9 2.3.2 In contrast the father had regular and sustained contact with the substance misuse services which is described at the end of this section. The reasons for the separation of these reports is that most professionals had limited contact with Father and few knew that he was living in the family home. The exception to this was the school who had regular contact with the father at the school gate and this is analysed in the later sections. Birth of Child 1 (April 2008 – February 2010) 2.3.3 Mother booked in for her pregnancy in April 2008 and reported that she had a history of intra-venous heroin use and that she was prescribed methadone and Subutex by a Specialist Substance Misuse Service in the past. This was also evident in the GP Referral for Maternity Care letter which stated that she had been “on hard drugs for 5 years until 3 years ago”. Mother also reported that she had depression in the past and had made a suicide attempt previously. There was no indication in the notes that any multi-agency communication took place between the Specialist Substance Misuse Service, GP or maternity about these matters. It would be normal practice where a pregnant woman is known to have previously abused drugs or experienced mental health problems for an Additional Support Form (ASF) to be generated which would be then sent to the Deputy Named Midwife, GP and health Visitor. This did not happen in either pregnancy and none of the midwives involved can provide an explanation for this omission. The practice concerning use of Additional Support Forms is considered further in the analysis section. 2.3.4 Just before the birth of Child1 there was a referral made by Probation to Childrens Social Care raising concerns about Father’s history, lifestyle and behaviours in the context of him becoming a father. These issues included him being subject to a 12-month Community Order for a Public Order Offence, an 8-year history of heroin use, though currently on a methadone programme, and concerns about his alcohol consumption. In response to the referral it was decided to complete an Initial Assessment, a proportionate response to the concerns. 2.3.5 The social worker undertook a prearranged visit to the parents at Mother’s flat. The purpose of the visit was to assess and analyse the potential risks to the baby arising from substance/alcohol misuse. Both parents were seen, and the social worker discussed fully with them their drug-use. Father confirmed that he was on a methadone programme and Mother said she no longer used drugs. Mother reported that her family and friends offered a good support network but that she had no contact with Father’s mother who she alleged used illicit drugs. Mother asserted that she would not tolerate drug or alcohol misuse around the baby; and Serious Case Review published 13.03.18 10 would end their relationship if Father relapsed. Preparations had been made for the baby’s arrival and the social worker had checked with Mother that she had engaged with ante natal care. The flat was described as small and cramped but clean and tidy and the parents said they had contacted the Housing Department for housing support. The social work assessment was that Mother presented as clean and well presented in appearance; an ‘articulate, sensible and independent woman who will be capable of making safe and appropriate decisions for herself and the baby’. Father conveyed complete acceptance of the ‘terms’ of their relationship and said that he was committed to making it work. The assessing social worker concluded that the concerns were not substantiated. Agreement for ‘No Further Action’ was given by the Practice Manager. Whilst possibly an optimistic assessment this was not an unreasonable response in the circumstances. 2.3.6 Mother had an uneventful pregnancy and gave birth by ventouse delivery. Father was present for labour and delivery. Mother and Child 1 were discharged home when the baby was two days old and both were seen three times by the community midwife at home. Mother was breastfeeding and there were no concerns reported. Mother had good continuity of care both antenatally and postnatally with her named midwife. Child 1 was deemed to be thriving, and was therefore transferred to health visiting, when ten days old. 2.3.7 The health visitor completed the ‘New Birth Visit’, within accepted timescales, at the home address. There was then a period of erratic engagement, with the mother failing to bring Child 1 to the child health clinic for a six-week check. The health visitor contacted the GP after two failed attendances, to find that the GP had completed a six-week check in December 2008, and that there were no concerns. The health visitor then asked the parents to bring Child 1 to clinic and both parents attended with the baby. The only issue of note was that the baby had a large weight gain, increasing the weight by three percentiles. There were no safeguarding concerns identified. Weaning was discussed, and it was agreed that attendance at clinic should be at the parent’s discretion until the next mandated check was due at six months of age. Change of address (February 2010 – June 2013) 2.3.8 The health visitor had no further contact with Child 1 and in February 2010 Child Health Records (CHR) requested the records be returned to the centre. It is not clear why the notes were requested. The health visitor reviewed the records and tried to contact the mother to ascertain further detail but received no reply. She Serious Case Review published 13.03.18 11 also contacted the GP and was told that Child 1 was last seen in surgery in April 2009 and that subsequent appointment letters had been returned marked ‘gone away’. The records were sent to CHR as requested. 2.3.9 In July 2009 Mother applied for housing benefit at the new address and for the first time reported the birth of Child 1; there was no mention of Father. In May 2010 Mother contacted the police and reported that Father was visiting her home to see his child but would become ‘verbally nasty’ to her when asked to leave. She said he was of ‘no fixed abode’ and would ask her to let him move back in. She said that Father drank and took methadone. She stated that there were no formal contact arrangements in place. The police advised Mother, over the phone, to get a custody order and arrange for the visits to be somewhere other than at home. Following this, Mother was seen at her parents’ address by a uniformed police officer and was advised to seek a formal custody order and to arrange Father’s visits away from her home. The information about the contact was passed by the police to children’s social care who sent Mother a letter of advice. The actions of both police and children’s social care in response to this incident seem appropriate and proportionate, however if the information had been passed to the health visitor the records would have been requested from CHR and further checks may have been completed. 2.3.10 In January 2011, a Duty GP was called out to an address in a neighbouring town to see Child 1, The record of the outcome of this visit is not available. Two days later a letter was sent to mother stating that as the Practice were aware she and her child were now living in another town, they were both being de-registered because they were now living outside the Practice area. It is not clear what address this letter was sent to as the GP’s paper records are lost. There is evidence that the practice had sent letters that were returned marked "gone away" to Mother’s old address however they did not have a record of her new address. The question of when and how children should be removed from GP lists and whether any checks should be made is further considered in the analysis section. Child 1 starts school (November 2013) 2.3.11 Child 1 started school in November 2013, the child was a ‘late-starter’ and was five. The parents visited the school prior to the child starting and school staff were immediately aware of the disability. This was discussed verbally with Mother who said that it did not cause Child 1 any problems and that there was no need for any special responses or adjustments to be made. The school staff understood that the family had newly moved into the area from London and that this was why the child was starting school late. Three days after starting school Serious Case Review published 13.03.18 12 Child 1 told a teaching assistant (TA) that Father was no longer living with them, and needed to go to the Salvation Army, and that friends of Father had been drunk and that they had been violent talking about one of them having black eye. Child 1 also told the TA that they had left their home and had now returned to it. This information was recorded by the TA and passed to the designated teacher, which was good practice, however no further action was taken. 2.3.12 Child 1 settled into school well and was considered to be a well presented, happy, confident, emotionally stable and high achieving child. There was good contact with both parents who were seen to be supporting the child’s attendance at school positively. With hindsight, this is particularly unusual as there is no evidence that Child 1 had attended any pre-school provision which could have placed the child at a disadvantage with other pupils. At this time, it was the school’s policy to conduct a home visit to all reception pupils – but only to do this for ‘late starters’ if there were additional concerns. The class teacher and senior leader at the time did not consider the child to have any additional needs – and felt that the child’s presentation outweighed any concerns raised by the disclosures made to the TA. Whilst understandable this decision was unfortunate as a home visit would have provided an opportunity for a professional to see the conditions in the family home. 2.3.13 A factor that may be relevant to this decision-making is that at the time of Child 1’s entry to the school, the substantive head teacher was asked by the local authority to lead another school for five days per week, requiring temporary ‘acting-up’ leadership arrangements. This resulted in the class teacher being asked to ‘act-up’ to a leadership role and to be out of the classroom for two days per week. Whilst all staff and governors report that there was good consistency in the leadership of safeguarding achieved through the temporary arrangements, this may have impacted upon the capacity for safeguarding leadership. 2.3.14 It is usual practice when a child starts school, for all reception children to be offered a vision and hearing screen for which parents’ consent is required, and parents are requested to complete a school health questionnaire which includes questions about immunisation status, bedwetting concerns, asthma, epilepsy and anaphylaxis. Dependant on the answers to these questions, parents may be sent information, signposted or contacted by a member of the school health team. This consent form and questionnaire was completed by Mother who agreed to Child 1 being screened however the child was not seen by the school nurse. This appears to be because the child was a late starter and the process for children starting late, to be seen by school nurses, was reliant on individual schools informing local teams of new arrivals. The issue of whether arrangements for Serious Case Review published 13.03.18 13 school nursing checks are sufficiently robust is considered further in the analysis section. Birth of Child 2 (January 2014 – March 2014) 2.3.15 In June 2013 Mother attended a GP as a walk-in patient because she thought she might be pregnant. She was advised to register with the GP and did so but did not register Child 1. When Mother was seen for her ‘New Patient Check’ the GP identified that she had an older child not registered at the practice but did not take any action. The GP referral to Midwifery was also inadequate as it did not include any details of Mother’s past substance misuse or her mental health difficulties. The Practice had significant difficulties in staffing in 2015 which meant that responsibility for all areas of clinical and administrative work requiring a lead, which were usually shared out between permanent GPs, had to be undertaken by one permanent GP, and this may have affected practice. The practice fully acknowledges these limitations and are working with the Named GP for child protection to resolve the issues. There is no evidence that this reflects normal practice across GPs. 2.3.16 Mother was late in booking in for ante-natal maternity care. She told midwives about her past mental health and substance misuse, however they did not complete an Additional Support Form (ASF) and could not provide an explanation for this omission. The pregnancy and birth were uneventful, and Child 2 and Mother were discharged from hospital within 48 hours and went to stay with maternal grandparents. They were seen by the community midwives on five occasions postnatally, with all contacts being either at the hospital or at the grandparents’ home. There was no continuity of midwifery care either antenatally or postnatally during this pregnancy. Mother and Child 2 were discharged to health visiting care fifteen days after the birth, and Mother told the midwife she would be returning to her home later that week. The midwives therefore never saw the family home in which the child would be living. The issue of home visits by midwives is further discussed in the analysis section. 2.3.17 At this point the midwife passed responsibility for the care of Child 2 to health visiting. Normal practice would be for a health visitor to undertake a new birth visit where a Family Health Assessment and assessment of Child 2’s health needs would be completed. The health visitor attempted to engage with the family and contacted Mother by telephone and letter and making three visits to the family home which were all unsuccessful. Mother only responded once to any contact when she asked for a visit on a Friday. Unfortunately, this could not be accommodated by the health visitor who was working part-time and there was no Serious Case Review published 13.03.18 14 other health visitor in the team who felt able to assist. After the third unsuccessful visit to Mother the health visitor wrote to the GP and advised him that she had not been able to see Child 2. The health visitor also discussed the issue with her line manager who advised her to ‘keep in contact with the family and document everything’. 2.3.18 The health visitor had recently returned to practice following a ten–year period away from health visiting. She started work in October 2013 with a full caseload (despite working part-time), with no additional preceptorship or mentorship support, and at a time when there were significant staffing issues within the health visiting team. A further pressure for her, was a perception that it was inappropriate to make unplanned visits to families; this meant that any visit had to be preceded by a letter or telephone call. This view was widespread within the health visiting service at that time and may persist to this day. 2.3.19 Another relevant factor, at this time, was that the health visiting service was in the process of changing their records from paper records to a computer system, ‘SystmOne’. The process for transfer of work over to the new computer was very disorganised. Health Visitors were expected to enter details of any families with whom they were actively working onto the new computer whilst administrators were transferring other records. Child 2’s name was recorded on paper in the ‘Birth Book’, which records all new births for the team, however the Child 2’s information did not get uploaded onto SystmOne online records when they came into use. Child 2 was not entered by the health visitor, probably because she had not contacted the family and did not consider that she was actively working with them. It was missed by later administrators uploading case details to SystmOne. The effect of this was that the electronic database system did not send out alerts or reminders to the health visitors that the family should be contacted for routine checks, thus there was no further opportunity for Child 2’s needs to be assessed. The impact of the culture, management and work pressures on the health visiting service at this time are discussed further in the analysis section. School attendance issues (November 2013 – July 2015) 2.3.20 From September 2014 Child 1’s attendance at school deteriorated. Letters were sent to Mother in late November 2014 and then in February 2015 with no response. The parents were invited to a meeting with the Education Support, Behaviour & Attendance Service (ESBAS) in April 2015. The parents did not attend, and no reason was given, or sought by the school. Soon after this the school ceased working with ESBAS and commissioned a private Education Welfare Service – ‘Team EWO’. ‘Team EWO’ then invited Mother to meetings in Serious Case Review published 13.03.18 15 May, she did not attend either of these meetings and gave no reason for her non-attendance. The Education Welfare Officer (EWO) then wrote to Mother arranging a home visit. When the EWO visited, she could not gain access to the house and so she contacted children’s social care and reported concerns as the child had not been seen for nineteen days (half term included). The EWO was advised by the duty social worker to attempt a further visit and if that was unsuccessful to contact the police. The EWO visited again three days later and still could not gain access, so called the police and asked for a police welfare check. The police visited and also could not gain access and so left a letter asking Mother to contact them. Following the police visit, Mother contacted the police and explained that she was staying with her parents because she had been ill. The police then visited the grandparents’ house and saw Mother and the children. Following the police visit Mother phoned the EWO, and Child 1 returned to school on the following Monday. After Child 1 returned to school, the EWO had two meetings with the parents to discuss attendance, and from that point forth the child’s attendance at school was satisfactory. 2.3.21 Arrangements within the school for attendance management meant that classroom staff were not significantly involved and there seemed to be a lack of awareness that attendance issues could be linked with potential safeguarding concerns. The school were clear that they have strengthened the management of school attendance within the school but raised concerns about how the role of the local authority with regards to school attendance has changed and some lack of clarity about mutual responsibilities when safeguarding concerns are raised in the context of school attendance. The issue of school attendance and how it relates to safeguarding are further discussed in the analysis section. Agency involvement with father (April 2008 – July 2015) 2.3.22 Father was well-known to the Substance Misuse Service and was receiving opiate substitution treatment in the form of prescribed methadone to support his physical dependence on heroin supported by psycho-social interventions to support him in his recovery. He had a longstanding addiction to heroin and was prescribed 60mg of methadone throughout his treatment which he picked up from the pharmacy three times a week. Father attended fortnightly one to one sessions with his key worker and collected his prescription at these sessions. As part of the treatment regime he attended medical reviews and provided regular drug tests, which showed no illicit drug use on top of his script. He did report having some issues around alcohol use, although he described his alcohol use as low, with no concerns. Serious Case Review published 13.03.18 16 2.3.23 Throughout his treatment Father reported to his substance misuse workers that he was single, that he had children with an ex-partner but that he was not living with them. He also reported having no fixed address and that he was ‘sofa surfing’. During ‘one to one’ key-work sessions Father described having contact with his children at his ex-partner’s parents’ address and said that he was trying to rebuild his relationship with his ex-partner and children. 2.3.24 After the birth of Child 1, few professionals had direct contact with Father and Mother presented to most agencies as a single parent. The exception to this was the school who had regular contact with Father, as following the birth of Child 2 he regularly took Child 1 to and from school. The school staff described Father as very open and presentable, they were surprised to be told that he had long-term substance misuse issues and said that this was not apparent in his demeanour at any of his contacts with school staff. 3. ANALYSIS Statutory guidance requires that serious case review reports provide a sound analysis of what happened in the case, why, and what needs to happen in order to reduce the risk of recurrence. The task for every review should be to answer the following question: - What light has this case review shed on the reliability of our systems to keep children safe? The task in analysis is to consider all aspects of practice in the case and identify any problematic areas. To understand their relevance to the wider safeguarding system, it is important that the analysis is used to: - identify in what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular context of this case; highlight any relevant information about how usual the problem is perceived to be locally, with any data about its wider prevalence; be clear about why it is important for the LSCB to consider the issues relative to their responsibilities, the risk and reliability of multi-agency systems. The following section considers a number of areas where analysis of practice in this case identifies problems that are relevant to the wider safeguarding system in that the view of the review team in conjunction with frontline staff is that they are likely to be repeated as they are considered to be ‘normal’ practice. 3.1 General Practice 3.1.1 Child 1 was removed from the GP list because the Mother did not inform the practice of her change of address and did not respond to any of the letters sent Serious Case Review published 13.03.18 17 to her by the practice. Child 1 remained without a doctor for four years and was not seen by any health professional for that period. During that time, the child became increasingly affected by a congenital condition which was treatable if identified. 3.1.2 Although not mandatory, registration with a GP is universally available to all children and is an essential requirement to ensure effective delivery of health care and is also a means of monitoring and supporting vulnerable children. The NSPCC fact sheet ‘Recognising signs of abuse at different stages of a child’s development’ includes under general signs of neglect for children of all age groups: ‘medical needs are not being met: not being registered with a GP.’2 Recent research regarding neglect compiled by Research in Practice in conjunction with the NSPCC and Action for Children defines medical neglect as including ‘Where parents/carers minimise or deny a child’s illness or health needs and/or they fail to seek appropriate medical attention’3 Clearly Child 1 experienced medical neglect, the issue of debate is how, and whether, the child’s health needs could have been identified and treated sooner by professionals within the healthcare or safeguarding system. 3.1.3 One of the professionals able to identify and respond to the child’s needs was the GP. The decision by the GP to remove the child from their list was reasonable given the assumption that the family had moved. The question this raises is whether the failure of the Mother to re-register the child with another GP should be considered as a safeguarding concern. Current systems for GP registration do not trigger any alert if a child is removed from one practice list and is not placed on another GP list and there are currently no mechanisms for knowing when this occurs. There is a central record of patients registered with GPs and when a patient is removed from a GP list the medical notes are returned to a central location from where they can be accessed when the patient registers on another GP list however there are no systems for checking when patients do not re-register. 3.1.4 NHS England has a statutory duty to maintain a comprehensive list of all NHS primary health service users and thus has responsibility for GP patient health records. Most GP health records are a combination of paper records and computer records, created or stored on the GP practice’s computer system. NHS England provides a range of support services for primary care. These are 2 Recognising the signs of abuse at different stages of a child’s development | NSPCC 18/06/2014 11:51 3 Appendix C Types of neglect and associated features https://www.rip.org.uk/resources/publications/evidence-scopes/child-neglect-and-its-relationship-to-sexual-harm-and-abuse-responding-effectively-to-childrens-needs/ Serious Case Review published 13.03.18 18 known as Primary Care Support Services (PCS). PCS deliver predominantly back-office administrative and business support functions to GPs, Primary Care Support Services specifically to: Operate the database to record which patients are registered at each GP practice. Provide the logistical arrangements to move the paper medical records held by the GP when patients choose to move between GP practices. Store the paper patient medical record when a patient dies or chooses to no longer be registered with a GP. Provide access to the paper medical records it holds either under a Subject Access Request or Access to Health Records Request. 4 Currently NHS England has contracted with Capita to provide PCS services for England. The contract with Capita started on 1 September 2015 and runs for seven years. The new service is known as ‘Primary Care Support England’ however NHS England retain accountability for how the service is delivered. 3.1.5 Discussion with practitioners indicated that, as there are a small number of families who move and do not inform their GP or register with a new GP, this is a situation that could recur. All present agreed that the failure to register a child with a GP was a risk indicator for neglect and it is included as such in current and past child protection procedures. There have other serious case reviews that have identified non-registration with a GP as a child protection concern. These include the Victoria Climbié report (2004), Sheffield Report (2005) and Danielle Reid (2006). 3.1.6 Possible solutions for addressing the problem that were discussed at the workshop included: - requiring NHS England to develop a system that raised alerts on any person under 18 years old who was not registered with a GP for a period of longer than three months; using the Children’s Index locally to make an entry when a professional is aware that a child is not registered with a GP; Using the SCARF process5 to pick up on this issue. There is a section for GP details on form – if this was blank the MASH6 could pick this up and follow up. 4 How NHS England is changing primary care support services - Overview for patients and the public www.healthwatchbedfordborough.co.uk/.../how_nhs_england_is_changing_primary 5 SCARF is the electronic form used by the police to record and share information with other agencies about children and vulnerable adults. Serious Case Review published 13.03.18 19 3.2 Midwifery 3.2.1 At the booking appointment for both the pregnancies mother disclosed past intra-venous (IV) heroin use and a history of depression but midwives did not complete an Additional Support Form (ASF) and no contact was made with other agencies. The IMR provided by East Sussex Healthcare Trust (ESHT) indicated that ‘usual’ practice was for midwives to complete ASFs whenever a woman had additional needs however clearly the practice in this case was not in accord with that ‘normal’ practice. Problems with the use of the ASF has been identified in previous serious case reviews and a Domestic Homicide Review in East Sussex. Currently, there are audits of the use of the ASF, but these only review cases where the form has been completed, and do not include a review of files where no form was completed. The ASF is used whenever the woman has any additional need which might be for medical as well as social reasons. Findings from the audits would suggest that if anything the form was over-used which led to discussion amongst practitioners as to whether the form was mainly used by inexperienced professionals who were anxious to raise any concerns. Both the midwives who completed the booking process with Mother were very experienced. 3.2.2 There was also significant debate amongst frontline professionals about how to determine when historic substance misuse remained a current relevant social factor and what type and level of alcohol and drug-use should be included. There was consensus however that a history of intravenous heroin use should have triggered the use of the ASF. Another factor that could have been a possible influence on the booking midwives was Mother’s presentation. The professionals who remembered their contact with her considered that she always appeared clean and well-dressed and seemed very capable. Most of the midwives had no memory of her and there was nothing recorded in her notes which suggested that her presentation raised any concern. 3.2.3 Professionals also thought that practice now would be different as the development of the MASH process meant that if Probation had referred this case to CSC there would have been an automatic consultation with midwifery and therefore greater scrutiny by midwives. Furthermore, there are regular liaison meetings between the Midwifery service and SWIFT and Adult Substance Misuse Service where pregnant women with a history of substance misuse are discussed, although this would only occur if the past substance misuse was identified as relevant. It was agreed however, that a random audit of all pregnancies (over a given period) to see when ASFs were completed would be 6 MASH is Multi-Agency Safeguarding Hub which is the multi-disciplinary assessment team that responds to child protection concerns. Serious Case Review published 13.03.18 20 informative and might shed light on the reasons that the forms had not been completed in this case and whether this reflects general practice. 3.2.4 The second pregnancy and birth were uneventful, and Child 2 and Mother were discharged from hospital within 48 hours, and immediately went to stay with maternal grandparents. They were seen by the community midwives on five occasions postnatally, with all contacts being either at the hospital or at the grandparents’ home. Mother and Child 2 were discharged to health visiting care fifteen days after the birth, and Mother told the midwife she would be returning to her home later that week. The midwives therefore never saw the family home in which the child would be living. This is usual practice as it is now commonplace for many postnatal contacts with midwifery to be at the hospital. While it is expected that at least one contact with the midwife would be in the community, there would not be an attempt to visit the usual home address if the mother is not staying there after the birth. This means that babies may be discharged home after birth with no professional oversight of home conditions which is a risk for children born to vulnerable mothers. The Review Team were concerned that this reflects a decrease in routine oversight of pregnant women and new-born babies which presents a challenge for agencies in identifying and safeguarding the most vulnerable children. 3.3 School Health Services 3.3.1 When Child 1 started school the child was not seen by the school nurse and therefore an opportunity for the congenital health problem to be identified was missed. This contact did not occur because the child was a ‘late-starter’ and there was no system in the school, or in fact across the county, to pass on the names of all ‘late-starters’ to the School Health Service. Since this review has started, new systems have been established across East Sussex whereby the central County School Admissions Service provides the School Health Service with updated school pupil lists every half-term. It should be noted however that the school nursing appointments require parental consent and if neither parents nor school report problems then it is unlikely that the school nurse will seek any further information. The school nursing appointment is not a medical assessment, it is a screening (vision and hearing) process that enables parents or school staff to raise concerns, which usually lead to sign-posting to other services, such as physio-therapy. The front-line professionals who discussed this considered that, as neither the school, nor the parents, nor Child 1 were raising concerns, it is possible that even if the child had been seen by the school nurse no further action would have been taken. Serious Case Review published 13.03.18 21 3.3.2 Another possible mechanism for Child 1 to have received assistance with her health needs would have been for the school to have initiated an individual health care plan. The Children and Families Act 2014 was passed in September 2014, and Section 100 designates specific responsibility to schools to ensure that pupils with medical needs can fully participate in all aspects of school life. The aim of the Act; ‘is to ensure that all children with medical conditions, in terms of both physical and mental health, are properly supported in school so that they can play a full and active role in school life, remain healthy and achieve their academic potential.’7 This is statutory guidance but parental involvement is voluntary and as school staff were clear that Child 1 had no difficulties accessing the school curriculum it is understandable that they did not consider an individual health care plan to be necessary. Given that the child’s physical presentation made her condition apparent however, this case could have warranted the use of a health care plan to work with the parents and school nurse to plan for any current or future needs. 3.4 Health Visiting Uploading records to SystmOne 3.4.1 When Child 2 was transferred from midwifery to health visiting the baby’s details were recorded in paper records and the Birth Book but not uploaded onto SystmOne because of confusion about arrangements for inputting this data. This meant that no reminders were sent to health visitors for routine assessments of the child. There was significant discussion amongst the front-line professionals about this issue. When SystmOne was introduced and staff had to upload data themselves there were no additional resources provided and the training on how to do it was inadequate. Particularly, it was felt that a certain level of IT literacy amongst health visitors was assumed, and that in fact competency was very varied, with some staff experiencing problems and some continuing to struggle. There is further complexity as the processes for uploading data have been inconsistent and there are different ways of recording information which may affect its accessibility. 3.4.2 Frontline professionals were clear that inputting children onto the system is now routine however it was acknowledged there were children that could have missed being uploaded on to SystmOne at that time and therefore could continue to be outside of the reminder systems. The only mechanism for checking this, would be to manually review the Birth Book, and cross-reference with SystmOne which 7 Supporting pupils at school with medical conditions Statutory guidance for governing bodies of maintained schools and proprietors of academies in England April 2014 https://www.gov.uk/government/publications/supporting-pupils-at-school-with-medical-conditions--3 Serious Case Review published 13.03.18 22 would be very time-consuming. It is therefore unclear how many other children are in the same position as Child 2 and are not being offered routine checks by the health visiting service. Workload pressures 3.4.3 When Child 2 was transferred from midwifery to health visiting there were significant numbers of vacancies in the health visiting service and caseloads were very high. The health visitor was very pressured as she was carrying a full-time caseload but working part-time. This was the reason she was unable to arrange a visit on a Friday and so was not able to see Child 2. The front-line professionals at the Learning Event identified that the team in which the health visitor was working did have capacity issues and that the team culture and working environment there made it unattractive to staff. The town centre has a more transient population, parking is difficult and there are greater numbers of families from ethnic minorities where English is not the first language. In the past staff, have been reluctant to move to work in the town centre which historically has had management issues. This has led to a lack of flexibility and co-operation between staff which was why Mother’s request for a Friday visit could not be accommodated. 3.4.4 The extent to which the problems and pressures in this team continue is not clear. There are currently no capacity measures that enable workload across teams to be compared. Vacancies have persisted in this team and senior managers are currently reviewing data and workloads. There is some evidence of change and improvements have been noted however this is considered to be slow progress. Certainly, the individual health visitor who remains in this team when interviewed suggested that workload pressures continue. Unplanned visits 3.4.5 When the health visitor was trying to visit to see Child 2 one factor that made it difficult to achieve the contact was a perception that there was a policy that health visitors should not make unplanned visits. Discussion with frontline staff confirmed that this had never been policy but that it was the management culture at the time. A senior manager with responsibility for health visiting (who did not have a health visiting or safeguarding background) felt strongly that it was disrespectful to visit without warning and advised all her staff that this was the practice she expected from them. Most professionals at the workshop did not think this perception continued however the health visitor when interviewed considered that the expectation for all visits to be planned and booked ahead remained. Serious Case Review published 13.03.18 23 3.4.6 This serious case review has identified some problems with the health visiting service. The issue of inputting to the computer data base clearly potentially affects all the service. It is less clear with the other two issues whether they are specific to that health visiting team or are applicable to general health visiting practice. 3.5 School Attendance 3.5.1 Child 1 had poor school attendance and the Education Welfare Officer (EWO) sent letters to the parents which they ignored. She attempted to visit the family home but could not gain access so contacted CSC who advised her to visit the house again and if access could not be achieved to ask the police for assistance in finding the child. School staff and the EWO when interviewed felt that systems and arrangements for managing safeguarding concerns associated with school non-attendance were not clear. In particular, there was confusion about whose responsibility it was for pursuing contact with children who had been absent from school for some time. The school were surprised that CSC did not take a more proactive role. On reflection, they accepted that managing pupil’s attendance was a school responsibility in conjunction with the local authority however it was felt that changes in service provision had increased school responsibilities. 3.5.2 All children, regardless of their circumstances, are entitled to a full-time education which is suitable to their age, ability, aptitude and any special educational needs they may have. Section 436A of the Education Act 1996 requires the local authority to have arrangements in place that establish the identities of children in their area who are not registered pupils at a school and are not receiving suitable education otherwise than at a school. Schools’ duties are to monitor pupils’ attendance through their daily register and to inform the local authority of the details of pupils who are regularly absent from school or have missed 10 school days or more without permission. Schools should monitor attendance and address it when it is poor. It is also important that pupils’ irregular attendance is referred to the authority. Schools also have safeguarding duties under section 175 of the Education Act 2002 in respect of their pupils, and as part of this should investigate any unexplained absences.8 3.5.3 Historically, the local authority employed education welfare officers whose responsibilities were to check on children with attendance problems and to facilitate their attendance at school. Over time with the transfer of budgets from the local authority to schools the responsibility for managing attendance has passed to the schools. The local authority still employs education welfare officers and the schools access them via the Education Support, Behaviour and 8 ‘Children missing education’ Statutory guidance for local authorities January 2015 https://www.gov.uk/government/publications/children-missing-education Serious Case Review published 13.03.18 24 Attendance Service (ESBAS). At the workshop, it was reported that many schools do not directly employ an EWO but buy in a service from ESBAS. The resources they can access however are limited and may involve the EWO only looking at top 10 worst attendees. Child 1 was not the worst attendee in the school and it was thought that in another school the concerns raised by the EWO might not have been picked up as the child was not strictly missing as the mother had rung in and said that the child was sick. 3.5.4 Professionals at the workshop felt that mutual responsibilities regarding children absent from school were not clear. It is difficult to determine when low level attendance problems become a safeguarding issue. It was felt that this is hard to evidence and that expectations of schools are unclear. School staff said that they did not know if they were responsible for doing a home visit if children were absent for long periods and there was no response/contact from the family. They reported that this has been expected of them in several cases but that they were unclear if this was policy and questioned whether there was a protocol and if so how well known it was across schools. 3.5.5 School professionals felt that funding cuts had impacted on the response to attendance issues. They considered that the old model of an EWO allocated to each school no longer exists and that the establishment of the ‘single point of advice’ (SPOA) has introduced a more robust multi-agency approach to referrals, however school understanding of their responsibilities around attendance are not yet fully developed. In particular, school staff said that if the school knows that they are expected to visit/follow up during holidays and look to see if contact has been made with friends then the schools will build this into their resources. They felt, however, that there needs to be a clear protocol about what actions are expected prior to them referring to SPOA. Schools need a clear protocol written with all agencies, drawing on DfE guidance, regarding the approach to be taken when a child has a prolonged period of absence. 3.5.6 It was suggested that a positive way forward would be to develop a multi-agency working group to further explore the development of a set of protocols that could be applied in a range of circumstances. 3.6 Contact with Father 3.6.1 After the birth of Child 1 most agencies thought Mother was a single parent and little was known about Father’s substance misuse. Father reported to substance misuse workers that he was single, that he had a child but that he was not living with the mother. Throughout his contact with Change, grow, live (CGL), Father worked positively with professionals, stated he was not using ‘street-drugs’ in addition to his prescription and tested negative, while generally seemed clean Serious Case Review published 13.03.18 25 and pleasant. He was always consistent with his explanation that he was only seeing the children at the grandparents’ house which added to his credibility. CGL were unaware that he was collecting and delivering Child 1 to school and were also unaware of Mother’s previous drug history. 3.6.2 Practitioners at the workshop reported that it was not unusual for service users attending CGL to be economical with truth. They would undertake home visits where it was known that there were children in the household however in this case Father told professionals that he was of ‘no fixed abode’. CGL record details of partners and family members are also linked to the client on the CGL records meaning that information can be cross-referenced. 3.6.3 Other areas, for example Kent, are looking to introduce access to information systems that would for example, notify staff when a client takes an overdose and is attended by the ambulance. CGL have in fact, since signed an information sharing agreement with SECAmb and have secured access to their information data-base IBIS, but this is only just being introduced and wasn’t in place at the time of the SCR. CGL also understand that they should be informed by GPs of any occasions when their patients are the subject of emergency calls. 3.6.4 This review has identified a pattern previously recorded in serious case reviews of agencies failing to take account of the role of male carers within the family process. ‘There were instances of ‘unknown’ males in some households … [who are] invisible to practitioners working with the family or child.’9 This reflects a wider issue about the lack of involvement by health and welfare professionals with men despite their significant involvement in children’s lives. The need therefore is for all agencies to ensure that relevant information about men is collected during assessment processes and to ensure that their assessment processes are adapted accordingly. 9 P52 Understanding Serious Case Reviews and their Impact: Brandon et al DCSF 2009 Serious Case Review published 13.03.18 26 4 CONCLUSIONS 4.1 This Serious Case Review has presented a conundrum that it has not been possible to solve. The conditions in which the children were found to be living were truly awful and yet, even with hindsight, no professional could identify any evidence that would have suggested that their home was out of the ordinary. In part this is because the parents were very adept at preventing professionals visiting the family home however it is remarkable that Child 1, who was seen regularly at school, did not present more obviously as living in such a squalid environment. 4.2 The Review Team did investigate closely whether there were any indicators present that should have required a more proactive response by professionals however, despite some weaknesses in the safeguarding system being identified, there were no obvious interventions that would have highlighted these children’s predicament. 4.3 As it has not been possible to interview either parent or the grandparents it is not clear when the home conditions deteriorated although they were not recent and may have been present prior to the birth of Child 2. It is also not clear why the adults allowed their physical environment to become so bad. It is known from information provided by professionals currently involved with Mother that she considers herself to be a victim of domestic abuse and it is probable that substance misuse by the parents is also relevant. These were not issues known to professionals prior to this review and there is little evidence of missed opportunities to discuss these concerns. 4.4 As with all reviews, the review has identified some areas where safeguarding arrangements could be improved. A significant feature was the absence of routine health contact with both children. Child 1 was not seen by any health professional for over four years despite having a significant congenital health problem that was treatable and Child 2 also had minimal contact with community health professionals. Some of the systemic problems identified have already been addressed (changes to notifications of late starters at school) however some are likely to remain without changes in practice. To that end the Review Team has included some recommendations for action to be taken, either to reassure that practice has changed, or to achieve changes in systems to enable children to be better protected in the future. Serious Case Review published 13.03.18 27 5 RECOMMENDATIONS 5.1 That East Sussex LSCB request that the CCG and NHS England consider the feasibility of developing systems for raising alerts on any person under 18 years old who is not registered with a GP for a period of longer than three months. 5.2 That East Sussex LSCB seeks assurance from East Sussex NHS Trust that the Midwifery Additional Support Form is fit for purpose and is being used consistently with women who meet the criteria for its use. 5.3 That East Sussex LSCB request East Sussex NHS Trust provide guidance to midwifery staff requiring that all women receive a post-natal visit at their normal address and that the Trust reports to the LSCB on compliance with this requirement. 5.4 That East Sussex LSCB request a report from the Local Authority, who have been providing the service since March 2016, regarding the capacity and workload pressures being experienced by the health visiting service. This report to address whether the practice of only visiting by prior appointment is universal or specific to that team. 5.5 That East Sussex LSCB request that the Local Authority review the impact of the past IT difficulties within the health visiting service and report any actions needed to resolve the safeguarding concerns. 5.6 That East Sussex LSCB request that the Local Authority establish a multi-agency working group to develop guidance regarding responsibilities for school attendance. 5.7 That East Sussex LSCB should continue to require that all agencies should satisfy the LSCB that their assessment processes enable the effective involvement of fathers, partners and other men within the household and where possible obtain independent verification of information rather than relying on self-report from service users. Serious Case Review published 13.03.18 28 Appendix 1 Recommendations from Individual Management Reviews East Sussex Health Care Trust Midwifery 1. An Additional Support Form (ASF) must be created for all women who have a past history of either substance misuse, domestic abuse or mental health issues. 2. There needs to be a system in place for community midwives to track whether women on their caseload have been asked the domestic abuse screening question. 3. Women with an ASF should be seen at least once in their home during their maternity care. 4. A system of tracking women’s hand-held records needs to be developed to ensure that all notes are retrieved and filed. East Sussex County Council Health Visiting 1. That all Health Visitors should receive regular, documented clinical supervision. 2. That all Health Visitor cases where there has been no engagement with a family should be taken to safeguarding supervision and an outcome-focused action plan to encourage future engagement with Health Visiting (or an appropriate health agency) should be put into place. 3. That KCHFT School Health Teams should, (in conjunction with schools and ESHT child health records) review the process for determining pupils who require health assessments and produce a pathway for agencies to follow, thereby ensuring no child is missed. Education 1. Review of record keeping approaches at an East Sussex school by the Standards and Learning Effectiveness Service (SLES) in order to ensure compliance with East Sussex LSCB and national guidance March 2016. 2. Record keeping training and development session for all staff at an East Sussex school to improve practice and ensure compliance with school and LSCB policy, as well as allowing DSL to review cases and quality assure recording and actions 09.05.16. 3. The health background and current involvement of health professionals should be evidenced and checked by school staff at the point of a child’s entry to school, or upon the emergence of the issue – to be incorporated into DSL training in preparation for September 2016. Serious Case Review published 13.03.18 29 4. East Sussex DSL training needs to include substantial training sessions on using and understanding the continuum of need, and in particular, understanding early help. To be planned in new training designed for roll out from September 2016. 5. An East Sussex school to Introduce home visits for all pupils and develop a new proforma for completion by staff which include sections on health, parental responsibility, previous addresses and reasons for change of address/ move of schools etc, implemented from Easter 2016. 6. Poor attendance, including that for children in reception year, should be recognised by all agencies as a potential indicator of abuse. This needs to be a more significant section of the enhanced DSL training programme from September 2016. 7. East Sussex SLES to work with LA s and other organisations responsible for seconding headteachers to other roles, or expanding roles (e.g. through the creation of executive headships) should undertake a thorough review and risk assessment of safeguarding practice and leadership capacity for this in order to sustain and further develop standards of safeguarding whilst the interim arrangements are in place. SLES to action, in preparation for the new academic year. 8. Schools need to be more rigorous in requesting and accessing pre-school records for reception year pupils. The East Sussex transition guidance document should be updated by the SLES EY team to reflect this key message by September 2016. 9. East Sussex SLES to work with ESBAS to ensure that where ESBAS are invited to attend “informal” school-led attendance meetings, ESBAS maintain records of names of pupils and families, as well as required actions. To be adopted as procedures by September 2016 10. East Sussex SLES to ensure that East Sussex providers of educational welfare / attendance support for schools should liaise regarding school caseloads where there is a change of provider in order to ensure continuity. Schools should ensure that this occurs on change of provider and information with regard to this recommendation will be included in enhanced DSL training programme. Primary Medical Care 1. Practice 2 to be supported by the Named GP to implement improved systems to enable effective child safeguarding. CGL 1. The service will comprehensively review the treatment reviews for all clients who have contact with children and who are ‘stuck’ and / or ‘cruising’ in their Serious Case Review published 13.03.18 30 treatment. This will support early identification of possible risk to children. This will be completed by Team Leaders and supported by the Designated Safeguarding Lead and completed by end July 2016. 2. An assessment of the implementation of the Safeguarding Policy and procedures at the service to ensure that these are being followed by all staff and that any issues are being identified and acted upon. 3. CGL to launch the children and families page on the CRiiS case management system to help identify children’s needs and support the early identification of risk to children. To be completed by end June 2016. 4. Training to be developed and delivered to the staff team to support their understanding of professional curiosity and disguised compliance and its importance in protecting our clients and their families. To be completed by end July 2016. 5. Review the management of clients living with or having contact with children so that they are reviewed in supervision and or clinical team meetings. This to be completed by the end of May 2016. Serious Case Review published 13.03.18 31 Appendix 2 1. Terms of Reference for the Individual Management Reviews I. Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse, and about what to do if they had concerns about a child’s welfare? Should the practitioners not have worked in this way, comment should be made about the reasons for this. II. Did practitioners recognise any indicators of neglect in this case, and if so, were these appropriately documented and responded to. III. When, and in what way, were the children’s wishes and feelings ascertained and taken into account of when making decisions about the provision of children’s services? Was this information recorded? If this work was not under-taken, the reason for this not taking place should be noted. IV. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? V. Did your agency consider that the threshold was reached for any relevant legal intervention at an earlier stage? VI. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the children and family? Do assessments and decisions appear to have been reached in an informed and professional way, and if this was not the case, what was preventing this? VII. Were concerns about these children shared between the relevant agencies in a timely manner, with appropriate communication and analysis? Should communications be reviewed between agencies, in order to identify if there were issues of concern that were not shared? VIII. Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments? If appropriate actions did not take place, what was obstructing this? IX. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours’ services? X. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability to the children and family, and were they explored and recorded? XI. Were senior managers or other organisations and professionals involved at points in the case where they should have been? If this did not take place, what were the reasons for this? XII. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, Serious Case Review published 13.03.18 32 and with wider professional standards? If this was not the case, what was preventing this from happening? XIII. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? XIV. Was there sufficient management accountability for decision making? If accountability was lacking, what would have assisted this in taking place. 2. Methodology for the Review 2.1 Individual agency reports were received from the following sources: - CRI – STAR Recovery Service now CGL ESCC, Children’s Social Care ESCC, Education ESHT Acute and Maternity ESHT Community Health Visiting National Probation Service Primary Medical Care Sussex Police 2.2 Individual and group interviews were undertaken by the Lead reviewer and a member of the Review team with front line staff from the school and health visiting and midwifery services. Additionally, there was a practitioner event where the Lead reviewer shared with front line staff and representatives of relevant agencies the early findings to gain clarification and understanding or the services provided to the family. 2.3 The Lead Reviewer and author of the report was Fiona Johnson an independent social work consultant. Head of Children’s Safeguards & Quality Assurance in East Sussex County Council between 2004 and 2010, Fiona qualified as a social worker in 1982 and has been a senior manager in children’s social care since 1997 contributing to the development of strategy and operational services with a focus on safeguarding and child protection. Fiona is currently Chair of the East Sussex Child Death Overview Panel but is otherwise entirely independent of East Sussex LSCB and its partner agencies. 2.4 The Lead Reviewer worked with a review Team that was representative of the agencies involved with the family. The Review Team Membership was as follows: - Andrea Holtham, Sussex Cafcass (chair) Serious Case Review published 13.03.18 33 Designated Doctor Safeguarding Children, East Sussex Designated Nurse Safeguarding Children, East Sussex Child Protection and Safeguarding manager, Special Investigation Branch, Sussex Police Head of Children’s Safeguards & Quality Assurance, ESCC SLES Manager East Sussex LSCB Business Manager Additionally, Fiona Johnson, the Independent Overview Writer attended review Panel Meetings. Serious Case Review published 13.03.18 34 Appendix 3 Glossary of terms ASF Additional Support Form CAF Common Assessment Framework CAFCASS The Children and Family Court Advisory and Support Services CCG Clinical Commissioning Group CGL Change, grow, live is a social care and health charity that works with individuals who want to change their lives for the better and achieve positive and life-affirming goals. CME Children Missing from Education CSC Children’s Social Care CHR Child Health Records ESCSC East Sussex Children’s Social Care ESBAS Education Support, Behaviour and Attendance Service ESHT East Sussex Healthcare NHS Trust EWO Education Welfare Officer GP General Practitioner IMR Individual Management Review LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub NSPCC National Society for the Prevention of Cruelty to Children PCS Primary care Support SCARF Single Combined Assessment of Risk SCR Serious Case Review SLES Standards and Learning Effectiveness Service SPOA Single Point of Access SWIFT Safeguarding with Intensive Family Treatment Service Family Substance Misuse Service SUI Serious Untoward Incident SystmOne Data base in use in the health visiting service TA Teaching Assistant TAC Team Around the Child TAF Team Around the Family |
NC52215 | Death of a 4-month-old boy in May 2016. Baby LL was found dead by his father. The post mortem identified the cause of death as acute pneumonia. Baby LL had lived with his father, mother and sibling. Baby LL and sibling were the subject of child protection plans under the category of neglect, and children's services worked with the family due to concerns around the care of both children. The family had been in contact with the police, accident and emergency services and children's services following referrals due to concerns around the children, and due to injuries to Baby LL's sibling. Father had previously been in prison for failing to protect another of his children from physical abuse, and mother had an older child in care due to emotional abuse and neglect. Child LL's ethnicity or nationality are not stated. Uses the SCIE Learning Together systems model. Findings include: issues of professional psychiatric opinion undermining social workers' views on the risks posed by parents; the need for consistent safeguarding practices in paediatric and accident and emergency teams, so that opportunities to identify hidden injuries are not missed; professionals sharing information on the presenting evidence, but not always clearly communicating underlying concerns and relevant historical information; GPs should have access to the records of family members, to understand a family's history and be aware of risk factors and past child protection concerns; the importance of professionals understanding financial challenges faced by families, and identifying risks that financial pressures may pose to children.
| Title: Report of the serious case review regarding Baby LL. LSCB: Surrey Safeguarding Children Board Author: Fiona Johnson and June Hopkins Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final report 15-6-2018 1 Surrey Safeguarding Children Board Report of the Serious Case Review regarding Baby LL Authors: Fiona Johnson and June Hopkins SCIE Lead Reviewers Final report 15-6-2018 2 Contents 1. Introduction 1.1 Why this case was chosen to be reviewed 1.2 Succinct summary of case 1.3 Family composition 1.4 Time frame 1.5 Organisational learning and improvement 1.6 Methodology 1.7 Reviewing expertise and independence 1.8 Acronyms and terminology 1.9 Methodological comment and limitations 1.10 Participation of professionals 1.11 Contribution of the family 2. The Findings 2.2 Appraisal of professional practice in this case: a synopsis 2.3 In what ways does this case provide a useful window on our systems? 2.4 Summary of findings 2.5 Findings in detail Appendices Methodology Glossary Bibliography 1. Introduction 1.1 Why this case was chosen to be reviewed Final report 15-6-2018 3 The Local Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the statutory criteria: (a) abuse or neglect of a child is known or suspected; and (b) (i) the child has died (Working Together to Safeguard Children, 2015 4:18 p 76) 1.2 Succinct summary of case 1.2.1 This review concerns services provided to Baby LL and his family. Baby LL was four months old at the time of death and lived in the community with his mother, father and Sibling 1 for all of his life. Baby LL’s parents had difficulties parenting their earlier children; his father had received a prison sentence for failing to protect his eldest child from physical abuse by her mother and his mother had an older child who was in the care of the Local Authority Children’s Services because of emotional abuse and neglect. Social Care (CSC) were working with Baby LL and the family at the time of his death, because there were concerns about the care being provided by the parents to both children and Baby LL and Sibling 1 were the subject of child protection plans because of concerns about neglect1. The cause of Baby LL’s death was unclear at the time of death, however the post mortem later identified the cause of death as Acute Pneumonia2 due to Klebsiell Oxytoca3 superimposed on upper respiratory tract viral infection. 1.3 Family composition Family member Age at the time of the child’s death Child LL Died aged 4 months old Sibling 1 (LL’s brother) 2 years Half-sibling 1 (LL’s maternal half-sister) 10 years Half-sibling 2 (LL’s paternal half-sister) 7 years Mother 30 years Father 33 years 1.4 Timeframe The time frame for the review was agreed as being from July 2015 when the first child protection plan ended and 12th May 2016 when the Baby LL was pronounced dead. 1 If child protection enquiries show that a child may be suffering or is likely to suffer significant harm, an initial child protection conference will be organised and if the conference decides that the child is suffering (or is likely to suffer) significant harm then the decision will be made for him/her to have a child protection plan. The aim of the plan is to try and stop any harm happening to the child and make things better for him/her. 2 Pneumonia is swelling (inflammation) of the tissue in one or both lungs. https://www.nhs.uk/search?collection=nhs-meta&query=pneumonia 3 Klebsiella Oxytoca, is a bacterium that is responsible for many urinary tract infections. Klebsiella Oxytoca is also responsible for Septicemia which is a very serious infection of the blood which could be life-threatening. http://klebsiellaoxytoca.com/ 1.5 Organisational learning and improvement Final report 15-6-2018 4 1.5.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.4 1.5.2 The Learning Together Review process requires that prior to starting the review the LSCB identifies broad research questions which go beyond the facts and issues in this case, to look more widely at their child protection systems. Specifically, it was felt that it would be useful to examine the following areas: • How effectively are agencies working together with families where children are on child protection plans because of neglect? • How effective are professionals at achieving change with families where there is disguised compliance? • How effective are professionals at using information and knowledge gained when working with older siblings in assessing risk for babies when all children are the subject of child protection plans? 1.6 Methodology Statutory guidance requires SCRs to be conducted in such in a way which: • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings’5 . It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: • ‘there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; • the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; 4 Working Together 2015, 4:7 http://www.workingtogetheronline.co.uk/chapters/chapter_four.html 5 WT 2015, 4:11http://www.workingtogetheronline.co.uk/chapters/chapter_four.html Final report 15-6-2018 5 • reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; • professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process’.6 To comply with these requirements, the LSCB has used the SCIE Learning Together systems model7. Detail of what this has entailed is contained in Appendix 1 of this report. 1.7 Reviewing expertise and independence 1.7.1 The review has been led by Fiona Johnson, an independent social work consultant, and, June Hopkins, an independent health consultant, who are both accredited to carry out SCIE reviews and have extensive experience in writing serious case reviews. Both reviewers have had no previous direct involvement with the case under review. 1.7.2 The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence. 1.8 Acronyms used and terminology explained Statutory guidance requires that SCR reports: ‘be written in plain English and in a manner that can be easily understood by professionals and the public alike’8. Writing for multiple audiences is always challenging. In the Appendix 2 we provide a section on terminology aiming to support readers who are not familiar with the processes and language of the safeguarding and child protection work. 1.9 Methodological comment and limitations 1.9.1 There was good attendance at review team meetings, although due to unforeseen circumstances and organisational priorities there was no representation by CSC at any of the review team meetings. However, the draft report was shared with the principal social worker prior to completion. Involvement by practitioners in the case group meetings was positive and there was good attendance by CSC staff at these meetings. 1.9.2 Another difficulty was that it was not possible to involve the parents in the review because they did not respond to requests for contact. 6 ibid 7 Fish, Munro & Bairstow 2010. Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 8 WT 2015, 4:11http://www.workingtogetheronline.co.uk/chapters/chapter_four.html Final report 15-6-2018 6 1.10 Participation of professionals The lead reviewers and the review team have been impressed throughout by the professionalism, knowledge and experience that the case group (the professionals involved with the family, from all agencies) have contributed to the review; and their capacity to reflect on their own work so openly and thoughtfully in the review process. All this has given the review team a deeper and richer understanding of what happened with this family and within the safeguarding network and why; and has allowed us to capture the learning that is presented in this report. 1.11 Input of the family 1.11.1 Significant effort was made to involve the parents in the review, but this was unsuccessful. The LSCB contacted the parents early in the review and initially Mother indicated that she would like to be involved but asked that this be delayed until after Christmas. Further contact was made in the spring by email, telephone and letter but there was no response. The family have moved out of the area and contact was made with local services to see if there was a professional who could facilitate contact however this was also unsuccessful. It is thought that Father did not want to be involved in the review and this may have influenced Mother’s later response. Final report 15-6-2018 7 2. The Findings 2.1 Structure of the report 2.1.1 Statutory guidance requires that SCR reports ‘provide a sound analysis of what happened in the case, and why, and what needs to happen to reduce the risk of recurrence’.9 2.1.2 This section contains priority findings that have emerged from the serious case review. The findings explain why professional practice was not more effective in protecting Baby LL. Each finding also lays out the evidence, identified by the review team, that indicates that these are not one-off issues, but are matters that if not addressed could cause risks to other children and families in future work, because they are issues that undermine the effectiveness with which professionals can do their jobs. 2.1.3 Immediately prior to the findings section an overview is provided of what happened in this case. This clarifies the view of the review team about how timely and effective the help that was given to Baby LL and the family was, including where practice was below expected standards. This is then followed by the section that summarises the views of the parents. 2.1.4 A transition section of the report highlights the ways in which features of the involvement with Baby LL and the family are common to work that professionals conduct with other families; and, therefore provides useful organisational learning to underpin improvement. 2.2 Appraisal of professional practice in this case. 2.2.1 This section provides an overview of ‘what’ happened and ‘why’. The purpose of this section is to provide an appraisal of the practice that is specific to the case and it therefore includes the review team’s judgements about the timeliness and effectiveness of practice including where practice was below expected standards. Such judgments are made in the light of what was known and was knowable at that point in time. For some aspects, the explanation for ‘why’ will be further examined in the findings in section 4 and a cross reference will be provided. 2.2.2 This case focusses on the dilemmas faced by professionals working with families where there are significant historical concerns about parents’ capacity to care adequately for their children but the immediate evidence of risk of significant harm is not apparent. There were questions about the parenting ability of both parents and there had been attempts made to work with the family to achieve change however despite this most professionals remained concerned about the long-term outcomes for the children even though there were no immediate signs of harm. TIMELINE 12/08/15 Review Child Protection Conference held. 22/09/15 Team About the Family meeting in respect of Sibling 1. Parents struggled to accept risks remained for Sibling 1 – CSC close the case. October 2015 Family have Council Tax arrears of £966.93. 8 WT 2015, 4:11http://www.workingtogetheronline.co.uk/chapters/chapter_four.html Final report 15-6-2018 8 20/10/15 Sibling taken to A&E by police and parents following concerns being raised by gardener. 21/10/15 SW1 visits the family and discusses events of previous day and concludes no evidence that father hit Sibling 2 22/10/15 – 23/10/15 Maternity Safeguarding team attempt to contact SW1 on 3 occasions 24/10/15 Neighbour contacted police expressing concern about a child heard crying at the address the previous day 11/11/15 Conversation between CSC and named nurse. SW1 informs maternity that family have been assessed and unborn remains a closed case. 12/11/15 Parents tell CSC that Half Sibling 1 cannot return to their care. 13/11/15 Half Sibling 1 accommodated under section 20 in the local authority’s care as placement with father broke down 30/11/15 Debt Enforcement agency visit 02/12/15 Mother made a further payment to the Enforcement Agents of £363.67 02/12/15 SW1 visits the family to ask for photos for Half Sibling 1. Mother decides no contact with Half Sibling 1 till after the birth of Baby LL. Social worker records a view that the relationship between Mother and father shows a high degree of controlling/coercive behaviours. 16/12/15 Debt Enforcement agency visit and agree payment schedule 22/12/15 Strategy meeting held (following incident on 24th Oct). Did not meet the threshold for section 47 07/01/16 Baby LL born at 38 weeks gestation. 22/01/16 Mother made a further payment to the Enforcement Agents of £45.00 26/1/16 Child and Family Assessment started by SW2 09/02/16 Separate Home visits by HV and Outreach worker. HV worried about rapid eye movement and advised LL be seen by GP urgently. 10/2/2016 Mother advises council she is starting work so housing benefit and council tax benefit cease at this point there is a small rent arrears of £44.47 plus the historic council tax debt. 11/02/16 – 17/02/16 HV attempts to chase up with mother and SW why GP appointment not made and to remind mother to register LL. GP attempts to ring HV but they keep missing each other. 17/02/16 Mother with SW2 present speaks with GP by phone. Reports that whilst HV is concerned she is not. GP agrees to review at 6-week check (2 weeks away). 22/2/16 Enforcement agent visits and warns mother that there will be no more chances and that the car will be taken if the arrangement is not kept to. 23/02/16 LL registered with GP 25/02/16 Home Visit by HV to Baby LL no concerns. 14/03/16 Baby LL seen by GP for 6-week check. All well except for horizontal nystagmus. No follow up planned. 15/03/16 Child and Family Assessment completed and results in a Strategy Discussion being held – recommendation from the assessment is that an Initial Child Protection Conference should be held 24/03/16 Family were given a pre-court rent arrears letter Final report 15-6-2018 9 29/03/16 NSPCC referral to CSC. NSPCC receive a referral from friend of mother saying that Mother was shouting and using derogatory words to address sibling 1, and Baby LL was left in a soiled nappy 11/04/16 ICPC for Sibling 1 and Baby LL. Both made subject to CP plan under neglect. Psychologist to be identified to undertake a whole family assessment. 22/04/16 Core Group Meeting. Parents not present as father had received bad news about an aunt. 29/04/16 Report of Sibling 1 seen in A&E with swelling and 2cm laceration below left eyebrow. Parents reported he had fallen from highchair. 11/05/16 Half Sibling 1 made the subject of a full care order. Mother did not go to court 12/05/16 SW3 visits family and sees both parents and both children. Parents tell SW that Baby LL has a slight temperature – she sees the child who appears a little warm but otherwise presents as fine and does not appear ill. 12/05/16 Whilst in the sole care of father, Baby LL was found pale, floppy and lifeless in his Moses basket at 4pm. Relevant background history 2.2.3 Prior to the review period Father was convicted in February 2011 of ‘causing unnecessary suffering to a child under 14’ and was imprisoned for 12 months. His daughter, Half-sibling 2, had suffered several serious injuries inflicted by her mother. Although there was no evidence that Father was involved with the assault, he lived in the family home at the time but denied any knowledge that his daughter was being harmed. The judge in the trial raised concerns about Father’s ability to empathise, understand the emotions of another and his failure to protect his baby or seek medical help. 2.2.4 Mother was the single carer of her older daughter, Half-sibling 1, for much of her life. During this time Mother had periods of drinking to excess which impacted on her ability to care for her daughter. Half-sibling 1, was made the subject of a Child Protection plan in 2013 after her mother commenced a relationship with Father and he moved into the family home, at this stage there were concerns about sexualised behaviour and that her emotional needs were not being met. Mother became pregnant with Sibling 1 and in November 2013 the unborn child was made the subject of a child protection plan and mother signed an undertaking saying that Father would not care for either child unsupervised. 2.2.5 In 2014 concerns about the family continued and CSC initiated Public Law Outline (PLO) proceedings10 with the major focus being on a psychological risk assessment of father and the risk he posed to both children. There were also concerns regarding the nature of the relationship between Mother and Father and questions about whether Father was coercive and controlling of Mother. She was adamant that their relationship was very positive, but professionals felt that Father appeared threatening on occasions and were anxious about the implications of this for her and the children. 10 PLO – Public Law Outline the framework within which court proceedings are initiated by the Local Authority under The Children Act 1989 – see glossary for more details Final report 15-6-2018 10 There was significant delay in this assessment being commissioned because of time taken to get permission from the High Court for documents associated with proceedings concerning Half-sibling 2 to be made available to the psychologist; there was then some delay in accessing the relevant expert for the assessment. During this time the children remained the subject of child protection plans, and the parents were co-operative. There were no real concerns about Sibling 1 who was developing well however there were continuing concerns about Half-sibling 1 who moved to live with her father in May 2015. There was also no evidence of domestic abuse although professionals continued to have concerns about the control exerted by Father over Mother. 2.2.6 At the start of the review period CSC received the expert psychological assessment commissioned through the civil court process which concluded that neither parent presented a risk of physical harm to Sibling1 and made recommendations for further work with the parents that included: attending a parenting programme; mother to have individual therapy; and the family to undertake a whole-family assessment with an independent provider. CSC were surprised by the conclusions of the assessment and considered that they had no choice but to cease the PLO process as the assessment did not support their judgement that the children were suffering significant harm. Review Child Protection Conference that ends the Child Protection plan for Sibling 1 and starts Team Around the Family process. 2.2.7 At the review child protection conference in August 2015, the social worker (SW1) recommended that the child protection plan for Sibling 1 should end and this was supported unanimously by all professionals present at the meeting. The chair said he felt the plan had worked well for Sibling 1 and there were no concerns about the parents' ability to understand his needs. He noted there may be concerns about father’s parenting in the future, especially about discipline as Sibling 1 gets older and that this will be looked at. All professionals at the conference agreed that Sibling 1 should be stepped down to a Team Around the Family and the HV agreed to take on the role of Lead Professional. It is interesting to note that the expert psychiatrist recommended continuing to work with the family via a child protection plan and this was agreed with regard to Half-sibling 1 however it was not felt appropriate for Sibling 1. This raises questions about the status given to ‘expert’ opinion particularly in the context of court process. This is explored further in finding 1. 2.2.8 Despite the psychiatric report saying that neither parent presented a risk of physical harm to the children, this report nonetheless made substantial recommendations for further work with the family and this was particularly important because the parents had previously indicated they were unwilling to work cooperatively with professionals around these issues. These factors suggest that a more appropriate step-down plan would have been to a ‘child in need’ plan with a social worker as the key worker which would have provided a structure within which there could have been escalation back to Child Protection plan if the family had not co-operated. The reasons for this and the implications of working in this way is explored further in Finding 2. From this point there was no allocated social worker however SW1 was a point of contact when referrals were received from other agencies. Final report 15-6-2018 11 Professional response to investigation by police of concerns by member of the public 2.2.9 On the 20th of October 2015, the police received a call from a professional gardener working in the vicinity of the parent’s house. This person reported that h/she had heard a baby crying and the sound of whacking followed by silence at the home address. When the police arrived at the home, Father explained that he was alone with Sibling 1 and had put him to sleep at 15:00 and reported that he was himself asleep and had been woken by Sibling 1 crying at 16:00. He could not recall raising his voice and denied hurting Sibling 1. Due to the parent’s history the attending officers felt Sibling 1 should be taken to Accident & Emergency (A&E) to be examined by a doctor, this was good practice. On arrival at hospital, a Senior House Officer examined Sibling 1 and discussed the case with the A&E Consultant. They in turn had a telephone discussion with the Paediatric Consultant who felt that because Sibling 1 had no visible injuries or symptoms there was no justification for him to be examined by a paediatrician. The Hospital spoke with an Emergency Duty Team (EDT) social worker who did not feel that the child needed a full paediatric assessment as there were no signs of bruises. Although the A&E consultant was concerned he took the advice of both the Paediatric Consultant and EDT and discharged Sibling 1. It is noteworthy that although all agencies knew some of the family history (particularly that there had been historic concerns about previous children) the full details of father’s conviction were not shared. Given the family history best practice would argue that the child should have been seen at this time by a paediatrician to check that there were no hidden injuries such as rib fractures or similar. The reasons for this action by the hospital consultant are considered in finding 3. 2.2.10 When SW1 was informed of the incident by the police on the 21st October she concluded that there was no evidence that Father had hit Sibling 1 and therefore the concerns were found to be not substantiated. Following a safeguarding intervention of this sort it is good practice to hold a strategy discussion11 to conclude the investigation and agree any further action – this is particularly true when, as in this case, the intervention is mainly single agency because it occurred out of hours. There was no attempt by the police or CSC to call a strategy discussion about this incident which was not good practice. This was discussed at length by the case group and review team who considered that the child protection procedures are not clear about how historic information should be addressed when investigations of this nature are undertaken. This is addressed in finding 3. It was however felt that the current MASH12 arrangements would mean that there would now be a multi-agency discussion of this case. This may be something that the LSCB examine in their regular review of MASH arrangements. 11 When there are concerns that a child may be at risk of significant harm, CSC will talk to partner agencies about the child and jointly decide if the threshold for a child protection investigation (see Section 47 below) has been met and who should carry out the investigation – CSC and the police (joint agency) or the police alone (single agency) these communications are called strategy discussions and may be by telephone or via a meeting. 12 Multi Agency Safeguarding Hub. The Multi-Agency Safeguarding Hub (MASH) is a partnership between The County Council, he Constabulary, and health agencies working together to safeguard children, young people and vulnerable adults. Final report 15-6-2018 12 2.2.11 Midwifery staff were informed of the attendance at Accident & Emergency by Sibling 1 and in October they unsuccessfully attempted to discuss this with SW1. On the 28th of October Sibling 1 was discussed at the weekly Safeguarding meeting which was attended by the Safeguarding Midwife and the social worker sent from the local team to attend the routine meeting and the Liaison Health Visitor. After this SW1 returned the midwife’s call and informed her that Sibling1 was no longer on a CP plan and confirmed that the case remained closed for unborn Baby LL. Midwifery staff decided to keep the case open to maternity safeguarding and provided enhanced midwifery care. Given the history of the family, and the significance of the allegation, it was important that the midwife was fully updated about any actions taken in response, to inform her work with mother. The midwife was tenacious in trying to contact SW1. 2.2.12 Despite there being no direct social work involvement with the family the social work team continued to have concerns. The Service Manager for the social work team had a management oversight meeting with the Area Head on the 17th of December where she discussed the family and her ongoing concern that ‘things were not right’ within the family but that she was anxious that she might be penalising them unjustly. A decision was made to call a Strategy Discussion meeting to discuss the two incidents when the police were called out to the family home – October 20th and October 24th regarding reports of hearing a baby crying and concerns for their welfare. The meeting was held on the 22nd of December. The outcome was that the case did not meet the threshold for a Section 47 investigation13 however it was agreed that a further Child and Family Assessment should be undertaken. It was very good professional practice that the manager discussed her ongoing concerns with her supervisors and that the advice given was to hold a further strategy discussion – it was also effective professional practice to recommend a further assessment. Communications between GP and Health Visitor about ‘flickering eyes’ 2.2.13 Baby LL was born in January 2016 and was discharged home within 24hours. There were no concerns about the baby from midwifery staff and the handover to the health visitor (HV1) was unremarkable. On 9th February 2016 however HV1 saw the family at home and was worried about Baby LL having a ‘rapid eye movement’. She advised mother to take Baby LL to be seen by the GP urgently. 13 A Section 47 enquiry is an investigation undertaken when social workers have ‘reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child Final report 15-6-2018 13 Over the next two days, HV1 checked if this appointment had been made and left a message on the 11th February asking to talk with the GP. The GP rang the health visitor on three occasions that day but was unable to make contact. When the health visitor discovered that mother had not made the appointment she told SW2 that mother needed to take Baby LL to a GP appointment and to remind mother to register Baby LL with the GP. On 17th February the social worker visited and when Mother told her she had not yet seen the doctor she made her ring the GP while she was still present which was assertive social work intervention. Mum talked with the GP and explained the health visitor’s concerns. The GP was unaware of the family history and explained that a baby’s eye movements do not become fixed until they are 6 weeks old. In the absence of any other concerns these eye movements can be part of normal development at that stage. The GP felt that a baby of 4 weeks old would not ‘fix and follow’ and therefore that it was too soon to make a proper assessment. As there were no other concerns the GP arranged for Baby LL to be seen at 6 weeks when eye movements were assessed routinely as part of the 6-week check. On 14th March 2016 Baby LL was seen by the GP for a 6-week check. The GP considered that all was well with Baby LL except that he had a horizontal nystagmus14. 2.2.14 It was good practice for the health visitor to both notice the unusual eye movement by the child and then to be proactive in contacting the GP and asking for an early assessment of the baby, and then involving the CSC when it became apparent that mother had not made the appointment as requested. Whilst it was clear that both GP and HV1 spent significant time trying to talk to each other the absence of email/written communication undermined the GP understanding of HV1’s concerns which was compounded by the GP being unaware of the family history. These issues are discussed further in findings 4 and 5. 2.2.15 The Child and Family Assessment was completed with a recommendation that an Initial Child Protection Conference (ICPC) should be held. This resulted in a Strategy Discussion being held on 15th March 2016. On the 29th of March 2016, mother contacted CSC to inform them that she had a disagreement with the MGM who had threatened to contact CSC. Subsequently on the same day NSPCC received a referral stating that mother had been abusive towards Sibling1 and was neglectful in respect to Baby LL. Mother explained that she had been upset when the social worker had told her that there was to be an ICPC and so had gone to see her mother in West Sussex (late at night 10.30pm). When she arrived mother and her friend were both drunk and an argument ensued. The referrer to the NSPCC was drunk and the social workers accepted mother’s explanation as to what had happened. Just over a week later on the 9th of April (2 days before the ICPC) another referral was made to the NSPCC reporting that mother was drinking daily and was being emotionally abusive towards Sibling 1. Once again, the referral was passed onto CSC. 14 Nystagmus is persistent, rapid, involuntary eye movement (most commonly from side to side), which usually impairs vision. Nystagmus may be present at birth, caused by defects in the eye or the visual pathway from the eye to the brain. https://www.nice.org.uk/guidance/ipg299/.../treating-nystagmus-by-horizontal-eye-m... Final report 15-6-2018 14 Further Initial Child Protection Conference 2.2.16 On 11th April there was an ICPC which received an assessment report from the social worker about the risks to the children. The concerns that the social worker identified were: the incident where it was reported by a neighbour that Sibling1 was being smacked in October; a recent report that Mother took both children unexpectedly to her parents at 10.30pm when most children were asleep; that mother did not take BabyLL to the GP when advised to do so by the HV because of his flickering eyes; and that Sibling1 had severely delayed speech and the parents are not being proactive in responding to this. 2.2.17 This assessment was needed to assess the risk posed to Sibling1 and LL by both parents and it was therefore especially important to explore ‘family and environmental factors’ including parental dynamics and where the children fitted into the parents’ priorities. The report of this assessment had minimal information about the family’s finances and no information about any debts or money pressures. It also did not address why mother was planning to return to work, with two children under three, (one a new born baby) and it did not fully examine what risks this may pose to the children as it meant that the Father would be caring for the children, alone and full time. Issues about why this assessment was limited are discussed in finding 6. 2.2.18 At the ICPC both children were made the subject of CP plans because of neglect, and plans were put in place to protect them. The decision to make the children subject to a plan was not clear-cut given there was comparatively little evidence of significant harm to the children. The chair of the conference was able to pull out effectively the risk factors including the parents’ lack of co-operation. Final report 15-6-2018 15 2.3 In what ways does this case provide a useful window on our systems? 2.3.1 The LSCB agreed broad research questions at the start of the process, which go beyond the facts and issues in this case, to look more widely at their child protection systems. The questions are set out at in paragraph 1.5.2 and directly link to the areas covered in the appraisal of practice and the findings. 2.3.2 A key area of research was how effectively agencies work together with families where there are concerns regarding neglectful parenting. This review has shown that these parents exhibited behaviour indicating low levels of neglectful parenting such as poor supervision, a child with delayed speech, and parents’ failure to act on professional advice. Professionals responded to these issues effectively and they were the main reason that at the time of Child LL’s death he and his sibling were the subject of child protection plans. 2.3.3 One of the research questions was concerned with how effective professionals were at achieving change with families where there is disguised compliance. This was an area where the review indicated that professional practice was less successful. In particular, the decision to replace the child protection plan with a family action plan led by the health visitor was unhelpful. The health visitor lacked authority for this role and it was evident from the start that the family were unlikely to co-operate. This decision also led to a lack of continuity in the case planning as the health visitor did not have full access to all the information contained in the independent expert assessment which was necessary to continue effective work with the family. 2.3.4 The LSCB was also concerned to understand better how effectively professionals were using information and knowledge gained when working with older siblings in assessing risk for babies. This review has shown that whilst information was known and shared, the key challenge was in being able to interpret the effect on the children of the parents’ actions, and in particular, in judging whether this was causing significant harm. 2.3.5 A further issue considered by the Review Team was the extent to which the issue of father’s controlling and coercive behaviour was addressed by the professionals working with the family. It was clear that all the professionals interviewed considered that Father could on occasion present to professionals in a threatening way. SW1 did record that she considered Father to act in a controlling way with Mother. Social workers involved later were aware of this view and did consider it in their assessments however they could find no further evidence of this behaviour. Mother continued to affirm that her relationship was very positive and that she felt supported by Father. Other professionals, such as midwife and health visitor, routinely inquired about domestic abuse and Mother was also positive about Father with them. The Review Team felt however that this was an issue that would have warranted further investigation, and that possibly professionals were inhibited from this by anxieties that they might be unduly penalising the family because of their past history. Final report 15-6-2018 16 2.4 Summary of findings The review team have prioritised 6 findings for the LSCB to consider. These are: Finding Category 1 Does expert opinion have an undue impact on case planning as opposed to social work professional experience when balancing the evidence of risk posed by a parent? Professional norms & culture around multi- agency working in assessment and longer-term work. 2 In the county social workers are not always allocated to work with families with ‘step-down’ plans from child protection to ensure effective co-ordination of the care plan; and there is inconsistency in the implementation of Child Protection conference recommendations regarding the allocation of lead professional for Child in Need and Family Action plans. Patterns in human– management system operation 3 The current child protection procedures in the county are insufficiently clear about the context and circumstances in which children should be subject to an assessment by a paediatrician and when strategy discussions should be held where there are historic safeguarding concerns Patterns in human– tool operation. 4 Professionals in the county do not routinely communicate and record underlying concerns and relevant historical information to inform analysis and decision making when they share information. Professional norms & culture around multi- agency working in assessment and longer-term work. 5 In the county, current primary care registration processes are inconsistent about how they ask for information regarding a family’s previous contact with social care and cross-reference with existing child protection records meaning that key information may not available when a GP sees a new baby. Patterns in human– tool operation. 6 The complexities of the current benefits systems, general levels of personal debt and families not readily disclosing, make it hard for professionals in the county to assess the relevance of families’ finances to child protection when undertaking assessment work. Professional norms & culture around multi- agency working in assessment and longer-term work. Final report 15-6-2018 17 2.5 Findings in Detail Finding 1 Does expert opinion have an undue impact on case planning as opposed to social work professional experience when balancing the evidence of risk posed by a parent? Professional norms & culture around multi-agency working in assessment and longer- term work. Introduction As part of an assessment of a family, particularly when initiating or progressing care proceedings, social workers may commission ‘expert’ assessments of parents. These assessments are often undertaken by psychologists or psychiatrists and are usually based on clinical judgements using information gathered from the professionals and the parents. They often have no direct contact with the children and are usually based on a small number of contacts. They are important assessment evidence for social workers but are one element of information that is considered alongside the social worker’s professional knowledge of the family over a longer period and with direct observation of the parents caring for their children. Parenting and multi-disciplinary assessments may be required before or during care proceedings. The main reason for commissioning an assessment will be in instances where there is a need for additional expertise or specialist opinion which cannot be provided by the local authority social worker. It is assumed that any qualified social worker will be able to assess immediate risk, basic care, and other aspects of child development and parenting capacity specified in the Core Assessment Framework and Professional Capabilities Framework15 . The courts expect a social work parenting assessment in each case. The social work parenting assessment should evidence that the social worker is the expert in the child’s life (i.e. that they know the child and the quality of their care). How did the issue feature in this particular case? The Review Child Protection Conference followed on from the completion of the assessment of the parents by the psychiatrist which determined that neither parent posed a risk of physical harm to Sibling 1. The social workers were very surprised at the outcome of the assessment and their managers felt that the effect was to undermine any case that they had to take legal action to protect Sibling 1 and so they ended the Public Law Outline process. The psychiatrist’s assessment also made recommendations for further work with the parents that included: attending a parenting programme; mother to have individual therapy; and the family to undertake a whole- family assessment with an independent provider. It also recommended that both children should remain the subject of child protection plans whilst the work with the parents was undertaken. At the review child protection conference, the social worker recommended that the child protection plan for Sibling 1 should end and this was supported unanimously by all professionals present at the meeting. The social worker’s 15 The Professional Capabilities Framework (PCF) is an overarching professional standards framework, developed by the Social Work Reform Board. The PCF gives social workers a framework around which to plan their careers and professional development. https://www.basw.co.uk/resource/?id=1137 Final report 15-6-2018 18 concerns were mainly focussed on half-sibling 1 who had been rejected by mother but did acknowledge that it was hard to know what the future held as Sibling 1 was quite young and had not presented much challenge to father who had only cared for him alone for very short periods. There was no discussion at the conference of the recommendation by the psychiatrist that both children should remain the subject of a child protection plan nor how the recommended work programme would be achieved. In part this was because whilst the social worker and the parents knew the content of the psychiatrist’s report this was not shared with other professionals at the conference. Another influence may well have been that it is not considered good practice for children to remain the subject of child protection plans for over two years and because of delays in achieving the psychiatric report promptly the children had already been the subject of child protection plans for almost two years. What was evident was that the judgement by the psychiatrist that the parents presented no risk of physical harm to the children became the dominant theme and that other aspects of the report that identified other risks of emotional abuse and neglect were lost. This was in part because only some professionals had access to the report, but also indicated how powerfully the psychiatric opinion undermined previously agreed professional judgements about the family and particularly the judgements of those workers who had been involved with the family over a significant period of time and who had seen them in a range of contexts and circumstances. How do we know it is an underlying issue and not something unique to this case? Discussions with the case group showed that whilst it is not common there are occasions when independent ‘expert’ opinions do challenge the dominant professional views on a family. It was also agreed that the Public Law Outline process means that when this happens it is often only the family and the social workers who have direct access to the information in the reports meaning that other professionals are very dependent on direction from the social worker as to the relevance and status of the expert opinion. It was noted that social workers can and do challenge expert opinion, but it was also agreed that currently the courts are likely to give greater weight to expert opinion than to the views of the social worker meaning that it is difficult for social workers to argue against ‘expert’ opinions. It was agreed by the Case group and review team that if expert opinion was to be challenged this would need a concerted effort across all agencies and that current case planning arrangements do not always facilitate such an action. In particular, there was discussion about whether there should be processes built into the PLO system that would allow the social worker to share with other agencies the findings from expert opinions which could therefore ensure that such findings were fully considered by all professionals involved in child protection conferences. How common and widespread is the pattern? This review only involved staff from one area within the county however the reasons given by professionals for the differences in working relations could apply across all of the county. During the period 01/04/17 to 31/03/18 there were 74 specialist assessments commissioned for 63 children subject to a Child Protection plan across the whole of the county. It is not known how many ‘expert’ opinions overturn the previously agreed child protection conference plan as such data could only be collected on an individual basis and this does not happen at present. Final report 15-6-2018 19 What are the implications for the reliability of the multi-agency child protection system? Assessment is an ongoing process, and whilst there is clearly a role for specialist ‘expert’ opinion, if this becomes too dominant there is a risk that other information and opinion will be lost meaning that risk assessment becomes too narrow. For children to be fully protected those professionals who have been involved over a period of time need to be as fully involved as those with ‘expert’ opinion and the risk assessment on the children needs to take into account both judgements to enable safe decision-making. Finding 1: Does expert opinion have an undue impact on case planning as opposed to social work professional experience when balancing the evidence of risk posed by a parent? This review has identified that on occasions expert opinion may be given too great a weight which potentially undermines the risk assessment of children. There is a need for any expert opinion to be shared across agencies and to be balanced by the judgements of those professionals who involved with a family over time and can provide a historic assessment as well as observe current behaviours. Considerations for the Board and partner agencies • Do the reasons given for this fully explain the issue? • What lies behind this? • Is it likely to apply to all the teams in the county? • Should attempts be made to amend the PLO initiation process to enable the sharing of findings of ‘expert’ opinion at child protection conferences? • Does the Board think it would be helpful to review/examine the outcomes of expenditure and impact of expert assessments? • Does the Board think that expert assessments are sometimes commissioned in the county because social work teams are insufficiently resourced to undertake parenting assessments? Final report 15-6-2018 20 Finding 2 In the county social workers are not always allocated to work with families with ‘step-down’ plans from child protection to ensure effective co-ordination of the care plan; and there is inconsistency in the implementation of Child Protection conference recommendations regarding the allocation of lead professional for Child in Need and Family Action plans. Patterns in human–management system operation. Description When a child is the subject of a child protection plan the services provided to the family are reviewed every six months at a Child Protection Review Conference. This conference must decide explicitly if the child has suffered, or is likely to suffer ‘significant harm’, and hence whether the Child Protection Plan needs to be continued. If the risk of significant harm has reduced consideration should be given to discontinuing the plan and at that stage a decision should be made about what ongoing services should be provided often described as a ‘step-down’ plan. Discontinuing the Child Protection Plan must never lead to the automatic withdrawal of services and in the county the Child Protection Review Conference can recommend that services should continue to remain available to the child/family as a ‘Family Action Plan16 ’. The Lead Social Worker must discuss with parents and child(ren) what services continue to be needed, based on the re-assessment of the child and family and a Family Action Plan made if support continues. After the discontinuation of a Child Protection Plan, the Family Action Plan will be reviewed. How did the issue manifest in this case? At the point of step-down from the child protection plan the case moved to a Team around the Family (TAF) plan as there were no Child in Need teams and the RAIS17 teams were mainly focussed on assessment work. The health visitor had a very large caseload and insufficient time and experience to manage effectively a ‘step-down’ plan with the risks presented by this family. Despite the psychiatric report denying that the parents presented a risk of physical harm to the child, this report nonetheless made substantial recommendations for further work with the family and therefore a detailed ‘step-down’ plan that included responding to the psychiatrist’s recommendations, with continued oversight by a social worker was required. This was particularly important because the parents had previously indicated they were unwilling to work cooperatively with professionals around these issues and therefore there was likely to be a need for the case to be re-escalated in the future. These factors suggest that a more appropriate ‘step- down’ plan would have been to a child in need plan with a social worker as the key worker. Given the psychiatrist had made specific recommendations about future work with this family to safeguard the child, the ‘Family Action Plan’ plan needed to explicitly link the services being offered to the family to the psychiatrist’s recommendations. 16 Current procedures in the LSCB indicate that when a child protection plan ends there is a step down to either a child in need plan or a family action plan – previously family action plans were known as Team about the family (TAF) plans. 17 RAIS – Referral, Assessment and Intervention Service, the team within CSC that responded to referrals and undertook immediate assessment work. Final report 15-6-2018 21 This would have provided a structure within which there could have been escalation back to a child protection (CP) plan if the family had not co-operated. It could also have been supported by a written agreement. Instead, the first ‘Family Action Plan’ meeting suggest the arrangements were all offered on a voluntary basis and there was evidence that the parents were un-co-operative from the beginning. How do we know it is an underlying issue and not something unique to this case? (what other evidence is there?) Current arrangements for ‘stepping-down’ child protection work in the county are that a ‘step- down’ from a CP plan can either be to a Child in Need (CIN) plan, if there are specific outstanding tasks that need to be completed and require a social worker’s input, or less typically to a Family Action Plan (i.e. what used to be TAF). It is primarily for the social worker and their manager to review each case to determine the ‘step-down’ process. The case group reported that the decision to end a child protection plan is a multi-agency decision based on the recommendation made to the conference by the key worker, but that if it is recommended that there should be a child in need plan, it is the decision of the CIN team manager whether they will accept the case. Thus, there can be circumstances where the Child Protection Chair recommends the case transfer to the Family Support Service, but local managers interpret thresholds differently and it is then ‘stepped down’ to a Family Action Plan not a CIN plan. The Review Team noted that Child in Need teams are the only CSC teams who are able to decide whether or not to accept ‘step down’ cases and members of the Case Group and Review team were able to identify cases where the Child Protection chair had identified a ‘step-down’ process to the Child in Need teams and the cases were ‘rejected’ by those teams. The review team thought that whilst there were probably not many cases currently where this happened but that when it did they were likely to be key cases. It was also noted that within CSC there had been a review of all ‘step-down’ cases because of concerns that children with child protection plans were being ‘stepped down’ too soon leading to them becoming the subject of a further child protection plan; this audit had identified some cases where plans had ended too early. A further issue that was identified by both Review Team and Case Group members was that where a Family Action Plan was agreed there was a lack of consistency about the role of the key worker and in particular how often that person would have contact with the family and how they would share information with other agencies. How common and widespread is this pattern? This review only involved staff from one area within the county however the reasons given by professionals for the differences in working relations could apply across all of the county. Sample data regarding child protection conferences in the first quarter of 2018 (from 15th Jan 2018 to 31st March 2018) showed that there were 49 conferences where the child protection plan was stepped children down to a Child in Need plan and that 34 of these were referred to the Family Assessment Service there were 5 conferences where the child protection plan was stepped down to a Family Action Plan. Where there is a Child in Need plan the key worker is usually a social worker but that is not usually the case where there is a Family Action Plan. Final report 15-6-2018 22 What are the implications for the reliability of the multi-agency child protection system? The period after a child protection plan ends is often as significant for protecting children as when all agencies are working together via child protection conferences and core groups. It is important that families continue to be supported in a multi-agency fashion even when the immediate risk of significant harm is reduced. An effective safeguarding system therefore has a multi-agency process of support for families that enable early identification of problems and has clarity about how agencies will support the family. Finding 2 Social workers are not always allocated to work with families with ‘step-down’ plans from child protection to ensure effective co-ordination of the care plan; and there is inconsistency in the implementation of Child Protection conference recommendations regarding the allocation of lead professional for Child In Need and Family Action plans. In the county the decision to end a child protection plan is multi-agency however, although recommendations can be made about whether the family is supported through a child in need plan, it is a CSC judgement as to whether the threshold for allocation to a social worker is met and some families are supported by other professionals through a family action plan. This review has highlighted that these arrangements may leave some families in a vulnerable position if they are not allocated a social worker and there is a lack of clarity about the support needed by the family and the role of the key worker in delivering that package of care. Considerations for the Board and partner agencies • Is this a known problem to the Board? • Does the LSCB think that the decision about whether a family should be supported via a child in need plan or a family action plan should be multi- agency in the same way that a child protection plan is agreed? • Does the Board think that the recommendations of a multi-agency meeting and an independent chair should be over-ruled by the manager of a Child in Need Team? • Does the Board think that there are differences between professionals and agencies in their understanding of thresholds around child in need work? • Does the Board think that all children ‘stepping down’ from child protection plans should be supported via a child in need plan for at least six months after the child protection plan ceases? Final report 15-6-2018 23 Finding 3 The current child protection procedures in the county are insufficiently clear about the context and circumstances in which children should be subject to an assessment by a paediatrician, and when strategy discussions should be held, where there are historic safeguarding concerns. Patterns in human–tool operation. Each hospital has its own individual protocols and guidance regarding safeguarding which are supported by the LSCB safeguarding procedures. These protocols provide staff with further detail regarding when and how children should be examined by paediatricians when there are safeguarding concerns. The protocols in place at one hospital in the county whilst providing clear guidance about examinations of children where injuries are evident has less clarity where they may be historic concerns but less evidence of immediate harm. Strategy discussions are multi-agency conversations or meetings that are convened to plan investigations whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm; they should routinely involve Children's Services and the Police, Health (Named Nurse and/or Named Doctor) and other bodies as appropriate (for example, children's centre/school and, in particular, any referring agency.) The LSCB procedures are clear that when emergency action is or has been taken by the Police or Children's Services, the Strategy Discussion must be held within 1 working day and that if the child is in a hospital setting and there are child protection concerns a Strategy Discussion/Meeting must take place within that setting before the child leaves it18. How did the issue manifest in this case? When the Sibling 1 was taken in to the hospital by the police officer because of an allegation by a member of the public that he’d been hit, he was seen by a junior doctor in Accident & Emergency. Although that junior doctor contacted the paediatrician, he declined to examine him because there was no bruise and the current protocols do not require that children in these circumstances are medically examined by a paediatrician. There was also consultation with the Emergency Duty Service19 who agreed there was no need for the child to be seen by a paediatrician in the absence of a visible injury. Whilst the hospital staff knew that the child had previously been the subject of a child protection plan and that the family had other children about whom there had been concerns they were not aware that the father had served a prison sentence for failing to protect a child. The police officer was aware that father had served a prison sentence but only have had minimal information about the previous multi-agency child protection plan. 18 The Safeguarding Children Board Procedures Manual - 4.7.2 Timescales of Strategy Discussion/Meeting - http://surreyscb.procedures.org.uk/zkpqq/managing-individual-cases/strategy-discussions-and-section-47- enquiries/#s1142 19 The Emergency Duty Team provides an emergency social work service for urgent situations which arise out of normal office hours and which cannot be left with an appropriate degree of safety until the next normal working day. Final report 15-6-2018 24 The Emergency Duty Service had electronic access to the social work case file which may not have included all the detail regarding the history. The rationale for the paediatrician not seeing the child, and for there not being a strategy discussion, was the same - in the absence of physical evidence of harm to the child (as witnessed by a bruise or similar) there were insufficient child protection concerns to warrant further action. The family history and previous concerns about the parents did not feature, partly because some professionals did not have the full story, but also because, in the absence of a bruise, it was considered that the allegation could have been malicious. How do we know it is an underlying issue and not something unique to this case? Within the Review Team and Case Group there was consensus that current procedures mean that it is unlikely that a strategy discussion would be held after a single agency investigation unless there was clear evidence that the child had been harmed. It was acknowledged that on occasions this would mean that the full history of a family would not be known or considered and that the decision to end an investigation would therefore be made based solely on the presenting information available at the time. The Review Team and Case Group was less sure about practice within hospitals and it was felt that in some hospitals the child would have been seen by a paediatrician regardless of the absence of physical evidence of injury because of the serious nature of the concerns that were reported to the police. It is evident that procedures across hospitals vary and there is the potential for inconsistencies in response as a result. How common and widespread is this pattern? This review only involved staff from one area within the county however the child protection procedures being used by social work and police staff are county-wide and therefore this would apply to all professionals across the county. The hospital procedures are locally agreed, and some members of the Review Team did suggest that in other hospitals the child would have been seen by the paediatrician automatically. The reasons given by professionals for the differences in working relations which were that in the absence of physical evidence of significant harm there are insufficient grounds to define the issue as child protection would appear to be applicable to staff across all of county. What are the implications for the reliability of the multi-agency child protection system? Professionals in paediatric and accident and emergency (A&E) teams have a vital role to play in spotting and responding to all forms of child abuse and neglect. If safeguarding practice especially in relation to when a Paediatrician should undertake an examination is not consistent across all hospitals in the county, then potentially opportunities to identify hidden injuries are missed. Final report 15-6-2018 25 Finding 3 The current child protection procedures in the county are insufficiently clear about the context and circumstances in which children should be subject to an assessment by a paediatrician, and when strategy discussions should be held, where there are historic safeguarding concerns. Within the county the child protection procedures are not currently clear about when children should be assessed by a paediatrician and when strategy discussions should occur where there is no immediate evidence of physical harm but there are historical concerns and there have been allegations made of abuse. Considerations for the Board and partner agencies • Does the Board recognise this issue? • Are there reasons for each hospital having their own procedures and protocols? • Are there reasons for different practice across hospitals in the county? • Should the criteria for calling strategy discussion be made more explicit? • Is the Board assured that all partners are involved in strategy discussions appropriately? Final report 15-6-2018 26 Finding 4 Professionals in the county do not routinely communicate and record underlying concerns and relevant historical information to inform analysis and decision making when they share information. Professional norms & culture around multi-agency working in assessment and longer-term work. Description: “Early sharing of information is the key to providing effective early help where there are emerging problems. At the other end of the continuum, sharing information can be essential to put in place effective child protection services.” (Working Together to Safeguard Children 2015) Good practice when communicating with other agencies / services requires the following: • Is your reason for contacting the other service / agency clear? • Is there consent to share information? • Are both parties clear about the content of the information sharing? • Are there any actions arising from the information sharing? • If so, what are they and who will be responsible for undertaking them? • By the end of the contact both parties should be clear about: • What information has been shared; • The purpose of the sharing; • What each party has agreed to do as a result of the communication; and • What is being recorded about the contact?20 How did the issue manifest in this case? On 9th February 2016 HV1 saw the family at home and was worried about Baby LL having rapid eye movement. She advised mother to take Baby LL to be seen by the GP urgently. Over the next days, HV1 checked if this appointment had been made and left a message on the 11th February asking to talk with the GP. The GP rang the health visitor on three occasions that day but was unable to make contact. When the health visitor discovered that mother had not made the appointment she told SW2 that mother needed to take Baby LL to a GP appointment and to remind mother to register LL with the GP. On 17th February the social worker visited and when Mother told her she had not yet seen the doctor she got her to ring the GP while she was still present. Mum talked with the GP and explained the health visitor’s concerns with SW2 present. The GP was unaware of the history of the family and did not know that there had been previous child protection concerns. The GP responded to the medical issues raised by the mother and explained that a baby’s eye movements do not become fixed until they are 6 weeks old. In the absence of any other concerns these eye movements can be part of normal development at that stage. The GP felt that you would not expect a baby of 4 weeks old to fix and follow and therefore that it was too soon to make a 20 http://hullscb.proceduresonline.com/chapters/p_effective.html#effective Final report 15-6-2018 27 proper assessment. As there were no other concerns the GP arranged for Baby LL to be seen at 6 weeks when eye movements were assessed routinely as part of the 6-week check. On 14th March 2016 Baby LL was seen by the GP for a 6-week check. The GP considered that all was well with Baby LL except that he had a horizontal nystagmus. Whilst it is clear that both GP and HV1 spent significant time trying to talk to each other the absence of email/written communication undermined the GP understanding of the HV1’s concerns which were probably informed by the past history of the family and about which the GP was largely unaware. How do we know it is an underlying issue and not something unique to this case? Discussion with the Review Team and Case Group indicated that practice in this case was usual and that when leaving messages for another professional it would be commonplace to focus on the action that was being requested rather than explaining explicitly the reasons and concerns that underpinned the request. It would also be the norm to leave messages rather than following up telephone requests with formal written records of the concerns. Reasons for this included that sometimes the underlying concerns would not have been discussed with the parents. So, it was probable that in this case the health visitor would not have been explicit with the parents about her reasons for being concerned about the flickering eyes. It was acknowledged that this obliqueness could on occasion be confusing for other professionals. How common and widespread is this pattern? This review only involved staff from one area within the county however there is no reason to consider that practice in this area was different from any other part of the county. The NSPCC and SCIE analysis of 38 Serious Case Reviews (SCRs), published between May 2014 and April 2015 identified problems with inter-professional communication and its impact upon decision making as a common theme in serious case reviews (SCRs).21 What are the implications for the reliability of the multi-agency child protection system? If professionals are not explicit in their communication with other professionals regarding reasons for referrals, then opportunities to safeguard children in a timely manner may be missed. 21 NSPCC/SCIE (2016) Learning into Practice: inter-professional communication and decision making – practice issues identified in 38 serious case reviews. London: NSPCC/SCIE. Final report 15-6-2018 28 Finding 4 Professionals in the county do not routinely communicate and record underlying concerns and relevant historical information to inform analysis and decision making when they share information. Professionals within the county are proactive in sharing information with fellow professionals, however, the information communicated focuses on the presenting evidence and does not clearly outline the referrers underlying concerns meaning that there is limited understanding of the risks. Considerations for the Board and partner agencies • Does the Board recognise this issue? • Is there need for an information-sharing form and if so what information would need to be included? • Does the Board think that professionals are over-reliant on telephone contact rather than e-mail and if so why? • Are there ways in which electronic systems could be used to enable improved written communication? Final report 15-6-2018 29 Finding 5 In the county, current primary care registration processes are inconsistent about how they ask for information regarding a family’s previous contact with social care and cross- reference with existing child protection records meaning that key information may not available when a GP sees a new baby. Patterns in human–tool operation. Description When a new child is registered with a GP, the usual current process for placing the child on the GP data-base does not require a cross-reference with existing records held on other family members such as siblings, mother or father. This means that information already held on the data-base may not be accessed by doctors seeing a baby for the first time. In England, there is no legal requirement for a parent to register their child with a GP. It is however normal practice for most parents to register their children with a doctor and certain health assessments and services, such as immunisations, are co-ordinated and provided through the GP. In particular, GP records are seen by other health professionals as the central point to which reports of all other health interventions are located for example when a child is seen in hospital a summary report is always sent to the GP. How did the issue manifest in this case? When the GP was contacted by the health visitor regarding Baby LL’s flickering eyes he was unaware of any of the wider family background and did not know that there had been previous concerns about the parenting provided by both parents to other children. This meant that the GP responded to the concerns raised by the health visitor purely as medical issues. If the GP had been aware of the past family history, it is possible that the GP would have asked mother to bring the child into the surgery to be seen. How do we know it is an underlying issue and not something unique to this case? The GP working with the Review Team was clear that this GP was operating to procedures and protocols that are common to most GP practices and that current normal practice means that GPs when registering new babies do not access wider information held on their data-bases unless this is triggered by an event such as the child becoming the subject of a child protection plan pre-birth. This means that at initial contact they may be unaware of wider family history. How common and widespread is this pattern? This review only involved staff from one area within the county however it would appear that this practice is common to many GPs in the county. The GP working with the Review team had undertaken an audit in Hampshire aimed at identifying ‘hidden adults’ involved in children’s lives. The term “Hidden Adult” is a Hampshire Safeguarding Children Board term to describe significant adults in a child’s life about whom professionals are unaware. The overall aim of the audit was to establish whether primary care practices were collecting information regarding adults living with or involved in a child’s life. Final report 15-6-2018 30 This audit identified that each GP practice followed their own registration procedures and there was not a standard registration form for children. The overall finding from the sample audit was that details of the parent or carer with Parental responsibility and relationship to the child was recorded in 54% of cases and a previous history of social worker or children’s services input was recorded in 0% of cases. This research included some county based practices and it is possible that research about practice throughout the county would have similar results. An example of good practice has been identified in a practice in the Woking area where a specific registration form for children under 5 is used. The form includes requests for information regarding persons of parental responsibility. Current and previous history of involvement with Children’s Services including the name of the social worker and information regarding looked after children status. This demonstrates what good registration procedures look like but also highlights inconsistency in primary care registration practices for children across the county. What are the implications for the reliability of the multi-agency child protection system? In order to provide an effective GP service, access to wider medical records is important to understand a family history. This is particularly true with regards to safeguarding where important social information could be withheld meaning that the GP was unaware of risk factors or past child protection concerns which could place children at risk. Finding 5: In the county, current primary care registration processes are inconsistent about how they ask for information regarding a family’s previous contact with social care and cross-reference with existing child protection records meaning that key information may not available when a GP sees a new baby. Full understanding of the history of a child is key to a GP being able to assess risk, as the previous history of a family is a good indicator of future risk. The GP is viewed by most health professionals as the ‘hub’ for all health information and therefore the link for all professionals. Full access to all the historic record is a key factor in enabling professionals to access important medical and social information that could be crucial in safeguarding children. This review has identified that there are some systemic issues that prevent this happening in a timely manner. Considerations for the Board and partner agencies • Is the Board aware of this problem? • Does the Board think that a GP should routinely check the whole family record when a baby is registered? • Does the Board think that GPs should routinely request parents to provide the same core data when registering a baby and that this should include questions about previous social work involvement? Final report 15-6-2018 31 Finding 6 The complexities of the current benefits systems, general levels of personal debt and families not readily disclosing, make it hard for professionals in the county to assess the relevance of families’ finances to child protection when undertaking assessment work. Professional norms & culture around multi-agency working in assessment and longer- term work. Description Parenting capacity is one of three core elements which practitioners assess when concerns about a child's welfare are raised. The other two elements are the child's developmental needs, and wider family and environmental factors. These three elements are inter-related and cannot be considered in isolation (HM Government, 2013). Poverty is neither a necessary nor sufficient factor in the occurrence of child abuse and neglect. Many children who are not from families in poverty will experience abuse in some form and most children in families who are living in poverty will not experience abuse. There are various explanations for the relationship between family socio-economic circumstances and the prevalence of abuse, which include either a direct effect through material hardship or lack of money to buy in support, or an indirect effect through parental stress and neighbourhood conditions. Disadvantaging socio- economic circumstances may operate as acute or chronic factors, including their impact on parents’ own childhoods. These interactions between poverty and other contributory factors are complex and frequently circular and may include factors such as life-style pressures and the failure of businesses. Evidence suggests that individual practitioners and child protection systems currently pay insufficient direct attention to financial matters and do not take sufficient account of the role of poverty in child abuse and neglect.22 How did the issue manifest in this case? At the initial Child Protection Conference in April 2016 all professionals involved with the family provided reports about the family. None of these professionals provided information about the family’s financial position or considered why mother was planning to return to work, with two children under three and one a new born baby. None of the professionals at the conference was aware that the family had been visited by bailiffs who were threatening to remove the family car and that there was court action regarding rent arrears. Furthermore, there was no evidence that they had specifically asked the parents about current debts. At the conference, Mother clearly stated that she was looking for paid work and said she had to do unpaid work because she was in receipt of job-seeker’s allowance. At the meeting it was agreed that a whole family assessment was to be ‘explored’ that assessed child/adult attachments but did not fully examine what risks mother returning to work may pose as it left father, about whom there had been most concern, caring alone for the children. 22The relationship between poverty, child abuse and neglect: an evidence review Paul Bywaters, Lisa Bunting, Gavin Davidson, Jennifer Hanratty, Will Mason, Claire McCartan and Nicole Steils. Joseph Rowntree Foundation, March 2016 www.jrf.org.uk Final report 15-6-2018 32 How do we know it is an underlying issue and not something unique to this case? The case group was clear that while it was routine to discuss finances with families when undertaking assessments there was an assumption that parents would volunteer this information and that if there were problems they would be told. It was acknowledged that at present there were no systems in place for routinely including the Housing Department in these assessment processes even though Housing may be consulted as part of the MASH processes. It was also accepted that current benefit systems are complex and that usually where there are benefit problems families are advised to access specialist services such as the Citizens Advice Bureau. The Review Team were aware that a lack of awareness by professionals of family financial difficulties had been a feature of recent domestic homicide reviews. How common and widespread is this pattern? This review only involved staff from one area within the county however there is no reason to consider that practice in this area was different from any other part of the county. According to a recent report by the Joseph Rowntree Foundation, 39% of people in households with children now live below the Minimum Income Standard. The figure has risen by over a third since 2008/09. Household debt is now the highest it has ever been. In January 2018, the average household debt was £57,943 (including mortgages) with consumer credit debt of £7629. 276, people a day in the UK are declared insolvent or bankrupt and 1756 county court judgements (CCJ’s) were issued every day between October and December 2017, with 18 properties a day repossessed23. Families with children are now at greater risk than any other group of having an inadequate income and the number of homeless families living in bed and breakfast accommodation has risen by 300% over the last five years as a direct result of austerity and welfare changes. The roll out of full Universal Credit24 in the county, scheduled in the autumn 2018, will further affect both working and non-working households on low incomes and together with high housing costs will continue to be a source of pressure on families. The links between poverty and a child’s chances of becoming subject to child protection processes or being looked after are undeniable according to the international and national research. A child in the most deprived decile of neighbourhoods nationally has an 11 times greater chance of being on a child protection plan and 12 times greater chance of being a looked after child than a child living in the most affluent decile25 . 23 http://themoneycharity.org.uk/money-statistics/ 24 https://www.gov.uk/universal-credit 25 http://www.communitycare.co.uk/2015/06/30/child-protection-must-dealing-symptoms-increased-poverty/ Final report 15-6-2018 33 What are the implications for the reliability of the multi-agency child protection system? Previous research by The Children’s Society has suggested that financial difficulties experienced by families have a detrimental effect on the wellbeing and mental health of parents as well as children and young people. Therefore, when working with families it is important to understand the financial challenges faced by a family and identify any additional risks it may pose to the children within the family.26 Finding 6: The complexities of the current benefits systems, general levels of personal debt and families not readily disclosing, make it hard for professionals in the county to assess the relevance of families’ finances to child protection when undertaking assessment work. In the county the obtaining of information in relation to family finances is not explored to the same extent as other areas of parental capacity. At a time when more families are experiencing financial challenges it is importance that professionals working with these families understand fully the extent of the pressures on the family. Considerations for the Board and partner agencies • Is the Board aware of this problem? • Does the Board think professionals have sufficient understanding and awareness of the relationship between poverty and safeguarding? • Does the Board think professionals are sufficiently curious about people’s financial problems when undertaking safeguarding assessments of families and always include it when assessing environmental factors? • Is the Board assured that all safeguarding assessments of families undertaken include all aspects of the assessment framework and that all agencies are involved appropriately? • Given that families may be reluctant to disclose financial difficulties to professionals how can the Board be assured that assessment of finance is included in all safeguarding assessments of families? • Should the Housing Department routinely be consulted by agencies when professionals are undertaking assessments? 26 Pople, L., Royston, S. & Surtees, J. (2014) ‘The Debt Trap - Exposing the impact of problem debt on children’. The Children’s Society & StepChange. Accessed 12th August 2016: http://www.childrenssociety.org.uk/sites/default/files/debt_trap_report_may_2014.pdf Final report 15-6-2018 34 Appendix 1 – Methodology 1. This SCR has used the SCIE Learning Together model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, to identify effective supports and solutions that go beyond a single case. Initially used as a method for conducting accident investigations in other high-risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009). National guidance in the 2015 revision of Working Together to Safeguard Children (2015) now requires all SCRs to adopt a systems methodology. 2 The model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families. Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively. 3 Learning Together is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working. However, some systems findings can and do emerge which relate to an individual agency. Where this is the case, the finding makes that explicit. 4 The basic principles – the ‘methodological heart’ – of the Learning Together model are described in summary form below: a. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’). What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system. d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums. e. Analytical rigour: use of qualitative research techniques to underpin rigour and reliability. 5 Typology of underlying patterns To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local child protection systems are functioning. Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively? Final report 15-6-2018 35 They are presented in six broad categories of underlying issues: 1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category. Anatomy of a finding For each finding, the report is structured to present a clear account of: • How the issue manifests itself in the particular case? • In what way it is an underlying issue – not a quirk of the particular individuals involved this time and in the particular constellation of the case? • What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally? • How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. Illustrated below. Final report 15-6-2018 36 7 Structure of the Review There were three main groups who worked together to complete the review: 7.1 The review team comprises senior managers from the agencies involved in the case, who have had no direct part in the conduct of the case. Led by two independent lead reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings. They are also a source of data about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints and changes in structure. The review team members also have responsibility for supporting and enabling members of their agency to take part in the case review. Review Team Members Fiona Johnson, SCIE Independent Lead reviewer June Hopkins SCIE Independent Lead reviewer LSCB Partnership & Support Manager County wide Deputy Designated Nurse Safeguarding Children County wide designated GP for safeguarding children Named Nurse for Safeguarding Children Children, Community Health Service Provider Service Co Ordinator, Child Protection Conferences Children and Families Detective Chief Inspector Public Protection Head of Housing Advice at a borough council Safeguarding Advisor Safeguarding & Health Team Early Help & Family Services 7.2 The Case Group are the professionals who were directly involved with the family. The Learning Together model offers a high level of inclusion and collaboration with these workers/managers, who are asked to describe their ‘view from the tunnel’ – about their work with the family at the time and what was affecting this. In this case review, the Review Team carried out individual conversations with 17 case group professionals, and up to 19 professionals were invited to attend the case group meetings which discussed the practice in this case and agreed the findings. 7.3 Review process A Learning Together case review reflects the fact that this is an iterative process of information-gathering, analysis, checking and re-checking, to ensure that the accumulating evidence and interpretation of data are correct and reasonable. The review team form the ‘engine’ of the process, working in collaboration with case group members who are involved singly in conversations, and then in multi-agency ‘Follow- on’ meetings. The report will be received by the Serious Case Review Sub-group and the GSCB Executive who will have oversight of the final report and response plan. Final report 15-6-2018 37 The sequence of events in this review is shown below: Date Event 3/11/17 Introductory meeting for the Case Group – to explain the Learning Together model/method, and the case review process which they will be part of. 7/11/17 & 23/11/17 Two days’ conversations with members of the Case Group (individual sessions of about 1.5 hours with conducted by the lead reviewers) 24/11/17 First Review Team analysis meeting 12/12/17 First Follow-on meeting (Review Team and Case Group) In this meeting, the group works together on identifying Key Practice Episodes (KPEs) in the case which affected how the case was handled and/or the outcome of the case appraising the practice in these KPEs considering what was affecting the work/workers at the time (the ‘view from the tunnel’) 7/2/18 Second Review Team analysis meeting 21/2/18 Second Follow-on meeting (Review Team and Case Group) At this meeting, the group were provided with the emerging underlying patterns and findings, and were asked to consider whether these are specific to this individual case or pertain more widely and form a pattern. 5/4/18 Final review team meeting - to consider final draft report 17/4/18 SCR Sub-Group meeting – to consider the draft final report 21/5/18 LSCB meeting – to consider the draft final report Final report, fit for publication, to be submitted to Department for Education (DfE) 7.5 Scope and terms of reference Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference, such as in a traditional SCR. This enables the data to lead to the key issues to be explored. 7.6 Sources of Data 7.6.1 Data from Practitioners Conversations, as described above, with members of the Case Group; these were recorded and discussed by the whole Review Team. Final report 15-6-2018 38 Members of the Case Group have also helpfully responded to follow-up queries and requests from the Lead Reviewers and the Review Team for clarification or further information, where this has been needed. 7.6.2 View from the Tunnel and Contributory Factors The data from the conversations with the Case Group translates into their ‘view from the tunnel’ which enabled us as reviewers to capture the optimum learning from the case. Case Group members are also an invaluable source of information about the why questions – an exploration of the Contributory Factors which were affecting their practice and decisions at the time. 7.6.3 Participation The Lead Reviewers and the Review Team are grateful for the willingness of the professionals to reflect on their own work, and to engage so openly and thoughtfully in this SCR. Everyone has contributed very fully in the process. Individual practitioners all have participated responsively in conversations, which have recalled their role in this story, and in group discussions which have at times been very difficult and challenging. All this has given the Review Team a deeper and richer understanding of what happened with this family and within the safeguarding network, and has allowed us to capture the learning which is presented in this report. 7.6.4 Data from documentation The Lead Reviewers and members of the Review Team reviewed the following documentation: Children’s Services records Midwifery records Hospital records Police records GCH records Community Health Records/ GP records 7.6.5 Data from family, friends and community As in traditional SCRs, the Learning Together model aims to include the views and perspectives of family members as a valuable element in understanding the case and the work of agencies. Final report 15-6-2018 39 Appendix 2 Glossary A & E – Accident & Emergency Department of Hospital CIN – Child In Need CP – Child Protection CSC – Children’s Social Care GP – General Practitioner HMIC – Her Majesty’s Inspectorate of Constabulary. Independently assesses the effectiveness and efficiency of police forces – in the public interest. LSCB – Local Safeguarding Children Board MARF – Multi Agency Referral Form MASH – Multi Agency Safeguarding Hub. A partnership between the county council, the constabulary and health agencies working together to safeguard children, young people and vulnerable adults. NHS – National Health Service NSPCC – National Society for the Prevention of Cruelty to Children Ofsted - Office for Standards in Education, Children’s Services and Skills. They inspect and regulate services that care for children and young people, and services providing education and skills for learners of all ages. PLO - Public Law Outline. This is the framework within which Local Authorities are required to work in cases where it is considered by the Local Authority the threshold criteria is or may be met. Within the framework of the Public Law Outline there is a requirement to attempt to work with the family and their legal representatives before issuing proceedings. Within the framework provision is made for an LBA (letter before action) to be sent to the parents setting out the Local Authority’s concerns, setting out what the parents are required to do to address those concerns and inviting them to a meeting with their legal representatives to discuss and plan how to address the concerns raised. If the actions agreed are not adhered to the Local Authority then goes on to consider/issue care proceedings. This means the Court receives and accepts an application on behalf of the Local Authority and sets a date for a first hearing. In order to issue an application the Local Authority must produce to the Court: 1. A completed application form prepared by the lawyer; 2. A statement of evidence prepared by the social worker; 3. A chronology of significant events prepared by the social worker; 4. A care plan for each child, again prepared by the social worker; 5. A threshold criteria document prepared by the lawyer. This document describes how the evidence prepared by the social worker and provided to the Court proves that the requirements of the legal test called the threshold criteria are met to the extent that the Court has sufficient evidence to “Find” (i.e. determine) on the balance of probabilities that the evidence in support of the threshold criteria is factually correct. Final report 15-6-2018 40 Where the Court is satisfied that the Local Authority has proved that the facts in the case are such that the threshold criteria are met it can make a Care Order. A Care Order lasts until the child is 18 unless there is any further order of the Court. The effect of the Care Order is to bestow parental responsibility upon the Local Authority. This means the Local Authority then shares parental responsibility with the parent(s). SCR – Serious Case Review Single Assessment - Single Assessment process is the assessment process used in children’s social care which replaced initial and core assessments SCIE - Social Care Institute for Excellence. The Social Care Institute for Excellence (SCIE) improves the lives of people who use care services by sharing knowledge about what works. They are a leading improvement support agency and an independent charity working with adults’, families’ and children's care and support services across the UK. Strategy Meeting/Discussion – A strategy discussion is held when there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. This may be following a referral and initial assessment or at any time during an assessment where a child is receiving support services if concerns about significant harm to the child emerge. The purpose of the strategy discussion is to enable the Children’s Services’ department, Police and other relevant agencies (e.g. health services, schools) to share information, make decisions about initiating or continuing enquiries under s. 47 of the Children Act 1989, what inquiries will be made and by whom, whether there is a need for action to immediately safeguard the child, and what information about the strategy discussion will be provided to the family. Decisions will be made regarding the provision of any medical treatment, how to handle inquiries in the light of any criminal investigation and whether other children affected are in need or at risk. TM – Team Manager Final report 15-6-2018 41 Bibliography Barnett, O., Miller-Perrin, C., Dale, R.D., Family Violence across the Lifespan: An Introduction, Sage Publications, 2010 Marion Brandon et al Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005, DCSF 2008 Marion Brandon et al Understanding Serious Case Reviews and their Impact A Biennial Analysis of Serious Case Reviews 2005-2007, DCSF 2009 Broadhurst, K., White, S., Fish, S., Munro, E., Fletcher, K., and Lincoln, H., ‘Ten Pitfalls and how to avoid them – What research tells us’, www.nspcc.org.uk/inform, September 2010 Paul Bywaters, Lisa Bunting, Gavin Davidson, Jennifer Hanratty, Will Mason, Claire McCartan and Nicole Steils. The relationship between poverty, child abuse and neglect: an evidence review Joseph Rowntree Foundation, March 2016 www.jrf.org.uk HM Government, (2013) Working_together_to_safeguard_children A guide to inter- agency working to safeguard and promote the welfare of children HMSO.[accessed 3/5/2013] HM Government, (2015) Working together to safeguard children A guide to inter- agency working to safeguard and promote the welfare of children. London: Crown copyright 2015. [accessed 15/6/2015] Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 Framework for the Assessment of Children in Need and their Families, Department of Health, 2000 Hall, David M. B. Elliman, David. & Joint Working Party on Child Health Surveillance Health for all children, 4th edition Oxford University Press, 2003. Munro, Prof. E., ‘A systems approach to investigation child abuse deaths’, British Journal of Social Work, 35 (4), pp. 531-546, 2005 (also LSE Research Online) NSPCC/SCIE (2016) Learning into Practice: inter-professional communication and decision making – practice issues identified in 38 serious case reviews. London: NSPCC/SCIE. Pople, L., Royston, S. & Surtees, J. (2014) ‘The Debt Trap - Exposing the impact of problem debt on children’. The Children’s Society & Step Change. Accessed 12th August 2016: http://www.childrenssociety.org.uk/sites/default/files/debt_trap_report_may_2014.pdf Reder, P., Duncan, S., and Gray, M., Beyond Blame: Child Abuse Tragedies Revisited, Routledge, 1993 Reder, P., and Duncan, S., Lost Innocents: A Follow-up Study of Fatal Child Abuse, London: Routledge, 1999 Rushton, A., and Nathan, J., “The Supervision of Child Protection Work”, The British Journal of Social Work, Vol 26 (3): 357-374 |
NC045037 | Serious incident involving a 21-month-old boy, who was admitted to hospital in September 2013, after ingesting 40-50mls of opiate-based medication. Mother pleaded guilty to charges associated with her care of Child H and received a custodial sentence. Mother had been known to children's services since she was 15-years-old. Child H was the subject of a child protection plan at birth; the case was later stepped down to a child in need plan, which was closed 5 months prior to the incident. Child H had an older sibling, who was removed from mother's care due to concerns about substance misuse. Mother had a history of offending and was subject to a community order while pregnant with Child H. Mother was known to be using class A drugs, in addition to receiving methadone treatment, during pregnancy and after Child H's birth. Issues identified include: normalisation of mother's drug misuse and acceptance of dishonest and manipulative behaviour; and widespread inward focus among agencies, leading to unjustified assumptions that other agencies or professionals were managing child protection concerns. Identifies service improvements made by agencies and makes various recommendations covering Oxfordshire Clinical Commissioning Group and health, police and probations services.
| Title: Serious case review: Child H. LSCB: Oxfordshire Safeguarding Children Board Author: Fergus Smith Date of publication: 2014 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. OXFORDSHIRE SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW CHILD H 15.09.14 Contents 1 INTRODUCTION 1 1.1 Background & decision to initiate a serious case review 1 1.2 Purpose & conduct of the serious case review 2 1.3 Executive summary 3 2 REVIEW PROCESS & RELEVANT BACKGROUND 6 2.1 Relevant agencies 6 2.2 Family Involvement 6 3 AGENCY CONTACT WITH MOTHER PRIOR TO REVIEW PERIOD 8 3.1 Introduction 8 4 AGENCY CONTACT WITH FAMILY WITHIN REVIEW PERIOD 9 4.1 Introduction 9 4.2 Antenatal period 9 4.3 Perinatal period 17 5 ANALYSIS 31 5.1 Introduction 31 5.2 How well were parental vulnerabilities & their impact on parenting capacity identified? 31 5.3 What actions were taken to safeguard child H on the basis of vulnerabilities & how well agencies worked on their own & together, where relevant ? 41 5.4 Policies & procedures 49 5.5 Co-operation & engagement of services with parents & child 54 5.6 Additional issues for the review 57 6 CONCLUSIONS & LESSONS LEARNT 58 6.1 Conclusions 58 6.2 Improvements already introduced 61 7 RECOMMENDATIONS 62 7.1 Introduction 62 7.2 Responsibility for implementation 62 8 GLOSSARY OF ABBREVIATIONS 65 9 BIBLIOGRAPHY 66 1 1 INTRODUCTION 1.1 BACKGROUND & DECISION TO INITIATE A SERIOUS CASE REVIEW 1.1.1 Emergency services were called to the home of child H (then 21 months of age) on a Saturday evening in September 2013. The child’s mother indicated that she had left prescribed opiate based medication in her handbag, placed on a chair whilst she went to another room. Child H reportedly picked up the bottle and appeared to have drunk from it. Emergency services were not called for approximately 1.5 hours. Once called, Ambulance staff arrived promptly. 1.1.2 In the ambulance, child H stopped breathing and needed resuscitating. Upon arrival at hospital, the child was admitted, required intensive care treatment and subsequently made a full recovery. 1.1.3 Child H was thought to have ingested between 40-50 ml of prescribed opiate based medication that had been in the bottle (which has a child-resistant lock). 1.1.4 Child H’s 24 year old mother had been known to Children’s Social Care since the age of 15 and had a history of drug use. When child H was born the case was monitored via a ‘child protection plan’. This was stepped down to a ‘child in need plan’ in September 2012 and closed in February 2013. The case remained open to other services. 1.1.5 Mother was arrested on suspicion of neglect and later bailed by Police. Child H was initially accommodated with mother’s agreement and subsequently made subject of an interim Care Order. Mother later pleaded guilty to charges associated with her care of child H and received a custodial sentence. 1.1.6 Child H has an older sibling who was removed when 5 months old because of concerns about mother’s substance abuse and its impact on her ability to parent. 1.1.7 The agency bringing the case to the Safeguarding Board for review had particular concerns and the serious case review panel agreed that this met the criteria for a serious case review, mainly because of a need to evaluate inter-agency work 1.1.8 On 26.06.13 the then Local Safeguarding Children Board (LSCB) chairperson supported the above recommendation and the Department for Education and regulatory bodies Ofsted and Care Quality Commission were subsequently notified of his decision. This introduction explains the purpose and process of the serious case review (SCR) and includes an executive summary of events, learning and required improvements. 1.1.9 The remainder of the report explores the experiences of child H and mother, evaluates the services and systems that sought to support and safeguard the child, and offers overall conclusions and recommended system improvements. 2 1.2 PURPOSE & CONDUCT OF THE SERIOUS CASE REVIEW PURPOSE 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government [latest edition 2013]. A ‘serious case’ is one in which abuse or neglect is known or suspected and either the child has died or been seriously harmed, and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to: ‘Establish what lessons can be learned about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children Identify clearly what those lessons are within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children’ 1.2.3 A serious case review (SCR) is not concerned with the attribution of culpability which is a matter for a criminal court. Terms of reference were established and section 5 (analysis) addresses each element of them in turn. Sections 6 and 7 respectively, offer conclusions and proposed improvements to local systems respectively. A copy of this report is being sent to the government-appointed national panel of experts and to the Department for Education (DfE). CONDUCT Serious case review panel 1.2.4 The panel consisted of the: Designated Doctor Oxford University Hospitals NHS Trust Trust Lead Nurse for Safeguarding Children Oxford Health NHS Foundation Trust Designated Nurse Oxfordshire Clinical Commissioning Group Deputy Director Oxfordshire Children’s Social Care & Youth Offending Service Safeguarding Manager Oxfordshire County Council Deputy Director Education & Early Intervention Service Oxfordshire County Council Detective Chief Inspector Thames Valley Police Head of Service Child & Family Courts Advisory and Support Service (Cafcass) 1.2.5 The need for further expertise was recognised and the commissioning manager of the Public Health Drug and Alcohol Action Team joined the panel. 3 Independent authorship 1.2.6 An independently authored overview report was commissioned from www.caeuk.org (an independent consultancy with experience of over 50 SCRs). It was agreed that upon submission of relevant material, author Fergus Smith would, in accordance with the appended terms of reference: Collate and appraise individual management reviews (IMRs) Develop for consideration by the serious case review panel an analysis, conclusions and recommendations for action by Oxfordshire’s Safeguarding Children Board, its member agencies and (if relevant) other local or national agencies Independent chairperson 1.2.7 The panel was chaired by an independent consultant Paul Kerswell who has no operational links with any of the agencies that provided services. Paul has extensive experience as a senior manager in child protection work and has chaired or written overview reports for over a dozen serious case reviews. Anonymisation 1.2.8 To protect the identity of child H, family members and involved professionals, identifying detail has been removed from what is in all other respects a complete and transparent account. 1.3 EXECUTIVE SUMMARY DECISION TO CONVENE, & CONDUCT OF THE SERIOUS CASE REVIEW 1.3.1 The decision to initiate a serious case review was made within 2 weeks of the overdose and in the view of the author, the time period selected for review an appropriate and proportionate one. Individual management reviews (IMRs) from each relevant agency were written by suitably experienced professionals who had had no involvement in the provision, supervision or management of services provided. Initial drafts were returned for clarification of facts or further explanation and all final versions were of a good or very good standard. 1.3.2 So as to maximise learning, authors were invited to attend panel to discuss and share with other authors their findings or experience. This provided a valuable further opportunity to reflect on judgements and decisions made in the course of the period under review. At the same time as publication by the Local Safeguarding Children Board of this report, a multi-agency learning event is being conducted with relevant professional stakeholders to share and debate findings from this and other recently completed case reviews. Agency-specific learning events are also planned. 1.3.3 The SCR was initiated in mid-November 2013 and its findings accepted by Oxfordshire Safeguarding Children Board in July 2014. This report is due for publication on the Board’s website in September this year. 4 FINDINGS Insufficient appreciation of risk 1.3.4 Strategic obstacles to achieving a clear and complete picture across the local agency network (in spite of a good deal of inter-agency information exchange) were: A relative passivity amongst medical staff in the Practice contracted to provide ‘shared care’, implying a need for clearer governance / commissioning arrangements A number of examples where professionals made unjustified presumptions about what colleagues in other agencies would / should do Some technical obstacles within Thames Valley Police to internal information transmission and an unjustified reluctance to share with Children’s Social Care, intelligence about mother’s drug-related lifestyle Good practice 1.3.5 There were examples of sound agency systems or commendable individual practice: Quality and continuity of ante-natal care by hospital’s specialist midwife A thorough assessment of need and risk by the hospital and other agencies following the birth of child H A comprehensive written handover from the first involved drugs worker DW1 to her successor DW2 The perseverance of the paediatric infectious diseases clinic in trying to provide hepatitis C screening to child H and in asking the GP Practice for an answer to the question about potential safeguarding concerns Sub-optimal practice 1.3.6 There were also a number of discrete failings: There was no recorded contact with health or other professional colleagues by GPs and a failure to respond to repeated and legitimate queries raised by a hospital clinic An arbitrary distinction was drawn by a health visitor (who otherwise liaised well with Children’s Social Care and the Harm Minimisation Service) between the issue of safe storage of prescribed opiate-based medication / illicit drugs and the hazards represented by other household materials A tendency across agencies to accept at face value, mother’s claims 1.3.7 The net result was that there was insufficient exploration or appreciation of the day to day experiences of child H and their likely impact on development and life chances. Mother’s condition made crises likely but the overdose that triggered this serious case review could not have been predicted with any significant level of certainty. 1.3.8 Readers should also note that even if the all the potentially available evidence had been aggregated it is unlikely to have been sufficient to convince a court that a Care or Supervision Order was justified. 5 Societal context 1.3.9 Panel members’ collective experience and consideration of this case prompted the observation that there exists a ‘societal ambivalence’ about substance mis-using parents. There is no assumption in law nor amongst the Judiciary or a proportion of professionals that a child raised by a drug-dependent parent is necessarily being exposed to an unacceptable level of risk to safety, health or emotional wellbeing. 1.3.10 The very large number of children living with drug-dependent parent/s anyway far exceeds any potential substitute care that might (by some) be considered justified. As early as 2003 it was estimated that between 250,000 and 350,000 children in the UK were affected by parental drug use. By 2009, a reported 120,000 children were living with a parent currently engaged in treatment and data collated in 2011-12, indicated that 60,596 adults with an opiate problem had parental responsibility and were receiving a prescribing intervention. 1.3.11 The above report also considered available serious case reviews of the last 10 years and revealed that there had been 17 fatalities and 5 non-fatal ingestions of opiate substitute therapy (OST) medication by children during this period (these figures are of necessity underestimates and exclude ‘near misses’ or incidents that failed to culminate in a serious case review for which there is no data publicly available). 1.3.12 This societal ambivalence leaves practitioners across professional boundaries with the task of evaluating risks to a child’s immediate safety or longer-term welfare and (when the need becomes apparent) collating sufficient evidence to convince a court of the need for compulsory intervention and sometimes substitute care. 1.3.13 In this case and with the advantage of hindsight, it is clear that throughout the period under review child H’s mother (without regard to her observed love for the child) awarded priority to her own drug-related needs. Her physical care of her child was though, generally ‘good enough’ and none of the involved agencies had reason to evaluate child H as being at high risk or a priority case. 1.3.14 The reader also needs to keep in mind that mother had little, if any, motivation to cease drug dependency. At times, she deceived agencies and used the tactics of diversion and dishonesty to minimise or obscure the impact of her lifestyle on child H, from whom she was desperate not to be separated. 1.3.15 Retrospective aggregation and consideration of the totality of information held by the local network has unsurprisingly served to identify some scope for improvements in local systems and professional practice. The remainder of this report encapsulates the learning that emerges from the case of child H. RECOMMENDATIONS 1.3.16 36 recommendations for improved systems / practice have been accepted by the Oxfordshire Safeguarding Children Board which is monitoring progress toward their completion. 6 2 REVIEW PROCESS & RELEVANT BACKGROUND 2.1 RELEVANT AGENCIES 2.1.1 The following were identified as likely to have information of relevance: Oxford Health NHS Foundation Trust (Health Visiting & Specialist Community Addictions Services (SCAS) subsequently known as Harm Minimisation Service) Oxford University Hospitals NHS Trust (Emergency & Acute Care) Oxfordshire Clinical Commissioning Group Oxfordshire Children’s Social Care & Youth Offending Service (Child Protection and Child in Need Services) Oxfordshire Education & Early Intervention Service (Children’s Centres) Child & Family Courts Advisory & Support Service (historical services to older sibling only) Thames Valley Police (investigation of crimes committed by the mother and emergency protection on day of overdose) Thames Valley Probation (Community Order on mother) 2.2 FAMILY INVOLVEMENT 2.2.1 The chairperson of the SCR panel made contact with both parents, informed them of the decision to convene a serious case review and explained the process it would follow. A further letter inviting her contribution was also sent to the maternal grandmother who had been a significant source of support to her daughter during the period under review and before it. When the panel had established the basic facts and developed tentative findings, the overview author sought to engage family members in discussions as follows. MOTHER 2.2.2 Mother was invited by letter to contact the overview author but did not do so. A further attempt to involve her was made following completion of the associated criminal process and a meeting was negotiated. Mother’s overall evaluation of the services provided was a fairly positive one and she offered no criticisms of systems or individuals. She did (understandably) regret the turnover rate of her drugs nurses. Mother also acknowledged that because of her fear that her child might be removed from her care, she had been less than open and honest at all times. FATHER 2.2.3 Though confirmation was received that he does not have parental responsibility and had no significant contact with his ex-partner during the review period, a letter inviting involvement was sent to his last known address. No response was received. 7 MATERNAL GRANDMOTHER 2.2.4 Child H’s maternal grandmother was invited by letter to contribute her views and experiences of local services. Family illness prevented what was to have been a negotiated face to face meeting and required instead an extensive conversation by phone at a pre-arranged time. 2.2.5 The maternal grandmother of child H challenged the accuracy of Thames Valley Police records formulated following child H’s overdose. With respect to her views about services provided whilst child H was in mother’s care (which was the focus of this SCR), her overall comment was that her daughter was better focused on compliance with professional expectations whilst her child was subject of a child protection plan and that, in her view) stepping down to child in need status was premature. 2.2.6 The maternal grandmother was robust and realistic in acknowledging that her daughter (like many substance-dependent individuals) could seek to deceive agencies. FAMILY DETAILS: MEMBERSHIP & LOCATIONS Name Gender Relationship Year of birth Ethnicity Female Mother 1984 White British Withheld Half-sibling to child H 2003 Not known Child H Withheld Subject of serious case review 2012 Dual heritage White / Black African Female Maternal grandmother Not known White British Male Birth father of child H 1963 Black African 8 3 AGENCY CONTACT WITH MOTHER PRIOR TO REVIEW PERIOD 3.1 INTRODUCTION 3.1.1 The historical context for agencies’ involvement with mother is that she had endured a difficult and disrupted childhood, an early introduction to heroin and gave birth at when 19 to a child, subsequently removed from her care. Those issues were known to involved agencies and will or anyway should, have informed services provided. 3.1.2 Aged 7, mother had witnessed and reported domestic violence. Her parents subsequently split up and she went to live with her mother. When 11, mother was noted to have emotional difficulties and be suffering respiratory symptoms from passive smoking and later skin and ear, nose and throat problems. 3.1.3 Sometime in 2007 mother and daughter returned from elsewhere and began to live in Oxfordshire. At the age of 14, mother was suspended from school and a year later records indicate that she had begun to use heroin. Medical records indicate a dependence on morphine / cocaine and clinical depression by the year 2000 (mother was then 16). When mother was first prescribed opiate substitute therapy in 2002, she dropped out of treatment after 3 months. Upon resumption of treatment she was injecting heroin daily. 3.1.4 A pre-birth conference for mother’s first child was convened in 2003 and that child was registered at birth under the category of ‘neglect’. Care Proceedings were initiated and following the granting of an interim Care Order an agreement was reached that the child would be placed with a relative. SUMMARY OF KEY CONCERNS ABOUT CARE OF FIRST CHILD 3.1.5 A report prepared by the Court and Family Advisory and Support Service (Cafcass) at the time of legal proceedings on the first child usefully summarised the concerns: Little or no antenatal care had been provided The birth was traumatic and without medical assistance The baby was born addicted to heroin A chaotic lifestyle Limited / sporadic contact Mother had discharged herself against medical advice and left her baby Concerns about her partner (not the child’s father) who had a history of violence and drug offences An arrest 10 days pre-birth for conspiracy to supply class A drugs Poor engagement with professionals including addictions nurse Refusal of a drug rehabilitation placement 3.1.6 The above list may usefully be compared with the narrative and analysis about mother’s care of her second child. 9 4 AGENCY CONTACT WITH FAMILY WITHIN REVIEW PERIOD 4.1 INTRODUCTION 4.1.1 The period for formal review extends from April 2011 (the estimated start of mother’s pregnancy with child H) until mid-September 2013 (the child’s removal from her care following hospitalisation). The review period has been divided into periods that have some developmental significance to child H. 4.1.2 Although some job titles and employing agencies changed across the period of review, the following abbreviations have been used with any following number indicating in which order they appeared: drugs worker (DW), health visitor (HV), social worker (SW), Probation employee (PO). INITIAL LEVEL OF DRUG DEPENDENCY 4.1.3 At the point in April 2011 that the ‘drug rehabilitation requirement’ (DRR) element of her Community Order ended, mother’s record of testing throughout the previous 18 months showed a consistent use of cocaine (positive in every test), and several positive tests for morphine and opiates. This usage was in addition to the prescribed methadone (100mls daily). 4.1.4 Mother herself claimed that she was using crack cocaine about 3 times per week; that she was not interested in rehabilitation and wanted to stay near her home and then boyfriend. 4.2 ANTENATAL PERIOD AGENCY AWARENESS OF PREGNANCY 4.2.1 In mid-May 2011 mother informed DW1 that she was pregnant. Her methadone prescription remained 100mls daily and its ingestion was supervised daily by the pharmacist (except for Saturday when she would collect the dose for use next day). As well as her methadone, mother admitted to using crack cocaine daily. 4.2.2 Mother reported that she was keen to stop crack cocaine usage and reduce the methadone1. DW1 explained the need to reduce slowly starting in the second trimester of pregnancy. The rationale for this is that too early tapering can induce premature labour morbidity and mortality of the foetus. 1 Methadone was being used as part of a drug addiction maintenance programme. It is a narcotic pain reliever, similar to morphine; it was used in this case to reduce the withdrawal symptoms when stopping the heroin without causing the high associated with drug addiction. Reduction programmes have to be carefully considered, as many women relapse into drug use, especially during the third trimester of pregnancy when the therapeutic effect from methadone may decrease. 10 ANTENATAL CARE & MIDWIFE’S REFERRAL TO CHILDREN’S SOCIAL CARE 4.2.3 Midwife 1 initiated a prompt and well-informed referral in mid-May 2011. As well as addressing a wide range of medical / obstetric issues, she passed on known health-related information, the fact that mother was living in a shared house and that she was about to move on. She named the putative father and indicated mother’s involvement with Probation was about to cease. No estimated date of delivery for the baby was captured in the electronic records of Children’s Social Care. 4.2.4 Much of mother’s antenatal care was delivered by one identified midwife for expectant mothers with drug and alcohol problems. This afforded good continuity of care. The Hospitals Trust IMR author was able to confirm that throughout the pregnancy there was evidence of considerable attention being paid to drug use and wider social circumstances e.g. changes in methadone dose, level of support offered by her partner and a recognition that she had not previously cared for a baby. 4.2.5 Mother attended the majority of the antenatal appointments and those she missed were always re-booked. Missed antenatal appointments are relatively unusual and might be seen as evidence of mother awarding insufficient priority to her own and the health needs of her child to be. VARIATIONS IN COMPLIANCE: PROBATION & HARM MINIMISATION SERVICES 4.2.6 Management of her methadone reduction was discussed in late May 2011 with the pharmacist present. DW1 reported that mother was receiving good support from what the author has been told is a local self-help service and her probation officer (mother was the subject of a Community Order after conviction for theft). In fact mother’s actual level of involvement with the local group was extremely limited. At this point mother was compliant with ‘pick-ups’ of prescribed medication and attended 75% of planned appointments. DW1’s intention was that mother should attend all appointments and have regular urine screens for illicit drugs. 4.2.7 At the end of May 2011 DW2 was introduced to mother and received a commendably comprehensive handover. Mother was 8 weeks pregnant and fully compliant with daily methadone pick-ups. The importance of attending all appointments was stressed by DW2 who also engaged the support of the pharmacist to explain methadone treatment in pregnancy. This was DW2’s first experience of the role of a drugs worker. She was reassured when mother referred to good support from her probation officer and from the self-help service. CRIMINAL ACTIVITY DURING PREGNANCY 4.2.8 In June 2011 mother was arrested on suspicion of handling stolen goods. She failed to appear at court and was arrested, held in custody and presented in court. At a delayed court appearance in October she pleaded guilty and received an 18 months Conditional Discharge. 4.2.9 Mother had anyway been further involved in crime in mid-June when she admitted taking items from a supermarket and was subsequently issued with a summons to appear in court in mid-October. On neither occasion were other agencies notified by the involved police officers. 11 4.2.10 At an appointment with PO1 on in late June 2011 mother spoke of an intention to reduce use of methadone and to be down to 50mls by the time of the birth. She admitted to ongoing use of crack cocaine and was no longer interested in rehabilitation. The declared target of 50mls per day was seen in no other records. 4.2.11 When mother attended in mid-July 2011 she admitted smoking crack cocaine2 weekly and acknowledged a need for support. DW2 provided contact details for the local self-help service. There had been no urine tests for drugs since pregnancy had been confirmed. When interviewed for this serious case review, DW2 recalled mother lacked motivation and was dismissive or ambivalent about advice given. 4.2.12 By late August 2011 during a call made by SW1 to midwife 1, it was revealed mother had moved to a new address. Her daily usage of 100ml of methadone was confirmed. A ‘new partner’ was mentioned, though this may have referred to the acknowledged father of child H. ACCEPTANCE OF REFERRAL BY CHILDREN’S SOCIAL CARE 4.2.13 It remains unclear what status had been awarded the midwife’s earlier contact but in response to a subsequent telephone conversation, a formal referral was logged and an ‘initial assessment’ begun in the hospital social work team. 4.2.14 Having had no success by phone SW1 made an unannounced visit and met mother, who said she ‘had been in a mess’. A further visit in early September was agreed and completed. SW1 also liaised with the allocated probation officer and was told mother did not want to attend rehabilitation. REDUCED CO-OPERATION WITH DRUGS WORKER 4.2.15 DW2’s plan had been to see mother weekly but her attendance dropped to 50% during DW2’s involvement (6-24 weeks of gestation). DW2 suspected mother was continuing to use crack cocaine and this was confirmed when mother (then 20 weeks pregnant) admitted giving up was ‘proving difficult’. Given the potential impact of crack mother’s conduct offers a pre-natal example of putting her child’s life at risk. 4.2.16 At mother’s request, DW2 began to reduce the methadone from 100mls to 95mls. Mother failed, in spite of reminders, to attend the next 3 appointments. DW2 consistently checked with the pharmacist that mother was compliant with methadone pick-ups, as did all the specialist drug staff. The plan was to reduce the methadone by 5mls at each prescription but only if mother attended appointments3. DW2 had had no communication with midwives or anyone in Children’s Social Care. 2 Crack cocaine is a strong central nervous system stimulant. The ‘high’ begins almost immediately after the vapours are inhaled and lasts for 5-15 minutes and after the initial rush the user experiences an intense desire for more. Users quickly develop a tolerance needing more to achieve the desired effect. Crack cocaine is expensive and ways of funding a supply have to be found. Research demonstrates that crack cocaine can negatively impact on foetal growth and development and risks continuation of pregnancy. 3 It is important to ensure that prescribed methadone is sufficient in quantity to deter heroin use. 12 FURTHER INVOLVEMENT IN CRIME 4.2.17 PO1 initiated contact with an unidentified hospital midwife in September 2011 and was given confirmation of mother’s ongoing use of crack cocaine but not heroin. 4.2.18 In mid-September mother was arrested for shoplifting then and on a previous occasion in late August. She was verbally abusive, refused to provide an address and provided a ‘no comment’ interview. Following an enforced strip search, she was found to have smoked from a pipe concealed about her person, what was assumed to be crack cocaine. She later informed officers that she always carried a crack pipe and lighter. 4.2.19 Mother was remanded and appeared in court next day when she was sentenced to a 6 month Community Order to include specified activity and attendance at a ‘Think Ahead for Women’ course (TA4W). Only an oral report was provided to the court. Probation Trust policy requires that any reports which have an element of child protection or domestic abuse require completion as a full written report. 4.2.20 Because there was no longer any DRR, the management of the case transferred to the generic Probation team and was allocated to a ‘probation service officer’ PO2 undertaking qualifying training and jointly managed by PO3. The assessment at the outset of this sentence was a ‘high likelihood of reconviction’ and (though the history of her first child was known and concerns about the current pregnancy acknowledged) a ‘low risk of harm to children’. 4.2.21 For the purposes of offender assessment, the Ministry of Justice defines ‘harm’ as ‘serious harm’ i.e. death, or physical or psychological harm from which it would be impossible or difficult to recover. ‘Low risk’ is when current evidence does not indicate a likelihood of serious harm. On these definitions, the assessment of ‘low risk’ was reasonable, though the minimal adjustments being made by mother to her usual lifestyle offered an insight into her limited capacity and motivation to prioritise the well-being of her baby over drugs. 4.2.22 An oppositional attitude was also apparent at her induction for her Community Order when she refused to consent to information sharing with her GP. PRE-BIRTH SAFEGUARDING PLANNING 4.2.23 SW1 tried in the remaining antenatal period to meet with mother (whose compliance with appointments varied). SW1 also liaised with extended family members. Child H’s maternal grandmother described a positive change in her daughter. 4.2.24 By mid-September the manager of SW1 (referred to in this report as TM1) had determined that a strategy meeting was required. However in order to avoid the possibility that the review conference which is required within 3 months of an initial conference would appear ‘overdue’4, the manager deferred the formal strategy meeting (required to trigger safeguarding procedures). 4 One of the performance measures collected by the DfE is the proportion of review child protection conferences convened within 3 months of the initial conference that determined a need for a child protection plan. 13 4.2.25 In exchanges between SW1 and DW2 the latter was ‘surprised’ mother did not wish to access a rehabilitation service, recalling that she had ‘always been keen for this’. It is not clear when, how or to whom mother had ever expressed any personal motivation for rehabilitation rather than being maintained on methadone. 4.2.26 SW1 helpfully wrote to the hospital maternity service in late September 2011. She confirmed mother’s current circumstances and use of prescribed and non-prescribed drugs. SW1 asked to be alerted when mother appeared to be in labour. In the event the pre-birth conference provided a substantive opportunity for information sharing. 4.2.27 A week later TM1 noted there had been no change since the last supervision session. She directed completion of a ‘core assessment’. TM1 also suggested a family group conference (FGC) be initiated and noted (correctly) that the planned November strategy meeting was likely to result in a pre-birth protection conference 4.2.28 Only an ‘initial assessment’ had been begun in August. The expectation at the time was that these should be completed within 10 working days. A further 35 working days was the then standard time allowed for completion of the more comprehensive ‘core assessment’ (since October 2013 Oxfordshire like most local authorities, has introduced needs-driven rather than government-imposed time limits). 4.2.29 At a meeting with SW1 in early October 2011 following an antenatal consultation, mother claimed to have attended all her antenatal appointments. She had in fact attended the majority, though missed 4 (these had been re-scheduled). 4.2.30 It emerged during October that mother had yet to inform child H’s father of her pregnancy. After further efforts by the social worker, contact with child H’s father was established. Children’s Social Care records indicate an expected date of delivery in January 2012 and note a supportive letter written to Housing seeking a new home for mother and her expected baby. 4.2.31 In early October mother was issued with a warning by Probation because she had missed her last appointment. Mother reported that she was not using on-top and (inaccurately) that Children’s Social Care was drug testing her weekly. She offered a more accurate account at her next appointment of her fortnightly testing being with the Specialist Community Addiction Service (SCAS) nurse (now the Harm Minimisation Service) at the Health Centre. CHANGE OF DRUGS WORKERS & AMENDED CARE PLAN 4.2.32 Toward the end of October DW3 took over from DW2 (mother was then 26 weeks pregnant) and remained the specialist addiction worker for a 10 month period up until child H was 8 months old. During that period 24 appointments were made for mother and she achieved an attendance rate of 75%. Initial appointments were not attended and DW3 saw mother (by then 32 weeks pregnant) for the first time in mid-November 2011. It appears that no handover report was provided by DW2. 4.2.33 Mother claimed she had not used crack cocaine for 3 months or heroin for 2 years. Records though, demonstrate that she had admitted heroin use 1 year previously. Her misinformation influenced future risk assessments. 14 4.2.34 DW2, with mother’s agreement began to reduce the daily dose of methadone by 5ml to 85mls. A Children’s Social Care record a week later suggests mother was at that point being moved from twice weekly collection to weekly. SW1 liaised further with midwife 1 in late October and they noted mother had then 3 missed ante natal appointments. 4.2.35 The Probation Service officer PO2 had alerted DW3 to her concerns about mother’s lack of commitment and engagement and to her breach of her Community Order .In spite of the circumstances, DW3 who had been involved at the time of mother’s previous pregnancy perceived there to be significant improvement in her current presentation and commitment. When mother was 33 weeks pregnant, mother discussed planning for the baby and appeared to DW3, to be more open and making good eye contact (her more usual demeanour was passive without any spontaneous engagement). INDICATORS OF MOTHER USING ‘ON-TOP’ [OF PRESCRIBED MEDICATION] 4.2.36 In early November, mother (29 weeks pregnant) was involved in a street fight with another woman. There were no visible injuries and mother declined an ambulance. Police took no further action and no notification was provided to any other agency. 4.2.37 At a home visit by the social worker, the maternal grandmother offered useful observations of how to discern when her daughter was using ‘on-top’ i.e. instant weight loss, becoming dirtier than usual, slurring her speech, eyes glazed; she also referred to behavioural changes such as being shaky and stopping calls and visits. 4.2.38 At an appointment in November 2011 DW3 completed a care plan which was scanned into the medical records. Such plans should be reviewed if there is a change in circumstances or an incident. Mother’s plan was not reviewed for the 10 month duration of DW3’s involvement. 4.2.39 DW3 was receiving positive feedback from the pharmacist and reported her sense that mother was turning her life around. At this point her prescription was 85mls of methadone with a daily supervised pick up from the pharmacist (on a Saturday she would take home the methadone for Sunday). Mother was reliable in following this routine. Mother continued to resist a referral to a Children’s Centre. ‘BREACH’ HEARING 4.2.40 Mother appeared in court in November 2011. She had not been attending her Probation appointments and walked out of a session in October. Though initially angry, she accepted that SW1 had contacted her baby’s father and explained her initial response as a fear that he might seek care of the child. 4.2.41 Mother’s Community Order was extended by 12 months. Mother told SW1 she was ‘keen’ to attend the Children’s Centre. Mother was asserting entirely opposite views to her probation officer and social worker respectively. It is known that she actually visited a Children’s Centre once only (for advice). The father of child H met SW1 at the local hospital. She learned his real name and other significant details e.g. his origin from a Christian family in North Africa. 15 COMPLETED CORE ASSESSMENT 4.2.42 The core assessment was formally signed off by Children’s Social Care team manager (TM1) in mid-November 2011. It had taken approximately 3 months to complete. Risks and protective factors were comprehensively outlined and a decision made to proceed to a pre-birth child protection conference alongside a family group conference (FGC). Some so-called ‘protective factors’ were questionable e.g. mother’s insufficiently tested claim to be drug-free and the absence of (detected) criminal offences whilst pregnant. There were also discrepancies in mother’s accounts of the last time she had used heroin viz: 2 years ago according to DW3 but only 1 year ago according to other agency records. 4.2.43 A further issue that arose immediately after completion of the core assessment was that of a threatened eviction as a result of rent arrears, albeit there was a consensual view that mother need alternative accommodation to get away from the influence of other known drug users and to offer more space for care of a new baby. 4.2.44 Health visitor HV1 first became aware of the case in late November following notice from FGC1 (the family group conference co-ordinator) that a family group conference (FGC) was to be arranged. The purpose of a FGC is to provide an opportunity for a family to identify sources of support from within its ranks and from local services and in this case, to find ways of ensuring the baby’s needs would be consistently met. HV1 had received no recorded communication from midwife, GP or the drugs worker and met mother for the first time at the forthcoming FGC. 4.2.45 It was reported that mother was gathering baby equipment for the imminent arrival. She failed though to attend an ultrasound appointment in early December and a further ante natal appointment 4 days later (possibly because she was viewing potential new accommodation). Mother’s subsequent failure in mid-December 2011 to attend a further ante-natal appointment caused concern because her hepatitis C+ status meant that a liver function test was advisable. The delayed ultrasound was re-scheduled and upon its completion revealed nothing abnormal. Though no specific reason was noted, a letter was composed and sent to a neonatologist 1. CONDUCT OF FAMILY GROUP CONFERENCE (FGC) 4.2.46 A well-attended FGC was held in mid-December. DW3 and midwife 1 were unable to attend and the birth father later explained his absence as work-related. Probation was not represented (mother had been resistant) but had provided a report from PO3. The availability of a Children’s Centre, Housing Support and Home Start were discussed. Given the history of poor clinic attendance, HV1 agreed to visit every 7-10 days for 6 weeks after the midwife handed over 10-14 days following the birth. 4.2.47 A review FGC was planned for early March 2012 (though later cancelled at the family’s request). SW1 within days questioned how much support the birth father was actually providing. At a further supervision of SW1 by TM1 the social worker’s concern about insufficient family support was discussed. Contact with the paternal grandmother ‘when she knows about the baby’ was contemplated. 16 4.2.48 Just before Christmas 2011 ‘neonatologist 1’ wrote to midwife 1 and advised mother’s use of methadone should be included in her notes, the baby offered hepatitis B vaccine and that mother’s blood needed to be tested ante-natally for hepatitis B and C. She also indicated the baby needed to be on withdrawal observations after delivery and there should be written assurances from Children’s Social Care before discharge. 4.2.49 Following a discussion between SW1 and TM1 a decision was reached to initiate s.47 enquiries (Children’s Social Care is obliged by virtue of s.47 Children Act 1989 to make enquiries if it ‘suspects a child is suffering or is likely to suffer significant harm’) with the possibility of convening a pre-birth child protection conference. On the same day mother was observed at her attendance with the drugs worker DW3 to ‘look well physically, be bright in mood and less anxious’. Her urine test was negative to opiates and crack cocaine and mother denied any substance misuse. PRE-BIRTH CHILD PROTECTION CONFERENCE 4.2.50 Invitations to attend were issued after Christmas to HV1, midwife 1, Connections Floating Support Service, SCAS, Police and Probation. A proposed home visit to meet parents together was thwarted by mother who also failed next day to attend a ‘Floating Support’ assessment. The pre-birth conference was convened on a date in early January 2012. DW3 was unable to attend because, according to Children’s Social Care she had clinics that day (material submitted during the course of the SCR indicates that she was on annual leave). She had submitted a brief report to social worker SW1 which included a chronology of appointments. She repeated the misinformation that mother had not used heroin for over 2 years. 4.2.51 Other professionals who attended were the hospital midwife, a housing officer and PO2 and PO3. Police had provided a report of their checks. According to Children’s Social Care records (though its origin is unspecified), the birth father had been planning to attend but did not do so because of a text from mother indicating she did not want him there. The conference was held only 5 days ahead of child H’s birth and included mother. An earlier date would have ensured more time for planning and presence of DW3. 4.2.52 Independent chairperson 1 decided (with unanimous agreement) that the baby would at birth need to become subject of a child protection plan (for neglect). Mother remained at imminent risk of eviction. HV1 agreed to see mother and baby weekly at home for 4 weeks and then to review. HV1 at interview stated she had been aware that if there was evidence of increasing concern e.g. use of illegal drugs, failing health or other professional appointments the social worker would consider requesting authorisation for pre-proceedings i.e. legal intervention to be initiated. 4.2.53 At the pre-birth conference, SW2 from ‘Family Support South’ team was nominated to take over from SW1. On the same day, mother failed a further consultant clinic meaning no bloods were taken prior to the birth of child H. 4.2.54 At TM1’s supervision next day of SW1, the latter was able to report that mother had re-homed some (unspecified) animals and there was no evidence of current drugs use. SW1’s view was that the family were now more willing to support than they had been at the FGC in December. The approach agreed at this supervision session was that there should be a core group / discharge meeting held after the baby was born and that the case would be formally transferred to SW2 at that point. 17 4.3 PERINATAL PERIOD BIRTH 4.3.1 The birth of child H in mid-January 2012 was relatively straightforward. Mother was supported by her own mother. Mother and baby remained in hospital and the baby observed for signs of drug withdrawal. No significant symptoms were noted and attending staff indicated mother was coping; changing nappies competently and beginning to express breast milk. Mother was asking for appropriate help and cared for her baby all day ‘except for 6 cigarette breaks’ and an occasion when mother had fallen asleep with the baby in her arms. Advice on the risks of ‘bed sharing’ was provided after the latter observation. 4.3.2 On a subsequent occasion mother insisted (contrary to advice from the midwife) on leaving her baby at the front desk whilst she left the building to smoke a cigarette. This episode illustrates the comprehensive record-keeping of ward staff as well as the fragility of mother’s care for her baby. 4.3.3 The birth had occurred on a Saturday and the hospital social work team was alerted on the Monday. SW1 in turn alerted the Housing Department and as a result of the birth, the priority for re-housing mother became greater. SW1 also informed Probation of the birth. 3 days after the birth, mother texted the father of child H to inform him of the news and in a telephone conversation with SW1, he agreed to meet up with SW2 who would be accepting case responsibility. 4.3.4 During the remaining time in hospital, other medical interventions were initiated. Child H was given the first hepatitis B and routine vaccinations and at completion of the ‘initial check’ next day the examining doctor commendably noted the child should not be discharged until an ultrasound had been completed, an infectious disease referral made (hepatitis screening) and the planned conference next day concluded. DISCHARGE FROM HOSPITAL 4.3.5 A discharge planning meeting (which also served as a core group meeting) was convened and minuted. Present were mother and baby, SW1, SW2, Connections Floating Support worker 1 and the hospital’s safeguarding midwife. SW2 from Family Support South became case accountable from this point. Probation had been invited but neither PO2 nor PO3 were able to attend at such short notice and DW3 was on leave. GP1 received prompt and comprehensive confirmation of the various medical interventions as well as the fact that the baby was subject of a child protection plan. CHILD PROTECTION PLAN 4.3.6 The plan agreed was for discharge next day and daily visits from community midwives for 4 days, then probation and housing officers over the following 3 days. Next day a consultant indicated that they would not process the hepatitis C blood test at the moment because a negative test could be misleading i.e. there remained a chance of manifesting a ‘hepatitis C +’ status for some time to come. 4.3.7 Mother and child H were as planned, discharged. A note from midwife 2 indicates that the patient was sent out with ‘no care plan’. There was a lack of communication from the hospital to community midwives at discharge about the plan agreed. 18 4.3.8 Following the pre-discharge meeting a detailed care plan was documented in the child’s hospital notes, but not written / transcribed into the discharge summary sent home with mother for the community midwives to follow. An entry in the electronic notes indicates that community midwives had a written plan, but there is no evidence for this in the maternity notes. This raises the possibility that the community midwife saw this information but it was not then filed appropriately. If that was so, the community midwives would not have been clear about what had been agreed, and what was required to care for and assess this vulnerable family. 4.3.9 Next day mother made what was her only visit to Children’s Centre 1 and was provided with housing advice. On her registration form, mother acknowledged daily use of prescribed methadone. Mother and baby were visited at home over the next few days by midwives 2, 3 and 4 none of whom noted any concerns. Child H at 9 days old was discharged into the care of the GP Practice and HV1. LEVEL OF MONITORING Contacts in first month after birth of child H 4.3.10 HV1 and SW2 completed a joint home visit in late January 2012. Mother was mostly formula-feeding and still living in her 1 bedroom flat in a multiple occupancy house. She reported support from her own mother. A follow up visit was agreed a few days later. On the same day as the home visit, mother failed to attend an appointment GP5 for a ‘pregnancy care’ appointment and a message was left on her telephone. 4.3.11 GP1 did see mother and child at her Practice in late January and early February 2012 and DW3 saw mother briefly when she came to collect a script. At a further visit HV1 was told by mother that she was prop feeding child H (then less than 3 weeks old). The risks of choking were explained and she was reminded of the need to bring her baby for a second hepatitis B jab, postnatal checks and 6 week check. HV1 was also told child H’s father wanted to meet his child and a rendezvous in town was planned. HV1 (who kept in constant touch with Children’s Social Care throughout her period of involvement) made contact with SW2 and reported her concerns about prop feeding. 4.3.12 At a visit by HV1 and school nurse 1 about a week later, mother was again seen to be prop feeding. She was again reminded of the associated risks. HV1 planned to report the event to SW2 and provided mother with written advice. Because mother had overlooked the appointment her management of child H was probably closer to everyday practice than if she had been expecting professional visitors. 4.3.13 HV1’s later call to SW2 spoke of mother’s intention to meet child H’s father and the advice given to do so in a public place because HV1 was ‘unsure of his history’. During her meeting with DW3 later that day, mother’s presentation was noted to be unchanged. She spoke of being tired, denied seeing old [and the implication was drug-using] friends, and made a reference to ‘hearing things’. Her urine test was negative. The reference to auditory hallucinations was apparently not explored. 4.3.14 An attempted home visit by HV1 was unsuccessful and she informed SW2. Neonatal screening of child H at 1 month old revealed no concerns. In mid-February SW2 tried to advocate for more suitable housing. DW4 indicated in a call to Children’s Social Care that the agency did not believe mother was using ‘on top’. 19 4.3.15 An opportunistic visit was completed that day by HV1 who had been receiving no responses to calls to mother’s mobile. Mother reported being unhappy about the very cramped accommodation and HV1 agreed to liaise with SW2 with a view to adding pressure to the Housing Service. HV1 also recorded that child H’s father had visited. HV1 subsequently liaised with SW2 and directly with the Housing Service. Contacts during second month after birth of child H 4.3.16 When her child was about a month old, mother consented and child H was given a second hepatitis B immunisation. Mother claimed she had forgotten the Personal Child Health Record (PCHR – often called the Red Book) and undertook to bring it next time. Child H was noted to look well. Mother failed her next SCAS appointment though was still collecting methadone from the pharmacy. At a further visit 5 days later HV1 noted mother was bidding for an alternative local property. A further visit a week later was agreed. In an email exchange on the same day as HV1’s latest visit, SW2 reminded SCAS of an email sent 2 days before in which she had raised concern that mother had not provided a urine sample for ‘some time now’. SW2 was informed that mother had failed today’s appointment. 4.3.17 SW2 discussed the case next in supervision with TM2 and concerns were summarised. Child H (2 months old) was seen by GP5 for a routine 6 week examination. No concerns were noted about mother or child. 4.3.18 During a home visit SW2 was told that mother was spending a lot of time at her own mother’s home. She alluded to the ongoing housing issue and promised to get a urine test completed. SW2 and FGC 1 liaised and the latter asked for the family’s view on the now imminent review FGC. After referring to pressure from the local MP the Housing Service discussed with SW2 the options for re-housing. HV1 continued her efforts to get mother re-housed though her description of a ‘recovering addict’ (when she was actually on a maintenance dose of methadone) was a little optimistic. DRUG MONITORING DURING SECOND MONTH AFTER BIRTH OF CHILD H 4.3.19 Mother had completed a urine test in late February 2012 which was negative to opiates, crack cocaine and benzodiazepines. The agreed child protection plan had stipulated she should attend Drug Service appointments and produce urine for screening weekly. In fact 1 month later the documented plan of DW3 (to whom conference minutes had been sent) had become to review mother every 2 weeks and carry out random sampling. There was, in consequence a distinction between the formal child protection plan and the actual service provided. 4.3.20 By February 2012 the floating support worker had been replaced. By March, mother was apparently managing well and had told FGC1 that she had enough support and there was no need for a further conference. 4.3.21 Mother failed to bring child H to see the paediatric infectious diseases consultant in March. A further appointment was made for April and also failed. In response to her contact with Children’s Centre 1, the manager commendably made 4 follow-up calls. She made a 5th final call in March and heard nothing more until learning of mother’s move which placed her in the catchment area of Children’s Centre 2. 20 CORE GROUP 2 4.3.22 In mid-March 2012 (child H 2 months old), a second core group was convened (the plan had been 6-weekly meetings). Though no minutes have been seen by the author, it is reported those present were SW2, HV1, PO2 and housing officer 1 i.e. DW3 did not attend. Reference was made to a ‘Connections’ worker who would help with grants and financing for a new property. SW2 referred to the negative urine test the week before and spoke of progress and a ‘better relationship with her parents’. 4.3.23 It was reported that alternative accommodation was expected soon. Child H’s father was, according to mother, having limited contact. Mother agreed to bring her child for the first primary immunisations and to be weighed a week later. She failed both appointments and HV1 immediately emailed SW2 to inform her. 4.3.24 At supervision session in late March provided by TM2 to SW2, mother’s progress was noted but it was agreed that there was a need for continuation of the protection plan and that this would be recommended at the review conference in April. A change of social worker was also planned because SW2 was about to begin her maternity leave. SW3 would become the case accountable social worker. 4.3.25 SW2 was informed by PO3 that mother was at risk of being ‘breached’ by Probation for missing 2 appointments. A third such failure would trigger action (in fact mother failed to attend her next 3 appointments and managed to avoid being breached). 4.3.26 Child H (2.5 months old) received the first set of primary immunisations in late March. A home visit by SW2 a couple of days later noted the accommodation to be chaotic because mother was packing up to move. Child H was ‘fine’. The move to new accommodation was imminent. It is now thought likely that mother was still involved in class A drug dealing at this stage. REVIEW CHILD PROTECTION CONFERENCE 4.3.27 The review conference in early April 2012 noted progress but also the missed drugs testing appointment and a reluctance to engage with the Probation Service ‘thinking skills’ course. Mother’s lack of organisation was attributed to her living arrangements, though the connection is not obvious. It seems more likely that it was intrinsic, albeit worsened by insufficient space and unsuitable neighbours. 4.3.28 PO3 was unable to attend though had shared her view with SW2 that child H should remain subject of a plan. Police were not represented though a fax of contacts with mother was sent in advance. It excluded any information from intelligence reports. 4.3.29 DW3 also sent her apologies though had provided the social worker with an update. Others who attended included mother, Connections support worker, SW2, SW3, HV1 and a student social worker. HV1 undertook to make one home visit after Easter Monday to the new home and then ask her to attend the clinic with child H once a month. Clearly verbal updates carry a higher risk of misinterpretation and mis-recording than written briefings. This may have been an early indication of HV1 removing mother from ‘health visiting partnership plus status’. 21 4.3.30 The decision was made that child H (then nearly 3.5 months old) should (justifiably) remain subject of a child protection plan. The GP Practice was informed promptly. At DW3’s next contact with mother, her urine test provide negative to all but prescribed methadone. On that same day mother failed to bring child H for his further hepatitis B immunisation. Messages were left for mother to call and re-arrange an appointment and a further appointment for May was offered. 4.3.31 HV1 made a home visit in mid-April 2012 and once again mother ‘had forgotten’. The home was noted to be clean and tidy and mother said she was well and was ‘happy’ to see HV1 at the Health Centre monthly. FURTHER CHANGE OF WORKER / FAILURES TO PRESENT CHILD H AT CLINIC 4.3.32 By late April 2012 child H received the 3rd hepatitis B and 2nd DTP, polio and Hib. immunisations and the ‘Red Book’ was updated. A further (negative) test of mother was completed and DW3 (by then employed in the ‘Harm Minimisation Service’) was told by mother of her new social worker SW3. A planned child protection visit by SW3 found the new home to be clean and tidy with child H clean and well dressed. SW3 was assured by mother she had taken her child to health visitor appointments. 4.3.33 A couple of days later DW3 raised the subject with mother of reducing the level of supervision of methadone use. DW3 suggested waiting to discuss this possibility at the scheduled core group. 4.3.34 For the third time mother failed to bring child H to infectious diseases consultant 2 and a further appointment was made for late May. A letter was sent to the GP highlighting missed appointments and follow-ups. A further letter from this consultant asked….’if you have any safeguarding concerns about this child in view of these recurrent DNA [‘did not attends’] would it be possible for you to inform us ?’. It is uncertain whether GPs had been informed prior to this, of failed appointments. 4.3.35 At a meeting of DW3 mother and child H at the Practice, mother claimed previous drug-using associates did not know where she lived and that she wanted to keep in that way; she had not been attending the Children’s Centre because she was ‘too busy’. In fact, mother never attended a Children’s Centre with child H. CORE GROUP 3 4.3.36 In mid-May 2012 SW3, HV2 and DW3 held a further (minuted) core group meeting with mother at the Health Centre. Mother’s compliance with health appointments was noted to be ‘good’ and drugs tests had all proved negative. Mother asserted that some of her drug and Probation appointments had been clashing. SW3 agreed to visit at fortnightly intervals and DW3 agreed to meet with her every other week and to liaise with Probation to ensure no conflicts in the times of appointments. Mother reaffirmed her agreement to attend monthly the child health clinic. 4.3.37 The rating of ‘good’ overlooked the hepatitis C issue as well as the less than planned frequency of testing. Arrangements subsequently negotiated between the Harm Minimisation Service and Probation reflected good inter-agency working. 22 EPISODE OF ILLNESS / ONGOING MONITORING 4.3.38 In mid-May 2012 mother presented child H (5 months old) at an out of hours Minor Injuries Unit (MIU) because of diarrhoea and vomiting. Commendably, the MIU discerned that child H was subject of a protection plan and agreed to examine him. The follow-up up 3 days later by GP1 also represented good practice. 4.3.39 As a result of revised reporting arrangements agreed by mother, Harm Minimisation and Probation, the proposed ‘breach action’ was withdrawn. A planned home visit by SW3 in late May 2012 had reportedly been overlooked by mother who nonetheless allowed her in. Child H was noted to be well cared for and the home in good condition. Mother confirmed that Probation and drugs appointments now alternated. DW3 met mother at the Practice next day and recorded no concerns about mother or child. On the same day mother reported early to PO3 and left before being seen. She then put the phone down on a follow-up conversation by PO2. 4.3.40 2 days later HV1 was informed by a GP about mother’s ongoing failure to bring child H for screening. She followed this up with calls to mother and maternal grandmother. The latter said that she had been providing and would continue to offer support. This professional exchange was a rare example of documented GP / health visitor liaison. 4.3.41 HV1 completed a lengthy home visit in late May. Daily routines were discussed and mother was offered contact details / literature about a Home Start Family Group and a ‘baby group’ on the local estate. HV1 followed up immediately with a phone referral to Home Start for child H (aged 4.5 months). Next day, GP1 was again alerted to mother’s failure to bring child H for a hepatitis C screen (a further appointment had been offered for June). Reasons for the persistent failure to attend were sought from the GP Practice. No response to that enquiry has been found. 4.3.42 Toward the end of May routine immunisations were administered in the GP Practice by its nurse. On the following day, at what was a regular supervision session of SW3 with TM2 mother was noted to have made ‘good progress’ though her loneliness following her house move was acknowledged. It is unclear whether further discussion between HV1 and SW3 took place before or after the latter’s supervision. 4.3.43 In early June DW3 observed nothing remarkable about mother’s interaction with child H. She noted they had spent the weekend with maternal grandmother. Mother denied any substance misuse and her urine screen had not revealed ‘on-top’ use. BREACH OF COMMUNITY ORDER & ONGOING MONITORING 4.3.44 At a home visit in early June 2012 6 month old child H appeared well. Mother reported feeling ‘low’ and was considering reducing her methadone prescription. She reported she was due in court for failing to sufficiently comply with her Community Order. This fact and a court date in late June was subsequently confirmed by PO3. During that week the Home Start worker asked (helpfully) that she be included in future core group meetings. Unfortunately she was unable to attend the July meeting. 23 LIAISON INITIATED BY PROBATION 4.3.45 In mid-June 2012 having tried to contact her by phone over the previous days, PO3 emailed SW3 and shared her concern about mother’s persistent failure to attend appointments. Mother was to be breached and was due in court toward the end of the month. Mother failed to appear at the court and the case was adjourned until early July (at which time she pleaded not guilty). 4.3.46 A few days later mother failed a promise to return in order to provide a urine screen. Mother also indicated that she would be unable to attend the core group scheduled for the following day. In fact, because of illness amongst the involved professionals the planned meeting was anyway postponed. HV1 anyway reminded mother of the need to bring child H to the clinic the following week and was told that the time / date conflicted with a court appearance but that she would, via her solicitor, try to award priority to the medical appointment. 4.3.47 PO3 made further attempts to obtain updates from DW3 and SW3 in early July. In a phone exchange DW3 confirmed she had not seen mother for about 4 weeks. PO3 left at least 2 messages with SW3 before eventually obtaining from her the view that all was well. The date for the postponed core group was discussed and SW3 indicated that this would offer an opportunity for an open discussion by involved agencies with mother present. 4.3.48 A planned visit by SW3 had proceeded albeit mother claimed that she had forgotten it. The flat was clean and child H (7 months old) appeared well. At her supervision next day SW3 reported child H was ‘developing well’ and that mother’s tests were clear. The only negative issue specified was her breach of the Community Order. 4.3.49 Mother failed an appointment with DW3 in mid-July but feedback from her and other involved agencies e.g. Connection Support suggested that mother was managing without ‘on-top’ use of illicit drugs. In mid-July mother was though suspended from a substance misuse group because of failure to attend. CORE GROUP 4 4.3.50 The 4th core group meeting was convened at mother’s home in late July. It included Probation but not HV1 or a representative from Harm Minimisation. Mother’s engagement with most agencies except Probation was considered satisfactory. A few days later mother again failed to bring child H to the infectious diseases clinic and a further opportunity was provided for September. Mother continued to fail to attend appointments with PO3 through the Summer and once again this professional tried hard to obtain an update from SW3. 4.3.51 At an appointment with DW3 in early August 2012, records confirm (for the first time) that safe storage of methadone was discussed. The worker was leaving and left ‘several messages’ for SW3 with a view to a briefing. She received no response. Children’s Social Care records neither confirm nor explain why messages from her and the probation officer were overlooked or ignored. 24 AGENCIES’ SUPPORT OVER SUMMER / AUTUMN 2012 4.3.52 HV1 made an unannounced home visit in early August 2012 having had no reply to several messages left on mother’s mobile. She noted how thin mother was. Because a friend was present, HV1 postponed until an agreed visit a few days later, discussion about the failure to take up hepatitis C screening. Child H (nearly 8 months old) was noted to be clean and appropriately dressed. At her follow-up HV1 advised on an imminent need for stair gates. She also drew mother’s attention to the 4 missed screening appointments. Mother asked for a text reminder the day before her next appointment. HV1 observed mother was loving and attentive with child H and she provided advice about how to meet developing needs for socialisation. 4.3.53 In mid-August 2012 SW3 completed what had been a planned visit (once again mother claimed to have forgotten it). Mother said that she was engaging with Home Start and was due to attend an event next day. Mother reported that the involvement of Connections was ceasing because financial issues were now sorted. 4.3.54 At her (regular) supervision session in late August 2012 SW3 recommended that child H no longer required a protection plan. She reported that the child was developing well; the home was clean and tidy and that ‘Home Start was involved’ (the latter assertion was uncorroborated). At a further child protection visit at the end of August SW3 learned that mother and child had not attended Home Start because (mother said) it had been raining. She also indicated that she no longer wished to use Home Start and preferred to depend upon her own mother for support. SW3 noted that because she was between drugs workers, the GP Practice was directly prescribing mother’s methadone. What would have been a 5th core group on the same day was abandoned for lack of any representation by involved agencies, the (unjustified) rationale being that the review conference was anyway imminent. 4.3.55 In mid-September, SW3 (who described a positive picture of mother and child H’s progress) provided Probation with a supportive letter to inform the imminent court hearing. DW3 also had a phone contact with mother who reported no problems. GP3 saw mother at this time and records spell out clearly the agreed arrangements for her collection and consumption of prescribed methadone. On the same day mother again (for the 5th) failed to bring child H to hepatitis C screening. 4.3.56 Breach proceedings were withdrawn as not being in the public interest. The Probation Service attribute that decision to a positive report of progress from SW3. 4.3.57 Following the 5th failed appointment, infectious diseases consultant 2 phoned HV1 to discuss his concerns. Later that month the clinician’s records refer to that conversation and note ‘a chaotic family…and a further outpatient appointment to be offered when child H is 15 months old’. The doctor followed up with a letter to GP1 in which he confirmed the conversation with HV1 and asked that mother be supported to get her child screened for the estimated 1:20 chance of being hepatitis C +. 4.3.58 Though in essence a parental choice, the expert advice was to undertake screening. The fact that child H had been defined as in need of a protection plan might have prompted a discussion about the justification for an application for a Specific Issue Order under s.8 Children Act 1989. 25 REVIEW CHILD PROTECTION CONFERENCE 4.3.59 The report drafted by SW3 for the September 2012 review conference (child H then 9 months old) recommended that there was no ongoing need for a child protection plan. The conference was attended by mother, SW3, HV1 and a Connections support worker. Neither Thames Valley Police, Probation nor the Harm Minimisation Service (DW3 had by then left) were represented. The former had sent in a copy of ‘checks’ prior to the meeting. HV1 at this conference shared what later transpired to be misinformation about mother attending the Children’s Centre once a week. 4.3.60 The independent chairperson concurred with the social worker’s recommendation (which was also supported by the other 2 professionals in attendance) and the case was stepped down to ‘child in need plan’ status. On the basis of the evidence available to the conference, that was a reasonable and proportionate decision albeit one that in hindsight can be regarded as insufficiently informed. The GP Practice received an immediate notification of the decision made. REDUCED LEVELS OF CO-OPERATION WITH PROFESSIONALS 4.3.61 SW3 also emailed Probation to inform that agency of the change of status and to confirm the remaining period on the Community Order. Throughout September and October mother failed to attend most of her appointments with PO3. In early October 2012 HV1 made telephone contact with mother who reported that she and child H were well. Mother agreed to being sent information about Children’s Centre activities. A home visit was agreed. 4.3.62 In mid-October mother used as an excuse for non-attendance at the Children’s Centre, having been on holiday with her own mother (a similarly unconvincing excuse was offered to explain her unavailability for the last 2 weeks of October). 4.3.63 Mother continued to miss Harm Minimisation appointments (DW5 was by then the allocated worker). At an appointment with GP6 it was noted she had also failed to comply with prescribed post-natal anti-coagulant medication. CHILDREN’S SOCIAL CARE CASE CLOSURE 4.3.64 At supervision in mid-October 2012 TM2 and SW3 agreed the case could be closed. They noted an appointment was in place for the required medical screening and that HV1 and a drugs worker remained involved. A ‘team around the child’ (TAC) was not considered necessary. Given 5 failures by mother to present her child at the clinic, the fact a 6th was on offer some months later offered no genuine reassurance. The judgment to close the case was, based upon the available evidence, premature. 4.3.65 HV1 failed to get a response to a planned home visit (mother had ‘forgotten’). She agreed to call next day when again mother ‘forgot’. Mother agreed to bring child H (10 months old) to the clinic next day and when she failed to arrive was phoned. She claimed to be ‘en route’ but did not appear. Mother was also failing appointments with her drugs worker at this stage. This level of disorganisation and/or apparent deceit seems likely to have been of relevance to her ability to organise care of child H. 26 4.3.66 By late October HV1 pointed out to SW3 that mother had not been tested for illicit substances since the beginning of August. The social worker subsequently visited though no notes of that visit have been provided. Although not shared at the time, information held by the Police suggests mother had considerable debts, was ‘dealing’ throughout the period of review and (presumably in exchange for money) may have been smuggling drugs into prison for a friend / associate. 4.3.67 PO3 consulted her ‘legal proceedings manager’ in late October 2012 because mother was again in breach. A view was formed that there was little purpose in taking formal action because: The Order itself was due to end in mid-November There had already been 3 attempts to breach mother The current Order was itself a function of previous breaches (with originating offences now old) Options were anyway limited to revocation or a re-sentence 4.3.68 Nonetheless at the end of October 2012 the court was asked and did revoke the current Order and imposed a new Community Order to include a curfew requirement for 4 months. No ongoing supervision was included. Messages were left for SW3 to update her on this which represented the end of Probation Service involvement. ONGOING INVOLVEMENT OF HEALTH VISITING & HARM MINIMISATION SERVICE 4.3.69 HV1 became aware and concerned about the proportion of mother’s failed appointments and commendably initiated contact with DW5. It was agreed that if mother failed her next session with DW5, he would alert SW3. Mother failed a health review appointment with the health visitor scheduled for later that day (having been reminded by phone at which point she said she ‘would be there in 10 minutes’). 4.3.70 HV1 made contact with SW3 and shared her concerns. SW3 agreed to follow up with a visit and let HV1 know the result. SHOPLIFTING AT THE PHARMACY & FOLLOW-UP OF CONCERNS BY SW3 4.3.71 Though the report of it was received a few days later, in late October 2012 an incident occurred at the pharmacy where mother collected her methadone. Mother had apparently been caught shoplifting there some 3 weeks previously though no action had been taken. On this occasion she was spotted via CCTV to be stealing. When confronted by the manager, mother could not remember the incident because she had ‘taken diazepam’. The pharmacy manager was rightly concerned for mother’s child though had not alerted Police, Children’s Social Care or health visitor at the time. The pharmacist had notified GP2 and DW5, neither of whom took any further action in response. A recommendation about this is included in section 7. 4.3.72 At an unannounced home visit by SW3 at the end of October 2012 mother claimed she had been staying at an aunt’s mobile home for the last 2 weeks and that her mother had been with her. She indicated she was due in court today for breach of her Community Order and agreed to a urine test 2 days later; also to take child H for an 8 month developmental check ‘if she had time’ after her court appearance. 27 4.3.73 Mother’s claims as to whereabouts in the previous fortnight conflict with HV1’s records and with closed circuit television (CCTV) evidence of her shoplifting. SW3 would not have known about the pharmacy incident but could potentially have recognised and challenged mother’s fabricated story (reported to her by HV1) of having been ‘on her way’ to the clinic. Sensibly, SW3 told mother that although her case had been due to close, it would remain open because of her failing appointments. SW3 subsequently emailed HV1 the results of her home visit. 4.3.74 Mother failed to appear for the urine test and DW5 relayed this in a message to SW3 and asked her to contact him. TM2 responded and deployed a duty worker to undertake an unannounced visit. SW4 visited later that same day. Mother arrived home in a car driven by an unknown man (whom she named). She sought to explain the incident in the pharmacy by explaining that she had bought 25mg of valium from a friend because she had fallen out with another friend on the day in question. 4.3.75 Mother said she would like to return to weekly testing. Child H was noted to be ‘well attached’ and home conditions gave no cause for concern. SW4 emphasised the importance of remaining ‘emotionally available’ to child H. Issues of mother fabricating her whereabouts, misuse of valium and avoiding agreed tests were not pursued. Child H received the overdue developmental assessment when 10 months old. Nothing of concern was reported at what was HV1’s final face to face contact. Later that week mother attended her appointments with DW5.Though challenged she denied any on-top use except for diazepam the day she had stolen. 4.3.76 There was a significant level of liaison and information exchange at this time between HV1, SW3 and DW5. Concerns about her non-compliance with drug workers remained and DW5 was concerned that mother might have relapsed. There were also acknowledged positives such as the interaction of mother and child and the fact that both appeared well. In addition, child H was always well turned out. RENEWED PROSPECT OF CASE CLOSURE BY CHILDREN’S SOCIAL CARE 4.3.77 A week later when SW3 received her monthly supervision, TM2 decided that after 2 further unannounced visits and, subject to compliance with DW5 contacts and clear urine tests, the case could be closed. Next day, mother failed her appointment with DW5. Information held by the Police though not shared at the time, indicated that mother was continuing to be involved in drug dealing in Autumn 2012. 4.3.78 Mother’s further failures to attend Harm Minimisation appointments were shared with HV1 and SW3. In mid-November 2012 a duty social worker SW6 made an unannounced visit to check on why mother had failed her latest appointment with DW5. Mother was not in and later claimed she has been unwell on the day in question. She agreed to attend the next weekly appointment. 4.3.79 Mother finally attended an appointment and her urine test proved negative to anything except methadone. She was reminded of potential support from OASIS and that the agency was liaising with Children’s Social Care and Health Visiting Services. Weekly appointments ensued and all completed tests were negative. Mother indicated she would like to start reducing her dose in the New Year. 28 4.3.80 By early December, mother reported that as a result of her shoplifting she was now obliged to wear an electronic tag (her curfew was 8pm-6am). She also reported attendance at appointments with DW5. SW3 told mother that unannounced visits would continue for the moment. ARREST FOR SHOPLIFTING 4.3.81 In early December 2012 mother was arrested for earlier shoplifting (nappies) and received a Police caution5 . She claimed to have stolen because she had had no money and reported (inaccurately) that she was on 60 mls per day of methadone. 4.3.82 On the day after her arrest she failed an appointment with DW5. By mid-December SW3 was again reporting to supervisor TM2 that the case was ‘settled’, that mother was doing well and engaging with DW5 (actually an appointment the week before had been failed). The hope was that a team around the child (TAC) could be put in place after Christmas when mother’s does of methadone could begin to be reduced. 4.3.83 On the same day, DW5 met mother and re-emphasised the importance of appointments. Mother agreed to use ‘Open Access Social Inclusion Support’ (OASIS), though did not do so and also failed her first appointment with DW5. 4.3.84 At an announced visit by SW3 early in January 2013 child H was noted to be well and able to crawl and stand against furniture (the increased mobility would have represented additional pressure on mother). Mother reported (inaccurately) that they went to the Children’s Centre every 3 weeks and went out to town most days. Mother was again told that once she engaged with professionals for a period, her case could be closed. By late January, mother’s pick-up of methadone was changed to 3 times weekly and she was told this could continue for as long as there was no evidence of ‘on-top’ usage. Safe storage was again discussed. It was noted that mother had not used OASIS. A reduction to 80mls of methadone per day was discussed. CHILDREN’S SOCIAL CARE CASE CLOSURE 4.3.85 At her supervision session in late January 2013 SW3 referred to the likely agreement of HV1 and DW5 that the case be closed. Confirmation of their views was subsequently sought and obtained by SW3, albeit DW5 qualified his agreement by suggesting further monitoring before case closure. Neither expressed the view that a team around the child (TAC) meeting was required in advance of case closure. 4.3.86 At the beginning of February 2013 the case was formally closed. Mother presented child H (13 months old) for further routine immunisations in early February. DW5 and mother agreed to reduce mother’s methadone dose by 5mls later that month. Safe storage was again emphasised. At her appointment in late February mother, who had provided a negative urine sample, said she no longer wished to reduce her methadone. 5 A Police caution is a non-statutory disposal for adult offenders and offers a means of dealing with low level, mainly first-time offenders when specified public interest and eligibility criteria are met (Ministry of Justice ‘Simple Justice for Adult Offenders’ p.4) 29 MOTHER’S FURTHER ARREST & LIAISON FROM DW5 4.3.87 In mid-March 2013 mother was arrested for breach of her Community Order and failing to report. She indicated she had left her child in the care of an elderly male who could provide good enough care during the day but not overnight. 4.3.88 Mother postponed an appointment with DW5 reporting she had breached tagging conditions and was in court. A few days later the GP Practice was informed of a presentation of child H (15 months of age) by his mother to the minor injuries unit (MIU). The records suggest that the child, whom mother reported had been ill with a raised temperature all day may have suffered a febrile convulsion. DW5 emailed Children’s Social Care to confirm that mother was testing clear and being moved to weekly screening. Because the case was closed, the email was regarded as ‘for information’ only. The need for a more precise system to ensure an informed response to incoming information on closed cases is provided in section 7. ONGOING SUPPORT FROM HARM MINIMISATION & UNIVERSAL HEALTH SERVICES 4.3.89 In late March and into April 2013 mother continued to insist she was not using un-prescribed drugs. Records confirm safe storage of medication was again emphasised. Mother readily referred to the incident when child H might have ‘fitted’ and had apparently ended with him being seen at the local hospital. 4.3.90 Mother’s then weekly urine test proved negative. She remained on 3 times a week collection. Mother told DW5 she was taking 16 month old child H to a toddler group once a week. No evidence was sought or been located since to confirm this claim. ARREST & FURTHER FAILURE TO ATTEND SCREENING APPOINTMENTS 4.3.91 Mother was arrested in early April for theft and later pleaded guilty. The date was close to the occasion on which she was observed buying crack cocaine. She was also questioned about other thefts and it is likely she continued to shoplift at various locations after her conviction and sentencing to a 2 year Conditional Discharge. Some activities took place at night raising questions about who was caring for child H. Children’s Social Care was not notified of mother’s arrest or its outcome 4.3.92 HV1 phoned mother and was reassured that she and her child were managing. Mother claimed she was taking child H weekly to the Children’s Centre (though never took him there at all). Mother once again failed to bring her child for the latest appointment in mid-April 2013. Infectious diseases consultant 1 notified the GP Practice and offered late April as a further opportunity. The consultant also asked whether HV1 might actually bring mother and toddler to the clinic and wrote …’ I would be very grateful if either the health visitor or GP surgery could let us know if there are any child protection concerns affecting this family’. No response was provided to that request. 4.3.93 As well as missing the screening appointments, mother continued to be unreliable about meeting DW5. She was though very reliably collecting her methadone. At the point that she had missed 3 appointments in a row, DW5 asked the dispensing pharmacist to relay to mother that there would be no more prescriptions until she attended an appointment. 30 4.3.94 In spite of the position adopted by DW5 and confirmed in writing, mother failed to appear for her next appointment. However, she presented some 5 hours after her appointed time and tested positive only for methadone. Mother was 3 hours late for her next scheduled appointment in May 2013 and again tested positive only for methadone. She reported that she was managing well and had not needed to seek support from OASIS. In spite of advice that she should not rely solely on prescriptions, she wished to remain on 70mls per day of methadone. 4.3.95 Toward the end of that month mother was again caught shoplifting and using the buggy of child H as a means to hide the stolen goods. There is no record of an arrest on this occasion and no notification was sent to Children’s Social Care. 4.3.96 Mother missed 2 Harm Minimisation appointments in June 2013 and was offered (via the pharmacy) the chance to meet on a third date that month. A letter was sent to warn her no further prescriptions would be issued unless she attended. When finally seen, mother admitted to using crack cocaine 3 times over the last 2 months. DW5 notified SW3 and HV1 though received no response from Children’s Social Care where the information was treated as ‘information only’. Mother told DW5 she was taking her son to a local commercial play centre. It is not possible to verify that claim. DW5 did not ask where child H may have been when mother was using cocaine. 4.3.97 At her next appointment, mother denied any further use of illicit substances and wanted to remain on her current dose of methadone. She failed in July to present child H at the clinic and another appointment was booked (and failed) in August. ARREST FOR BURGLARY & CHILD H’S OVERDOSE 4.3.98 In early July 2013 mother was arrested on suspicion of a burglary. Though it appears likely (from a number of associated events known to Police at this time) that she had committed the offence, there was insufficient evidence for Police to pursue the case. 4.3.99 At her July appointment mother was still denying any ‘on-top’ usage and her urine tests confirmed only methadone. She had lost a further kilogram and was advised to consult her GP. HV1 was informed in mid-July that although referred in late May, mother had not attended any Home Start sessions. A further appointment with DW5 later that month revealed that mother had lost a further kilogram which might have been an indicator of a health problem and/or drug misuse. Mother again claimed to be taking child H to a toddler group. Mother failed further Harm Minimisation appointments in August (though continued to collect her methadone reliably) and was again told that further prescriptions depended upon her compliance. By late August DW5 discussed his concerns with HV1. She noted his intentions to return to a daily pick up routine and to notify Children’s Social Care of the latest situation. 4.3.100 HV1 was then notified of the latest failure to bring child H (20 months of age) to the infectious diseases clinic (in spite of the HV1 reminding her of it) and provided the clinic with contact details for Children’s Social Care. 4.3.101 DW5 managed to make contact by phone about a week later and also reminded mother of what he described as 6 (it is thought there were as many as 8) missed appointments for hepatitis C screening. At her last session with DW5 before her child’s overdose, mother revealed that she did not want her child tested but would let the health visitor know if she changed her mind. Mother remained on daily pick-ups at this point. Child H’s accidental overdose occurred in mid-September 2013. 31 5 ANALYSIS 5.1 INTRODUCTION 5.1.1 Each element of the terms of reference for this SCR is addressed below. 5.2 HOW WELL WERE PARENTAL VULNERABILITIES & THEIR IMPACT ON PARENTING CAPACITY IDENTIFIED? How well were issues of substance misuse and any other vulnerabilities e.g. domestic abuse, financial circumstances, parental mental health, parental conflict and unstable accommodation assessed and understood? What were the key relevant points / opportunities for assessment and decision making in this case in relation to child H and his family? If opportunities were missed, why were they? Do assessments and decisions appear to have been reached in a timely, informed professional way to include an assessment of the impact these decisions made? SUBSTANCE MISUSE / IMPACT ON PARENTING 5.2.1 Because she had had no recorded communication with the midwife, GP or Harm Minimisation Service HV1’s opportunity for comparative assessment post-birth was significantly limited; no robust assessment of vulnerability was undertaken and no written reports submitted to child protection conferences as required by the Trusts’ safeguarding children policy (prior to child H’s birth and throughout the review period, HV1’s clinic was short of 10 hours per week of health visiting time). 5.2.2 Mis-information provided at the initial conference that mother had not used heroin for over 2 years provided a false sense of mother’s stability. Though HV1 liaised well with Children’s Social Care, an 8 month delay in forging a partnership with the Harm Minimisation Service was rooted in that reassurance. It was also a result of insufficient awareness of the effects of cocaine, and a surprising opinion that any drug use and related behaviour was the remit and the responsibility of the drug worker, unless there was an observed impact on a child. 5.2.3 HV1 (and others) accepted missed appointments as reflecting mother’s disorganisation. The implications for child H should have been considered more and self-evident deceit challenged. DW1’s records demonstrate concern and recognition of vulnerability and when mother’s pregnancy became known, the impacts of heroin and crack on the developing foetus were discussed. DW2 utilised the expertise of the pharmacist and Oxford Health NHS Foundation Trust’s IMR confirmed that at interview, all staff demonstrated more understanding of mother’s vulnerability than that seen in records. Vulnerability of child H was inadvertently increased by an unjustified readiness to accept information from mother e.g. attending midwifery and probation appointments. 5.2.4 DW3 had direct knowledge of mother’s history and her considerable progress since the birth of her first child. This reduced the level of concern though DW3 remained aware of and addressed the risk of relapse in pregnancy. Because mother’s engagement with DW3 was better than with colleagues it enabled a greater exploration and risk analysis to take place. 32 5.2.5 DW5 had not familiarised himself with mother’s history, accepted her failure to attend appointments as commonplace and was reassured by her compliance with methadone pick-ups. He did not identify the distinct decrease in engagement following taking over the case. The absence of representation from the SCAS / later Harm Minimisation Service at either child protection conference was an obstacle to optimal multi-agency working. 5.2.6 All of the Police staff in contact with mother were aware of her long standing struggle with illegal drugs and understood this motivated her offending. Few believed the situation represented any significant risk to child H or required a referral to the Police ‘Protecting Vulnerable People (PVP) Referral Centre. More extensive research could have alerted officers to the fact that, for some time, child H was subject to a child protection plan. That knowledge would have raised the level of concern. PO2 did raise concerns with Children’s Social Care and SCAS (the provider which later became the Harm Minimisation Service) about ‘gaps’ in periods when mother should have been being tested regularly as part of the child protection plan. 5.2.7 Mother’s wish to parent this child and become drug free were taken seriously by Children’s Social Care, and Care Proceedings were not considered necessary because of the perceived change and support from wider family. Mother had reported using crack cocaine pre-birth and was reticent to consider a rehabilitation centre, which might have suggested a higher incidence of drug reliance than was being presented. Her then housing situation was regarded by social work staff and mother as heightening the risk of drug use. 5.2.8 The risks of drug relapse were well recognised and understood though agencies involved assessed (on the basis of partial information) that mother was managing to remain drug free, despite her apparent lack of co-operation at times. 5.2.9 Antenatally, appropriate referrals to Children’s Social Care, to addiction and smoking services, health visitor and Connexions were all promptly made. It was also clearly identified that her accommodation was not ideal, but that she ‘would be moving shortly’. No financial difficulties or conflicts within the family were identified, and her support network was identified as parents rather than a partner. Thus vulnerabilities were very thoroughly assessed and appropriate action taken to involve relevant agencies to support mother. No mention was made of mental health issues (which might imply this was thought of and no concerns were identified) and there is an almost complete absence of any comment about her partner. 5.2.10 Appropriate plans were made (with input from hospital social workers) for the baby to be observed in hospital after birth and mother seems to have been well-informed about the medical risks to child H of her drug use, and why the new-born baby needed observation in hospital. It was recognised that mother had not looked after a baby before and detailed notes written by the midwives demonstrate that mother’s ability to complete baby routines was carefully observed. 5.2.11 Hospital care therefore included thorough assessment of mother and child’s needs, recognition of the various vulnerabilities, and good liaison with Children’s Social Care leading to a robust discharge plan. There was some poor communication about that plan from the hospital to community midwives at discharge. 33 5.2.12 From the age of 3 months to 15 months child H was not brought to numerous appointments (which were always re-booked). There is little evidence that the relevance of mother’s substance misuse to these missed appointments was considered, possibly because the medical risks to child H of missing the appointments were relatively low. Levels of concern were not high and the wider picture of what was going on in the child’s life was not considered. 5.2.13 It was not clear from the records who had overall control of prescriptions and responsibility for when mother did not attend appointments. Interviews conducted by the Oxford Health NHS Foundation Trust IMR author clarified the position and explained that some of the allocated drugs nurses were authorised to prescribe methadone and some were not (in which instance the responsibility reverts to the GP as it did during the period when no drugs nurse was allocated). OTHER VULNERABILITIES / IMPACT ON PARENTING 5.2.14 HV1 had been alert to the negative impact on mother and child of their cramped accommodation which they were obliged to share with other substance misusers and actively lobbied the housing department for alternative accommodation. Her administration of specific questions recommended by the National Institute for Clinical Excellence (NICE) to assess mental health in pregnancy and in the post natal period was tardy. The Healthy Child Programme stipulates that this it should be done when a child is 6-8 weeks old but child H was 10 months old before its completion. An absence of any concerns about mental health following mother’s move to her new accommodation in the context of workload explains why. 5.2.15 HV1 was sensitive to the possibility of domestic abuse and (based upon the history shared with her at the initial conference) had urged mother to take precautions when meeting with the father of child H. From a Probation perspective, mother’s several convictions for theft (shoplifting) were indicative of having to fund drug use and she had previously had significant rent arrears. The cost of all travel to and from Probation reporting appointments was helpfully met by Probation. 5.2.16 Mother was not identified as being in a relationship during her period of supervision, nor regarded as having any mental health issues. Attempts were made to involve the father at an early stage without fully understanding the risks he might have posed. Mother was initially unaware that the father was being contacted and both individuals subsequently disguised their contact from professionals. Concerns about the father of child H were not recognised until Police intelligence was shared with the child protection conference chairperson. 5.2.17 There is no evidence in GP records about financial circumstances, parental conflict, domestic abuse or accommodation, none of which would routinely be recorded within a patient’s GP records unless the information was given directly by the patient or from a third party e.g. a health visitor. Such information would have been useful in building a better picture of the home situation and was potentially available had the GPs been more involved. 34 KEY POINTS / OPPORTUNITIES FOR ASSESSMENT / DECISION MAKING? 5.2.18 The opportunities for assessment / decision-making by Health Visiting and Probation services may be highlighted as follows. Ante-natal period 5.2.19 Midwives and health visitors are expected to communicate so that vulnerable clients recognised ante-natally can receive a targeted visit by the health visitor. In this case, information exchanges between HV1 and midwife 1 were informal and opportunistic and there was no written exchange. Given the shortfall of health visiting hours at the time, it is not certain that HV1 would have had the capacity to do more than she did. 5.2.20 DW1 when he learned of the pregnancy, took the opportunity to assess the appropriate management of mother’s methadone in view of foetal development / obstetric risk. He assessed mother’s attitude as positive and physical health as good. He addressed her emotional health and liaised with a local self-help source, Probation, and the pharmacy. His ‘care plan’ was followed by his successor DW2. At the FGC, an extensive package of support was agreed. The lack of a specialist drug worker at the pre-birth child protection conference may though have impacted on the understanding of risk for those who did attend. First visit following birth of child H & case transfer 5.2.21 HV1’s first visit to the home was (usefully) a joint one with social worker SW1 after the birth of child H. Their assessment of the environment prompted a referral to housing. DW2 received a comprehensive handover from DW1 including an introduction to mother. This sound practice was atypical and reflected extra effort to support DW2 for whom it was the first post in that specialist role. 5.2.22 DW3 received only a verbal handover from DW2 and completed her own assessment which included liaison with Probation and through that, with the social worker. It included mother’s physical health plus a urine screen, community support and engagement, a review of progress to date and her mental health status. When DW3 left there was no one available to hand over to. During her care of mother, the Drugs Service provider changed from ‘SCAS’ to become the ‘Harm Minimisation Service’. Although this transition had not immediately impacted on the care delivered DW3 has reported that the reduction in specialised practitioners meant it was difficult to manage a face to face handover. DW5, at his initial meeting with mother appropriately challenged her about the shop lifting reported by the pharmacist. 6- 12 month health assessment 5.2.23 When child H was 10 months old HV1 completed a health assessment covering all aspects of growth and development including an assessment of mother’s mental health. To that point, service provision had been ‘universal partnership plus’. Following the assessment HV1 reported she offered a ‘universal plus intervention’ and attributed the change to an absence of identified concerns. It is unclear whether other agencies appreciated the implications of the status change. HV1 also addressed home safety but not safe storage of methadone. 35 When considering a change in methadone prescription. 5.2.24 When child H was just less than 1 year old DW5 changed the methadone prescription from daily supervised pick up, to 3 times per week (consumption unobserved). DW5 reported that he had assessed mother’s suitability for this based upon continued compliance with pickups and 2 clear urine screens. Mother had attended less than 30% of his appointments in the previous year and DW5 had himself raised the possibility of a relapse less than 2 months before his decision. His still-remaining doubts about which he spoke at the time, meant that he had been reluctant to accept the proposed case closure by Children’s Social Care though he took no action to challenge its decision. Prior to case closure by Children’s Social Care 5.2.25 SW3 consulted HV1 and DW5 about the intention within Children’s Social Care in early 2013 to close the case. DW5 responded via email explaining that he still had some (unspecified) concerns. HV1 and DW5 spoke with one another about mother’s failure to attend hepatitis C screening for child H, and her own with DW5. HV1 had not seen child H since he was 10 months old and her next contact with mother was by phone 6 weeks later and concerned a further attempt to get child H screened. 5.2.26 HV1 accepted what is now known to be an untrue assertion by mother of weekly attendance at a Children’s Centre. HV1’s focus on the general health and development of child H excluded current and future impact of illicit drug use. 5.2.27 The absence of a face to face meeting with all involved professionals to discuss the pros and cons of case closure and perhaps agree a team around the child (TAC) could be regarded as a missed opportunity. Significant incidents 5.2.28 2 other incidents offered an opportunity to re-assess and take relevant decisions: Receipt of the letter from the pharmacist informing of the shop lifting episode (child H was then 10 months old) Mother’s disclosure in late June 2013 of a relapse into illicit drug use (child H 17 months old) 5.2.29 Key assessments / decision-making opportunities by Police and Probation were as follows. Use of crack cocaine whilst in custody 5.2.30 When mother (then 21 weeks pregnant) was discovered to be smoking in a cell a referral to Children’s Social Care should have been initiated. The incident provided clear evidence of mother’s drug misuse on top of her methadone prescription and of the risk of harm to which she was exposing her unborn baby. The reasons why this referral was missed appears to be largely because many people were involved and no one single person accepted responsibility for informing the Child Abuse Investigation Unit (CAIU) (this incident pre-dated PVP Referral Centres). 36 Sharing of Intelligence 5.2.31 If details of Police intelligence pointing toward illicit usage and dealing had been shared, Children’s Social Care might have had a clearer understanding of mother’s involvement with illegal drugs above and beyond her methadone prescription. The failure to relay all relevant information reflected the Police ‘conference writer’s belief that Children’s Social Care was already aware of mother’s drug use and a lack of confidence in how carefully such intelligence might be handled. Categorisation of events 5.2.32 In late February 2013 (informed by intelligence received) officers attended the home address to complete a ‘welfare check’. If a ‘child protection – non crime incident’ had been created straight away for child H it would have ensured immediate oversight by the child protection referral manager within the PVP Referral Centre. 5.2.33 Within Probation too much reliance was placed on positive feedback from other agencies. Had checks with the Police ‘area intelligence team’ been carried out at point of offender assessment review, behaviours might have been identified which could have raised the assessed level of risk mother posed to children. 5.2.34 For Children’s Social Care, key assessments and decisions were as follows. Pre-birth 5.2.35 Whilst an initial referral was received in May, the assessment did not start until August 2011. The previous Care Proceedings and history of drug mis-use should have prompted an earlier response. 5.2.36 The most significant issue pre-birth appears to be the deliberate delay in holding a strategy meeting, so that ensuing responses would not lead to a review child protection case conference pre-birth. The unintended consequence was that the initial conference was held too close to the baby’s birth, leaving little time to adequately address risk including that perhaps posed by father of domestic violence. It is unlikely however that Care Proceedings would have been commenced because of the progress mother was making and her stated wish to care for this baby (regarded as different from a lack of motivation to do so with her first child). 5.2.37 The Family Group Conference (FGC) was successful in engaging wider family which in turn had a significant influence on the decision not to seek legal advice. Observations of the maternal grandmother about mother’s apparent drug-free state was highly influential. Ending child protection plan 5.2.38 The child protection conference made a timely decision to end child protection planning and recommended continued child in need planning. The early closure of child in need planning (after 1 month) recommended by the team manager was influenced in part, by pressures the team were under. When there were signs that mother was not managing as well shortly afterwards, the case was kept open. 37 Case Closure (no use of ‘Team around the Child’ (TAC)) 5.2.39 At the point of case closure (February 2013) the use of a ‘Team around the Child’ was discounted as there was ongoing support from the health visitor and Harm Minimisation Service. Another influence upon the decision making at this point was mother’s reluctance to engage with other professionals. In the absence of any signs of ‘significant impairment’ (s.17 Children Act 1989) the case closed. A team around the child might have been effective at this stage. Contacts / referrals after case closed 5.2.40 There was further contact from the Police indicating that mother had taken her child with her to buy crack cocaine. When visited, mother denied the allegation and viewed it as a malicious allegation by a [named] male. The case remained closed. The event should have been dealt with as a new Contact / Referral, although it is likely that the outcome would have been the same. 5.2.41 There was a further email from DW5 in late March 2013 to Children’s Social Care reporting that mother was testing clear for drug use and being moved to weekly drug screening. As the case was closed this was viewed as ‘information only’ and did not prompt any further action. DW5 emailed again in May 2013 stating that mother was missing appointments and he would not be providing any further methadone scripts if she missed the next one. These contacts, after the case was closed, were not recorded effectively on the Integrated Children’s system (ICS) system. 5.2.42 With respect to hospital and GP services, key opportunities for assessments and decisions were as follows. Ante-natal care 5.2.43 The first chance of an assessment was mother’s initial attendance at ante-natal clinic. The midwife completed the health and social care assessment well and all appropriate referrals were made. The next opportunity was observation during the pregnancy and in the postnatal period when mother and baby were still in hospital. Ante-natally, mother missed 4 appointments suggesting that she was not prioritising her own health needs. In some instances, SW1 was informed, in others she was not. For 2 missed appointments, there is no evidence that anyone (Children’s Social Care or midwives) was informed; appointments were simply rebooked. The missed appointment were early examples of what was to become typical behaviour with respect to routine appointments. 5.2.44 It is clear that thorough formal (discussions and meetings with Children’s Social Care) and informal (observations of mother’s behaviour on the postnatal ward) assessments were made and decisions taken in the light of these assessments. 5.2.45 The next key opportunity for assessment related to the missed infectious disease appointments. Their primary purpose was to assess the child’s medical status rather than social well-being but because they were regarded in purely medical terms, the opportunities to feed back to Children’s Social Care observations on mother’s abilities to recognise, and prioritise her baby’s needs were not taken. 38 5.2.46 A policy for what to do if children are not brought to medical appointments in the hospital - the ‘Procedure for Ensuring Children and Young People’s Access to Healthcare is Safeguarded’ (Did Not Attend (DNA) policy)’ - has been in place since October 2009. Even for children deemed ‘low risk’ a referral to Children’s Social Care is indicated after the third missed appointment. In child H’s case, it was not until the 3rd missed appointment that a letter was written to the GP and at no point was direct contact made with Children’s Social Care. 5.2.47 HV1 was phoned both by the screening co-ordinator and one of the clinic doctors to discuss the situation. HV1 described the family situation as ‘chaotic’. Although all but one of these contacts took place at a time when child H was still subject of a child protection or child in need plan, this fact was not provided to the clinic by the GP (from whom there was no reply at all) or the health visitor. The potential consequences of the above were compounded by the fact that there was no record in child H’s notes that the child was subject of a child protection plan. This latter fact was an omission due to human error. Electronic Records had been introduced only 1 month previously and this significantly affected the way in which midwives needed to make these notifications. 5.2.48 The doctors involved were unaware of the policy so that all ‘DNAs’ were considered and acted upon individually. Subsequent discussion has confirmed that awareness of the policy in general is poor with most paediatricians relying mainly on contact via the GP unless they are already aware of very specific child protection concerns. The policy has recently been revised and it is clear that it needs to be ‘re-launched’. 5.2.49 In addition, the purpose of the clinic visit was ‘screening’ a healthy baby for a potential health problem. Such babies are unsurprisingly ‘over-represented’ amongst non-attenders. Advice provided to the serious case review panel indicates that the chance of the baby of a hepatitis C positive mother becoming infected is about 20% and blood tests cannot give a clear answer until the baby is about 15 months of age. If a baby is affected s/he would not become noticeably unwell until the age of 2 or 3 years (and active treatment not offered until at least 2 years of age). Thus, in a medical sense, missing an appointment at ages up to 1 year or 15 months has no immediate consequence. Like all such screening tests, there is parental choice. 5.2.50 Thus, non-attendance is pursued less vigorously than for a child with an established medical problem who would become avoidably more unwell if not treated. All in all, the response of clinic staff of trying persistently to secure attendance via contact with GP and HV for a screening test was reasonable. 5.2.51 Child H’s direct encounters with GPs were limited to a 6 week check, attendance for a routine matter and 2 encounters with the ‘out of hours service (the first when it was noted ‘mum was coping well’ and that ‘appropriate safeguards were in place’). There were letters from the infectious diseases clinic informing the Practice that mother had repeatedly failed to present her baby for follow up testing for hepatitis C. There is no evidence any GP responded to any of the 6 letters. An assertion in the GP IMR that responsibility anyway lay with the health visitor is questionable. Even if the GPs had believed that to be so, when further letters offered evidence that child H had still not been presented, then at the very least, a recorded conversation with the health visitor was required. 39 5.2.52 The Practice reportedly holds a weekly primary healthcare team meeting attended by GPs, health visitor, midwife and Practice and district nurses where any relevant information on ill or vulnerable patients would have been shared. No documents have been located which would confirm that child H was discussed at these events. (which are now formally minuted). The absence of response by GPs to the clinic letters reflected beliefs about roles rather than being a function of poor administration. 5.2.53 The Practice has a good system in place for the management of incoming information. Letters are scanned onto ‘Docman’ (a system which stores letters / documents and which is linked to the patient’s medical records) and are then read by the GP who is involved with that patient’s care. If that GP is not available to read the incoming letters then a ‘buddy’ system is in operation. This means that a 2nd GP will read the unavailable GP’s post / results and action these appropriately. S/he can also ‘flag’ any important issues with the unavailable GP by sending a message. The arrangement sounds robust but it is of concern that no GP responded to any of 6 letters and to the specific question about any safeguarding concerns. ASSESSMENTS / DECISIONS REACHED IN A TIMELY, INFORMED & PROFESSIONAL WAY? 5.2.54 An overall evaluation of the quality of assessments and decisions by Health Visiting, Harm Minimisation Service, Police and Probation follows. 5.2.55 Had the pre-birth conference been convened earlier the health visitor would have had the opportunity to establish contact and complete an antenatal assessment. This would also have promoted opportunities for collaborative care planning and enabled comparative assessments to be done (mood, attitude, motivation, integration etc.). 5.2.56 Historical evidence suggested a highly vulnerable mother. From when child H was 10 months old mother’s engagement with the Harm Minimisation Service was minimal. The decision to change to 3 times a week pick-up in spite of mother’s non-compliance and recent misuse of diazepam reduced the level of monitoring and entrusted larger amounts of methadone to store safely. This prescription continued even after her disclosure that she had used cocaine over the previous 3 months. 5.2.57 A number of examples have been identified where no, or insufficient research was conducted on mother by the police officers and staff dealing with her. The Police IMR also found inefficiency in internal communication about children subject of child protection plans. If child H had been more visible within Thames Valley Police as a child in need of protection then officers / staff dealing with mother and child might have had his care and welfare at the forefront of their mind rather than viewing the interaction as ‘just another shoplifting’ or ‘just mother again’. 5.2.58 With respect to Probation, reviews of the offender assessment required by National Standards were completed in a timely way, in accordance with policy. In the earlier part of Probation’s involvement, the emphasis on drug testing was the focus. During the period of this review, staff felt that multi-agency meetings were convened with little notice. The fact that other agencies had such a positive view of mother’s progress and apparent engagement, in stark contrast to her engagement with Probation, impacted on the supervising officers involved. 40 5.2.59 Probation staff were influenced by this perspective in how they managed the enforcement of mother’s sentence e.g. the decision to revoke her supervision and replace this with a Curfew Order was guided by the ‘good progress’ being identified by Children’s Social Care, health visitor, and Harm Minimisation Service. 5.2.60 With respect to the quality of other key assessments / decisions, ending child protection plan status appears to have been made at the right time, based upon (what is now known to have been an incomplete) information from the agencies involved and agreed within a multi-agency setting. Mother was viewed to be drug-free and her housing issues were resolved. The care of child H was viewed as adequate. The child’s need to be screened for hepatitis C was still outstanding at the time, but it was legitimate for this to be followed up under a child in need plan. The next appointment for that screening was not until April 2013 (6 months away). 5.2.61 The incident at the pharmacist shop in October 2012 was not reported to Children’s Social Care for some days, by which time a social work home visit had already taken place. Mother’s claim that she had been away for 2 weeks is likely to be false. No effort was subsequently made to clarify the event, even after the valium use was discovered. The incident did though prompt the case to remain open for a further 3 months, during which time care of child H was viewed as good and there were no further concerning incidents known to the professionals involved. 5.2.62 By February 2013 it was known that mother was attending her Harm Minimisation appointments and had moved to 3 times weekly methadone pick-ups. It is understandable that Children’s Social Care viewed this as the right time to close the case, as care of the child continued to be good and mother appeared to be coping well. At this time it was known that there was the change in methadone script routine, a further imminent change of drugs worker and a request that the case remain open to for longer. This information does not seem to have prompted a question as to whether a further few weeks of CiN planning was required. 5.2.63 With respect to the timing and quality of assessments and decisions by hospital and GP services, hospital staff contributed effectively to the initial decision-making in pregnancy and after delivery by referring to and liaising with Children’s Social Care. With respect to the medical implications of child H not being presented for screening, staff made considerable efforts to alert the GP Practice. 41 5.3 WHAT ACTIONS WERE TAKEN TO SAFEGUARD CHILD H ON THE BASIS OF VULNERABILITIES & HOW WELL AGENCIES WORKED ON THEIR OWN & TOGETHER, WHERE RELEVANT ? Were appropriate services offered / provided, or relevant enquiries made, in the light of parental requests, identified needs and the professional referrals? Were the appropriate assessments and plans made including the antenatal period? Was there adequate and clear communication between agencies? How well was information recorded and analysed to reduce risk? If opportunities were missed, why? Health services offered & communication 5.3.1 Mother would typically agree to a service and then fail to engage. Her lack of motivation was explained by professionals as disorganisation. With hindsight it appears increases in personal chaos were at least in part related to increased drug use / dealing and an inevitable reduction in her capacity to focus on child H. Mother failed to make proper use of advice or other services on offer from Children’s Centres, Home Start as well as from Probation and the Harm Minimisation Service. 5.3.2 Initially mother did (according to DW1 and DW2) engage with local drug support services, however the organisation changed and became the OASIS service with many different workers. There is no information about the work the former source of support undertook nor any evidence she attended OASIS though she was encouraged to do so. GP2 was involved in pregnancy care and also regularly prescribed mother’s methadone. The GP IMR refers to an expectation of frequent communication between doctors and health visitors. Though HV1 had and used her access to medical records to add information, she was unable to recall or indicate any recorded conversation with GP2 about mother. There was no GP present at any of the 3 conferences. The Practice had known mother for some 12 years. The absence of any record of information sharing and assessment suggests missed opportunities. Shared care 5.3.3 Shared care is described as the joint delivery of care for patients with a drug misuse problem. All drugs nurses said they would seek out the GP if they wished to discuss a patient. There was though, no evidence of organised liaison. In interview DW5 stated that he trusted the GP to read what he had documented in the records and vice versa. This was one of a number of unwarranted assumptions made by professionals which are summarised in section 6. Communication 5.3.4 Before child H was 10 months of age there was no communication between DW5 and HV1 (who initiated contact after numerous failed appointments when attempting to complete the baby’s 6-12 month health assessment). By looking at the medical records she was aware that DW5 was having a similar problem obtaining compliance from mother. From this time, there was ongoing information shared (largely by email) between these professionals and SW3. Both health professionals were aware when the other had an appointment pending with mother and encouraged her to attend if they encountered her. 42 5.3.5 Neither health visiting nor SCAS / Harm Minimisation records contain core group minutes though formal records of most were made (and it believed circulated). DW5 in a brief email in January 2013 questioned the decision in Children’s Social Care to close the case. The basis of his concerns were not documented and an offer apparently made in a conversation with SW3 to speak with her manager was not followed up. Communication with the pharmacist was frequent for all drugs workers and this role offered an important source of expertise as well as regular feedback on the patient’s presentation. Recording 5.3.6 HV1 had access to and recorded on Rio (the Health Trust’s database) and GP records for mother and child H. Drugs workers had no access to Rio but added information to GP records. Records made by DW1 and DW2 were considered and reflective. Sometimes mother’s assertions were accepted as fact, thus reducing the possibility of a well-informed assessment of risk. Records maintained by DW3 were thorough and included an on-going assessment of risk and a future plan. There was a sense from the records that the appropriate information had been collected from which a knowledgeable risk assessment could be made. 5.3.7 At the outset of her involvement, DW3 had drafted a care plan that was scanned onto the GP system. The plan was due for review in 3 months though in practice it never was. The explanation provided was that scanning renders it hard to use the plan as a continuous working document. DW3 compensated for this system weakness by documenting her risk assessments on the medical records as events unfolded. Although this did not disadvantage child H, standardised ways of documenting a risk analysis would offer an improved chance of continuity of care. 5.3.8 The contents of DW5’s records were described by the Health Trust IMR author as ‘variable and at times lacking analysis and an assessment of risk’. Though DW5 regularly recorded that he had contacted HV1 and SW3 he did not record the content of those contacts. Therefore there is no evidence whether this included collaborative analysis or was just notification of missed appointments. 5.3.9 Mother was a patient in ‘shared care’ for the duration of the period under review. Records suggest that the appreciation of risk reduced though her behaviour had become less stable and engagement with the Harm Minimisation Service decreased. 5.3.10 HV1 clearly documented actions taken and her liaison. The Health Trust IMR confirms she retained a child focus documenting observations of child H at contact. Paper records were well organised with up to date summaries of inputs. What was lacking in documentation was analysis. Failed appointments were repeatedly recorded though records offered no consideration of why. It appears that HV1 was operating on an assumption that all drug users fail to attend appointments. HV1 never recorded any observed cause for concern and her records lacked inclusion of a plan of care rendering it difficult to identify the outcome of any visit and what consequent service provision would be. 43 Why were opportunities missed? 5.3.11 HV1 had little knowledge about the impact on parenting of drug use or the risks associated with being on a methadone and did not consider it her role to address the safe storage of methadone. Because clients on a methadone programme were / are common on her case load, HV1 should have accessed training via the Oxfordshire Safeguarding Children Board website. 5.3.12 DW5 at interview referred to a finding that 20% of people fail to attend NHS appointments and his belief that mother was one of that cohort. He also stated that assumptions about the use of drugs or abstinence could not be based on whether people were engaged with drug services or not. Such fixed thinking may have reduced his ability to identify that there was a significant reduction in her engagement with him as opposed to with predecessor DW3. 5.3.13 There were also additional issues to be considered e.g. shop lifting, weight loss, missed methadone pick up and admission of cocaine use. The ‘quality’ of discussion between professionals was insufficient to promote consideration of alternative hypotheses or conflicting versions of events e.g. when it was reported to DW5 via the pharmacist that mother was ‘out of it’ when caught shoplifting, there was no exploration about child H’s safety. The incident was not considered in the context of history, risk of harm, protective factors etc. Mother’s assertion that she had taken diazepam on a ‘one off’ basis should not have been considered sufficient. 5.3.14 It remains unclear, though asked by Children’s Social Care to do so, why HV1 and DW5 did not consider or discuss forming a team around the child (TAC). There was insufficient reflection by professionals about the impact on child H of parenting described in interview by DW5 as ‘chaotic’ and by HV1 as ‘extremely disorganised’ e.g. could the child (albeit loved) depend upon a feeding or bedtime routine, any planning for safety and meeting the need for socialisation ? Police & Probation Services & communication 5.3.15 Each time that mother came into Police custody she was asked whether she would like to speak to a ‘custody interventions programme’ (CIP)6 worker. She declined this service on each occasion. Thames Valley Police was invited to contribute to the assessments and plans as part of the child protection conferences. Historically officers from CAIUs would only attend if there was current Police involvement with a child / family or the case was complex and clearly needed Police involvement at the conference. Child H’s case satisfied neither of these criteria. The other lost opportunity was the incident in February 2013 when Police received intelligence to suggest child H was being neglected due to mother’s drug misuse. The child was never actually seen by officers, though the decision made by the intelligence officer to request a welfare check was a good one. 6 The CIP offers support to vulnerable adults who have been taken into police custody. CIP staff work in the designated custody suites alongside custody staff to identify and work with those who may need help in terms of people using illicit drugs, experiencing problems with alcohol, those with a mental health condition or a learning difficulty 44 5.3.16 Police records indicate that a phone referral to Children’s Social Care was made by an attending officer but that has not been confirmed by Children’s Social Care’s IMR. Formal communication between Police and Children’s Social Care was limited to: An invitation from Children’s Social Care to attend the initial conference. A record of the conference minutes and copy of the protection plan provided by Children’s Social Care (the review conference dates were included at the end of the minutes) Reports submitted to the conferences by Police in lieu of attendance 5.3.17 Officers / civilian staff had commendably gathered a large amount of information submitted by them in relation to mother. The majority was recorded correctly on either the intelligence or crime recording databases. The systemic weakness was in the flagging of the intelligence to the correct department and in the failure to share with Children’s Social Care that which could be relevant to the well-being of child H. 5.3.18 Probation officers made every effort to inform Children’s Social Care knowing that any remand in custody would have impacted upon care of child H. Within Probation, assessments of mother and the risk she posed to children were completed at the required points in supervision, and there is evidence of management oversight. The supervision task was re-allocated to a qualified probation officer once the risks were identified ante-natally and the case was co-worked with a trainee officer for the remainder of her involvement with Probation. 5.3.19 Probation records indicate that communication with some Children’s Social Care and Drug Services workers was not easy. Records indicate several attempts to contact them and on occasions voicemail messages left without a response for some days. Once communication did take place the outcomes were positive e.g. the avoidance of ‘double-booking’ of appointments with Harm Minimisation Service which had been used by mother to explain her failures to attend. 5.3.20 Information that Probation staff obtained was incorporated into the assessment of the risk posed by mother to her child. In hindsight there were gaps in information which could have informed the assessment i.e. mother’s lifestyle and associates, and her offences pointed toward continued drug misuse and could have led to her being assessed as a higher risk to children. Children’s Social Care Services & communication 5.3.21 The likely needs of the unborn child had required an earlier multi-agency meeting. The risks of the baby arriving early were significant. Whilst the decision to initiate a safeguarding approach was justified, any implications for ‘performance indicators’ should have been outweighed by what was in the unborn child’s interests. The belated pre-birth assessment, was good, and utilised available information. A significant issue identified related to poor housing. Despite efforts from agencies to assist, the only effective intervention was from the local MP. 5.3.22 There were attempts made to integrate mother and child H in to Sure Start activity. Care of her baby was viewed as good, and the failure to engage with early years support not viewed as indicative of poor parenting. Mother was engaged with drug services and there was communication from these services to other professionals. 45 5.3.23 A common perception was that the biggest hurdle for practitioners was working with mother’s ‘dis-organisation’ and ‘scattiness’, rather than a deliberate attempt to undermine the support being offered. In contrast though, there was a different perception in relation to missing Probation appointments, which were widely acknowledged to reflect active avoidance. The perception of mother being ‘dis-organised’ probably overshadowed times when mother was being manipulative. 5.3.24 The 2 contacts received after case closure raise issues as to whether they should have prompted further involvement of social workers. In the first, after visiting, the child’s well-being was viewed as no different from when the case closed. The second contact was clearly made outside any formal referral mechanism and there was no follow up from Harm Minimisation or Children’s Social Care. 5.3.25 There was a clear pre-birth assessment that prompted a family group conference and initial child protection conference. The assessment acknowledged that mother had a background of significant drug use, but viewed her presentation, wider family support and her wish to care for her new baby as mitigating factors that reflected a positive outlook on her abilities. The assessment acknowledged that mother would effectively be a ‘first time mum’ and the report to the initial child protection case conference noted that engagement with ante-natal services had been unreliable (70% attendance for appointments with the midwife). At this point the assessment viewed her ability to ‘organise and attend appointments’ as a ‘significant concern’ recognising that this was the first time she appeared to be ‘drug free’. 5.3.26 The assessment noted ‘it is unclear if mother is concealing her drug use at times or failing to understand the importance of demonstrating she is drug free’. Throughout subsequent involvement, social workers and managers expressed a ‘frustration’ in that they could see how much mother loved her child and how well child H was doing, but her ability to organise and attend appointments remained a worry. 5.3.27 During the child protection planning process there were appropriate plans made. In hindsight, it is unclear whether she was co-operative with the child protection planning because there was a Community Order in place. Once formal monitoring by Probation lessened, a possible relapse took place quickly (shop-lifting and valium use in October 2012). Core groups and information sharing between agencies appears to have been appropriate during child protection planning. 5.3.28 Once child protection planning ceased there was no clear child in need plan in place. Child in need planning processes are now reported to be improved within the Family Support Teams. At the point of case closure there was a view from Harm Minimisation that Children’s Social Care should remain involved, though the purpose of ongoing involvement was not clearly outlined. At the point of closure child H’s care and development were not of such concern that the s.17 Children Act 1989 (‘significant impairment’) could be said to be present. 5.3.29 Communication with the Probation Service was not adequate. There are records indicating the Probation Service thought Children’s Social Care undertook drug testing with mother and the clash between the Drugs Service and probation appointments was not recognised for some time. Relevant information does generally appear to have been communicated at conferences. 46 Children’s Social Care recording & analysis 5.3.30 There was a clear focus upon the potential risks to a new born child, while balancing the mitigating factors relating to mother’s presentation and wish to care for this child. The information relating to the child’s father was limited at first and the apparent collusion between both parents to limit the information to which Children’s Social Care had was not fully recognised (visits by the father that were not reported). The housing situation and need to evidence a drug-free lifestyle was fully recognised. 5.3.31 During the child protection planning period, new information was included in an assessment of risk and a gradual picture of improvement and good care of child H appears to have been valid, based upon the information available at the time. Following child H ceasing to be the subject of a child protection plan information that indicated a heightened risk appears to have been reacted to appropriately though reflection on the longer term implications was not always fully considered. The shoplifting incident did prompt further involvement and child H’s situation appeared to be settled at the time that the case was closed. Hospital & GP services 5.3.32 Appropriate referrals were made by hospital services to other agencies during pregnancy; and midwifery staff contributed their observations on mother’s capabilities when asked to do so. There was one request for information - the health visitor’s request in May 2012 to be informed if mother did not bring child H to the next appointment. This was not acted upon as the appointment was changed by the hospital, and the request then not recorded in the section initially looked at by clinic staff. Thus when child H was not brought to the re-scheduled appointment, the information was not readily apparent to clinic staff. This minor human error was of relatively little significance 5.3.33 During the antenatal period, robust plans were in place. Appropriate plans were also made, and followed, for the medical management of child H during the first few days of life. Documentation of Children’s Social Care plans with respect to discharge from hospital as a neonate was not as good as it might have been. 5.3.34 Antenatally mother appeared to engage in the services that were offered to her and information from Children’s Social Care concerning their assessment and plans, and a copy of the pre-birth child protection conference was received and filed in mother’s ante-natal notes, indicating that unborn child H was subject of a child protection plan. Postnatally, whilst there is plenty of contemporaneous information about ongoing assessments and communications, there is lack of precise documentation in child H’s notes about the protection plan e.g. there is no copy of any notes following the meeting with mother and Children’s Social Care (merely a summary of key points written by the midwife who had attended). In addition, information which was readily available within mother’s notes was not transferred to child H’s notes. 5.3.35 Interagency communication about pre-birth assessments was therefore good: but internal communication about it was not as good as it should have been. There was communication between the health visitor and hospital but no response from the GPs to letters sent. The absence of response by the GP to letters specifically asking whether were safeguarding concerns was interpreted as ‘no concern’. 47 5.3.36 It would have been prudent to confirm this fact with Children’s Social Care, but there was no communication with that agency initiated by hospital staff. Had there been clearer documentation in the notes about the initial child protection plan, hospital staff could have contacted Children’s Social Care. Handwritten or directly entered electronic information in the hospital notes at all stages was generally of a good quality. Analysis of information pre-birth and in the post-natal period was good. There are though concerns about the filing of items which originated from outside the hospital such as minutes of meetings. 5.3.37 During pregnancy, information relevant to mother and baby can only be filed in maternal notes. Until a baby is born and allocated an NHS number, s/he does not have notes. Any information in maternal notes relevant to baby (medical or social) must be transferred by a midwife. Thus the record which made ‘unborn child H’ subject to a child protection plan was filed in maternity notes, but not subsequently transferred into child H’s own notes. Because the same midwife would be looking after mother and baby, she would anyway be aware of the circumstances. Such an oversight became important later when child H did not attend clinic and the only available notes were those of the child which did not contain all relevant information. 5.3.38 There is no evidence of the minutes from the pre-discharge meeting in the notes of child H. There is clear evidence of what was decided in a handwritten note, about who was to visit mother and baby at home post-discharge, but it seems that this was not passed on to community midwives. This was a significant omission. An alert was placed on child H’s Electronic Patient Record (EPR), and ‘case notes’ (an older electronic system being phased out, but still in use) stating the child was subject to a child protection plan for neglect. The EPR however, was not used in children’s outpatient notes, so the absence of transfer of written information within them was a significant factor leading to the paediatrician’s erroneous analysis of non-attendance as ‘low risk’. One of the doctors at interview said that if he had known child H was subject to a protection plan, he would have ‘looked at the DNA in a different light’. 5.3.39 GP records show very little evidence of contact with GP services for child H although the child was seen for the appropriate developmental checks and the records show good documentation of this by HV1. In theory, any concerns would have been raised at the weekly Primary Healthcare Team meeting or by direct contact with GPs. No concerns were raised by GPs. When child H was not presented for routine childhood appointments at the GP Practice, this was followed up appropriately by HV1 and the child subsequently received the routine immunisations. 5.3.40 There is good evidence in the GP records that when mother’s pregnancy was confirmed she was referred for appropriate ante-natal tests (blood testing and scan). As mother was known to be having prescriptions of methadone and had previously had multiple blood clots in the lungs with possible inflammation of the inner lining of the heart, she was appropriately referred to secondary care for obstetric services. There is evidence of comprehensive history taking (physical and social), awareness of her having her first child taken into care and that her then current relationship was documented as ‘not a stable relationship but will support the baby’. 5.3.41 GP records confirm that when child H was 5 days old a child protection plan was in place. There is no mention in the records of GP involvement at this stage and it seems likely that GPs would presume that the mother and baby would be under regular review by the social worker and midwife and subsequently health visitor. 48 5.3.42 There is evidence that a discussion took place between HV1 and a consultant paediatrician about the importance of attendance for hepatitis C screening. Because HV1 was in direct contact with mother and child, it seems to have been presumed by GPs this was being followed up by her. The GP IMR author refers to ‘clear entries in the GP records of encounters with the health visitor and Harm Minimisation Team’. No evidence has been provided of a recorded discussion between health visitor and GP on this or other aspects of the health care of child H and his mother. 5.3.43 In addition to weekly Primary Healthcare team meetings the Practice holds a quarterly meeting with GPs and health visitors at which all ‘at risk’ patients (those subject of a child protection plan or where domestic violence has taken place) are reviewed. This helpful potential opportunity for debate about child H was not taken. Hospital & GP recording & analysis 5.3.44 There is good evidence of appropriately recorded medical documentation throughout GP records of the consultations. This conforms to the requirements of the General Medical Council (GMC’s) ‘Good Medical Practice’ 2013. Although methadone was being prescribed by the GPs leading up to the methadone overdose, responsibility for reviews was with DW5 from the Harm Minimisation Service. 5.3.45 There was no evidence that information about non-attendance had been passed directly on to the GPs but after discussion with the Practice it is clear that there were ‘conversations’. Best practice requires that such conversations or the actions from them should be recorded in medical records. Any ‘missed opportunities’? 5.3.46 It is arguable that seeking a legal order at the point of the FGC might have helped to safeguard child H. The assessment at the time however, was that mother could adequately care for child H in the community. Tunnard (2002) notes that a number of research studies have found the support from family and friends networks to be crucial with drug using parents, providing closer monitoring and practical support than professionals can. There is evidence that the maternal grandmother was involved in helping to assess risks at various points, though as time went on, contact with her reduced. Maintaining contact with this individual and providing her with some support would have helped to build a more accurate picture of risk. 5.3.47 Following the ending of child protection planning mother’s mis-use of valium did prompt further involvement. The incident was viewed as a ‘blip’, but could have resulted in a further s.47 enquiry. It is clear that the social work team was under significant pressures at this point, and while staff assured child H’s immediate safety there was a propensity to look for positive signs rather than question whether mother was covering up a more significant return to drug use. 5.3.48 The lack of recording following case closure is a significant issue that has been referred to the worker’s manager. In interviews the manager was clear that she would anyway have maintained the decision to close the case (following allegations that mother and child were seen at a drug users house), however the social worker’s actions were undertaken with no management oversight or awareness of the case. 49 5.3.49 With respect to the hospital, there were no missed opportunities antenatally. Post-natally, an opportunity to take action and share information with Children’s Social Care was missed when child H was not brought to outpatient appointments because: There was no record that child H was subject of a child protection plan for neglect A narrow medical approach was taken with insufficient thought given to wider social issues underpinning non-attendance 5.3.50 Some of these missed appointments were at a time when child H was no longer subject to a child protection or child in need plan. Knowledge of the failure to present child H might have prompted Children’s Social Care to respond differently. It is unlikely it would have led to the case remaining open. Children of substance abusing families should though be regarded as ‘increased risk’ no matter how trivial the medical problem itself may be. Plans emerging from the conferences in April and September 2012 were found in GP records but it is unclear which GP was taking responsibility. GPs took no proactive steps in consequence of the plans. 5.4 POLICIES & PROCEDURES What local single agency and inter-agency procedures (safeguarding and general practice) and professional practice standards were in place? Were they followed and were they effective? Supervision 5.4.1 The SCR has identified a number of examples (outlined below) where the internal or inter-agency procedures or professional practice could be improved. HEALTH VISITING & HARM MINIMISATION SERVICES 5.4.2 The Trust’s IMR confirms that the health visiting service had in place adequate policies and procedures. The position of the specialist addiction service was rendered more complex by Oxford Health NHS Foundation Trust, replacing in 2011 service provider SCAS with the Harm Minimisation Service. No new policies of relevance to this case have been developed since then. The most relevant operational policy was one developed by the SCAS (dated 2011) which does not cover the entire review period. 5.4.3 A ‘care plan’ was used by all drugs nurses. The expectation was that it should have been reviewed at 12 week intervals but there is no evidence this was achieved. Each drugs nurse developed her/his own approach to its management. All these staff were aware that a ‘medicines management policy’ 2012 existed. The practitioners were guided by the National Treatment Agency (now Public Health England) and the Department of Health, Drug Misuse and Dependence, UK guidelines on Clinical Management 2007. 5.4.4 There was no evidence that sufficient ‘joined up’ working was achieved at the GP Practice. There was no evidence that any audits had been undertaken within SCAS or the Harm Minimisation Service (aside from the existence of an audit undertaken by the Public Health Drug and Alcohol Team) during the review period. 50 5.4.5 The Healthy Child Programme (HCP) highlights the importance of ante-natal contact by the health visitor. Oxfordshire HCP Framework for ante-natal contact indicates that the midwife remains responsible for the care of mother and infant until discharge post-delivery. However, health visitors should be notified of all ante-natal women via the 12 week ‘midwifery health and social assessment’ process which should generate a form to be sent to the health visiting team. Health visitors are then to review the information, identify the level of service / support required and liaise with other professionals as required. 5.4.6 Those clients identified as requiring additional or progressive intervention will be offered a face to face contact with a member of the health visiting team during the last 2 months of pregnancy. This should allow a more detailed assessment of vulnerability and promote early identification of additional risks. In reality, communication between midwives and health visitors was variable across Oxfordshire during the period of this review. HV1 reported that health and social care forms were not received and meetings with midwives were opportunistic. 5.4.7 The ‘Healthy Child Programme’ offers every family a programme of screening tests, immunisations and developmental reviews, along with information guidance and support with parenting. HV1 ensured that these aspects of the government’s programme were offered to this family. She was persistent in her approach to missed appointments and managed to see child H on her 4th attempt for the 6-12 month health assessment. She also followed up on all immunisations and made every attempt to encourage attendance for the hepatitis C screen. 5.4.8 Universal services use the RIO data input system as the main record keeping tool. In addition, complex cases had a paper file in which there was a front sheet detailing significant details of family composition and key professionals, a summary sheet of key events and an individual health action plan for the child. There was evidence that HV1 accurately recorded all contacts and failed contacts with mother plus all relevant professionals in a timely manner. Use of the complex paper record complied with documentation guidelines apart from the lack of a health action plan for child H. HV1 has stated that this was because the child had no identified health needs. The failure to indicate ‘no health needs identified’ on a plan suggests a lack of assessment. The absence of structured approach to writing up consultations resulted in a difficulty defining the visit objectives, assessment and consequent plan. 5.4.9 Oxford Health NHS Foundation Trust non-engagement guidelines acknowledge that ‘disengagement with health services by parents and carers can be partial, selective, intermittent and persistent in nature. It may signal an increase of stress within a family and potential abuse or neglect of children. Practitioners must take account of each child’s circumstances and the possible implications of failure to receive appropriate services. All staff must assess the risk to any children when a family disengage from health services and if there are safeguarding concerns, should discuss them with relevant colleagues, line manager or the safeguarding team’. 51 Child Protection & Safeguarding Children Policy October 2011 5.4.10 Oxford Health NHS Foundation Trust has recognised its statutory duty under s.11 Children Act 2004 to work in partnership to keep children safe and ensure the agency’s functions are discharged with regard to the need to safeguard and promote the welfare of children. The most relevant aspects of this policy are: Training: identification of vulnerability / assessment / analysis Contribution to child protection planning Supervision Escalation 5.4.11 All staff reported being up to date with the mandatory triennial child protection training, which is monitored and reported upon within the Trust. Attendance at initial, pre-birth and review child protection conferences as well as child in need conferences should be prioritised by health visitors for unborn babies and children under 5 years of age. HV1 did (commendably) attend all such conferences and the core groups that were convened after child H was made subject of a protection plan. 5.4.12 Though invited, neither DW1, DW2, DW3 nor DW5 attended any child protection conference. DW3 attended 1 of the 3 core groups. Policy requires that a report should be submitted by the health professional to the independent chairperson in advance of the conference and a copy be retained within the child’s or parent / carers records. No comprehensive report was prepared and submitted by the health visitor or any drugs worker. This insufficiency of commitment to the child protection process impacted on the quality of assessment and subsequent planning. Supervision 5.4.13 The Trust’s ‘safeguarding children team’ offers child protection advice, support and supervision to all staff and aims to balance support and professional challenge which supplements clinical supervision. All clinical staff working directly with children should access supervision commensurate with their role. HV1 was a regular attender at group child protection supervision. However this particular case was (understandably) never discussed due to there being cases of greater concern. 5.4.14 The Harm Minimisation Service has been receiving supervision from the ‘safeguarding children team’ since December 2012. DW5’s attendance at supervision was verified, however there is no record of DW3’s attendance. DW5 was very positive about the quality of supervision given by the ‘named nurse’. Escalation (within child protection & safeguarding policy) 5.4.15 Staff should try and resolve disagreements at practice level. If they remain unresolved staff should contact the Trust’s ‘safeguarding children team’ for advice and support. DW5 objected to the proposed case closure in January 2013 but did not escalate or seek advice in order to do so. 52 THAMES VALLEY POLICE Referral of concerns to Children’s Social Care 5.4.16 The Police IMR very usefully explored what appears to be the simple term ‘referral’ –the passing of information from Police to Children’s Social Care if an officer forms the view a child may be suffering or be at risk of suffering significant harm. The IMR author comprehensively explored which staff within the Service are best positioned and how such referrals might be made with respect to incidents within the home or relating to a parent detained in a custody suite. Recommendations about required system changes are provided in section 7. Processing of Intelligence reports 5.4.17 A large number of Intelligence reports about mother were submitted to Police. They suggested she regularly shoplifted and committed other thefts alongside active involvement in drug supply, so as to fund her addiction to crack cocaine. Apart from a single (unconfirmed) report of February 2013, there is no record of any of those intelligence reports being shared with Children’s Social Care. Recommendations for more effective information-sharing are included in section 7. Visibility of child H on Police systems 5.4.18 A related procedural issue is how information about those subject to child protection plans is recorded by Police. The fact is only recorded on 2 generally accessible databases. In consequence, without conducting a significant amount of research, an officer can easily miss this vital information. Interviews with relevant staff confirmed this to be a real rather than a theoretical issue. Recommendations for system improvement are included in section 7. Police provision of information to / representation at child protection conferences 5.4.19 A further issue of policy / procedure was identified during the course of the SCR. Thames Valley Police had been invited to all conferences and although not present at any, had on each occasion supplied a report ahead of the meeting. Established policy / procedure is that following receipt of an invitation to a conference a ‘case conference writer’ (a civilian role within the Service), having completed checks against systems and databases, drafts a report containing all relevant information. This is sent to a detective sergeant from the Child Abuse Investigation Unit (CAIU) who make a decision about attendance at, and/or provision of a report to conference. In this case, no information from recent reports was included lest it be inappropriately shared with mother or others. It was also thought that Children’s Social Care was anyway aware of mother’s drug use the information would add nothing to a risk assessment. Such assumptions were mistaken. 5.4.20 The IMR author points out that whilst the current version of the statutory ‘Working Together To Safeguard Children’ lacks detail, its 2010 predecessor (still widely regarded as reflecting best practise) indicates that ‘those attending conferences should be there because they have a significant contribution to make, arising from professional expertise, knowledge of the child or family or both.’ 53 5.4.21 Established practice in Oxfordshire has been that officers would only attend if there was current Police involvement with the child / family or the case was complex. At the time of the initial and review conferences for child H, none of the investigations involving mother were ‘ongoing’. Neither could her recorded history be described as complex. Thus, whilst the decision not to send a representative was consistent with policy, it did deny those at the conferences a more complete appreciation of the lifestyle mother was leading, the centrality or drug usage and dealing and the inevitable risks this posed her child. 5.4.22 A preferable policy would be one that that is closer to the criteria included in the 2010 Working Together to Safeguard Children. A recommendation to that effect is included in section 7. PROBATION 5.4.23 Thames Valley Probation staff are expected to work in a manner consistent with the Trust’s ‘Policy and Practitioner Guidance on Safeguarding Children, National Standards for the Supervision and Assessment of Offenders, including Enforcement Policy and Working Together to Safeguard Children 2010 (now 2013 edition). 5.4.24 Policies were followed. The supervision of mother was allocated to the appropriate level of qualified staff, and there is evidence of management oversight in this process. The supervising officers attended conferences when possible, and submitted written contributions if unable to attend. Mother was visited at home on a number of occasions. CHILDREN’S SOCIAL CARE 5.4.25 There are pre-birth assessment procedures (Oxfordshire Safeguarding Children Board Procedures section 3.1) that the hospital social work team followed. In light of the evidence emerging, there is a need to review the appropriateness of waiting to start risk assessments for cases where significant drug mis-use is known and when a mother has already been through Care Proceedings. In addition, the practice of delaying strategy discussions for unborn babies needs to be reviewed. 5.4.26 The Oxfordshire Safeguarding Children Board has on-line publication of procedures relating to child protection conferences and thresholds of need. At the time of Children’s Social Care involvement these would have complied with Working Together to Safeguard Children 2010. Within these procedures is a section relating to drug mis-using parents (section 3.12) and it outlines issues to be considered. Observations of child H re-assured professionals that the potential risk factors listed were not impacting upon the child’s development or care. It is notable that for as long as there was increased scrutiny e.g. child protection plan and the Community Order, the above factors were mitigated or not present. 54 OXFORD UNIVERSITY HOSPITALS NHS TRUST 5.4.27 The IMR provided by the Hospital Trust identified a comprehensive range of relevant policies. ‘Maternity pathways’ were potentially effective enough to ensure that mother’s needs were identified and appropriate support put in place. The hepatitis B policy was effective and child H received appropriate vaccinations prior to and after discharge. The hepatitis C policy was effective insofar as child H was flagged as in need of follow-up. The ‘Procedure for Ensuring Children and Young People’s Access to Health Care is Safeguarded’ (did not attend / was not brought) was not strictly followed, though some actions recommended in it were complied with. There was good communication with health colleagues though not with Children’s Social Care. Child H was perceived as being ‘low risk’ (medically) and there was a lack of clarity amongst medical staff about the policy. 5.4.28 Because child H was eventually brought to clinic at a time when still medically relevant, actions could still be described as effective in terms of ensuring access to health care. There was though, a very long time lag and the lack of response to letters to GPs containing direct questions about safeguarding is concerning. GP SERVICE 5.4.29 Oxfordshire Safeguarding Children Board has encouraged the system of ‘Practice leads’ for child protection in Primary Care. The relevant Practice has a nominated doctor with whom concerns should be raised. If a GP has specific urgent concerns these may also be discussed with the ‘named nurse’ or directly with Children’s Social Care. None of those options was employed. All GPs have to undertake child protection training for ‘continuing professional development’ (CPD) purpose and provide evidence for re-validation. GPs are also bound by General Medical Council (GMC) rules cited above. There was no inadequacy of policy or procedure. 5.5 CO-OPERATION & ENGAGEMENT OF SERVICES WITH PARENTS & CHILD How did professionals understand child H’s behaviour, wishes and feelings and support the child? How well did professionals engage with the family? Was father’s potential impact included and assessed and responded to appropriately? Were the wider family members included and assessed? 5.5.1 Child H was assessed by HV1 as developing normally and mother-child interactions noted to be loving and sensitive. Mother reported she had visited her child’s father twice though the relationship had been casual with no plan for its resumption. 5.5.2 Recorded evidence refers only to child H’s behaviour as being settled and age appropriate. DW1, DW2 and DW3 established reasonable relationships with mother. Records include very few references to child H’s behaviour unless it related to the needs of mother e.g. a discussion by DW3 of the positive impact of child H’s improved sleeping pattern on mother. There is little evidence that professionals discussed how mother felt about the loss of her first child or her level of anxiety about losing child H. At the author’s meeting with mother, she indicated that fear was of central relevance to the (often deceptive) way in which she related to agencies. 55 5.5.3 Mother was generally described as passive, quiet, unchallenging and welcoming of opportunistic visits. She apparently listened attentively to advice and was supported by her family. One IMR author neatly encapsulated these observations by suggesting that because of mother and child’s unremarkable presentation (and greater demand from many other service users) professionals were ‘under-whelmed’. 5.5.4 HV1 attended the family group conference (FGC) in 2011 and was therefore aware of the support that had been agreed. She had little knowledge of the family’s background, apart from the fact that parents were separated and mother’s first son was resident with extended family. Mother informed HV1 in the post-natal period that she saw her mother every week (she confirmed to the author that she saw / sees little of her father. There is no record of the health visitor service engaging with family members or exploring their relationships with one another. 5.5.5 The maternal grandmother of child H attended occasional addiction appointments with her daughter. DW5 spoke of her presenting as a typical mother of a long term drug-abuser i.e. worn down, wanting to be optimistic but with a suspicion that all was not well. Exploring these fears might have highlighted or exposed additional risk. 5.5.6 Very little was recorded about the father of child H. Mother’s stated intention was to be single. There was awareness that he had been abusive in a previous relationship and HV1 had discussed mother’s need to stay safe if meeting him. No health care professionals reported or recalled having contact with wider family members. 5.5.7 Police had very little contact with child H. The child was only seen by Police once following a ‘fear for welfare’ incident following threats to harm mother. On this occasion the toddler was spoken to briefly and assessed as being happy and content. Police did not engage with mother beyond (appropriately) completing required processes (arrest, interview, charge) to further crime investigations. No Police records or interactions with mother / child H suggested they had contact with the child’s father. Checks were completed and included details of previous and impending convictions. Thames Valley Police did not have any reason to contact wider family members in any of the interactions with mother or child. 5.5.8 Observations by Probation staff indicated child H was in a clean and tidy home, and well cared for. Staff were reassured by health visitor and social workers that the child’s development was normal. Probation had no contact with the wider family since historic contact several years earlier at the point of mother’s release from her prison sentence. Information about the father of child H and mother’s wider family came via input to professional meetings from other agencies and from mother. 5.5.9 Child H was a pre-verbal infant throughout the period of review and professionals relied upon their observations. In addition to observing a positive bond with mother information provided by the health visitor presented a picture of a child being well cared for. As a ‘first time mother’ issues such as the time a child should be in a ‘baby walker’ or ‘prop feeding’, were seen to be about maternal learning not neglect. 5.5.10 After the move to the current address, the household was seen to be in good order and child H was clean and presented well. This may have served to reinforce the notion that mother’s problems had been more external than internal. 56 5.5.11 Social workers within the hospital and Family Support team appear to have made good efforts to engage with mother prior to the birth of child H and subsequently. Mother challenged the hospital social worker for insisting on developing her support network, but there continued to be a good working relationship. Throughout the initial assessment and during child protection planning there was a good balance of support and challenge to mother. 5.5.12 Mother was clear at the outset that she did not want the father to be contacted and cited a concern that he would want to take her child from her. Mother appears to have maintained some contact with him after knowing about allegations of domestic abuse and both parents sought to hide the details of the amount of contact that they had with one another. Risks from father were recognised, but after initial efforts to include him in his child’s life, his lack of support and motivation to help enabled him to disappear from professionals’ focus. Following cessation of child protection planning there was far less contact with the maternal grandmother of child H, although she continued to be seen as a significant support for mother and child. 5.5.13 During the pregnancy, there was an effective relationship with mother and good continuity of care with evidence that the midwife worked hard to ensure that mother remained engaged. Child H’s father did not attend hospital at any stage, so there was no opportunity to engage with him. 5.5.14 With respect to missed appointments, relevant letters to the GP were copied to mother and fresh appointments sent to her, and one of the doctors did try, unsuccessfully, to telephone her. Attempts to engage her were mainly via the health visitor – a common and generally successful strategy used by hospital staff to engage families. Information received back from the health visitor, whilst not specifically mentioning the child protection plan, indicated she knew the family well. 5.5.15 There are only two brief mentions of a partner in mother’s notes (it is even unclear if the partner she is referring to was child H’s father). There is no mention in mother’s maternity notes, nor child H’s medical notes of any member of the wider family. 5.5.16 Due to the infrequency and short time spent in GP consultations it is difficult to say from the records whether behaviour, wishes and feelings were understood. There was an entry in the GP records from the midwife at the start of the pregnancy which stated that the father’s relationship with mother was not stable. GP involvement in a patient’s wider family is only likely in cases where specific concerns have been raised or if noted at the time of a GP consultation. In consequence of the vulnerability of child H, the health visitor was closely involved with the family and one would expect there to have been regular discussions between the health visitor and a GP. No documentary evidence of any such discussion was found in either GP or health visitor records. 57 5.6 ADDITIONAL ISSUES FOR THE REVIEW 5.6.1 The extensive terms of reference required that in addition to the above key issues the SCR should: Establish whether practitioners were sensitive to the cultural needs of the child and the family in their work, and their needs were taken into consideration Make recommendations for local, regional or national multi- agency practice Identify commendable good practice as well as learning Provide a multi-agency overview report in accordance with ‘Working Together 2013’ guidance including a clear multi-agency action plan that addresses any areas highlighted for change or improvement Include an executive summary Put in place a process for publication and ensure that findings are communicated to ensure public confidence in the safeguarding arrangements for children / young people in Oxfordshire Establish a clear action plan for individual agency implementation and disseminating learning Put in place a process for monitoring the implementation of the individual and multi-agency actions identified Scrutinise the commissioning arrangements for health services 5.6.2 The first of the above additional issues is addressed below. The remaining elements of the list above are considered to have been addressed elsewhere in this report and the measures now in place to implement those changes that have been recommended and agreed by respective agencies and/or the LSCB. SENSITIVITY TO THE CULTURAL NEEDS OF THE CHILD & FAMILY & THEIR NEEDS TAKEN INTO CONSIDERATION: ALL AGENCIES 5.6.3 Child H is of dual heritage but was too young during the period under review to directly experience any of the prejudice that can be experienced by such children in predominantly White areas. 5.6.4 Agencies showed a considerable sensitivity to the needs that existed in consequence of mother’s apparent inability to organise her life e.g. Probation made more home visits than officers would normally do and HV1 went out of her way to enable mother to present her child at health-related appointments. 5.6.5 With hindsight, some examples of sensitivity toward mother e.g. accepting her reluctance to take up Home Start and accepting at face value that she was involved with family and (non-drug using) friends may have cost child H some opportunities. 58 6 CONCLUSIONS & LESSONS LEARNT 6.1 CONCLUSIONS PREDICTABILITY & PREVENTABLITY 6.1.1 Given the priority mother awarded drugs (usage and dealing) coupled with the growing demands of a healthy toddler, crises of one sort or another were likely. 6.1.2 In spite of a good deal of information exchange across agencies Children’s Social Care had not been able to develop a complete picture of child H’s day to day experiences (a significant proportion of what was known or suspected by Police was not made available), nor what risk they implied. On the basis of the partial picture understood by each agency, actions (including case closure by Children’s Social Care) fell within the range that can be described as ‘rational and reasonable’. 6.1.3 Hence, though accidents such as ingestion of methadone was to some very limited extent ‘predictable’, it cannot reasonably be claimed to have been ‘preventable’ by decisions or actions available to the professionals working with the family. 6.1.4 Even if the all the potentially available evidence had been aggregated it is unlikely that a court would have concluded that a Care or Supervision Order was justified. STRATEGIC CONTEXT 6.1.5 Professionals in England are obliged to work within a framework of legislation and policies that indicates an ambivalence toward those who are substance-dependent and (often) using additional illicit drugs. A proportion of those who combine Opiate Substitution Therapy (OST) with parenting may do so well enough; a further significant proportion do not, sometimes with fatal results. 6.1.6 Medication in Drug Treatment: Managing the Risks to Children7 examines cases where children have died or come to harm from ingesting OST medicines prescribed to help people overcome drug addiction. It cites 17 serious case reviews involving ingestion of OST drugs by children plus potentially more incidents that did not reach that level of inquiry. 6.1.7 In recent years, there has been an acceptance that those who wish can opt for ‘harm minimisation’ i.e. to continue to be provided prescribed substitute drugs such as methadone. The SCR panel was informed and welcomed the advice that national policy is moving toward a position whereby OST clients will all be encouraged toward cessation of use of prescribed and illicit drugs i.e. the goal will be abstinence not maintenance. 7 Medication in Drug Treatment: Managing the Risks to Children a research report published by ADFAM in 2014 59 NORMALISATION OF ABERRANT BEHAVIOURS 6.1.8 In this case, the network came to regard mother’s drug-dependent lifestyle as normal and her manipulative (often dishonest) behaviour as simply a lack of organisation. Clearly, the misuse of drugs was mother’s paramount priority e.g. she never missed a ‘pick-up’ of methadone whilst persistently failing to present her baby / toddler to health-related and other appointments that were in child H’s best interests. 6.1.9 The evidence was that mother was not motivated to adjust her lifestyle and examples of dishonesty came to be accepted without challenge, in part because of what has been termed professional optimism e.g. a good deal of self-reported information was accepted as fact and not corroborated. INWARD FOCUS 6.1.10 There was a widespread tendency to focus narrowly on a particular or central role of each agency so that it would appear: From the absence of documentation, that GPs initiated little liaison with the drugs workers (specialist nurses) and virtually none with the involved health visitor Police officers responded frequently to mother’s ongoing criminal behaviours with insufficient thought about the growing significance of mother involving her toddler in the commission of her crimes The health visitor (who otherwise initiated and maintained a commendable level of effective liaison with Children’s Social Care and Harm Minimisation Service) made an artificial and unjustified distinction between the risks to child H arising from everyday items / issues and from the presence of dangerous prescribed (and other illicit) drugs The Specialist Community Addiction Service (SCAS) and later Harm Minimisation Service did not provide a representative to either the pre-birth or review child protection conferences DAY TO DAY EXPERIENCE OF CHILD H 6.1.11 No professional could have described with any level of accuracy or confidence how a typical day might be experienced by child H. 6.1.12 Retrospective examination of agency records suggest that the life of child H was probably fairly limited and involved accompanying mother to methadone collection, screening visits and shop-lifting outings. 6.1.13 The social opportunities that mother claimed to have been introducing her child to e.g. visits to Children’s Centres seem to have been predominantly fabricated. 60 TECHNICAL OBSTACLES TO RECOGNITION OF RISK 6.1.14 In addition to strategic and systemic weaknesses, some technical obstacles have been highlighted in the course of this serious case review e.g the: Fact that a child is subject to a child protection plan is not sufficiently visible on Thames Valley Police databases and systems Apparent absence of shared records of all core groups further undermining a shared understanding and approach across agencies to ensuring the safety and well-being of child H WEAKNESSES IN PRACTICE & COMMUNICATION 6.1.15 Beyond oversight of prescribing, GPs were essentially passive and failed to respond to written requests from the infectious diseases clinic. There was no evidence that child H was discussed at quarterly meetings as suggested in the IMR supplied. Poor recording of claimed exchanges between DWs and GPs has been found. Nor was there clarity about which GP was taking the lead role for child H and the child protection plan. 6.1.16 When information was exchanged, its receipt failed to sufficiently inform respective agencies’ assessments and planning i.e. facts were exchanged but their meaning not jointly explored and agreed. Nor, was any corroboration found in medical notes of any HV / GP debate about wider family issues. LESSONS LEARNT 6.1.17 When professionals are working with substance-dependent service-users, they need to guard against undue optimism and against any assumptions that can serve to add to the level of risk being experienced by a child, e.g.: The assumptions at investigating police officer / custody sergeant levels that GPs / Health Services would take any required action to safeguard the unborn, later child H GPs’ assumptions that health visitors would initiate action on behalf of the Practice including chasing hepatitis C screening The health visitor’s assumption that her role was to look forward not back (and avoid any discussion about drugs) The Police conference writer’s view that Children’s Social Care already knew about the drug misuse and did not need further briefing An assumption within the very attentive paediatric infectious diseases clinic that an absence of response from GPs to the question of ‘safeguarding concerns?’ meant there were none The assumption by GPs and drugs workers that the other would initiate a conversation if need be An assumption within Children’s Social Care and Harm Minimisation that mother was (as she claimed) socialising and providing child H with time with other non-drug using families (it is likely that a considerable proportion of time, whilst with child H, was committed to acquisitive drug-related crime) 61 6.2 IMPROVEMENTS ALREADY INTRODUCED 6.2.1 To reduce an otherwise excessively lengthy and unmanageable list of recommendations, the following improvements to service design and delivery have (in response to this case) already been put in place: Thames Valley Police policy is now clear that an unborn child is to be treated as a child and details entered on its ‘Crime Evaluation and Data Analysis Recording (CEDAR) database – this position has been promoted with frontline staff in the ‘Domestic Abuse Master Class’ training delivered between November 2012 and February 2014 and shown in an audit completed by the PVP Strategy Unit to have achieved a high level of compliance Guidance and training on safeguarding and the role and expectations of police community support officers (PCSOs) has already been, or is currently being rolled out Midwifery safeguarding training now includes reminders on the importance of prompt, accurate transfer of information from maternal to baby notes; and of clear communication of discharge plans to community midwives in the case of babies with social concerns Since the beginning of January 2014, if a woman misses a hospital maternity appointment, a note is made in her ‘electronic patient record’ (EPR) record of who has been contacted which should encourage positive action and more effective information sharing in future Children’s Social Care has already introduced mandatory ‘toolkits’ (covering neglect and substance misuse) and is currently undertaking work to clarify expectations of ‘team around a child’ arrangements Children’s Social Care now routinely monitor and report attendance rates of partner agencies at child protection conferences and core groups An ‘ante-natal pathway’ now stipulates that ante-natal visiting following communication with the midwife is part of the health visitors’ core work The Harm Minimisation Service is improving its service provision through a robust system of audit of clinical practice to provide an up to date picture of the quality of practice and identify trends or issues regarding joint working There has been audit work undertaken by Public Health Drug & Alcohol Team and an action plan is in place led by a team manager with support from the ‘safeguarding children’ team to address safeguarding responsibilities including child protection conference attendance and core group working Health Visiting Services are currently considering the need to maintain a continued support period for children and families following formal removal from s.17 Children Act 1989 support i.e. children could receive a ‘universal plus service’ until a robust assessment has confirmed all known concerns are resolved 6.2.2 At a national level, the introduction of an inspection framework for GP Practices should serve to highlight insufficiently clear arrangements in the commissioning or delivery of ‘shared care’ arrangements. 62 7 RECOMMENDATIONS 7.1 INTRODUCTION 7.1.1 Of the recommendations below, the first 3 for the LSCB were generated by the overview author and panel. The rest were identified by IMR authors. When effectively implemented in accordance with detailed ‘action plans’ accompanying this report, they should further strengthen local safeguarding arrangements for children. 7.2 RESPONSIBILITY FOR IMPLEMENTATION Oxfordshire Safeguarding Children Board 1. The independent chair of the Board should propose to Children’s Social Care that a well-informed and sensitively worded letter is drafted and retained in records so that when child H is of sufficient age to do so, s/he can establish why, when and how alternative care became necessary and that a serious case was completed 2. The Board should recommend that pharmacists in the County be reminded of the expectation that Children’s Social Care or Police should be informed if they are concerned a drug dependent person might pose a risk to their own or another child 3. The Board should recommend that the Commissioners of GP Services and Public Health Commissioners review their monitoring processes to ensure collaborative management of contracted services provided in General Practice in particular drug and alcohol services. Oxfordshire NHS Foundation Trust Health Visiting Service 4. Review training needs of health visitors in relation to parental substance misuse and its impact upon parenting 5. Raise awareness (by means of amended guidance, and audits of compliance) of the need to include the safe storage of methadone in discussions about accident prevention 6. Continue to promote the use of assessment tools, neglect tool kit and the threshold matrix to inform risk assessment and robust care planning 7. Review joint working between health visiting and Harm Minimisation Service with respect to substance misusing parents to ensure risks are fully assessed and robustly managed Harm Minimisation Service 8. The service should review arrangements for attendance at child protection conferences and core groups so as to ensure compliance with Oxfordshire Safeguarding Children Board and Trust policies 9. Review and ensure that all documentation is standardised and subject to regular audit and review 10. Ensure that comprehensive risk assessments including client’s history are undertaken and recorded 11. Ensure within all shared care arrangements (addiction services) regular joint reviews and assessments are completed with the responsible GP 63 Thames Valley Police (TVP) 12. TVP should lead a scoping exercise into the viability of making routine referrals to Children’s Social Care about parent / carers presenting with substance misuse 13. TVP should effectively communicate to staff the importance of thorough research into parents, children and unborn children (to provide a full picture) and to then consider the effect of any drug or alcohol misuse identified on parenting ability. If there are concerns a ‘child protection – non crime incident’ should be created for referral to PVP Referral Centre. 14. TVP should liaise with the Police National Computer to assess the viability of flagging the children (to include unborn children) and the parents of children subject to child protection plans; consideration also to be given to what other databases within Thames Valley Police (NICHE) could be flagged to increase awareness of the existence of Child Protection Plans. 15. TVP should run a pilot in Oxfordshire whereby the Neighbourhood Policing Teams are made aware when children in their area become subject to child protection plans 16. TVP should effectively communicate to relevant staff that it is the responsibility of an officer identifying safeguarding concerns to create a ‘child protection – non crime incident’ and not assume that: it will be created by someone else; or other agencies already know the information 17. TVP should ensure custody sergeants are aware that any safeguarding concerns identified in custody are communicated to the investigating officer and they are instructed to create a ‘child protection – non crime incident’; the custody sergeant is responsible for ensuring this happens and the reference number is placed in the custody record 18. TVP should create guidance for ‘case conference writers’ about sharing intelligence information in child protection conference reports; this guidance is to be effectively disseminated to the writers to promote confident and effective information sharing in this area 19. TVP should draft and provide guidance for source managements officers in relation to child safeguarding information and how to deal with it 20. TVP, in consultation with Children’s Social Care and other relevant agencies should expedite completion of its current review of policy across the three counties with the intention of ensuring a physical presence at child protection conferences based upon the criterion of need rather than previous or current level of agency involvement Thames Valley Probation Service 21. The Probation Service should confirm (and initiate any further actions required) that all staff working with substance misusing parents have attended specialist training on the particular risks posed to children (including unborn) by those individuals Oxfordshire Clinical Commissioning Group 22. The learning from this and other SCRs should be shared with the GP practice that provided a service to mother and with other practices across the County; summaries should be circulated in locality newsletters and briefings undertaken within the locality; training events should include a section on SCR learning 23. The safeguarding lead in each GP Practice needs to be supported so that they can ensure the Practice is meetings expectations of safeguarding child patients 24. A safeguarding information resource hosted by Oxfordshire CCG should be established on the GP intranet and used to update practice guidance and procedures 25. The documentation process in the involved GP Practice should be reviewed and best practice guidelines developed so as to ensure accurate and timely information sharing across the Practice and with multi-agency professionals 64 26. When invited to child protection conferences, GPs should ensure that they provide direct feedback to the conference chairperson about their involvement or ensure representation by active agreement with others in the primary care team Children’s Social Care 27. Pre-birth assessment practice procedures should be reviewed and amended to ensure that assessments start at latest by 28 weeks of gestation where previous Care Proceedings 28. Pre-birth conferences should be held at least 1 month before the child’s estimated date of delivery 29. Training and guidance in relation to working with drug mis-using parents should be developed and highlight the importance of maintaining a close working relationship with wider family and friends to assist with ongoing risk assessments 30. When a professional provides information on a closed case a decision as to whether to respond to it as a ‘contact’ or new ‘referral’ should be made within 24 hours by a team manager and confirmed with the professional providing the information Oxford University Hospital NHS Trust 31. A policy for actions to be taken, including who should be informed, in the event of cancellation or non-attendance at routine antenatal appointments (including scan appointments) should be developed 32. Mechanisms for transferring information from maternal to baby notes about medical or social issues relevant to baby need to be made more secure 33. Midwifery safeguarding training should include reminders of the importance of prompt, accurate transfer of information from maternal to baby notes and of clear communication of discharge plans to community midwives in babies with social concerns 34. The children’s did not attend (DNA) policy should be re-written to reflect the fact that children of parents about whom there are concerns relating to substance misuse, domestic violence or mental health, or those already subject of child protection plans should automatically regarded as high risk if they are not presented at appointments 35. All paediatricians should be notified of the re-written policy and the flowchart that summarises it laminated and displayed at each outpatients clinic; the importance of careful assessments of ‘DNAs’ should be highlighted in training 36. The neonatal referral form to the paediatric infectious disease clinic should be amended to highlight in relevant cases, the fact that if a baby is the infant of an intravenous drug user; a system of flagging such babies on the clinic list should be developed Overview child H Oxfordshire FINAL 09.09.14 65 8 GLOSSARY OF ABBREVIATIONS Agency / Abbreviation Meaning AIT Area Intelligence Team CAFCASS Court and Family Advisory and Support Service CAIU Police Child Abuse Investigation Unit CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group CCTV Closed circuit television CEDAR Crime Evaluation & Data Analysis database CHC Child Health Clinic CSC Children’s Social Care CPD Continuing professional development DRR Drug Rehabilitation Requirement EDT Emergency Duty Team (an out of office hours service provided by Children’s Social Care) HCP Healthy Child Programme IA Initial Assessment IOM Integrated Offender Management IMR Individual management review IVDU Intravenous drug user LASAR Local Single Agency Assessment & Referral Service LDU Local Delivery Unit (of Probation Service) MIU Minor Injuries Unit OASIS Open Access Social Inclusion Support OST Opiate substitute therapy PCHR Personal Child Health Record PNC Police National Computer (history of previous convictions) PCSO Police Community Support Officer PVPU Protecting Vulnerable People Unit SCAS Specialist Community Addiction Service TAC Team Around the Child TVPT Thames Valley Probation Trust Roles Meaning DW Drugs worker (specialist nurses) GP General practitioner HV Health visitor PO Probation officer SW Social worker TM Team manager (in Children’s Social Care) 66 9 BIBLIOGRAPHY General Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008 Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1April 2007 to 31 March 2008 Published December 2008 The Child’s World Jan Horwarth Jessica Kingsley 2008 Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE Healthy Child Programme DH 2009 A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009 Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009 Working Together to Safeguard Children, HM Government 2010 & 2013 Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Munro Review of Child Protection: A Child-Centred System TSO www.tsoshop.co.uk Professor Munro 2011 New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012 Improving the Quality of Children’s Serious Case Reviews Through Support & Training@ NSPCC, Sequili, Action for Children; DfE 2013 (revised Feb. 2014) Case-specific Think child, think parent, think family: a guide to parental mental health and child welfare: Social Care Institute for Excellence. 2009 Think Family Toolkit (Improving Support for Families at Risk). DCSF 2010 The National Institute for Health and Clinical Excellence Guidelines All Babies Count Rayns, Gwynne, Dawe, Sharon, Cuthbert, Chris (2013): Spotlight on drugs and alcohol. London: NSPCC. http://www.nspcc.org.uk/spotlight Derbyshire Local Safeguarding Children Board: Serious Case Review Overview Report In respect of Child BDS12 November 2013 Serious Case Review ‘Daniel’ Wolverhampton Safeguarding Children Board 2013 Medications in Drugs Treatment: Tackling Risks to Children ADFAM 2014 67 Recommendations for Child H Serious Case Review for Child H Recommendations for the Oxfordshire Safeguarding Children Board The recommendations from the Serious Case Review of Child H for Oxfordshire Safeguarding Children Board (OSCB) are detailed below. These recommendations have been used to produce an action plan for OSCB, which is monitored on a quarterly basis by the Quality Assurance and Audit (QAA) subgroup of the board. Actions and progress made against them will be reported in a 6 month update. Recommendations: 1. The Independent chair of the Board should propose to Children’s Social Care that a well informed and sensitively worded letter is drafted and retained in records so that when child H is of sufficient age to do so, s/he can establish why, when and how alternative care became necessary and that a serious case review was completed. 2. The Board should recommend that pharmacists in the county be reminded of the expectation that Children’s Social Care or Police should be informed if they are concerned a drug dependent person might pose a risk to their own or another child. 3. The Board should recommend that the Commissioners of GP Services and Public Health Commissioners review their monitoring processes to ensure collaborative management of contracted services provided in General Practice in particular drug and alcohol services. Actions: The Independent Chair of OSCB has written to Children’s Social Care to propose a letter is written for Child H, in regards to recommendation 1. The Independent Chair of OSCB has written to Public Health and NHS England Thames Valley Area Team in regard to actioning recommendations 2 and 3 in Oxfordshire. |
NC52802 | Femur fracture to an 8-week-old girl in December 2022. Medical investigations showed C101 had suffered multiple fractures that occurred on more than one occasion. C101s parents and older sibling were previously known to childrens services. Learning considers: recognition and response to domestic abuse and coercive control; effectiveness of communication and information sharing; the importance of good quality, SMART, multi-agency planning; the importance of professional curiosity when working with parents/carers accessing substance misuse services; and assessing the strengths and potential risks from male carers. Recommendations include: training on domestic abuse to promote the recognition of abuse, coercive, controlling and stalking behaviours, and the consistent use of risk assessment tools; changes of worker to be kept to an absolute minimum in the childs journey through the services; health partners to consider enabling a safeguarding alert on information recording systems, to fully explore records on the family history, to improve handover between workers, and for indicators of domestic abuse in GP notes to be effectively communicated; childrens services to provide assurance that the introduction of a child in need (CIN) reviewing officer impacts on the quality, timeliness and sharing of CIN plans and reviews; for providers of substance misuse services to be made aware of the learning regarding professional curiosity; to consider the introduction of a pre-birth tool to help workers identify the roles of each parent/carer in parenting and aid the identification of risk factors for newborn children; and for the research, The myth of invisible men (2021) to be disseminated across midwifery, health visiting, early help and social work services.
| Title: Report of the safeguarding children practice review regarding C101. LSCB: Torbay Safeguarding Children Partnership Author: Siobhan Burns Date of publication: 2023 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. REPORT OF THE SAFEGUARDING CHILDREN PRACTICE REVIEW REGARDING C101 Independent Safeguarding Consultant and Author Siobhan Burns 2 Contents 1. The incident that triggered the review. .......................................................................................... 3 2. The purpose of this review. ............................................................................................................ 3 3. Key themes arising from this review include: ................................................................................. 4 4. Family Composition. ....................................................................................................................... 4 5. Family Background. ......................................................................................................................... 4 6. A pen picture of C101. .................................................................................................................... 5 7. Views of the parents and wider family. .......................................................................................... 5 8. Changes made since the commencement of this review. .............................................................. 5 9. Analysis and linked recommendations. .......................................................................................... 5 10. Conclusion ................................................................................................................................. 13 11. Appendix 1 ................................................................................................................................ 14 3 1. The incident that triggered the review. 1.1 C101’s mother called 111 at 4am on the 4th of December 2022. She reported to have noticed that C101 had pain in her leg. C101 was seen in hospital at approximately 6am where it was suspected that she had an oblique midshaft fracture to her femur. A strategy discussion1 was triggered and s.472 enquiries were commenced. 1.2 The outcome of the child protection medical investigations showed that C101 had suffered multiple fractures that occurred on more than one occasion. The fractures included a rib fracture and metaphyseal fractures3. The rib fracture was dated to have occurred “10 days” prior to the medical investigation4. The CT scan indicated that the skull fracture was an old fracture. 1.3 Both parents were arrested. 2. The purpose of this review. 2.1 This review commenced following the Rapid Review meeting held in December 2022. The recommendation from the Rapid Review Meeting was that there was such a detailed and thorough review of the information in that meeting, that there was no need for a Local Child Safeguarding Practice Review. The Torbay Safeguarding Children Partnership’s Executive Group recognised that the Rapid Review meeting was comprehensive, however it was recommended that a Local Child Safeguarding Practice Review (LCSPR) should be undertaken. The National Panel later concurred with this view. 2.2 The Torbay Safeguarding Children Partnership was keen to elicit the learning from the review as soon as possible and requested an interim report from the author, so that any emergent learning could be acted on in a timely manner. This was completed on the 6th June 2023. 2.3 Findings of the Rapid Review meeting in December 2022 shaped the terms of reference for this review. 2.4 The full terms of reference for this review can be found in Appendix 1. These also set out the methodology and those engaged in the review process. 2.5 This review focusses on the period 22nd February 2022 to the 12th December 2022. The reason this scope period was to ensure that learning from the pre-birth period for C101 was taken into account and also to capture any learning from the investigation process after the injuries to C101 were detected. 1 A strategy meeting takes place between a social worker and other agencies when they are worried a child may have suffered significant harm. 2 A Section 47 Enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of the child. 3 These fractures are associated with episodes of shaking a baby. 4 Expert report 2022 4 3. Key themes arising from this review include: Recognition and response to domestic abuse Communication and information sharing The importance of good quality, SMART, multi-agency planning The importance of professional curiosity when working with parents/carers accessing substance misuse services Assessing the strengths and potential risks from male carers 4. Family Composition. Role in the family Age (at the time of the incident) C101 Child who was harmed 8 weeks C101’s sibling Sibling to C101 3 years 5. Family Background. 5.1 C101 and her sibling are full siblings. They had no contact with the maternal relatives and the only support available to the family was from the paternal grandparents. 5.2 A referral was made to early help in January 2021 by the GP. The family declined support at this time. The family came to the attention of children’s services between October 2021 and March 2022. C101 was not born at this point. Concerns that prompted support for C101’s older sibling included: • Father’s alcohol and cannabis use • The mother feeling overwhelmed by the stressors on the family • Feeling unsupported by the father in the care of C101’s sibling • The mother finding it difficult to prioritise C101’s siblings needs • The mother was pregnant with C101 5.3 This period of support ended after the father was believed to have successfully engaged with drug and alcohol services, a family group conference had taken place and it was believed that a clear contingency plan was in place if the family’s circumstances changed. 5.4 Later C101 and her sibling were open to children’s services as children in need from June 2022 to the date of the incident triggering this review. This assessment was started after the mother called the police, having realised that the father had been driving whilst under the influence of alcohol or drugs. She was concerned that he had relapsed from his drug and alcohol abstinence. He had left the family home by the time the police had arrived. 5.5 The mother described to the attending police officer her fears about the father’s relapse and that she felt unsupported. She shared concerns regarding the couple’s relationship5, believing that the father had been unfaithful and he had accused her of having an ‘affair’ with her brother. This prevented any contact with her brother and wider family. She also told the police that she had been assaulted in November 2021 by the father, later describing this as being “restrained" when she was having a miscarriage. He ‘restrained’ her while she was hitting her stomach. 5 Cited from Rapid Review Meeting Notes 5 5.6 C101’s sibling was not present during this incident. This event led to a single assessment and a Child in Need plan for C101’s sibling. Police carried out a DASH6 risk assessment. This period of Child in Need planning lasted until December 2022, when steps were taken to secure the immediate safety of the children. 5.7 The father has a diagnosis of ADHD and reported to have used Ritalin and self-medicated with LSD in the past. Historically he had also used cocaine and magic mushrooms. The mother had pre-existing mental health issues including an eating disorder in her childhood and poor mental health, including post-natal depression after the birth of C101’s older sibling. 6. A pen picture of C101. 6.1 C101 was born at 37 weeks. She was a small child, very petite but was described by the health visitor as being ‘in proportion’. She had received her first set of immunisations and was not on any medication. When seen in November 2022 she was described by her mother as a ‘settled baby’ and that she was ‘chilled’. Her weight was going up after some early feeding issues. These comments and observations were made a few weeks before the injuries were discovered. 6.2 Now that she is in a safe place she is thriving and developing the expected skills for a child her age. She has been described as a ‘happy’ baby, as ‘content’ and ‘full of smiles’. She is almost rolling over and sitting with aid. She is smiling and ‘babbling’7. Despite her fractures she was able to move freely with no evidence of pain or distress in January 2023. 6.3 C101’s sister is also safe and thriving. 7. Views of the parents and wider family. 7.1 Unfortunately, the parents and paternal grandparents were not able to contribute to this review due to the ongoing criminal proceedings and the Finding of Fact hearing in July 2023. 8. Changes made since the commencement of this review. 8.1 Children’s Services have implemented specific SMART planning guidance and training to improve the quality of Child in Need planning. A Child in Need Independent Reviewing Officer post has been introduced within the Local Authority’s Safeguarding and Reviewing Service. The purpose of this role is to ensure consistency and quality in respect of Child in Need planning. This role has also been created to provide training and workforce development for front line practitioners on effective Child in Need planning. 8.2 Children’s Services have produced Child in Need practice standards which set out expectations of social workers in respect of Child in Need planning and reviews. 9. Analysis and linked recommendations. 9.1 Identified good practice. 9.2 The hospital midwife recorded her observations of the father’s handling of C101 and her concerns about the hygiene of the cup that the mother was using to feed C101. Her recording was of a high standard and is an example of good practice. 6 DASH risks assessment measures potential risk to survivors of Domestic Abuse. 7 At age 6 months 6 9.3 The family’s GP was thorough in reviewing the paediatric liaison form received after C101’s birth. This highlighted the concern about hygiene and the potential impact on feeding of C101, which the GP then asked the health visitor to follow up. 9.4 The frontline practitioners, managers and leaders that participated in this review were open and reflective and showed that they were keen to implement learning at the earliest opportunity. It is noteworthy that work to address any systemic, procedural or practice issues identified following C101’s injuries, began from the point of the rapid review process meeting in December 2022. 9.5 Recognition and response to domestic abuse and controlling and coercive control. 9.6 The police responded to the mother’s call in June 2022 when she discovered that the father returned home from work, having driven under the influence. When the police attended the family home the mother told the police that she had previously been assaulted by the father, later stating that she was “restrained” by the father when she experienced a miscarriage in November 2021. A DASH risk assessment was undertaken by the police. The outcome of the DASH risk assessment was deemed to be ‘low’ but the ViST8 cited the risk as ‘medium’. The DASH risk assessments were not shared in the report that was sent to the MASH. 9.7 Midwifery and health visiting staff did ask the mother if she was experiencing domestic abuse or felt ‘safe’ at home in the antenatal appointments leading up to August 2022 and a further four times leading up to October 2022. She did not disclose any domestic abuse. Midwifery staff do not have access to GP notes and therefore it would not have been possible to detect the indicators of domestic abuse in the GP notes in 2021 and 20229. 9.8 The GP was alerted to the fact that the father was ‘controlling’ in the report received from the MASH in June 2022. There was also a historical record in the GP notes relating to C101’s sibling, where it was reported that the mother was ‘threatened’ by her husband in January 2021. 9.9 The Children’s Services recording relating to this incident in June 2022 shows some good analysis of the fact that the mother may be ‘scared of the father leaving her’ due to being ‘wholly financially dependent’ on the father and also noting that she was pregnant, which is a time that women are at an elevated level of risk and harm10. It describes how she had ceased any contact with her brother due to the father’s concerns about her relationship with him and how the mother’s wider family lived some distance away. The language surrounding the description of the reported assault changed from ‘assault’ to the father ‘restraining her’ after she hit her ‘tummy’ at the time of the miscarriage. 9.10 The single assessment in respect of unborn C101 and her sibling did engage the father and was thorough in respect of the children’s wider needs, seeing the children at home, analysing the impact of the father’s working hours and his availability to co-parent as well as mother’s need for support. However, there was no explicit reference to indicators of domestic abuse. 9.11 The indicators of domestic abuse were in the professional network but they were not pulled together in the children’s services single assessment. This resulted in key information not being analysed and domestic abuse not being clearly articulated in the assessment. There was a recommendation that a DASH risk assessment should be completed by the social worker. However, this was linked to the rationale that the father ‘repeatedly threatens to leave’ the 8 Vulnerability identification screening tool completed by the police 9 See Fig 1 10 Chisholm et al 2017; Devries et al 2010 cited from Supporting women and babies after domestic abuse. A toolkit for domestic abuse specialists. 2019. Women’s Aid 7 mother. It is not clear if this was ever undertaken and the concerns about domestic abuse appear to be lost from the point of the single assessment. 9.12 A review of the chronology shows that there were indicators of domestic abuse, these are set out in chronological order below in Fig 1: Fig 1: Jan 2021 Note in the GP records that the father had threatened the mother 27.06.2022 MASH referral. Mother told police of being assaulted in November 2021 – later described as being ‘restrained’ by the father. DASH risk assessment completed but not shared across the multi-agency team around the child. 27.06.2023 A notification was sent to midwifery following the mother’s call to the police from the MASH stating “while pregnant last time she hit her tummy and her partner had to stop her by restraining her” 27.06.2022 GP note stating that father was ‘controlling’ July 2022 Single assessment commenced – mother ‘scared of the father leaving her’ due to being ‘wholly financially dependent’ on the father and also noting that she was pregnant. Describes how mother is isolated from her family. DASH risk assessment recommended but not undertaken. 17.08.2022 Assessment by peri-mental health services – mother described that father had secretly set up cameras to film her, due to concerns he had about her relationship with her brother. 24.08.2022 Entry by health visitor from Unborn Tracker meeting citing “partner reported to be gaslighting the mother by saying she is not sane” 9.13 The Domestic Abuse Act 2021 defines domestic abuse as abusive if it consists of the following: (a) physical or sexual abuse (b) violent or threatening behaviour (c) controlling or coercive behaviour (d) economic abuse (e) psychological, emotional or other abuse It does not matter whether the behaviour consists of a single incident or a course of conduct11. 9.14 The Act goes on to describe coercive control, some elements of which appear to have been experienced by the mother; including isolation from her family, ‘control’, ‘gaslighting’ and stalking behaviours12 i.e. being covertly filmed by cameras put in place by the father. 9.15 Unfortunately, these pieces of information were not recognised and analysed in the single assessment and the absence of any multi-agency planning meetings prevented any multi-agency professional curiosity, or challenge about domestic abuse or coercive control. 9.16 One practitioner reflected: 11 Domestic Abuse Act 2021, S1 (3) p 12 Domestic Abuse Act 2021 – descriptor of stalking behaviours. Para 58. P 34 8 “There is a difference between domestic violence and domestic abuse – we need to do more work on recognising coercive and controlling behaviour.” 9.17 This comment was made after, with the benefit of hindsight, it was recognised that indicators of domestic abuse were present. She reflected that, there was no evidence of actual violence and the less obvious indicators were not recognised. Linked recommendation 1: For the Partnership to gain assurance that local single and multi-agency training offers in relation to domestic abuse promote the recognition of abuse, coercive and controlling behaviour and stalking behaviours and promote the consistent use of risk assessment tools such as the DASH. 9.18 Effectiveness of communication and information sharing 9.19 There was evidence of systemic failures in communication and information sharing from the referral in June 2022. 9.20 Police: The domestic abuse indicators that the mother shared when speaking to the police were not fully shared with the wider network of professionals as set out above. 9.21 Midwifery: The hospital midwife recorded her concerns about the father’s handling of C101 and the hygiene concerns. An attempt was made to contact the allocated social worker, after a message was left on the social worker’s mobile telephone no further contact was made. 9.22 There was no verbal handover from the hospital midwife to the community midwife, as the named community midwife had had time off sick. On the day of the Family Group Conference the named community midwife’s case load was being covered by another midwife, who was new to the team. She did not see the concerns noted by the hospital midwife on the recording system. Practitioners have reflected that the current recording system flags up ‘reminders’ to highlight certain information. The ‘reminder’ function is so commonly used that practitioners can find themselves clicking through these to clear the screen so that they can access the system. The fact that the 3rd midwife was very new to the team and the information recording system, meant that she did not see the notes from the hospital midwife. 9.23 The newly allocated community midwife attended the virtual Family Group Conference and recorded the expectations of her as set out in the agreed family plan. These actions did not reference the concerns about the father’s handling or the historical indicators of domestic abuse. The plan only required the midwife to see C101 every day, observe handling and record any positives or concerns, which is what would normally be expected of the midwife in the first days of C101’s life. 9.24 Health visiting: There were 3 health visitors. The number of changes occurred due an administrative error. It was agreed that C101 was to become a Child in Need at the Unborn Tracker meeting13 held in August 2022. There is an expectation that children in need are served by the ‘universal plus’ health visiting service, rather than the ‘universal’ service, which provides for children that don’t have identified additional needs. 9.25 Despite the plan for C101 to be a Child in Need, she was allocated a health visitor from the ‘universal’ service who undertook the pre-birth visit. A different health visitor undertook the new birth visit. This error was then recognised and responsibility for C101 moved from the ‘universal’ service to the ‘universal plus’ service in late November 2022. This health visitor saw C101 twice before she was injured and admitted to hospital. The allocation of three health visitors in 3 months meant that neither of the health visitors got to know C101 and her family. 13 a children’s social care Panel which provides oversight and monitoring of pre-birth planning 9 9.26 The health visitor that was working with C101 just prior to her injuries was an experienced practitioner but had not received a hand over from the previous health visitor or given a copy of the initial birth assessment. The letter from the midwife setting out her concerning observations was addressed to the previous health visitor, resulting in the second and third health visitors not being made aware of the concerns. 9.27 The third health visitor attended the Child in Need meeting held on the 1st of December 2022. Prior to this meeting she was not aware of the outcome of the Child in Need assessment or what the Child in Need plan entailed. 9.28 Children’s social care: C101 had four social workers. It is not unusual for children to experience one change of social worker when moving from an initial assessment team to a team with social workers that work with families longer term. 9.29 C101’s second social worker had time off sick so C101 was allocated to a third social worker and finally allocated to a fourth social worker number in November 2022, who remains allocated to C101 to date. The changes in social worker were significant not only in terms of providing the family with the opportunity to develop relationships with those working with them but also impaired communication within and between agencies. The third health visitor allocated to the family in November attempted to make contact with the third social worker, but the responsibility for the case had moved to the fourth social worker. One contact took place between the health visitor and social worker until the Child in Need review meeting in December 2022. 9.30 The changes in social worker resulted in the original ‘written agreement’ which aimed to prevent the father from having unsupervised care of C101, not being handed on to the subsequent social workers. Although, having reviewed the evidence to date there was insufficient evidence to warrant precluding the father from caring for his children. The exclusion of a parent caring for their child is only usually for instances of extremely high risk. 9.31 The concerns about domestic abuse were identified in the single assessment but only in as much as the relationship appeared to be ‘unstable’. As a result, the concerns about the father’s handling of C101 and the indicators of domestic abuse were not relayed to the fourth social worker, resulting in her view that the family were ‘low risk’. 9.32 In summary, C101 and her family experienced multiple changes of workers in the first eight weeks of C101’s life which prevented effective communication and information sharing. These changes included: • Three midwives • Three health visitors • Four social workers Linked recommendation 2: For the Partnership to seek assurance from all agencies that changes of worker are kept to an absolute minimum in the child’s journey through the services. Linked recommendation 3: For health partners to consider: • enabling a safeguarding alert on the information recording systems that require an acknowledgement before the practitioner can move on to other parts of the recording system, to ensure when concerns are noted these are read and acknowledged. 10 • Ensure health visitors fully explore records on the family history when a child is allocated. • Ensure verbal handovers take place and when there are changes of worker a joint visit takes place with the previous and newly allocated worker. • For local health partners to ensure that there are effective mechanisms to ensure that indicators of domestic abuse held in GP notes are communicated to midwifery and health visiting staff. 9.33 Opportunities for planning: 9.34 The Unborn tracker meetings in August and September 2022 recommended that a discharge planning meeting took place. 9.35 The pre-birth planning meeting was replaced by a Family Group Conference (FGC), which is not in line with procedures. The FGC was requested at very short notice leading up to C101’s birth. This gave the, very able, part time FGC coordinator very little time to set the meeting up, prepare with the social worker or meet and prepare the family members. As a result, the safety plan arising from the FGC was not robust and only provided a plan for immediately after the birth of C101. The key worker from the Peri-Natal Mental Health Team was not invited to the FGC. 9.36 This was a missed opportunity to create a multi-agency support plan to meet the needs of the mother and children, as well as the opportunity to discuss: • the concerns about hygiene • the indicators of domestic abuse 9.37 It has not been possible to establish why the discharge planning meeting led by Children’s Services did not take place and was replaced at the last minute by a FGC, as the worker that made these plans is no longer working for the authority. Discharge meetings usually happen shortly after discharge from hospital. This was a missed opportunity for the hygiene concerns, the indicators of domestic abuse and the concerns about the handling to have been pieced together. 9.38 The FGC coordinators that contributed to this review reflected that practice has changed since September 2022. Historically, when first set up, the team would have been flexible enough to offer conferences at short notice. Such a referral would not be accepted by the team in the current day, due to the tripling of numbers of referrals into the team and the role of the team being better established. Therefore, there is no linked recommendation in relation to family group conferencing. 9.39 The Child in Need plan created by the third social worker in September 2022 was completed with the following: • C101’s sibling’s nursery • A representative of the substance misuse service • The parents 11 9.40 The Child in Need plan did not highlight the concerns about the father’s handling or indicators of domestic abuse. It was not SMART14 and only contained actions for the parents. There was no evidence of any support to be provided to the family. This plan was not shared with the health visitor or perinatal worker who was supporting the mother. It is expected practice that any plan arising from the FGC is included in any Child in Need planning. The FGC plan only focussed on the immediate needs of the family post discharge and did not address the ongoing support needs of the family. The Child in Need plan handed to the fourth social worker was not fit for practice. The Child in Need plan was completed approximately 10 weeks after the trigger referral in June 2022. This is not in line with good practice, given that the assessment appears to be regarding simple issues of parental substance misuse and ‘support’ for the mother. 9.41 There was a significant delay in holding the review Child in Need meeting which was, in part, due to a delay in allocating a social worker from the longer-term team, the fourth social worker. 9.42 The review meeting in December 2022 was attended by the C101’s siblings’ nursery and the third health visitor. Included was a verbal update from the substance misuse team. The Peri-Natal Mental Health Team were not invited to the review meeting. 9.43 By this time, the team around the family had changed. The only constant for the family was the nursery worker who had not met C101. The health visitor and social worker were newly allocated to the family. Linked recommendation 4: For Children’s Services to provide assurance to the Partnership that the planned improvements and the introduction of a Child in Need Reviewing Officer impacts on the following: • The quality of Child in Need (CIN) plans • The timeliness of reviews of CIN plans • The invitation of all partners to planning and review • Records of CIN plans and reviews are shared with all of the team working with the children, including GPs 9.44 Effectiveness of the arresting procedures and safety planning post injuries 9.45 The terms of reference for this review required an examination of the use of arresting procedures immediately following the first injury to C101. The day that the injuries were detected a strategy discussion was held. At this time only the fracture to the femur had been detected and a decision was made to arrest the father and treat the mother as a witness. This decision was based on the following information: • The father had cared for C101 between 8pm and 2am on the day the first injury was discovered by the mother. • The mother shared a text message with a doctor that had been sent by the father, stating that he might have caused the leg injury by holding C101 over his head. • The medical professional at the time felt this was a plausible explanation for the injury. 9.46 It was only on the 6th of December, following the outcome of the child protection medical investigations that the injuries that C101 had suffered were fully understood. It became apparent that C101 had a range of injuries, that could have occurred on more than one occasion. 14 Specific, measurable, achievable, relevant and timebound 12 This triggered a second strategy meeting, following which both parents were treated as potential suspects and were arrested. 9.47 C101 was safe in the hospital and her sibling was placed in the care of the paternal grandparents. Both the police response and the multi-agency immediate safety planning appear to have been appropriate and responsive as new information came to light about the injuries. Therefore, there is no linked recommendation in relation to the application of the arresting procedures or the safety planning for the children. 9.48 Impact of Covid 19 9.49 The terms of reference specifically required reflection on any potential impact of the Covid 19 pandemic. There was no evidence from written records or feedback from practitioners that indicated that Covid 19 had a negative impact on services offered to this family. 9.50 Supporting parents with substance misuse issues 9.51 The father sought support from Walnut Lodge in February 2021 and later this was an expectation set out in the Child in Need plan in September 2022. He self- reported low levels of substance use, describing smoking ‘two spliffs a day’ and ‘one can of beer a day’. He told the worker that he wanted help with abstinence but had not smoked any herbal cannabis or drunk alcohol for 12 days prior to the assessment. He was later discharged from the service after reporting that he had managed to remain drug and alcohol free. 9.52 There appears to be a lack of professional curiosity at the time of the initial assessment by the substance misuse worker about the amount that the father reported to be using. It was never questioned why the threshold for a Child in Need plan linked to his substance misuse was in place or why he was not ‘allowed any unsupervised contact’ with his child, when he was self-reporting low levels of usage and later abstinence. Linked recommendation 5: For Walnut Lodge and linked providers of substance misuse services to be made aware of the learning from this case review regarding professional curiosity when working with parents whose children are open to Children’s Services. 9.53 Supporting fathers/male carers as parents 9.54 The father appears to have had very limited input into the single assessment in September 2022. The assessment sets out expectations from the social worker that he should prioritise his family’s needs over that of his employers. However, there was a lack of clarity about the role of the father in caring for the two children and no assessment of the support that he may require. The second community midwife that was allocated to the family did meet the father and encouraged him to support the mother. She found him to be hard to engage at times and reluctant to be involved in parenting. 9.55 The first assessing social worker, did not know of the handling concerns raised by the hospital and this information was therefore not handed on to the following three social workers. The fourth social worker, and the current health visitor for the children had not observed the father’s interaction with the children, leading up to December 2022 when the injuries to C101 were discovered. The combination of the multiple changes in worker and the father’s working hours meant his parenting capacity was not assessed and it was assumed that the mother would be the main carer. There is no evidence that the father was asked if he wanted any support in developing his parenting skills. 13 9.56 There has been recent research carried out by the National Panel15 which shows that: in the ‘vast majority’ of cases where babies have been injured or killed – men are the perpetrators’. (Opcit p6) 9.57 This research showed that contextual factors such as substance misuse, domestic abuse and living in poverty are linked to non-accidental injuries in children under the age of 1 year. 9.58 In this case the father’s capacity to co-parent was not assessed and there was an unconscious bias leading professionals to accept that the mother would be the main carer and provide all of the care for the children. It is important that all services engage, support and intervene with male carers16 to identify their role in the family and identify potential indicators of risk and/or support they might need. Linked recommendation 6: The Partnership to consider the introduction of a pre-birth tool to assist workers to identify the roles of each parent/carer in parenting and aid the identification of strengths and potential risk factors for newborn children. Linked recommendation 7: For the Partnership to be provided with assurance that the learning from the National Panel’s research The Myth of Invisible Men. Safeguarding children under 1 year from non-accidental injury caused by male carers (2021) is disseminated across midwifery, health visiting, early help and social work services. 10. Conclusion 10.1 As with the majority of case reviews, the combination of the analysis of the history and the engagement of frontline practitioners has elicited some important learning. It is notable however that multi-agency safeguarding systems are complex and sadly, even if the indicators of risk were recognised by the multi-agency team, it is unlikely that this would have enabled practitioners to predict the harm suffered by C101. 15 The Myth of Invisible Men. Safeguarding children under 1 from non-accidental injury caused by male carers. (2021) 16 Opcit The Myth of Invisible Men. Safeguarding children under 1 from non-accidental injury caused by male carers. (2021) 14 11. Appendix 1 Local Safeguarding Child Practice Review Terms of Reference Child: C101 March 2023 1. Reason and Context for Review 1.1 This review relates to a young child who has been given the pseudonym C101. C101 has a three year old sibling. C101, her sibling and both of their parents were living together at the time of the incident in question. On 4th December 2022 C101 was presented in a very distressed state at Torbay Hospital ED by her mother, with C101 being suspected to have an oblique midshaft fracture to her femur. The mother gave no adequate explanation for the nature of the injury. C101 was eight weeks old at this time. Hospital staff alerted Children’s Services to request a strategy meeting and the subsequent Child Protection medical revealed that C101 had multiple fractures which had occurred over more than one occasion, with it being deemed conceivable that some of the fractures had occurred ten days or more before hospital presentation. This information was formally communicated to the Local Authority on 6th December 2022, both parents were arrested by the police and the children became cared for under S20 within the same foster placement. The children were made subject to Interim Care Orders on 15th December 2022. 1.2 Further concerns regarding C101 and her sibling’s welfare were identified within the Rapid Review process, with examples of these being: • The parents being reported to have a poor relationship. • C101’s older sibling exhibiting concerning behaviour and development. • The mother experiencing low mood. • The mother being concerned about the father’s level of alcohol consumption. • The concerns above leading to the GP making a referral to Early Help services in January 2021 but the parents declined support. • The mother made a referral in October 2021 reporting concern about the father’s drug and alcohol use. • The father was reported to have cared for C101’s sibling whilst under the influence of substance/s. • In June 2022 the mother reported to the police that the father was driving under the influence of alcohol, adding that his place of work is concerning in respect of illegal drug supply. • The father reportedly had a sexual relationship with another person whilst the mother was pregnant with C101’s sibling. • The parental relationship dynamics and self-reports of transactional sexual behaviour which leads to a potential hypothesis of coercive control by the father. 15 • The father accused the mother of having a sexual relationship with her own brother whilst she was pregnant with C101. • The father’s rough handling of C101 in the hospital. • Child in Need planning was in process at the time of the injuries to C101. 1.3 The Serious Incident notification was submitted to National Panel by the TSCP on 12th December 2022 and the Rapid Review meeting was held on 22nd December 2022, with the associated report being submitted to National Panel on 4th January 2023. Although the Rapid Review meeting concluded that all learning had been identified the TSCP Executive recommended the undertaking of a local CSPR, with National Panel responding to the TSCP on 8th February 2023 and concurring with this view. National Panel agreed with the lines of enquiry identified by the TSCP and Siobhan Burns was confirmed as the Independent Reviewer on 23rd February 2023. 2. Purpose 2.1 This review will be based on the key lines of enquiry recorded in section four below. However, during the review, if further learning opportunities are identified these will be added at the discretion of the TSCP C101 Review Panel. The key purpose of the review is to prevent future similar harm and learn lessons where appropriate to further safeguard and promote the welfare of children. The review should aim to identify systematic learning, rather than holding individuals or organisations to account for their actions. 2.2 If concerns are identified within the review process that fall outside these terms of reference, such as those of a safeguarding or misconduct nature, the Independent Reviewer will refer to the TSCP who will then consult with the relevant body to consider appropriate responses and processes. 3. Period under Review 3.1 The period under review is from the confirmed date of the mother’s pregnancy, 22/02/2022, until 12/12/2022 when the SIN was submitted by the Local Authority. 3.2 The Independent Reviewer may also request summary background and contextual information outside of this period and analyse as relevant. 4. Key Lines of Enquiry 4.1 The following key lines of enquiry have been established, based on the findings of the Rapid Review, and have been noted by National Panel. Further questions have been agreed by the TSCP C101 Review Panel and are recorded under their linked line of enquiry via bullet points. A Analyse the effectiveness of communication and information sharing between agencies during the period under review and identify if this led to missed opportunities to support/safeguard C101. B Report on the quality of CIN and safety planning for C101. • Did the delay in care planning post completion of the single assessment on 6th September 2022 elevate risk and/or prevent the family accessing services? • Do local agencies understand the purpose and legal limitations of written agreements? C Comment on the effectiveness of existing local systems to protect children. Are these robust enough and/or being applied correctly? 16 • Were effective child protection procedures initiated in line with WT2018 and correctly applied following the identification of C101’s injuries? • Was safety planning initiated after the strategy discussion/s SMART, robust and effective, including the timely identification of the pool of potential perpetrators? • Review and comment on the timeliness of arresting procedures for both parents. • Review the impact on safeguarding of the lack of professional curiosity following the assumption that the father was the perpetrator following his statement that he dangled C101 by her legs. D Comment on the accessibility and quality of professional supervision for staff engaged in the safeguarding of children. • Were all professionals able to access supervision, and if not, why not? • How could local supervision be better used to improve the safeguarding of children? E Review local agencies understanding of the importance of awareness and knowledge around feeding difficulties and associated impact on infants’ safety. F Comment on whether agencies fully understood the status and impact of the parent’s relationship. • Did this impact on risk management? • Was there evidence of coercive control and domestic abuse, and if so, what were agencies responses? G Review local multi-agency practice in respect of ‘hidden fathers’ and identify potential learning for local agencies. • Was the father visible to services and considered within recording processes and care planning? • Review the pathway from midwifery services to health visiting to ensure it is effective and being applied correctly, including the frequency and level of health visiting for children subject to Child in Need or early help planning. • Identify risk and potential learning regarding the transition processes between midwifery and health visiting teams. • Do health practitioners routinely record the presence of birth marks or similar marks on a child's file? • Identify why Universal Plus health visiting status did not elevate the level of visits to the family in line with agreed local process. • Was whole family care planning considered by health practitioners? H Review and comment on the residual impact of Covid 19 on local safeguarding and support services and determine if this impacted on C101’s safety and care planning. 5. Methodology: 5.1 This review will be carried out according to statutory guidance and using best practice to ensure appropriate learning opportunities are identified and analysed. The final report should identify recommendations that can be converted into SMART actions to assist learning. It is anticipated that the review will be conducted remotely, however if 17 ‘face to face’ meetings are required the need for these will be evaluated in advance by the TSCP C101 Review Panel. 5.2 The Independent Reviewer will feedback progress to the TSCP at regular planned intervals via the TSCP C101 Review Panel. In situations where urgent/unplanned feedback is necessary this will be undertaken via the TSCP Business Team. 5.3 The TSCP C101 Review Panel will meet monthly, however meetings can be held more frequently if required at the discretion of the Chair. 5.4 The TSCP C101 Review Panel will consist of: • Divisional Director, Safeguarding (Chair) • Children’s Social Care • Police • Designated Health Professional (covering the health system) • Early Years (if required) • Independent Reviewer • TSCP Business Team • Additional members as deemed necessary 5.5 Legal advice will be provided by the Local Authority Legal Department. 5.6 Communications/PR support will be provided by the Local Authority communication lead for Children’s Services. 5.7 The TSCP Executive have requested an interim report be completed at the midway point of the CSPR timescale. 5.8 Final learning from the review will be presented by the Independent Reviewer in the form of a full CSPR report that will be completed to timescale as far as is practicable. The final draft report will be agreed by the TSCP C101 Review Panel before being presented formally to TSCP Executive Group for review and sign off via partnership business channels. Any agreed amendments to the report will be required to be undertaken by the Independent Reviewer. 5.9 The timescale for submitting the final version of the report to National Panel is six months from the TSCP being notified of the need to complete the local CSPR. The last submission date to National Panel is therefore considered to be 8th August 2023. 6. Review of Existing Materials and Papers 6.1 The Independent Reviewer will identify the information they require to undertake the review with the support of the TSCP C101 Review Panel. The information will be sourced and provided by the TSCP Business Team and partner agencies will be expected to comply with information requests (where legally permitted) in a timely manner. 7. Involvement of Practitioners and Staff 7.1 The Independent Reviewer will identify and engage with relevant practitioners, managers, and key workers to ensure any learning opportunities are fully incorporated into the reviewing process. It is anticipated that there will be at least one ‘practitioner event’, combined with the offer of 1:1 or small group sessions for workers to meet with the Independent Reviewer where this is deemed more conducive to the identification of learning. The TSCP Business Team will coordinate these events. 18 8. Involvement of Families/Other Parties 8.1 Parents, carers and family members of the siblings will be notified of the review by the TSCP and invited to participate at an appropriate time. 8.2 Involvement of other interested parties will be considered as appropriate by the TSCP C101 Review Panel. |
NC51306 | Death of a 5-year-old boy in March 2017. Child M died of stab wounds while in the family home with his mother. Child M's mother had suffered from mental illness and been a patient of mental health services or treated by her GP for at least five years. In 2015, Child M had been placed in foster care by another local authority at the request of his mother, telling professionals she had thoughts about harming him which were understood to be part of her psychotic thinking. In the weeks before the death, Child M's mother showed no signs of serious mental illness. Ethnicity or nationality of Child M is not stated. Findings: those working with Child M and his mother had a limited understanding of possible risks to Child M; after the family moved to Oxfordshire no professional had a comprehensive knowledge of the mother's mental health history as case transfer and closure summaries did not contain full details; there was no coordinated transfer with agreed objectives and plan. Recommendations include: to consider whether the LSCB's current threshold of need document places sufficient emphasis on the need to consider previous and historical concerns; that mental health service providers and GPs have adequate arrangements in place to identify and assess the needs of children of patients being treated for psychiatric illnesses; to ensure staff have clear expectations for obtaining and reading case histories; to seek reassurance that implementation of GDPR has not led to inappropriate limitations on information sharing.
| Title: Serious case review: services provided for Child M and his mother: executive summary. LSCB: Oxfordshire Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2019 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Serious Case Review Services provided for Child M and his mother Executive Summary Independent Chair Oxfordshire Safeguarding Children Board Richard Simpson Independent Lead Reviewer Keith Ibbetson 2 1. INTRODUCTION 1.1. Between July 2017 and November 2018, Oxfordshire Safeguarding Children Board (the LSCB) conducted a Serious Case Review (SCR) in relation to the services provided for a five year old boy, referred to in this report as Child M, and his mother. Child M died of stab wounds while in the family home with his mother in March 2017. His mother had self-inflicted knife wounds. 1.2. Child M’s mother was known to have been a patient of mental health services in Oxfordshire and in two other local authority areas where she had lived during her pregnancy and following the birth of her son in 2012. There were no other members of the household as Child M’s mother had avoided contact with his father and other members of her family for some time. 1.3. The SCR was carried out under the guidance Working Together to Safeguard Children 2015. Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.1 This document summarises the SCR findings which are published in full in a separate report. Reasons for conducting the Serious Case Review 1.4. The circumstances of Child M’s death were discussed by the LSCB Case Review and Governance Group on 3 May 2017. At that point the LSCB was informed that: • Child M had died as a result of abuse • His mother had suffered from mental illness and been a patient of mental health services or treated by her GP for at least five years • The family had lived in Oxfordshire since mid 2015; earlier that year Child M had been placed in foster care by another local authority at the request of his mother • In the months prior to his death Child M’s mother had been in regular contact with her health visitor; he had frequently been observed to be a happy, contented boy; he had started to attend his local primary school and there had been no concerns about his care or presentation • In the weeks before the death, Child M’s mother showed no signs of serious mental illness • She had been assessed by the psychological service because of her anxiety and her reported fear of using public transport; arrangements 1 Working Together to Safeguard Children (2015), 4.1 and 4.7 3 were being made through the school to provide practical and emotional support to his mother. 1.5. The group decided that the circumstances met the criteria for a SCR and Paul Burnett, the Independent Chair of Oxfordshire Safeguarding Children Board confirmed the decision on 02 05 17.2 The focus and scope of the Serious Case Review 1.6. The review team decided that the SCR should consider events between mid 2014 (when the mother’s mental health problems became known to services in Swindon) and the death of Child M in March 2017. As the work of the SCR progressed it focused on the following: • The services provided for Child M and his mother • Whether or not professionals could have identified the risk of Child M suffering serious physical harm • The nature of the risk assessments that took place and in particular whether they were informed by a full knowledge of the mother’s history of mental illness • The effectiveness of working between professionals in services for children and those in adult mental health services • Transfer of responsibility when the family moved from Swindon to Oxfordshire in 2015 • Decisions relating to the involvement of the mother’s own family and Child M’s father In addressing these the SCR has taken account of the findings of the internal NHS serious incident investigation carried out by Oxford Health NHS Foundation Trust and considered their particular implications for work with parents who have a mental illness. 1.7. As well as identifying aspects of the case history that point to weaknesses in service provision, the SCR has identified examples of good, diligent individual practice and systems that worked effectively. Agencies involved 1.8. The SCR considered the work of the following agencies and contracted professionals: Oxfordshire • Primary school and preschool • Oxford Health NHS Foundation Trust (mental health services and health visiting service) 2 The criteria for a SCR are in Regulation 5 of the Local Safeguarding Children Boards Regulations 2006, 5 (2) (a) and (b) (1) 4 • Children’s centre in Oxfordshire (managed at the time by Action for Children under contract to the County Council) • General Practice • Oxfordshire County Council (children’s social care) Swindon • Swindon Council (children’s social care) • Avon and Wiltshire Mental Health Partnership Trust • Primary care and health visiting services How the review was undertaken 1.9. Details of the principles underlying the approach to review and the steps taken to carry it out are set out in Appendix 2. 1.10. Child M’s mother, his father and maternal grandmother were informed about the SCR in January 2018. This action was delayed because of reports of the mother’s mental illness and also because of the parallel police investigation into Child M’s death. Other family members had little or no contact with professionals during the period under review. 1.11. In May 2018 the independent lead reviewer held meetings with Child M’s mother and with his maternal grandparents. Their views are summarised in Appendix 1 and are reflected at a number of points in the report. Parallel investigations and proceedings 1.12. The death of Child M was investigated by Thames Valley Police. Child M’s mother pleaded guilty to causing his death by manslaughter on the grounds of diminished responsibility and was made the subject of an indefinite hospital order under the Mental Health Act.3 1.13. There have been two other reviews of different aspects of the services provided to Child M and his mother conducted under health service procedures. The full report describes their remit and considers whether the commissioning of three separate professional inquiries in relation to the death of a child in these circumstances would in future be the best way of learning from such an incident. 2. KEY EVENTS AND SCR FINDINGS Key events 2.1. Child M’s mother suffered episodes of mental illness as a young adult and during her pregnancy. There were also long periods when she was free of obvious symptoms, usually when she took prescribed medication. Her parents date the development of her psychiatric problems to her early 20s, 3 Sections 37 and 41 of the Mental Health Act 1983 5 but say that for many years they were not consistently diagnosed or treated. She had no history of violence. 2.2. Child M was born in 2012. There is no evidence to suggest that his mother had any difficulties in her care of Child M during the first three years of his life. In mid 2014 she moved to Swindon, found Child M a place in a nursery, registered with a GP who continued to prescribe her medication and kept in touch with her health visitor. 2.3. The first risk to Child M was identified in January 2015, when his mother attended the Emergency Department in Swindon with signs of delusional thinking. Her symptoms focused on perceived threats to Child M or her fear of losing him and on a small number of occasions over the following days she reported thoughts of killing Child M, which she believed would prevent others harming him. 2.4. On this occasion Child M’s mother had sought help when her mental health deteriorated, the professionals involved responded quickly and sensitively and as a result Child M was not harmed. He remained in foster care for seven weeks and support services were provided when she resumed his care. 2.5. Child M’s mother moved to Oxfordshire in June 2015. After this there was a lengthy period during which the family had regular contact with a children’s centre, pre-school and a health visitor. All the professionals who had contact with Child M found him to be a calm, happy child who was developing normally and there were only ever minor concerns about the mother’s care of Child M, none of which related to her mental health. 2.6. Whilst the family was living in Oxfordshire major concerns about the mother’s mental health abated. She was assessed by the community mental health team in September 2015 and briefly had support from a care coordinator. The mental health service ceased its involvement in February 2016 when prescribing and monitoring her medication became the responsibility of the mother’s GP. 2.7. In June 2016 Child M’s mother approached a number of the professionals to report her fears about having to seek work when her son started school and her phobia of public transport, a problem that she had experienced in the past. This led her briefly to have suicidal thoughts. 2.8. A number of agencies made additional visits and Child M’s mother was referred to a primary care level counselling service and then to the mental health trust psychological service. Her suicidal ideas ceased and the mother’s mental health was judged to have stabilised. 2.9. Child M (who was already attending preschool) started full time primary school in September 2016 without any significant concerns. Professionals thought that social isolation was a continuing risk factor for Child M’s mother and this was addressed by encouraging her to be able to work 6 closely with staff at the primary school and by having a named worker with whom she could discuss any concerns. 2.10. In early 2017 Child M’s mother experienced another deterioration in her mental health without signs or symptoms being apparent to professionals. Unlike the episode in Swindon in 2015 Child M’s mother was not aware that her mental health was deteriorating and did not make contact with professionals to seek help. Knowledge of the family history and perceptions of possible risk to Child M 2.11. A mental health homicide review has been published in parallel with this report.4 This report evaluates in detail the involvement of mental health services with Child M’s mother throughout her life, including her diagnosis and treatment. It concludes that mental health professionals could not have predicted or prevented the death of Child M. 2.12. The Serious Case Review has identified a number of areas in which practice could be strengthened to reduce the likelihood of a future, similar death. 2.13. The deterioration in the mother’s mental health in January 2015 posed a significant risk to Child M, but he came to no harm because she sought help at an early point and professionals ensured that Child M was safeguarded. 2.14. After this episode the knowledge that professionals had of the mother’s history of mental health problems and (in due course) of this incident itself diminished, leaving those who were working with Child M and his mother with a limited understanding of possible risks to Child M. At no point after the family moved to Oxfordshire did any professional have a comprehensive knowledge of the mother’s mental health history. 2.15. Over this period there were a substantial number of changes in the professionals working with Child M and his mother, most notably when case responsibility was transferred both in the local authority social care service and in the mental health service when the family moved in mid 2015. In Oxfordshire different agencies started to work with the family and in most agencies there was a natural turnover of professionals. 2.16. During the 2015 episode the mother’s psychotic symptoms had focused on her child. Details of these indicators of possible future risk to him were not known to those such as the health visitor, children’s centre, pre-school and school who undertook assessments or provided care for Child M in Oxfordshire. Case transfer and closure summaries did not contain the full details of the incidents that had placed Child M most at risk and would do so again if repeated. 2.17. By 2017 the mother’s mental health was believed to be stable and as far as everyone understood she was complying with a regime of treatment that 4 Anne Richardson Consulting Ltd (2019) Independent review into treatment and care provided by Oxford Mental Health NHS Foundation Trust. NHS England 7 had been in place for at least 15 months. There was no evidence of a return of her previous psychosis and she had been assessed and was due to start receiving treatment for a relatively minor mental health concern (travel phobia). 2.18. The main agency working with Child M and his mother at the time of his death was the school. Staff there had discovered minor details of the mother’s mental health history fortuitously or from comments made by the mother, but no detailed records had been passed from other agencies. The school had only a general idea that the mother had been mentally ill in the past (by that time over two years previously) and no idea of the most concerning comments that she had made at that time. 2.19. Across all of their contact with the mother, professionals found further, understandable reassurance in their very positive observations of Child M and his interactions with his mother. Both in Swindon and in Oxfordshire Child M was closely observed by a range of professionals (including health visitors, social workers, children’s centre, nursery, preschool and school staff). The consistent picture provided was one of warm, positive interaction between Child M and his mother, a child who had reached all of his expected developmental milestones and who was calm and happy. Child M was cherished by his mother who was anxious about how he would mix with other children and settle in at school. At times there were minor, individual signs of neglect, though even had information about them been collated they would not (even with the benefit of hindsight) have merited a referral to social care. Signs of possible risk in the days before Child M’s death 2.20. Review of records gives no indication that any of the professionals involved missed signs of a serious deterioration in the mother’s mental health or risk to Child M in the days or weeks leading up to his death. Although it is not possible to be certain about the mental state of Child M’s mother when he was killed in March 2017, the circumstances point to a sudden and drastic deterioration in her mental health. 2.21. The professionals working with Child M and his mother in early 2017 had a good level of contact with her and every reason to believe that they had a good understanding of the immediate circumstances. In contrast they had only a very limited understanding of the nature and level of risk that had existed historically. 2.22. It is possible that a fuller understanding of the history might have made professionals more cautious when Child M and his mother moved to Oxfordshire in 2015 or when she reported worries about her mental health in 2016; even if different arrangements had been put in place to coordinate services for Child M at those times they are likely to have been reviewed and relaxed by early 2017. At that point she was cooperating with professionals even if she did not always agree with their opinions. There 8 was no indication that the mother’s mental health was deteriorating, no reason to see the mother’s pattern of behaviour as presenting a high level of risk and no reason to think that steps needed to be taken to safeguard Child M. 2.23. The SCR identified a number of aspects of service provision where there were identified weaknesses in practice or challenges for agencies which could have implications in other cases: • The way in which the needs of Child M and his mother were assessed, including the risk that she might harm him • Whether assessments were based on a full knowledge of the history of the mother’s mental health difficulties and the concerns about the impact of these on the parenting of Child M • How the family’s move from Swindon to Oxfordshire and the transfer of information between agencies affected the understanding of risk and the provision made • Whether Child M’s extended family (and particularly his maternal grandparents) should have been involved. 2.24. Despite its tragic outcome this was a case where agencies with responsibility to work with children were properly focused on the needs of the child. The SCR has identified strengths in professional practice and service provision which would contribute to good outcomes for children in other cases. These included: • The decision to accommodate Child M in Swindon and the collaborative working between social care and mental health professionals while he was in foster care and after his return home • The active approach taken by a number of professionals and agencies in Oxfordshire to obtain information from their counterparts in Swindon when the family moved into their area • Services provided to Child M and his mother by agencies in Oxfordshire (including the health visitor, children’s centre and pre-school) which promoted his wellbeing and supported her mental health needs (so far as they could be ascertained) • The allocation of additional support and resources by Child M’s school so that his mother had a point of contact with whom she could raise any concerns about him. 2.25. These are also described in the full SCR report. Agencies involved should consider further what enabled staff to work in this way so that the approaches taken can promoted. 3. RECOMMENDATIONS Introduction 9 3.1. The review has made recommendations in the following areas of practice and service provision: • Establishing the principle and practice of joint assessment of need and risk by mental health and children’s social care professionals when a patient with a psychiatric illness has the care of children or close contact with children • Improving the practice of professionals in accessing and taking account of historical records when undertaking assessments • Improved transfer of cases of children in need across local authority boundaries • More efficient review of complex cases where service users have been seriously harmed or killed. 3.2. These recommendations are designed to complement those made by individual agencies in internal reviews of their involvement with Child M and his family. Recommendation 1 3.3. Oxfordshire LSCB should establish the extent to which professionals in mental health services and local authority social care professionals and others working with children in their areas undertake joint assessments. The LSCB should consider how best to promote joint assessment activity when a patient with a psychiatric illness has the care of children or close contact with children and identify any barriers to implementing this approach. Assessment activity should be supported by multi-agency training which provides a better mutual understanding of knowledge, roles and responsibilities. 3.4. Swindon LSCB should consider the relevance of this recommendation for its member agencies. Recommendation 2 3.5. Oxfordshire Safeguarding Children Board should consider whether its current threshold of need document places sufficient emphasis on the need to consider previous and historical concerns and might reoccur in the life of a child, such as the re-emergence of a serious parental mental illness. Recommendation 3 3.6. Oxfordshire LSCB should satisfy itself that mental health service providers and GPs have adequate arrangements in place to identify and assess the needs of the children of patients who are being treated for psychiatric illnesses, by either the GP or the appointed care coordinator. Recommendation 4 3.7. Oxfordshire and Swindon LSCBs should ensure that member agencies set their staff clear expectations for obtaining and reading case histories and 10 giving them due weight in assessment. Member agencies should report back to the board on progress and any difficulties in meeting the agreed standards. Recommendation 5 3.8. Swindon LSCB and Oxfordshire LSCB should identify current approaches to the transfer in and out of their authority areas of child in need cases and others that fall below the threshold of child protection (i.e. under Section 47 investigation or subject to child protection plan or care proceedings). Boards should satisfy themselves that current approaches are satisfactory. Recommendation 6 3.9. Swindon LSCB and Oxfordshire LSCB should seek reassurance that the implementation of the General Data Protection Regulation (GDPR) has not led to the imposition of inappropriate limitations on information sharing about the welfare of children in need, including those who move in and out of the local authority area. Recommendation 7 3.10. Oxfordshire Safeguarding Children Board, its member agencies (including health commissioners and the police) and NHS England should consider how in future a more streamlined approach to reviewing complex incidents can be developed. The approach should take account of statutory reviewing processes including Local and National Serious Child Safeguarding Practice Reviews, Mental Health Homicide Reviews and Domestic Homicide Reviews. |
NC043972 | Death of three children and their mother in April 2013. Children were aged 3-years, 2-years and 13-months at the time of their deaths and mother was 7 months pregnant. Evidence suggests mother killed the children prior to committing suicide by jumping from a multi-story car park. All three children were subject to child protection plans under the category of neglect. Parents, particularly mother, were highly resistant to professional involvement; father's presence in the home was not constant and it is unclear what periods of the children's lives he was involved in. Issues identified include: adversarial relationship between parents and professionals from outset; parental non-attendance at health appointments and child protection meetings; lack of stimulation and infrequent opportunities for children to interact with others leading to social, language and emotional development delays; and professional uncertainty over mother's mental and emotional health. Identifies lessons learned, including: background information about parents' childhoods is essential to understanding their parenting capacity; and the Public Law Outline process requires strong management oversight and an understanding of the separate roles, responsibilities and accountability for decision-making of children's services and legal services.
| Title: Serious case review: the Anderson family: overview report. LSCB: Suffolk Safeguarding Children Board Author: Ron Lock Date of publication: [2014] This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. 1 SERIOUS CASE REVIEW THE ANDERSON FAMILY Overview Report Independent Safeguarding Leads; - Bob Cook (Chair of SCR Team) - Ron Lock (Report Author) December 2013 2 Contents 1. Introduction 1.1 – 1.3 Page 3 2. Serious Case Review process 2.1 – 2.9 Page 3 3. Summary of case and findings 3.1 – 3.9 Page 6 Genogram Page 8 4. The Facts : – June 2009 – May 2010 4.1 – 4.16 Page 9 June 2010 – July 2011 4.17 – 4.25 Page 12 August 2011 – December 2011 4.26 – 4.34 Page 14 January 2012 – December 2012 4.35 – 4.45 Page 15 2013 4.46 - -4.56 Page 17 5. The Children’s Experience 5.1 – 5.12 Page 20 Analysis 6. The legal strategy and CP Plans 2009/10 6.1 – 6.20 Page 22 7. The legal strategy and CP Plans Aug 2011 onwards 7.1 – 7.31 Page 26 8. Physical and Emotional Neglect 8.1 – 8.13 Page 34 9. Working with a hard to reach/avoidant family 9.1 – 9.21 Page 36 10. The Impact of work with a complex family 10.1 – 10.4 Page 42 11. Maternal Mental Health 11.1 – 11.6 Page 43 12. Organisational Factors 12.1 – 12.5 Page 44 13. Summary 13.1 – 13.7 Page 45 14. Lessons Learned 14.1 – 14.13 Page 47 15. Recommendations 15.1 – 15.7 Page 48 3 1. INTRODUCTION 1.1 This report will summarise the findings of the Serious Case Review which was conducted in respect of the multi-agency involvement with the Anderson family, for the period of almost 4 years before the tragic deaths of all three children in April 2013 and the subsequent death of their mother on the same day. At the time of her death the mother was 7 months pregnant. The parents of the children were not married and the father of all three children lived separately from the family for much of the period of time of this review. 1.2 The Anderson family were known to a variety of child care agencies from the time of the mother’s first pregnancy in mid-2009 up until the deaths of all three children. At the time of writing there has been no coroner’s inquest, although current evidence would suggest that the mother took the lives of the children prior to taking her own life. 1.3 There were two periods of time when Child Protection Plans were in place for one or more of the children; for almost a year up until June 2010 and then from October 2011. These Plans identified concerns in respect of possible physical and emotional neglect, and were in place at the time of the children’s deaths. There were also legal initiatives to obtain care proceedings in respect of the first child and although these were withdrawn, later legal strategy meetings were held to continue to consider if the children met the criteria to seek care or supervision orders. Overall there was very limited success in engaging the mother and the father in professional interventions especially by Children and Young People’s Service (CYPS) although other professionals such as health workers and children’s centre workers did achieve a limited level of involvement. 2. THE SERIOUS CASE REVIEW PROCESS 2.1 Suffolk Safeguarding Children Board made the decision to conduct a Serious Case Review (SCR) which reflected the government guidance contained in Working Together March 2013. The purpose of the SCR is to “Identify improvements which are needed and to consolidate good practice”1. Additionally, SCRS should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed, and • Makes use of relevant research and case evidence to inform the findings.2 1 Paragraph 7, Chapter 4, Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – HM Government - March 2013 2 Paragraph 10, Chapter 4, Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – HM Government - March 2013 4 2.2 Suffolk Safeguarding Children Board chose to use a SCR learning model to undertake the review consistent with the principles in the government guidance. This model is referred to as a Partnership Learning Review, and formed the basis of the work of the SCR and is attached as an appendix to this report. 2.2 An independent Chair, Bob Cook, was appointed to lead the SCR and another independent person, Ron Lock, was appointed to be the author of the SCR Overview Report. Both independent persons have considerable experience in safeguarding children and young people, including involvement in SCRs in other parts of the country. Neither had previously worked in Suffolk in a professional capacity. 2.3 Senior managers from Suffolk were appointed to be part of the SCR team, whose role was to assist with the scrutiny and analysis of professional practice in the case. These were: - - Detective Supt., Joint Protective Services, Suffolk Constabulary - Manager, Suffolk Safeguarding Children Board - Designated Nurse Safeguarding Children and Looked After Children, Suffolk Clinical Commissioning Groups - Director of Patient Safety and Quality, Health East - Interim Head of Safeguarding, Children and Young People’s Services, Suffolk - Lead Lawyer, Suffolk Legal 2.4 The SCR team met on three occasions with the independent chair and independent author in order to progress the SCR and to provide comment in respect of draft Overview Reports. Members of the SCR team were also very active in their contribution to the two one-day “Learning Events” which were conducted with frontline practitioners and their line managers. These meetings were held in order for as many of the practitioners and line managers who had worked with the family as possible, to contribute to the SCR team’s understanding of the detail of the work that had been undertaken with the family and to contribute to the analysis of professional practice. In total 41 professionals attended the first Learning Event and there were 31 attendees at the second. The local agencies represented by these professionals at the Learning Events were: - East Coast Community Health Care (e.g. health visitors, named nurse for safeguarding) - Norfolk and Suffolk NHS Foundation Trust (named nurse for safeguarding) - Ipswich & East CCG/West CCG (named nurse for safeguarding) - James Paget University Hospital (midwives) - Suffolk Constabulary - Education (e.g. head teachers, nursery school staff) - Children and Young People’s Services (e.g. social workers and line managers, children centre workers, family support practitioner, child protection conference chair) - Legal Services - Waveney District Council (Housing Options advisors) - Cafcass - Access Community Trust 5 2.5 The outcome from these Learning Events, which were chaired by the Independent Chair of the SCR Team, was clarification of the factual details of the work undertaken with the family and contributions to the analysis of practice which in turn informed the key lessons learned from the work undertaken with this family. The findings from these Learning Events have been included within the body of the report in terms of both the factual and analysis components. Additionally to ensure greater understanding of particular parts of the work with the family, the Independent Overview Report Author spoke individually with some of the practitioners and managers 2.6 At the outset of the SCR process, detailed chronologies were requested from all of the involved agencies as identified above, of their involvement with the family from the time of the mother’s pregnancy with her first child in early/mid 2009 until the children’s deaths in April 2013. Each person completing the chronologies (the Individual Agency Representative) had no direct line management involvement in the case and was also asked to complete a summary of commentary and analysis of the professional practice within their agency. They also completed a separate document to identify any organisational or contextual factors which may have impacted on the work with the family. All of this material was collated and reviewed by the SCR Team, and the factual contents of the chronology were fully shared with all attendees at the Learning Events. 2.7 Each of the Learning Events were evaluated by the completion of a questionnaire by attendees, and this will prove useful for the Suffolk Safeguarding Children Board in determining what lessons to take from these evaluations and how these might inform the structure of future SCRs locally. The SCR Team have learnt lessons from the sessions, and those participants who felt a different approach would have been more productive, have made their views known. Overall the evaluations considered the different components of the Learning Events and an amalgamation of all the responses rated the Learning Events as: - Excellent (22%), Good (67%), Adequate (10%), and Poor (1%) 2.8 The father of the children was interviewed by the independent Overview Report author in order to gain an understanding of his experiences of the professional interventions with himself, the children and their mother. His contributions are included in the body of the report. Additionally, the maternal grandparents met with the Chair of Suffolk Safeguarding Children Board and LSCB Manager to discuss the Report and lessons identified. Their views were shared with the overview author. 2.9 At the time of the presentation of the final Overview Report to the Suffolk LSCB in December 2013, the “Lessons Learned” in section 14 of this report were utilised to develop appropriate actions by local agencies and the LSCB for future learning and for the development of safeguarding practice in Suffolk. 6 3. SUMMARY OF THE FACTS AND FINDINGS OF THE SCR Facts 3.1 In terms of professional interventions with the family, this can be divided into three distinct phases. The first began just prior to the birth of the couple’s first child, Levina, when there were high levels of professional concern about possible neglect of this child and the parental refusal to accept any professional advice or contact. As a result, the unborn child was made subject to Child Protection (CP) Plans and Care Proceedings3 were instigated although an application by the Local Authority was not granted by the court in June 2009. 3.2 By the time Levina was approximately 6 months old, the local authority withdraw the Care Proceedings in recognition that the assessment which had been completed did not provide the necessary evidence to substantiate the concerns. Levina nevertheless remained subject to CP Plans for a further 6 months before they were discontinued when it was considered that the family were appropriately accessing universal services and living with the family network which was viewed as a protective factor. 3.3 The next phase of professional involvement was from June 2010 to July 2011 when there were no formal “child protection” or “child in need” inter agency procedures in place to work with the family although some concerns were on occasions raised about possible neglect. By this time, the second child of the family had been born. Health and local children’s centre involvement continued throughout much of this time, although this was limited in nature because of the parent’s continued reluctance to accept professional interventions. 3.4 The final phase of professional interventions occurred from August 2011 until the death of the children when they were all subject to CP Plans under the category of neglect. The third child of the family was born in May 2012 and included in the CP Plans. Although legal interventions were again considered in order to protect the children, the plans for these drifted and ultimately no Care Proceedings were initiated. Although there continued to be considerable concerns about the care of the children, the refusal of the mother particularly to accept any intervention, meant that there was minimal contact with her and the children, and therefore the CP Plans achieved very little. Parental attendance at Child Protection Conferences (CPCs)4 and Core groups was almost non-existent. Whilst the mother’s behaviours and attitudes to her children and to professionals raised concerns during this time, the process of the CP Plans was unable to secure any psychological or mental health assessment of the mother. 3 Care Proceedings are when a court is asked to consider the care needs of a child or children based on evidence of the care of child concerned provided by the local authority and other agencies involved with the family. A number of court hearings are usually held before a final hearing can hear all the evidence and assessment of the family and a final decision is made. 4 A formal meeting of professionals from key agencies such as Health, Police, Children and Young People’s Services and those professionals who have worked with and know the family. The purpose is to decide the level of concerns for any child or unborn child in the family and whether they are at risk of significant harm or will likely be in the future. The parents are invited to attend the full conference. 7 Findings 3.5 Despite some committed interventions by a number of practitioners, no success was ever achieved in effectively engaging the family in interventions by professionals, and this meant that overall the implementation of the CP Plans was significantly compromised. The early application for Care Proceedings in respect of Levina set a tone of an adversarial relationship for the parents, particularly with Children and Young People’s Services (CYPS), and this strained relationship changed little for the final period of CP Plans and up until the deaths of the children. 3.6 Overall, the child protection process was implemented in line with procedures, but were not ultimately successful in engaging this most challenging of families who were avoidant of professional interventions. It was inappropriate for the CP Plans to continue largely unchanged for a period of eighteen months from August 2011 without some form of review and formal revision of the way forward with the family. Whilst there was a system of senior management overview in place, it did not impact on this case. 3.7 Although there was much consideration of the need for a legal intervention to secure the safety of the children during the latter phase of involvement with the family, this was never taken forward and unfortunately the process was allowed to drift for a period of over a year. Ultimately this was the key remaining strategy to use as a form of sanction with the family and to demonstrate the seriousness of the professional concerns, but its effectiveness was never tested. 3.8 Whilst the main professional concern was in respect of neglect from both a physical and emotional perspective, it was the physical neglect which was given most attention when there was also evidence of emotional neglect. Overall the professional interventions and the concerns about neglect were never sufficiently supported by evidence that needed to be collected and collated on a multi-agency basis. Emotional neglect proved especially difficult for professionals to evidence, although a more concerted collation of these areas of concern could potentially have realised greater evidence. 3.9 There had been no known history of either the mother or the father intentionally causing physical harm to the children, or of any self-harming episodes by the parents themselves. In this respect, the deaths of the children and their mother was completely unexpected and not predictable or thought in any way likely, from what the professionals knew of the family. _____________________________________________________________ 8 Genogram/Family Tree Kyden 11.5.12 Addy 1.6.10 Levina 21.7.09 Mother Father Unborn Child All three children died in April 2013 – Their mother died at shortly after – she was aged 23 years old at the time. The father was aged 22 years. 9 4. FACTUAL SUMMARY OF THE CASE – KEY EVENTS The year from June 2009 – May 2010 4.1 The midwifery services made a referral to Children and Young People’s Service (CYPS) in June 2009 due to the mother’s poor ante natal attendance, her vulnerability, difficult family background and low mood. A “cause for concern” sheet was also shared with the health visitor. Numerous attempts to contact the mother by the midwife and encourage her to attend medical appointments had been unsuccessful from March 2009. In response to those concerns the social worker who was allocated the case (a student social worker) made direct contact with the family on the 29th June 2009, which was the third occasion of trying. The Child Protection/Legal processes 4.2 Very soon after the referral was received by CYPS, who considered the concerns to be serious, plans were made for an Initial Child Protection Conference to be setup, followed immediately by a legal initiative to secure Care Proceedings in respect of the new born child. These processes then ran simultaneously for the period from July 2009 until May 2010 in respect of Child Protection (CP) Plans, and until November 2009 in respect of the Care Proceedings. 4.3 Therefore the first key decision made at this time by CYPS was to call an Initial Child Protection Conference (ICPC) in respect of the unborn baby, not only because of the poor engagement of the parents but also because “some prior knowledge about both parents suggests that parenting capacity will be limited”. As a result of the ICPC on the 13th July 2009 a Child Protection Plan5 was established for the unborn baby. Although invited, the parents did not attend the ICPC and the mother refused to speak with either the police officer or social worker later that day when a visit was made to the home. The father was however engaged in conversation. 4.4 The next significant event was that a Legal Strategy Meeting6 was called the day after the ICPC with the legal advice given that the threshold criteria for care proceedings were met in these circumstances. CYPS’s interim care plan was for an Interim Care Order7 and removal of the 5 If a child or unborn baby is considered by the ICPC and by later CPCs to be at risk of or suffering significant harm, then a set of Child Protection Plans are set up to address the concerns and identify what needs to happen to reduce the risks and improve the care of the child. These plans identify who will action and monitor each specific plan. 6 A legal Strategy Meeting is usually held between Children’s Social Care staff and the legal officers of the local authority, when legal advice is sought about the strength or otherwise of evidence of concerns about a child within a family, and based on that advice Children’s Social Care will decide whether to initiate care proceedings. 7 This is where an application is made for a Care Order but that the application is adjourned by the court, potentially whilst awaiting further assessment. The court will only grant an Interim Care Order if it is satisfied that there is reason to believe that the threshold criteria pertaining to a full Care Order are present. This is a short term measure which will likely include the child being removed from parental care, and will last for a specified period of time until a full Care Order is applied for or the application is removed. There are restrictions to the time period for which Interim Care Orders can continue to exist. 10 baby to foster care in order to complete a core assessment to identify either alternative carers for the baby or whether it would be appropriate for the baby to be returned to the parents. 4.5 Levina was born on the 21st July 2009. CYPS formally requested the parents to agree to a voluntary arrangement for Levina to be placed into care (under Sec. 20 of the CYP Act 1989) – they refused. 4.6 In terms of the Care Proceedings, an Interim Care Order was not granted in court on the 24th July 2009 and the child’s guardian opposed the application and did not consider that there was sufficient evidence of concerns to warrant separation of Levina from her mother. The case was progressed by way of a written agreement that the parents would cooperate and work with professionals. Assessments were to be undertaken to ascertain parenting capacity. 4.7 The child’s guardian initial Analysis and Recommendations Report in mid-August 2009 identified that there were no concerns about Levina’s health, that the mother had cooperated sufficiently with professionals and that the local authority should provide assistance and support to the mother. The guardian stated that she was unclear about CYPS’s current concerns and whether these met the Care Proceedings threshold. 4.8 At the 5th and final court hearing in November 2009, the local authority applied to withdraw from the Care Proceedings. The core assessment had been completed but the evidence it contained did not support the Court making an order. Whilst there was satisfaction that Levina’s basic needs were being met, there remained concerns about the stability of the family and of their housing situation. It was recognised that the CP Plans were continuing and it was anticipated that these would monitor the situation and address any concerns if they arose. The child’s guardian’s position had been that the family were in the need of support and that if the care proceedings were dismissed (or withdrawn) that Levina should remain subject to the CP Plans. 4.9 The CP Plans therefore continued beyond the cessation of the Care Proceedings, and there were Core Groups8 held in August, October and December 2009, the first of these not attended by the parents. They also did not attend the Review Child Protection Conference (RCPC)9 in October 2009 although the decision was made to retain Levina as subject to CP Plans. It was only the father who attended the next Core Group in April 2010 and at the following RCPC on the 4th May 2010, the CP Plans were ceased because it was considered that there were appropriate preparations (relevant equipment acquired) for the next child, soon to be born, and that the parents were accessing universal services. 8 Core Groups are held regularly between Child Protection Conferences and include the key professionals working with the family along with the parents, to monitor and ensure that the Child Protection Plans are being progressed. 9 Review Child Protection Conferences follow three months after the Initial Care Protection Conference if the child/children have been made subject to Child Protection Plans, and then continue on a six monthly basis until the child/children are deemed to no longer need a Child Protection Plan. 11 Concerns about parenting and engagement with professionals 4.10 The professional’s concerns about the care of Levina related to the parental lack of preparation for her birth, and then for concerns about neglect in terms of sufficient feeding, lack of stimulation and that overall the parents were refusing to engage with professionals. 4.11 At a very early stage of intervention, there was a mental health assessment with the mother and father at home on the 15th July 2009 by a mental health link worker, which identified no presentation of depression or anxiety in the mother, and she denied ever experiencing these. Overall there was no presentation of concerns about mental illness and therefore it was concluded there was no role for mental health services. The couple stated that they were unhappy with CYPS’s “interference” and the style of intervention at this time, e.g. regular visiting, once with the police, and checking food cupboards. The issue of the need to assess the mother’s mental health arose again from a Core Group meeting a month after the earlier assessment, and whilst an appointment was set up for the mother to meet with the mental health link worker on the 25th August 2009, the mother did not turn up and later said that she did not need it as she considered she was not suffering from post natal depression. 4.12 There were concerns about Levina’s physical development and her poor weight gain and in this regard, breast feeding nurses were involved to support and monitor this with the mother. In fact Levina was admitted to hospital in early September 2009 following serious concerns about her low weight although she had gained sufficient weight to enable discharge 3 days later. The mother had remained in the hospital throughout the stay. 4.13 Different views emerged regarding worries about Levina’s poor weight gain, sometimes with conflicting information about the actual level of concern. There were other concerns about how easily the mother could be distracted and that she did not always recognise when the baby was hungry. There were periods of progress in the feeding by the mother and despite some of the difficulties of getting access to the mother and child, there was some consistency of involvement by health professionals, with regular checks on the status of Levina’s dirty nappies to help identify whether she was being appropriately fed. 4.14 In terms of the concerns about parental non engagement with professionals, there was considerable evidence of the parents avoiding contact with CYPS staff who were endeavouring to undertake the parenting assessment, with only six out of the 12 assessment sessions attended by the parents by 11th September 2009. On other occasions of planned visits to the home, reasons were given for not being present or cancelling, and when they did attend appointments, they were often very late. There was greater success for the health interventions. Some of the inconsistency of the parental attendance at Core Groups and CPCs has already been referred to. 4.15 The family moved to stay with friends when they were evicted in October 2009. The family had made formal requests for CYPS to provide financial assistance to avoid the eviction, but they failed to provide the necessary financial details to enable this to be considered. The family eventually moved to live with the paternal grandparents. 12 Summary 4.16 During the first year up until May 2010, the level of professional concerns about the parenting capacity of these parents, especially the mother, began at very significant levels, leading to the establishment of CP Plans and an application for Care Proceedings being made with the plan to place the new baby in foster care. The first social worker to be appointed to the case was a student social worker. Whilst the threshold for making an application of Care Proceedings had been met, the social work assessment provided insufficient evidence to justify the making of a Care Order, and was therefore withdrawn. Levina needed a brief hospitalisation because of weight concerns but overall the initial serious concerns about parenting ability and Levina’s physical care were not supported by the evidence, although concerns in this respect nevertheless remained for much of the year. The avoidance and lack of parental engagement in the professional interventions continued to be a concern and it remained the view of professionals that the family would continue to need support to manage Levina and to plan for the new baby, which was due. Nonetheless, at the end of this period, there was greater professional confidence in the parenting and care of Levina, leading to the CP Plans ceasing. A parental mental health assessment had not identified any concerns about depression or anxiety. Because of the understanding that the parents were engaged with universal services, then CYPS closed the case on the 21st May 2010. The year from June 2010 to July 2011 4.17 The first key event for this period of a year was the birth of the couple’s second child, Addy on the 11th June 2010. Housing Issues 4.18 It was also during this period that the family had further housing difficulties and were evicted for rent arrears. The couple and the children went to live with a relative who then wrote a letter to evict them by the 5th July 2010. However no eviction followed as the couple did not want to move into B&B accommodation. The father made a homeless application to the District Housing Department but by the end of July 2011. 4.19 By August 2010 it was apparent that the family were “sofa surfing” and were living with another family previously assessed by professionals as “unsuitable” – there were concerns that they were living in unkempt conditions and in an environment that was unsafe. The mother and children then moved into temporary council accommodation without the father who moved into hostel accommodation. CYPS had been briefly involved because of the housing difficulties but then closed the case at this time in their understanding that the housing problem had been solved. This was not the position of the housing authority who considered that the housing issues still had not reached a satisfactory conclusion. 4.20 In December 2010, the mother and children moved to an address in Lowestoft and then moved to another home in Lowestoft by February 2011. There were no further house moves. 13 Concerns about parenting 4.21 There was a domestic abuse incident reported which occurred in November 2010 when the mother complained that the children’s father was outside the home refusing to leave and being aggressive. As a result, a Strategy Discussion between the Police and CYPS was held, and it was decided that there was no need for any further action. 4.22 At the end of May 2011, concerns were expressed from an anonymous referral about neglect, claiming that the children had been sleeping in a double pushchair for 13 nights and had only been fed biscuits. This resulted in CYPS initiating an Initial Assessment two days later on the 30th May 2011. The result of this was that as the mother had agreed to engage with the local children’s centre, then CYPS subsequently closed the case. 4.23 On the 27th June 2011 there was a domestic abuse incident when the mother called the Police and claimed that the father had pushed her whilst holding Levina. The Police reported that whilst the flat was in reasonable condition, the children looked malnourished, very tired with full nappies. There were bits of bread lying on the floor with only a large carton of milk in the fridge and a dry loaf of bread. There was a home visit by the social worker on the 28th June 2011 and a visit from the family support worker from the children’s centre followed the next day when the children were witnessed to be in play pens for long periods with little stimulation and both silent – Levina looked very thin. The support of the nursery was offered but refused by the mother – this was because the mother said that she thought that the children would be exposed to sexual abuse. 4.24 By early July 2011 the health visitor also witnessed the children in their play pens when she visited, but they were removed and fed by the mother. The health visitor recorded that Levina had lost weight for the second consecutive month and Addy also had a slight weight loss – she was also concerned about the children’s social and emotional development. A referral was sent to Speech and Language therapy. A professionals’ meeting took place on the 11th July 2011. By the 13th July 2011 the health visitor made a referral for a paediatric assessment of the children and two days later, a Strategy Discussion was held because of the health concerns and because of the recent domestic incident. By this time the mother had said that she wanted to renew her relationship with the father and have another baby. A decision was made to call a new Initial Child Protection Conference (ICPC). Summary 4.25 This period of a year from June 2010 began with greater professional confidence about the parenting of Levina and of the preparations and eventual care of the second child, Addy. Therefore, throughout the period there were no child protection or child in need processes in place, although involvement of the health visitor continued, and the children’s centre became involved. Housing services were also involved and eventually the family’s housing situation was satisfactorily resolved. It was the emergence of two domestic abuse incidents and renewed concerns about neglect at the end of this period which led to an ICPC again being undertaken at the end of this period. 14 The four months from August 2011 to December 2011 The Child Protection/Legal processes 4.26 The key decision during the latter part of 2011 was to once again make the two children subject to CP Plans under the category of neglect. Neither parent attended the ICPC on the 3rd August 2011, but it was reported that the children were attending the children’s centre where they were noted to be well presented, clean and playing. A joint visit by the health visitor and social worker to discuss the CP Plan was made on the 5th August 2011 where the children were seen to be interacting well with their father. The mother talked incessantly. 4.27 At the same time a Legal Strategy Meeting was held, when concerns about the lack of stimulation of the children were discussed as well as their language difficulties and that they appeared malnourished. The legal advice to CYPS was that if the mother failed to engage in any of the children’s medical appointments, the local authority should immediately issue Care Proceedings and seek an Interim Care Order. 4.28 Following parental failures to attend the Core Group and because CYPS had only been able to engage the family in a very limited way, on the 20th September 2011 a letter was sent by CYPS to the parents expressing concern about their non-engagement, explaining that should this continue, legal advice would be sought. 4.29 Because it became known that the mother was again pregnant, the Review CPC on the 31st October 2011 for the two children was linked with an Initial CPC for the unborn child. The decision was made that the two children would remain subject to CP Plans and the unborn child would now also be included. The parents did not attend the next two Core Groups up until the end of the year. 4.30 The mother said that she was very offended by the suggestions that she was not a good mother and said that she felt victimised by the child protection process. At a Legal Strategy Meeting on the 16th December 2011, it was decided that the case would move to the pre-proceedings stage.10 Concerns about parenting 4.31 The main concerns during these four months related to lack of stimulation of the children and for example, that the home went from no toys to lots of toys but that the children did not know how to play with them. There were concerns about the poor weight of the children and their physical and emotional development, and this led to a paediatric assessment on the 9th August 2011 by a community paediatrician, when both children were considered to be cheerful and happy during the assessment. The outcome of the assessment was that Levina was small and needed to increase her calorie intake. The paediatrician reported that there was no need for a follow up although the health visitor challenged the outcome and was able 10 This is part of the Public Law Outline process in that these “pre-proceedings” meetings need to be held with the family to explain the process, agree and arrange assessments and to consider possible different options with the family, potentially including the extended family. A successful “pre-proceedings” meeting could negate or avoid the need to progress to Care Proceedings. 15 to discuss the children later with a community paediatrician who advised the children’s weights to be checked every four-six weeks. 4.32 Two days prior to the paediatric assessment, the mother presented at the A&E Dept. of the local hospital as very distressed and talking non-stop, wanting Levina to be examined because of her poor weight gain. Whilst the doctor examined Levina and reported there were no signs of physical abuse, the doctor was concerned about the mother’s high anxiety and accordingly informed the Emergency Duty Services for CYPS. The matter was followed up by a home visit by the day time services 4.33 During this latter four months of 2011, the non-engagement by the parents was of significant concern to professionals, particularly CYPS. Although there was better engagement by the parents with health workers and the children’s centre, this still tended to be inconsistent. The speech and language therapist also experienced difficulties in sustaining contact with the family at this time. A Core Group in November 2011 considered that the mother would benefit from a psychological assessment due to her own childhood experiences and the affect it was having on her own adult/parenting life. Summary 4.34 This four month period saw the reinstatement of CP Plans and formal consideration of legal interventions although the latter was not progressed by CYPS. The concerns about neglect were similar to those identified in 2009/10 and the parental lack of engagement appeared to become more intransigent. Whilst there were concerns by CYPS and the health visiting service about the parenting abilities, these were not necessarily supported by the paediatrician and the speech and language therapist. During this time, the children’s centre began to have some limited involvement and was able to provide some observations of the care of the children. 2012 The Child Protection/Legal processes 4.35 Throughout 2012, Levina and Addy remained subject to CP Plans under the category of neglect, with the third child of the family, Kyden, added to these plans following his birth on the 11th May 2012. Kyden had already been the subject of CP Plans as an unborn child. 4.36 Review CPCs were held in late January 2012 and again in June and November 2012, but only the father attended the first of these. There were no substantive changes to the CP Plans at this time. During the year, of the nine Core Groups held, seven of them were not attended by the parents. 4.37 CP Plans were unable to be progressed because of lack of engagement of the parents. In January 2012, the need for the mother to have a psychological assessment was again discussed among professionals, although it was considered again in June 2012 and more particularly in the CP Plans of the Review CPC in November 2012. On this occasion it was felt that such an assessment would be appropriate for both parents. This proposed assessment was linked to the need to understand the parental lack of engagement and the impact of their 16 background on their parenting. No such assessment was ever able to be progressed. Also at this Review CPC, as the mother was again pregnant, it was noted that an ICPC now needed to be set up in respect of the unborn child and that this would need to coincide with the next Review CPC for the older children. It was also noted that a pre-birth risk assessment would need to be completed. 4.38 In respect of the legal processes, whilst a pre proceedings meeting was held at the beginning of the year on the 13th January 2012 to confirm the instigation of the Public Law Outline11, the parents failed to attend. The meeting identified concerns about the children’s weight, lack of food in the home and a general lack of stimulation of the children. Since a home visit a month earlier there had been ten attempted visits by CYPS but no access had been gained. The meeting considered that the threshold had been met for Care Proceedings. The meeting stated the need for an updated paediatric assessment. 4.39 The parents failed to attend a further pre-proceedings meeting in February 2012 and although it was planned to hold another, this did not take place. Prior to the birth of Kyden in May 2012, there was a plan to undertake a pre-birth risk assessment but this was abandoned as it had not been completed in time, but that a core assessment nevertheless needed to be undertaken. By August 2012, it was decided that once the core assessment and chronology had been completed, that a Legal Strategy Meeting would be called. The assessment was not completed during 2012 and it was acknowledged by CYPS in October 2012 that the Public Law Outline had not been progressed. As a result the social worker was asked to make a home visit and to send a summary of concerns to the Legal Department. There was no record that any summary was sent to Legal. Concerns about parenting 4.40 For 2012, the concerns about the care of the children was little different from previously, but was against the backdrop of increased lack of engagement by the parents, particularly with CYPS. With other professionals, the mother would talk incessantly about her anger with CYPS and her distrust of social workers. Joint visits between professionals often took place to try to facilitate contact with the children, on one occasion on 24th January 2012 the Police attended with the social worker and health visitor, but this led to the mother becoming distressed and only prepared to speak through the door. 4.41 The need for a paediatric assessment of the children was immediately identified by the health visitor and CYPS because of the lack of contact with the children and the lack of clarity about the level of concerns about possible neglect. The parents failed to attend the first paediatric appointment offered, but the two children were eventually seen on the 21st February 2012 by a community paediatrician, (a different paediatrician than the one who conducted and assessment a year earlier), when it was identified that the children were meeting their developmental milestones apart from Levina’s social and interactive skills and that Addy was slightly quiet, with concerns about his vocal development. The paediatrician recommended 11 Public Law Outline (PLO) is a process which requires a local authority to complete all relevant assessments before applications are made to the court. If any pre-proceedings action or assessment has not been taken, the local authority must explain why in the application. 17 that Levina, now 2 years 7 months old, would benefit from a nursery placement. An additional comment by the paediatrician was that the mother was focussed more on her own needs than the children’s. 4.42 Overall there was a continuation of missed health appointments and inconsistent involvement with the children’s centre, but the parents did attend some sessions with the children, although there was very poor take up of the nursery for Levina. (In fact there was only approximately 15% attendance). These initiatives had been promoted when discussed at Core Groups, but it proved very difficult for professionals to encourage the mother to attend and make use of the support facilities being offered. Against medical advice, Kyden was weaned at 12 weeks but due to non-engagement with the family it was not known what he was being weaned onto. He had been observed to be a very passive baby. 4.43 On the 12th November 2012, Levina arrived at nursery with a bruised cheek and marks on her face and the nursery contacted CYPS who suggested that they (the nursery) gain an account from Levina. The explanation from both the mother and Levina was that she had fallen in the car park and the mother said that Levina had been taken to the GP. The health visitor was asked to obtain confirmation of this, which she did and the GP said that there were no concerns about non accidental injury. 4.44 Although it was not apparent that the father lived with the family, he was in evidence for a lot of the time, and on some occasions when seen at home with the children, he was noted to have a good relationship with them and played with them very well. Summary 4.45 Throughout 2012, whilst the child protection and legal processes continued, they had little impact on being able to engage the parents in taking forward the elements of the CP Plan. Evidence of concerns had not been provided to legal services to progress any Care Proceedings. Whilst there were some family support services available for the family, in effect these were sparsely used by the parents. As had happened since the birth of Levina, whilst there were continual professional concerns about neglect, often via poor care witnessed occasionally in the home, overall there was no objective evidence to support these concerns, as demonstrated by the paediatric assessment which did not identify anything significant. Also the health visitor felt that the baby’s (Kyden) weight was a concern whereas the paediatrician considered that it was acceptable. In this way, alongside the lack of engagement by the parents, the professional impasse with the family continued unabated during 2012. By the end of 2012, professionals had become aware that the mother was pregnant with her fourth child. 2013 The Child Protection/Legal processes 4.46 Little changed during 2013 in respect of these processes in that it remained difficult to progress the CP plans although there was some improvement in the parent’s engagement in terms of attendance at the first two Core Groups and the mother’s agreement to an adult 18 attachment interview12, although ultimately this did not go ahead. The alternative for this was the intention for the mother to have a psychiatric assessment. Whilst during January and February 2013, there were plans to have a Legal Strategy Meeting “as a matter of urgency”, this did not materialise. One reason given for this was the agreement to await the outcome of the adult attachment interview. 4.47 A decision had previously been made to include the unborn child as part of the Review CPC, although this meeting was brought forward to 17th April 2013 as no pre-birth risk assessment had been completed. Therefore no further Review CPC was held prior to the children’s deaths. Concerns about parenting 4.48 The mother placed Levina in a new nursery school and she started there on the 23rd January 2013. In this school, Levina told one of the staff that she was not to touch her because she was a bad lady like the ladies in her other school. She said “they did bad things to my body. My mummy says ladies must not do bad things to me.” This was after Levina had been removed from the previous nursery by the mother because she complained that Levina had sustained cuts and bruises there, although the nursery challenged this. 4.49 By mid February 2013, Addy’s weight had increased to the 50th centile13 and Levina was now on the 25th centile although there were concerns about Kyden’s lack of expression (he was 10 months old at this time). The midwife made a referral to CYPS in respect of the unborn baby – the mother was 25 weeks pregnant. At this time the other three children were aged approximately 3 ½, 2 ½, and 9 months old. 4.50 The relationship between the parents became more strained during 2013 with the mother referring to the father’s lack of help with the children, and by March 2013 the father reported that the couple were not talking and that she was jealous that he was spending time with another local resident. The mother reported that the couple had separated. The father later confirmed in his contribution to the SCR that he had separated from the mother at this time but that he continued to visit the flat daily to make lunch for the children. 4.51 The family support worker who had been allocated the case earlier in the year undertook a home visit on the 4th April 2013 when no concerns were identified although the mother said that the children had been out a lot with their father and that she had been up a lot at night because the children kept waking. The mother said that she wanted to attend the next CPC. ____________________________________________________________ 4.52 During the afternoon of the 14th April 2013, the father reported (via his statement to the Police), that he had been at the home and had fed the children lunch on that day and had left 12 An Adult Attachment Interview asks a series of questions that ask the person being interviewed to consider their childhood and how this might affect their thought and behaviour in the present, especially as a parent. 13 If a child’s weight is on the 25th centile, this means that for every 100 children of that age, 75 would be expected to be heavier and 24 lighter. A child’s weight can be similarly placed on a centile chart. Therefore the lower the centile, the lighter or shorter the child to the average (which would be the 50th centile) 19 in the evening telling the mother that she needed to accept that their relationship was over. He was now in a relationship with another woman. 4.53 At 8.05 p.m. the father called an ambulance claiming he had been stabbed from behind by an unknown male. As the initial statement by the father had said he had been in the vicinity of the mother and children’s flat, in the early hours of the next morning, a police officer spoke to the mother at her address through the intercom. The Police also thought the incident might have been linked to a domestic dispute. She said that she had not seen the father for a month and would not come to the door. 4.54 Just before 9 a.m. on the 15th April 2013 the mother was found deceased in a public location – it was believed that she had jumped from a nearby multi story car park. Just after 11 a.m. that morning, the three children were found deceased at their home. 4.55 Later that day, the father informed the Police that it was in fact the mother who had stabbed him following an argument about their separation in which she said that if he remained with his new girlfriend, he would not be able to see the children again. He also explained that soon after the stabbing incident, when in hospital he had told the mother via text that he had not told the Police what had happened and that she should hide the knife. He was then discharged from hospital, although prior to this the mother had telephoned his accommodation and had been both upset and angry about the situation with the father, when speaking to a staff member at the hostel. She said that no one was helping her and that people were trying to take the children away. The mother was offered the number of the Samaritans but declined to take this. 4.56 The mother arrived at the father’s accommodation the next morning at 6.21 hours and handed her flat keys in for collection by the father. It was just over two hours later that she was found deceased. _______________________________________20 5. THE CHILDREN’S LIVED EXPERIENCE The purpose of this section of the report is to try to convey an understanding of the day to day lives of the children and to view the circumstances of family life from their perspective, to better understand the impact and affect upon them of the parenting they received and of other experiences such as school and the involvement of professionals in their lives. The information is taken from case records which described the behaviour and reactions of the children, but also from the observations and recollections of the numerous professionals involved with the family who contributed directly to the SCR process via the Learning Events. Based on what was known about the parenting and adult behaviours and actions, then it is acknowledged the understanding of the children’s experiences has been based on the likely impact of such care. This nevertheless facilitates the analysis from the child’s perspective. Levina 5.1 Levina was 3 ¾ years old when she died, and during her life she experienced a number of house moves and attendance at two nursery schools, although her attendance was so inconsistent that it was said to be like her first time each time she attended. Her father in his contribution to this SCR commented that Levina was always keen and excited to go to nursery school, and that it was very unfortunate that her mother only allowed her to go infrequently. 5.2 Those practitioners who worked with the family had some different experiences of their contact and observations of Levina, but what was clear was that her social development was delayed and she had limited opportunities to establish relationships with her peer group. 5.3 Whilst some practitioners considered that there was a special relationship between Levina and her mother, who it was said idolised her, and always dressed her very well, others considered that there was limited interaction from mother to child, especially as a baby, and that Levina craved attention, often seeking it from visitors to the home as she got older. 5.4 As she developed, Levina went from being quiet, to being boisterous, and was able to display some strong thoughts at nursery and at times appeared fearful of adults when outside home, calling nursery workers “bad ladies”. This view seemed to have been influenced by her mother who presented as highly suspicious of nursery school and of the motivations of professionals generally. In this way this appeared to have influenced Levina’s attitude to people outside her home environment. Levina did struggle with her toilet training. There was evidence that sanitary towels were used as knickers for Levina. Her lack of social development made it difficult for her to follow routine or to play with other children. 5.5 As with her siblings, the children’s father was observed to have had a more natural relationship with Levina and it was said that she was always happy to see him. However his presence in the home was not constant so it was not very clear for what periods he was involved in her life on a day to day basis. He has maintained in his contribution to this SCR that he generally visited the flat daily and prepared lunch for the children on a regular basis. 21 Addy 5.6 Addy thrived more as a baby and the mother seemed more natural in her handling of him. Overall though he was described as a passive child, sometimes left in his pushchair for long periods for which he appeared to give no resistance. He could however be mischievous at times. In terms of his play there was evidence of a level of control by mother in this regard in that on occasions he was only allowed to play with one toy at a time and also on one occasion when he played with girl’s toys, his mother put him in a dress and called him Abby. In contrast to this, the activity of the children dressing up appeared to have been a positive feature of the mother’s care of them. Because of the difficulties in engaging the family, there was limited contact with Addy by professionals, and so it remained unclear what the overall impact of this lifestyle had upon him. At a paediatric assessment it was stated that the mother was more focussed on her own needs than the children’s. 5.7 Addy was considered to be a bright child and like his older sister, had little opportunity to interact with other children and families. He was less than a year younger than Levina and died at the age of 2 years 10 months. Kyden 5.8 Less was known of Kyden who died at the age of 13 months. However the practitioners who came in contact with him considered that there was not a strong emotional bond and that the mother was mechanical in her handling of him. Kyden showed little emotion, though as with the older siblings, was always immaculately dressed. ___________________________________________________________ 5.9 It is striking that observations of each of the child’s experiences were not particularly consistent among those practitioners who came in contact with them, especially of their relationship with their mother and of their personalities and demeanour. Their mother’s energies were often used in avoiding contact and help from professionals, though whilst having three small children to care for would have been very demanding, she did not use the local facilities to any extent that would provide much needed respite. 5.10 As the levels of concern among professionals about the level of neglect in the family fluctuated over time, it may well have been that the children’s day to day experiences also changed and they experienced a wide range of parenting, food and emotional stimulation. There were certainly different occasions when observations of the mother – child interaction were quite concerning in that she was very much focussed on her own needs. On other occasions however, she could relate to the children very positively. These different observations account for the range of experiences at home for the children. The lack of consistency would however have been unsettling for them. 5.11 Their weight fluctuated and on occasions the children may have been hungry. Their father seemed to be much more consistent in his approach to the care of the children and this was reflected in the positive nature which was observed of his relationship with them. However he was not present all of the time, and so did not provide a regular balance of parenting styles but nevertheless generated some additional positive experiences for the children. Lack of 22 social interaction was a factor for all children as well as a lack of regular stimulation – being in play pens or push chairs was often reported as well as the children hardly ever playing outside. 5.12 It was generally difficult to understand with any certainty what the day to day experiences were like for the children as they were seen infrequently by professionals and when they were, it was often their mother who monopolised the contact by talking incessantly, making it impossible to have any meaningful dialogue with her. She appeared to have little insight into the impact of this sort of behaviour on others and upon her children. The lack of regular professional contact meant that it proved difficult for any professional to develop a continuous relationship with any of the children. _________________________________________________________ THEMES FOR ANALYSIS 6 The appropriateness and effectiveness of the legal strategy with the family from the outset, and of the simultaneous work with the children subject to CP Plans for the period June 2009 - May 2010 6.1 It was very evident from the content of the Initial CPC minutes, that before the first child was born to the couple, there were significant concerns about the lack of preparation for the baby, that the mother would leave their accommodation when in labour and deliver the baby unattended, that there had been no antenatal care, and a belief that the mother had mental health issues for which she was not receiving treatment. These were strong concerns which were exacerbated by the limited engagement of both parents who avoided professionals and were clear that they did not want or need any advice. Within these circumstances it was very appropriate that an ICPC had been called to consider the concerns in greater detail on a multi-agency basis. The professional concerns were rightly heightened by the failure of the parents to attend the ICPC. 6.2 An appropriate decision was therefore made to make the unborn child subject to CP Plans, and these detailed a range of actions by professionals to secure the protection of the child. These are referred to later, but one significant part of the Plan was for “legal advice to be sought with a view to initiate Proceedings”. 6.3 The decision to initiate Care Proceedings the day after the first ICPC meant in effect that the CP process was not given any opportunity to assess risk, generate sufficient support to the family or to safeguard Levina once she was born. In fact whilst the initiation of Care Proceedings moved the presenting situation onto a higher threshold of concern, it implied that there was limited confidence in the implementation of CP Plans with this particular family. 6.4 The legal advice given was that the circumstances of the unborn child met the grounds for Care Proceedings, although not for the removal of the baby at birth, although this remained CYPS’s objective via their Care Plan. CYPS needed to make decisions based on a number of factors, the legal advice being one of them, but this crucial part of the Care Plan remained. Whilst, because of the lack of knowledge about the family, there remained a lack of detailed 23 evidence to support the concerns, it therefore seemed unlikely that a court would agree to an order which would result in removing the couple’s first baby at birth. 6.5 At the first hearing no Care Order was made but requirements for a parenting assessment to be undertaken instead. This was appropriate in the circumstances as there was clearly so much of the proposed risk to the new baby and of the parenting capacity which was un-assessed. Significantly the view of the child’s guardian was that the threshold for Care Proceedings had not been reached, and therefore challenged CYPS in this regard within the court processes. This was understandable in the circumstances, as the level of concerns were not yet sufficiently coherent or based on detailed evidence to make any application for Care Proceedings a foregone conclusion. This is not to dispute the high level of concerns which professionals felt, and it was a matter of professional judgement to what extent the new baby’s situation met the legal threshold for Care Proceedings. Whilst the judge did not grant an order, he did agree that CYPS were right to have concerns, though asked them to file a revised Care Plan, and set a new court date. 6.6 Ultimately it was apparent that the simultaneous use of CP Plans and the strategy of pursuing Care Proceedings in the early stages of the case, achieved little in understanding the parenting ability or to what extent Levina was at risk of significant harm at the time of her birth and soon after. However the key question is whether this strong strategy was necessary in these circumstances and at the commencement of the working relationship with the family, and whether a more measured approach utilising the CP Plans only would have had a greater chance of success. 6.7 It is not possible to say whether any different approach, for example without the instigation of Care Proceedings, would have had any different outcome or helped to engage the parents more effectively, but if lessons are to be learned, then there is value in considering whether alternative approaches could have been used and whether they could achieve different levels of success in similar cases in the future. 6.8 It was understood from discussions within the Learning Events that there was a strong lead from Safeguarding in CYPS in that area which gave limited opportunity for professionals from other agencies to challenge child protection decisions or to encourage a different approach. This might help explain why such a strong line was taken with the family at this early time but which went unchallenged. 6.9 As part of his contribution to the SCR, the father recalls this time very well and was clear that CYPS “were trying to take the children off us” but he viewed the concerns they had that Levina would be neglected and then that she was underweight etc., as being unfounded. In fact he referred to them as “lies” which tended to show the strength of feeling that existed between the family and CYPS at this early stage. The father also explained that the mother was even stronger in her negative views about CYPS. This approach to the parents therefore appeared to exacerbate the adversarial relationship developing between the parents and professionals and did not help with the challenge of trying to engage the parents in interventions. 6.10 The decision to withdraw the application for care proceedings in November 2009 was an appropriate one in the circumstances, although the process which led to this happening was 24 unsatisfactory. It was clear that the legal advice to CYPS was that the assessment reports for court did not reflect the level of concerns that had been promoted, were contradictory, lacked analysis and was unable to provide any compelling evidence that the parents would have problems with parenting in the long term, particularly now that Levina appeared to be thriving. The case lawyer expressed a view with the student social worker and the senior practitioner that the case had not been well managed. Also, CYPS had not shared the assessment report with legal services prior to submitting it to court, when this would have been normal procedure. This meant that there was no objective legal oversight of the report and to what extent it was fit for purpose. In fact the legal opinion at the time was that the CYPS evidence required wholesale changes but that it was too late to do so because the documents had already been filed. This reflected a poor communication between the two departments with CYPS seemingly unclear about the expectations upon them. 6.11 CYPS clearly had considerable difficulties in completing an assessment because of the parental stance of not engaging and consistently being unavailable for assessment sessions, but numerous contacts were nevertheless made. The assessment however failed to link the CYPS concerns with sufficient evidence or analysis that the child would be at significant harm in the long term. Clearly the fact that Levina was now thriving went against these concerns. The assessment was not of a sufficient depth and analysis to have supported CYPS’s request for a Care Order. 6.12 One of the reasons for CYPS to have failed to provide a good quality assessment with the depth of analysis that was needed, may well have been the fact that a student social worker was allocated the first key role of working with this family whilst the Care Proceedings were being instigated. This was a most inappropriate decision in the circumstances. It was soon clear that this was a complex case and, whatever the level of supervision and oversight that the student received, it was always going to be a very demanding case which required much greater experience and safeguarding knowledge in order to be able to achieve positive outcomes. If the case lawyer’s views of the court assessment were accurate, then it was apparent that the supervision of the student social worker was inadequate for the tasks at hand. In fact two months into the case, the legal officer recommended that a more experienced social worker be allocated. Whilst other more experienced workers were then added and provided some of the direct work with the family, the student social worker still provided much of the CYPS interventions. For example although the student was not formally identified on the CPC minutes as the key worker for the CP Plans, it was the student’s reports to the conferences which provided the CYPS contribution to the understanding of family functioning and risk. 6.13 To understand how such a decision to allocate a student social worker to the case came about, an unannounced Ofsted inspection in July 2010 of CYPS’s contact, referral and assessment arrangements, identified that in the area where this family lived, there were cases with CP Plans which were “carried out by unqualified staff or staff who are not yet registered as social workers. This practice falls well below expected standards and may place children at risk of inadequate protection”. Whilst this inspection was undertaken approximately 8 months after these particular Care Proceedings were withdrawn, it does seem to reflect the culture of practice that had developed through 2009 and 2010 in this part of Suffolk. An 25 internal post inspection review at that time confirmed these findings and had identified that many of the managers had a fatalistic view of working in Lowestoft, and that as the furthest away from County Hall, resources were tight and that other areas were better staffed. It is important to acknowledge that this was a view which was held, and was not supported by the evidence. A lot of support went into this area at this time and it did not compare unfavourably with staffing in other areas. 6.14 Management oversight of the case during the early stages of intervention was therefore insufficient to ensure that the correct approach to completion of the assessment for court was made and which allowed a student social worker to take such a key role in the case. There was a lack of consistency in terms of different managers and supervisors which certainly did not support effective management oversight. In June - July 2010, extra management capacity was sought and provided for Lowestoft in response to these inefficiencies, nevertheless by October of that year, concerns about poor quality practice and managers holding cases inappropriately were still evident. (See paragraphs 12.1 and 12.2) 6.15 There was a clear link in that whilst there was acknowledgement of the need to withdraw the application for Care Proceedings, it was intended that the CP Plans would remain in place and therefore provide the necessary opportunities to monitor Levina’s care and in particular her weight and development. This was a most appropriate decision in the circumstances as there remained concerns about parenting capacity. 6.16 There was no evidence to suggest that the application for Care Proceedings led practitioners to put any less commitment into the work with the family as part of the CP Plans, although it may well have impacted upon the parents in that their main concern was no doubt to challenge the Care Proceedings. Interestingly however, this did not encourage them to comply with the CP Plan in an attempt to avoid the need for the legal proceedings. The health visitor, Connexions worker and input from midwives and breastfeeding nurses all made important contributions to the CP Plans although they also tended to suffer from the parental reluctance for professional interventions. It was also useful that the child’s guardian attended the first two CPCs which helped to make the links between the CP Plans and the legal strategy. 6.17 For the remainder of this period up until the CP Plans were ceased in May 2010, approximately 6 months after the Care Proceedings ended, the general view from professionals involved with the family considered that the care of Levina was generally good with a belief that their living arrangements with extended family supported this. For example, two contacts by the health visitor had confirmed good care by the parents and that Levina’s development was as expected. The mother was also attending ante natal appointments as she was again pregnant. 6.18 However, between the January and May 2010 CPCs there were only three occasions when the key worker saw Levina although it was said that the parents were engaging better and that they had agreed to a pre-birth risk assessment. However as early as mid-January 2010, a supervision session within CYPS again considered the need for a legal strategy meeting to take place following the refusal of the parents to have contact from the student social worker. However there was no further reference to this, presumably because there was a view 26 accumulating that the care of Levina was at an acceptable level. However it does demonstrate the fluctuation of concerns and how quickly a legal initiative was suggested to address problems in working with the family. 6.19 Despite the apparent agreement of the parents to a pre-birth risk assessment, there was no evidence that this went ahead as a separate piece of work by CYPS. In fact it was the CPC in May 2010 that was also termed a Pre Birth Initial CPC. The input from health practitioners seemed to provide sufficient assurances that the parents were well prepared for the new baby. As had become the norm, neither parent attended the CPC, nor had they attended earlier core groups. 6.20 Although there were arguments that the CP Plans could cease at this stage primarily because the level of concerns had not materialised, a new baby was imminent, and in such circumstances there was a clear potential of the need to continue with the CP Plans whilst the care of a new baby was monitored. In the absence of CP Plans it was therefore questionable that no action was taken to initiate a step down process that would have placed Levina and the new baby on Child in Need plans. Nevertheless there was a view that the family were sufficiently engaging in universal services, although to cease any form of coordinated multi agency interventions just at the time of the birth of a new baby, seemed premature. It may well have been the continuing reluctance and avoidance by the parents to engage in services from CYPS which led to this decision, but it has to be questioned whether there was sufficient management scrutiny about this as a way forward. It was recorded that the CPC recommended no Child in Need plan and that the CPC chair said that the case needed to be closed. Although the latter was not the CPC chair’s decision, it was no doubt influential. CYPS should however have given this matter more critical consideration, despite the CPC chair’s view. 7. The implementation of CP Plans from August 2011 alongside consideration of further Care Proceedings via the PLO process Implementing the Public Law Outline (PLO) 7.1 The reasons for a reinstatement of CP Plans approximately fourteen months later were largely based on similar concerns to those previously, although now there was greater evidence of poor stimulation of the children, their lack of social interaction and the poor development of Levina. The lack of engagement by the parents and their avoidant behaviour was again a consistent difficulty which generated further concerns which, according to the CPC minutes “reduces the possibility of either substantiating or disproving the concerns that the children are at risk of harm”. There were also domestic incidents between the parents, on one occasion when the mother was holding one of the children. Therefore the decision to instigate a new set of CP Plans was understandable. 7.2 It was during this second period of CP Plans that the engagement of the parents was minimal, and the CP process continued without having any real direct impact on the family, other than to create another period of conflict and disagreement between the professionals and the parents and about the quality of their parenting. Once again a Legal Strategy Meeting followed soon after the ICPC, although on this occasion it was decided to await a paediatric 27 assessment and to identify what the parent’s commitment to engage in the CP Plans would be, before instigating care proceedings. There was also a request of the social worker (no longer the student social worker) to compile relevant assessments and analysis from other professionals involved with the family. 7.3 Whilst this seemed a sensible approach to instigate CP Plans in the circumstances, it was questionable whether there was the necessity to again move so quickly into the legal arena, with a Legal Strategy Meeting again taking place within a few days of the ICPC. The legal advice that the CYPS’s grounds for concerns were well founded, confirmed that there was some clearer evidence compared to the previous application for Care Proceedings, but in reality much of the earlier concerns remained, and there had been no progress on the ability to engage the parents. Once again for example, the weight of the children was a matter of concern although, as had happened previously, a paediatric assessment failed to provide evidence to support such concerns. 7.4 It was not until five months after this new set of CP Plans had commenced that a decision was made to initiate the Public Law Outline. This decision seemed to be informed by some evidence of renewed concerns and it was linked in with the CP process in that a major concern was again the parental avoidance of professional interventions. 7.5 There was no inherent difficulty in the CP Plans and a PLO process being undertaken simultaneously, and in fact it would generally be expected that if the PLO process is being instigated in respect of a case of safeguarding, then there should be a CP Plan in place. 7.6 However, whilst the children remained subject to CP Plans during this time from August 2011, the PLO process drifted, even though on occasions it was recorded that pre-proceedings needed to be “urgently” held. In fact the parents failed to attend the arranged pre-proceedings meetings and, similarly to the CP process, the parents could not be encouraged, persuaded or cajoled to attend. The reasons for allowing the process to drift was partly due to CYPS awaiting the completion of assessments, chronology updates and medical evidence regarding whether the children were failing to thrive or not. The completion of such work was compromised by the poor parental engagement, and it remained difficult to identify clear evidence to support the concerns. The continued lack of engagement meant that the ability to achieve a range of multi-agency information and assessments proved difficult. Additionally the relevant CYPS report to the SCR noted that the social worker and manager were to a degree inhibited by the outcome of the earlier proceedings which may therefore have been one of the reasons for the failure to progress this work. The CYPS report for this SCR identified that CYPS workers considered that their practice had been questioned surrounding the thresholds for the first Care Proceedings and which had led to no order being granted, therefore they considered that more solid evidence needed to be put before the court on this occasion. 7.7 Overall the responsibility lay with the CYPS staff to respond to the legal advice they had been given and to seek out the necessary information and assessment to support their concerns. Further input and advice should have been sought from the legal officers if it was felt that there was a mismatch between what evidence was necessary, and what could be provided, but this did not happen. Also, at the outset in August 2011, the legal advice to CYPS was that 28 if the mother failed to attend any medical appointments for the children or failed to participate in assessments, then to immediately issue Care proceedings and seek an Interim Care order. 7.8 In fact the mother did comply with the first paediatric assessment which did not report evidence of developmental delay of the children, but the legal advice was that evidence of non-engagement and the children’s poor emotional development could still be sufficient to support the initiation of the PLO. However it was apparent that CYPS were unclear about the level of concerns and reported back to the legal officer that they would not proceed with the PLO. 7.9 Nevertheless, the reference to the need to process the PLO and for further legal strategy meetings to be held, still figured in discussions within the CYPS management/supervision sessions and were referred to in all of the five CPCs held during this period up until November 2012. A completed Core Assessment by the social worker at the end of October 2011 recommended that a Legal Strategy Meeting should be convened due to the non-engagement of the parents and when a pre-proceedings meeting was set up in mid-January 2012, the parents failed to attend. A later response from the legal officer was that the threshold for proceedings had been met because of the continued lack of engagement and of the concerns about the children’s health and development. Relevant reports from health services and the children’s centre were advised to be collected. 7.10 There was no confirmation that CYPS had implemented the advice given about conducting the required assessments and collating the multi-agency information. It was left to the legal officers to chase up CYPS re what their instructions were and there were enquiries made of CYPS in January and July 2012 and again in March 2013 to ask what the current position was with regard to their intentions with the family in terms of the PLO, but no instructions were received as a result. In fact CYPS’s confused position was evidenced by a new social worker being appointed in mid-July 2012 who recorded the need to “unpick the case and ascertain if the PLO is still in place” even though this had followed communication from the legal officer and the practice manager a short while earlier which had identified that a new paediatric assessment was pivotal to a decision to proceed. 7.11 Clearly there should have been more effective communication between the two departments to ensure that the case did not drift in the way that it did. However responsibility for the drift was with CYPS and one of the main reasons for this was clearly the lack of management oversight. A fairly constant change of social workers and supervisors/managers made this more difficult but there was no evidence of a Service Manager having oversight of what was happening, which should have been the case for a family where the PLO process had been requested to be undertaken. 7.12 Whilst acknowledgement that inadequate safeguarding practice, as confirmed by the Ofsted inspection, may have explained some of the practice deficiencies in 2009 and 2010, by 2011 these shortfalls should have been addressed and yet the poor oversight and management of the case by CYPS continued. Whilst the CYPS report to this SCR identified that “there was good evidence of management oversight and supervision by the practice manager, but there was a lack of grip on the case to ensure progress (of the PLO) was made” it is difficult to 29 reconcile how the two findings could co-exist. Changes in managers and lack of continuity meant that a pattern of starting again emerged. In some respects this reflected the family dynamics of things getting worse, then better, then worse again. 7.13 In many respects this strategy of implementing CP plans alongside a legal strategy for Care Proceedings had been tried unsuccessfully previously and so to take this same route was always going to be fraught with difficulties, especially as the type of concerns about neglect were the same and the same lack of definitive evidence existed for these concerns. The muddled process which then followed with the parents being told that legal interventions were being considered, but with no actions following, must have been very confusing for them and certainly did not aid their engagement with professionals, especially CYPS. 7.14 The very nature of the PLO meant that it was a Local Authority initiative, and therefore tended to exclude other agencies from the process. It was apparent that other practitioners working with the family did not fully understand the legal processes, and even when the legal advice in 2012 was to seek information and assessments from other agencies, this did not fully materialise. 7.15 Professionals trying to work with the family under the auspices of the CP Plans were aware of the continuing expectation that care proceedings were being planned or considered via the PLO process, and from contributions via the Learning Events, it was apparent that this gave some form of reassurance that the challenges of resolving the difficulties of working with the family were being undertaken elsewhere. Additionally, professionals from health and education, were not engaged in the PLO and therefore could not challenge or contribute to it. In this way the PLO process, particularly during 2012/13 was allowed to drift, with no challenge from professionals outside CYPS. 7.16 By June 2912, the children, who now included Kyden at one month old, had been subject to CP Plans for almost a year with no significant change in the parenting and diminishing engagement of the parents in the CP Plan. A month later the legal team contacted CYPS to ascertain what was happening but received no instructions back. At some stage, because of the lack of any progress in the case, and based on the apparent continuing strategy to take legal proceedings, then these should have been formally undertaken. At the social worker’s supervision in October 2012 it was noted that the “case needs refocussing” and that the PLO had not been progressed. However, as had happened on earlier similar occasions, these acknowledged concerns did not lead to any actions on CYPS’s part. A firm decision was needed to either implement Care Proceedings or not, and according to legal advice there had been grounds to do so from the outset of CYPS’s new involvement with the family from August 2011. 7.17 It is not possible to say what success Care Proceedings would ultimately have had if they had have been taken and whether it would have led to the children coming into care, but it was not acceptable professional practice to have allowed this decision to drift for a period of approximately eighteen months. A clear and purposeful stance needed to be taken. The first legal strategy meeting had been held in August 2011 although recommendations from within CYPS or the CPCs to have further legal strategy meetings continued for the next eighteen 30 months with no outcome. A decision at a supervision session to request such a meeting was still being made as late as the end of February 2013. 7.18 The reasons why the PLO proceedings were not progressed and no Care proceedings were initiated appeared to be primarily because: - - Changes of social workers and managers failed to generate any consistent plan, with a tendency to “start again” with the family. - CYPS management oversight was not sufficiently focussed or robust to ensure decisions reached in supervision or in CPCs, were carried through to completion. - The lack of engagement of the family and their avoidant behaviour made it difficult for practitioners to fully assess what level of risks exited for the children. - There was a lack of confidence among practitioners about whether there was sufficient evidence to take legal proceedings – this was probably enforced by the experiences in 2009. - Decisions about legal initiatives were often deferred in order to await assessments (e.g. in February 2013 when there was a decision to await the outcome of an adult attachment interview before proceeding to a legal strategy meeting). - A failure to collect and collate information and evidence which would demonstrate not only physical neglect but also emotional abuse/neglect. - Small parenting improvements or agreements by the parents to engage in a piece of intervention were seen in an overly positive light in consideration that his reflected a more fundamental change. In such circumstances, concerns lessoned temporarily. Disguised compliance by the mother needed to be recognised when it occurred. - The Child Protection process failed to provide any objective challenge to the drift of the case in terms of legal proceedings. - The fact that much effort was being made by a range of practitioners to work with the family and effect change, may have given a sense that the high level of work being undertaken would ultimately achieve some positive outcomes. Implementation of the Child Protection (CP) Plans. 7.19 Generally the five CPCs which occurred between August 2011 and November 2012 had very similar CP Plans attached to them, reflecting the overall lack of progress of the case. The need for legal strategy meetings, to continue to try to engage the family and to monitor the health of the children were always included in some form within these plans. In effect the family had completely disengaged from the process and failed to attend all of the CPCs apart from one attended by the father. Similarly the vast majority of the Core Groups went unattended by the parents. 7.20 The role of the CPC Chair was pivotal in this situation, in that clear recommendations within the CP Plans regarding the legal strategy were not being progressed. Alongside the fact that 31 CP Plans were simply being repeated without any achievements, then the CP Chair had a key role in terms of their objectivity and independence to make strong challenges to CYPS about the lack of progress in the case. In her contribution to this SCR, the CPC Chair said that she was concerned about the lack of progress regarding the legal issues and had raised the matter in supervision and had spoken with CYPS managers on occasions outside of the conferences to try to gain further progress on the legal initiatives. The CPC Chair said that the changes in social workers (there were three between August 2011 and April 2012) and their managers made it difficult to successfully challenge CYPS’s lack of action and decision making. These discussions and any actions agreed within them were not recorded and so it would have been difficult to hold managers to account unless the discussions had been more formalised. 7.21 Also the lack of progress of the CP Plans could have been challenged by agencies engaged in the CPC process, other than CYPS, but this did not happen. It was as though this was not expected practice and to some extent that the different professionals were all in the same situation of trying to engage the family, and so no one stood outside the process in order to make effective challenges to the lack of progress. This is more understandable when looking at the attendance of the different CPCs in that all attendees were those directly involved in working with the family. This had the potential to make it more difficult to be objective. At only one of the CPCs is there a record that a CYPS practice manager attended and although safeguarding nurses had been consistently invited to the CPC’s, none of them attended. This also applied to the community paediatrician. (NB; Due to staff ill health, there were no minutes produced of the June 2012 RCPC, so the Overview Author has not been able to confirm who attended on that occasion).` 7.22 The CPCs were therefore missing any real objectivity or challenge to what was happening. In this scenario of a lack of progress, then an initiative should have been taken to ensure that managers attended, especially with regard to CYPS, but also that other specialists such as within health, who had not had any direct involvement, should have been encouraged to attend. If any case required a fresh set of objective eyes to view what was happening, it was this one, which was generating so much frustration for the professionals involved. There seemed little point in repeatedly inviting line managers and health specialists, if their continued response was to send their apologies. It may have been that a practice had developed whereby these additional invitations were automatically made so as they would have sight of the minutes, but where there was no real expectation of their attendance. If that was the situation then this should have been challenged– in this case there was a clear need for objective, management or specialist input, but it was not achieved. 7.23 It was not apparent that the professionals recognised when a stage had been reached by the involved agencies to identify that “enough was enough” and that a position had been reached when a different set of strategies was needed. During this second period of CP Plans, it was apparent that they were not able to be progressed, and yet this was not seen as sufficient reason to acknowledge the impasse that was now well entrenched, and to formally cease the multi-agency discussions and review what was happening from an objective standpoint and in so doing, to take a fresh and innovative stance with the family. This would need to have been done in conjunction with the family, but if there had been a clearer agreement among agencies when this stage had been reached, and that concerted actions were needed, a new 32 joint and different approach could have been considered. Escalation to senior managers to address the problem at a more senior level was not referred to as an action in the CP minutes although this would have been necessary in order to review the progress formally. Although the parents did not attend the CPCs or the vast majority of Core Groups, the CPC process was unable to change this. This must have given the parents the view that they had control of the situation – and in many ways they did. 7.24 Also the fact that the parents, by failing to attend, negated not only the work of the CP Plans but also the legal process when threats of legal action were made in 2012 but did not materialise, must have given them a sense of control. One potential message this also gave to the parents was that the concerns that the different professionals were expressing, were not in fact as worrying or significant as they were saying, otherwise the formal CP and legal processes would have been more vigorously enacted. 7.25 There were examples of some good inter agency communication within this case in terms of commitment of involved professionals to attendance at CPCs and Core Groups as well as communication between meetings about developments or new concerns within the family. This was clear evidence of a multi -agency approach to working with the family. 7.26 It is now understood that a process has been developed locally whereby if CP Plans are continuing with a family for fifteen months that an exception report needs to be produced for safeguarding managers in order to consider what actions are needed to cease the need for continual CP Plans. However at the time of these particular CP Plans, the cut off period was eighteen months and this stage was therefore not achieved until early in 2013. However this process was apparently less embedded in practice then and not known to the CPC Chair and so it was unfortunate that no formal review or exception report regarding the case took place. 7.27 Whist it is an appropriate principle for more senior managers to review a case that continues to be subject to CP Plans for a prolonged period of time, in this particular case it was not just that the children continued to be subject to a set of CP Plans, but that the plans were basically unchanged. In this respect the CPC system failed to be responsive to continued concerns about the care of the children. The current practice is that two processes are now said to be embedded in practice and that this includes an expectation of the CPC Chair to formally raise concerns to the social worker and manager when the CP Plans have not been progressed leading to the possible audit of the work and the need to identify the patterns of the case. The second process is that the safeguarding managers (who supervise the CPC Chairs) throughout Suffolk meet with equivalent Service Managers to review concerns about the lack of progress of CP cases and review the supervision records to help identify what has transpired and potentially blocked progress, and to consider an appropriate way forward. 7.28 There were infrequently some discrepant views between professionals about risk and concerns about the children, and the parents, especially the mother, used these discrepancies in their arguments that they were meeting the children’s needs. This was certainly the case with the different stance being taken by the child’s guardian at the outset of interventions with the family. Paediatric assessments generally gave the evidence of the children meeting their developmental milestones, but there seemed to be no agreement about whether there needed to be different areas of focus, e.g. the children’s social and emotional development. 33 There was also some disagreement between the health visitor and a paediatrician on one occasion about whether the child’s weight was sufficient. It was not apparent that additional meetings or discussions took place to resolve some of these discrepant views when this would have been helpful. There was one occasion however when the health visitor sought the additional advice from a community paediatrician – this was good practice. 7.29 There was just one occasion when one of the children, Levina, presented with some facial bruising in the nursery school in November 2012. The school appropriately made contact with CYPS but were told to seek information from Levina and gain her explanation, which they duly did. With it being later confirmed that the GP had seen the child and reported no concerns, no further action was taken. However, in trying to engage with hard to reach and avoidant families, it is important to utilise opportunities or crises when they arise, as a means of fresh intervention. Whilst it clearly would have been most challenging to have made the necessary enquiries with the mother and Levina regarding these injuries, to have done so would nevertheless have clarified that concerns did exist and that as the children were subject to CP Plans, that any new concern needed to be investigated. 7.30 This was a missed opportunity not only to address potential and specific child protection concerns, but also to have a different sort of intervention with the family. Procedurally a social work enquiry should have been undertaken as a minimum, or a strategy discussion held with the Police to help to decide the response needed. It was through the health visitor, rather than directly by the social worker, that the GP had said that there was no reason to believe there had been any non-accidental injury. The detail of the medical examination was not recorded when as a minimum it should have been. The fact that it was not a formal child protection medical may account for this although in the circumstances it would have been relevant to undertake this type of medical as part of a formal child protection enquiry. The reasons for CYPS not responding more robustly to this incident seemed to be that the social worker did not consider the injury to be significant or to potentially reflect abuse, and although the first impressions from the telephone call might have given this suggestion, it still needed more detailed enquiry as the child was subject to CP Plans. Interestingly, the RCPC soon after this incident commented that the nursery school needed to review its child protection procedures as a result, although it should have been CYPS who needed to make a direct response to the family at this time rather than identify that the nursery should have responded differently. 7.31 Similarly, the CP Plan did not address Levina’s very poor attendance at nursery, when although this was seen as an important component of support to the family and to aid Levina’s social development, it was not sufficiently challenged by the CP process. Despite nursery attendance not being compulsory, this issue could have been agreed among the professionals as the priority to formally and consistently address to the parents, and to try and achieve a good level of nursery attendance. However, whilst the mother was advised and encouraged about the nursery involvement, the CP Plans were unable to be utilised as effectively as possible in this regard. Also there was a capacity issue within one of the schools which was unable to follow up every child that was absent, particularly when they were not of compulsory school age. Nevertheless the nursery provision for the children provided in two locations, particularly for Levina, was very good and despite the poor attendance, had shown 34 themselves the sort of experience that the children needed to provide some important compensatory experience to their home life. Understanding by professionals of the characteristics and dynamics of physical and emotional neglect of children, and how to intervene effectively. 8.1 Whilst concerns about physical neglect of the children related to low weight, poor food intake and poor physical growth, emotional neglect was more about parental unavailability and lack of response to the children’s emotional and social needs. In this way it was considered that the mother’s focus on her own needs, her obsessive talking, and her refusal to accept advice about parenting or to allow the children to socially interact, meant that they were emotionally neglected. This was considered to be a significant theme for the practitioners and their managers working with this family and yet there was a difficulty in building a full picture of the level of any neglect because of the inconsistencies of engaging the parents and the inability to document the home life, particularly from the children’s perspective. In this way there tended to be an over-emphasis on looking for quantative signs of physical neglect. 8.2 Even though the very first ICPC referred to the parent’s “substantial history with Social Care Services” it was not apparent that the details of this background was ever formulated or put together in a chronology as requested by the CPC Chair. If this had happened, it would have helped to understand the mother’s and father’s own experience of being parented and in turn how this could have influenced their own parenting abilities. 8.3 The urgency of the concerns at the presenting situation with the family, especially at the time of Levina’s birth, and the need for a speedy response, seemed to mean that less attention was given to accessing past information about family background. However this needed to form part of later assessments, but within the SCR process, none of the practitioners involved with the family, knew with any certainty what the parent’s, and particularly the mother’s, own experiences of family life were. 8.4 It was stated in the very first Core Group that “information from Norfolk Social Services about mother’s background was shared”. The detail of this information is unknown to the SCR process and it did not appear to inform any assessments at the time. There was some knowledge of the father’s background, but it was not apparent how this was used to formulate any assessment of parenting. In part the family background, particularly the mother’s, was to be addressed by the planned Adult Attachment Interview, but this was in early 2013 whereas there had been professional involvement since 2009. 8.5 It may well have been that there was no significant history known to CYPS or that the information was not accessed at the early stages of interventions for the reasons identified above. It may also have been that background information was only known by professionals who worked with the family at the time, had been working in the area a long time, but were no longer involved. Whatever the reason, this lack of clarity about the parents’ past experiences, compromised the ability to generate a full understanding of the possible impact this might have had on the children. 35 8.6 Many of the professionals within the Learning Event held the view that the children were living in an environment of continued neglect and that their belief was that this in turn had a significant impact on their overall development. There were clear occasions when there was evidence of this, although much of the concerns were based on professional instinct and sensitivity to the family situation and in particular the mother’s very challenging presentations. This placed more pressure upon professionals to try to intervene and to bring about the necessary changes as quickly as possible, but then was frustrated by the lack of parental engagement. Generally the mother’s response was to ignore professional advice about child care issues and decide that she knew better. This meant that there was often the need to challenge or disagree with the mother, which from her perspective would not have been conducive to establishing a trusting relationship with her. 8.7 There was clearly a disconnection between the professionals and the parents about the quality of care of the children. It was not apparent that the parents saw any need for intervention and that their parenting was perfectly adequate, whilst at such times there were high levels of professional concerns. Apart from the period of time when there were no CP Plans in place, these different views appeared to become further entrenched as time went on. This was certainly true during 2012. 8.8 It was easier to seek evidence of physical rather than emotional neglect, although even this proved difficult to substantiate when concerns about low weights, lack of growth and development were never really supported by the evidence from the health assessments carried out. This in turn made it easier for the mother to claim that her parenting was good enough. Also the predominance of tasks within the CP Plans related to aspects of physical neglect – e.g. the need to monitor weights, implement a feeding chart, ensure attendance at health appointments etc, and when the CP Plans were discontinued in May 2010, it was reported that the “basic care was fine and the children clean and well fed”. When CP Plans were re-introduced in August 2011, it was then apparent that there was a greater focus on concerns about emotional neglect. By this time the children were older and in particular there was evidence of the lack of social development. For example, the August 2011 CPC minutes still had a greater focus on the physical neglect concerns but also identified that “the children do not have adequate stimulation, either cognitively or socially, as they have very little in the form of toys and books and do not have contact with many other children”. 8.9 Emotional neglect was felt by those involved with the family to be particularly challenging to evidence and identify, although there were clear concerns about the mother’s approach and attitude to the children, and these were challenged when appropriate. Whilst these observations were raised and discussed within the later CPCs it was not apparent that these were collated as part of a multi-agency assessment to inform the legal initiatives. 8.10 However there were examples of emotional neglect which emerged – for example, Addy being restricted to one toy, dressed in girl’s clothing, professionals viewing the children as “frozen” in their responses, long periods of time in the play pen/pushchair, a sense of “learned helplessness” in their behaviours, etc. Although the possibility of emotional neglect was raised in the second period of CP Plans (from Aug2011), it was only at the last RCPC in November 2012 when the CP Plans gave a clearer set of actions in respect of addressing 36 emotional neglect. This appropriately included funding for Addy at Nursery and focussed on the general need to get the children into nursery much more regularly in order to meet their emotional and social development needs. However, this tended to falter because of the mother’s lack of intent to send them, on one occasion saying that she did not want to send the children to nursery and that it was not a legal requirement that she had to. 8.11 Overall, the professional interventions appropriately focussed on the neglect of the children, but with physical neglect being difficult to consistently evidence and limitations to when the children were seen to consider the impact of emotional neglect, then the professional interventions, largely via CP Plans, were compromised. 8.12 It was appropriate for professionals to be concerned with the family situation that they were being presented with, but it remained difficult for professionals to articulate concerns that were often based on intuition, even if this was supported by professional experience of working with similar families. Perhaps a different multi-agency initiative to the CPC process, to unpick these concerns may have clarified their relevance and how they could be more appropriately formulated as evidence of concern. A greater focus on the children’s experiences, even if this required professional judgement, about the likely impact on them of their parenting, could have given further clarity about potential future risks if their level of care continued in the same vein. The difficulty was that the mother usually took up much of the energies of those who worked with her, and she would usually disagree and reject advice about avoiding or desisting from behaviours which had the potential to be emotionally neglectful or abusive. 8.13 Ultimately, little appeared to change in the parenting that the children received, so the professional interventions in the way that they were developed were unable to address these concerns and generate much change. The main examples of emotional neglect cited in a recent NSPCC publication14 identify “ignoring the child’s need to interact”, “failing to express positive feelings to the child, showing no emotion in interactions to the child” and lastly, “denying the child’s opportunities for interacting and communicating with peers or adults”. There was some evidence that these examples existed in the care that these children received. To have viewed the situation from the children’s perspective and of their day to day experiences might have given a stronger insight into the level of emotional neglect they were suffering and potentially informed some of the interventions that were needed. Nevertheless, the professionals all remained concerned, but the system which focussed on the implementation of CP Plans or in identifying evidence to support applications for Care Proceedings, did not easily enable the impact of emotionally neglectful care on the children to come through within the concerns. 9. The challenge of working with families where there are child protection concerns, who are very difficult to engage in professional interventions. 9.1 The parents, and particularly the mother, were clear in their wish not to have intervention in their family life from professionals, and these feelings were particularly strong in respect of CYPS. The parents therefore refused to attend meetings, if they did were often very late, and 14 “Emotional neglect and emotional abuse in pre-school children” – Information leaflet, NSPCC – May 2012 37 did not make themselves accessible to home visits, sometimes refusing to allow entry or allowing one preferred practitioner in and leaving another outside. This challenging behaviour by the parents placed considerable demands on the professionals who were endeavouring to understand the adequacy of the care of the children and to deliver services to address these. 9.2 The family remained very difficult to engage because of their avoidant behaviour throughout the full period under review. Because for much of the time, the children were subject to CP Plans, the most used strategy to engage the family was to use greater insistence with the parents, with the backdrop of legal action, to achieve this. As the children were considered to be at significant risk of harm, then there was a reasonable perception that the lack of access to them reflected increased risk. 9.3 The main strategy therefore was to threaten to escalate the situation to the parents for example via instigating Care Proceedings (or the PLO process) when the lack of engagement was seen as exacerbating the child care concerns. In fact the early proceedings were taken partly as result of the parent’s initial refusal to engage with social workers and other professionals. With hindsight this early authoritative stance meant that there was nowhere to go once the Care Proceedings were withdrawn when the evidence in the social work assessment did not support the concerns about parenting. The dynamic which followed was that CYPS were then identified by the parents in a very negative and distrustful light. This was certainly the view of the father in his contribution to the SCR in that he considered their approach deceitful in their desire to remove Levina at birth. Whilst there was certainly no suggestion or evidence from the SCR process that CYPS in any way tried to mislead the father, this was nevertheless his view that he wanted represented in this report. It was this view which then coloured his and the mother’s later responses to CYPS. 9.4 Whilst social workers were strongly rejected by the parents at the outset, this did not mean that other agencies were readily accepted as an alternative. One of the reasons for this was that, with the children subject to CP plans, this had multi agency support, and therefore quite rightly professionals from other agencies had to challenge the parental non engagement just as vigorously as CYPS. They certainly did this and it was important that they retained a joined up approach to the parents in this regard. 9.5 Whilst one strategy could have been for the non-statutory agencies, such as the health visitor, Connexions or children’s centre staff to take the lead in work with the family, the fact that the case was dealt with primarily within the CP system and also the potential for Care Proceedings, meant that it would have been difficult to have given the lead to another agency who did not possess the necessary authority to do so. The child’s guardian did attend three Core Groups during the initial period of CP Plans in which there was an intention to support an improved relationship between CYPS and the family, but this was not successful. Once started, it was difficult for CYPS to draw back from their stance, and in fact when the application for the Care Proceedings was withdrawn, the parents appeared to consider it a victory for them, and so this did not dispel the adversarial relationship which had developed and which then continued into the next set of CP plans over a year later. If greater attempts had been made by CYPS to engage more positively with the parents, focussing on offering 38 support and help, then this might have had a better chance to achieve an effective early working relationship with the parents. 9.6 Despite their clear anger and distrust of CYPS in respect of the Care Proceedings, It was apparent right from the outset that these parents were not generally prepared to engage with a number of professionals – the lack of acceptance of ante natal services at the outset was one of the major reasons for the first referral to CYPS. Non engagement then became a major focus of concern for professionals from the beginning, but it might have been more helpful to have focussed on it as an issue about understanding the best way to intervene, rather than as a safeguarding issue in itself. For example it would be perfectly possible for a parent to be extremely hard to reach or who wishes to avoid professional interventions, but also to be a capable parent. There were however some clear concerns, but these had not been assessed or understood, so to inextricably link the lack of engagement with poor parenting may not have been the best early strategy. To separate out the concerns about parenting from the parent’s unwillingness to engage would undoubtedly have been challenging, but a different approach may have had a better chance of success. For example to promote a stance with the parents about the importance of their input to help the professionals correctly understand their circumstances and their parenting, might have generated a culture of undertaking the work with the family rather than to them. Whilst it is often the case that a CP Plan identifies the need for announced and unannounced home visits by the lead social worker, and as was promoted regularly with this family, for example, a strategy of agreeing a compromise with the parents to initially undertake announced but very regular visits only, may have given an indication to the parents of a willingness to work with them on their terms. “Parents who felt that professionals shared power with them tended to engage in work, rather than fighting workers by openly opposing them or “playing the game” by feigning cooperation”15 9.7 It is apparent that professionals did work hard to engage the parents and were persistent in undertaking home visits and in doing all they could to gain access to the family home. The health visitor was described by the CPC Chair as being “100% committed to engage with the family and was relentless in her attempts to do so”. With such a difficult family, this was praise worthy. There was evidence of creative attempts to engage the family, for example by joint visits undertaken between professionals from different agencies, utilising different venues, trying to use one professional as the main link, and line managers making visits with the practitioner. Additionally the children’s centre did enjoy some success in engaging the family and worked hard to achieve this. Their input provided much needed information to inform assessments and considerations of risk when discussed in CPCs or Core Groups. 9.8 Overall however, the main thrust of the approaches to the parents from the child protection perspective did not significantly change over time. The most interventions in terms of generating positive change in parenting relies on getting the balance correct between providing support on the one hand and exercising authority and control on the other. Balancing these two concepts is very important in order to effectively engage with a family. 15 “The carrot or the stick – Towards effective practice with involuntary clients in safeguarding children work”, Calder M,C et al – Russell House Publishing 2008. 39 “Outcomes are improved for involuntary clients when workers focus on helping them to understand the role of the worker and the role of the client in the direct practice process. This involves ongoing discussions about issues such as authority and how it might be used, the dual role of the worker as helper and social controller, the aims and purposes of the intervention from both the client and worker perspectives”16 . 9.9 In this family’s circumstances it appeared as though the authority/control aspect of the relationship with CYPS was the major component from the outset and that it was difficult to move away from this and generate a more appropriate balance. The child’s guardian, in her final position statement in 2009 supporting the CYPS’s decision to withdraw from their application, expressed hope that their intervention “will be more focussed on supporting the family without the pressure of the proceedings”. However this did not happen and in fact when support services were offered, although not necessarily by CYPS, the mother tended to refuse this help or accessed it inconsistently. This reflected how extremely difficult the mother was to engage in any meaningful way. Nobody really understood why the parents were so adamant about not wanting professional help and without this, the practitioners wouldn’t have known the best way to address the problem. 9.10 To look at the situation from the parent’s perspective can give a different understanding. It was apparent that there were many professionals who were involved and their intensity at the time of the birth of the couple’s first child must have been difficult for the parents to understand or appreciate. The majority of the early CP Plans were about control rather than support – e.g. legal advice to be sought, daily checks to the home, the landlord to be encouraged to exercise his rights to inspect the home, the parents to attend all relevant appointments etc. Despite them being well intentioned in trying to address worrying child care concerns, this may well have generated more mistrust rather than enabling the parents to view interventions as a source of support or help. This reflects the recent view that “unintended consequences” of professional interventions can occur when a prescriptive approach is applied other than one which is freed up to use greater professional judgement.17 9.11 Although both parents had experienced previous involvement with agencies when younger, as a couple and new parents, their involvement with the helping professions had been almost non-existent and yet within a matter of a few days around the birth of their first child, there was involvement from midwifery services, the health visitor, the hospital, CYPS and mental health services. This may well have been overwhelming, and once it was quickly decided that this case met the threshold not only for CP but also for legal intervention, then the professional involvement intensified, so much so that the Police were involved to ensure access and to convey the seriousness of the situation to the parents. 9.12 One component of the first set of CP Plans, which was repeated until the CP Plans ceased some 10 months later, was for the parents to “access and engage with appropriate support services” and it then listed six different agencies “and other support as identified”. Even if it was not realised at the outset that it would be unachievable for these parents to engage with 16 “Working with involuntary clients – A guide to practice”, Chris Trotter, Sage Publications 1999. 17 The Munro Review of Child Protection – Part one – A Systems Approach – Eileen Munro 2011 40 six different services, it should have been recognised by the next RCPC that these expectations needed to be reframed and made more realistic for the parents to be able to accept. 9.13 Despite the pressures upon them, the parental resistance did not waiver, and during the first period of CP plans and Care Proceedings, their strong stance was indirectly supported by the child’s guardian and by the outcome from the paediatric assessment, neither of which supported the level of concerns being expressed by other professionals at that time. Therefore this gave the parents the “evidence” to deny professional intervention especially from those who represented the most authoritarian stance being undertaken, i.e. by CYPS. In fact the parents were quite clear in telling CYPS and others that this was proof of their good parenting. For the second period of CP Plans this same process existed. 9.14 Within these scenarios, it was still nevertheless important for social workers and other professionals to gain involvement with the family and it was apparent that there was significant commitment and energy for the task, to try to achieve this. In fact it created high levels of frustration for professionals in having to repeatedly try to gain access to the home or to speak to the parents. Whilst it was of course important to be clear to the parents what the sanction or outcome would be if they failed to engage, these became ineffective, as the Care Proceedings were withdrawn in the acknowledgement that there were insufficient concerns presented in the social work assessment to warrant continuation. Therefore there was little further sanction or pressure that could be placed on the family to get them to engage during the 2009/10 period of CP Plans. 9.15 After August 2011 when the children again became subject to CP Plans, a letter was sent to the parents saying that there would be a move to legal proceedings if they did not engage with the CP Plan. This approach had already been applied previously and there was no greater evidence that it would work on this occasion, in fact there was probably less, particularly when there was no follow through in respect of the legal initiative. In this way the same dynamic was promoted from the outset between the parents and key professionals of the parents being defiant in not wanting to accept interventions, and the professionals working hard to change this, usually by the suggestion that legal interventions would follow. No alternative strategy was developed, promoted or introduced. 9.16 Because this non-engagement issue became such a focus of concern and priority for change, then there was the likelihood that simply getting into the home was seen as a success in itself. For example in this case it was acknowledged by practitioners that on occasions the children were not always seen when access was gained to the home. In other respects there was some evidence that there was greater focus on the professional relationship with the mother and in trying to maintain this, leaving insufficient focus on the children. There was also the potential that once in discussion with the parents, it felt more difficult to challenge them on their child care, and there were descriptions by practitioners about the delicate nature of discussions that needed to be had with the mother in particular, in order to have any chance of getting the appropriate message across and to be able to gain access to the home on the next occasion. 9.17 In the father’s contribution to the SCR, he said that whilst he was clear that he did not want CYPS involvement, he recognised that it was the mother who was the most adamant about 41 not accepting help from professionals. He said that he did try to convince her to accept help, for example regarding the nursery placement and to accept a mental health assessment, but she was adamantly against these. He explained that the difficulty was that if he disagreed with her too much, she would not allow him to see the children, so in this respect he felt that there was little he could do. He described how he attended one RCPC on his own but that the outcome was that he became the link with the mother and that the professionals mainly wanted to communicate with her, and that he felt he couldn’t help with this. 9.18 Therefore it was recognised that this inability to effectively engage the parents in the child protection process was an issue that permeated much of the professional working relationship with the family. Despite this, there were some interventions, particularly to monitor weight gains and the mother’s feeding regime, which did provide important knowledge about parenting. Much professional and personal energy was needed by the health practitioners to achieve this with any consistency. 9.19 Overall therefore, despite considerable concerted attempts by practitioners to engage these parents, this was never really achieved with any consistency. There were probably a number of reasons why this was, the first being that even before safeguarding issues were raised, the mother failed to engage with ante natal services, which showed that in principle, she was not happy about accepting professional intervention. And then, when concerns were raised, all the practitioners had little choice but to commence their work with the family in the context of child protection and legal processes, thereby presenting an authoritative stance without the balance of welfare and support provision. 9.20 Clearly the personality, background and strength of conviction of the parents on this matter, particularly from the mother, made it very difficult to change their strength of feeling. When some objective evidence of the children’s care emerged as generally being satisfactory (e.g. as from the paediatrician), this simply made it much more difficult to convince the parents that they were nevertheless in need of professional interventions and support. Furthermore there was a high turnover of staff among the agencies involved and this meant that the establishment of meaningful relationships with the family was very difficult with each new practitioner who became involved, and this process was strongly confirmed by the father as very frustrating for both parents. 9.21 Without the problem being sufficiently escalated to senior managers, they were not in a position to create the necessary environment to generate an innovative process that would cease current thinking and objectively review what was needed. Alongside recognition that the case had become “stuck”, this meant that without any objective input and force for change, that the situation continued in an unhelpful way for much of the time of involvement with the family. The lack of objectivity within the CPC process, the fact that the process of exception reporting to senior managers was not embedded in practice, and the poor management oversight all played a part in making it difficult for a fresh and objective review process to take place. In effect, the continuing CP Plans were being repeated without actions taken against them, and this in itself was providing evidence that despite their existence, the children were continuing to be subject to abuse. Calling a strategy meeting would have been unusual in such circumstances, but the situation called for innovative strategies to solve the 42 problem. One component of the CP Plan for “all agencies to continue to try accessing the home to see the children” was identified in all of the five CPCs undertaken between August 2011 and November 2012. The child protection system should have been used more flexibly to accept that the process was not working and needed a fresh, different and innovative approach to address the prevailing situation. 10. The impact on professionals and agencies of working with a very complex family alongside high levels of child protection concerns. 10.1 The degree of drift in the management of this case, particularly during 2012 and into 2013, reflected a degree of frustration by the workers, in that no matter what attempts were made to engage the parents, these were generally unsuccessful. When interventions did seem to be successful or generate an action from the parents, these were limited and short-lived, no doubt leading to further professional frustration. 10.2 It could be argued that a change of worker is sometimes a useful strategy to generate a more positive response from parents, but these occurred too frequently and were unable to build on any previous achievements with the family. In fact from 2009 there were three CYPS service managers, six practice managers, three senior practitioners, seven social workers, two student social workers and four family support workers involved, as well as staff from the children’s centre. This high turnover clearly had a significant impact upon management of the case for example in respect of the failure to progress the PLO and CP Plans. The circumstances of this case needed a consistency of practitioner so as effective working relationships could be built. Information from the SCR process identified that the changes to CYPS staff was beyond senior management control and reflected staffing and retention difficulties in the area. However neither was there evidence in the case of a senior manager becoming involved to help select a social worker who was likely to be in the area long term. 10.3 All of these changes of practitioner must have had an impact on the parents in terms of generating a level of apathy in that they already had little commitment to want to engage with social workers, but to have to do so repeatedly was hardly going to achieve success. In the father’s contribution to the SCR he described how social workers seemed to be always changing, and felt that just when there was some connection with the worker, that they were replaced. His perception was the change seemed to take place soon after a social worker began to understand their perspective better. In this way he felt that the work had to start all over again and that he and the mother did not have the inclination to continue to do this. Additionally, it needed to be considered what sort of message this might have given to the parents, and whether they perceived this as a lack of interest in them and that they were on the receiving end of a bureaucratic process. They certainly held strong views that they were capable parents and that there was no need for concerns for the care of their children, and the regular changing of workers may well have given them an unintended message that the concerns were not in fact high and did not warrant greater consistency of worker. 10.4 It was apparent that the continuing pressure of trying to engage the parents as effectively as possible was very challenging and had the potential to be overwhelming. “For every 43 frustration on the part of a fearful parent with an open child protective case, there are a multitude of frustrations that workers experience as well”18 11. The extent to which the mental/emotional health of the mother was a key factor and needed understanding in terms of the assessment of risks to the children and the family’s ability to engage with professionals. 11.1 For the duration of professional involvement with the family, there was no diagnosis of any mental health difficulties and although the mother did access support from the mental health services soon after Levina was born, this did not identify any mental health issues or depression. All of the Edinburgh Postnatal Depression Scores19 were low and the last entry just a month before the mother and children’s death, was a score of 1, which was exceptionally low, (no indicators of depression) and brought in to question the validity of the mother’s answers to the questions. This reflects how, even at this late stage, there remained professional uncertainty about the mother’s emotional health at the post natal stage. It is important to note that the Edinburgh score only deals with the symptoms of depression post birth and does not assess all types of mental illness nor personality disorder which may have been a factor in this case. 11.2 There were various incidents which led professionals to have some concern for the mother’s mental health, and these included the very highly anxious state in her presentation to the A&E to have Levina examined, her irrational concerns about the nursery reflecting an apparent fear of the outside world, single mindedness and inability to listen to others or accept any sort of advice. 11.3 Because professionals were unable to get close to her, it was difficult to understand the mother’s fears and anxieties and to what extent her background experiences had had upon her. When anxious, it was reported how incessantly she spoke, making it very challenging to engage her in any meaningful way. It also reflected the anxiety she felt and her inability to express this coherently. Clearly if this was a persistent personality trait, then it would have impacted on the children and made communication with their mother extremely difficult. It was a noted success to get the mother to agree to attend an adult attachment interview, but the health visitor had tried to do this for some time and reported that in the last interview in respect of this, it took 1 ½ hours to reach this stage by constantly challenging the mother to look at the family’s home life from the children’s perspective. 11.4 No detailed mental health assessment was proposed or set up for the mother, and it would have been very difficult to get her to agree to this anyway. However, psychological assessments were identified as being necessary within the CPC process, but these were not 18 “The carrot or the stick – Towards effective practice with involuntary clients in safeguarding children work”, Calder M,C et al – Russell House Publishing 2008. 19 The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire that was developed to identify women who have post-partum depression. Items of the scale correspond to various clinical depression symptoms, such as guilt feeling, sleep disturbance, low energy, and suicidal ideation. Overall assessment is done by total score, which is determined by adding together the scores for each of the 10 items. Higher scores indicate more depressive symptoms. The EPDS may be used within 8 weeks postpartum and it also can be applied for depression screening during pregnancy. 44 processed and as previously discussed, reflected the impotence of the CP Plans and Core Group processes. 11.5 As part of his contribution to the SCR, the father acknowledged that he did not initially see that the mother had any sort of mental health problem, but that as time went on, he said that he felt she needed some help and that he wished some sort of assessment could have been set up. He said that he tried to convince her but that she never really listened and always thought she was right. However, it was identified in the November 2012 CPC minutes that the mother had expressed a desire to the health visitor that she wanted to parent more effectively but required psychiatric help to do so. It was in this context that the adult attachment interview was eventually set up and agreed to, but her death occurred before it could take place. Clearly knowing the background, it was questionable whether the mother would in fact have taken up this interview. 11.6 The question of whether the mother suffered with any mental health problems or whether there was any form of personality disorder therefore remained unanswered. The very early assessment suggested that there were no mental health issues, but there was no later clinical assessment to confirm whether this was the case later on as a parent of young children. Those practitioners working with her were unable to convince her to attend any assessment and clearly there was no way that the situation could have been forced without some form of legal process to support its necessity. Organisational and Contextual Factors 12.1 The latest Ofsted Inspection in June 2013 found that the overall effectiveness for arrangements to protect children in Suffolk was “adequate” and there was no specific reference to any concerns about the north area of the county where this family resided. However, although there were initiatives to address the problems identified in this area in 2010 by increasing the management capacity, and a two day Ofsted visit In July 2011 confirmed issues were improving within Lowestoft, unfortunately there was little evidence within this case to suggest that the improvements had been made. The poor management oversight which allowed such drift to occur with the case from August 2011 to March 2013 was concerning. 12.2 Following the 2010 Ofsted Inspection, the internal post inspection review in October of that year showed serious shortfalls in practice in Lowestoft but that these were not reported to senior management. Also the role of Northern Area Safeguarding Children Committee appeared to be compromised when reports to them in September 2009, February and May 2010 were “surprisingly positive” in that for May 2010 it was reported that “the teams continue to demonstrate good performance in all areas” even though about sixty cases were being held by Social Care Managers. This analysis of practice in the Lowestoft area and a description of the culture of sorting things out locally meant that the feedback process of any poor practice to the wider Local Authority and to the SSCB did not occur. “Caseloads were 45 also too high to ensure that social workers could undertake meaningful work with all the children allocated to them”20 12.3 In July 2011 a new Operating Model was implemented within the Local Authority which encompassed significant organisational change leading to changes for staffing and to team boundaries. This was likely to have had an impact on operational stability. Social work salary levels in Lowestoft were not competitive with their geographic neighbours in Norfolk at this time, although this has now been addressed. However the situation in 2011-12 may well have impacted on staff commitment and sense of recognition. Within the particular social work staff in this case, three of them who held case responsibility had high levels of sickness and some others who were allocated were not established or experienced. This may help to explain why achieving consistency of social work allocation to this case was so problematic and the case allowed to drift. 12.4 Coupled with these organisational issues was the fact that this case was a very demanding and complex one. Although it had a high priority because of its CP status, the challenge of the persistent non engagement of the parents meant that within the context of high caseloads, significant energy would have been needed to effect change in this case. Also the fact that the case presented with chronic concerns over time rather than significant individual events or crises, meant that it presented with a more diffuse set of concerns which did not always immediately identify the need for robust intervention. 12.5 There were numerous contextual factors which had implications for the health visiting services in the Lowestoft area, with some staff sickness issues and budget restrictions meaning that covering arrangements were quite challenging during 2009/10 and that there was some uncertainty for staff at this time. This was also at a time when there were increasing numbers of young families subject to CP Plans. The launch of the East Coast Community Healthcare CIC in October 2011 brought in numerous changes to practice as well as new training and staff support processes. The same health visitor remained with the family from 2011 and worked to achieve one of the more effective relationships with the mother. 13. SUMMARY 13.1 None of the professionals who had worked with the family would have been able to prevent or predict the final tragic outcome. There was never any evidence to suggest that the mother would harm herself or the children, and without any letter or definitive statement of intent by the mother, it remains unclear why she took the actions she did. During 2013 there was no new initiative or different sanction which was being utilised at this time which would have generated a significant negative reaction from her. In some respects therefore, the analysis of the professional practice in this case goes little way to understanding the final acts by the mother. 13.2 It was apparent that in respect of the incidents which ultimately led to the death of the mother and the children, that neither parent had been honest with professionals, namely the Police, at this time. The father did not tell the truth that the mother was the person who had 20 Suffolk post inspection review – internal review process – Kathy Bundred October 2010. 46 stabbed him,(in order to protect her), and she was not truthful to the Police about her recent contact with the father, when they called that night to check out the father’s story regarding a local assailant who had stabbed him in the street nearby. The Police were not able to gain access to the flat as the mother would not allow them in. This was accepted by the Police and was understandable in that it was late at night and there was no reason to request to see the children as no concerns had been raised about their care in respect of this particular incident. 13.3 There is a body of research that has considered the issue of filicide, (the act of the murder of a child by a parent), and one of the most influential pieces of research has classified six different sets of characteristics of child murder21. Of these characteristics, it is challenging to identify which might apply to the acts by this mother but two of these may have relevance. The first would be in relation to “Altruistic Filicide - where the parent kills the child because it is perceived to be in the best interests of the child”, and the second would be “Spouse Revenge Filicide - where the parent kills the child as a means of exacting revenge upon the spouse, perhaps secondary to infidelity or abandonment”22. In fact the most common motive found in the original research was that of altruistic filicide and the least common that of spousal revenge. It may have been significant that the mother allegedly made a statement to the father that he would not see his children again after he had said that he would be commencing a relationship with another woman. Whilst it can only be conjecture what she actually meant by this, it could suggest that both of the possible motivations identified above could be relevant in this case. These issues will of course more appropriately be a matter for consideration at the Coroner’s inquest. 13.4 The predominant feature of this case was the challenge of how to engage this hard to reach family, and especially the mother who specifically avoided professional interventions. Whilst some creative and committed approaches were made by practitioners, factors such as staff changes had a considerable impact on achieving success. Whilst some alternative approaches to engage the family have been suggested within the report, it is not possible to say whether they would in fact have made any real difference as it was very clearly a strong personality trait of the mother not to accept any help unless it was on her terms. Nevertheless in terms of future learning, it is appropriate to give consideration to how other forms of intervention could be used in the future and which may prove to be successful. 13.5 The determination of the mother not to accept help was considerable and unwavering although whether a completed PLO process or an application for Care Proceedings at some stage from August 2011 onwards would have changed this, was never tested. Clearly if the children had been placed in care, this could have avoided the tragic outcome, but there was never any guarantee that an application for a Care Order for the children would have been successful, or that the children would not again return to her care even within the context of successful Care Proceedings. It was nevertheless concerning that a clear decision was not made by CYPS in respect of the need for a legal intervention and instead allowed the process to drift in a most unconstructive way. 21 Resnick, PJ, “Child Murder by Parents: a psychiatric review of Filicide. American Journal of Psychiatry 1969 22 Sara G West, “An Overview of Filicide” – Psychiatry MMC – February 2007 47 13.6 Overall, the child protection process in terms of the requirements for CPCs and Core Groups to be held and for them to consider the risks to the children was fully adhered to. It was not apparent however that these processes were flexible enough to change a pattern of poor parental engagement and their avoidance of professionals, and to affect unchanging CP Plans. Lack of objective input to the CPCs and poor management oversight impacted on the ability of the CP processes to create a more challenging environment in which to monitor and improve the care of the children. 13.7 Other challenges for staff that emanated from the difficulty of engaging the family, was being able to secure appropriate assessments either for the children or for the mother. Although psychological and psychiatric assessments of the mother were proposed and discussed with her, unfortunately these were never achieved because of the mother’s reluctances. She had the right to choose not to accept that she needed a mental health assessment and there was no legal order in place to help secure such an assessment. LESSONS LEARNED 14.1 Working with hard to reach and avoidant families is very challenging for professionals and has impact upon the parents in the anxiety it creates for them and for the loss of the benefit of receiving supportive services. Innovative multi-agency interventions and new initiatives are likely to be required to engage parents in a more constructive working alliance. There is considerable research and literature on this subject which can give direction to practitioners and managers on how to attempt different strategies and achieve effective outcomes. 14.2 An effective way to identify whether emotional abuse or neglect exists within a family is to focus on the experiences of the children and identify what the impact of any emotional neglect might be. Practitioners need effective supervision and support to enable them to retain a child focus and assess their behaviours and development within families where the parents have high levels of need. 14.3 To allow CP Plans to continue unaddressed throughout a number of CPCs means that the children will continue to be subject to significant harm whilst still within the child protection process. 14.4 The role of the CPC Chair is a pivotal one in challenging the management of a case which is not achieving CP Plans and by inference it is maintaining children in at-risk scenarios. 14.5 For CPCs to only include those professionals directly working with the family will deprive the CPC of objective input by managers and specialists to help progress the case and reduce safeguarding risks of the children. 14.6 All professionals have the responsibility to challenge inappropriate or ineffectual practice, which has become intransigent and is not protecting children. This does not solely apply to CPCs and should include the need to escalate concerns to senior managers when necessary. 14.7 In demanding child protection cases, robust management oversight of the progress of the case is essential and should be shown to have a direct role and impact on the professional interventions. 48 14.8 To generate the appropriate response and relevant assessment of parents when there are concerns about possible adult mental health issues will prove to be very difficult when the parent does not see the need for any such assessment and is avoidant of any assessment activity focussed upon mental health. It nevertheless must remain on the agenda for multi-agency discussions in consideration of any changing family circumstances, and whether this might enable pertinent mental health assessments to be newly progressed and offered to the parent in question. 14.9 When cases are not progressing in terms of the protection of children, and the multi agency process has become entrenched, if there is no separate process utilised to objectively review why the case has become problematic, then the children would continue to be at risk of significant harm, and the multi-agency interventions become further entrenched. 14.10 Background information of a parent’s own childhood is essential to understanding their own parenting capacity, and if this information is not collected and shared among professionals, it will limit the accuracy of any parenting assessment. 14.11 Drift of the Public Law Outline process must be avoided by strong management oversight and via an effective working relationship between CYPS and legal services. This can only be achieved if there is a shared understanding and clarity about the separate roles, responsibilities and accountability for decision making. 14.12 If there is a shared understanding by non CYPS agencies of legal processes instigated for children, then they are more able to contribute and challenge the process when appropriate, as part of partnership working. 14.13 To fail to record important discussions and agreements reached between CPC Chairs and managers outside of the CP process, will mean that any actions agreed to ensure that a case is properly progressed, cannot be effectively reviewed or monitored and could enable management drift to occur. Ron Lock 5.12.13 |
NC52348 | Serious head injuries to a 6-week old baby in 2018 considered to have been caused by violent shaking. The brain injuries are likely to have caused permanent damage and lifelong disability. Baby E is a twin to Baby F and lived with her Mother and Father, and a sibling. Baby E was taken to hospital, described as "pale and floppy." Examination showed that she had suffered serious head trauma, and during further examinations both twins were found to have historical healing fractures. Family were known to universal services only. Parents are White British. Learning focuses on: abusive head trauma (AHT) and how it can be prevented; the impact on parenting of multiple births, including parental anxiety and additional vulnerabilities which arise from multiple births; working arrangements between Midwifery and Health Visiting, both at a strategic and operational level. Recommendations include: consider a public health campaign to promote awareness of AHT informed by current research into how AHT can be prevented and what existing resources and strategies are available including those specifically aimed at fathers and male care givers; evaluate the impact of the Health Visiting Transformation Programme and outcomes for children particularly with regard to assessment; consider how to improve professional relationships to enable agencies, particularly Midwifery, Health Visiting and GPs, "to offer help and support in an integrated way."; consider the significance of multiple births and whether there should be an enhanced information sharing protocol or service delivery; ensure that the introduction of electronic records has a positive impact on safeguarding practice.
| Title: Serious case review: Baby E and Baby F. LSCB: Karen Tudor Author: South Gloucestershire Safeguarding Children Board Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. SERIOUS CASE REVIEW Baby E and Baby F Independent Reviewer Karen Tudor June 2019 Baby E and Baby F, May 2019, Page 1 CONTENTS PAGE INTRODUCTION Events leading to this Serious Case Review Method Family Background 2 2 2 3 SUMMARY OF EVENTS 4 FINDINGS The Pregnancy Midwifery GP Involvement The Birth The twins at Home Health Visiting The Pre-Birth Assessment Information for Parents Discharge Summaries Electronic Records Baby F in Hospital Second Health Visitor Home Visit 5 5 5 5 6 6 7 7 8 9 10 10 11 THE INJURIES Abusive Head Trauma (ABT) 11 CONCLUSION 13 CONSIDERATIONS FOR THE SAFEGUARDING CHILDREN BOARD 15 APPENDICES 16 Baby E and Baby F, May 2019, Page 2 INTRODUCTION Events leading to this Serious Case Review 1. Towards the end of 2018, a six week old baby was taken to hospital, described as “pale and floppy.” Examination of the baby showed that she had suffered serious head trauma considered to have been caused by violent shaking. The brain injuries are likely to have caused permanent damage and lifelong disability. This baby is known as Baby E and is twin to Baby F. 2. During further examination both children were found to have historical healing fractures. 3. A Child Protection investigation began and Care Proceedings were initiated to ensure the babies (and an older sibling) were protected; an investigation is taking place to find out how the injuries were caused and who was responsible. There will be a Finding of Fact1 hearing in the Family Court and a decision about criminal charges will be made in due course. 4. The local Safeguarding Board carried out a Rapid Review2 which concluded the case met the criteria for a Serious Case Review. The recommendation was endorsed by the National Panel3 and the process began. Method 5. The local Safeguarding Children Board had not yet fully implemented the new arrangements set out in Working Together 2018 therefore the method and terminology is that described in Working Together 2015. The Serious Case Review sub-group oversaw the process and an Independent Reviewer commissioned. 6. The Review covered a period of 11 months, comprising the mother’s pregnancy and the six weeks leading up to the discovery of the babies’ injuries. Written reports were requested in the form of chronologies, analysis of events and conversations were held with the 1 A Finding of Fact hearing considers evidence in the Family Court in order to determine what happened and who might have been responsible. The Family Court is not a criminal court and cannot prosecute parents, the findings are based on the balance of probability and reported by a Family Court Judge. The findings can be used by other agencies to inform planning for children. 2 Rapid Review – Safeguarding Boards are required to undertake a Rapid Review into all serious child safeguarding cases within fifteen working days of becoming aware of the incident. 3 The National Safeguarding Practice Review Panel decides if a Serious Case Review (WT 2015)/ Local Child Safeguarding Practice Review (WT2018) is required and informs the local LSCB/Partnership of their decision. Baby E and Baby F, May 2019, Page 3 agency authors and practitioners. Learning was identified and considered in the light of current research and relevant evidence from other Serious Case Reviews. 7. Chronologies were requested from: Midwifery Health Visiting GP Children’s Social Care (Care Proceedings) Nursery (older sibling) Children’s Hospital Police Family Background 8. Both parents are White British and were in employment, they lived in an owner/occupied house in an area of mixed economic prosperity. 9. The couple have an older child who was 2½ years old when the twins were born. The sibling had started nursery just before the twins’ birth and the nursery staff had no concerns about his well-being or development and had not observed anything unusual in the parent/child relationship. 10. The family were known to health professionals, the GP, Midwifery and Health Visiting, they had not come to the attention of Children’s Social Care or the police. Family Participation in the Review/Parallel Proceedings 11. At the time of writing Care Proceedings and the criminal investigation were underway. Whilst acknowledging the value of family participation in Reviews, in consultation with the Investigating Officer, it was decided not to involve the babies’ family as this could potentially compromise evidence. This decision will be revisited at the end of the criminal process and Finding of Fact. Anonymisation 12. For the purposes of anonymisation the family members are referred to as follows: Baby E – the twin subject to the brain injury Baby F – the other subject twin Sibling – aged 2½ when twins born Ms BM – Babies’ mother Mr BF – Babies’ father Baby E and Baby F, May 2019, Page 4 SUMMARY OF EVENTS Week Number Event 1 Ms BM pregnant. Second pregnancy, sibling aged 2 years. 4 Booking with community midwife 6 Twin pregnancy confirmed. Ms BM has 11 contacts during pregnancy with Health and Midwifery services, this is higher than average due to the twin pregnancy and some related maternal health issues. 32 Sibling 2 year developmental review with a Health Visitor who used the opportunity to carry out an pre-birth “assessment.” Ms BM informed the Health Visitor she was expecting twins. There are no concerns about the family suggesting they need additional support. 38 Baby E and Baby F born by planned Caesarean section. The babies’ weight was within normal limits. The delivery was complicated by post-partum haemorrhage.4 39 Ms BM and the babies return home. 39 Midwifery visit daily for the first week, 8 visits altogether. 39 During the first midwife visit Mr BF is described as being “very angry”. The source of his anger, directed at the midwife, was recorded as being about his wife’s experience of the birth process. 40 Health Visiting make a new birth visit5 but the visit is disrupted because the parents are concerned Baby F is unwell. A 111 call results in an paramedic visit and the baby is taken to hospital. 40 Baby F is examined and the parents reassured, the baby is treated for oral thrush and returns home. 41 The Health Visitor makes a second visit and discusses with Ms BM the subjects normally covered in the “new birth” visit. 44 Baby E, aged 46 days, is found to be pale and floppy and is admitted to hospital where, after examination, she is found to have suffered a serious head trauma considered to have been caused by a shaking injury. She also has two fractures of varying ages. Baby F has a leg fracture. 44 and ongoing A Child Protection investigation is initiated followed by Care Proceedings and the children are placed with foster carers. A criminal investigation begins to try and establish who is responsible for the babies’ injuries. 4 Postpartum bleeding or postpartum haemorrhage (PPH) is often defined as the significant loss of blood within the first 24 hours following childbirth. The most common cause is poor contraction of the uterus following childbirth. 5 New birth visit - The first visit made by the Health Visitor at home after the baby is born, where health visitors will check on the health and wellbeing of the parents and baby, support with feeding and other issues and give important advice on keeping safe and to promote sensitive parenting. Baby E and Baby F, May 2019, Page 5 FINDINGS THE PREGNANCY 13. According to NHS England statistics, multiple pregnancies (including twins) occur in 1 in 65 births.6 When a twin pregnancy is diagnosed some additional health screening is provided. In this case the babies developed normally but Ms BM had some additional health needs including gestational diabetes7 and low iron levels. Midwifery 14. As a result Ms BM has a higher than average number of contacts with health services, 11 contacts in total.8 There was good continuity, with Ms BM seeing the same midwife on a number of occasions enabling a relationship to be established. Mr BF attended the majority of appointments with his wife. 15. During the ante-natal period it is expected practice that, in addition to medical care, midwives will carry out an assessment of the family to determine if they have any additional needs which may require referral for support services. The current policy reminds practitioners that the risk of domestic abuse is higher during the period of pregnancy and immediately after the birth (puerperium) and that midwives need to be alert to signs and symptoms. In this case the records indicate an assessment took place and nothing of concern was identified. GP Involvement 16. Ms BM had expressed some anxiety to her GP about the pregnancy as she had experienced a traumatic birth with her first child. In addition to the contacts with maternity services, during her pregnancy Ms BM had over 30 contacts with her GP surgery for ailments, mostly associated with the pregnancy; this included the gestational diabetes which required monitoring and management in order to reduce the risk of harm to the unborn twins. 17. The professionals who had contact with Ms BM and Mr BF during the pregnancy were up to date with their safeguarding training and aware that multiple visits to a GP with minor ailments may be an indication of emotional distress or underlying difficulties, for example 6 In 2013 around 11000 sets of twins and about 200 sets of triplets, or more, were born in the UK. That means that about 1 in every 65 births in the UK today are twin, triplets or more. This is a big increase from 1984 when 1 in every 100 births was a multiple birth. https://www.nhs.uk/conditions/pregnancy-and-baby/what-causes-twins/ 7 Gestational Diabetes is high blood sugar that develops during pregnancy if the body cannot produce enough insulin to meet the extra needs of pregnancy. It can cause problems for the unborn baby during and after the birth, the risk of ongoing problems is reduced if it is well managed. 8 For a single, uncomplicated pregnancy, 4 or 5 contacts with midwifery would be average. Baby E and Baby F, May 2019, Page 6 stress or depression. Staff at the practice were trained in the IRIS programme9 and were observant of indications of domestic abuse, there were no indications of risk in this case. 18. Given Ms BM’s health issues associated with the pregnancy, there was no indication that there was anything unusual about the frequency of contact. 19. During the ante-natal period there was no indication of any safeguarding issues or that the family would have benefitted from referral for support services. THE BIRTH 20. The twins were born by a planned Caesarean Section at full-term, their weights were Baby E, 2868g (6lb 5oz) Baby F 3282g (7lbs 3oz) 21. The birth did not go smoothly, Ms BM suffered a post-partum haemorrhage, as she had when her first child was born. Having returned to the ward after the birth, she suffered a second haemorrhage and had to have further surgery with a general anaesthetic. This left Ms BM bruised and sore, extending her recovery time. THE TWINS AT HOME 22. 48 hours after the birth Ms BM and the babies were discharged home. The doctors and midwives had no concerns about the health or well-being of the twins or Ms BM. In line with policy and usual practice, a community midwife visited the family daily for a week and then made two further visits before handing the case over to a Health Visitor. 23. There were two issues of note during this period. 24. On the first midwife visit, the day after discharge, when the twins were four days old Mr BF was described by the midwife as being “very angry.” In her record, the midwife ascribed his behaviour to his feelings about his wife’s experience during child birth. (This midwife has since retired and was not available for a first-hand account of the incident.) 25. Other records show that Mr BF was present during the visits and was frequently observed holding both babies, appearing to have taken on a substantial role in child care. Ms BM 9IRIS is a general practice-based domestic violence and abuse (DVA) training support and referral programme including training and education, clinical enquiry, care pathways and an enhanced referral pathway to specialist domestic violence services. Baby E and Baby F, May 2019, Page 7 was observed as being “weak, tired and in pain” and with a “flat” demeanour. On another visit, the 2½ year old sibling was described as “manic,” his behaviour being very disruptive, but managed well by Ms BM. 26. The second finding of note was that Mr BF and Ms BM were reported as being anxious about Baby F having some feeding difficulties and slow weight gain. This is significant because the couple had experienced similar circumstances with their first child who was later diagnosed with a congenital medical condition requiring life-long medication. 27. By the time the midwife visits came to an end, Ms BM was described as being “completely different” her mood had lifted and she was answering the door and moving better, “as if in less pain” from her surgery. 28. The midwife did not discuss Mr BF’s angry feelings, Ms BM’s anxiety about the pregnancy and birth and the couple’s continuing anxiety about Baby F’s feeding with the Health Visitor. Health Visiting 29. Health Visiting had met the family on three occasions during the period of this Review and had two telephone calls. The first meeting was the “pre-birth assessment.” The Pre-Birth Assessment 30. This took place when an opportunity arose when at the siblings two-year developmental assessment; the appointment took place at the local clinic and Ms BM and Mr BF were both present. In line with the information sharing policy, Midwifery had informed Health Visiting about the pregnancy, it was at this meeting that Ms BM, now seven months pregnant, told the Health Visitor she was expecting twins. 31. The Health Visitor reports that after the siblings review, she spoke to Ms BM and Mr BF about “responsive parenting”10 including, for example, the risks of co-sleeping and what parents can do if they “feel tense” (put the baby in a safe place and take time out to calm down) The Health Visitor did not complete the assessment required at the time which 10 The Institute of Health Visiting, Healthy Start, Happy Start, (2017) promotes Responsive Parenting which is defined as family interactions in which parents are aware of their children's emotional and physical needs and respond appropriately and consistently. Sensitive parents are “in tune” with their children. Baby E and Baby F, May 2019, Page 8 looks at the Child and Family Strengths, Needs and Risks or use the Promotional Guidance11 approach required at the time. 32. It seems likely that at the time of the sibling’s developmental review, in a clinic setting and with Ms BM experiencing ongoing serious maternal health issues, this was not the optimum environment or timing for conversations about “responsive parenting” to babies who were yet to be born. 33. In 2017, during a review of services, the benefits of ante-natal visits was described by managers as “undervalued” and they were not universally offered to prospective parents. Provision was described by practitioners as “opportunistic or targeted” although there were no specified criteria for the targeting. 34. Prior to the Review, the Health Visiting service had recognised the need for improvements in service delivery which are set out in detail in their Service Transformation Programme.12. 35. Since 2017 there have been changes, but by the summer of 2018, when Ms BM was pregnant, the anticipated improvements in practice had not yet embedded and practice was still inconsistent. A training programme to improve assessment skills was underway however the Health Visitor in this case was among the last tranche of staff to attend and, at the time of these events, had not yet received the training. 11 Promotional Guidance promotes early infant development and early parenting using materials to facilitate personalised guided conversations with parents to explore key topics and priorities during pregnancy and early infancy. 12 Service Transformation Programme - The plan sets out how health and care services will work in partnership to develop plans that will enable them to continue to meet the health needs of the local population at a time of increasing demand and constrained resources. To read the plan and the summary document and watch a video providing an overview, see the South Gloucestershire Clinical Commissioning Group website. LEARNING POINT The pre-birth assessment is a valuable opportunity for Health Visitors to begin to establish a relationship with a family and provide a responsive service. The quality of the initial assessment will be improved, and more likely to be useful to new parents, if the contact is planned and purposeful and priority is given to discussing pregnancy, birth and parenting. Baby E and Baby F, May 2019, Page 9 Information for Parents 36. The practice at the time, and currently, is that parents are not given any information in writing, in the form of leaflets, booklets etc. about the myriad of subjects relevant to new parents. This is because feedback from parents to Health Visiting indicated that they felt an “information overload” and did not read most of the written information. Current practice is that all useful information is contained in the “Red Book” which is given to parents for each child, to record their medical history and development. The Book also contains information about, for example, feeding, sleeping and coping with crying. 37. The Red Books have recently been updated to include information about the risks of shaking babies, but this was not present when the twins were born. Discharge Summaries 38. When the Community Midwife’s role comes to an end the policy is that a discharge summary is completed and passed on to the Health Visitors. This is a paper exercise and the completed document is passed to Health Visiting for filing. 39. This process of information exchange was not working well. Practitioners acknowledged that discharge summaries rarely appeared before the case was handed over and the Health Visitors made their first visit and, when they were produced, they might be filed without actually being seen. 40. In this case the Health Visiting team and Community Midwives are co-located, that is based in the same building; given the incidence of twin births, the complications of Ms BM’s pregnancy and traumatic birth process and the relatively low number of “new birth” visits each Health Visitor undertakes, it is disappointing that the practitioners involved with this family did not communicate effectively at the point of handover. 41. From the limited information available, it seems that there was a total reliance on the discharge summaries, although the system was known to lack rigour. It was assumed that if any practitioner had “concerns” about a family, in this case the midwives, they would take steps to make sure Health Visiting were aware. This means that if there are no obvious safeguarding concerns, more nuanced information about, for example, the stresses of coping with twins, a new parent’s anxiety about feeding or maternal health, will not be communicated. Baby E and Baby F, May 2019, Page 10 Electronic Records 42. The practitioners participating in this Review were optimistic about the imminent introduction of electronic records and the benefits of being able to access information more easily. 43. Electronic records alone are not a substitute for effective communication between professionals and will not lead to improved service delivery without professional understanding and skill at managing the risk of information overload. LEARNING POINTS In this case it was the parents who informed the Health Visitor that the pregnancy was a twin birth. Pro-active communication between Midwifery and Health Visiting, particularly when there are additional vulnerabilities, is likely to lead to better continuity of care. Effective communication is a two way process which works well when information is both sought and shared by all professionals; effective information exchange will enable a more robust and timely assessment of the degree of stress or significance of anxiety experienced by parents and whether Early Help is indicated or there are any emerging safeguarding concerns. LEARNING POINT: Whilst electronic record sharing is a welcome development, it is essential that commissioners, managers and practitioners do not lose sight of the need for information sharing to be focussed and purposeful. It is essential to avoid information overload and ensure communication systems highlight key elements of risk. This will enable practitioners to consider the information alongside their professional knowledge and assessment skills. Baby E and Baby F, May 2019, Page 11 BABY F IN HOSPITAL 44. The Health Visitor made a “new birth” visit when the twins were 11 days old. On arriving at the family home it soon became evident that Ms BM and Mr BF were anxious about Baby F who they thought was not gaining weight satisfactorily and who was more than usually sleepy. 45. In order to appease the parents, the Health Visitor who was not particularly concerned, suggesting calling the NHS helpline 111.13 This resulted in a paramedic being sent and the baby being transported to hospital in an ambulance accompanied by Ms BM. 46. On arrival at hospital, Baby F was examined by a senior paediatrician who concluded she was generally well and prescribed medication for oral thrush before discharging her home. Expected practice is that the baby would have been undressed and weighed, although this is not recorded, nothing of concern was noted. 47. Given the guidance about the purpose of the NHS 111 number, it is surprising that a health professional considered this a better option than, for example, making an appointment with a GP. Second Health Visitor Home Visit 48. A week later and in order to complete the new-birth visit, the Health Visitor called again and saw the twins with Ms BM. Mr BF was at home but remained upstairs “hoovering.” On this visit the Health Visitor saw both babies and covered the subjects of responsive parenting, the risks of depression and domestic abuse and availability of family support. There were no indications of anything suggesting the twins were at risk of harm. THE INJURIES 49. Four weeks after the second visit from the Health Visitor Baby E, aged 6½ weeks, was taken to hospital by ambulance after being described by Mr BF as “pale and floppy” when she woke for a feed. The baby was admitted for observation and suffered a seizure. Medical investigations showed she had suffered a subdural haemorrhage thought by the medical 13 111 is designed to facilitate easy access to NHS health care services in England if health care advice is needed and urgent help is required but the situation is not life-threatening. The Guidance indicates that the service is for those who “don’t know what to do” or who don’t have access to a GP or health advice. Baby E and Baby F, May 2019, Page 12 staff to have been caused by shaking. The baby is likely to have suffered permanent brain damage which will leave her with a life-long disability. 50. After further examination and x-rays, both babies were found to have fractures of varying ages. At the time of writing there had been no explanation for the injuries or identification of who was responsible. Abusive Head Trauma (AHT) 51. Abusive Head Trauma is defined as: “an inflicted injury to the head and its contents” and “associated with a spectrum of serious and often permanent neurological consequences” 52. Alison Kemp in her paper “Abusive Head Trauma: Recognition and Essential Investigation” states that: “Abusive head trauma (AHT) affects one in 4000–5000 infants every year and is one of the most serious forms of physical child abuse that has a high associated mortality and morbidity.” 14 53. It is seen as a leading cause of death in children under 2 years old.15 54. The research proposes that AHT is largely preventable and suggests that the most common incident leading to abusive head injury is infant crying; 16 and that the person most likely to shake an infant “is the father or male surrogate”17 55. The research about AHT and prevention indicates that in order to be effective a strategy for prevention should promote awareness of the dangers of shaking in response to crying and ensure fathers and male carers are included in education. 56. During pregnancy and after the birth of the twins the family were given some information about responsive parenting. The practitioners involved in this review indicated that during pregnancy the emphasis of health promotion is on feeding, after the birth the information for parents is found in the Red Book which at this time had no information about the risks of shaking and associated head trauma. 14 Abusive head trauma: recognition and the essential investigation Alison M Kemp, Abusive head trauma: recognition and the essential investigation Alison M Kemp. BMJ, September 2012. 15 Abusive head trauma: Evolution of a diagnosis Issue: BCMJ, Vol. 57, No. 8, October 2015, page(s) 331-335 Margaret Colbourne, MD, FRCPC 16 Dr Suzanne Smith, Mechanisms, Triggers and the Case for Prevention, January 2017 17Parent Education by Maternity Nurses and Prevention of Abusive Head Trauma Robin L. Altman, Jennifer Canter, Patricia A. Patrick, Nancy Daley, Neelofar K. Butt, Donald A. Brand Baby E and Baby F, May 2019, Page 13 CONCLUSION 57. When the work done with a family is scrutinised in detail, it is almost inevitable that a Review will conclude that some of the practice could have been better. In this case maternity services and Health Visiting have identified some weaknesses in their systems which require improvement. 58. Midwifery have identified a need for all recording on patient records to be properly signed and also general frustrations among staff about the adequacy of notes and templates. Whilst these issues did not affect the outcome of this case, they require further work. 59. For Health Visiting the service provider changed in 2016. In 2017 the new arrangement was confirmed and an assessment of staff development needs was undertaken as a precursor to the Transformation Plan. The service recognised that it was not performing well and is currently attempting to improve performance by setting out clear policy expectations, skill development and moving from a medical model of service delivery to a more holistic approach. 60. In 2018 when Health Visiting was working with this family, the “transformation” was underway but the family’s Health Visitor had not yet completed the associated training. Pre-birth assessments are reported as being more consistent and of better quality. 61. The effectiveness of communication between Midwifery and Health Visiting remains a serious concern which impacts on continuity of care and effective assessment. The chronologies requested as part of this Review indicate that there is little effective communication at a strategic level, an Agency Reviewer reflected on feeling “unwelcome” at strategy meetings and questioned their effectiveness indicating that there are systemic issues to be addressed. 62. Communication between practitioners working with families was described by participants in this review as “inconsistent “or “variable.” LEARNING POINT: The research into AHT indicates that it can be prevented by providing evidence-based education programmes aimed at supporting parents in coping with crying. Baby E and Baby F, May 2019, Page 14 63. As a consequence there is no effective mechanism for improving continuity of care within agencies (health providers) or sharing information about individual families unless the threshold for Early Help or Child Protection is met. Information about, for example, the potential impact of parental anxiety on child development, the significance of the experience of pregnancy, are less likely to be considered as part of an assessment of need. 64. Apart from increased medical input, there appeared to be no consideration among practitioners of the added stress of parenting twins, particularly in families with other young children. During the past five years SCRs about cases involving twins indicate common themes.18 Research is limited but some studies suggest there is an enhanced risk of harm when there is a multiple birth.19 Common themes among the published SCRs20 are the high incidence of prematurity in multiple births leading to babies spending time in special care, with a potential impact on attachment, the babies extra health needs, additional parent vulnerabilities and lack of discharge planning. 65. Abusive head trauma has devastating consequences for babies and children, it may not be predictable but the research shows that health promotion strategies highlighting the risks of shaking can help prevent injury. Ongoing learning from this and other practice reviews point out that It is essential that men and fathers are not just present during appointments and meetings, but are actively engaged in learning about the risks. 18 See NSPCC Repository. 19 For example see Lang CA et al, Maltreatment in Multiple Birth Children. Child Abuse and Neglect, 2013. 20 See for example “BY” Blackpool Safeguarding Children Board 2018, Baby H Oldham Safeguarding Children Board 2018, Baby A and Baby B, Somerset Safeguarding Children Board, 2013. Baby E and Baby F, May 2019, Page 15 CONSIDERATIONS FOR THE SAFEGUARDING CHILDREN BOARD 66. The learning from this case comes from the detailed analysis of practice and focuses on: Abusive head trauma and how it can be prevented; The impact on parenting of multiple births, parental anxiety and additional vulnerabilities which arise from multiple births; Working arrangements between Midwifery and Health Visiting, both at a strategic and operational level. Recommendations: 67. The LSCB should; Consider a public health campaign to promote awareness of AHT informed by current research into how AHT can be prevented and what existing resources and strategies are available including those specifically aimed at fathers and male care givers. Ensure that commissioners and managers are evaluating the impact of the Health Visiting Transformation Programme and outcomes for children particularly with regard to assessment. Consider how to improve professional relationships to enable agencies, particularly Midwifery, Health Visiting and GPs, “to offer help and support in an integrated way.” 21 Consider the significance of multiple births and whether there should be an enhanced information sharing protocol or service delivery; Seek assurances that the introduction of electronic records has a positive impact on safeguarding practice. 21 From South Gloucestershire Draft Early Help Strategy for Children Young People and Families, 2019 – 2014. Baby E and Baby F, May 2019, Page 16 SUMMARY OF LEARNING A. The pre-birth assessment is a valuable opportunity for Health Visitors to begin to establish a relationship with a family and provide a responsive service. The quality of the initial assessment will be improved, and more likely to be useful to new parents, if the contact is planned and purposeful and priority is given to discussing the pregnancy, birth and parenting. B. In this case it was the parents who informed the Health Visitor that the pregnancy was a twin birth. Pro-active communication between Midwifery and Health Visiting, particularly when there are additional vulnerabilities, is likely to lead to better continuity of care. C. Effective communication is a two way process which works well when information is both sought and shared by all professionals; effective information exchange will enable a more robust and timely assessment, including the degree of stress or significance of anxiety experienced by parents and whether Early Help is indicated or there are any emerging safeguarding concerns. D. Whilst electronic record sharing is a welcome development, it is essential that commissioners, managers and practitioners do not lose sight of the need for information sharing to be focussed and purposeful. E. It is essential to avoid information overload and ensure communication systems highlight key elements of risk. This will enable practitioners to consider the information alongside their professional knowledge and assessment skills. F. The research into AHT indicates that it can be prevented by providing evidence-based education programmes aimed at supporting parents in coping with crying. Baby E and Baby F, May 2019, Page 17 APPENDICES Agencies Participating in the Review Avon and Somerset Constabulary North Bristol NHS Trust Maternity Services Sirona (Health Visiting) University Hospitals Bristol NHS Foundation Trust South Gloucestershire Children’s Integrated Services Nursery Bristol, North Somerset and South Gloucestershire (BNSSG) CCG GP Practice Membership of the SCR Sub-Group Head of Safeguarding, South Gloucestershire Council - Chair Head of integrated Children’s Services, South Gloucestershire Council Legal Services, South Gloucestershire Council Designated Doctor, BNSSG CCG Area Manager, Lighthouse Safeguarding Unit, Avon & Somerset Police Head of Education Learning & Skills, South Gloucestershire Council Specialist Health Improvement Practitioner, Public Health Service Manager, Next Link Domestic Abuse Services SGSCB Business Manager |
NC52297 | Significant developmental delay in a 7-year-old boy due to neglect. Developmental delay issues were identified when Child Y started school in October 2020. Learning includes: when a young child is missing from education, while it is a priority to ensure that the child starts or returns to school, the possibility of parental neglect should also be considered; systems need to support information sharing between health professionals to ensure that a child's needs are met if there are indications of developmental issues or if appointments are missed; when professionals have concerns that a child is not in education, there needs to be timely information sharing and consideration of the child's lived experience, which includes the child being seen; COVID-19 restrictions have allowed parents who are hard to engage with to avoid professional contact, which indicates that professional rigour and persistence are required to meet the needs of children during a pandemic. Recommendations include: review procedures in relation to children missing from education to ensure that reference is made to younger children, and to links with neglect; seek assurance on the effectiveness of the local authority education service when a child missing education meets the criteria for a school attendance order; ensure partner agencies hold Working Together compliant strategy meetings to plan investigations and visits, and that there is consideration of a child protection medical in neglect cases.
| Title: Local child safeguarding practice review (LCSPR): Child Y. LSCB: Dudley Safeguarding People Partnership Author: Nicki Pettitt Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Local Child Safeguarding Practice Review (LCSPR) Child Y Independent Reviewer: Nicki Pettitt Date published: 2nd February 2022 2 Local Child Safeguarding Practice Review (LCSPR) Learning identified from considering Child Y1 Contents 1. Introduction page 2 2. Process page 2 3. Learning page 3 4. Recommendations page 11 1 Introduction 1.1 The DSPP agreed to undertake a CSPR by considering a case to be referred to as Child Y. They recognised that lessons could be learned from reviewing the practice in the case, with the aim of better safeguarding the children of Dudley. 1.2 Child Y was nearly seven years old when they first started school and was significantly developmentally delayed due to neglect. The child lived with their parents who had managed to avoid professionals for a number of years. The review considered the professional involvement with this family in order to identify learning for the wider systems and practice in cases where neglect and lack of engagement features. 1.3 Learning has been identified in the following areas: • The link between child neglect and missing school • Information sharing with health visitors if there are concerns about a young child’s development • The importance of seeing a child and meaningfully considering their lived experience • The impact of working in difficult and exceptional circumstances2, particularly when working with families who are hard to engage • Ensuring child protection procedures are followed when neglect is a concern • The importance of professional challenge • Meaningfully considering fathers 2 The Process 2.1 An independent lead reviewer was commissioned3 to work alongside local professionals to undertake the review. Information provided to the rapid review meeting was considered and individual agency chronologies including analysis were requested from all involved. These identified important single agency learning. 1 The child is to be referred to as Child Y initially; this may be subject to change following consultation with the safeguarding partners and the family. 2 Covid 19 in this case. 3 Nicki Pettitt is an independent social work manager and safeguarding consultant. She is a lead reviewer undertaking Serious Case Reviews and now Child Safeguarding Practice Reviews and is entirely independent of the DSPP. 3 2.2 Professionals involved at the time were involved in discussions about the case and the wider system. Due to the on-going response to Covid-19, a practitioner participation session4 was held in July 2021 using video technology. 2.3 The lead reviewer met with Child Y’s mother and spoke to his father on the telephone in order to identify any learning from their perspective. 3 The Learning 3.1 The learning identified for the safeguarding system and partnership is as follows: Learning point 1: When a young child is ‘missing from education’, while it is a priority to ensure that the child starts or returns to school, the possibility of parental neglect should also be considered. 3.2 ‘Children missing from education’ (CME) refers to children of compulsory school age who are not on a school roll or being educated otherwise, such as in alternative provision or by home schooling. The Dudley Metropolitan Borough website states clearly that ‘these children can be amongst the most vulnerable in the country, and it is essential that all services work together to identify and re-engage these children back into appropriate education provision as quickly as possible.’ The West Midlands regional child protection procedures identify this as a potential safeguarding concern. They quote the 2016 guidance5 which states that children missing education are ‘at significant risk of underachieving, being victims of harm, exploitation or radicalisation, and becoming NEET (not in education, employment or training) later in life’. As a young child these were not immediate issues for Child Y, however they should have been in receipt of an education and have had the safeguard of being regularly seen in an educational setting. Indications of Child Y’s significant developmental delay and neglect were not identified due to them being missing from education and because they had no contact with any professional for a number of years. At no stage prior to Child Y starting school in October 2020 was neglect identified. A recommendation has been made that the procedures are reviewed as this case shows the impact that not being in education can have on younger children. 3.3 In Dudley children start primary school the September after their 4th birthday. The law states all children must start school by the latest the beginning of the term after their 5th birthday. Child Y was due to start school in September 2018, and there was a legal requirement that they start school by the latest January 2019. The process of gaining a school place for a child involves a parent or carer taking the initiative and putting in an application either on-line or using a written form delivered to the council prior to 15th January of the year that they are due to start. Child Y’s parents did not complete an application form and this was not identified by the council or any other agency at the time. If a child is registered in early year’s provision in the borough, information is shared by the providers and applications are sent directly. If parents still fail to apply, the case is referred to the CME team who work with the family as the child approaches compulsory school age. Child Y was not part of this process as they were not in registered early-years provision. There is currently has no other mechanism of getting data on children approaching school age. The admissions service is in the process of establishing links with school health to establish if they can access data from GP records to track pupils in Dudley who are due to start school. A recommendation is made in respect of this. 3.4 Local authorities have a duty under section 436a of the Education Act 1996 to make arrangements to establish the identities of children in their area who are not registered pupils at a school and are not receiving suitable ‘education otherwise’6. It was in June 2019, a year after they should have started school, that it was established that Child Y was living in Dudley, was not attending school and had no school place in the borough or in any other area, due to a housing issue. It became apparent that the parents had probably been avoiding professionals since Child Y was three years old. Action was then taken by the CME team to enable Child Y to access an education, but it took another 16 months 4 Four groups were organised chronologically. Each group considered a period of professional involvement with the Child J and her family. Some professionals attended more than one session. 5https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/550416/Children_Missing_Education_-_statutory_guidance.pdf 6 For example formally being home schooled. 4 for Child Y to start school. By then Child Y was nearly seven years old. Child Y’s mother told the review that she had no contact with any friends or family members with young children and that she genuinely was not aware of the need to put in a school application. There is a need to consider how to improve awareness of the application process and timescales. 3.5 Between June 2019 and June 2020 the council’s CME team took responsibility for ensuring that there was a satisfactory conclusion to this matter. There was significant drift and delay in the response, despite the involvement of the CME team and the consideration of the child at the Fair Access Panel7, the weekly CME meetings and the monthly CME Board. Statutory Guidance states that ‘prompt action and early intervention are crucial in ensuring that children are safe and receiving suitable education. The CME officer explained to the review that they sought to develop and use a relationship with the parents to encourage them to accept a school place and ensure the child started school. While this may work with some families, it was not effective in this case. A school was identified and asked to offer Child Y a place, using the Fair Access process, in January 2020. It was ten months before Child Y started there. This further delay had an impact on Child Y’s health and well-being as it was not until they were attending school that the neglect they had experienced was recognised. 3.6 There was an appropriate request for a School Attendance Order (SAO) to be considered in this case, and Child Y was referred to the Education Investigation Service by the CME team, as once the school place was offered Child Y’s lack of attendance then became the issue. No SAO was sought however despite the threshold for an order being met. The review was told that at the time there was a review of the standard operating procedures which had an impact on this case, and others. There was also a Covid-19 impact as the council8 agreed that no prosecutions should be pursued during the pandemic. The review has established that not all of those involved at the time were aware of what was happening in this regard however, and assumptions were made that this matter was being progressed, when it wasn’t. Those who were aware did not communicate that the SAO referral had been put on hold whilst the SAO procedures were being reviewed and that the previous procedures should have been in place until the review was completed. However SAOs were not being used at the time due to COVID 19. A recommendation has been made regarding this. 3.7 The allocated school began pursuing the parents to ensure that the child started school following the fair access panel in January 2020. This included asking a school attendance consultant to conduct a home visit. All attempts to contact the family were unsuccessful. The school have a procedure that they do not place a child on roll until a start date is agreed. This is because they have experience of children who are no longer living in the area and not actually requiring the place. This did not impact on their attempts to ensure that Child Y was welcomed to the school. A wider issue has been identified in Dudley about inconsistencies across schools regarding when a child is placed on the school roll. For example, some schools do not add the child to the roll until their first day at the school, others place them on roll right after the Fair Access Panel has made a decision or a parent has applied for the child to transfer to the school. The Department of Education September 2016 Children Missing Education Statutory guidance for local authorities states that schools must enter pupils on the admission register at the beginning of the first day on which the school has agreed, or been notified, that the pupil will attend the school. If a pupil fails to attend on the agreed or notified date, the school should then undertake reasonable enquiries to establish the child’s whereabouts and consider notifying the local authority at the earliest opportunity. The local education authority is currently undertaking a consultation in the hope of agreeing a consistent approach across all schools in Dudley. The review was told that is likely that a child will be put on a school roll when a start date is agreed with the parents, which was what happened but did not resolve the issues in this case. 3.8 The CME team policy at the time was to close a case when a child is placed on the roll at a school. In the case of Child Y the decision was made to close the case in June 2020 when the mother told the officer she was in contact with the school and planning for Child Y to start. No start date had been 7 It is the role of the Fair Access Panel (FAP) is to agree a Fair Access Protocol, oversee the process and ensure that the amount of time any child is out of school is kept to a minimum. 8 This was common across the country at this time. 5 agreed with the school and Child Y was therefore not on roll. This was an issue as when the CME team close the case, it is the responsibility of the school if the child does not then attend. It is positive that the policy has since changed so that cases are not closed until it has been confirmed that the child has started at the school. This case shows that when there is a history of lack of engagement and avoidance of school, there is a need for on-going CME team oversight until the child starts or returns to school. In this case the CME team were aware that the school were working hard to engage the family and ensure the child attended. The school undertook home visits and attempted communication by telephone, text message and email. They were not permitted access to the home and did not meet Child Y, although they tried to do so on a number of occasions. 3.9 The CME team identified learning when compiling their contribution to the review. This included the need to ensure that records are kept up to date and that management oversight is robust, the need for closer working with health services and housing to ensure that all children approaching school age are identified, and the need for more regular ‘safe and well’ checks to be undertaken on children who are not on a school roll and are not being seen by professionals in other services. Changes that have been made already and their on-going action plan should make a difference to the system and practice. Learning point 2: Systems need to support optimum information sharing between health professionals to ensure that a child’s needs are met if there is any indication that there may be issues with the child’s development or if appointments are missed. 3.10 When Child Y was three years old the parents approached the GP sharing concerns about their child’s delayed speech, and the GP referred the child to a consultant paediatrician. Neither had been able to examine the child or undertake any assessment due to the child’s distress during the consultations. The paediatrician also appeared to have been reassured by the family’s statement that they were no longer concerned, and that Child Y was ‘now fine’. Rather than making another appointment or speaking to the child’s health visitor, whose role it is to monitor a child’s health and development, the paediatrician referred the child back to the GP. When the GP saw the child for a health issue a few months later, there is no evidence that the previous concerns about their development were discussed. The review has identified the need for information sharing with the child’s health visitor when there are identified issues or a need for assessment of the development of any child under 5. 3.11 Child Y was not then seen by any other professional for over two and a half years. The health visitor had contacted the family to undertake a standard universal offer developmental check but the family did not respond. The health visitor followed agreed processes, instigated the No Access Policy and asked the GP to place a flag on the system that the health visitor needed to be contacted if and when they came to the GP’s notice. The flag was put in place but the request does not appear to have been discussed with the family on the one occasion the child was seen shortly afterwards. The learning identified for the heath visiting service from this review is the need to always follow up if a child is requested to attend but then not bought to the healthy child clinic, and the need to include housing in checks for the no-access process. There is also a need to ensure when a child who has missed a key developmental check is transferred to the school nursing service, they need specifically identified to school nursing via a formal hand over. 3.12 Child Y’s mother told the review that they understood both that Child Y should be in school and that he was behind developmentally, but that the longer they left it to seek help, the harder it became. She said she was avoiding professionals because she felt worried about getting into trouble and losing her child. Her partner’s immigration status was also a concern and she did not want to draw attention to him. She described being ashamed of her home and her own presentation and that she was worried what people would think. She said all of this stopped her asking for help. The professionals involved with families who are avoiding services need to consider what might be stopping engagement, and consider which professional is best places to provide initial support and reassurance to improve engagement and assess the child and families needs. 6 3.13 Once Child Y was seen at school, developmental delay was swiftly identified. The areas of delay included speech and language, mobility, wearing nappies and being unable to drink from a cup or use cutlery. There were also concerns about hygiene. Building on the school’s good working relationship with the school nurse, she was contacted and undertook an assessment the same day, identifying neglect as a reason for Child Y’s delay. The school, along with the school nurse and the family support worker showed persistence and respectful challenge when their referrals to the MASH were not accepted as child protection concerns that required an investigation and assessment. The School Nursing service will be using this case as an example of positive practice. Learning point 3: When any professional has concerns that a child is not in education, there needs to be timely information sharing and early consideration of the child’s lived experience, which includes the child being seen. 3.14 The housing fraud team first identified that Child Y was not attending school. They were able to provide this information to the CME team, including where in Dudley the family were living, that they had established that the child was not attending school in any neighbouring authority, and that they had also spoken to the mother who had confirmed the child was not yet attending school. Their extensive enquiries meant that the education authority could work quickly to engage the family and ensure the child was enrolled at a school. The housing professional involved liaised promptly with both the CME team and the MASH in respect of Child Y. 3.15 The MASH considered the information provided by the housing professional and forwarded the information to Early Help, although the housing officer had not completed a multi-agency referral form (MARF) as would be expected. This was not challenged and there was no record made of the contact by the MASH. The analysis from children’s social care (CSC) provided for this review found a need for email information on closed cases to be available on the information system so that they can be seen if further information is shared, and the need to ensure that MARFs are used consistently when referrals are being made to the MASH. An action plan has been devised to ensure improvements in this area of practice. Learning has also been identified about the need for ‘professional curiosity’ in the MASH about children who are not in school, and an improved awareness that this may be a safeguarding issue. In this case a note to early help that they should consider referring back to the MASH if they were unable to engage the family could also have been considered, bearing in mind the link between children missing education and neglect. 3.16 Early Help involvement remained an appropriate plan at this stage, as there was a need for a sensitive assessment to understand why the child was not yet attending school. Other than the child not being in school, no other concerns about the child had been identified or shared at this stage. The fact that the child had not been seen by any professional for a number of years, therefore not allowing for any concerns to be identified, needed to be considered. An early help worker contacted the family in writing and attempted two home visits to the known addresses in an attempt to meet the family during June 2019. As there was no response, the case was closed. In order for any early help work with a family and information sharing about a child, parental consent is required. This was not available in Child Y’s case due to the lack of engagement. The early help worker had confirmed that the CME team were still pursuing the family before closing the case. This was reassuring, but they did not consider consulting the MASH about the lack of contact and the fact that the child had not been seen. The connection between neglect and children missing from education had not yet been made. 3.17 Once the address where the family were staying was confirmed, the CME Team requested that the school admissions team send a school application form to the address where they had been told the family were living. The form had not been returned a month later so the CME team were informed, and they requested that a second form be sent. During this review the LEA (local authority education service) has identified that there is an issue with their IT system that can result in a child’s home address being altered9 during data collection exercises, and in this case it appears that the forms 9 Addresses that include a number then an a, b, c, etc were automatically changed to number only. This is being rectified as a priority. 7 were being sent to the wrong address. This led to a review of the system and there is a plan to solve the glitch in the next software update. 3.18 The review has identified that as well as a need for improvements in the I.T system, there also needs to be professional curiosity about why a child is not in school and why the family have not returned the application form, and a more proactive and timely response to ensure that children do not miss too much education. The Child Safeguarding Practice Review Panel stated in their annual report 2018-19 that ‘whilst technological solutions are a critical component, we also need to think in terms of human factors. Complexity of practice requires sophisticated conversation, hard wired into the DNA of our child protection practitioners. How do we help people talk to each other within a context of high-risk, high-volume and limited resource?’ This is a pertinent and valid question that needs to be considered by the partner agencies in Dudley, as is the case nationally. 3.19 While the process of trying to engage the parents was on-going, the child was not seen by any professional until seen June 2020. This sighting was brief, with the CME team officer confirming to the review that they had only seen the child for a few minutes, that they were in their father’s arms and that they did not engage with them at all. They were not able therefore to consider the well-being of the child during the visit, other than that they were present and ‘seemed fine’. The fact that they were in nappies and had limited speech and delayed mobility was not identified. The poor quality of the accommodation was noted however, and there was an awareness that the parents were consistently trying to avoid the child going to school. The fact that the child had been seen and there were no obvious concerns about Child Y’s safety led to a degree of professional optimism about how Child Y was, and this contributed to a further delay in identifying the neglect. The CME officer was contacted by the school and they too were prematurely reassured that the child had been seen and was well. Covid-19 had an impact as the resulting restrictions meant that the visit completed by the CME officer had to be a doorstep visit and therefore limited the opportunity to grasp a fuller awareness of the child’s lived experience. The CME team went on to close the case without informing the school. 3.20 In order for young children to be the focus of any contacts with a family, they need to be seen, spoken to and observed with their parents. All professionals require the time and opportunity to ensure they see the child and that this contact is meaningful. Reviews of cases in which children have died or been seriously harmed have shown that abused children have often been seen but that workers either were unable or were prevented from identifying abuse10. There are examples of serious cases where professionals have been in the same room as a child but did not engage with them. The type of home visits that were undertaken in this case are very difficult for professionals. They were largely kept on the doorstep (or had to be on the doorstep due to Covid-19) and they had to negotiate with parents who did not want to engage. Being able to see the child in a meaningful way was almost impossible, yet this was the only way of identifying how the child was. The parents were not sharing any concerns and getting Child Y to school was the focus of the work at the time. 3.21 There was limited consideration at the time of why the parent’s may be avoiding services and what was stopping them sending their child to school. The CME worker was told by the mother that she was worried about Child Y attending school and that she had a tendency to ‘baby’ the child. Mother also told the lead reviewer this. It is now known that financial difficulties, poor and overcrowded housing and the wish to avoid professionals due to the father’s insecure immigration status probably had an impact on the lack of engagement and then on Child Y’s development. The stress the family must have been under at the time needed to be considered and acknowledged with them, including consideration of the father’s race and culture. These predisposing stressors were not entirely established prior to October 2020. After Child Y started school consideration was given to the impact of poverty and poor housing on his development and support is being provided. Child Y’s mother told the review how overwhelming their financial insecurity and debt was at the time and that this had an impact on her mental health and ability to focus on her child and their needs. She was estranged from 10 Ferguson H. (2009) Performing child protection: Home visiting, movement and the struggle to reach the abused child’ Child and Family Social Work. 8 her family because they did not approve of her relationship, and this added further stress and isolation. The third national CSPR11 published in September 2021 found that cases considered in reviews often involve families living with additional pressures such as poverty, mounting debts, deprivation, worklessness, racism. 3.22 Good practice was shown by the Family Solutions early help worker who became involved in September 2020 following a MAAM (multi-agency action meeting) also attended by the school. She was persistent in trying to get the child to visit the school with the parents, in the hope that they would then be reassured about the child starting there. They also saw the child briefly when visiting the family in September, just the second professional to do so after the fact that they were missing from education was identified. As was usual, the mother ensured the visit was on the doorstep and blocked a view into the home. The child was seen briefly in a coat and again there was no meaningful engagement or the opportunity to identify any concerns about their development. They were curious about the mother’s mental health and whether there was domestic abuse through control as the mother stated she could not take the child to visit the school as her one and only pair of trousers had split. 3.23 There was confusion about whether the police saw Child Y in September 2020, as had been recorded by some agencies. A police officer had been in attendance at the September MAAM where Child Y had been discussed, and had said they could visit if there was no success in seeing Child Y. The officer in attendance does not always make a record of the discussion on a case which led to a gap in the police chronology submitted for this review. It has since been confirmed that as the FSW had then seen Child Y, the police did not visit. 3.24 There was very limited communication with Child Y’s father, and the focus was on the child’s mother to get Child Y into school. Services are often ‘mother focused’ rather than seeing both parents as equally responsible for the child and the need to be equally involved in any plans made. There was very little information available about Child Y’s father. He was not registered with a GP for example, and it is now known that his precarious immigration status had an impact on his willingness to engage with professionals. It was in fact the father that first took Child Y to the school, along with the family support worker who took the initiative to ensure that the visit took place when Child Y’s mother would not attend the appointment. This was a turning point in being able to assess Child Y’s health and development. The review was told that the need for professionals to consider fathers more rigorously is a reoccurring issue in Dudley. In the 2015 NSPCC report, ‘Hidden Men - Learning from Serious Case Reviews’12 it is pointed out that men can be ‘ignored by professionals who sometimes focus almost exclusively on the quality-of-care children receive from their mothers and female carer.’ Other research13 also confirms that professionals do not always engage with fathers, that they have limited expectations of them, and that when plans are made to support or protect children, it is often assumed by professionals and the parents themselves, that ‘parent’ really means ‘mother’. This was found in regard to Child Y, particularly in the early attempts to engage with the family. Child Y’s father spoke to the lead reviewer and it was evident that his spoken English is limited and that he did not appear to understand all that was discussed. He said that he does not always understand what is being discussed and that an interpreter would be helpful. There was no evidence that this was considered by those involved at the time, and may have been another reason why Child Y’s mother rather than father was the main focus of professional engagement. Child Y is dual heritage as his mother is white British. Learning Point 4: The response to COVID 19 has allowed parents who are hard to engage with to avoid professional contact. Professional rigor and persistence are required so that the needs of children continue to be met despite the challenges of working during a pandemic. 11 The myth of invisible men: safeguarding children under one from non-accidental injury caused by male carers. 2021 12 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf 13 Family Rights Group, Fatherhood Institute, Daryl Dugdale (Bristol university), Professor Brigid Featherstone (Open University) 2012 9 3.25 Attempts to ensure that Child Y’s parents took up the school place that was allocated in March 2020 were hindered by the decision to close schools for all children except those who were vulnerable or the children of key workers on 20 March due to the COVID-19 pandemic. It is impossible to say whether Child Y would have started school sooner without the lockdown, but there is evidence that the child’s mother stated that the family were ‘shielding’ when the issue of school attendance was raised with her, and it provided another reason for the parents to avoid sending their child to school. There were attempts by the school over the months following the first lockdown to engage the family in home schooling for Child Y, to no avail. The school had not yet met Child Y, did not know what level of work to provide (although age-appropriate resources were delivered to the home address, partly due to assurance from the CME worker that the child had been seen) and it is acknowledged that all professionals were working during unprecedented times. The annual report from the national Child Safeguarding Practice Review Panel published in May 2021 stated that the first national lockdown reinforced the crucial role that schools play in safeguarding children. 3.26 School attendance for vulnerable pupils was recommended but not compulsory during the government imposed lockdowns. At the time of the lockdown in March 2020 no professional was aware of how vulnerable Child Y was and they were still not on the roll at the school, so their attendance was not considered. (They continued to attend school during the later lockdown in January 2021 as they were on a child protection plan at that stage.) Child Y was seen very briefly by professionals in June and September 2020 but none were able to meaningfully identify or consider Child Y’s vulnerabilities. Child Y was effectively invisible to all services from October 2017 to October 2020 and both parents kept their child away from the scrutiny that professionals would bring. 3.27 There had been challenge about the child not having been seen from a School Improvement Director from the Academy Trust who was working at the school during February 2020 to increase leadership capacity. They contacted the CME team for information and to challenge them about why the child had not been seen yet. The following day the matter was again raised at the Fair Access Panel and the chair suggested that the CME team visit the home within the next two days. The CME officer was in text and email contact with Child Y’s mother at the time and had attempted home visits, but Child Y was still not seen until June 2020, when they were very briefly observed. The national lockdown which started in March would have had an impact on CME attempts to see the child. The review was told that there were debates about whether it was safe and appropriate to undertake home visits and whether PPE was required for example. Schools were given PPE in order for the attendance officers to visit children’s homes shortly after the start of the first national lockdown. The CME Officer was also provided with PPE but initial guidance to staff was to complete virtual or doorstep visits. 3.28 Covid-19 has provided families who are hard to reach and who wish to avoid professionals with the opportunity to do so. A number of reviews nationally are finding that families have been using ‘shielding’ as an excuse for children to remain at home, which in some cases increases risk and limits support for vulnerable children. To a degree this was the case for Child Y. With or without the pandemic, the parents ensured that professionals were not able to establish what impact their non engagement with services may be having on the life of the child. The neglect of Child Y’s educational and developmental needs was not identified due to the parent’s long-term avoidance of the agencies trying to assist them, and while Covid 19 added to the difficulties in engaging the family, the review has shown that their avoidance and drift in the plan to get Child Y into school was a feature prior to March 2020. Learning point 5: When there are concerns about a child, all agencies need to be clear about the child’s place in the system and to challenge if there is a disagreement or delay. 3.29 Good practice was evident within the system when challenge was required due to concerns about Child Y and differences of opinion regarding whether they required a safeguarding response. There was individual agency challenge to the MASH from the school, from Family Solutions and from the school nurse regarding the MASH decision that family support was the appropriate response for Child Y after they started school. There was good communication between these professionals about the 10 need to challenge and a number of attempts to show evidence that Child Y had suffered neglect and was at risk of ongoing neglect. While this debate was on-going, appropriate support was provided by the school and the school nurse, and the child was referred for assistance from speech and language therapy and the continence service. Practical support was also provided including nappies, food bank vouchers and school uniform. 3.30 This challenge and the persistence of those involved led to a change in the plan for Child Y, and a social worker was allocated to undertake an assessment two days after they started school. The child’s current social worker, who became involved later, told the review that the extensive knowledge of the child’s needs and the experience of those involved, regarding the behaviour of the parents and their reluctance to engage with professionals, particularly the school, allowed her to have an understanding of the case quickly which enabled an informed response. Child Y’s mother also spoke about the non-judgemental approach of the social worker and how this has helped her to engage and consider and understand the concerns about Child Y. 3.31 There was some confusion regarding the nature of the CSC and police involvement, which was not identified at the time. Following the agreement from CSC that they would undertake an assessment, a social worker visited with the police. They met the parents and the child. During the visit the police officer issued a Community Resolution Order (CRO) stating that the parents must work with CSC, and the parents consented to an assessment. The use of this order would have involved the police officer acknowledging that an offense of some kind had been committed. CROs are an ‘opportunity for the police to deal with appropriate low-level offences and offenders without recourse to formal criminal justice sanctions.’14 Without a full investigation of the impact on Child Y of the neglect they had suffered, and without giving the parents the opportunity to work with a social worker (this was the first contact CSC had with the family) this initially appeared to be a premature decision. Further discussions with West Midlands Police show that this was a pragmatic response to ensure compliance from the parents. The CRO was not necessarily a final decision and the police assured the review that this decision could be reviewed at any time and alternatives such as a criminal investigation would be considered if further evidence of neglect was identified. What was not clear is whether there was in fact a review and whether other professionals involved were aware that this was a possibility which they could request. 3.32 The status of the case at this stage was not clarified. Police records state that it was a single agency S47 investigation had been agreed, however CSC decided to pursue the assessment under S17. Procedures are clear that a S47 investigation is usually undertaken following a decision made at a strategy discussion. There was no strategy discussion / meeting in this case until 4th November, nearly a month after Child Y started school and the serious concerns were identified. This led to a delay in a child protection medical being considered and no opportunity for debate about whether a criminal investigation was required. While it was unlikely to be appropriate in the case of Child Y, in other cases it may be. This has highlighted a need in Dudley to consider if this is a wider issue and a recommendation has been made in regard to this. 3.33 Around a week after the visit from the police and CSC, the social worker had a discussion with the Child Protection Chair service regarding whether the child should be subject to an initial child protection conference (ICPC). Discussion with the CP chairs in Dudley is common when considering thresholds and is largely good practice. In this case the chair was spoken to and the fact that the parents had been cooperating with the assessment, that Child Y would remain a child in need with an allocated social worker and coordinated multi-agency support would continue, it was felt that an ICPC was not required. It was noted that if this was not sustained, the need for a conference should be reconsidered. The decision did not take into consideration the extensive history of lack of engagement with all professionals, that the cooperation from the family may have been due, at least in part, to the police CRO and the fact that Child Y had already suffered significant harm from neglect. 14 https://www.west-midlands.police.uk/your-options/community-resolution 11 3.34 As outlined above, there was appropriate earlier challenge when the Academy Trust that manages the school contacted the LEA in February 2020 asking why the child had not been seen. The school have identified single agency learning, recognising the need to develop confidence in escalating using the DSPP process if they have concerns about partner agencies not completing agreed actions. The review reflected on the use of the restorative practice model in Dudley when working with families and how in this case the clear neglect of Child Y was not the primary focus. The aim of CSC to work with the family to meet the child’s needs in the medium to long term was a good one, however the investigation of the abuse and a clear focus on the risk to Child Y needed to receive equal focus. There was evidence of reflection within CSC that focused on the mother rather than Child Y, and an optimistic view of both the past and the plan for working with the family. 3.35 A medical was undertaken on Child Y a month after concerns about neglect were identified. The West Midlands child protection procedures15 state that a child protection medical should be undertaken where there are indicators of neglect, as there were for Child Y. The procedures state that the need an assessment in the context of S47 enquiries should be discussed with the doctor due to undertake the medical assessment ‘to ensure they are aware of its strategic significance’ and that the ‘doctor should demonstrate a holistic approach to the child and assess the child's well-being, including mental health, development and cognitive ability.’ In this case the medical concluded that Child Y’s educational, developmental and possibly medical needs had not been met in the family environment by the parents and may indicate neglect. 3.36 The decision to have an ICPC was made the same day as the medical, and while the conference was then held within 15 days of the strategy discussion, it was seven weeks after the first visit by the police and CSC. No agency challenged the delay in either the medical or the decision to hold an ICPC. This was because they were relieved that CSC were now involved, because Child Y was now attending school, because there had been a referral to a paediatrician via the school, and because of a more general lack of knowledge of the required timescales within child protection procedures. 4 Conclusion and recommendations 4.1 When Child Y started school it was identified by experienced and skilled professionals that they had been neglected and that they were delayed in their physical and cognitive development. This CSPR has considered the learning from Child Y’s case and identified learning that will be helpful for the wider system. It shows that good information sharing, open communication between professionals and embedded relationships between the professionals working with a child can make a positive difference, but it also exposes the vulnerabilities, particularly when a child and their family are effectively invisible to the services that safeguard children. 4.2 Single agency learning has been identified during the review and recommendations have been agreed to address these, including single agency SMART action plans. There has been excellent cooperation with this review from partner agencies, which was essential in establishing the learning from this case. 4.3 Having considered the learning from this review that has not been addressed in the single agency actions, the following additional recommendations are made to ensure improvement actions are taken. Recommendation 1: The DSPP should request that the West Midlands procedures in relation to children missing education are reviewed to ensure that reference is also made to younger children missing education and the links with neglect. Recommendation 2: 15 https://westmidlands.procedures.org.uk/ykpzl/statutory-child-protection-procedures/additional-guidance/#s536 12 That the DSPP seeks assurance and an update from the LEA regarding the effectiveness of their service when a child missing education meets the criteria for a school attendance order, and requests that the Education Investigation Service undertakes a review to ensure that all children who require a SAO are receiving timely consideration and that any other children missed during 2019/20 have been considered. Recommendation 3: The DSPP should ask the relevant partner agencies to ensure that Working Together compliant strategy meetings are being held to plan investigations and visits and there is consideration of a child protection medical in neglect cases. Assurance should then be provided in relation to this. Recommendation 4: The DSPP to request that the LEA Admissions Team provide assurance about what processes are in place to ensure that all children living in Dudley who are due to start school are known about and receive timely support if an application has not been received. All partner agencies may be required to provide information to the Admissions Team if a fool proof system is to be in place. |
NC049212 | Circumstances leading to a 15-year-old boy being placed in a secure setting in September 2015. When Mark was 12 years old his school were concerned about his use of drugs and in May 2013 made a referral to Children's Social Care (CSC) indicating concerns that his health and presentation had deteriorated significantly. CSC assessed the referral but took no further action. For the next 3 years different agencies were involved with Mark and his mother in response to escalating drug use, offending behaviours and frequent periods of going missing. He was made subject to a Child Protection Plan under the category of Neglect. His mental health deteriorated and he was sectioned under the Mental Health Act and placed in a secure setting in September 2015. Findings include: the need to improve understanding of adolescent choice and risk, especially in terms of substance misuse; the importance of shared assessment processes to pull out indicators of need or vulnerability; a lack of professional curiosity to investigate what the underlying reasons were for Mark's behaviour and drug misuse; the need for a clear chronology of events to show where risks lie. A Thematic report was completed before this review was published which led to significant changes in processes and systems in Sunderland and these changes have been taken into account. Recommendations to the LSCB: develop a multi-agency framework to support the development of resilience and improve outcomes for vulnerable adolescents; support staff to engage effectively with young people and better understand issues of risk such as child sexual exploitation and substance misuse.
| Title: Serious case review: Young Person Mark. LSCB: Sunderland Safeguarding Children Board Author: Sunderland Safeguarding Children Board Date of publication: 2017 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Final - 8th November 2017 Serious Case Review Young Person Mark1 1 Not his real name Final - 8th November 2017 2Contents Section Page 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 3 2. The circumstances which led to this SCR 3 3. Family Involvement 4 4. Links with other Serious Case Reviews 5 5. The context under which this SCR was commissioned 5 6. The approach used 6 7. Analysis of Practice and Findings 7 7.4.. Understanding Adolescent Behaviours 7 7.5. Responding to Adolescent Risks 9 7.6. Risk Assessment and Planning 15 7.7. Multi-Agency working and Collaboration 18 7.8. Engaging adolescents 20 8. Situation Now 24 9. Conclusion 25 Appendices Appendix 1: Summary of Findings and Recommendations 26 Appendix 2a: SSCB Impact Statement 28 Appendix 2b: Sunderland CCG Impact statement 31 Appendix 2c: Education and School Impact Statement 33 Appendix 2d: General Practitioner (GPS) Impact Statement 34 Appendix 2e: South Tyneside NHS Foundation Trust Impact Statement 35 Appendix 2f: Northumbria Police Impact Statement 36 Appendix 2g: Together for Children (CSC) Impact Statement 38 Appendix 2h: Youth Offending Service 40 Appendix 2i: Youth Drug and Alcohol Service 41 Final - 8th November 2017 31 Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 are to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance3, which accompanies legislation and underpins the work of LSCBs, is very clear in its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared. 1.2. In situations where abuse or neglect of the child is known or suspected, and children die or are harmed, LSCBs are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce the risk of future harm to children. There is an expectation that these processes known as Serious Case Reviews (SCRs) should be transparent with the findings shared publicly. 2 The circumstances which led to this Serious Case Review 2.1. Mark came to the attention of agencies in 2013 when he was 12 years old and his school were concerned about his misuse of drugs. During the next three years, professionals from different services were involved with Mark and his Mother in response to his continued and escalating drug use, his offending behaviours and frequent periods of going missing. Early in 2015 Mark was made subject to a Child Protection Plan under the category of Neglect but concerns about his safety and wellbeing continued. Despite professional optimism that things were beginning to change for Mark, his mental health began to deteriorate and in September 2015 Mark was sectioned4 first under S2 and later under S3 of the Mental Health Act 5 and was placed in a secure setting amid continued concerns about his safety, behaviour and mental health. The Youth Offending Service (YOS) referred Mark’s situation to Sunderland Safeguarding Children Board (SSCB) as they were of the view that Mark had suffered significant harm because agencies did not act early enough to safeguard his safety and well-being. 2 Children Act 2004, s14 3 Working Together to Safeguard Children 2015. HMSO 4 ‘Being 'sectioned' is the term that is often used when someone is detained under the Mental Health Act 1983. The Mental Health Act is the law which can allow someone to be admitted, detained (or kept) and treated in hospital against their wishes. 5 Section 2 of the Mental Health Act (1983) allows compulsory admission for assessment, or for assessment followed by medical treatment, for duration of up to 28 days. Section 3 of the Mental Health Act is commonly known as “treatment order” it allows for the detention of the service user for treatment in the hospital based on certain criteria and conditions being met. These are that the person is suffering from mental disorder and that the mental disorder is of a nature or a degree which warrants their care and treatment in hospital and also that there is risk to their health, safety of the service user or risk to others. Final - 8th November 2017 42.2. The retiring SSCB chair took a decision in October 2015 to undertake a SCR in respect of Mark, but this decision was challenged by Children’s Social Care (CSC) and the SCR did not immediately commence. The decision to commission a SCR was later reviewed in May 2016 by the incoming Interim chair of SSCB who confirmed that the circumstances which led to Mark being sectioned under the Mental Health Act together with concerns about multi-agency working met the criteria for a SCR. 2.3. Given the context in which this SCR was commissioned6, the Interim Chair of SSCB requested a short focused report 7 which reviewed decision -making and practitioner involvement with Mark and his family between March 2013 and September 2015 and which considered: • To explore how well the system worked together in identifying, responding, and meeting the needs of both young people. • To determine what collective understanding there was in terms of the young person’s vulnerabilities and the risks to which they were exposed. • Building on learning from previous [and not dissimilar] SCRs to examine the barriers and system challenges for agencies and professionals in working effectively with young people with complex and challenging behaviours. • How well were staff supported and supervised when working with these young people and were they able to, use evidence, research, and good practice to exercise professional judgement in a safe and appropriate way? • Identify required system changes to enable and support practitioners to work more effectively with older children like Mark and Rachel. • Identify opportunities to learn from and improve frontline practice when working with vulnerable adolescents. 3 Family Involvement 3.1. The Review Team took advice on three occasions to determine whether Mark could contribute to this SCR but was informed by social workers and health professionals that his mental health was not good and he was, at the time of writing this report, extremely vulnerable. The Review Team therefore agreed not to contact Mark directly and left open the possibility that he may at some point in the future want to know more about the SCR and its findings. 6 The context was in relation to the sheer number of reviews already underway in Sunderland and the learning already identified. This required a more proportionate form of SCR rather than a disproportionate use of resources rehashing learning already identified. In addition a Children’s Company was being formed to run the local authority’s children’s service and the implementation of significant changes were already taking place. 7 The Chair of LSCB advised the Lead Reviewer that given the context in which this SCR was being undertaken, the SCR report was required to be a short focussed report and agencies were not required to submit the usual Agency Learning Reports. This posed a particular challenge for the SCR Review Team which then had to rely on scoping and review meetings to review agency practice. Final - 8th November 2017 53.2. Attempts were made by the SSCB to involve Young Person Mark’s Mum in the process but she declined to be involved. Further attempts will be made to share the overview report with her and if she would want to add anything to the report regarding her views on the work undertaken with Young Person Mark and his family an addendum to this report will be published. 4 Links with other Serious Case Reviews 4.1. In late 2015, two SCRs in Sunderland were finalised, which related to the sad and tragic deaths of two adolescents. There were some similarities which emerged from both reviews, and the then independent Chair of SSCB commissioned a thematic review to ensure that the learning from both reviews was collated and the lessons fully captured. The report from that review was completed in June 2016 and is referred to in this report as the Thematic Report. 4.2. The themes identified in the Thematic Report have already led to some significant changes in processes and systems in Sunderland, some of which have already been introduced and some which at the time of writing this report are still in progress. In the recent past, SSCB has published other SCRs which although not related to adolescents, nevertheless identified common themes which all highlighted that multi-agency services in Sunderland at that time were not working as well as they should have been. 4.3. At the same time as the SCR for Mark began in September 2016, another SCR, which related to a 16-year-old female, also began. The Safeguarding Board partners agreed that both SCRs should have due regard to any common areas of learning and should also relate these to previous findings from other reviews which related to work with adolescents. The Review Team were also asked to take into account the changes already being embedded in Sunderland, especially given that the SCRs related to roughly the same period. 5 The context in which this SCR took place 5.1. In July 2015, children’s services and safeguarding departments in Sunderland were placed into special measures when they were deemed by Ofsted to be inadequate. As a result of that rating, many changes to single and multi-agency systems were introduced and other longer-term improvements are currently underway. Recent monitoring visits by Ofsted in 2017 have confirmed that steady progress is being made and there is clear evidence of significant and steady improvements. 5.2. To date, nine SCR reports have been published in Sunderland and 5 more are moving towards completion. Given that all these SCRs have reviewed practice up to and including 2015, it is not surprising that some of the findings also reflect those identified in the Ofsted report. The challenge therefore for this SCR was to Final - 8th November 2017 6ensure that any findings were viewed against a landscape of significant change within and across the authority which continues to emerge and develop. There is an acknowledgment by SSCB that certainly in relation to work with adolescents there is still much to be done but it is encouraging to see this work has been identified as a priority in the 2017 – 2018 SSCB Business Plan. 5.3. In light of this context and in relation to the findings in this SCR, the Review Team has sought to identify where changes have taken place, where changes are in progress and where further work is still required. It must also be reiterated that this SCR is reviewing practice 2 to 3 years old, and whilst other SSCB reviews and the Ofsted monitoring visits suggest that the improvement journey is still on-going, there is evidence of steady progress being made to achieve better outcomes for children and young people in Sunderland. 5.4. The Review Team was grateful to the practitioners involved in this review, who willingly engaged in this process and volunteered their reflections and professional insights, which have helpfully contributed to this report. 6 The approach used 6.1. A Review Team was established which included senior managers from all the agencies known to Mark and his family. The members of this group are listed below: • Independent Lead Reviewer • SSCB Strategic Business Manager • Northumbria Police • Sunderland City Council: Youth Offending Service, Children’s Social Care, Education • Northumberland, Tyne & Wear NHS Trust • South Tyneside NHS Foundation Trust • Housing Provider Gentoo • North East Ambulance Service • Sunderland Clinical Commissioning Group 6.2. The senior managers also identified practitioners from their own agencies who knew or had worked with Mark during the period under review. These practitioners were known as the ‘Practitioner’s Group’ and they contributed to the SCR process and offered an opportunity to discuss lessons from previous SCRs and how and where these had relevance for their work with Mark. 6.3. The practitioners were extremely forthcoming about the issues they faced in working with adolescents and their reflections of the challenges of working with Mark and other adolescents were particularly illuminating. The group later came together for a full day with the Review Team and other practitioners who had not worked with Mark, to discuss and to explore whether single and multi- agency Final - 8th November 2017 7systems and processes were changing to better support existing work with adolescents. 7 Analysis and Findings of Practice 7.1. The purpose of Serious Case Reviews is to support improvements in safeguarding practice. This means it is not sufficient just to describe professional activity in a case or to identify elements of practice that were problematic, without explaining why they occurred. The analysis needs to provide an explanation of what influenced professional activity and decision-making at key points in the management of the case. 7.2. This SCR has not identified a significant contravention or action by any professional that was a critical factor in what happened to Mark in September 2015. Indeed there was evidence that many professionals with whom Mark came into contact were concerned about his welfare and safety and sought to engage him or seek access to other services. 7.3. The learning from the SCR does, however, invite and require a better understanding by managers and practitioners in education, health and social care of the interplay between adolescent choice and risk, especially in terms of substance misuse, the importance of shared assessment processes for children showing indicators of need or vulnerability but who have not reached thresholds for statutory safeguarding, and the management of concerns and referrals when dealing with young adolescents whose life style, circumstances and mental capacity may be factors that require a more assertive and inquiring approach. 7.4. Understanding adolescent behaviours 7.4.1. Risk-taking is a normal part of adolescent development and most young people experiment with the increased opportunities for risk that their growing independence allows. For some young people this includes experimenting with drugs and alcohol. However, unless professionals understand the difference between normal experimentation and the signs which identify seriously troubled young people, opportunities for effective and timely interventions will be missed leaving some young people at greater risk. 7.4.2. The first recorded concerns about Mark’s substance misuse occurred soon after he began secondary school at around 11 years of age. Education records suggest that Mark had four moves between schools between the ages of 11 and 13 in connection with his drug use 7.4.3. In May 2013, Mark’s school made a referral to Children’s Social Care (CSC) referring to his persistent use of use of cannabis and indicating concerns that that although he was an able pupil, his health and presentation had deteriorated significantly over the last few months. CSC assessed the referral but took no Final - 8th November 2017 8further action noting that Mark and his family were working with YDAP. This decision was made by a duty social worker that appears to have been reassured that the family were engaging in early intervention services and therefore the referral did not meet the threshold for statutory intervention. 7.4.4. There is however no evidence to suggest the duty social worker sought to establish with YDAP the extent and impact of their involvement, which would have been expected given the nature of the school referral. Had this contact been made, it would have emerged that although some initial contacts had been made, Mark and his family were not in fact engaging with YDAP. 7.4.5. The school were verbally advised by the duty social worker to contact them again if further concerns emerged. This response was accepted by the school as they believed that CSC had fully assessed the situation and concluded there was no immediate risk to Mark. This readiness of referring agencies to accept the decisions of social workers without being offered a clear rationale for their decision-making has emerged in other SCRs, both in Sunderland and elsewhere. If CSC are noted ‘not to be concerned’, referring agencies can sometimes be reassured that ‘things can’t be that bad’. Despite Mark’s continued deterioration, no other referrals to CSC were made by education services around that time or later. 7.4.6. Given Mark’s age and the nature of the schools concerns – persistent drug use and a marked deterioration in his health and appearance - the referral to CSC should have led to an Initial Assessment which would have provided an opportunity to gather more information about Mark and his family and importantly would have highlighted YDAP’s difficulty in engaging effectively with Mark’s Mother and his Father, who did not live with the family and worked abroad six weeks of out every nine. 7.4.7. Practitioners suggested to the Review Team that that the CSC decision not to pursue an Initial Assessment may well have been influenced by a range of additional factors not least of which were the numbers of young people on caseloads and in the locality who also misused substances and who were disengaging with education. The issue of Mark’s behaviour being viewed as ‘similar to that of many other young people’ in some parts of Sunderland was acknowledged by some practitioners although they pointed out that Mark was at the time thought to be receiving a service and his Mother was seen then as a protective factor. When Mark’s Mother informed YDAP that they no longer required their services, increasing the potential risks to Mark, this should have prompted contact with CSC given the earlier referral by the school. Had there been more collaboration between the three services, this would have been seen as an appropriate and necessary course of action. Final - 8th November 2017 97.4.8. The Review Team was curious to know how YDAP was working at the time as there was no evidence that Mark had been assessed by the service or that subsequent action had taken place when he failed to engage with the service. The Review Team learnt that the model and systems used in YDAP at the time were not as robust as they could have been and at the time of this review, YDAP were not using a structured assessment framework to plan interventions. A framework is now in place which betters identifies levels of vulnerability in young people and can better evidence when the threshold for a referral to CSC is needed. 7.4.9. There was an acknowledgement that some professionals supported by their agencies can too easily view substance misuse as ‘something that young people do these days’ and therefore may unwittingly minimise the dangers and risks involved. These early days were an opportunity to better understand what was happening to Mark and to try and identify the reason for his substance misuse so that the right services were offered and taken up by the family. This did not happen and Mark’s vulnerabilities went unrecognised and remained so for almost two years. 7.4.10. Finding 1: Without analytical assessments, multi-agency collaboration and challenge, the harmful behaviour of some adolescents may be too easily viewed as ‘just what teenagers’ do’ and this perception can prevent early intervention for those adolescents at greatest risk. Training and workforce development, including quality supervision, must ensure practitioners have the skills to work with adolescent choice and complex behaviours and have opportunities to develop their understanding of the adolescent world, including substance misuse and other forms of risk. Issues previously identified in SCRs/Thematic Report: Multi-agency working, assessments, supervision, appropriate training for workforce 7.5. Responding to adolescent risk- taking behaviours 7.5.1. Mark’s offending and use of alcohol and substances escalated during 2013 and became daily occurrences. He was frequently reported to be using legal highs including MCAT8. It is worthy of note that even the young people with whom Mark associated and who also took drugs, raised their concerns with education staff about Mark’s welfare and suggested that he was too often ‘out of it’ and would take anything to ‘get high’. There is little to evidence that any action was taken in response to these concerns, which in itself raises questions about how well young people are listened to and their views taken seriously. 8 MCAT is a stimulant drug belonging to a group of drugs related to amphetamine compounds like speed and ecstasy. Final - 8th November 2017 107.5.2. Concerns began emerging around this time that Mark was being sexually exploited. There has been, since 2009, an array of public documents and initiatives aimed at local authorities to advise about how to recognise and respond to concerns about CSE. Even so, as late as 2014 professionals in Sunderland were slow to respond to Mark’s vulnerabilities and the risk of sexual exploitation. 7.5.3. Mark was referred in 2014 to SEAM9, a set of multi-agency arrangements aimed at meeting needs of children at risk of sexual exploitation but no disruptive or preventative actions were taken. The Review Team was of the view that had Mark been female there may well have been a far more urgent response by professionals, a view supported by professionals given the services to young people at that time. An Ofsted report (2015) recorded that services for children and young people missing and at risk of child sexual exploitation were at that time ‘insufficient and poorly coordinated and the report was critical about the viability and effectiveness of the SEAM arrangements. SEAM was replaced later that year by MSET, a set of multi-agency arrangements designed to be a more robust and efficient multi-agency response to child sexual exploitation. 7.5.4. The Review Team had access to the minutes of the MSET meetings which related to Mark, and were concerned to note how often actions by social workers were not progressed within the agreed timeframe. There was evidence that even after 5 months, when issues about inaction had been escalated to senior managers; these concerns had still not been acknowledged. This is very poor practice and impacts upon the effectiveness of MSET from both operation and strategic perspectives. SSCB needs to continually monitor this service to ensure that current MSET10 arrangements are not compromised by such practices which can too easily lead to drift and delay for some young people. 7.5.5. Mark was discussed at an MSET meeting in February 2015 following Police reports about the number of times Mark was going missing. According to CSC records, there were at least 14 contacts or referrals to children’s services between May 2013 and January 2015 including child concern notifications (CCNs) from the police. Each of these described or highlighted the same concerns, but it was not until the intervention of the MSET Coordinator that a decision was taken that Mark would be subject to a MASH11 discussion to determine whether further enquires were required under child protection procedures. Even so, Mark was assessed as low risk, but given what was known about his circumstances, the MSET co-ordinator urged CSC to undertake an Initial Assessment. This was good practice. 9 Sexual Exploitation and Missing arrangements 10 Missing, Sexually Exploited and Trafficked arrangements – these arrangements were multi-agency focussing on operational activity and replaced the SEAM arrangements. 11 Multi-Agency Safeguarding Hub: The Sunderland MASH was a joint initiative between Sunderland City Council, Northumbria Police and the NHS to co-locate key members of staff in order to ensure a timely, appropriate response to safeguarding children concerns Final - 8th November 2017 117.5.6. It is important to note that at that time CSC were not subject to any challenge by other agencies about their lack of response. Whilst YOS did challenge CSC about drift and delays and the frequent change of workers, the Review Team concluded that these challenges were not sufficiently robust and were certainly not escalated, as they should have been. 7.5.7. What is clear is that referrals and concerns when they were raised with CSC were viewed as individual and singular episodes rather than emerging and escalating patterns of risk and consequently opportunities to view what was happening to Mark from a wider perspective were lost. 7.5.8. At twelve years old and certainly until he was 15, Mark was showing clear signs of being a troubled young person, yet it appears that no serious questions (a seeming lack of professional curiosity) were asked by professionals as to why he misused alcohol and substances, what the underlying reasons might be for such behaviour and what the impact of long term drug misuse could be on his mental and emotional health. 7.5.9. What emerged from discussions within the Review Team and with practitioners and managers was evidence that for some professionals the interplay between adolescent choice and risk was not well understood nor carefully explored. According to various agency records, Mark’s behaviours seem to have been seen as ‘freely chosen, informed, and adult-equivalent’. In one agency report there is reference to Mark making a ‘lifestyle choice’ in terms of his continued substance and alcohol misuse. Even the rationale for placing Mark on a child protection plan for ‘Neglect’, in March 2015 was recorded as ‘not being a reflection of the care offered by his Mother’ but was in response to Mark’s ‘informed decisions’ which placed him at risk of significant harm. Research12 suggests that where choice and behaviour are playing a part in the lives of children about whom there are growing concerns, this is typically because one or more of the following factors or processing are at work or are interacting; • Normal adolescent developmental processes (risk taking, peer influence, the desire for high status with friendship groups) • Adaptive behaviour in response to previous maltreatment and/or adversity • Societal attitudes and policies which increase risk or harm in response to adolescent choices and behaviour i.e. responding to youth offending which inadvertently reinforces criminal identify) 7.5.10. The Review Team was not confident that any of the above factors were explored in sufficient detail as part of any assessment process and this was very possibly due to an unconscious bias which left professionals reassured by what appeared 12 Beyond simple models of adolescence to an integrated circuit-based account: A commentary BJ Casey(2015) Final - 8th November 2017 12to be a protective family and a young adolescent just making the ‘wrong choices’. Mark was most certainly viewed as ‘the problem’ within his family and this perception seems to have been mirrored by some professionals, evidenced in case notes when for example, discussions about Mark continued with his Mother even when Mark was clearly angry and left the room. 7.5.11. It seems that the view that Mark was ‘the problem’ was also reflected in a professional system, which sought to stop his substance misuse rather than understand it. There was a sense that despite her reluctance to engage in family therapy or with services, Mark’s Mother was seen as deserving of extra support and sympathy rather than an assessment as to whether she or Mark’s Father were adequately meeting their son’s emotional needs. Yet there are references in CSC records which suggest that Mark was emotionally distant from his Mother and her behaviour towards him and her unwillingness to engage with services may have contributed to his difficulties and may have been a form of unintentional emotional neglect. This was however, not explored in any detail and so the focus remained on Mark’s behaviour. 7.5.12. There are some vague references in CSC case notes to family conflicts in the home prior to this time and records which infer there was a poor relationship between Mark and his Mother and conflict between Mark and his absent Father but without any assessment which captured information from other agencies, the full picture of Mark’s life did not emerge. From records seen by the Review Team, there appears to have been a greater focus by some professionals on educating Mark about the dangers of substance misuse and the impact of his behaviour on his Mother’s well-being rather than any professional curiosity about what may have happened to him which made substance and alcohol abuse such an apparent necessity in his life. 7.5.13. Many factors influence whether an adolescent tries drugs, including the availability of drugs within the neighborhood, community, and school and whether the adolescent’s friends are using them. The family environment is also important and family conflicts, parent’s lifestyle and mental illness can increase the likelihood an adolescent will use drugs. In addition, an adolescent’s inherited genetic vulnerability; personality traits like poor impulse control or a high need for excitement; mental health conditions such as depression, anxiety, or ADHD; and beliefs such as that drugs are “cool” or harmless make it more likely that an adolescent will use drugs.13. Add to this all the vulnerabilities that arise if a young person is at risk of or involved in sexually harmful behaviour or sexual exploitation and the need to understand the source or cause of such drug use becomes evident. Again the Review Team were unable to evidence any curiosity or 13 Alcohol and drug use among adolescents: and the co-occurrence of mental health problems. British Medical Journal (2010) Final - 8th November 2017 13consideration by parents or professionals as to why Mark took refuge in substance misuse and this led the Review Team to conclude that his behaviour was indeed perceived as a ‘lifestyle choice’. 7.5.14. It is clear from records and discussions with practitioners, that Mark’s Mother was concerned about her son and sought help to address his behaviours at various times during the period under review. What is less clear is how professionals sought to engage both Mark’s parents in discussions about the best way to help Mark. Direct work that incorporates a family-centred approach, with the adolescent and family engaged together, has the best chance of achieving successful outcomes for adolescents with substance use disorders. Family members are a critical component of the adolescent’s recovery process and some level of family involvement is essential for successful outcomes. In contrast to interventions that focus just on the young person, family-centred work capitalises on the youth’s and family’s strengths, resources, values and culture and maintains the integrity of the family-unit while developing resiliency and demanding responsibility and accountability. 14 Although records suggest that neither parent elected to engage with professionals, the Review Team was unable to determine if this was as a result of a lack of commitment or a lack of understanding about what would best help Mark. 7.5.15. The notion of ‘problematic’ drug or alcohol use is different for young people than for adults. This is partly because they are younger – what might seem to be ‘normal’ adolescent experimentation in a 17 year old should be grounds for intervention in an 11 year old. Crucially, drug and alcohol use among young people is often thought to be problematic because of its relationships with other problems in the young person’s life. Research15 highlights that drug and alcohol misuse among teenagers ‘is usually a symptom rather than a cause of their vulnerability’, and compounds other problems in their lives such as ‘family breakdown, offending, truancy, anti-social behaviour, and mental health concerns such as self-harm’. There was evidence to suggest that Mark’s behaviours were initially viewed within the category of normal adolescent risk taking behaviour rather than adaptive responses to maltreatment, emotional neglect, and/or adversity. 7.5.16. Finding 2: There was a lack of professional curiosity about Mark’s background, what had happened, and what was happening in Mark’s life, which meant that his behaviour and substance misuse were regarded as ‘the problem’, rather than being symptomatic of other stressors in his life. 14 Santisteban, D.A. (2008). Engaging reluctant family members into an adolescent’s substance abuse treatment: A guide for practitioners. Southern Coast Addiction Technology Transfer Center. 15 NTA: ‘Substance in Young People 2010 – 2011 data, Public Health England Young People’s Drug, Alcohol and Tobacco use: Planning for Services 2016 - 2017 Final - 8th November 2017 14Issues previously identified in SCRs/Thematic Report: Quality Assessments, lack of professional curiosity. 7.5.17. It was suggested to the Review Team that many professionals are not sufficiently aware of the impact of different illegal substances, including the relatively new range of synthetic and often legal drugs, which are now easily available. It was also suggested that cannabis can sometimes still be seen as less of a risk than LSD or heroin. Various research studies16 highlight the trend for young people to use synthetic cannabis, which has been developed to be more potent than the cannabis in use in previous years, but which can have negative effects on emotional and mental health. The use of legal highs such as MCAT for example, can lead to dis-inhibited behaviours and can result in low mood, anxiety and paranoia all of which were evidenced in Mark’s behaviour at various times. 7.5.18. Although recreational alcohol and drug use are more common in adults, studies17 have shown that youths who engage in drugs and alcohol use are at greater risk for lifelong negative consequences, especially when they start using at a young age. Because the teenage brain is still growing and changing, alcohol and drug use at an early age have a greater potential to disrupt normal brain development. The most affected brain regions include the hippocampus—which is related to learning and memory—and the prefrontal cortex, which is responsible for critical thinking, planning, impulse control and emotional regulation. Drug and alcohol use also interfere with many other physiological processes and have been shown to destabilize mood. Thus, adolescent substance use is associated with higher rates of depression, aggression, violence and suicide. These findings are particularly disturbing given that, for most teens, like Mark, initiation of substance use tends to be at an early age. During discussions with practitioners, the Review Team were told that an unintended consequence of having specialist youth and alcohol services in an authority can mean professionals are less likely to learn more about substance misuse as they perceive that to be the remit of other services. 7.5.19. Certainly, Mark’s continued use/progression from cannabis to the use of MCAT and other drugs did not appear to generate any additional concerns and despite his young age, referrals to CSC were not actioned until early 2015, almost two years after concerns had first been raised about his substance misuse. Given the diversity of drug and alcohol use in young people, practitioners told the Review Team it is not always easy to decide what constitutes problematic use. Not all young people who experiment with substances develop problem substance misuse and the Review Team was told it can be challenging to decide who should 16 NPS: Coming of Age. Drug wise May 2014 17 as above Final - 8th November 2017 15receive targeted interventions or more comprehensive, multi-agency interventions. 7.5.20. Finding 3 (NEW) Many practitioners are not always clear what they should be doing in relation to substance use and their role expectations vary according to their specialist area of practice, their knowledge of substance use, and their levels of confidence. Whilst adolescents who use and misuse substance require specialist services that function as an integrated part of a broad range of support, professionals who work with adolescents in a wider range of services need to develop their skills and knowledge base about substance misuse. 7.6. Risk Assessments and Planning 7.6.1. Numerous agencies were involved to varying degrees with Mark and his Mother during 2013 and 2014 including YOS, CAMHS and the family GP, but the Review Team could find no evidence of any risk assessments which sought to identify his needs or which captured views and information from other agencies. It is these assessments, which are needed to contribute to carefully design, and purposefully maintained child in need and child protection plans. 7.6.2. Some agencies clearly considered risks to Mark in the context of his repeat offending and failure to reach educational targets, but there was no evidence of any shared assessment between agencies about the risks to which Mark was exposed and which were impacting his well-being or future safety and welfare. There is little to evidence however that Mark was assessed during 2013/2014 in terms of his psychological vulnerabilities which, had they been recognised, may have indicated he was at significant risk of mental health problems known to be associated with cannabis and MCAT and other legal highs. The absence of a multi-agency risk assessment is not only the outcome of agencies not working collaboratively, it is, according to practitioners also a result of there being no agreed multi-agency risk assessment tool in use in Sunderland, so agencies inevitably resort to their own systems when undertaking risk assessments and opportunities to share information with other agencies are lost. A clear framework is needed to undertake comprehensive, multi-agency assessments of the unique needs of all young people and a case management structure to ensure a seamless service and accountability. 7.6.3. Finding 4: Without a purposefully designed multi-agency risk assessment tool, embedded within all organisations and accessed through a single point of access, professional judgment about risk is more likely to be flawed and this will reduce the likelihood of effective interventions leaving some young people vulnerable. Such tools are known to be most effective when if the practitioners and managers who will be using them are engaged in their design and implementation. Final - 8th November 2017 16Issues previously identified in SCRs/Thematic Report: Use of Assessment tools including risk assessments to aid professional judgment 7.6.4. It was of concern to the Review Team that many practitioners who had contact with Mark were unaware of many aspects of his life. The Review Team discussed with practitioners the single and multi-agency systems in place to support the production and maintenance of quality records and in particular why chronologies, an essential and invaluable assessment tool, were not used to better effect. The Review Team were of the view that practitioners were not being negligent in not ensuring that chronologies were maintained but that inadequate and failing ICT systems, pressure of work, poor quality supervision and not having enough time combined to make the production and upkeep of useful and effective chronologies less likely to happen. Inevitably, this leads to criticisms when chronologies are either missing from reports or full of inaccuracies. Whilst professionals acknowledged that the time has yet to come when single agency IT systems communicate with each other, they also pointed out that there is currently is no system or agreed process in place to support the production of shared chronologies within a multi-agency framework. 7.6.5. Creating integrated chronologies is time consuming and costly but unless there are more simplified systems and clearer expectations that these must be produced when opening, reviewing or closing a case, practitioners will struggle to see the child’s history and the significant events and transition in their lives. This issue has been raised repeatedly in SCRs. It will always be practitioners who must determine the key events in a case and the degree of impact on the child. Learning what should be transferred into a chronology is an important skill which managers should help professionals to develop but without functioning and effective IT systems it will remain a challenging task. To do justice to chronologies of course, practitioners need to spend time with families and the Review Team was told that very often that time was simply not made available to establish good working relationship with adolescents and their families. Practitioners advised the Review Team that this remains a key challenge in terms of current practice. 7.6.6. Mark was made subject to a child protection plan in March 2015 under the category of neglect. Education records indicate that the designated safeguarding person in school was asked by the IRO to submit a referral to YDAP. The referral to YDAP was made as requested although it is unclear why the referral is dated 14.10.2014 whilst also referring to the ICPC conference which did not take place until March 2015. There does not appear to have been any education representative at the subsequent Core Group meetings and the Review Team was unable to ascertain why and were informed that the safeguarding records for Mark had been mislaid. Final - 8th November 2017 177.6.7. The child protection plan produced at the first core group meeting was of poor quality. It did not identify defined goals, expected outcomes, or the measures by which progress or actions could be measured clearly. In effect the plan was not SMART18 and consequently it did not drive forward any improvements in Mark’s life. Despite the information available, the plan did not address issues with Mark’s mental health, neither did it refer to risks of sexual exploitation, possibly the Review Team was told, because Mark was already on the radar of MSET, illustrating what may be a significant misapprehension about the role and function of the MSET service, which is to support casework with young people, not to replace it. 7.6.8. Mark’s child protection plan was reviewed in June 2015 and Mark and his Mother both reported good progress in that Mark was back at school part-time and was reporting that he no longer took legal highs. He was reported to be far ‘less angry’. A decision was taken that Mark should remain subject to the plan for a further 3 months; this was a sensible move given this was still early days and Mark at the time, was being investigated for a serious offence. 7.6.9. Although the child protection plan had, in March 2015, identified the need for a paediatric assessment this action had still not been actioned three months later by the social worker and Mark was seen by the YOS nurse for a health assessment only. The Review Team was unable to determine why the request for a paediatric assessment was not actioned. As there were no records available and no practitioner or manager could recall what happened, it was suggested that because there was significant activity regarding MSET and drug and alcohol issues, professionals possibly became involved in that activity rather than following the agreed child protection plan. Even if this was the case, it simply reiterates the point made above about the importance of producing and implementing good quality plans which are regularly reviewed. 7.6.10. There is a reference in CSC records, to Mark having ADHD, however it is unclear when and where this diagnosis was made and by whom. Certainly most of the practitioners who contributed to the SCR process were unaware of this diagnosis. Mark and his Mother continued to report improvements in the spring of 2015 but any changes, if they existed, were not sustained, and concerns about Mark escalated in the summer of that year. 7.6.11. Finding 5: When concerns are raised about a child, a clear chronology of events can show agencies where risks lie but unless practitioners understand how to build and maintain purposeful chronologies and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making is less likely to happen. 18 Specific, Measurable, Achievable, Realistic and Timely Final - 8th November 2017 18Issues previously identified in SCRs/Thematic Report: Use of Chronologies as multi-agency tool. 7.6.12. As concerns about Mark’s safety and welfare increased during the summer of 2015 and into September, social workers sought to secure a suitable placement for Mark, once it became apparent that family and services could not meets his needs within the community and keep him safe. What emerged from this process was recognition of the difficulty in finding suitable mental health provision for Mark which could meet his needs without depriving him of his liberty. As his mental health rapidly deteriorated Mark began to threaten others and continued to self-harm eventually resulting in the need for him to be sectioned under the Mental Health Act 1983. 7.6.13. Finding 6: There remains a significant national shortfall in placements for children and young people with complex needs who require placements that can keep them safe and manage their vulnerabilities without needing to deprive them of their liberty. Issues previously identified in SCRs/Thematic Report: Shortage of placements for young people with mental health needs 7.7. Multi-Agency Working and Collaboration 7.7.1. The Thematic Report states that in Sunderland, there was ‘a safeguarding partnership seemingly operating at a basic and pragmatic level only, and working in parallel rather than in an integrated, cohesive manner’. This was evident in reviewing practitioner involvement with Mark between 2013 and 2015. 7.7.2. Practitioners intimated that within their own agencies there is still considerable reliance on their own agency procedures and recourse to multi-agency working is not always a first consideration. Other issues include barriers to specialist intervention and multi-placements, differing thresholds within each agency or differing interpretation of the thresholds. The SSCB threshold document, practitioners suggested, is not user friendly and given that agencies have differing protocols the threshold document needs to be simplified in order to facilitate better multi-agency working. 7.7.3. Practitioners acknowledged the benefits of multi-agency working but suggested that actually collaborating across agencies is not always easy given other time and workload pressures. Findings in relation to the lack of multi-agency collaboration have been widely publicised in previous SCRs and SSCB have acknowledged in their response to the Thematic Report that the changes they have introduced will lead to improvements in partnership working and agencies will be better supported to ensure that practitioners work more effectively with multi-agency partners. Final - 8th November 2017 197.7.4. Research carried out by ADCS19 suggests that many areas in the UK are seeing an increase in adolescents such as Mark coming to the attention of formal CP services and without sound and effective multi-agency working, interventions are likely to be less than effective. Practitioners stated that they knew the value of multi-agency working but suggested there was and still is a need for greater clarity as to when professionals should have recourse to multi-agency meetings outside CIN and CP processes and what the status of those meetings should be. Agencies confirmed there remains a tendency to give greater priority to meetings called by CSC than by other agencies and this led the Review Team to conclude that more could be done to ensure that systems and processes better support multi-agency working. 7.7.5. In attempting to understand and attend to the needs of young people who misuse substances the Government’s Drug Strategy stressed even in 2010 the ‘... range of vulnerabilities which must be addressed, by collaborative work across local health, social care, family services, housing, youth justice, education and employment services’, In a report on UK child health services, Kennedy20 (2010) endorses such a ‘whole systems’ perspective. He observes that ‘providing high-quality services for children and young people requires agencies to work collaboratively.’ 7.7.6. Until March 2015, when Mark was placed on a Child Protection Plan, there was little evidence of any multi-agency working. Some agencies were working in isolation and were unaware of other agency involvement or the extent of work being undertaken by other professionals. For some professionals, it was only when they participated in the SCR process that they became aware of the involvement of other agencies in Mark’s life. The School Nurse for example was not aware of Mark’s background and until the SCR process; she did not know and was not consulted about Mark’s substance misuse and deterioration in presentation and health whilst he was attending school. Not only are nurses uniquely qualified to spot early warning signs of mental ill-health they are also able to offer pupils a different sort of relationship to teachers. The Review Team was unable to determine why the school nurse was not consulted about Mark but the ensuing discussions with practitioners suggested that unless there is a visible presence in school and clear roles and communication channels, recourse to collaboration with school nurses is less likely to happen. The issue has been raised in previous SCRs and is clearly highlighted as an issue in the Thematic Report. 19 ADCS is a membership organisation. Our members hold leadership roles in children’s services departments in local authorities in England. They specialise in developing, commissioning and leading the delivery of services to children, young people and their families, including education, health, youth, early years and social care services 20 Kennedy I (2010) Getting it Right for Children and Young People Final - 8th November 2017 207.7.7. Mark was referred to Intensive Community Treatment Service in September 2015 a children and young people's service to children and young people living in South Tyneside and Sunderland who present with mental health difficulties. The referral was made by YDAP due to concerns that Mark was withdrawn and writing suicide notes. The referral was deemed a priority and attempts were made to see Mark that day. He was eventually seen in late summer 2015 and workers indicated that Mark’s mental health problems were due to his substance misuse and no intervention had been offered other than YDAP. 7.7.8. Mark was seen and acknowledged his low mood but denied any suicidal ideation and denied writing a suicide note. The assessment concluded that Intensive Community Treatment service was not required, but a further appointment was offered later the same month. According to ITCS records, Mark kept the appointment and self-reported that he had been excluded from school, but had stopped using cannabis and he claimed to be in a brighter mood. The assessment concluded that Mark making more positive life choices/progress and he was discharged by ITCS. The Review Team were unable to determine why there does not appear to have been any liaison with other agencies to find out more about Mark’s background and history although the Review Team were informed this would be usual practice. 7.7.9. Finding 7: Assessments should be comprehensive addressing physical and emotional needs as well as risk of self-harm and sexual exploitation. This requires close collaboration between agencies and inevitably raises the question of who takes responsibility of coordinating this work. Multi-Agency collaboration did not work as well as it should have done with Mark and this left him vulnerable. Issues previously identified in SCRs/Thematic Report: Multi-agency information sharing and collaboration. 7.8 Working with and engaging adolescents 7.8.1 The Review Team could find no evidence of any shared values and principles to govern specific work with adolescents. Reading through records and the integrated chronology for Mark, the Review Team did find evidence of child centred work; Mark was encouraged to take responsibility for the impact drugs were having on his health and the impact this was having on his Mother; a written agreement was put in place to help Mark and his mum manage the perceived risks, but whenever talk centred on his drug use, Mark often became angry, left the room and the sessions usually continued without him, a response eminently suitable for younger children, but perhaps less so for adolescents. The Review Team and the practitioners considered that even the term child-centred, while laudable in work with young children was not a particularly useful or appropriate approach when working with adolescents. These discussions highlighted the Final - 8th November 2017 21need for a different way of working and perhaps a different language when working with young people. 7.8.2 Practitioners suggested that for the most part the existing child protection/child in need systems do not adequately fit in with young people’s lives and experiences but in the absence of any different service designs they have to make the most of existing processes. It was also suggested that risks to young children are too often seen as more of a priority for services/intervention because adolescents are thought to be able to ask for help or ‘choose’ to remove themselves from risk situations. 7.8.3 The pathways leading to a number of harms that adolescents experience are however complex and do not easily fit with accepted child protection categories. Mark was made subject to a CP plan under the category of neglect although Substance Misuse would have been a more appropriate categorisation, had it existed. Maltreatment in adolescence is no less harmful than maltreatment at an earlier age. Indeed it could be argued that the opposite is true given what we know about the cumulative impact of harms over a given period and that adolescents are more likely to be subject to ‘polyvictimisation’ i.e. being victim to multiple forms of harm because of the external world/environment they also inhabit. 7.8.4 Harnessing and working with the risks of adolescent choices and behaviours is an essential aspect to them keeping safe but existing child protection processes, public opinion and media coverage make this a particular challenge for practitioners trying to work with, rather than for adolescents. Whilst the Thematic Report urges a wide-ranging review of services to those adolescents who are known to be vulnerable, the Review Team would argue that there is an equal and perhaps more pressing need to examine how well risks in adolescence are understood in Sunderland. Research in Practice argues that a child protection system that is conceptualised primarily around preventing harm and maltreatment in younger children, who may be at risk within their own family, may not be well placed to serve the needs of adolescents and an adolescent- centred approach as opposed to a child-centred approach requires a different set of underpinning principles. 7.8.5 The Thematic Report states that ‘without a clear statement of values guiding and underpinning the actions of those with responsibilities for safeguarding [young people] with often complex needs and at considerable potential risk, there lies an opportunity for inconsistency and outcomes for [these young people] will fall short of what good parents would accept as ‘good enough’. 7.8.6 In reading the Sunderland’s Themed Report, the Review Team were struck by the similarities between the experiences of the four young people who were each subject of SCR processes during 2015 and 2016. Although there were different Final - 8th November 2017 22circumstances, each young person had to varying degrees experience of the following: • Complex and difficult families • Domestic abuse and/or family breakdown and family disruption • Subject to child protection plans • Appeared unable to make and sustain good relationships or develop strong attachments • Self-harming, going missing, struggling to stay in education, and using substances, and ‘legal highs’ • Emotionally vulnerable, distressed and depressed and at times in need of specialist mental health interventions • Experiencing difficulties at school and used or were bullied through social media • Associating with older men and sexually active from a young age In addition, professionals were unable to effectively engage with family members. 7.8.7 Professionals acknowledged that many of the adolescents with whom they worked or who were referred to CSC, also had these factors in common and expressed some frustration in a system, which was predominantly focused on younger children. Examples were given of having to record the ‘voice of the child’ but not having enough time to build a relationship with the adolescent in order to ascertain their ‘wishes and feelings’. Practitioners were very vocal in expressing their views that a different way of working with troubled adolescents was urgently required. They expressed the view that senior managers in all agencies needed to address this despite the challenges of shifting resources from already stretched services. 7.8.8 Finding 8 (NEW) The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience and research. The identification of a multi-agency framework with clearly defined underpinning principles would support better practice for those professionals working with adolescents at risk of harm. 7.8.9 The evidence suggests that professionals struggled to engage Mark to the point where he felt able to participate meaningfully in activities or with services. One of the key negative outcomes for Mark, which is common to many adolescents who require services,21 appears to have been a lack of trust in adults including the many professionals who had attempted to intervene in his life. The lack of trust led to a pattern of seeking help and then withdrawing and this led to the professional perception of a ‘hard to reach’ adolescent who did not engage with 21 Brandon / NSPCC / University of East Anglia, 2013 Final - 8th November 2017 23services. The model of his Mother’s inconsistent engagement with professionals may also have reinforced his non-engagement attitude. 7.8.10 The use of non-engagement as a coping strategy is known to be a common feature in adolescents. Professionals trying to help sometimes interpret such behaviour as sabotaging attempts to support the young person and too easily may rationalise non-engagement as adolescent ‘resilience’, within a ‘self-determining and young person’s rights’ perspective. This can lead to a negative cycle of mutual rejection and result in a lack of effective help for the young person, leading to them becoming even more vulnerable. References in agency records to Mark’s laughing ripostes when professionals tried to talk with him about the dangers of sexual exploitation may well have unwittingly led practitioners to feel reassured about Mark’s ability to keep himself safe. 7.8.11 Changes in social worker or other key professionals are a constant complaint from young people. For adolescents who have strained or fragmented relationships with their family, and particularly for those who have experienced abuse or neglect and have poor attachments to their parents, frequent changes in key professionals can be unhelpful or even devastating and militate against attempts to engage or support them in a meaningful way. Changes of social worker can also undermine care planning and contribute to placement difficulties. Mark had contact with 4 social workers between March 2013 and September 2015, but the nature of three of those contacts were essentially short term or assessment based. A fourth social worker was involved with Mark just prior to his hospital admission. Despite the child protection plan no core groups took place in April or May 2015 and it is significant that it was just after this period that Mark and his Mother self-reported that all was going well and Mark had ‘changed’. 7.8.12 It is acknowledged that there are significant challenges for professionals in trying to engage adolescents who resist attempts by professionals trying to help. There is evidence that many individual practitioners certainly tried hard to work with Mark but without a multi-agency understanding of how best to work with adolescents with complex and harmful behaviours, individual work was compromised. In addition, many practitioners spoke of not having the time, or not having a managerial/organisational mandate, to prioritise the building of a relationship with the young person, despite the volumes of research and young people’s voices which say this is what they need before they can feel confident to engage with workers. 7.8.13 Practitioners involved in this Review said that the need to develop authentic and sufficiently intensive long-term relationships with young people is not fully recognised and is not yet part of the service response in Sunderland. 7.8.14 Finding 9 (NEW): If authentic and sufficiently intensive long term relationships are not part of the service response to young people and professionals are not Final - 8th November 2017 24actively supported to invest time in establishing these relationships, then interventions to reduce risk and promote resilience in young people is likely to be ineffective. 7.8.15 The issue of professional supervision was explored with practitioners and the very clear message that emerged from this discussion was that practitioners in all agencies needed and wanted access to regular and quality supervision by managers well skilled to deliver reflective supervision. Whilst some practitioners said they were satisfied with their supervision sessions others were far less so and cited sessions that were too often cancelled, reduced to ‘catch up’ conversations or even left to email exchanges. Practitioners were acutely aware of the demands placed on their managers but many felt that vacant, interim, or merged managerial positions significantly weakened managerial oversight of their work and supervision was not always a high priority. 8. The Situation now 8.1. The Thematic Review identified six overarching issues in relation to work with adolescents in Sunderland which also have a bearing on this SCR: • Importance of values and principles to underpin multi-agency work with young people • Age appropriate services to vulnerable adolescents • Working with young people and their families • Recognition of and response to Child Sexual Exploitation • Need for quality assessment, timely interventions and robust planning processes • Multi-Agency collaboration 8.2. The response of SSCB to the findings from previous SCRs is captured in Appendix 1. If these actions are implemented as stated, they will support improved practice across the Children’s Workforce and drive forward improvement in outcomes for children and young people. Care does however need to be taken to ensure that action plans, improvement plans, indeed plans of any sort, clearly identify intended outcomes or impacts rather than just state what actions have been or are to be implemented. Equally important is that the processes through which changes or the desired results are measured are clearly identified. Unless action plans are robust, purposeful and explicit and progress regularly reviewed, agencies will struggle to demonstrate how and if learning from reviews are making a difference to the lives of children and young people. Reading even the revised impact statements attached to this report, it is clear that agencies need to further develop skills and knowledge in respect of this area of work. Final - 8th November 2017 258.3. The Review Team asked practitioners for feedback about what if anything is different now. Responses indicated that they were beginning to sense changes in their organisations and especially within Children’s Services but they also indicated that many developments were not involving practitioners in a way which was inspiring and importantly the changes were not happening fast enough and this left young people vulnerable. 8.4. Further details in relation to changes in Sunderland can be found in Appendix 2. 9. Conclusion 9.1 The risks that adolescents face are particularly complex and wide-ranging but there is no reason to believe that they are any less harmful than those experienced by younger children. It is important to acknowledge that there are likely to be some young people in Sunderland who may not be having their needs met effectively by services and this review and other more recent reviews relating to adolescents suggests more needs to be done as a matter of some urgency to work with young people to avoid, reduce and recover from risks they face. 9.2 The Review Team concluded that the lack of active engagement between the professional system and the young person and his family was a key factor in not being able to get effective help to address his vulnerability and emotional wellbeing during the time frame of this review. There is a wealth of talent and knowledge across partner agencies, which needs to be galvanised through multi-agency working, strong leadership, and appropriate adolescent-centred policies to create a more sophisticated model of risk prevention and protection for adolescents in Sunderland. Final - 8th November 2017 26Appendix 1 Summary of Findings and Recommendations A. Findings from this SCR which have identified new learning: Finding 3 (NEW) Many practitioners are not always clear what they should be doing in relation to substance use and their role expectations vary according to their specialist area of practice, their knowledge of substance use, and their levels of confidence. Whilst adolescents who use and misuse substance require specialist services that function as an integrated part of a broad range of support, professionals who work with adolescents in a wider range of services need to develop their skills and knowledge base about substance misuse. Finding 8 (NEW) The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experiences. The identification a multi-agency framework with clearly defined underpinning principles would support better practice for those professionals working with young people at risk of harm. Finding 9 (NEW) If authentic and sufficiently intensive long term relationships are not part of the service response to young people and professionals are not actively supported to invest time in establishing these relationships, then interventions to reduce risk and promote resilience in young people is likely to be ineffective. Recommendation for SSCB In order to improve the effectiveness of multi-agency practice with adolescents who are at risk due to substance misuse, other forms of risk taking behaviour and/or abuse/exploitation, the SSCB should work with the Children’s Strategic Partnership, the Safer Sunderland Partnership and the Sunderland Safeguarding Adult Board to develop a multi-agency framework to support the development of resilience and improve outcomes for vulnerable adolescents. This framework should include: a) A strategy, robust systems, protocols and tools for working with vulnerable adolescents and b) Workforce Development opportunities to support staff to engage effectively with young people, better assess and understand issues of risk such as CSE, substance misuse and transition etc. This will be implemented by June 2018. Final - 8th November 2017 27B. Findings which have been previously identified (and therefore should already have led to changes) Finding 1: Without analytical assessments, multi-agency collaboration and challenge, the harmful behaviour of some adolescents may be too easily viewed as ‘just what teenagers do’ and this perception can prevent early intervention for those adolescents at greatest risk. Training and workforce development, including quality supervision, must ensure practitioners have the skills to work with adolescent choice and complex behaviours and have opportunities to develop their understanding of the adolescent world, including substance misuse and other forms of risk. Finding 2: There was a lack of professional curiosity about Mark’s background what had happened and was happening in Mark’s life which meant that his behaviour and substance misuse were regarded as ‘the problem’ rather than possibly being symptomatic of other stressors in his life Finding 4: Without a purposefully designed multi-agency risk assessment tool, embedded within all organisations and accessed through a single point of access, professional judgment about risk is more likely to be flawed and this will reduce the likelihood of effective interventions leaving some young people vulnerable. (Thematic Report Recommendation) Such tools are known to be most effective when if the practitioners and managers who will be using them are engaged in their design and implementation. Finding 5: When concerns are raised about a child, a clear chronology of events can show agencies where risks lie but unless practitioners understand how to build and maintain purposeful chronologies and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making is less likely to happen. Finding 6: There remains a significant shortfall in placements for children and young people with complex needs who require placements that can keep them safe and manage their vulnerabilities without needing to deprive them of their liberty. (Thematic report Recommendation) Finding 7: Assessments should be comprehensive addressing physical and emotional needs as well risk of self-harm and sexual exploitation. This requires close collaboration between agencies and inevitably raises the question of who takes responsibility of coordinating this work. Multi-Agency collaboration did not work as well as it should have done with Mark and this left him vulnerable. 28 Final – 7th November 2017 Appendix 2a What have we done, what are we going to do and what difference has it made/will it make? Sunderland Safeguarding Children Board (SSCB) impact statement A new Board structure was implemented from April 2017 with a new permanent Chair in place from May 2017. The new arrangements have strengthened governance arrangements to ensure high support and high challenge across the system, with clearer functions, a new structure, and newly developed and robust approaches to performance management, quality assurance, practice development, and the application of learning from research, evidence and review, as well as evaluating compliance with required standards of practice. The Board has been more effectively supporting (and challenging) the improvement programme for Children’s Services and continually evaluating the improvements taking place, the investments being made and the differences these are making to children, young people and vulnerable families as well as supporting and challenging each partner agency’s own improvement and development plans. The SSCB has strengthened its MSET Sub Committee arrangements and this was confirmed by an independent review in 2016 which identified that the Board’s MSET Subcommittee showed clear evidence of coordination, scrutiny, and challenge, including of the work of the MSET Operational Group, challenged partners to provide updates on their activities to address the risks to children, and raised issues about the attendance of key partners. The Reviewer concluded that the outcome of this work has been to deliver a focussed discussion of current, local safeguarding risks to children with clear leadership. The Ofsted Monitoring Visit Letter published December 2016 also found improvements concluding that “Sunderland’s multi-agency arrangements to respond to children at risk of going missing and being sexually exploited and trafficked have been strengthened. The quality of information recorded and collated in the risk management tool ensures a well-coordinated multi-agency response. The child sexual exploitation referral tool is a comprehensive assessment document that has a strong focus on the views of the child. Arrangements for return interviews for children missing have been strengthened through the commissioning of a voluntary agency to undertake this work. Analysis of information and intelligence is informing preventative work for individuals and more widely. Examples seen were detailed and focused on risk, and were used well within the missing, sexually exploited and trafficked children meetings to inform practice on individual cases and also in relation to wider disruption activities.” Work undertaken by the Sub Committee includes: • Multi-agency detailed audits undertaken in respect of 6 CSE cases and a sample of 20 CSE Risk Assessment Tools led to a review of the toolkit to strengthen practitioners’ skills in respect of CSE cases. Both SSCB audits identified positive aspects of practice since the adoption of the revised tool and the inclusion of professional judgement and the voice of the child have 29 Final – 7th November 2017 informed the continued learning and reflective practice. This gives a demonstrable influence of frontline practice on strategic direction. This was confirmed by practitioners who were part of this SCR and the Young Person Rachel SCR. • The toolkit is currently under consultation and implementation of the new tool aims to lead to more robust identification, assessment and intervention for young people who are being sexually exploited/at risk of CSE. The tool will be launched March 2018 • In September 2016 the SSCB undertook a multi-agency Self-Assessment against the Joint Targeted Inspection Framework for children at risk of CSE or who go missing from home. The response included only 10 completed responses with a variety of approaches but demonstrated high levels of confidence in the awareness of CSE and the MSET arrangements across agencies, leadership and the SSCB and the overall effectiveness of the multi-agency arrangements were deemed Good by 80% of respondents. Gaps were identified in the ability to capture the preventative work undertaken and any work with adult offenders. These areas of work will be taken forward as part of the work of the Board and included in the development of a vulnerable adolescent framework. • Challenged the commissioner and provider of the contract for the return home interviews for children who go missing from home and care. This has resulted in improved commissioning arrangements and improved provision for vulnerable adolescents. Performance data demonstrates an improved completion rate but further analysis of quality is required as outlined below. • The Strategic CSE Co-Ordinator funded by Children’s Services to work across the partnership delivered MSET (Missing Sexually Exploited and Trafficked) briefings to multi-agency practitioners and the voluntary sector, that is, 780 practitioners, 30 foster carers/adoptive parents, 220 taxi drivers, 15 licences, and 30 elected members received this training which also included changes to the Trafficking legislation brought in by the Modern Day Slavery Act • Robust scrutiny and analysis of performance data relating to vulnerable adolescents to better understand the vulnerable adolescent population, their needs and how these can be addressed. The outcomes of this analysis has to date identified issues with the return home interview provider as mentioned above, a potential gender bias in respect of application of the missing vs. absence category by the Police. This relates to similar gender bias issues identified in this SCR with males being seen to be better able to protect themselves. The Board is developing a strengthened performance monitoring and assurance framework for the MSET Operational Group to more effectively focus on these areas. The VASPG will start to monitor this data from November 2017 • In recognition of the wider issues related to CSE the Board has ended the MSET Sub Committee and established a Vulnerable Adolescent Strategic Project Group (VASPG) which has a wider focus on the risks to vulnerable adolescents. The MSET subcommittee was sufficiently robust to support this 30 Final – 7th November 2017 shift and this is in keeping with the updated definition of CSE in Working Together 2015 (amended February 2017). The anticipated outcome is that there will be a more comprehensive and robust approach to addressing the needs of vulnerable adolescents in Sunderland. This was originally for a 12 month period and as a result of this and the Young Person Rachel SCR, the Group has been extended until September 2018 • Learning from this SCR and the SCR for Young Person Rachel the Group has commissioned focussed reports from the commissioner and provider of the Return home interview contract November 2017, the YDAP service October 2017, the CAMHS Transformation work in October 2017 and the Transition Board. These reports are intended to provide an understanding of how effective these services are and what difference they making to children and young people, including when an adolescent is transitioning into adult hood. • Met with the CSE National Working Group (NWG) regarding transitions and the learning that has been identified from this and the Young Person Rachel SCR. The learning from the SCRs was shared with the NWG as part of research they were producing. The Board has agreed to undertake a benchmarking exercise in 2018 led by the NWG to have an evaluation of the arrangements for CSE etc. in Sunderland. This will provide the Board with a progress check; identify what difference we have made and where we can improve to better meet the needs of our vulnerable adolescent population. The SSCB Strategic Plan 2017-2019 and the SSCB Business Plan 2017-2019 has been developed partially based on learning from this SCR. The Board has 3 Service Priorities in these plans which are neglect, vulnerable adolescents and compromised parenting. In conjunction with the Children’s Strategic Partnership the Board is developing a framework for vulnerable adolescents which will address the key learning identified from this and the Young Person Rachel Review. Working with the other partnerships across the City to deliver a campaign highlighting where young people and adults can seek help if they are struggling to cope due to issues such as emotional or mental health issues. The aim of this campaign is to highlight that there are services available for our young people and their parents/carers and to reduce the incidence of self-harm and suicide. A further SSCB audit of neglect practice is planned for 2018 to understand and asses if practice is improved around identifying and dealing with child neglect. The Board will continue to audit to understand how effectively learning from the reviews has been embedded access the partnership. An audit undertaken in early 2017 around the Learning from 6 Serious Case Reviews published in September 2016 identified some evidence that learning has been embedded. It has identified further work is needed to embed the learning. A second audit will be completed in November 2017. 31 Final – 7th November 2017 Appendix 2b Individual Agency Impact Statements Sunderland CCG The CCG Safeguarding Team will take a key strategic and operational lead role in sharing the learning from this review with all GPs and Practice staff across Sunderland to support individuals to meet their learning and competency needs in accordance with the Intercollegiate Guidance 2014 and their role and responsibilities. Young people will be seen by a highly skilled workforce who understand the importance of liaising and sharing information with professionals involved with young people, and make appropriate referrals in a timely manner therefore ensuring the needs of young people are met. The aim of the Team’s work specifically in Primary Care (GP) is to: • Provide telephone advice and support to individual practitioners who have identified a possible concern about a child or young person – this can be measured by the number of calls to the team and evidenced on a tracker tool held by the team. Work is evolving with Together for Children – Sunderland to ensure that their Liquid Logic system can identify the separate agencies representing “health” and ensure feedback to relevant health leads on referrals which may be inappropriate or contain insufficient information. Should concerns be identified from TfC the Team will work with individual GPs/practitioners to improve safeguarding practice. There have been no quality assurance issues highlighted by TfC to the CCG regarding referrals from Primary Care since April 2017. In addition the annual primary care safeguarding audit cycle includes an audit into the quality of referrals submitted from GPs/practice staff. This will be undertaken November/December 2017. • Support individual Practices in developing their internal systems and processes to monitor outcomes of referrals. This can be evidenced by the Practice visits undertaken by the Named GP (either planned or in response to queries, incidents or significant events) and the CQC inspection framework. • Provide peer support and supervision to GP Safeguarding GP leads. Evidence - there is an annual programme of quarterly peer support sessions. 32 Final – 7th November 2017 • Plan, deliver and evaluate bespoke training packages to those staff requiring Level 3 Safeguarding Children Training – Evidence - an annual training programme is in place and numbers of attendees and evaluation reports are compiled by the CCG Safeguarding Team – copies available on request. Regular updates are also provided via Time in Time out sessions – a calendar of events is available. • Disseminate immediate learning from reviews via a Primary Care briefing – this can be evidenced within the CCG files. Evidence - copies available on request. • Disseminate safeguarding updates by a quarterly safeguarding newsletter – this can be evidenced within the CCG files – copies available on request. • Seek assurance that the GPs in Sunderland understand their statutory responsibilities and respond to learning identified in reviews. Evidence – annual SSCB S11 audit, SSCB mystery shopper audit and the SSCB multi-agency audit programme. In addition to the multi-agency audits a range of single agency audits are undertaken with GPs – reports available on request. 33 Final – 7th November 2017 Appendix 2c Education and School The learning has been focused on ensuring that safeguarding procedures and protocols are more robust and properly followed, particularly in relation to record keeping, information etc.: • Handover arrangements between the Link School and the excluding or dual registered school are conducted face to face with all relevant information shared and files handed over; • All safeguarding information now recorded electronically at Link School on Child Protection Online Monitoring System (C-POMS) which is regarded as the best practice system; • C-POMS, a referral system for any concerns records information in real time, requires receipted responses and note of any further actions. It also produces electronic chronologies; • No concern considered too small or insignificant to be recorded; • As a result of the above procedures for archiving have also been tightened up for historic and paper files; • Stronger professional curiosity and challenge to other agencies is encouraged and followed up in school safeguarding meetings Issue with Mark was the swift acceleration and manifestation around drug taking/ behaviour etc. Link School referred appropriately and were involved in strategy meetings with agencies and with Ferndean etc. 34 Final – 7th November 2017 Appendix 2d General Practitioner (GPS) 1) All GPs in Sunderland to receive information in training and briefing papers regarding the learning and recommendations from this review. • On publication of the SCR a briefing document will be circulated to all GP practices. • Learning from the SCR will be highlighted in the GP Safeguarding Newsletter • Learning from the SCR will be discussed at the quarterly Safeguarding leads meeting; the Safeguarding Leads will disseminate the learning to practice staff. • Learning will be shared at future TITO events. • There will be a coordinated approach to the dissemination of the learning to ensure all staff across primary care have knowledge of the themes identified within the report. • The dissemination of the learning from this review will reinforce lessons learned from previously published SCRS in Sunderland in relation to young people with complex problem 2) When working with complex adolescent/teenagers who have issues which impact on emotional health, GPs to consider if the threshold has been met for a referral to Children’s Services or support via Early Help Services. • Adolescents/young people will be referred in a timely manner to Children’s Services and other supporting services in order to receive appropriate assessment and support for their specific needs • GPs will be familiar with Threshold Guidance and liaise with Children’s Services/Named GP if unsure whether or not to refer therefore ensuring young people are referred to the correct service • The learning is similar to previous SCRs and highlights the complexities and challenges within GP practice when working with extremely vulnerable adolescents who are being neglected and who have complex needs. 35 Final – 7th November 2017 Appendix 2e Individual Agency Impact Statements – South Tyneside NHS Foundation Trust During the timeframe for this SCR Young Person Mark accessed STNHSFT health services provided by the School Nursing service, and the Young Person nurse. Discussions also took place within the ICRT during this timeframe, following concerns raised with regard to Mark this meeting was attended by the ICRT nurse advisor also employed by STNHSFT. Prompt information sharing was noted across all health services involved with Young Person Mark and also prompt attendance at requests to attend multi-agency meetings. It was evident to the author of STNHSFT learning report that confusion existed across health and multi-agency partners with regard to the role of the Young Person Nurse. The health assessment documentation utilised by the Young Person Nurse during the period reviewed also required updating, with specific reference to sexual health advice and support. Action Outcome Impact The health assessment completed by the Young Person Nurse needs to reflect the sexual advice given. The Young Person Nurse health assessment documentation has been amended and incorporates as standard practice advice and support with regard to Sexual health. YP have a risk assessment completed which demonstrates advice and support either given or sign posted. The assessment form will be audited 2018. Young person Nurse to be more visible across health and partner agencies. The Young person Nurse is to be moved into the Sunderland School Nursing team. The YP Nurse works with YDAP who are now part of TfC. The school nursing team will be able to access the YP as part of early intervention. This will take place in October 2017. 36 Final – 7th November 2017 Appendix 2f Northumbria Police Changes made to custody procedures for Force Medical Officers: The processes and model used by Northumbria Police in relation to Force Medical Officers and assessment of detained persons has changed since YP Mark’s period in police custody. A custody nurse was based at all of our 4 sites although at time. However, due to staffing / sickness this may not be the case apart from Forth Banks custody (due to the demand). The FME was generally based at South Shields Custody but may have had to travel to other stations as there are certain tasks only they can do. It must be noted we are moving from this model and we are in the process of implementing Senior Nurse Practitioners with limited FME cover with on call FME facilities. Northumbria Police have amended the model to further reduce time delays. TASCOR are the provider and they have performance targets to deal with requests within one hour. TASCOR are hitting targets at 97/98% most months with the others reported upon. This system will provide improved service and recognition of risks to children and young person’s whilst detained in custody. There were lots of missing episodes which were not always reported by Mark’s Mother. His Mother’s responses to his missing episodes were poor: Northumbria Police now have two dedicated Missing from Home Coordinators. Their role includes the flagging of missing persons to MSET. This has a positive impact on the early identification and flagging of those children and young persons at risk. A lot of Child Concern Notifications submitted by the Police. CCNs not always clear as they do not pick up MSET process. He displayed significant levels of risk taking behaviours which were put in as Child Concern Notifications and not referrals: The Northumbria Police Central Referral Unit process for submission of CCN’s has changed. They are no longer graded as Notifications or Referrals. The receiving organisation now assesses the content. This removes risk of wrongly categorised CCN’s. A ‘front end app’ is being developed to be used on officers hand held devices (phablets). The app will replace the current CCN process. The app will allow officers to complete the CCN without returning to a station; will be an improved format with revised fields (which will only allow an officer to progress to the next stage of the app on successful completion of each field/page). This will positively impact on the 37 Final – 7th November 2017 quality and clarity of CCN’s and in turn on the multi-agency information sharing process for children and young persons. Mark was associating with older males where there may have been exploitation or grooming of him: Northumbria Police have invested in a bespoke training package with Safeguarding Associates For Excellence (SAFE) for a targeted audience within the force which will be mandatory for all staff involved. This training incorporates all aspects of CSE including recognising the signs. The training will improve officers ability to recognise CSE and in doing so taking the first step towards prevention and intervention for children and young persons at risk. 38 Final – 7th November 2017 Appendix 2g Together for Children – Children's Social Care Project/Action Activity (how much) Outcomes (how well) Impact (what difference your action has made/will make) 1. To make sure the Together for Children (TFC) children’s social care workforce is fully aware of lessons learned from previous serious case reviews involving adolescents A series of workshops have been delivered to all frontline staff through team meetings (x11) covering the recommendations set out on the single agency action plans Young Person(s) K&I Worked collaboratively with partners to design an adolescent risk management panel (proposed implementation April 2017) Reviewed MSET procedures and The TFC workforce will be aware of the risk factors associated with venerable adolescents and will have the knowledge and skills to assess, respond, and reduce the risk/s More streamlined multi agency response to adolescents who are assessed as at risk Young people receive an appropriate and timely and co-ordinated response from all agencies that reduces risk and creates the opportunity for maximising positive change. This will be evidenced in the outcome of audits, quality of assessments, evidence of timely access to services in children’s plans (child protection, child in need, looked after and pathway plans) The impact of the new arrangements will be monitored by the group and shared with the SSCB 39 Final – 7th November 2017 risk assessment tool Planned e safety training for staff for October and November 2017 This has to be put in place – planned for October and November 2017 2. Quality of assessment is improved for adolescents who are at risk • All staff will receive assessment training that includes gender awareness consideration • Self-referrals by young people to children’s services should be regarded as an additional level of concern Assessment workshops delivered by OFSTED in Spring 2017, attended by all frontline practitioners. This will be included this in the development of the assessment training and will be a component of the Strengthening Practice programme Improving the quality of assessment leads to improved responses to risk and as a result improved outcomes for young people. This will be evidenced through audit, feedback from young people through MOMO and case closure questionnaires. Evaluation of the Strengthening Practice programme will include risk and adolescence. 40 Final – 7th November 2017 Appendix 2h Youth Offending Service Mark was not well known to the Youth Offending service but he presented a number of challenges to staff particularly when he was arrested in the summer of 2015 and staff were concerned about his mental health. This led to numerous discussions with health to request further assessments. Subsequently pathway was agreed with CAMHS and shared with staff in the YOS. However it will not be possible to establish the impact of this unless similar situation arose. The YOS continued to work with Mark on a voluntary basis after he was detained under the mental health act; by that stage he had also been subject to a Child Protection plan which highlighted concerns about parenting. A workshop was held for all staff in March 2017 which uncovered topics such as disguised compliance, The impact of this is that staff should be better able to identify neglectful parenting etc. and refer parents for appropriate support including specific parenting programmes now in place through Early Help. Prior to Mark being diagnosed with a psychosis he had been open to the YOS on a caution for 3 months. As a service our performance on first Time entrants (FTE’s) was not as good as some of our neighbouring local authorities we therefore reviewed our practice and presented a number of reports to the YOS Board from July 2016. To date our performance has improved markedly from an annual rate in 2015/16 of 591 to a rate in 2016/17 of 434. This rate continues to be monitored by the YOS Board as it is one of our performance targets .The impact of this is that young people can be diverted from the Criminal Justice System. 41 Final – 7th November 2017 Appendix 2i Youth Drug and Alcohol Project The Youth Drug and Alcohol Project has since April 2017 been incorporated into Targeted Youth Services as part of early help and since then there has been significant developmental activity. The team has a new manager who has introduced a new assessment and planning framework as well as a programme of quality assurance. The assessment framework is a holistic assessment of all aspects of the young person’s life. It is anticipated that the impact of this is that staff are better able to identify safeguarding issues and ensure appropriate support is in place. A new screening tool and brief intervention toolkit has also been developed and available to any staff who work with young people. A training programme has also commenced in September 2017 which will be evaluated to ensure staff feel confident in working with young people and also that we are reaching staff across all services. It is anticipated that the training programme and screening tool will allow professionals to embed brief interventions in their own work and better identify which young people need a referral to YDAP for a more intensive Tier 3 service .This in turn will allow YDAP to be more effective in targeting the young people they work with. The YDAP manager has also undertaken a consultation exercise with approximately 150 young people. This consultation will be written up and used to inform service delivery. It is anticipated that the impact of using young people’s views to inform service delivery will improve engagement rates. We plan to undertake a data analysis in December to benchmark how many young people we successfully engage in the service and if needed will agree an action plan as to how to improve this in partnership with referring agencies. |
NC52474 | Death of a 3-week-old boy in June 2020 after apparently being overlayed by his mother who fell asleep whilst breastfeeding. Learning is embedded in the recommendations. Recommendations include: promote the empowering of staff within health, social care, criminal justice, community and voluntary sectors with knowledge of alcohol risk identification and the ability to deliver advice to those whose alcohol use is problematic as an integral part of their practice; assurance from children's social care that where the risk of unsafe sleeping is assessed as high by the 0-19 public health nursing service this is given appropriate weight in decision making about the child concerned; ensure the hospital trust has a system for oversight of urgent safeguarding concerns sent to children's social care from individual midwives; seek assurance that pre-birth assessments are routinely shared with the 0-19 public health nursing service by children's social care; seek assurance that the 0-19 public health nursing service schedule antenatal visits in sufficient time to ensure they take place; seek assurance that pre-birth assessments do not contain overly optimistic assumptions; amend the pre-birth procedures to advise professionals to consider the role of friends as well as fathers and wider family members; and ensure the voice of children is listened to.
| Title: Local child safeguarding practice review: Child X. LSCB: Barnsley Safeguarding Children Partnership Author: David Mellor Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Strictly Confidential 1 Barnsley Safeguarding Children Partnership Local Child Safeguarding Practice Review – Child X Contents Page Number Introduction 2 Terms of Reference 2-3 Glossary 3-4 Synopsis 5-16 Family contribution 17 Analysis 17-30 Findings and Recommendations 30-34 References 35 Appendices Strictly Confidential 2 1.0 Introduction 1.1 Three weeks old child X died in his family home after apparently being overlayed by his mother who fell asleep whilst breastfeeding. Mother had a history of periodically excessive alcohol use and it appears that she was under the influence of alcohol at the time of child X’s death. Child X’s death and one of his siblings were being supported by child in need planning and another sibling was subject to child protection planning. Concerns that mother may have been co-sleeping with child X and using alcohol led to the escalation of concerns from midwifery to children’s social care management which were under consideration at the time of child X’s death. 1.2 Barnsley Safeguarding Children Partnership decided to conduct a local child safeguarding practice review (CSPR). David Mellor was appointed as the independent reviewer. He is a retired police chief officer who has nine years’ experience as an independent reviewer of CSPRs and other statutory reviews. He has no connection to services in Barnsley. A description of the process by which the review was conducted is set out in Appendix A. 1.3 An inquest into the death of child X will be held in due course. 1.4 Barnsley Safeguarding Children Partnership wishes to express sincere condolences to child X’s family. 2.0 Terms of Reference 2.1 The period on which this review has focussed is from November 2017 when concerns about mother’s alcohol use when caring for her children first arose until the death of Child X on 28th June 2020. Significant events which took place prior to November 2017 have also been considered. 2.2 The key lines of enquiry addressed by the review are as follows: • How effectively did practitioners respond to persistent concerns about mother’s alcohol use? • Was the impact of mother’s alcohol use on her parenting capacity fully considered and addressed? • What support was offered to mother to help her address her alcohol use? Was her alcohol use seen in the context of her risk of domestic violence and abuse from partners and her anxiety and depression? • When concerns about co-sleeping, mother’s alcohol use and her co-operation with practitioners arose in the period following the birth of Child X, how effectively were these concerns escalated and addressed? • Is there a formal multi-agency escalation procedure? Was the procedure invoked when risk began to escalate following the birth of Child X? If invoked, what was the outcome? Is there a common understanding of the escalation procedure across all agencies? Strictly Confidential 3 • How effective was partnership working between midwifery, the Hospital Safeguarding Unit, the Public Health Nursing Service and Children’s Social Care? • How comprehensive was the pre-birth assessment in respect of Child X? • How effective was the Child in Need Plan for Child X and his sister and the Child Protection Plan for his brother? • Was there sufficient enquiry into the role of males in the household, particularly the father of Child X and his sister, who was considered to be a high risk perpetrator of domestic violence and abuse and another male who appeared to be involved in the care of the children in the period following the birth of Child X? • Did restrictions imposed as a result of Covid-19 impact in any way on measures necessary to safeguard Child X? • Is the learning from this LSCPR consistent with the learning from the National Panel Review of Sudden Unexpected Death in Infancy? 3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, psychological, physical, sexual, financial and emotional abuse. The Domestic Violence Disclosure Scheme (DVDS) – often referred to as ‘Clare’s Law’ after domestic homicide victim Clare Wood. The principal aim of the Scheme is for the police to consider the disclosure of information in order to protect a member of the public who may be at risk of harm from domestic violence or abuse. The Scheme recognises two procedures for disclosing information, namely a ‘Right to ask’ which is triggered by a member of the public applying to the police for a disclosure and a ‘Right to know’ which is triggered by the police making a proactive decision to disclose information to protect a potential victim. The term Early Help describes the process of taking action early and as soon as possible to tackle problems and issues emerging for children, young people and their families. Effective help may be needed for at any point in a child or young person's life. Health visiting levels of service. The health visiting service provide four levels of service as follows (1): • Community: health visitors have a broad knowledge of community needs and resources available e.g. Children’s Centres and self-help groups and work to develop these and make sure families know about them. Strictly Confidential 4 • Universal: health visitor teams ensure that every new mother and child have access to a health visitor, receive development checks and receive good information about healthy start issues such as parenting and immunisation. • Universal Plus: families can access timely, expert advice from a health visitor when they need it on specific issues such as postnatal depression, weaning or sleepless children. • Universal Partnership Plus: health visitors provide ongoing support, playing a key role in bringing together relevant local services, to help families with continuing complex needs, for example where a child has a long-term condition or additional concerns such as safeguarding, domestic abuse and mental health problems. A Legal Gateway meeting is an opportunity to discuss a case fully, and to consult with colleagues to ensure that children are the subject of active case management and effective child protection planning and that appropriate legal action is taken when required to promote and safeguard the welfare of the child. Every local authority has a statutory responsibility to have a Local Authority Designated Officer (LADO) who is responsible for co-ordinating the response to concerns that an adult who works with children may have caused them or could cause them harm. Multi-Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality. The perinatal period refers to pregnancy and the first 12 months after childbirth. Specialist community perinatal mental health teams offer specialist psychiatric and psychological assessments and care for women with complex or severe mental health problems during the perinatal period. SafeLives DASH (Domestic Abuse, Stalking and 'Honour'-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi-Agency Risk Assessment Conference (MARAC) and what other support might be required. Section 47 Enquiry is required when children’s social care have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry. Strictly Confidential 5 4.0 Synopsis 4.1 Mother is a registered nurse who works in a nursing home. She had three children, child 1 who was born in 2009, child 2 who was born in 2017 and child X who was born on 6th June 2020 and died on 28th June 2020. The father of child 1 is referred to in this case summary as father 1 and the father of child 2 and child X is referred to as father 2. 4.2 Mother suffered domestic violence and abuse in her relationships with both father 1 and father 2, including an assault on her by father 1 when holding two week old child 1 in her arms. During her relationship with father 2, the police were periodically called to domestic abuse incidents by child 1 who disclosed that he was scared by the ‘screaming and banging’ that father 2 was ‘mean’ to him ‘all the time’. Mother was reluctant to support any prosecution of father 2 but alluded to a history of controlling behaviour and aggression on his part. Concerns began to accumulate over mother’s capacity to care for child 1 and about her use of alcohol. There were numerous reports of staff at child 1’s school smelling alcohol on mother’s breath when bringing the child to, and collecting him from, school. 4.3 From 13th July 2017 until 3rd December 2018 mother received support from an Early Help Family Support worker. The primary focus of this work was on supporting mother to parent child 1 who had issues with anger, agitation, frustration and self-harm. At the time Early Help support began, child 1 was 8 years and child 2 was 4 months old and mother was on maternity leave. During this period a diagnosis of auditory sensory processing disorder was being investigated in respect of child 1 and he was supported through an education, health and care (EHC) plan because of a diagnosis of moderate learning disability. The purpose of an EHC plan is to identify educational, health and social needs and set out the additional support required to meet those needs. 4.4 On 12th November 2017 the police were called by a member of the public after mother appeared drunk whilst taking child 1 and 2 home from a family party. The police went to mother’s home where she was found lying on the floor, smelling strongly of intoxicants and slurring her speech. Child 1 was attempting to care for his younger sibling who he had placed on a double bed with pillows either side of her to try and prevent her rolling off. However, child 2 was ‘totally covered’ in bed clothes on which faeces were noted. Mother was arrested on suspicion of child neglect and detained overnight as she was assessed as too drunk to be interviewed. 4.5 Children’s social care were notified of the incident and worked together with the police. The police decided to take no further action was taken as the incident was treated as an ‘isolated’ incident for which mother appeared very remorseful. Children’s social care closed the case in January 2018 on the grounds that mother was not considered to be alcohol dependent and the incident had been a ‘one-off’. It was noted that child 1’s school had smelled alcohol on her breath, which mother had denied. It was decided that the support provided by the Family Support worker would continue. 4.6 Early Help referred mother to the Local Authority Designated Officer (LADO) as she was employed as a registered nurse in a care home and therefore worked with adults with care and support needs. The LADO’s role is limited to cases in which an adult works with children and so it seems likely that the referral would have been considered within the local authority’s Person’s in a Position of Trust (PIPOT), but the outcome of the referral is unknown. Strictly Confidential 6 4.7 Early Help continued to support mother and the children. Mother’s relationship with child 1’s primary school became strained. The school did not perceive the 12th November 2017 incident as an isolated event. Child 1 disclosed that mother drank at weekends and a strong smell of alcohol was noted when mother and father 1 attended a meeting at school to discuss a disclosure from child 1 that he had been kicked by his mother. Father 1 acknowledged that he had been drinking but it was suspected that mother may also have been drinking. 4.8 During February 2018 child 1 disclosed that his mother picked him up from school and took him to her friend’s house where she drank a bottle of wine. Child 1 added that when they got home, mother went to bed leaving him to look after child 2. Child 1 was later seen by a social worker and there were said to have been ‘huge gaps’ in his account. 4.9 Mother claimed that her relationship with child 1’s school had broken down and began looking for an alternative school. The school expressed concern about disguised compliance from mother. Mother began avoiding school because she ‘felt judged’ by them and began sending relatives to take and collect child 1 from school. 4.10 Child 1 moved to a different primary school in June 2018 although he was excluded from his original primary school shortly before he transferred to the new school. 4.11 Early Help referred mother to IDAS, which supports people affected by domestic abuse, after father 1 was arrested for drugs and violence offences which made her fearful for her safety - although father 1’s violence was directed at another family member. Mother declined IDAS support. 4.12 On 25th January 2019 mother reported an incident to the police in which she had invited father 1 into her home to see child 1 and an argument had taken place during which mother feared father 1 was going to head-butt her. The police attended and subsequently arrested father 1 although the Crown Prosecution Service (CPS) decided not to authorise a charge because of ‘evidential difficulties’. Mother also reported a mark on child 2’s neck which she believed to have happened when father 1 tried to grab her to say goodbye. Child 1 was said to have been very upset by the incident and was frightened of seeing or speaking to his father. A DASH risk assessment identified a medium risk. There is no indication that alcohol played any part in this incident. 4.13 Children’s social care were informed and a further period of assessment followed although the case was closed in February 2019 as mother and father 1 ‘had separated’ and mother was to be supported through an Early Help Assessment. Father 1 was documented not to want contact with child 1 and was advised that if he wished to renew contact with child 1, children’s social care would need to carry out a risk assessment. 4.14 On 1st June 2019 father 2 attended the family home in a drunken state. Child 1 was home alone and after texting his mother, she told him to contact the police. During the call to the police child 1 said that he was scared because previously when mother and father 2 argued there had been ‘blood everywhere’. The police notified children’s social care. When the latter service spoke to mother she said that child 1 had lied about the incident, adding that he ‘always tells lies.’ 4.14 On 15th June 2019 mother reported child 1 as missing to the police who subsequently located him at his maternal grandmother’s address. Child 1 disclosed that he had been Strictly Confidential 7 assaulted by his mother, not for the first time he said, and maternal grandmother raised concerns about mother’s mental health and alcohol consumption. 4.15 A strategy meeting took place on 21st June 2019 at which concerns were expressed about mother’s alcohol consumption, the emotional and physical abuse of child 1 and child 2 presenting as unkempt at nursery from which the child was often collected by her aunt. The matter was to be progressed to Initial Child Protection Case Conference (ICPCC). The disclosure of assault by child 1 was treated as ‘over chastisement’ and no further action was taken. 4.16 The ICPCC was held on 10th July 2019 when both child 1 and 2 were made subject to a Child Protection Planning in respect of concerns about domestic abuse, alcohol use and risks in the community. In particular there was concern that the children continued to be exposed to violent incidents between father 2 and mother; that there was strong evidence that mother was using alcohol to excess in order to manage her low mood and her current relationship with child 1 and there had been reports of mother being ‘drunk’ whilst pushing child 2 in her pushchair; and that child 1 was often unsupervised in the community during mother’s working hours and that she did not accept responsibility for his behaviours and continually requested for him not to be in her care. 4.17 On 26th July 2019 maternal grandmother contacted the police after child 1 arrived at her house after returning home from school to find the front door unlocked and neither his mother or child 2 at home. Maternal grandmother advised the police that she had also contacted children’s social care who had agreed that child 1 could stay with her for the night. As children’s social care were thought to be aware, no further action was taken by the police. No enquiries were made by the police to locate mother and child 2 and no referrals were submitted. Children’s social care had been informed of the situation by maternal grandmother but no further action was taken other than adding the incident to the chronology of concerns about the family. In their chronology of concerns, children’s social care documented that mother was reported to have returned home with child 2 whilst ‘drunk’ later in the evening. 4.18 On 9th August 2019 father 2 contacted the police to express concern that mother was preventing his access to child 2 due to her being in drink. The police contacted children’s social care who advised that mother had already informed them that child 2 was unwell and that the family had been engaging well with their service. The police visited mother at home and concluded that she was not ‘in drink’, having consumed one glass of wine. The police shared this incident with the subsequent Review Child Protection Conference meeting held on 2nd October 2019. 4.19 On 22nd October 2019 mother contacted the police to report that father 2 had falsely informed her employer that when she called in sick it was actually because she was drunk. Mother decided against making a formal complaint about father 2. The police completed a DASH risk assessment which highlighted a standard risk and offered her a referral to IDAS which mother declined. Children’s social care were also notified. 4.20 On 6th December 2019 mother attended a booking appointment with midwifery in respect of the unborn child X. When asked about alcohol consumption, mother said that she drank 12 units per week prior to her pregnancy. She said she was prescribed propranolol for anxiety and cyclizine for morning sickness. She said that she was no longer in a relationship with the father of child X (father 2). Safeguarding was discussed and she said that the Child Protection Plan was in place because of drug abuse by father 1 – which was false. Strictly Confidential 8 4.21 On 9th December 2019 mother registered with GP practice 2 and during the new patient health check she stated that her weekly alcohol consumption was zero. 4.22 On 4th January 2020 child 1 contacted the police. He said he was not at home but had been texted by mother asking him to call the police because father 2 was at his home address and refusing to leave. He disclosed previous domestic violence incidents which usually involved father 2 punching his mother in the face and that ‘sometimes, blood gets all over the place’. The police attended mother’s address where she disputed the account provided by child 1. Father 2 was present but had fallen asleep on the sofa after visiting her at her invitation. She said that she believed child 1 had been worried about her because of previous disagreements she had had with father 2 – which she said had not involved violence. The police escorted father 2 from the address but child 1 was not further spoken to or any texts noted. Due to child 1’s disclosures, a crime of assault was recorded and a DASH completed (standard risk). The police notified children’s social care and maternity services in view of mother’s pregnancy. (The account of this incident shared with the review by children’s social care adds that father 2 fell asleep having become intoxicated and that mother had gone upstairs ‘to stay out of the way’). 4.23 One of the previous domestic violence incidents disclosed by child 1 took place in June 2019 when father 2 attended the family home in a drunken state. Child 1 had been home alone. When children’s social care later spoke to mother about this incident she said that child 1 had lied about the incident, adding that he ‘always tells lies.’ 4.24 On 9th January 2020 maternity informed health visiting of mother’s estimated date of delivery which was 24th June 2020. 4.25 On 10th January 2020 social worker 1 made a Child Protection visit. It was noted that father 2 was taking some responsibility for child care in respect of child 2 and mother regarded him as reliable in this regard. He looked after child 2 in his caravan which mother said she had visited and found it to be clean and tidy, with appropriate toys for the child to play with. 4.26 On 17th January 2020 midwifery notified children’s social care that mother was 16 weeks pregnant with Child X. Mother had not been attending ante-natal appointments which led midwifery to refer her to Grimethorpe Family Centre for ante-natal care, which she began attending from 21st January 2020. 4.27 On 20th January 2020 a core group meeting took place at which continuing concerns about child 1’s behaviour at school were discussed. His school stated that they were often unable to contact mother due to her being in work and advising them that she was unable to take breaks due to her role in caring for residents in the care home in which she was employed. Father 2 was said to have been making calls to mother’s workplace. The content of these calls was not documented although mother was said to have discussed them with social worker 1 who advised her to contact the police. 4.28 On 29th January 2020 social worker 1 made a Child Protection visit following which it was documented that child 1 was struggling with his behaviour at school which was said to have deteriorated, indicating that ‘he had worries that he felt unable to speak about’. Strictly Confidential 9 4.29 On 31st January 2020 midwifery responded to the police notification of the 4th January 2020 incident by issuing an instruction that direct questions about domestic abuse should be asked when mother attended appointments. 4.30 On 6th February 2020 social worker 1 made a further Child Protection visit. It was documented that child 1’s school had raised concerns that his behaviour had deteriorated significantly since the last core group meeting in that he had been ‘hurting himself’ at school, spending a lot of time in the community - sometimes until 10pm - and arriving very early at school and without a coat. Mother was said to remain difficult to contact, saying that she was unable to receive calls between 9.30am and 8.30pm on working days. There were said to be no concerns about child 2. 4.31 On 11th March 2020 children’s social care arranged a ‘pre-planning meeting’ in accordance with the Barnsley pre-birth protocol following the referral from maternity in respect of the unborn child X. It was noted that there continued to be concerns in respect of child 1 and his behaviour in the community. He remained subject to child protection planning due to ‘extra familial harm and lack of supervision and safety plans by surrounding adults’. Mother was noted to be 25 weeks pregnant, was now attending ante-natal appointments at Grimethorpe Family Centre and there were no concerns about how the pregnancy was progressing. It was also noted that during her previous pregnancy, a friend (friend 1) moved into her property to provide support to enable her to recover and adjust to a new baby being in the household. No concerns were said to have been raised by health agencies. Midwifery had been invited to this meeting but it is unclear if they attended. 4.32 When mother attended hospital after experiencing bleeding on 16th March 2020, direct questions were asked about domestic violence. Mother disclosed no incidents and said that she did not feel unsafe. A DASH risk assessment was completed which identified a ‘medium’ risk which was increased to ‘high’ following a conversation with the Named Midwife for Safeguarding. The domestic abuse concerns were documented as follows: • A previous high-risk event involving strangulation. • Continued incidents despite mother and father 2 being separated. • Father 2’s continued contact with child 2 with access providing the opportunity for further domestic abuse. • ‘Unpredictable nature’ combined with alcohol use – it is unclear whether this referred to father 2, mother or both. • Mother’s apparent lack of acceptance that the risk of domestic abuse remained. • Child 1’s disclosure of previous assaults which were denied by mother. • Mother had declined specialist support and a referral to IDAS • Father 2 had previous children who he had no contact with. • Father 2 identified as a previous high-risk perpetrator of domestic violence with another victim in 2017 - six incidents with that victim in which strangulation involved on four occasions. Restraining order taken out. • It was questioned whether or not mother was aware of Clare’s law (the Domestic Violence Disclosure Scheme). 4.33 On 22nd March 2020 a Review Child Protection Conference took place. The report prepared for this meeting by children’s social care noted that when child 1’s concerning presentation was discussed with mother, she was visibly frustrated and dismissive of the concerns, stating that none of this is new behaviour and that child 1 is a ‘typical boy’. She was said to disagree with the child safeguarding concerns and did not feel there were any additional steps she could take to safeguard child 1 when she was at work. When child 1’s safety in the community was discussed with mother, she demonstrated a poor Strictly Confidential 10 understanding of risk. Father 2 expressed concern that child 1 was displaying unsafe and dangerous behaviour in the family home and the community, adding that the child had knives in his bedroom and in the community. Father 2 went on to say that child 1’s behaviour placed child 2 at risk of harm and he said he was worried about the impact on the unborn child X. Father 2 also said he was worried that mother was not telling professionals the full extent of what was happening and not being honest. Mother disagreed with this and said that father 2’s comments were untrue and were the result of them having a disagreement earlier in the week. 4.34 Overall, it was felt that limited progress was being made on the Child Protection Plan because mother was reluctant to engage with services which would aim to increase her understanding, help her implement strategies and build a clear safety plan for child 1. Children’s social care wished to make a referral to CAMHS in respect of child 1’s behaviour and early life experiences but mother did not agree that this was required. Additionally, children’s social care had considered presenting child 1’s case to the Contextual Harm Panel but did not yet have an evidence base to support the level of concern held by professionals. It was decided that child 1 was to remain subject to child protection planning on the grounds of emotional abuse and physical harm, but that the threshold for child protection planning was no longer met for child 2 who was said to be thriving in all areas. She was to be supported as a Child in Need for a period to ensure progress was maintained. The plan for the unborn child X was to be discussed by children’s social care and midwifery. Child 1 was to be referred for family support and targeted youth support. There was said to be no evidence of mother using alcohol around the children. 4.35 On 26th March 2020 the case was transferred from social worker 1 to social worker 2 due to the former’s maternity. The expected joint home visit by both social workers could not take place to due to Covid-19 restrictions. 4.36 On 31st March 2020 a pre-birth assessment was completed in respect of the unborn Child X. The assessment noted that mother had been difficult to engage with. It was noted that mother’s pregnancy with child x was unplanned and due to a brief relationship with father 2, with whom she said she did not wish to be in a relationship with as a result of his past behaviour. Father 2 had wanted mother to terminate the pregnancy. Father 2 expressed concern that prior to the pregnancy mother was consuming alcohol excessively, although there was said to be no evidence to support this. He was also concerned that following the arrival of the unborn child, she would return to this behaviour. The assessment found that there continued to be evidence that mother was able to meet the basic needs of a young child, had an appropriate understanding of child development, the importance of routines, hygiene and had the ability to implement boundaries. There was concern that as a child grows and begins to engage in risk taking behaviour, that mother's parenting ability was different in that her understanding of appropriate supervision for child 1 was of concern and needed to be addressed to prevent the unborn child from having similar experiences as they grew. Mother was said to minimise concerns about domestic abuse and was unwilling to undertake any work with IDAS to develop her understanding of domestic abuse. However, she was no longer in a relationship with father 2, which was regarded as a ‘protective factor’. Mother had limited family support and was said to rely upon friends and neighbours in the local community. She remained resistant to engagement with children’s social care and had declined a referral to parenting and behaviour management. It was noted that the Child Protection plan in respect of child 2 had recently been ended because there was evidence that mother was able to meet the child’s basic needs. It was said that there was no evidence that this would not be the case for the unborn child. A child in need plan was recommended in respect of the unborn child X. Strictly Confidential 11 4.37 On 31st March 2020 the case was discussed by social worker 2 in supervision and child 1’s case was RAG rated as ‘amber’ as he was attending school and, due to mother’s maternity leave, he was no longer unsupervised in the community. Child 2 and the unborn child X were RAG rated ‘green’. (RAG rating of cases had been temporarily introduced as a direct result of the impact of Covid-19 restrictions on social work practice in order to afford cases priority on a ‘red’ (high), ‘amber’ (medium) and ‘green’ (standard/low) basis). 4.38 On 1st April 2020 MARAC considered the 16th March 2020 referral from maternity following concerns that mother, who was pregnant, was minimising issues with father 2, including his alcohol consumption. The police shared details of the 15th June 2019 and 22nd October 2019 incidents and domestic abuse incidents involving mother and father 2 and their previous partners. Father 2’s alcohol consumption was referred to but there was no mention of mother’s consumption of alcohol. The outcome was that partner agencies were asked to ensure that any incident ‘tags’ were up to date. 4.39 On 2nd April 2020 social worker 2 made a CIN visit and to introduce herself. Given Covid-19 restrictions the social worker stayed at the front door. Mother, child 1 and 2 were present. The home was noted to be cluttered with toys. Mother said she was struggling to attend appointments due to caring for the children and the impact of Covid-19 restrictions which prevented members of the wider family caring for the children. The social worker advised mother that she would share the unborn assessment completed by the previous social worker with her once she was authorised to do so, to which mother responded by saying that she had been told that the likely outcome of that assessment was that the case would be closed. The children engaged well with the social worker. 4.40 Social worker 2 made a further CIN visit on 23rd April 2020. Mother had begun her maternity leave. She also said that she was in the process of moving house but that Covid-19 restrictions had put this on hold. Child 2 was having weekend contact with father 2. 4.41 On 27th April 2020 mother was sent a text message inviting her to contact the infant feeding service which offered advice and support. She subsequently declined this service. 4.42 On the same date a CIN meeting took place which was conducted through updates being provided by email in view of the Covid-19 restrictions. Social worker 2 confirmed that child in need planning had been recommended in respect of the unborn child X, that she had been unable to do any direct work with child 1 as yet as a result of Covid-19 restrictions. There had been no concerns during home visits in that mother had engaged appropriately and the children had presented well. On her next visit the social worker said she planned to speak to mother about child 1 arriving at school early (8am). Midwifery’s update was that mother had been changing her mind about which GP she would be seeing and had not attended a recent appointment with the midwife (date given as next day – 28th April). No other email updates were received. 4.43 The case was discussed in supervision by the social worker and her manager on 30th April 2020. There were no concerns about the basic care needs of the children. The previous concerns about mother’s supervision of child 1 had diminished as she was now on maternity leave. Mother’s ability to sustain change once she returned to work was considered. Child 1 was attending school and said to be disruptive in class. Child 2 was seeing father 2 at the weekends and there had been no recent reported domestic abuse incidents. Strictly Confidential 12 4.44 A further CIN visit took place on 12th May 2020. Mother and the children were seen in the rear garden. Mother said she was feeling ‘fed up’ as the prospective buyers of her house had pulled out. She said that she would need more space once the baby was born. The social worker discussed concerns about the early arrival of child 1 at school – as early as 7.30am. Child 1 said he woke up at 7.30am and set off for school 15 minutes later which mother confirmed, adding that he avoided washing his face and brushing his teeth. 4.45 The birth plan was completed by children’s social care and sent to the safeguarding midwives on 14th May 2020. 4.46 Social worker 2 discussed the case with her manager in supervision on 21st May 2020. Mother was now in a position to move house to Grimethorpe which would necessitate child 1 living in a friend’s care during the week so that he could continue to attend his junior school before transferring to secondary school in September. A junior school place in Grimethorpe also appeared to be an option. A police check on mother’s friend was to be actioned and child 1 would need to be visited at the friend’s house. It was planned to work towards case closure but it was noted that a plan would need to be in place for when mother returned to work in terms of supervision of child 1 and the service would need to be satisfied about mother’s understanding of concerns about domestic abuse. 4.47 A further CIN visit took place on 2nd June 2020 during which mother was unpacking her belongings, the move to Grimethorpe having taking place. Mother appeared annoyed at the outcome of the pre-birth assessment. She said that she had understood that the case would close for the unborn child X and child 2. When asked about her understanding of the concerns which had led to children’s social care involvement she replied that she knew that what had happened shouldn’t have happened and referenced the concerns about the fathers in particular father 1’s use of substances. She added that both fathers were ‘nice to begin with’ and then ‘things changed’. Mother said that father 2 would be having contact with the unborn child X, adding that he knew where she now lived although father 1 only knew the area to which she had moved. She added that she was happy that she had moved as fathers 1 and 2 wouldn’t just be turning up at the house as they had done previously. Mother’s alcohol use was discussed and she said that she was not going to lie and say that she would not drink. Mother agreed to ensure that she was capable of caring for the children and know when to stop drinking. 4.48 Child X was born on Saturday 6th June 2020 and she and the baby were discharged the following day. It had not been possible for the health visitor antenatal visit to be completed as the child had been born earlier than the EDD. Child X was allocated to a health visitor from the Partnership Plus team. 4.49 Midwife 2 made a home visit on Monday 8th June 2020 and no concerns were raised about the condition of the bedroom and no alcohol was seen on the premises. Mother was asked about her alcohol intake and said that she was not drinking. It was noted that mother had moved into the address within the last two to three weeks. Mother said that child X would not be co-sleeping with her. 4.50 On Tuesday 9th June 2020 a CIN meeting took place in the form of email updates. Children’s social care noted that child 1 was currently staying with maternal grandparents. The primary school update indicated that this was proving a positive move for child 1, that he was enjoying staying with them and appeared more settled in class knowing that he will be dropped off and picked up by his grandparents each day. However, he told the social Strictly Confidential 13 worker that he missed his mother and child 2. The health visitor planned to make the new birth visit shortly. There appeared to be no update from maternity. 4.51 On Thursday 18th June 2020 health visitor 1 made a new birth visit. Mother wasn’t expecting the visit as she assumed that the visit would be conducted by telephone. The home was extremely cluttered and untidy with old used cutlery and pots lying around on the table but also covering the sink and all the kitchen sides were covered with clutter. The living room was covered with toys and clutter. Mother was asked about her alcohol consumption and said she liked to have a drink at the weekend but was not drinking currently as she was breastfeeding. When the health visitor went upstairs she saw a glass of half-drunk wine, an empty wine glass and a can of cider. The moses basket was full of clutter and dirty nappies were left on the side in the bedroom. The moses basket did not appear to be being used currently which raised co-sleeping concerns. When asked if she had been drinking, mother became very flustered and said ‘friends’ had been round, identifying one as friend 1. Mother said that whilst child X would sleep in her bed during the day, when mother was awake, she denied that he slept in her bed overnight. During the conversation it emerged that child 2 had moved child X from where mother had left him into his bouncer chair whilst mother was upstairs. Mother said that child 2 was staying with father 2 on alternate weekends. Mother expressed concern that father 2 was living in a caravan which may not be clean and in which the toilet did not work properly. 4.52 Health visitor 1 shared the details of this visit with the duty social worker that day and via email with social worker 2 the following day and asked whether children’s social care were aware that child 2 was having unsupervised contact with father 2. She also asked whether a LADO referral should be made as mother was a registered nurse and one of her children was subject to child protection planning. The duty social worker advised that children’s social care were aware that mother did drink and that safe drinking levels had been addressed with her. The concerns were also escalated to the midwifery team lead. Health visitor 1 had also carried out a safe sleep risk assessment in respect of the potential increased risk around co-sleeping and alcohol use. The health visitor chronology states that the ‘first part of the escalation policy’ commenced. 4.53 On Friday 19th June 2020 midwife 1 made a home visit and found the house to be untidy but not unclean. The moses basket was clean and the midwife had no concerns during this visit. Mother commented that she was ‘too honest for her own good’. 4.54 Also on Friday 19th June 2020 social worker 2 rang mother who said that because she had not been expecting a visit from the health visitor, she had not tidied up. She denied drinking alcohol and said that it was friend 1, who mother said was known to children’s social care, who had been drinking in the house. She denied co-sleeping and also denied that there were dirty nappies in the moses basket, adding that the nappies in the moses basket were clean. Mother largely rejected the health visitor’s observations and said that she didn’t want the health visitor to visit anymore ‘as she could be saying anything’. The social worker reinforced the co-sleeping advice given by the health visitor. Mother again said that she was ‘too honest for her own good’. 4.55 The social worker was to check the file in respect of friend 1 and would visit the following week with the health visitor and said that all home visits would be joint social worker/health visitor visits. 4.56 Also on Friday 19th June 2020 the Named Midwife for Safeguarding escalated the following concerns to children’s social care: Strictly Confidential 14 • Home conditions poor, cluttered; baby sleeping area ‘dirty nappies and cluttered to the point where a baby was unable to sleep in the moses basket’. • Possible co-sleeping/risk of overlay: concern that mother says she isn’t bed sharing with baby yet the moses basket shows signs that baby can’t sleep there. I feel this leads to possible dishonesty and the risk of alcohol combined with co-sleeping is a very high risk of SIDS • Indications of on-going alcohol use: concern about mother’s explanation re the alcohol, as it was unlikely that one of the glasses wasn’t hers given that it was her bedroom. • Domestic Abuse. It is understood that mother and father 2 are separated and that father 2 had an alcohol problem. The two types of alcohol indicate a second person. If this was father 2 then there was concern that mother was not being honest about the relationship. Father 2 is known as a high-risk perpetrator in a previous relationship which included strangulation on four occasions. (The police have a record of two strangulation incidents involving different partners in 2017 and 2018 – not involving mother). Mother had been advised of Clare’s Law (Domestic Violence Disclosure Scheme (DVDS)) but unclear whether she had taken this option. • Significant Others: concern that mother says there were visitors in her bedroom drinking alcohol, which is very inappropriate if this is the case. Given this explanation is in the context of Covid-19, this is an additional significant factor. • Context of the past: There appears to be a long history linked to domestic abuse and excessive alcohol use which led to mother being convicted of child neglect in 2008. The family composition in 2008 was unknown. Midwifery concluded by stating that, given the past history of a child neglect conviction (there was an arrest but no conviction for child neglect) which included alcohol and domestic abuse as a trigger, concerns are heightened and it is felt that the threshold for risk of significant harm was now met. 4.57 Midwifery also asked the social worker if mother had been asked if father 2 had been staying over and whether alcohol had been drunk in the bedroom. They also asked if the case needed to be reviewed in the light of the current concerns and also asked when the next CIN meeting was due to take place. 4.58 On Sunday 21st June 2020 midwifery made a home visit and noted that child 1 was at home with mother having been in contact with another pupil who had tested positive for Covid-19. Although child 1 had tested negatively for Covid-19 test, his school had advised necessitated isolating for 14 days. Midwifery had been asked by mother whether the rest of the household also needed to isolate and they said that they would get back to her to advise. The midwife acknowledged that this could affect home visits by professionals. She advised social worker 1 of the circumstances via email. 4.59 On Monday 22nd June 2020 social worker 2 and health visitor 1 arranged a joint visit to coincide with the six week check during week commencing 20th July 2020, although it was intended to arrange a prior joint home visit during the current week but this did not take place. 4.60 On Tuesday 23rd June 2020, midwife 1 made a home visit and found child 2 and child X to be clean and dressed appropriately. Child X was alert, gaining weight and being exclusively breast fed. Child 1 was now staying at friend 1’s address. Mother said she has had no advice on Covid-19 other than the text from child 1’s school advising self-isolation. The family were displaying no symptoms and did not appear to be isolating with mother saying that she planned to visit her solicitor that day. The home environment had improved, Strictly Confidential 15 and the living room and mother’s bedroom were tidy and no alcohol was visible. The moses basket appeared to have been used as sheets and a blanket were in place. The risks of co-sleeping were reinforced with mother. Mother again denied co-sleeping at night. The kitchen area was cluttered, with unwashed pots in the sink and clothes on the table but the floors were clean and there was no visible food on surfaces. Mother said that she had made an effort to remove the clutter over the weekend. 4.61 Mother had phoned the midwife in advance to ask for the time of the visit, saying that she needed to know as she was visiting her solicitor. The midwife expressed concern that mother had allowed child 1 to go to stay elsewhere against the school’s advice. Mother had said that friend 1 had been drinking in the house prior to the health visitor’s visit and had used two glasses. 4.62 On the same day (Tuesday 23rd June 2020) social worker 2 also made a (unannounced) home visit. Mother had been visited by a friend from University and did not consent to any concerns being discussed in her friend’s presence. The social worker saw child 2, who was asleep on the sofa and child X who was in his car seat as mother said he had just come from the car. The social worker documented that home conditions were safe for the children and that there were no indications of alcohol use. Mother said that child 1 had been taken to maternal grandparents by friend 1 due to a Covid-19 ‘scare’ at the school. The social worker said that she would call back to discuss the concerns. 4.63 Also on Tuesday 23rd June 2020 social worker 2 responded to the Named Midwife for Safeguarding’s concerns in an email as follows: • Home conditions: These had improved by the time the midwife visited on 21st June 2020 and the social worker planned to continue to visit announced and unannounced in line with CIN planning. She added that during her visits the home conditions were cluttered but not unsafe and noted that mother just moved in to the property and had a baby, hence the clutter. • Possible co-sleeping/risk of overlay: This had been discussed with mother and would continue to be discussed with her. The moses basket was empty during the recent midwifery visit and mother states it to have items in only during the day. • Indications of on-going alcohol use: The social worker said she shared the concerns about mother’s alcohol use however this was the first time it has been observed since she was allocated the case, and mother had stated that the alcohol was not hers. This would be monitored. • Domestic Abuse: The social worker said that individual at the property was not father 2. • Significant Others: The social worker said that she shared this concern which would be addressed throughout CIN planning. • Context of the past: The social worker confirmed that child 1 was in mother’s care and was subject to child protection planning due to contextual safeguarding currently. Progress had been made and the child protection plan was to be reviewed. The social worker concluded the email by saying that unannounced visits would evidence concerns and that she would keep all parties updated in line with CIN planning. The next CIN meeting was scheduled for 29th June 2020. Strictly Confidential 16 4.64 On the same date (23rd June 2020) the Named Midwife for Safeguarding escalated further concerns to the Designated Nurse and Children’s Social Care management. In her email the Named Midwife wrote that there was a risk of drift in this case which would benefit from ‘fresh eyes’. She also expressed disappointment in the response of social worker 2 to the concerns she expressed in her email of 19th June 2020 (Paragraph 4.55). She warned against false reassurance from improvements noted on more recent visits. The Named Midwife went on to express concern that mother was not self-isolating nor ensuring the self-isolation of child 1 following possible exposure to Covid-19. 4.65 The escalation email was received by a Service Manager in Children’s Social Care who arranged for the matter to be discussed with social worker 2’s team manager. This discussion was planned for Friday 26th June 2020 but did not take place due to action being required to address another case which involved immediate care proceedings. 4.66 On Wednesday 24th June 2020 the health visitor discussed the case in supervision. She outlined the action she had taken so far and it was agreed that the health visitor would raise the increased risk of sudden infant death syndrome (SIDS) arising from mother’s alcohol use and her lack of support as a single mother at the forthcoming CIN meeting. It was documented that a CIN meeting had recently taken place but that neither the health visitor nor midwifery had been invited (Paragraph 4.50). Health visiting had been represented at the meeting but maternity had not. 4.67 On Thursday 25th June 2020 midwife 3 made an unannounced home visit. Mother had been visited by a female friend and two children and both adults and all four children were in the garden. Child 1 was said to be ‘staying with relatives’. The midwife reminded mother of the Covid-19 restrictions including questioning whether it was appropriate for mother to be having friends visit when she was supposed to be isolating. The midwife described the garden as ‘slightly chaotic’ with toys all over the long grass. The midwife found the interior of the house to be messy and ‘a chaotic house’ with lots of old pots piled up in the kitchen sink and the kitchen table with lots of clothes, boxes etc. on top of it, suggesting it was not used as a kitchen table. Mother said she had only moved in a few weeks ago but it looked to the midwife as though the mess was long term mess. Child X had quite inflamed red sticky eyes and so the midwife asked her to ring the GP and the midwife arranged another visit to ensure this was done (Mother had left GP practice 1 in May 2020. It has been confirmed that she had registered with a new GP following her move to Grimethorpe. However, child X was not taken to see the GP as requested by midwife 3.). The midwife checked mother’s bedroom and noticed an empty can of cider under the bed. 4.68 Midwife 3 sent an email to social worker 2 at 8.55pm the same day summarising what she had found on her visit. The social worker did not pick up the email the following day (Friday 26th June 2020) because she was out of office. Her automatic out of office reply was activated. 4.69 On Sunday 28th June 2020 the ambulance service contacted the police to notify them that they were transporting child X to hospital following suspected cardiac arrest. The police attended the hospital to find that child X had died and were told by a hospital nurse that they could smell intoxicants on mother’s breath. Mother said that she had breast fed child X during the early hours of that morning and woke at around 5am to find the child lifeless. 4.70 When the police searched mother’s house, they found an empty wine bottle on the bedside table at the side of mother’s bed, unopened cans of cider in the fridge and the wheelie bin was ‘full’ of empty wine bottles and cans of lager. Strictly Confidential 17 5.0 Contribution of family members 5.1 At the time of writing the criminal investigation of child X’s death was ongoing. Mother is a suspect and maternal grandmother is a witness and so it has not yet been possible to offer either of them the opportunity to contribute to the review. 6.0 Analysis 6.1 In this part of the report each key line of enquiry will be addressed in turn. How effectively did practitioners respond to persistent concerns about mother’s alcohol use? 6.2 Child X died whilst co-sleeping with mother who was noted to smell strongly of alcohol by a nurse at the hospital to which the child was taken after being found lifeless by mother. When the police searched mother’s house following the death of child X, they found an empty wine bottle on the bedside table at the side of mother’s bed, unopened cans of cider in the fridge and the wheelie bin was ‘full’ of empty wine bottles and cans of lager. 6.3 There were longstanding concerns about mother’s use of alcohol. The primary school attended by child 1 smelled alcohol on mother’s breath on many occasions during the daytime (Paragraph 4.2, 4.5 and 4.7) and it is possible that mother’s drinking may have been a factor in her avoiding school and sending relatives to take and collect child 1 from school (Paragraph 4.9). There were several occasions when mother was known or suspected of being drunk whilst caring for her children (Paragraphs 4.4, 4.16 and 4.17). There were several reports of mother being adversely affected by drink which were not accepted at face value; reports from child 1 (Paragraph 4.8) could have been given more weight and this issue will be considered in more detail later in this report. The credibility of reports from father 2 (Paragraphs 4.18, 4.19 and 4.36) were affected by the fact that he was a high risk perpetrator of domestic abuse and there were indications of coercion and control in his relationship with mother. Some of his reports of mother’s alcohol use appear to have been perceived by professionals as malicious attempts to apply pressure in order to exert control over her. It is possible that father 2’s reports were motivated by malice whilst also being accurate. 6.4 Assessments carried out by children’s social care invariably referred to mother’s use of alcohol. Her use of alcohol ‘to excess’ was one of the concerns which justified child 1 and child 2 becoming subject to child protection planning in July 2019 (Paragraph 4.16) although by the time child 2 was stepped down to child in need support on 22nd March 2020, the assessment concluded that there was no evidence of mother using alcohol around the children (Paragraph 4.34). At that time mother may have been abstaining from alcohol as she was pregnant with child X. When the pre-birth assessment was completed in respect of child X on 31st March 2020, there was said to be no evidence to support father 2’s concern that mother had been consuming alcohol excessively prior to her pregnancy with child X and he feared that she would resume excessive alcohol consumption following the baby’s birth (Paragraph 4.36). 6.5 No concerns arose about mother’s use of alcohol arose during the fairly substantial contact which agencies had with her during her pregnancy with child X. All the indications are that she largely or fully abstained from alcohol during this period. However, father 2’s concern that mother would begin consuming alcohol again following the birth of child X Strictly Confidential 18 appeared to have been borne out by what was noticed by the health visitor during an unannounced visit on 17th June 2020 (Paragraph 4.51) and during a subsequent unannounced visit by midwife 3 on 25th June 2020 (Paragraph 4.67). During a child in need visit 4 days prior to the birth of child X, mother said that ‘she was not going to lie and say that she would not drink (Paragraph 4.47). 6.6 It is concluded that longstanding concerns about mother’s relationship with alcohol were very visible to professionals at the time that child 1 and child 2 were made subject to child protection planning in July 2019 but received much less attention at the time of the pre-birth assessment for child X eight months later (March 2020), possibly because mother abstained from alcohol during her pregnancy with child X. Although mother was not seen to be under the influence of alcohol whilst caring for the new born child X, there were indications that mother had resumed alcohol consumption which were not treated with sufficient seriousness by all partner agencies. Was the impact of mother’s alcohol use on her parenting capacity fully considered and addressed? 6.7 Most parents who drink alcohol do so in moderation, which doesn’t present an increased risk of harm to their children (1). However, learning from serious case reviews about parents who misuse substances indicates that substance misuse by a parent or carer is widely recognised as one of the factors that puts children at risk of greater harm and that the most significant risk to children is that parents, when under the influence of drugs or alcohol, are unable to keep their children safe (2). 6.8 This learning from serious case reviews stresses the importance of timely and thorough assessments which contain a clear picture of the parent’s alcohol consumption which is properly analysed to understand the risks that this poses to their children. This should include an assessment of parenting capacity (3). 6.9 There is no indication that any discrete assessment of mother’s parenting was carried out. Had this taken place it might have been possible to more fully explore the impact of her alcohol use on her parenting capacity. What support was offered to mother to help her address her alcohol use? Was her alcohol use seen in the context of her risk of domestic violence and abuse from partners and her anxiety and depression? 6.10 Only limited GP information has been shared with this review. However, a previous GP with whom mother was registered referred her for support in relation to her alcohol use during the period 2013-2015. The outcome of any referral(s) at that time is unknown. Mother’s GP records also include a single entry relating to mental health services at the time she was arrested by the police in November 2017, but the CSPR has received no further information about this. In more recent years mother has denied problems with alcohol use when asked about it by her GP. It is not known if her GP discussed her alcohol consumption in connection with her low mood (mother was prescribed propranolol for anxiety (Paragraph 4.20)). However, there is no indication from her contact with other agencies that mother acknowledged that there was anything problematic about her alcohol use although there are strong indications that she was not always honest about the extent of her alcohol use. 6.11 There is no indication that the causes of mother alcohol use were explored with her. The child protection plan drawn up for child 1 and child 2 in July 2019 suggested that Strictly Confidential 19 mother may have been using alcohol to excess in order to manage her low mood and her current relationship with child 1 (Paragraph 4.16). Mother had experienced domestic abuse in her relationships with both father 1 and father 2. Domestic abuse is a leading cause of depression and anxiety among women (4) who may use alcohol to manage the resultant distressing thoughts and feelings. 6.12 Additionally, mother’s marked reluctance to engage with various offers of support may have dissuaded professionals from suggesting she seek help with this issue. The July 2019 child protection plan represented a prominent opportunity to offer her support in respect of her alcohol issues but the otherwise comprehensive plan made no mention of this. 6.13 The practitioner learning event arranged to inform this review posed the question of whether professionals from the key disciplines involved in this case had sufficient knowledge of approaches to take to identify and advise people at risk from their consumption of alcohol. Government guidance for professionals who are not specialists in preventing alcohol misuse, recommends that health and social care, criminal justice and community and voluntary sector professionals should routinely carry out alcohol risk identification and deliver brief advice as an integral part of practice (5). When concerns about co-sleeping, mother’s alcohol use and her co-operation with practitioners arose in the period following the birth of Child X, how effectively were these concerns escalated and addressed? 6.14 Mother and the new born child X were discharged home on Sunday 7th June 2020 and the child died three weeks later. 6.15 The first home visit – by midwife 2 on Monday 8th June 2020 – was reassuring (Paragraph 4.49). 6.16 The second home visit – by health visitor 1 on Thursday 18th June 2020 – raised concerns about co-sleeping (moses basket full of clutter), alcohol consumption (glass of half-drunk wine, an empty wine glass and a can of cider found upstairs), lack of supervision of child X (child 2 had moved child X from where mother had left him, into his bouncer chair whilst mother was upstairs), extensive clutter and lack of cleanliness and mother’s honesty (mother became very flustered when asked if she had been drinking and attributed the alcohol to ‘friends’ including friend 1) (Paragraph 4.51). Mother claimed that she would not use alcohol whilst breastfeeding. Following the death of child X, mother’s home was searched and the presence of formula milk suggested that child X was being fed partly or wholly by formula milk (Paragraph 4.70). 6.17 During this visit the health visitor conducted a safe sleep assessment which disclosed high risk factors associated with unsafe sleeping. The safe sleep assessment, which is informed by national and international evidence of the key characteristics and risk factors associated with sudden infant death syndrome (SIDS). The sleep assessment checklist is a tool to identify vulnerability to SIDS, to promote discussion to reinforce safe sleep messages and to identify any action planning the professional and/or the parent may need to take. The safe sleep pathway is integrated with midwifery service. Key touch points for safe sleeping assessments and messages from the health visitor is at antenatal contact, the new birth contact and the 6-8-week contact. The first safe sleep assessment by health visitor 1 was undertaken at the new birth visit. The safe sleep assessment is left with parents for their reference and is retained in the personal child health record (PCHR), also known as the red book. The PCHR is a national standard health and development record given to parents Strictly Confidential 20 when they have a baby, holds information about the child such as vaccines and growth measurements and is maintained by the parent/carer. The PCHR is not intended to be used as the child’s health record nor is it used to record personal, sensitive or safeguarding information. Historically the 0-19 Public Health Nursing Service retained the paper duplicate copy of the safe sleep assessment, but due to moving to more paperless systems and the need to mitigate potential data breaches through carrying paper information this ceased and a move towards taking a digital image of the assessment for upload to the child’s electronic record was advised as good practice. However, the need to reduce the risk of cross contamination of the Covid-19 virus led to staff not handling items which cannot easily be cleaned such as the PCHR. However, in this case, health visitor 1 recorded a comprehensive account of the safe sleep assessment within child X’s electronic health record, which includes a prompt to check that a safe sleep assessment has been completed. The high risk of unsafe sleeping was shared with children’s social care but what became apparent at the practitioner learning event is that it is relatively rare for a health visitor to arrive at an assessment of a high risk of unsafe sleeping. Given the small number of cases which attract a high risk assessment, it was felt that these cases could be given more weight by partner agencies. 6.18 Subsequent home visits – by midwife 1 on Friday 19th June 2020 (Paragraph 4.54), Sunday 21st June 2020 (Paragraph 4.58) and Tuesday 23rd June 2020 (Paragraph 4.60) – were more reassuring in that the moses basket appeared to being used for child X and there was no sign of alcohol. However, concerns arose over mother’s compliance with Covid-19 restrictions. 6.19 However, mother’s management, or possibly manipulation, of home visits could have given rise to concern. In a telephone conversation with social worker 2, mother largely rejected the health visitor’s concerns, implied that the health visitor had not been completely truthful and said she didn’t want her to visit again (Paragraph 4.54). Mother also rang midwife 1 in advance of the Tuesday 23rd June 2020 visit to request the time of the visit (Paragraph 4.61) although this may have been for a genuine reason as she said she had an appointment with her solicitor. 6.20 There were two further home visits prior to child X’s death. Social worker 2 made an unannounced visit on Tuesday 23rd June 2020 which could not be fully completed as a friend of mother was present and mother did not consent to any concerns being discussed in the friend’s presence (Paragraph 4.62). Although child 2 and child X were being supported as children in need which therefore necessitated parental consent, a more assertive approach could have been adopted on this occasion. 6.21 The final home visit was conducted by midwife 3 on Thursday 25th June 2020 and documented concerns about the ‘messy’ and ‘chaotic’ house and found evidence of alcohol consumption in mother’s bedroom (Paragraph 4.67). Unfortunately, children’s social care did not become aware of the concerns arising from this visit until after child X’s death. Although an email, setting out the concerns, was sent on the day of the visit, it went to the email address of social worker 2, who was not working that day. 6.22 When mother’s home was searched following the death of child X, a clean moses basket was found by the door of mother’s bedroom but was full of toys, leaving insufficient room for a baby to sleep in it. 6.23 It is concluded that concerns about co-sleeping and mother’s alcohol use were well assessed by the health visitor. These and other concerns about child X were thoroughly Strictly Confidential 21 articulated by midwifery and appropriately escalated to children’s social care and then further escalated to children’s social care management. As stated below midwifery and health visiting viewed the indications of unsafe sleeping combined with mother’s suspected alcohol use more seriously than did children’s social care. The response to concerns about mother’s co-operation with professionals could have been more consistently assertive. Is there a formal multi-agency escalation procedure? Was the procedure invoked when risk began to escalate following the birth of Child X? If invoked, what was the outcome? Is there a common understanding of the escalation procedure across all agencies? 6.24 The Named Midwife for Safeguarding escalated a number of concerns about child X via email to social worker 2 on Friday 19th June 2020 (Paragraph 4.56). These concerns included indications of mother’s on-going alcohol use, the possibility that mother was co-sleeping with child X and the risk of overlay. Having listed these and other concerns, the Named Midwife concluded by stating that it was felt that the threshold for risk of significant harm had now been met. At the practitioner learning event colleagues from children’s social care expressed the view that it would have been premature to move to ‘risk of significant harm’ after one suspected incident of alcohol consumption which mother disputed. 6.25 Social worker 2 replied to the Named Midwife’s email two working days later (Tuesday 23rd June 2020) after making an unannounced visit to mother earlier the same day (Paragraph 4.63). Her response reflected apparent improvements noted in three home visits carried out since the visit by health visitor 1 which prompted the escalation email from the Named Midwife. Two of these visits had been unannounced although, as stated, social worker 2’s unannounced visit on the day she replied to the Named Midwife had been limited in part by the presence of a friend who was visiting mother. 6.26 The Named Midwife was disappointed with the response from social worker 2 and further escalated the matter to a children’s social care Service Manager on the same date (Paragraph 4.64). The children’s social care chronology does not include this second escalation nor does it include the details of any response. At the practitioner learning event, colleagues from children’s social care said that the second escalation was received by the Service Manager who arranged for the matter to be discussed with social worker 2’s team manager on Friday 26th June 2020 but this discussion did not take place due to more pressing priorities and child X died before this meeting could be rearranged. 6.27 Whilst many of the key principles necessary to resolve a professional disagreement were evident in this case, Barnsley Safeguarding Children Partnership’s then Escalation Policy (for resolving professional disagreements) does not appear to have been formally invoked. This policy has since been revised and in order to identify relevant learning from the manner in which the professional disagreement was handled in this case, the revised policy will be referred to. The revised policy envisages the policy being formally invoked as this is necessary in order for the Barnsley Safeguarding Partnership Manager to be informed so that she or he is able to initiate and update the escalation tracker through which the discussions and outcomes are recorded. 6.28 The response to the first escalation by social worker 2 was rapid and was informed by an unannounced visit to mother. This was good practice. Stage One of the revised escalation policy allows five working days and only two days were taken. However, there is no indication that prior to formulating her response to the first escalation, social worker 2 consulted her Team Manager. Whilst the revised escalation policy envisages that most Strictly Confidential 22 disagreements can be resolved ‘professional to professional’, Stage One of the policy states that both practitioners should discuss the matter with their safeguarding lead/manager. Given that the escalation from the Named Midwife stated that in her opinion the threshold for risk of significant harm had now been met, it would have been appropriate for the social worker to have consulted her Team Manager. 6.29 The second escalation was initiated but not resolved. Had the revised escalation policy been invoked this would have been Stage Two of the process which again should be completed in five working days. The revised policy envisages a discussion at the next tier of management. In the event the Named Midwife escalated from social worker 2 to the Service Manager. It would have been helpful if the Service Manager had advised the Named Midwife of the action she planned to take in response to the escalation and provided timescales for a reply but there was no indication that this was done. Had the revised escalation policy been followed this could have applied a greater degree of structure into the process. 6.30 Whilst this process of escalation was underway, a further unannounced midwifery visit took place which reinforced concerns that mother may be consuming alcohol in the bedroom she shared with child X. The concerns arising from this visit were promptly shared with social worker 2 who by then was away from work until after the death of child X. There is no indication that this email was sent, or re-sent on receipt of an ‘out of office’ reply from social worker 2, to the duty social worker and it is not known if the email was shared with the Named Midwife for Safeguarding which would have given the latter the opportunity to include it in the ongoing escalation. 6.31 During this brief period of escalation – a period of six working days – the primary method of communication was email. Email is an entirely appropriate method of communication for escalating professional disagreements because the issues of concern are documented and there is a clear audit trail. However, email is often a less successful method of resolving professional disagreements than in-person, video conferencing or telephone communication. It could have been helpful if greater use of telephone communication had been made in addition to email in this case. 6.32 Looking back at the case, it seems clear that midwifery and health visiting viewed the indications of unsafe sleeping combined with mother’s suspected alcohol use more seriously than did children’s social care. This divergence of view was also apparent in the practitioner learning event. Midwifery also viewed father 2’s history as a high risk domestic violence perpetrator as a further risk factor. (Further risk factors which could have been highlighted included mother’s long term lack of co-operation with professionals and indications of untruthfulness and manipulation). For the health visitor and the Named Midwife for Safeguarding these factors unquestionably increased the risk of SIDS, whereas the social worker’s view was that this was the first time alcohol use had been suspected since she had been allocated the case and that this issue would be monitored (Paragraph 4.63). Given mother’s substantial history of alcohol use and at least one incident in which she drank to the point of incapacitation whilst caring for child 1 and child 2 – who was seven months old at that time (Paragraph 4.4), children’s social care may have under estimated the risks associated with mother’s use of alcohol. 6.33 In this case the escalation process could be perceived to be less like a process for resolving professional disagreements between equals and more like an appeals process in which agencies sought to appeal against the position adopted by children’s social care who, because of their statutory responsibilities, retained ultimate decision making authority. Strictly Confidential 23 How effective was partnership working between midwifery, the Hospital Safeguarding Unit, the 0-19 Public Health Nursing Service and Children’s Social Care? 6.34 Maternity notified children’s social care of mother’s pregnancy with child X, although there was a delay in over a month in making this notification despite the fact that mother had disclosed that her children were subject to child protection planning at the booking in appointment. Maternity notified health visiting of the correct EDD in good time. 6.35 Although invited to the pre-planning meeting held in accordance with Barnsley’s Pre-Birth protocol, the BHFT chronology states that is unclear if maternity attended. 6.36 It is unclear how well sighted midwifery and health visiting were on the decisions being taken - in parallel to the pre-birth assessment for child X - in respect of child protection planning for child 1 and child 2 . The ‘Health’ sector was represented at the Review Child Protection Conference in March 2020 but it is unclear whether information from the child protection planning process was shared with maternity and health visiting to better inform their antenatal and postnatal care of mother and child X. It is acknowledged that information about child protection planning for child 1 and child 2 was summarised in the pre-birth assessment but this was not shared with health visiting, as was customary at that time. This review has been advised that health visiting are now provided with a copy of the pre-birth assessment. 6.37 The CIN meeting on 27th April 2020 was conducted via email updates. No email update was received from health visiting although they had yet to make contact with mother. The 0-19 Public Health Nursing Service state that the case was being worked jointly by the health visitor and the school nurse and it was the latter service which provided an email update on 31st March 2020. There is no record of this update being considered by the CIN meeting on 27th April 2020. Mother did not receive the nationally mandated visit by a health visitor at 28 weeks or later in the pregnancy (6). It is concerning that this antenatal visit did not take place in a case where the unborn child had been subject to a pre-birth assessment, his siblings were subject to child protection and child in need planning and the highest level of health visiting support – Universal Partnership Plus – was subsequently provided. The 0-19 Public Health Nursing Service state that the antenatal visit was scheduled for 8th June 2020 which was in advance of the estimated date of delivery of 24th June 2020. In the event, child X was born on 6th June 2020. However, the antenatal visit should take place from 28 weeks pregnancy. The 0-19 Public Health Nursing Service point out that there are several difficulties which can impact upon the timeliness of antenatal visits including late presentation of pregnancy, pregnancies booked outside the Barnsley midwifery service, cancelled contacts by parent who may decline the antenatal visits and house moves – which was also a factor in this case. No antenatal health visitor visit took place in a previous CSPR (Child V) although on that occasion the cause was an inaccurate EDD from maternity. In child X’s case he was born prematurely but that should not have prevented the antenatal visit taking place. There is no indication that a joint visit to the family by midwifery and the health visitor between 31 and 32 weeks of the pregnancy, in line with Barnsley’s Pre-Birth Assessment Pathway took place. This was an omission noted in some of the cases recently included in a multi-agency audit conducted by Barnsley Safeguarding Children Partnership. The 0-19 Public Health Nursing Service state that there is no record of midwifery contacting them to arrange the joint visit, which they state is midwifery’s responsibility as lead agency during the pregnancy. Strictly Confidential 24 6.38 Between the date of child X’s birth and his death 22 days later, there was considerable multi-agency communication and information sharing. The process by which concerns were escalated has been considered earlier in this report. The CIN meeting which took place during this period was conducted via email updates and there appeared to be no update from maternity. The health visitor update was not provided by mother’s health visitor as the case was to be allocated to her shortly. Overall, information sharing was generally prompt and complete and nearly always generated a timely response from the recipient. Midwifery visits during this period were completed by three different midwives, which was not ideal, but did not appear to detract from multi-agency working. 6.39 There was no further CIN meeting scheduled until 29th June 2020, the day after child X died. No multi-agency discussion took place during the period between the birth and death of child X. As concerns escalated this would have been helpful. Social worker 2 and the health visitor intended to conduct a joint visit during the week prior to child X’s death but appear to have been unable to arrange this. 6.40 It is concluded that, whilst there was much effective partnership working in this case, improvements which could have been made include the sharing of the pre-birth assessment with health visiting, a joint visit by maternity and the health visitor, the antenatal health visitor visit and consideration of a multi-agency discussion when concerns about child X began to escalate. How comprehensive was the pre-birth assessment in respect of child X? 6.41 Barnsley Pre-Birth procedures state that young babies are particularly vulnerable to abuse, and early assessment, intervention and support work carried out during the antenatal period can help minimise any potential risk of harm (7). The procedures identify a number of risk factors which could indicate that an unborn child may be likely to suffer significant harm, and therefore justify a pre-birth assessment, many of which were present in child X’s case, specifically: • Involvement in risk activities such as substance misuse, including drugs and alcohol (mother’s history of alcohol misuse); • Victims or perpetrators of domestic abuse (the risk of domestic abuse to mother from father 2. Although they were no longer believed to be in a relationship, there was a continuing risk of domestic abuse around child contact arrangements for child 2 and child X); • Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children (Mother was arrested for a crime of child neglect against child 1 and 2 for which she was not prosecuted); • Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care (child 1 was subject to child protection planning and child 2 had recently been stepped down from child protection planning to child in need support); • Recent family break up and social isolation/lack of social support (mother was a single mother who lacked family support and was said to be reliant on friends and neighbours. Her house move and Covid-19 restrictions may have further increased her isolation) (8). The procedures point out that if there are a number of risk factors present – which there were in the unborn child X’s case – then the cumulative impact may well mean an increased risk of significant harm to the child (9). Strictly Confidential 25 6.42 Children’s social care arranged a pre-planning meeting on 11th March 2020 which maternity do not appear to have attended (Paragraph 4.31), contrary to the Pre-Birth procedures which emphasises that all agencies should be involved in the development of a safeguarding assessment (10). 6.43 The pre-birth assessment was completed on 31st March 2020 (Paragraph 4.36) well before the estimated delivery date on 24th June 2020. The assessment was generally sound although father 2’s concern about what he described as mother’s excessive alcohol consumption could have been further explored in the light of her history of alcohol use. Additionally, there was an assumption that because mother was able to meet the basic needs of child 2 (then aged 3 years), ‘there was no evidence that this would not be the case for the unborn child’. It is concluded that this was a questionable assumption for a number of reasons: • Until recently both child 1 and child 2 had been subject to child protection planning. Although it was appropriate to take comfort from the improvements in mother’s parenting of child 2, minimal progress had been made in child protection planning for child 1, largely as a result of mother’s intransigence in rejecting professional’s views of the risks to which child 1 was exposed, a failure to accept personal responsibility as a parent and her unwillingness to work with professionals to reduce the risks to which child 1 was exposed. • Mother’s perception of child 1’s presentation to be merely that of a ‘typical boy’ demonstrated a deficit in her appreciation of risk. • Mother’s insight into domestic abuse appeared limited and she had declined the support of IDAS on at least two occasions. Although she was no longer in a relationship with father 2, this could quickly change as had been the case when she became pregnant with father 2 and he would remain in close contact with her as he had regular contact with child 2. • The concerns about her use of alcohol appear to have receded but greater weight could have been given to the fact that she had drunk alcohol to the point of incapacitation when child 2 was a baby. • The arrival of a third child would bring pressures which could put at risk the progress achieved by mother in the parenting of child 2 and increase the risk of alcohol consumption which children’s social care had previously assesses mother as using to address low mood. How effective was the Child in Need Plan for child X and child 2 and the Child Protection Plan for child 1? 6.44 The child protection plan for child 1 and child 2 drawn up in July 2019 consisted of 17 actions which addressed a range of issues including the role of father 1 and father 2, although there is no reference to encouraging support from wider family other than the need to arrange a ‘family meeting’ to look at how to protect the children. In the event, attempts were made to engage the maternal grandparents in the plan which had only limited success. Mother’s relationship with the children was to be assessed including her motivation to change. As previously stated there was no reference to encouraging mother to Strictly Confidential 26 seek help in respect of what the plan described as ‘strong evidence’ of mother’s use of alcohol ‘to excess’. 6.45 When the review child protection conference report was completed in March 2020 it was clear that whilst considerable progress had been made in respect of child 2 and that father 2 had played his part in providing support for the child when mother was working, little progress had been made in respect of child 1 whose presentation had deteriorated and the risks he was exposed to had not abated. Efforts to engage family members in formulating a safety plan for child 1 when not in school remained an outstanding action. Was there sufficient enquiry into the role of males in the household, particularly the father of Child X and child 2, who was considered to be a high risk perpetrator of domestic violence and abuse and another male who appeared to be involved in the care of the children in the period following the birth of Child X? 6.46 The Barnsley Pre-Birth procedures stress the importance of all agencies involved in pre and post-birth assessment and support, fully considering the significant role of fathers and wider family members in the care of the baby even if the parents are not living together and, where possible, involve them in the assessment (11). This should include the father's attitude towards the pregnancy, the mother and new born child and his thoughts, feelings and expectations about becoming a parent. 6.47 Father 2’s attitude to mother’s pregnancy appeared quite hostile, initially arguing for a termination and questioning the wisdom of adding a third child to a family in which the two existing children were known to children’s social care. He was consulted as part of the pre-birth assessment and as stated earlier, expressed concern about the risk of mother resuming her excessive use of alcohol once the baby was born. Mother said that father 2 would be having contact with the new born child X although she perceived a benefit of her house move just before the birth of child X as preventing father 1 and father 2 ‘just turning up’ at the house as they had previously (Paragraph 4.47). 6.48 As previously stated, maternity were particularly worried about the presence of father 2 in the lives of child 2 and child X and were concerned that mother did not appear to have availed herself of the opportunity to find out about his violent history through the Domestic Violence Disclosure Scheme (DVDS) (Paragraph 4.56). In response to these concerns, social worker 2 pointed out that mother was currently being supported in the household by friend 1 as opposed to father 2. The police have confirmed that they have no record of an application under the DVDS from mother but point out that agencies should not advise domestic abuse victims to make application, but should do so on their behalf. 6.49 This brings us on to friend 1 about whom there was insufficient enquiry, particularly as one child in the household was subject to child protection planning. The Barnsley Pre-Birth procedures refers to the significant role that the father and wider family members can play in caring for the new born baby but doesn’t mention the role of friends. This may have been a factor in the lack of curiosity about the role of friend 1. 6.50 A police check on friend 1 was to have been actioned when child 1 was to stay with him so that he could continue to attend his primary school after mother moved home to Grimethorpe (Paragraph 4.46). However, the police check did not take place because child 1 stayed with his maternal grandparents instead. Strictly Confidential 27 6.51 Friend 1 appeared to have a pivotal role in the concerns about mother’s alcohol consumption following the birth of child X. Mother attributed the two wine glasses and the can of cider found by the health visitor on 17th June 2020 (Paragraph 4.51) to ‘friends’, including friend 1. There appears to have been no attempt to verify mother’s account by speaking to friend 1. Social worker 2 was to check mother’s file for information about friend 1, who had supported her following the birth of child 2, but this did not appear to have been actioned prior to the death of child X. This review has received no further information about friend 1’s history. 6.52 It is concluded that agencies had a satisfactory knowledge of the role of father 2 in the life of child 2 but were unsighted on whether mother had sufficient knowledge of father 2’s history as a high risk perpetrator of domestic violence. The role of friend 1 was insufficiently explored which is an important omission in this case. Did restrictions imposed as a result of Covid-19 impact in any way on measures necessary to safeguard Child X? 6.53 The restrictions imposed as a result of Covid-19 have had a profound effect on the delivery of in-person services. Child X was born during the first UK ‘lockdown’ which was not substantially eased until 4th July 2020, which was after the child’s death. However, to their credit, professionals from a range of disciplines managed to make home visits and gain access to the family home during this period, although there were some doorstep visits. The home visit by health visitor 1 on 18th June 2020 which highlighted a number of concerns about unsafe sleeping demonstrates the importance of in-person visits and the importance of making appropriate judgements about which families require in-person visits based on vulnerability and risk. 6.54 Multi-agency meetings were adversely affected. In this early stage of the pandemic - prior to the extensive use of video conferencing technology - meetings were held via email updates which obviously limited the opportunity for the exploration of views through discussion. 6.55 Mother appeared to regularly flout Covid-19 restrictions (Paragraphs 4.58, 4.60, 4.62 and 4.67). She was given advice about this by professionals and her lax approach to Covid-19 risks was raised in both of the maternity escalations of concerns to children’s social care (Paragraphs 4.56 and 4.64). Her approach to the risks to herself and her children from Covid-19 could have been linked to mother’s attitude to other risks, such as the risks to child 1, and her willingness to accept professional advice. Is the learning from this LSCPR consistent with the learning from the National Panel Review of Sudden Unexpected Death in Infancy? 6.56 This case has many of the features of the cases considered by the National Child Safeguarding Practice Review Panel’s review ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (12), hereinafter referred to as ‘the SUDI review’. These cases represented one of the largest groups of cases notified to the National Panel and involve parents co-sleeping in unsafe sleep environments with infants, often when the parent had consumed alcohol or drugs. Additionally, there were wider safeguarding concerns – often involving cumulative neglect, domestic violence, parental mental health concerns and substance misuse. The National Panel concluded that whilst there was no evidence to suggest that advice on Strictly Confidential 28 reducing the risk of SUDI had not been routinely given, this advice was not clearly received or acted upon by some of those families most at risk. 6.57 Whilst the case of child X has many of the features of those considered by the SUDI review, the key difference is that mother is a registered nurse. Although her area of specialism is nursing older people, she would have been familiar with the general principle of evidence based advice to prevent adverse health outcomes and would have been accustomed to interacting with health professionals. There is a single reference to mother having been ‘diagnosed with a learning disability whilst studying to be a nurse at University’ in 2015 in the pre-birth assessment. 6.58 However, despite her professional background and training, mother appeared resistant to professional intervention in her life and did not adopt a collaborative approach to working with agencies. When concerns arose about co-sleeping accompanied by suspicions that mother was using alcohol, mother responded defensively with a focus on managing visits to her home by professionals in order to present her parenting of child X in the best possible light, rather than addressing concerns raised by professionals and complying with safe sleeping advice. Additionally her professional background gave mother a knowledge of how agencies worked which may have helped her to manipulate professionals. 6.59 The SUDI review arrived at the following three conclusions: • Professionals needed to obtain a better understanding of parental perspectives in order to develop a supportive yet challenging relationship which facilitates more effective safer sleep conversations. • Work to reduce SUDI needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals. • The use of behavioural insights and models of behaviour change to support interventions to promote safe sleeping need to be explored. 6.60 Applying these conclusions to the case of child X, mother’s reluctance to engage with professionals restricted the understanding of her perspective. The review has received no indication that a parenting assessment was completed. With hindsight, this could have been valuable had she been willing to fully engage. This case also indicates that there is further work to be done to embed work to reduce SUDI in multi-agency working. As stated there did not appear to be a shared appreciation of the increased risk of SUDI in this case across midwifery, health visiting and children’s social care. In particular the latter service did not appear to give sufficient weight to the ‘high’ risk of co-sleeping assessed by the health visitor. 6.61 One further point is that the analysis of cases by the SUDI review identified a category of risk they referred to as ‘situational risks and out-of-routine incidents’ which included factors such as temporary housing, change of partner, altered sleeping arrangements and alcohol or drug use on the night in question. Whilst there is strong evidence of alcohol use on the night in question, it is also worth considering the impact of the recent house move on sleeping arrangements. Moving house in the late stages of pregnancy as a single parent seems likely to have been quite challenging for mother, who appeared to struggle to properly unpack and organise her new household following the move with the moses basket intended for child X seen to be ‘full of clutter’ (Paragraph 4.51). Discussing how mother could have prioritised organising the house to meet the needs of the children and the support she might need to accomplish this, might have been a valuable conversation to have had. Strictly Confidential 29 The ‘voice’ of child 1 6.62 This was not an issue this review was initially asked to consider but, looking back at the case, there is learning for agencies from how concerns reported by child 1 were responded to. 6.63 He not infrequently reported incidents of domestic abuse to the police, sometimes independently and also when asked to do so by his mother (Paragraphs 4.2 and 4.13). He raised concerns about his mother’s alcohol consumption (Paragraphs 4.7 and 4.8) and found himself caring for his sister when his mother was unable to do so through alcohol consumption (Paragraph 4.4). Child 1 was not always believed by professionals (Paragraph 4.8) and mother often contradicted her son’s account, on one occasion saying that he ‘always tells lies’ (Paragraph 4.13). 6.64 It is unclear to what extent professionals fully explored child 1’s lived experience. He was noted to be upset by incidents of domestic abuse (Paragraph 4.12, 4.22). He began to take knives and a screwdriver to bed with him (Paragraph 4.33) which may have been connected to his fear of domestic violence. He also began to carry weapons with him in the community. He disclosed physical abuse by his mother which on one occasion was treated as ‘over-chastisement’ (Paragraph 4.15), he experienced long term parental neglect, specifically being left to fend for himself in the community when his mother was working during the evenings, arriving for school very early and without a coat during the winter months. There were concerns about mother’s attachment to him and she asked for him to be removed from her care on more than one occasion (Paragraph 4.16). She appears to have deliberately made herself unavailable for calls from school about him (Paragraph 4.30). 6.65 Opportunities to explore child 1’s concerns were sometimes overlooked (Paragraph 4.17, 4.22), partner agencies did not always take action necessary to safeguard him (Paragraph 4.17), he was said to have worries that he was unable to speak about (Paragraph 4.27) and mother was unwilling to consent to a referral to CAMHS (Paragraph 4.34) in which it may have been possible for those worries to be explored. 6.66 His presentation at school had caused concern for a number of years and continued to deteriorate. Whilst it is acknowledged that much positive work was completed with child 1 within his school environment by the schools he attended, Early Help and children’s social care, attendees at the practitioner learning event felt that opportunistic encounters with child 1 were handled much less effectively than planned work with the child. 6.67 Looking back, child 1 comes across as a resourceful boy who demonstrated considerable maturity in seeking assistance from services when he and his sister were at risk from his mother’s alcohol use and from her partners’ domestic violence and abuse. Looking back, he was probably a more reliable witness to events than his mother, but was often not regarded as such. Good practice 6.68 Mother had not been attending ante-natal appointments which led midwifery to refer her to Grimethorpe Family Centre for ante-natal care, which she began attending from in January 2020 (Paragraph 4.21) Strictly Confidential 30 6.69 On 31st January 2020 midwifery responded to the police notification of the 4th January 2020 incident by issuing an instruction that direct questions about domestic abuse should be asked when mother attended appointments, which was actioned (Paragraph 4.22). 6.70 When mother attended hospital after experiencing bleeding on 16th March 2020, direct questions were asked about domestic violence. Although mother disclosed no incidents and said that she did not feel unsafe, an opportunistic DASH risk assessment was completed which identified a ‘medium’ risk which was increased to ‘high’ following a conversation with the Named Midwife for Safeguarding. This led to a MARAC referral (Paragraph 4.24). 6.71 Health visitor 1 clearly identified child X to be at high risk of SUDI and promptly escalated her concerns to children’s social care and shared them with midwifery. She also informed her manager and undertook case supervision 6.72 The detailed articulation of concerns about child X by midwifery and the escalation of those concerns to children’s social care was good practice as was the speed which social worker 2 responded to the escalation. 7.0 Findings and Recommendations 7.1 This is a tragic case in which child X died at the age of three weeks after being overlayed by mother who fell asleep whilst apparently breastfeeding the baby. There is evidence that mother had consumed alcohol before falling asleep. The risks to child X arising from concerns that mother may be co-sleeping with him and using alcohol had been recognised by partner agencies. However, there was a difference of professional view over the level of risk to which child x was exposed. Attempts were being made to informally escalate and resolve this professional disagreement at the time of child X’s death. Mother’s alcohol use 7.2 There were longstanding concerns about mother’s relationship with alcohol including being under the influence of alcohol whilst caring for her children and on at least one occasion drinking to the point of incapacitation whilst caring for a very young child. These concerns were very visible to professionals at the time that child 1 and child 2 were made subject to child protection planning in July 2019 but received much less attention at the time of the pre-birth assessment for child X eight months later (March 2020), possibly because mother abstained from alcohol during her pregnancy with child X. 7.3 There is little evidence that mother was encouraged to seek support in respect of her alcohol use. Although professionals asked her about her alcohol use and challenged her about her use of alcohol when caring for her children, it could have been helpful for the professionals from a range of disciplines she came into contact with to have greater knowledge of approaches to take to identify problematic alcohol use and give advice to people who are placing themselves and/or others at risk as a result of their alcohol use. 7.4 It is therefore recommended that the Safeguarding Children Partnership promotes the empowering of health, social care, criminal justice, community and voluntary sector professionals with knowledge of alcohol risk identification and the ability to deliver brief advice as an integral part of their practice. Recommendation 1 Strictly Confidential 31 That Barnsley Safeguarding Children Partnership promotes the empowering of appropriate staff within health, social care, criminal justice, community and voluntary sector professionals with knowledge of alcohol risk identification and the ability to deliver brief advice to those whose alcohol use is problematic as an integral part of their practice. Safe Sleep Risk Assessments 7.5 The health visitor carried out a safe sleep assessment which disclosed a high risk of unsafe sleeping. Although the high risk of unsafe sleeping was appropriately shared with children’s social care, the relative rarity of an assessment of high risk of unsafe sleeping indicates that this small number of cases could be given more weight by children’s social care. 7.6 It is therefore recommended that the Safeguarding Children Partnership seeks assurance that where the risk of unsafe sleeping is assessed as high this is given appropriate weight in decision making about the child concerned. Recommendation 2 That Barnsley Safeguarding Children Partnership seeks assurance from children’s social care that where the risk of unsafe sleeping is assessed as high by the 0-19 Public Health Nursing Service, this is given appropriate weight in decision making about the child concerned. 7.7 The 0-19 Public Health Nursing Service intends to obtain assurance that safe sleep assessments are being undertaken by health visitors and action plans initiated where risks are identified and that this is recorded in the child’s electronic health record. To this end, the 0-19 Public Health Nursing Service will be internally auditing SystmOne electronic health records. Escalation Policy (for resolving professional disagreements) 7.8 Although a significant professional disagreement arose in this case, the principles of the then Barnsley Safeguarding Children Partnership Escalation Policy were followed to an extent. The initial attempt to resolve the disagreement was handled well at a practitioner to practitioner level, although there is no indication that line managers were consulted at this stage, as advised by the Partnership’s revised Escalation Policy. When the disagreement was not resolved at the first practitioner to practitioner stage, it was escalated to senior management and appeared to lose impetus at that stage, although child X died before matters could be concluded. The revised Escalation Policy includes a clearer process and a means for monitoring discussions and outcomes which could have prevented this loss of impetus. Additionally it was notable that the majority of communication in the escalation process was by email and at no stage did a telephone conversation or multi- agency discussion take place. 7.9 Whilst the revised Escalation Policy appears sound, it may need to be further promoted so that it is formally invoked when required. Additionally the Policy should extoll the benefits of discussion between people as an alternative to over-reliance on electronic communication. It is therefore recommended that the Safeguarding Children Partnership further promote the revised Escalation Policy and reminds professionals of the benefits of talking through disagreements. Recommendation 3 Strictly Confidential 32 That Barnsley Safeguarding Children Partnership further promotes the revised Escalation Policy (for resolving professional disagreements) and reminds professionals of the benefits of talking through disagreements in an effort to resolve them. 7.10 The significant home visit by midwife 3 on Thursday 25th June 2020 was overlooked by decision makers because it was emailed to social worker 2 who was away from work for the rest of the week. It is recommended that the Safeguarding Children Partnership seeks assurance from Barnsley Hospital NHS Foundation Trust that where urgent safeguarding concerns arise they are emailed to the duty social work inbox in addition to the social worker in the case and that the Trust has a system for oversight of urgent safeguarding concerns sent to children’s social care from individual midwives. Recommendation 4 That Barnsley Safeguarding Children Partnership seeks assurance from Barnsley Hospital NHS Foundation Trust that where urgent safeguarding concerns are identified by midwifery they are communicated to the duty social worker in addition to the social worker in the case and that the Trust has a system for oversight of urgent safeguarding concerns sent to children’s social care from individual midwives. Partnership working 7.11 There are a number of improvements which could have been made to partnership working between midwifery, the 0-19 Public Health Nursing Service and children’s social care in this case. It was not standard practice for children’s social care to share the pre-birth assessment with the 0-19 Public Health Nursing Service at that time, although the review has been advised that this is now done as a matter of course. Mother did not receive the nationally mandated antenatal health visitor visit. The premature delivery of child X reduced the window for this visit to take place but that should not have prevented the visit, particularly as this was a case in which the siblings of child X were subject to child protection and child in need planning. 7.12 It is therefore recommended that the Safeguarding Children Partnership seeks assurance that pre-birth assessments are now routinely shared with the 0-19 Public Health Nursing Service by children’s social care and that the 0-19 Public Health Nursing Service schedule antenatal visits in sufficient time to ensure they take place. Recommendation 5 That Barnsley Safeguarding Children Partnership seeks assurance in that pre-birth assessments are now routinely shared with the 0-19 Public Health Nursing Service by children’s social care. Recommendation 6 That Barnsley Safeguarding Children Partnership seeks assurance that the 0-19 Public Health Nursing Service schedule antenatal visits in sufficient time to ensure they take place. Pre-Birth Assessments Strictly Confidential 33 7.13 The pre-birth assessment in this case contained an assumption that because mother had (only recently) demonstrated that she was able to meet the basic needs of child 2, there was no evidence that this would not be the case for the unborn child X. Paragraph 6.38 sets out the grounds on which that assumption was open to challenge. 7.14 It is therefore recommended that the Safeguarding Children Partnership seeks assurance from children’s social care that pre-birth assessments do not contain overly optimistic assumptions. Recommendation 7 That Barnsley Safeguarding Children Partnership seeks assurance from children’s social care that pre-birth assessments do not contain overly optimistic assumptions. Pre-birth procedures: the role of friends 7.15 The Barnsley Pre-Birth Procedures stress the importance of fully considering the role of fathers and wider family members. The procedures make no reference to the role of friends. In this case friend 1 appears to have played a significant and not altogether positive role in supporting mother following the birth of child X, which appears to have been largely overlooked. It is therefore recommended that the Safeguarding Children Partnership amends the Pre-Birth Procedures to ensure that the role friends as well as fathers and wider family members is considered. Recommendation 8 That Barnsley Safeguarding Children Partnership amends the Pre-Birth Procedures to advise professionals to consider the role friends as well as fathers and wider family members. The extent to which the voice of child 1 was listened to. 7.16 Looking back at this case, child 1 comes across as a resourceful boy who demonstrated considerable maturity in seeking assistance from services when he and his sister were at risk from his mother’s alcohol use and from her partners’ domestic violence and abuse. Despite his young age, he was probably a more reliable witness to events than his mother on several occasions, but was often not regarded as such. 7.17 When the learning from this case is disseminated, it is recommended that the Safeguarding Children Partnership highlights the missed opportunities to listen to child 1’s voice and better understand his lived experience. Recommendation 9 That Barnsley Safeguarding Children Partnership highlights the missed opportunities to listen to child 1’s voice and better understand his lived experience. The National Panel’s SUDI Review 7.18 The SUDI review arrived at the following three conclusions: • Professionals need to obtain a better understanding of parental perspectives in order to develop a supportive yet challenging relationship which facilitates more effective safer sleep conversations. Strictly Confidential 34 • Work to reduce SUDI needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals. • The use of behavioural insights and models of behaviour change to support interventions to promote safe sleeping need to be explored. 7.19 The case of child X indicates that there is further work to be done to embed work to reduce SUDI within multi-agency working. As stated earlier, there did not appear to be a shared appreciation of the increased risk of SUDI in this case across midwifery, health visiting and children’s social care. In particular the latter service did not appear to give sufficient weight to the ‘high’ risk of unsafe sleeping assessed by the health visitor. 7.20 One further point is that the analysis of cases by the SUDI review identified a category of risk the report referred to as ‘situational risks and out-of-routine incidents’ which included factors such as temporary housing and altered sleeping arrangements. The impact of mother’s recent house move on sleeping arrangements could have been given greater consideration in assessing risk and offering support to mother in this case. 7.21 It is therefore recommended that the Safeguarding Children Partnership highlights ‘situational risks and out-of-routine incidents’ in assessing the risk of SIDS and considering the support needs of new born children and their parents. The CSPR has been advised that a steering group has been established and that training has been provided to social workers in respect of the findings of the national SUDI review and safe sleeping generally. Recommendation 10 That Barnsley Safeguarding Children Partnership highlights ‘situational risks and out-of-routine incidents’ in assessing the risk of SIDS and considering the support needs of new born children and their parents. Domestic Violence Disclosure Scheme 7.22 Partner agencies expressed concern that mother did not appear to have availed herself of the opportunity to find out about father 2’s history as a high risk domestic violence perpetrator through the Domestic Violence Disclosure Scheme (DVDS). The police have pointed out that agencies should not advise domestic abuse victims to make application to the DVDS scheme, but should do so on their behalf. 7.23 The Safeguarding Children Partnership may wish to draw this learning to the attention of the Safer Barnsley Partnership so that they can remind professionals accordingly. Recommendation 11 That Barnsley Safeguarding Children Partnership informs the Safer Barnsley Partnership of the learning from this case that professional awareness of the need to make application to the DVDS scheme on behalf of victims of domestic abuse may need to be enhanced. Strictly Confidential 35 References: (1) Retrieved from https://learning.nspcc.org.uk/children-and-families-at-risk/parental-substance-misuse (2) Retrieved from https://learning.nspcc.org.uk/media/1348/learning-from-case-reviews_parents-who-misuse-substances.pdf (3) ibid (4) Retrieved from https://avaproject.org.uk/wp-content/uploads/2016/09/Alcohol-Concern-AVA-guidance-on-DA-and-change-resistant-drinkers.pdf (5) Retrieved from https://www.gov.uk/government/publications/alcohol-applying-all-our-health/alcohol-applying-all-our-health (6) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/464880/Universal_health_visitor_reviews_toolkit.pdf (7) Retrieved from https://www.proceduresonline.com/barnsley/scb/p_pre_birth.html (8) ibid (9) ibid (10) ibid (11) ibid (12) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf Appendix A Process by which the CSPR was conducted It was decided to adopt a broadly systems approach to conducting this CSPR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports and chronologies which described and analysed relevant contacts with child X and his family were completed by the following agencies: • Barnsley Children’s Services • Barnsley Early Start and Families Service Strictly Confidential 36 • Barnsley Hospital NHS Foundation Trust • Barnsley Public Health Nursing Service • GP Practice • South Yorkshire Police The independent reviewer analysed the chronologies and identified issues to explore with practitioners and managers at learning events facilitated by the lead reviewer. At the time of writing it had not been possible to offer child X’s family the opportunity to contribute to the review as a result of the ongoing criminal investigation into the circumstances of child X’s death. The independent reviewer then developed a draft report to reflect the agency reports, chronologies and the contributions of practitioners and managers who had attended the learning event. The report was further developed into a final version and presented to Barnsley Safeguarding Children Partnership. |
NC52338 | Death of a 15-year-old girl in September 2018 by suicide. Pippa was subject to a care order and lived in a care home at the time of her death. Learning includes: the importance of considering how childhood experiences can impact the behaviour and vulnerabilities of troubled adolescents; child sexual abuse in the family will often come to the attention of agencies because of a secondary presenting factor, which then becomes the focus of intervention; practitioners need to proactively assess and engage with all significant men in a child's life; where child sexual exploitation is suspected, risk assessments need to consider risks which emerge from vulnerabilities arising from past abuse, loss and trauma; professionals need to maintain a questioning and curious response to what they are told or what they see; a lack of knowledge among professionals about the evidence base related to risk indicators for adolescent suicide could leave them ill-equipped to discuss or recognise signs and respond accordingly. Recommendations include: support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents; ensure that agencies have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents; ensure that practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source; provide learning and development opportunities about adverse childhood experiences, trauma and familial child sexual abuse; audit the effectiveness of meetings to ensure that they lead to improved and timely outcomes for children and young people.
| Serious Case Review No: 2022/C9342 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. Pippa SCR/LR/03.02.2022/updated Final Report 1 Serious Case Review ‘Pippa’ October 2019 Updated February 2022 Amended May 2022 Pippa SCR/LR/03.02.2022/updated Final Report 2 Acknowledgement Language is a powerful tool for communication but we now know that sometimes the way words and labels are used by social work professionals creates stigma and barriers for the children and young people with whom we work. Language That Cares is a collaborative effort led by TACT, an adoption and fostering agency that aims to change the language used by professionals when referring to the care system and children’s experiences. Building on these collaborative efforts, the local Children’s Partnership has begun to change the language used to talk about all children needing help and support. Understanding that language is power, the Partnership is committed to doing all it can to ensure children are empowered by their experiences of needing support and/or care. This includes not only changing the language used by professionals but also thinking carefully about what is written down about the children including those who need help to live away from their own family for a time. This report about Pippa was written in 2019, well before professionals understood the full impact of how professional jargon can impact on the lives and well-being of children in their care and/or with whom they work. Since then the Children’s Partnership has made clear its commitment to ensuring that the language used by all professionals is more personal, less stigmatising and easier to understand by children and young people. They have been supported in their efforts by a group of care-experienced children and young adults who continue to work alongside professionals to ensure that it is they who dictate how their experiences are understood and described by social work professionals. This report should therefore be read within the context of the changing social work landscape both locally and nationally. Pippa SCR/LR/03.02.2022/updated Final Report 3 Contents Overview 1. Local Safeguarding Children Boards and Serious Case Reviews 2. Circumstances which lead to a Serious Case Review 3. The approach used 4. Scope and terms of reference 5. Family Involvement 6. Summary of key periods in Pippa’s life 7. Analysis and appraisal of practice. ASP 1: How well did professionals understand Pippa’s vulnerabilities? ASP 2: Quality of Timeliness of Assessments ASP 3: Professional Judgment and Decision-making ASP 4: Extent to which agencies worked effectively together ASP 5: The voice of Pippa 8. Summary of Learning Points 9. Recommendations for Consideration Appendix 1: List of agencies involved Key Subject: Pippa (not her real name) Mother of Pippa MP Half Sibling of Pippa HSP Mother’s Partner 1 P1 (birth father of Pippa) Mother’s Husband P2 (Birth father of HSP) Mother’s Partner 3 P3 Mother’s Partner 4 P4 (current partner) MGM Maternal Grandmother, separated from MGF Maternal Grandfather KTP Known to Pippa. [Male] through social media. Also known to Police and CSC Area 1 Location of Pippa’s home town Area 2 Location where MP and P4 lived in 2017 Area 3 Location of Care Home 1 Area 4 Location of Care Home 2 Police Force A covers Areas 1 and 4 Police Force B covers Areas 2 and 3 Pippa SCR/LR/03.02.2022/updated Final Report 4 Overview Pippa was described by all who knew her as a beautiful, bright and spirited young person. Whilst her behaviour could at times be challenging, aggressive and confrontational, Pippa could also be funny, and amusing. Known to be very insightful, Pippa surprised various professionals on different occasions with her astute observations on a range of topics including her analysis of how well staff were doing their jobs. She enjoyed singing and performing and was always happy to be the centre of attention. Family and professionals recall Pippa as being strong minded with an ability to resist doing anything she did not want to do but they also remembered times when Pippa was kind and thoughtful. The death of any child is always tragic. It is especially so, when a child takes action, deliberate or otherwise, which leads to their death. We do not know what Pippa was thinking or what happened in the residential home where she was living, after she was given a drink sometime around 22.00 hrs the night before she died. Conversations with care home staff, with her grandparents and text messages to friends on that evening offer no clue as to Pippa’s intentions or give any indication that she was in any way troubled. This review cannot identify a significant contravention or confirm any action by a professional that was a critical factor in what happened to Pippa. Her sad and tragic death is however, a reminder to all agencies of the complexities involved in understanding and assessing the risks facing young people. The circumstances of Pippa’s death could not have been predicted and there is much to evidence that most professionals working with Pippa did so with commitment, care, and tenacity. The learning from the SCR does however invite and require a better understanding by managers and practitioners in all agencies about the circumstances that can lead to a young person taking action which leads to their death and the interplay between childhood experiences, cumulative adversities, and risky behaviours in adolescence. Without this understanding professionals may not always recognise the emotional, psychological, sexual and physical risks young people can face. The review also offers a stark reminder to all agencies of the importance of robust assessments, effective plans and well managed reviews and meetings. 1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews1 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs)2 at the time this SCR was commissioned were to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance, which accompanies legislation and underpins the work of LSCBs, set out its expectation that LSCBs should maintain a local learning and improvement framework so good practice can be identified and shared. 1.2. In situations where abuse or neglect of the child is known or suspected and children die or are harmed, local authorities and their partners are required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce any future risk of harm to children. There is an expectation that these processes known then as Serious Case Reviews (SCRs) are transparent with the findings shared publicly. 2. Circumstances which led to this SCR 2.1. Pippa was subject to a Care Order3 when she died. She had been living in a care home for just under two months and was expecting to be moved when she was found in her bathroom having taken her own life. She was 15 years old. 2.2. A decision was taken by the independent chairperson of Local Children’s Safeguarding Board (LSCB) on the 27 September 2018 that Pippa’s death met the criteria for undertaking a Serious Case Review. (SCR) 3. The approach used 3.1. The board appointed an independent lead reviewer who had no prior connections to any of the agencies involved, to lead the review process and to produce the SCR report. A review team of senior professionals, representing the agencies that had been involved with the family was established; their role being to provide strategic information about their agencies’ involvement and to identify learning for their agency through the submission of an Agency Learning Report. This group met on four occasions and the agencies represented are listed in Appendix 1. 3.2. Other LSCB’s were informed of the SCR as Pippa was placed in residential care in other areas for a short period of her life. 3.3. Members of the review team identified frontline practitioners and first line managers who were known to, or had worked with Pippa and her family. These practitioners formed the ‘Practitioner’s Group’ and offered useful insights to support learning. This group met on 3 occasions. 3.4. At the start of the review, a time line of agency interventions was collated to illustrate multi-agency activity and who knew what and when. Agency leads were then asked to complete an Agency Learning Report, which described and analysed practice within their own agencies and which were presented to 1 This Serious Case Review (SCR) was commissioned in line with 2015 statutory guidance ‘Working Together to Safeguard Children’. With effect from September 2019, the arrangements for undertaking reviews where a child has died or been seriously injured have been amended. They are now referred to as [local] Child Safeguarding Practice Reviews. 2 Children Act 2004, s14 3 A Care Order is an order, which places a child under the care of the Local Authority. This is otherwise known as a child ‘ Pippa SCR/LR/03.02.2022/updated Final Report 6 the review team for comment and challenge. Further data was provided through scrutiny of various assessments and agency records. 4. Scope and terms of reference 4.1. The review team agreed that the period under review would be from early December 2015 when Pippa made an allegation of physical assault against P4, to September 2018 when Pippa died. 4.2. At the first meeting of the review team and the practitioners group, key issues began to emerge and as the review unfolded, these lines of enquiry allowed a wider exploration of events, which helped the review team, understand what happened, when and why. With the benefit of Agency Learning Reports five ‘Areas of Specific Practice’ (ASP) were identified which the review team agreed would provide a framework for the appraisal of practice. These were: ASP 1: How well professionals understood Pippa’s vulnerabilities. ASP 2: The quality and timeliness of assessments ASP 3: Professional judgments and decision-making ASP 4: The extent to which agencies worked effectively together ASP 5: Pippa’s lived experiences 5. Family Involvement 5.1. The lead reviewer, accompanied by the Business Manager from the LSCB initially met with MP and P4 in the presence of MP’s solicitor and a paralegal from the same firm; with MGM in her own home and with MGF and his partner in their own home. The purpose of the initial meeting was twofold: firstly to talk with the family about the SCR process and secondly to gather their views about professional involvement in Pippa’s life. A second meeting took place towards the end of the SCR process. MGM had arranged for a friend to be present for support. A separate meeting with MGF was attended by his partner, Pippa’s uncle and his long term partner. The meeting with MP and P4 was again in the presence of MP’s solicitor and the paralegal from the firm. MP and P4 5.2. MP told the independent reviewer of the struggles she experienced with Pippa from a very young age and indicated that she felt she did not get the support she needed from agencies when it mattered. MP described how even when Pippa, around the age of 11 or 12, became physically violent towards MP and BP, the authorities did not step in to help. MP suggested that only when she expressed a worry that she might retaliate and injure her daughter in self-defence, did social workers began to take an interest in what was happening in the family. MP stated that after she moved to Area 2 to live near P4, she never received invitations to meetings about Pippa, was not kept informed of significant events in her daughter’s life and was not consulted by the local authority about key decisions that were made. 5.3. MP attended court when Pippa was made subject to a Care Order in February 2017, and stated she wanted to maintain contact with her daughter but was not helped to do so by the local authority. MP said she was not informed that Pippa had made a disclosure about P3, mother’s partner at the time, or that the police had chosen not to take any further action. MP said she had always wondered if either of her children had been abused by P3 but had been told by social workers, after they had spoken with Pippa SCR/LR/03.02.2022/updated Final Report 7 Pippa and HSP that ‘nothing had happened’. MP said that Pippa ‘lied’ about lots of things and shared with the lead reviewer examples of when Pippa had told lies to ‘get her own way’. 5.4. MP acknowledged that her relationship with her daughter had always been difficult and she knew that Pippa, when she came into care, told social workers that she did not want contact with her. However, MP pointed out that when Pippa ran away she would often turn up at MP’s home in Area1 and later in Area2. MP said she had been advised by SW1 not to give Pippa money but to let them know of Pippa’s whereabouts which she said, she always did. 5.5. The lead reviewer was told that HSP had suffered because of Pippa’s behaviour and had not wanted any contact with his sister after she came into care. Both she and P4 stated their belief that MGF should have taken Pippa to live with them rather than let her go into the care system and this has caused friction in the family. MP said that her mother had done as much as she could to care for Pippa and that she had strongly objected to Pippa living there because of MGM’s poor health. MP believes she has Pippa’s phone, which was sent to her through the post by CH2 with a note saying they ‘thought’ it belonged to Pippa. According to MP, the police still have Pippa’s laptop and a password protected tablet which they removed from CH2. Maternal Grandmother (MGM) 5.6. MGM shared her view that MP had not always been able to meet the needs of her children as they were growing up and this was particularly the case with Pippa, who MGM said, always wanted just to live with her mother and brother. MGM told the lead reviewer that MP struggled to be the parent Pippa needed, even with the support of social workers and the relationship between MP and Pippa became even more strained when P4 became involved with the family. MGM said she and MGF attended most of the review meetings when Pippa was in care but she could not remember her daughter attending any meetings after she moved to Area2, even though, according to MGM she was always invited. Although MGM said she felt supported by social workers and had good contact with Pippa’s school, she felt more could have been done by professionals to help with accommodation especially given that Pippa had to sleep on her sofa bed for over a year. MGM said she now had very little contact with MP and her grandson. Maternal Grandfather (MGF) 5.7. MGF’s conversations with the lead reviewer reiterated most of what was said by MGM. MGF said with insight he wished he had done more to help Pippa, but said he had no issue with the professionals who were trying to help Pippa. He did feel more should have been done to help with accommodation but said professionals responded promptly when he reported seeing sexualised images on Pippa’s phone. MGF also said he had reported his concerns about KTP who approached him at Pippa’s funeral. MGF said he and the wider family wanted to have contact but for whatever reason his attempts at contact with MP and HSP were always blocked. 5.8. There are clearly rifts and tensions within this family, but the review team is grateful to all the family members for their willingness to talk openly about Pippa and her life and the struggles they had in trying to care for her and keep her safe. Where appropriate, other comments made by family members are referenced throughout this report. Pippa SCR/LR/03.02.2022/updated Final Report 8 6. Summary of key periods in Pippa’s life (from agency records and conversations) Background information taken from agency records 6.1. According to agency records, MP’s relationship with P1, Pippa’s birth father, ended before Pippa was born. MP married P2 and HSP was born when Pippa was three; MP told the lead reviewer that she suffered postnatal depression for a number of months after the birth of HSP. MP described Pippa as being a difficult child, who at 5 years old, was referred to CAMHS4 because of her behaviour problems at home and school. 6.2. Concerns about MP and P2’s lack of concern for Pippa’s emotional well-being as a young child led to a referral to Children’s Social Care (CSC) by CAMHS. According to agency records, although support was provided to the family by the local authority’s Family Support Team (FAST), the parents did not always engage with agreed work or keep appointments so work was not as effective as it might have been. Around this time, Pippa’s great grandfather died and she received grief counselling. MP and P2 began to express concerns to children’s services about Pippa’s mental health. 6.3. It would appear that MP’s relationship with P2 ended sometime in 2011 and MP began a relationship with P3 who moved in with the family. An allegation by Pippa that she had been physically abused by P3 led to a child protection investigation by Children’s Social Care (CSC). The allegation was not however substantiated. Police records refer to Pippa running away from home around this time. 6.4. During the time P3 was involved with MP, P3 was arrested and charged with downloading indecent images of children and Pippa spent a short time living with her MGM whilst a second child protection investigation took place. Pippa eventually returned home but a third child protection investigation occurred when CSC learnt that MP was still in contact with P3 and he had access to both of her children. At the ensuing child protection conference, concerns were expressed by professionals about MP’s negative attitude towards Pippa. Both children were assessed as being at risk of significant physical and emotional harm and were placed on a child protection plan under the category of emotional abuse. The plan remained in force for 8 months before CSC ended their involvement in May 2014. 6.5. Between June 2014 and December 2015, the family received offers of support from Early Help services in response to continued concerns about the behaviour of both children. MP told the lead reviewer that the services offered by the local authority did not help to change Pippa’s behaviour. Agency records refer to the fact that MP was spending more time out of the area with P4, whom she met sometime in 2015. Early help involvement continued but MP reported that Pippa’s behaviours were becoming increasingly violent toward herself and HSP. There are records of various allegations and counter allegations made by Pippa against MP and P4. MGM reported that Pippa would often come to stay when ‘tensions in the house’ were high and MP felt the family needed ‘time out’. Agency records describe MGM as frail but despite a disability, it seems she was happy to care for Pippa. Pippa's school attendance was described as good; her transition from primary to secondary school was relatively straightforward and she was regarded as a bright and able pupil despite her loud and challenging behaviours, which were often evident. School considered they detected traits of autism in Pippa’s behaviour and with MP’s 4 Child and Adolescent Mental Health Services Pippa SCR/LR/03.02.2022/updated Final Report 9 agreement; Pippa was referred to CAMHS in October 2015 to be assessed for Obsessive Compulsive Disorder (OCD) and Autism. The referral was supported by the family GP. Period 1: December 2015 – July 2016– (aged 12/13) 6.6. According to agency records and the maternal grandparents, Pippa lived at various times with her mother, HSP and P4, and sometimes with MGM during this period. MP told the review team that she continued to seek help from agencies to manage her daughter’s behaviour. With MP’s agreement, HSP and Pippa were made subject to a child in need plan. However, CSC concerns about Pippa’s welfare increased and when MGM’s health deteriorated and, according to agency records, MP and P4 refused to allow Pippa back into their home, Pippa became a Looked after Child in July 2016 and was placed with foster carers. (FC1). Period 2: August 16 – February 2017 (aged 13) 6.7. Within a few weeks, Pippa was moved, at her request, from the foster placement as she indicated to her social worker she felt ‘uncomfortable ‘in the presence of the male foster carer. Pippa was moved in August to a second placement, with a single foster parent (FC2) and, according to agency records, had regular overnight stays with MGM and, very occasionally, with MP, HSP, and P4. 6.8. In September 2016, Pippa was made subject of an Interim Care Order but she stayed with FC2 until she was made subject to a full Care Order in February 2017. At the hearing, the local authority was directed by the judge to return Pippa to the care of MGM and to ensure suitable accommodation was found. 6.9. MP had at some time during this period moved out of Area1 to live in Area2 some distance away. A Looked after Child (LAC) review for Pippa was held on 24.10.16. MP’s apologies are noted on record. Pippa is recorded as having told the Independent Reviewing Officer (IRO) that MP would not take her calls and hadn’t rang her ‘for ages’ so she wasn’t bothered about contact with her mum. Period 3: March 2017 – July 2017 (aged 13/14) 6.10. Pippa began to go missing during this period and MGM told the school nurse and SW1 that she was struggling to cope with Pippa’s behaviour, describing her granddaughter’s refusal to say where she was going and with whom she was spending her time. MGM also described arguments about money and cigarettes going missing. MGF found explicit sexual images on Pippa’s phone and there was evidence that Pippa was planning to visit an unknown male she had met online. Police secured Pippa’s phone and laptop. It later transpired that Pippa had access to another mobile phone. Concerns began to emerge that Pippa could be a victim of online grooming. MP, HSP, and P4 had at some point moved back to Area1, although according to records P4’s living arrangements seemed to alternate between Area1 and Area2. A LAC review for Pippa was held on 11.4.2017. Pippa continued to say she did not want contact with MP. SW1 spoke with HSP who confirmed he did not wish to see Pippa. MP did not attend the meeting but agency records confirm that apologies were sent via SW1. MGM and MGF attended. Period 4: August 2017 – December 2017 (aged 14) 6.11. Information came to light that Pippa had ‘a new boyfriend’ (KTP) who was known to Children’s Services. This was a young male who was thought to befriend ‘vulnerable’ females. SW1 referred Pippa to a multi-disciplinary specialist project (MDSP) in Area1 because of concerns about possible child sexual exploitation (CSE). MP told the lead reviewer that she was unaware of this referral or that there were concerns that Pippa could be at risk of CSE. Pippa was referred also to a specialised CSE project run by a Pippa SCR/LR/03.02.2022/updated Final Report 10 large children’s charity. MGM continued to advise professionals that she could not cope with Pippa’s behaviour and plans were made to consider other placements. Towards the latter part of this period, MDSP records offer a view that that CSE risks were reducing. Pippa told her SW1 that she wanted to be in foster care. 6.12. A LAC review for Pippa was held on 1.10.2017. According to records, MP was invited to this meeting but did not attend. However, it appears she advised SW1 that she was willing to give support to her daughter through weekend visits but this would depend on bed space and P4, as contact visits would have to be supervised as per contact arrangements. An annual LAC assessment highlighted that Pippa’s behaviour was continuing to give cause for concern although MGM indicated she was willing to continue the placement ‘with support’. The assessment noted that MP had ‘limited contact’ with the local authority since the court proceedings. Period 5: January 2018 – June 2018 (aged 14/15) 6.13. Following a multi-agency discussion, Pippa was removed in January 2018 from the MDSP process as risks of CSE were thought to have reduced. However, from February 2018, Pippa’s missing periods and school exclusions for unacceptable behaviour began to increase, and MP, who had occasional contact with her daughter, told MGM that she believed Pippa was involved with drugs. During this period, Pippa presented on three occasions to A&E/Plastic Dressing Clinic for minor injuries which had occurred when she had gone missing and had apparently been drinking and taking substances. According to education records, Pippa was excluded from school for 3 days for writing inappropriate sexualised content in her English book. SW1 was informed. 6.14. A LAC review for Pippa was held on 4.4.18. MP did not attend although it appears that Pippa by this time was occasionally visiting MP in Area2. MP told MGF that she had seen Pippa’s laptop and believed she was in contact with a known ‘drug dealer. This was reported by MGF to SW1. 6.15. Following an argument and a physical assault on MGM in May 2018, Pippa was moved as an emergency, to a residential establishment (CH1) in Area3, about 20 miles away from Area1. Staff concerns began to emerge about her sexualised behaviours towards other residents. Pippa disclosed to a member of staff that she had been sexually abused by P3 when she was a young child; this information was reported to her social worker two days later along with information that Pippa had also told a member of staff that she had had unprotected sex with an unknown male and had, on 5 occasions, had sex with another resident in CH1. SW1, who had worked with Pippa since early 2017, left the authority around this time and SW2 was allocated to work with Pippa. 6.16. A strategy meeting was held 5 days later, attended by Police Force B. A decision was taken at the end of the meeting, that police and SW2 would make further enquiries about Pippa’s disclosure of historical abuse. CH1 gave the local authority 7days notice to find another placement for Pippa because of her ‘sexualised behaviour’ and the risks she posed to other residents. Period 6: July 2018 – September 2018 (aged 15) 6.17. Pippa was moved to a residential therapeutic home (CH2) for a 6-week assessment in Area 4 in mid-July. Pippa refused to engage with police regarding the allegation of sexual abuse by P3, and was told there would therefore be no further action. Pippa declined the offer of any support. Agency records suggest that Pippa enjoyed living in CH2; she continued to go to school, there were no missing episodes and no Pippa SCR/LR/03.02.2022/updated Final Report 11 significant concerns raised about her behaviour, which according to CH2 could still be challenging. Two LAC visits by a ‘new’ social worker were made in July and August. Records indicated that Pippa was ‘happy’ in the placement but stated she did not want to engage in any therapeutic work. 6.18. Pippa was excluded from school on the first day of the autumn term for threatening behaviour towards staff and pupils. She was also challenged about arriving at school with purple coloured hair. She returned to school the following day without having changed her hair colour and was sent home again following abusive and aggressive behaviours towards staff and refusing to join a meeting to discuss her behaviour and the reasons for it. Staff recall it was almost as if she was deliberately seeking to be excluded. 6.19. Pippa spoke to both grandparents on the evening before her death, talking about Christmas and arranging to see MGM, a couple of days later. School friends reported that Pippa sent ‘run of the mill’ text messages the same evening, although CH2 records indicate that her phone was locked in the safe. 6.20. Agency records suggest Pippa went up to her bedroom after watching TV with other residents and later came down stairs saying she wanted a drink. A casual member of staff on duty at the time, later told police that Pippa received a brusque and dismissive reply by another staff member at the time, although this is disputed by the member of staff concerned. CH2 records refer to a member of staff seeing Pippa later dancing in her room with her bedroom door propped open with a chair. 6.21. Pippa was found dead by staff the following day around 11.45 pm. 7. Analysis and appraisal of practice 7.1. The purpose of Serious Case Reviews is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems were in place, which influenced professional activity and decision-making at key points in their work with Pippa. 7.2. It is also important to be aware how much hindsight can distort judgment about the predictability of an adverse outcome. Once the death or a serious injury to a child is known it can become too easy to look back and conclude that certain assessments or actions by professionals were critical in leading to that outcome. The review team were mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and, importantly, what systemic factors in place then, might still be impacting upon practice in 2019. 7.3. The examination of single and multi-agency working with Pippa and her family has identified some single and multi-agency learning which, alongside some important reflections about working with adolescents may assist in improving services in the area in order to reduce, wherever possible, the very real risks to which vulnerable adolescents are exposed. 7.4. The analysis is structured around five areas of significant practice, which highlight key findings or learning points. Recommendations for LSCB are grouped under thematic issues. The ASPs are listed below and further details follow: Pippa SCR/LR/03.02.2022/updated Final Report 12 ASP 1: How well professionals understood Pippa’s vulnerabilities ASP 2: The quality and timeliness of Assessments ASP 3: Professional Judgment and decision-making ASP 4: The extent to which agencies worked effectively together ASP 5: Pippa’s lived experience 7.5. ASP 1: How well professionals understood Pippa’s vulnerabilities. Impact of Adverse Childhood Experiences 7.5.1. Various agency records suggest that growing up, Pippa was subject to number of adverse childhood experiences (ACES); parental mental ill health, family conflict, feelings of rejection by her mother, emotional abuse and very probably sexual abuse by P3. Research shows that the impact of these early experiences on children can lead to trauma which is linked to a long list of cognitive, behavioural and mental health disorders in children.5. There is little to suggest that these factors, which may have offered some insights into why Pippa behaved as she did, were considered in any significant depth either when she was a young child or when she grew older and risks around CSE began to emerge. 7.5.2. The possibility, that Pippa’s behaviours could be attributable to a diagnosis of Autism Spectrum Disorder6 (ASD) was a reoccurring theme evident in agency records from when she was a young child. Young people who have experienced adverse childhood experiences and early trauma can present with signs and symptoms similar to those present for ASD, such as difficulty in establishing and maintaining relationships, avoiding eye contact and being overly obsessive about certain rituals, and it may be that, at least initially, this distracted professionals from thinking more deeply about Pippa’s early life. However, in October 2016, CAMHS concluded that Pippa’s behaviours were linked not to ASD, but to an Attachment Disorder.7 Whilst the exact cause of attachment disorders is not known, inadequate or compromised parenting are widely thought to be directly linked to children with behavioural problems and attachment issues. 7.5.3. The topic of a child's vulnerability is a long-standing and well-recognised subject in work with children about whom there are concerns. It is, however, such a common concept that it is easy to underestimate its significance and allow presenting behaviours to be the focus of work. This appears to have been the case with Pippa. Most of the work described in assessments and plans both prior to and during the period under review, describe work which was focused on supporting MP ‘learn’ how to manage her daughter’s behaviour and helping Pippa ‘gain insight’ into her emotions so she could ‘develop strategies to control her behaviour’. This was undoubtedly important work but what appears to be missing was any intervention, which sought to directly address the impact of Pippa’s early life experiences, her feelings of rejection and belief that her mother did not want her. The impact on Pippa, learning during a family argument at the age of 12 that P2 was not her birth father must have come as a shock, yet there is little to evidence the impact of this was analysed in any detail 5 The impact and long-term effects of childhood trauma Heather Dye. Journal of Human Behaviour in the Social Environment Volume 28, 2018 6 Autism is short for autism spectrum disorder (ASD). It's a group of neurodevelopment (or brain pathway) disorders that cause behaviour and communication problems. 7 Attachment disorders’ are diagnoses, which are sometimes applied to children who have experienced significant patterns of insufficient care. Pippa SCR/LR/03.02.2022/updated Final Report 13 within the context of her displayed behavior. According to school records, it was soon after this that Pippa’s behaviour began to deteriorate even further. 7.5.4. There is a wealth of research, which suggests that children who have been traumatised have had experiences that have overwhelmed their sense of safety. For Pippa, her early childhood experiences, despite the care offered by her grandparents, are likely to have threatened her sense of security and feelings of control, yet there is no evidence to suggest any one to one work was undertaken with Pippa until July 2018, when she was moved to CH2. A deeper understanding of childhood trauma may have helped professionals determine that work with Pippa needed to include, as a priority, a focus on instilling feelings of belonging, control and security, especially at times of crisis when she had to be moved from one place to another. 7.5.5. Although conversations with CH2 staff indicate that Pippa ‘declined’ the offer of therapy, there is some evidence to suggest that Pippa may well have responded to sensitive outreach by a skilled practitioner had there been earlier opportunities in place for her to do so. Sadly, it was not until July 2018, that Pippa’s need for one to one therapeutic work was recognised. In discussions with some practitioners, it appears that the ‘involvement; of CAMHS in Pippa’s life led to an assumption that this ‘type’ of work was being or had been undertaken by that agency. 7.5.6. Research around ACES and trauma is not new but it has come to the fore in recent years. Whilst some agencies have delivered training around ACES and trauma to staff, there has to date, been no multi-agency training on ACES commissioned by the LSCB. Learning Point 1: It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours. Child Sexual Abuse and Child Sexual Exploitation 7.5.7. In 2014, the Office of the Children’s Commissioner published the results of an inquiry into child sexual exploitation. The inquiry found that.’… many young people told…of their early histories of being sexually abused within the family home and of their experiences never being acknowledged.’ 8 Research from the inquiry, highlights that children and young people are often identified as victims of sexual abuse following the provision of support for other presenting problems, such as challenging behaviour, substance or alcohol abuse or missing from health, care or education. Yet, many of the factors, which bring the child or young person to the attention of professionals, can also result from, or be exacerbated by, the impact of the sexual abuse. 7.5.8. The inquiry also concluded that while society now better recognises the existence of the sexual abuse of children by family members or people close to their family and child protection practice has improved over the last two decades, the outcomes for children do not appear to have improved. 8 The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation In Gangs and Groups 2014 Pippa SCR/LR/03.02.2022/updated Final Report 14 Nationally, the numbers of children made the subject of a Child Protection Plan for sexual abuse has fallen steadily over the last decade. It is suggested that this decline, which was still evident in 2018, is not commensurate with what is known about the overall prevalence of CSA9, and has resulted in, or has been the result of, declining levels of professional understanding and awareness in relation to the issue of CSA. 7.5.9. Prior to Pippa’s disclosure to a care worker in 2018, there are no references in case files, (other than those relating to the initial investigation) which suggest there was any ongoing consideration that Pippa may have been a victim of sexual abuse by P3 and that her behaviour was a response to what happened to her when P3 was living in the home. There are references to Pippa running away around this time and not wanting to undress for PE but despite concerns about her challenging outbursts, professionals did not appear to be overly curious as to whether sexual abuse could account for some of her behaviours. 7.5.10. Certainly, there were some concerns about Pippa’s behaviour at school and in the family evident before P3 joined the family and this may have deterred professionals from looking more closely into any link between P3 living in the family and Pippa’s behaviour. However, the fact that P3 lived with the family for almost two years before he was convicted of downloading indecent images of children, should have prompted professionals to consider that Pippa and HSP had been victims of sexual abuse by him. It is not known whether Pippa ever told MP about P3 at the time. Records from CH2 in July 2018 do refer to Pippa asking staff why her mother did not want her and why she did not believe what Pippa had told her. Pippa did not, it would appear, expand on these thoughts. 7.5.11. Agency records refer to Pippa withdrawing the various allegations she made at different times and some records seem to accept this as being ‘typical of Pippa’. It is vitally important that professionals do not take retractions that children make at face value but understand the pressure on children to take back what they have said in the face of overwhelming family pressures. In the chaotic aftermath of ‘telling’ children can be blamed for destroying the family, can face hostility from family members and may even feel professionals do not believe what they have disclosed. At times like these, children are known to want things ‘just back to normal’ and are more likely to retract what has been said. In these circumstances, the message to the child is often that the child’s ‘lie’ is more believable to adults than the claim of abuse. 7.5.12. In June 2018, Pippa did tell a member of staff at CH1 that she had been sexually abused by P3. At this point, there should have been an immediate strategy discussion but Pippa’s disclosure was not discussed until two weeks later at a strategy meeting convened to discuss concerns about her drug use and her claim to have had unprotected sex with an unknown male and with a resident of CH1. At that meeting, the local authority was given 7 days to move Pippa to another placement due to her being a safeguarding risk. It is, perhaps, not difficult to imagine what ‘message’ Pippa received following these proceedings. 9 How Safe are our Children. NSPCC 2018 Pippa SCR/LR/03.02.2022/updated Final Report 15 7.5.13. According to the chronology, officers from Police Force B, spoke with Pippa, two months later when she was living in CH2. From records, this visit seems to be in relation to her alleged sexual behaviors in CH1. Records suggest a conversation was held at the same time with Pippa about her allegation of abuse by P3 but Pippa told police officers just to ignore what she had said and it would appear they did exactly that and no further enquiries were undertaken. Police records are confusing - the police entry in the integrated chronology states that ‘officers updated the suspect’, and advised the matter ‘would be closed’. It is not exactly clear however, to whom this entry refers, it is assumed to be P3. Expected practice would have been for P3 to have been interviewed about Pippa’s allegation. 7.5.14. In seeking to understand why this did not happen, the review team was unable to establish with any confidence the reasons why Pippa’s allegations were not followed through as would be expected. Although the Police Force A would normally have investigated the alleged offence by P3, it was Police Force B who spoke with Pippa in line with the other enquiries they were making at the time. It seems that once Pippa said she had no wish to pursue the matter, no further action was taken. Whilst pursuing historic allegations without the cooperation of the alleged victim is difficult, the circumstances under which Pippa refused to engage with police were not as well considered as the might have been and her response to police enquiries were too readily accepted at face value. There was no challenge by officers from Police Force A to this decision nor from any other professional working with Pippa at the time. MP told the lead reviewer that she was unaware that Pippa had disclosed this information about P3. 7.5.15. It is well known that disclosing abuse is difficult under any circumstances but the response to Pippa’s disclosure by the police from Area2 fell short of expected standards. Pippa was given a clear message that what happened to her was not important. It is possible, she may also have concluded, given the circumstances of her move from CH1, that if she spoke about what happened she could be moved again. It is, perhaps, not surprising that Pippa decided not to co-operate with what the police described in their records as her ‘complaint’ against P3. 7.5.16. As with many types of abuse, there can be an overreliance on children to come to statutory services to disclose abuse happening to them, but the responsibility lies with professionals being attuned to, and curious about changes in behaviour of children, their emotional responses and other indicators that things are not going well in their lives. Professionals need to consider a number of hypotheses to explain a child’s behaviour and abuse, including sexual abuse, should always be considered as one possibility amongst others, even though it may be discounted then or later. The review team was told by practitioners that it would not be usual practice to consider the possibility of sexual abuse for all concerns that came to their attention and were hesitant about ‘thinking sexual abuse’ inappropriately in some situations. The fact that Pippa may have been a victim of CSA does not appear to have been explored in any depth even when concerns were raised about CSE several years later. 7.5.17. Discussing Child in Need statistics for Area1 with practitioners, the review team was informed that neglect of children is the biggest challenge for professionals in the area as opposed to child sexual abuse and although it is recognised when there is clear evidence of it occurring, it is less frequently identified as the main category under child protection plans. Pippa SCR/LR/03.02.2022/updated Final Report 16 Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention. It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the area to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a child’s increased vulnerability to this form of abuse. 7.5.18. Protecting children and young people from sexual exploitation is a challenging area of practice across all sectors including social care but also health, education, the police and third sector organisations. The indicators for child sexual exploitation can be mistaken for ‘normal risk-taking adolescent behaviours’ but CSE is a complex form of abuse and can be difficult for those working with children to identify and assess. It is important that professionals recognise how adverse childhood experiences can increase a child’s vulnerability to exploitation and take these factors into account when determining risk. The review team was of the view that Pippa’s vulnerabilities associated with child sexual abuse and child sexual exploitation were not as well understood as they could have been either by social workers or by the MDSP process which viewed the risk to Pippa only in terms of a one off episodic incident. Her childhood experiences including what may well have happened with P3, her low esteem are factors known to contribute to children being pushed towards situations where their vulnerabilities and ‘need to belong’ are exploited by others. 7.5.19. The review team was informed that arrangements in the MDSP process and the CSE risk assessment tool are now based around the Signs of Safety approach and this will better support practitioners to consider the cumulative impact of childhood experiences when identifying risk and vulnerabilities. ASP 2: Quality and timeliness of assessments 7.5.20. During the period under review, Pippa was subject to various assessments by key agencies. 7.5.21. The Single Assessments10 undertaken by CSC in May 2016 and September 2017 contain a good deal of information but they do fall short in a number of areas. Whilst there are detailed narratives, which demonstrate some understanding of the issues facing Pippa and HSP, the analysis which explores the impact of these issues on the development and well-being of both Pippa and HSP, was not as robust as it should have been. There is no exploration for example, of family relationships, past partners, the role of P4 or MP’s lack of awareness about Pippa’s emotional needs. There is a sense that at times the assessments are written only from MP’s perspective rather than with Pippa and HSP being the main focus. 10 The Single Assessment is a detailed assessment to determine whether a child is need, requires a protection plan, or requires immediate protection. These assessments are conducted in line with statutory guidance and are used to identify which services may be required to meet a child’s needs Pippa SCR/LR/03.02.2022/updated Final Report 17 7.5.22. Much of the information provided by MP appears to have been taken at face value without any evidence of, what is described, as ‘respectful uncertainty’, an approach that requires professionals to critically evaluate the information they are given. It is possible that there was, initially, an over-reliance on an expected diagnosis of ASD to account for Pippa’s behaviour and therefore the more complex issues around family relationships were not challenged but this inevitably left the possibility and sustainability of any future work with MP, and P4, far less likely to happen. 7.5.23. The review team queried to what extent the assessment template and a requirement to use the same template for each assessment rather than adding to a previous version made a ‘cut and paste’ approach more likely. Compared to the volume of information presented in both assessments, the analysis sections are very brief and do not address the ‘so what’ implications of the descriptive content. There was certainly a view that the document template does not help or encourage practitioners to ‘think analytically’ and perhaps more could be done to support them in this task. Certainly, when talking through the assessments with practitioners there was far more evidence of analytical thinking and critical reflection than appeared in the actual document itself. Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect so a multi-agency analysis can support and be seen to support professional judgments and decision-making. Engaging with significant males in a family 7.5.24. Both assessments completed over a 16-month period make little reference to P4, despite him clearly being a key figure in the family. It is possible that MP explained to social workers that P4 had his own accommodation in Area2 and did not always stay with the family, but, as a partner of MP with access to the children, his relationships, his views and his background should have been included in the assessments undertaken, especially, according to agency records, Pippa stated a dislike of the man and his involvement in family decisions which affected her. 7.5.25. Men play a very important role in children’s lives and have a great influence on the children they care for or with whom they are in regular contact. Prior to and throughout the period under review, there was a strong emphasis on supporting MP to develop her parenting skills and build a more nurturing relationship with her daughter, but there is no evidence to suggest that any of this work involved the male who was living with the family at that time. What became evident during the review process from records and conversions with professionals and other family members, was that P4 was a significant and very influential person in MP’s life. The relationship was relatively new in December 2015 and Pippa struggled to accept him as part of her family, which was another important reason for him to have been included in both assessments undertaken by CSC. 7.5.26. A repeated finding in case reviews and audit work nationally is how often fathers and male figures are absent in recordings, assessments and care plans. Recurrent shortcomings highlighted in serious case reviews have pointed towards the failure of many social workers and health professionals to engage with men whose involvement with mothers is clearly evident even though they may appear on the periphery of family life. The review team noted that because P4’s role within the family was not explored at all as part of the assessment, it actually compromised any support work with MP to help positively engage with her daughter. Pippa SCR/LR/03.02.2022/updated Final Report 18 7.5.27. Conversations with practitioners highlighted the wider and varying challenges in trying to identify and then engage with significant males in a child’s life. It is clear that some practitioners would welcome more support and guidance in this complex area of work. Learning Point 4: When working with children, practitioners need to proactively assess and engage with all significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both. Where concerns exist and there is evidence of conflict between a child/young person and significant none birth related males in a family, this should always be explored in assessments and be incorporated into ongoing work. Assessing capacity, motivation and willingness to change 7.5.28. Where there are significant concerns about a child’s safety or welfare, well-informed social work assessments concerning the ability of parents or family members to keep their children safe and meet their developmental needs are essential to making appropriate decisions about a child’s future. However, the assessments undertaken in respect of Pippa’s needs did not consider whether, given past concerns, MP was actually willing or had the capacity or motivation to change her lifestyle or her own behaviours to meet the emotional and developmental needs of Pippa. Whilst MGM and to some extent MGF had the motivation to care for Pippa realistically, their capacity to do so was limited and it was always highly unlikely they would be able to care for Pippa in the longer term. 7.5.29. Assessment models, which assess parent or family member’s ‘capacity to change’, are less concerned with the adult’s report of their intentions but are more concerned with the direct assessment of actual change. Such an approach considers only the attainment of goals as evidence of a parents’ capacity to change, and it is this that allows for a better prediction of future parental functioning. In reality, this process is no different to the effective monitoring of a good child protection or child in need plan, but the emphasis on this aspect of the assessment process is finding out whether a parent is willing and able, regardless of whether they are motivated, to change their behaviour for the benefit of their child. 7.5.30. Parenting capacity can be compromised for a variety of reasons and the ability of parents to sustain change in the long term depends on a number of factors. MP had her own struggles growing up, and had experienced abusive relationships and in this respect, she was herself, vulnerable and may well have struggled as a parent. Agency records comment on MP’s negativity towards Pippa even as a young child, including requests for her to be taken into care when Pippa was as young as 6 or 7 years old. 7.5.31. It would have been helpful for these issues to be explored in some depth as it remains unclear given the various services and interventions that had been put in place over the years whether MP had in fact, the capacity or motivation to change how she parented or cared for Pippa. There was evidence from agency records that suggested that whilst MP stressed that she wanted what was best for Pippa and HSP, she was not always able to prioritise the needs of her children over her relationships and work with early help services was rarely sustained. 7.5.32. Although both grandparents independently wanted to care for and look after Pippa, the practicalities and implications of them doing so were never realistically assessed. MGF lived with a partner who was concerned about Pippa making allegations, which could place her job in jeopardy. MGM was frail and had recently suffered a stroke, whilst Pippa was a lively and boisterous 13 year old whose behaviours had, for several years proved problematic to the adults around her. None of the Pippa SCR/LR/03.02.2022/updated Final Report 19 assessments seen by the review team addressed these issues in sufficient depth, had they done so it is possible that, despite residential care often being perceived as a placement of last resort, Pippa’s deep rooted need for stability and security may have been met much earlier through the care system. 7.5.33. Agency records clearly indicate that both MGF and MGM were seen as protective factors in Pippa’s life. It was also clear from records that MP was not willing or able to provide the care and security that Pippa needed. The direction by a judge to return Pippa to live with MGM went against the views of the local authority but they were compelled to act as directed. Even so, as Pippa grew older, it became apparent that much as MGM wanted to keep Pippa safe and living with her, it was becoming increasingly difficult for her to do so and this situation was not likely to change. The LAC reviews did not pick up that MGM’s age, and poor health significantly reduced the capacity of MGM to exert influence over Pippa and apply boundaries. These factors, including the fact that Pippa had no personal space of her own when at home, were effectively creating ‘push’ factors which actually increased Pippa’s vulnerabilities and susceptibility to influences outside the home. Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family members have the motivation and capability to make such changes in line with their child’s needs and timeframe. The CAMHS Assessment. 7.5.34. There are references in various records, to the fact that CAMHS was ‘working’ with Pippa, implicit in which is an assumption that Pippa was receiving ‘help’ from that agency. According to records made available to the review team, CAMHS was assessing Pippa for a mental health disorder rather than undertaking any therapeutic work with her. CSC records indicate that following a Section 47 investigation in May 2016, CAMHS were approached to provide information, which could support the CSC assessment, but it appears that no report could be forwarded, as the assessment was still ongoing. The CAMHS worker (CMS1) did however attend various multi-agency meetings, which took place throughout 2016. 7.5.35. Records do suggest that MP often contacted the crisis team at CAMHS during 2015/2016 to report Pippa’s behaviour. The assessment to determine if Pippa met the criteria for an ASD diagnosis took almost a year to complete; the review team was unable to determine exactly why it took so long, although they were informed that such assessments can take several months to complete. It was not until CAMHS were directed by a judge in September 2016 to conclude their assessment that they were able to confirm four weeks later, that Pippa did not meet the criteria for a diagnosis of ASD but there was evidence of an attachment disorder. A review of CAMHS case notes from meetings and phone calls with the family seem purely descriptive and there does not appear to be any assessment of Pippa’s mental health needs or any attempt to place her behaviours in any context. The review team was reminded however that the involvement of CAMHS at that time, was to just to undertake an assessment, not to undertake any therapeutic work. 7.5.36. CAMHS concluded that Pippa’s needs at the time did not meet the threshold for any ongoing work and the case was closed. This was a missed opportunity for Pippa to receive specialist help even indirectly, as the review team was informed that in some circumstances CAMHS can offer support to Pippa SCR/LR/03.02.2022/updated Final Report 20 professionals who remain involved with the family. It may have been helpful if such a working relationship had been established but such an arrangement was neither offered nor sought by any professional working with Pippa, neither was the detailed CAMHS assessment shared with CSC to inform their work with Pippa and her family going forward. Looked after Child (LAC) Health Assessments 7.5.37. The review team had sight of a LAC Assessment dated September 2017 which indicated that Pippa was generally fit and healthy. Pippa answered No to the question about self harm. The review team was curious about the many references to Pippa’s ‘self-harm’ in agency records but it would seem there was no evidence of this other than what was reported by MP - that Pippa cut or scratched herself ‘until she bled’. Although school nurse records (SN1) indicate that Pippa told SN1 that she self-harmed, this does not appear to have been explored and no additional details are provided. There is no information in GP records, which indicate evidence of self-harm. There are references in the records of two agencies that Pippa took an overdose in May 2014, but again there are no records, which can confirm this. 7.5.38. Research recently published in the Lancet Psychiatry Journal and published in the Guardian newspaper 11(4.6.19) suggest that self-harm is almost becoming normalised as new figures from the NHS show that there has been a huge increase in self-harm amongst children, more prominently in young girls. Whilst self-harm was recognised by practitioners as being a worrying concern, it was acknowledged that in Pippa’s case, there was a lack of professional curiosity about Pippa’s reported self-harm, how or if it was manifest and what it entailed. This was almost a form of professional bias in that it was perhaps expected behavior so it was not challenged but accepted as given. Risk assessments undertaken in residential homes 7.5.39. Good risk management demonstrates that staff understand each child, recognise the triggers for unsafe behaviour and know what steps to take in order to reduce to reduce harm. Above all, risk assessments have to be dynamic if they are to be an effective part of the overall plan to care for children and keep them safe. 7.5.40. The review team was advised by CH1 that in line with their usual practice, they undertook a risk and pre-admission assessment based on information provided by the social worker and the commissioning team from the local authority. The review team was informed by the manager of CH1 that although the information made available to them was ‘inaccurate and inadequate’, Pippa’s placement was nevertheless confirmed. The review team have not had sight of any risk assessment undertaken by CH1 on her arrival in early May but have access to a copy of a risk assessment which was completed one week before Pippa left the placement in late June 2018. 7.5.41. In that document, the risks posed by Pippa to other residents from Pippa’s sexualised behaviours are assessed as being ‘very high’. There were no concerns noted relating to self-harm. The review team was told there was however a discrepancy in the initial documents provided by the social worker in 11 https://www.theguardian.com/society/2019/jun/04/one-in-five-young-women-have-self-harmed-study-reveals Pippa SCR/LR/03.02.2022/updated Final Report 21 that the placement request form indicated no concerns around self-harm yet the risk assessment rated the risk of self-harm as medium. The review team was of the view that given this was not initially explored at the outset of the placement, its significance has only become apparent with hindsight. Best practice would be that risk assessments are regularly reviewed and updated in light of significant daily occurrences and reported incidents. This does not appear to have happened in CH1. 7.5.42. The review team had sight of a risk assessment completed by CH2 in the first few days of Pippa’s arrival at the placement. The identified risks by CSC on their placement request form were considered and appropriate control measures were identified. However, the risk of self-harm/suicide, assessed by CSC as being low/medium, was included only in a sub section under Substance Misuse and Exploitation rather than as a section in its own right. The risks, triggers and control measures associated with self harm/suicide are however quite distinct and despite CSC indicating there ‘was no evidence of self harm’, this specific risk and possible measures to mitigate harm could have been better considered. The review team were of the view however, that even had this risk been more carefully explored in relation to Pippa, there was very little to suggest self harm or suicide ideation. 7.5.43. The risk assessment in CH2 was not reviewed between July and September as would be expected and although all staff indicated they had read the assessment not all staff had signed the document to this effect. According to agency records, these issues have now been appropriately addressed by CH2. 7.5.44. There were it would seem, and in stark contrast to her time at CH1, no reported incidents of any significance whilst Pippa was at CH2 and the review team was keen to explore why this might be. However, neither the manager nor any staff from CH1 attended review team meetings or the practitioners group and neither did they respond to overtures by the lead reviewer to meet as the SCR process unfolded. Assessments of Risk 7.5.45. A risk assessment for Pippa was undertaken in September 2017 by SW2 and discussed at a MDSP practitioners meeting the following month. The risk assessment identified the presence of 8 High Risk indicators of CSE, 17 Medium Risk indicators and 1 Low Risk indicator. The MDSP practitioners discussed the ongoing risk of CSE for Pippa in November 2017 and again in January 2018 where it was noted that the level of risk for Pippa, emerged from only one reported episode several months earlier and had not changed. A decision was taken that Pippa should be removed from the MDSP process on the basis that she no longer had a phone, she was attending school, had a CSE worker allocated to her and she was subject to a LAC plan. The review team was of the view that further exploration of these issues would have highlighted Pippa’s continuing vulnerabilities; she did in fact have access to a mobile phone and was not engaging with the CSE worker. Furthermore, it was becoming increasingly evident that MGM was struggling to exert any influence over Pippa and her whereabouts. 7.5.46. Pippa went missing on four occasions after she was ‘closed’ to MDSP in January 2018; on two occasions, she was missing overnight. The review team queried why this did not lead, as they should have done, to further referrals to MDSP so risk to Pippa could be reassessed. The review team was Pippa SCR/LR/03.02.2022/updated Final Report 22 advised that police assessed two of these missing episodes as medium risk, and as MDSP only dealt with high risk cases, these were not referred back into the MDSP process. 7.5.47. The risk to Pippa was clearly viewed as a one off episode rather than an early indication of sexual exploitation. Understanding how different factors interact to increase vulnerability is particularly relevant when exploring risks in relation to children and young people especially those who go missing from home, education or care, because being ‘missing’ increases vulnerability. There are no reports which indicate where Pippa was or who she was with when she went missing, perhaps it would seem, because she always returned to MGM’s home rather than anywhere else. There were missed opportunities to use local intelligence and to explore in more detail Pippa’s contacts in the community and the influences they had or may have had on her behaviours. One of Pippa’s known contacts (KTP) was well known to MDSP but the extent of his involvement with Pippa was not explored nor was any risk he may have posed to her. 7.5.48. A lack of analysis and critical thinking has consistently been highlighted in a number of serious case reviews, inquiries into child deaths and inspection reports. Assessment practice has been criticised for adopting a procedural, checklist approach when in fact assessing risk of sexual exploitation is complex and messy and certainly not straightforward. Risk-taking is a normal part of adolescent development and most young people experiment with the increased opportunities for risk that their growing independence allows. Deciding what is risk taking behaviour, what is ‘normal’ adolescent behaviour and what behaviours may be considered adaptive responses to adverse experiences is not easy. 7.5.49. It is not known whether Pippa was initially testing out her independence when she was first found missing from MGM’s home or whether she was seeking to spend less time with MGM - perhaps a combination of both – but what is known is that there were a number of pre-disposing factors which were not as well considered in the MDSP assessment as they might have been and which, coupled with Pippa’s living arrangements, meant that Pippa was particularly vulnerable to CSE. Whilst these indicators should have influenced to a far greater extent subsequent decision making and planning, it is not possible to determine that any other course of action may have prevented the actions which led to her death. However, the continuing focus on Pippa’s behaviour obscured and hid the effects of cumulative adversity and this left Pippa vulnerable. Learning Point 6: Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma. Adolescents, self-harm and suicide 7.5.50. Suicide is the act of intentionally causing one's own death. It is not known whether Pippa intended to end her life and it is outside the remit of this SCR to consider whether the outcome of Pippa’s actions were deliberate or accidental. 7.5.51. Pippa’s death has however highlighted the importance of professionals understanding the factors that can lead to adolescent deaths by suicide. Suicide in young people is rarely caused by one thing; it usually follows a combination of previous vulnerabilities and recent events. Although Pippa was the subject of a risk assessment for CSE, the review team was not aware of any specific assessment to determine whether she was at risk of suicide. Research suggests that the circumstances that lead Pippa SCR/LR/03.02.2022/updated Final Report 23 to suicide in young people often seem to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversities, high risk behaviours in adolescence and early adulthood, and often, but not always, ‘a final straw’ event. It is not possible to determine whether something ‘flipped’ for Pippa, but even knowing the combination of her history and her existing struggles, the possibility of Pippa taking her own life was never considered as a risk factor by any of the professionals who knew her. 7.5.52. In discussions with the review team, practitioners described their shock upon learning of Pippa’s death and the way in which she died. Comments such as ‘I would never have thought it of Pippa’ and ‘it never crossed my mind that she, of all young people would take her own life’ are testament to how little is known about what goes on in the minds of young people who take actions, deliberate or otherwise, which end their life. 7.5.53. Whilst referrals into CSC during the period under review were made and accepted appropriately, they were too often viewed as individual episodic events and focused on the content of the referral, Pippa’s aggressive and violent behaviours’ while failing to consider in sufficient detail not only her history, but also what she may have been subjected to during her missing periods. Incidents need to be considered in context; concerns need to be connected in order to build up a fuller picture of a child’s life. Whilst some practitioners felt that there is not always enough time to read through a child’s file, without a careful sifting of case history and a realistic understanding of the impact of new and recent experiences, work with children may not be as effective as it could be. Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful to ensure that all assessments for adolescents thought to be at risk contain a standalone section which requires professionals, including health colleagues, to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps can be taken in all circumstances to minimise opportunities for a young person to harm themselves. 7.6. Professional Judgment and Decision-making Terminology and the use of language 7.6.1. The language used by professionals provides a medium for describing perceptions and therefore has an extraordinary capacity to influence the way professionals think.12 Pippa’s behaviours were described by MP as ‘violent and aggressive’, a phrase frequently repeated in case files but without any clear analysis of the what, when and why aspects of this behaviour. The references to ‘self-harm’ littered through agency records are accepted as given, even though there is no description as to how these harms were manifest, or whether they actually existed. The way professionals describe what they hear and what they observe is hugely significant. 7.6.2. The description in CH1 records, that Pippa was seen coming out of a male resident’s room ‘giggling’ is, within the context of the recording, meant to infer, without any specifics, that ‘something was 12 This is sometimes called the Sapir-Whorf hypothesis. ‘Language may indeed influence thought’ Jordan Slatev and Johann Blomberg. Phil Papers October 2015 Pippa SCR/LR/03.02.2022/updated Final Report 24 going on’. Records also state that she was seen to ‘entice and pester’ another resident, a clear example of language being an indicator of a biased and less than objective judgment. 7.6.3. The 2017 Single Assessment has entries copied from a previous assessment but there is also additional and more up to date information included. Pippa’s behaviours continue to be conceptualised as a problem within herself, rather than being a symptom of any underlying issues. Evidence for this, is found in comments in the assessment such as ‘there were several violent incidents in the home… caused by Pippa reacting badly when she can’t get her own away’ and ‘Pippa needs to learn to deal with emotions appropriately’. Professionals can compound misconceptions through their attitudes and inappropriate language and euphemisms, and the words professionals use to describe a child or their behaviours clearly indicate a particular perspective which is not always helpful. The review team found the contrast between how CH1 and CH2 described Pippa and her behaviours particularly noticeable. Bias and Professional Curiosity 7.6.4. There is a substantial body of research evidence13 that has identified the tendency for ‘early evidence bias’ in human decision-making that a first summing up of a situation strongly influences the analysis of subsequent or new information. Given the need to record judgments at an early point, there is a very real danger that practitioners who are not mindful of this potential bias in human reasoning will simply search for and accept evidence that confirms their first hypothesis. 7.6.5. The review team found numerous examples during the review of professionals and to some extent MP, simply not being curious enough about Pippa’s behaviours or even what she said; MP described at a network meeting how Pippa, then aged 13 became physically aggressive one evening when MP prevented her from phoning her ‘grandfather’ after midnight and Pippa’s comments that she had a 17 year old boyfriend were dismissed as Pippa ‘telling lies’. There does not appear to have been any curiosity of follow up to Pippa expressing her discomfort about being around a male foster carer. 7.6.6. As part of an English assignment in early 2018, Pippa produced a piece of writing in her English lesson, explicitly written in the first person, the text describes an abusive sexual relationship involving what might be described as a form of ‘strangulation’. There is also a reference to ‘my sexual abusive past’. According to education records, Pippa was excluded for three days for submitting this piece of work and although SW1 was informed and it was recorded in the LAC review meeting which took place the following month, there was no significance attached to this incident. Even acknowledging the possibility of hindsight bias, such explicit writing submitted by a young adolescent with Pippa’s history should have led to sensitive outreach by SW1 and further exploration of CSE risks. 7.6.7. There were at times assumptions made by professionals and by MP that Pippa’s outbursts, her aggression, and certainly her prose, as in the example above, were just ‘typical’ of Pippa. What would have been more helpful was for professionals to have explored in much greater depth, what had 13 Munro, 2011, 1999; Burton, 2009. Pippa SCR/LR/03.02.2022/updated Final Report 25 happened to Pippa in the past, and importantly, exactly what was still happening to her in the present and with whom. 7.6.8. Young people rarely disclose abuse or neglect directly with practitioners, if they do, it is most often through unusual or testing behaviour or comments. Equally, young people are unlikely to comfortably disclose risky sexual behaviours they may encounter or which they find themselves in. This is where professional inquisitiveness or curiosity is so important. Professional curiosity is the capacity and communication skill to explore and understand what is happening to a child rather than making assumptions or accepting things at face value. The review team considered that professionals could have been more curious and inquisitive about what Pippa’s was experiencing as a young adolescent and how or if she was making sense of these experiences, some of which were clearly abusive. Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up conversations with young people will be limited and they may be left vulnerable. Lack of challenge 7.6.9. For much of the time during the period under review, Pippa lived with MGM and did not have a room of her own. It is puzzling how this situation was accepted for so long, without challenge either from professionals, their managers or the IRO. The decision by the judge, supported by CAFCASS, to remove Pippa from a foster home where she had lived for 6 months to be placed with MGM conflicted with the views of the local authority. The judge also directed that the local authority should support MGM secure appropriate accommodation and although two housing association homes were viewed, neither was found to be suitable and Pippa remained sleeping on a sofa bed from February 2017 until May 2018. 7.6.10. The absence of any sense of urgency by CSC led to Pippa’s placement drifting without evidence of any long term planning. Managerial oversight was not robust and case supervision records lacked reflection and focus. The review team was advised that the number of management changes compounded oversight even further and this was reflected in the supervisory arrangements not being as effective as they should have been. More recently, there has been a move to address these issues through a series of practice skill sessions aimed at improving supervisory practice within children’s services. Whilst managerial oversight in CSC was not good, neither did any other agency check or challenge the appropriateness of Pippa’s placement, or the drift and delay in addressing the escalating risk to Pippa of living with a grandparent who found it increasingly difficult to exert any boundaries or manage her behaviours. The review team thought it highly unlikely that agencies would have been content to leave a younger child for so long without a proper bed or robust adult supervision. 7.6.11. The range and nature of adolescent risks are different to those facing younger children and the traditional response to such risks does not necessarily fit with young people’s lived experience and research. The review considered that the response of practitioners and the lack of challenge might Pippa SCR/LR/03.02.2022/updated Final Report 26 have reflected a faulty assumptions that Pippa was perhaps more resilient by virtue of her age despite the evidence that she had experience of more cumulative harms. 7.6.12. Research in Practice14 states that ‘all too often services do not recognise or respond to underlying causes of crises, do not adequately ‘work with the grain’ of adolescent development, do not draw on the strengths of young people, their families and peers, and do not support practitioners sufficiently to manage the complexity involved with adolescent risk.’ The Review Team found evidence of significant amounts of professional activity and some good practice but little to suggest the activity was in response to well thought out plans or clearly defined expected outcomes. This aspect of work with Pippa should have been challenged at so many levels but a lack of direction and urgency was evident despite the efforts of those involved. Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable. 7.7. ASP 4: The extent to which agencies worked collaboratively. 7.7.1. Agencies have a collective responsibility to safeguard and protect children and this demands effective communication and co-ordination of services at both strategic and operational levels. Although there was good information sharing between agencies, multi-agency working was not as effective as it might have been. Around 10 multi-agency meetings, appear to have taken place in 2016, some were referred to as CIN meetings, whilst others were described as Network meetings. The review team was told these were different names for the same meeting. In 2017, according to the integrated chronology, only 4 multi-agency meetings were recorded and in 2018, only one LAC review was recorded. Not all agencies recorded the same dates for meetings and some meetings were recorded in agency records but not included in the integrated chronology. Use of Chronologies to share significant events 7.7.2. As in many other SCRs, it was only when the integrated chronology was shared with all agencies that the gradual and steady risks to Pippa became apparent. Chronologies have been identified as invaluable tools to record a child’s development throughout ongoing work and to track a child’s pathways, especially when a child’s journey takes them into areas of risk such as CSE. However, single agency and multi-agency chronologies are too often completed retrospectively after harm and adverse outcomes have been identified. 7.7.3. In reviewing agency records and examining Pippa’s assessments, there is much information provided but so much is repeated and reworded that it was not easy to gain a true sense of Pippa’s journey. Without a multi-agency chronology, it is almost impossible to ‘see’ any emerging patterns or understand how the work of individual agencies does or does not, contribute to a child’s overall plan. Despite, this and it is a key learning point in many SCRs, the process of creating a shared and multi-agency chronology from the outset of work with families, where there are concerns is not common or expected practice. 14Research in Practice Developing a more effective response to adolescent risk (2014) Pippa SCR/LR/03.02.2022/updated Final Report 27 7.7.4. Reading through the integrated chronology, even from December 2015, Pippa’s fractured relationship with MP, her lack of stability and security and what must have been the inevitable frustration as an adolescent of not having any personal space whatsoever, other than her phone, reveal a number of ‘push’ factors which made Pippa particularly vulnerable to exploitation by others. These patterns and pathways are not so easily observed through reports, assessments, and minutes of meetings but they do become crystal clear through the lens of an integrated chronology. 7.7.5. Whilst chronologies are invaluable tools to systematically monitor patterns and significant incidents, the practicalities of creating and maintaining them are numerous and complex. Yet, these tools can greatly aid case analysis, and encourage practitioners to contextualise presenting issues in the wider family history. Health colleagues describe how they use every fourth entry in a significant incident chronology as a trigger to discuss concerns in supervision. There does not appear to be similar systems in other agencies and there is no current system or agreed process in place in the locality to support the production of shared chronologies within a multi-agency framework. This is a key area which if developed could have significant impact on multi-agency analyses and decision-making. Learning Point 10: When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie, but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making will not happen. Multi-agency collaboration. 7.7.6. There were many examples of professionals communicating with each other, sharing information via emails and phone calls; the school nurses kept social workers up to date after health assessments, social workers regularly liaised with school staff and police usually ensured that reports were submitted following Pippa’s missing from home episodes. In this respect multi-agency working was as expected. However, these communications, important as they are, are not the same as multi-agency collaboration. When important and relevant information related to a child is shared or communicated to colleagues, it is important that professionals take the next step of exploring within a multi-agency context what this means and why significance is attached to certain issues and not others. 7.7.7. Multi-agency meetings remain the key mechanism for implementing and progressing plans to promote a child’s well-being, safety, and welfare. When these meetings work well, they ensure that everyone works collaboratively towards agreed goals so the very best outcomes for a child can be secured. Where they existed, the review team obtained copies of minutes from the various multi-agency meetings, which took place during the period under review, including minutes from LAC reviews. These documents record feedback from practitioners and note what should happen next, they are not particularly helpful in determining who should do what and why and how progress of that work would be monitored and measured. 7.7.8. Health services, and especially school nurses, make a significant contribution to supporting children and young people and especially those at risk of or harmed through sexual exploitation. Pippa was Pippa SCR/LR/03.02.2022/updated Final Report 28 under the Universal Partnership Plus for school nursing services, which provided targeted packages of support. School Nurse 2 (SN2) had several contacts with Pippa and MGM during the period under review and records indicate she was concerned about the viability of Pippa’s placement with MGM. There is evidence that the school nurse liaised with the LAC nurse when Pippa became a looked after child, but the review team were curious as to why the there was no involvement from school nursing service in multi-agency meetings and whether this is a capacity issue and/or a policy decision. School Nurse 1 (SN1) was not informed, when Pippa became looked after for the first time and SN2 was not kept informed about Pippa being the subject of the MDSP process. The School Nursing service is, the review team was told, now represented on the MDSP practitioner group. 7.7.9. The LAC reviews simply listed a number of tasks, which had to be achieved, or which had not been completed. None of the minutes seen by the review team indicated close collaboration between agencies and it was difficult to understand what goals had been agreed and what progress had been made towards their achievement. The format and style of these documents are clearly designed to meet the needs of an IT system rather than the individuals who have to make use of them. What emerged from the review of minutes from a number of multi –agency meetings was the absence of any robust multi-agency plan to inform and guide work undertaken with Pippa throughout the 2 year period under review. Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they give the impression of progress. Quality of Plans 7.7.10. Children’s plans, built and designed for children who need care or protection, represent the framework in which professionals help children develop and be safe. It is well researched that they are best developed and implemented through the functioning of multi-agency groups. The issue of how plans - are produced and utilised is a vexed one, but families and practitioners - need to be clear about what needs to change, by when and what the expected outcome will be and, importantly, how and where the intervention of professionals will make a difference. Such plans are crucial to multi-agency working in that they provide the agenda and direction of work to be undertaken with families. 7.7.11. Given how central these plans are in improving outcomes the review team was concerned to note that the CIN plan and the subsequent Care Plan for Pippa were vague, unrealistic and without the means by which progress could be easily measured, making them largely ineffective. One example extracted from a CIN plan in June 2016 was for ‘parents to support Pippa to develop strategies to help her manage her emotions and behaviour in a positive manner ‘as if by stating this, changes in the family would simply happen. The language, too, is careless, Pippa had only one parent involved in her life, and P4 was not her parent. 7.7.12. Neither MP nor MGM could recall seeing any copies of plans for Pippa or receiving any minutes of key meetings. Whilst this issue is one, which should be addressed, the review team also concluded that the format of plans and minutes are not produced in ways which are helpful and especially not for the children to whom they refer. Pippa SCR/LR/03.02.2022/updated Final Report 29 7.7.13. The objective of the Pippa’s LAC plan in August 2016 was to ‘ensure that Pippa is in a stable and safe environment in which her physical and emotional well-being will be promoted.’ In effect, between July 2016 and August 2018, plans to provide a stable environment for Pippa did not materialise and there was considerable scope for the IRO to challenge how realistic the plans were for Pippa and how well they were being executed. On the occasions when placements broke down, plans for Pippa should have been subject to greater scrutiny by the IRO. It would have been helpful if upon learning that Pippa’s placement had broken down in CH1 that the due date for her LAC review in October was brought forward to July/August so plans could be reviewed. There was certainly a sense of drift and little challenge to a precarious family placement where professionals were repeatedly told by MGM that she could not manage or control Pippa’s behaviour. Neither is there evidence that Pippa’s Care Plan was updated or changed once risks of CSE became known. Learning Point 12: Unless all children’s plans have SMART15 objectives and are regularly scrutinised, work with families will lack focus and will be ineffective, leaving some child vulnerable. A shared responsibility 7.7.14. MP informed the lead reviewer and the LSCB Business Manager that she had received no communications from CSC inviting her to meetings about Pippa, neither had she received any information about what was happening in her daughter’s life. The review team have however had sight of letters and minutes that were sent to MP at her address in Area1 in 2016 and later to her address in Area2. Agency records suggest that MP sent her apologies to some meetings through contact with SW1. Pippa was made subject to a full Care Order in February 2017 and the local authority supported contact between Pippa and MP initially, it seems, through occasional supervised contact sessions. Pippa’s views are later recorded several times as saying she did not want contact with MP and her wishes in this respect were respected. MP told the lead reviewer she would have attended meetings if she had been able to attend and had been invited. 7.7.15. During the period under review, Pippa had four out- of- home placements. Two of these were with foster families, one of whom Pippa lived with for 6 months before she was returned to the care of her MGM. Pippa then stayed with MGM for 15 months before moving into CH1. After 7 weeks, Pippa was moved again to CH2. The review team could find no evidence that disruption or end of placement meetings took place when any of the previous placements ended. Such meetings are known to be best practice as they provide the means by which the child and the placement provider can be supported to understand why the placement has ended and what support might be needed to ensure the stability of any future placements. 7.7.16. Practice experience and key research findings support the critical importance of placement stability for children and young people who need looking after. Children who experience multiple caregivers undergo repeated and stressful transitions to and from different living arrangements. Research and practice wisdom attest to the negative impact of multiple placement changes not only on children’s development, confidence and well-being but also on their internal working model and self-beliefs. Even prior to coming into the care system Pippa had experienced multiple moves back and forth 15 Specific, Measurable, Achievable, Realistic and Time bound (SMART) Pippa SCR/LR/03.02.2022/updated Final Report 30 between her mother and her grandmother’s home and the issue of her lack of stability was a significant aspect of her vulnerabilities. 7.7.17. Once it became evident that Pippa could no longer live with MGM, a decision was taken that Pippa’s needs would best met through the provision of a therapeutic residential environment. At a national level, the situation regarding the lack of suitable adolescent mental health beds remains a concern and even with early intervention, the right assessment, and good planning, finding the most appropriate resource remains a challenge for local authorities in relation to children with complex needs. Professionals face particular challenges when seeking placements, which can meet all the needs of the young person. Placement providers are, understandably, selective in terms of who they will accept, clearly wanting to offer placements, but equally not wanting to take excessive risk in agreeing a placement, which would prove disruptive of their regime or prove to be a risk to other residents. This places an immense burden on responsible professionals in securing a suitable placement for children whose needs are complex and significant and especially so where there is an urgent need for accommodation as there was with Pippa in May 2018. 7.7.18. Negotiations took place with CH1 some 20 miles in Area3. At this time SW1 had left and SW2, an agency worker, had recently been allocated to Pippa. From records it seems that SW2 was not as familiar with Pippa’s background history as she might have been which, given the circumstances was clearly of some concern to CH1. Pippa stayed at CH1 for around 7 weeks before CSC was given 7days notice that the placement was to be terminated. Regulations stipulate that the local authority must be given 28days notice but the manager of CH1 insisted that Pippa, because of her sexualised behaviour, posed a risk to other residents. According to records, this manager demanded that the social worker remove Pippa from the placement and with nowhere to go, Pippa spent two nights in a hotel with her social worker before accommodation was found in CH2, a newly established local placement offering therapy. 7.7.19. The review team was concerned not about the placement ending but the way in which it was managed, causing extreme stress to a child who had already experienced repeated and stressful transitions to and from different living arrangements. The issue of Pippa’s behaviour in CH1 is not in question; the placement might not have been right for either party, but the conflict which emerged between the local authority who asked for a longer period to find an alternative placement and the refusal of the manager of CH1 to accede to this request was of some concern to the review team, especially as the request to move was made soon after Pippa’s disclosure about historical sexual abuse. 7.7.20. The manager of CH1 completed an Agency Learning Report and the review team was disappointed to note that the only learning identified was the need for CH1 to revise their pre-admission format and risk assessments when in fact there was much learning to be gained in terms of how CH1 manage placements in future if young people begin to display sexualised behaviour. The tone and language of some recordings related to Pippa’s behaviour is not what would be expected of staff working in a caring environment with young people. Pippa SCR/LR/03.02.2022/updated Final Report 31 7.7.21. It is important that professionals in all services utilise knowledge about child development, attachment and trauma and acknowledge that children, especially those coming into care, are more likely than not to be struggling with feelings of loss, bereavement, fearfulness and mistrust. Behaviour difficulties and challenging behaviours in this respect are perhaps to be expected and responded to in ways which do not further damage the child’s well-being and mental health. The needs of one individual of course need to be considered in line with the need of other residents, but the review team was of the view that if sexualised behaviour cannot be sensitively and safely managed in a care home, this should be made explicit on websites, literature and at initial meetings with Commissioners. 7.7.22. Pippa was placed in CH2 for an initial six week placement and the review team was told that Pippa was aware that her time at CH2 would be for a limited period. CH2 was also a mixed therapeutic environment, where Pippa was described as ‘challenging but lovely’. There were no significant incidents relating to her behaviour. She was reported to be frequently baking cakes for staff and residents or performing a song or drama for their entertainment. Agency records suggest she was settled in the placement but what emerged from records was that Pippa needed to be reassured by staff that they cared about her and her anxieties noticeably increased as the date for another move was approaching. 7.7.23. It is unclear to what extent Pippa was involved in key decisions about what was happening, she certainly gave the impression to staff in CH2 that she believed the move was based on financial considerations by the local authority and this undoubtedly would have made it hard to accept her move even if this was not the case. The review team was unable to determine why Pippa believed her future was based solely on financial considerations and which professional, if any, had spoken to her about this. Despite previously refusing support, Pippa asked staff in CH2 only a few days before her death, to find her an advocate so she could be supported to stay in CH2. 7.7.24. Clear communication about the reasons why moves are necessary, and frequent reassurance for children and young people, is essential to manage the process of changing placement. Not long after her arrival at CH2, Pippa was allocated her third social worker since SW1 had left earlier that year and there would have been very little time to establish any meaningful relationship, coupled with the fact that the ‘new’ social worker was male and Pippa had previously indicated she felt ‘uncomfortable’ around males she did not know. The impact of changes in social workers at important times of transition and the detrimental impact of a lack of a trusted adult for some children at these times should never be underestimated. 7.7.25. Asked about the time it took for staff in CH2 to find Pippa, the review team was told by the manager of CH2 that Pippa would often sleep late when she was not school, sometimes staying in bed until noon. Staff were aware that Pippa would not be going into school that day and despite a knock on her bedroom door around 9.00pm, staff did not return to her room until around midday. CH2 have since changed their procedures to ensure that all residents are seen or spoken to by 9.00 am every morning. Pippa SCR/LR/03.02.2022/updated Final Report 32 7.7.26. Managers at both residential establishments raised concerns about the difficulties they encountered in trying to contact someone in the local authority to clarify or obtain key details relating to Pippa. Examples were given of calls not being returned, confusion about which social workers were involved and important paperwork not being completed. Both establishments indicated these issues happen often and even managers, did not always call back when messages were left. Neither establishment indicated they were aware of the LSCB escalation procedures. Whilst CH2 participated in the SCR process, conversations with the commissioners identified that there was no contract requirement for them to do so and this issue should be addressed in future contracts. 7.7.27. There would be value in the commissioning team in children’s services reviewing all contracts with providers of residential services to ensure they include references to LSCB’s safeguarding procedures for escalating concerns about professional practice and/or decision-making. Information should also be provided about the requirement for all providers to cooperate with any national or local safeguarding practice reviews, which may be established. 7.8. Pippa’s lived experience 7.8.1. It perhaps would be fair to say that from a very young age, Pippa received messages that she was a problem to her family and as she grew older, this version of herself was reinforced through the involvement of a range of professionals who tried to help with her behaviour. Reading through records and talking with practitioners it is clear that practitioners from all agencies wanted to do the very best for Pippa yet there are relatively few records, which give voice to Pippa’s wishes and feelings. 7.8.2. For adolescents who have strained or fragmented relationships with their family, and particularly for those who have experienced abuse or neglect, engagement with professionals can be difficult yet these relationships can be key for some children. Due to staffing issues, Pippa had at least 4 different social workers in contact with her between May and September 2018, the very time when she perhaps most needed to draw on support that was familiar, friendly, and, most importantly, trustworthy. 7.8.3. Research16 provides evidence of the powerful and central role that relationships play in adolescent’s well-being. SW1 had remained her social worker for almost two years before she moved to another post. Records do not comment on how Pippa handled this but undoubtedly, the timing of her move just prior to Pippa’s first residential placement would not have been without impact. SW1 no longer works for the authority so the review team has been unable to benefit from her perspective and what would undoubtedly have been some very useful insights. According to records, SW1 prepared Pippa well for her departure and wrote a warm letter to her outlining the work they had done together and expressing encouragement for Pippa’s future. Between May and August 2018, Pippa had 2 other social workers in contact with her and was allocated a fourth social worker a few weeks before she died. 16 World Health Organisation (2014) Health and Well-being of young people Pippa SCR/LR/03.02.2022/updated Final Report 33 7.8.4. Practitioners describe how Pippa would usually not want to talk to professionals if she could avoid it. There are records, which refer to Pippa saying that meetings were ‘boring’ and would often retort she did not want to spend ‘three hours’ just talking. The use of non-engagement, as a coping strategy, is a common feature in adolescents but perhaps professionals could have been more persistent and creative about helping Pippa explore what must have been some very difficult issues. References in agency records to Pippa’s ‘quirkiness’, her apparent confidence and carefree approach together with her flippant remarks when professionals tried to encourage her to talk about herself, may well have unwittingly led practitioners to feel reassured about her ability to keep herself safe. 7.8.5. Listening to the ‘voice of the child’ does not only refer to what children say directly, but to many other aspects of their presentation, how they look, how they behave and with whom; it essentially means seeing a child’s experiences from their point of view. Professionals talked warmly about Pippa describing her as funny and engaging, stroppy and challenging, kind and abusive but with a personality that could not be ignored. The review team have also had sight of various records, reports, and assessments, but within those documents there is a scarcity of records, which describe in any depth Pippa’s thoughts about her lived experiences. 7.8.6. Whilst it is recognised that adversity in childhood is not in itself deterministic of a poor outcomes in later life, there is substantial evidence that it does make it more likely that, without the right sort of support, things can go wrong for the child and for the adult they will become. The fact that Pippa didn’t ‘seem’ like a young person to take her own life highlights that perhaps more needs to be done to equip professionals to better understand issues for young people whose actions, deliberate or otherwise, can lead to their death. Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly. 7.8.7. According to agency records, it appears that Pippa spent time in the company of other young people known to CSC and police. Whilst it is not known to what extent social media impacted on her life, MGM and MGF told the review team that Pippa was always on her phone, tablet or laptop. Access to these devices was however limited when she was living in CH2 but they were removed by police after her death. 7.8.8. After Pippa’s death, police removed a laptop and tablet from CH2 but the review team was told information could not be accessed as both devices remain password protected. When a child or young person takes their life and the police have ascertained that a crime has not been committed, the review team learnt that police have no power to examine these devices to determine if the death was as a result of harm or incitement by someone else or was a result of access to websites about suicide. Investigating a child’s digital footprint as soon as possible after their unexplained death should be an immediate task, led by police, to determine any factors which may have led to the death of the young person and/or which could safeguard other young people. 7.8.9. In 2018, the Department for Education circulated a new draft of Working Together to Safeguard Children guidance, which includes attention to adolescents who are “vulnerable to abuse or exploitation from outside their families”. Inquiries into serious failures in other authorities have led to a national focus on improving understanding of and response to the complex risks faced by adolescents. Pippa SCR/LR/03.02.2022/updated Final Report 34 7.8.10. It is impossible to say whether the sad death of Pippa was preventable. Pippa’s family and those professionals who knew and worked with Pippa have searched and continue to search for reasons, which help them understand what triggered the actions, which led to her death. Just as it was not possible to predict the death of Pippa, neither is it possible to attribute the cause of her death to any failings on the part of professionals who knew her or her family. This review nevertheless reminds all professionals working with young people to be aware that the pathways leading to harms that adolescents face are complex, not least because they often involve what appear to be adolescent choices and behaviours which can mask, rather than expose, hidden vulnerabilities. 8. Summary of Learning Points 8.1.1. The learning points identified by the lead reviewer and the review team were shared,, discussed and agreed with practitioners as being relevant to current practice in Middlesbrough. Learning Point 1: It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours. (REC 1 and REC 2) Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention. It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the locality to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a child’s increased vulnerability to Child Sexual Exploitation. (REC 1) Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect, so the multi-agency analysis can support and be seen to support professional judgments and decision-making. (REC 3) Learning Point 4: When working with children, practitioners need to proactively assess and engage with all significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both. Where concerns exist and there is evidence of conflict between a child/young person and significant none birth related males in a family, this should always be explored in assessments and be incorporated into ongoing work (REC 3) Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family members have the motivation and capability to make such changes in line with their child’s needs and timeframe. (REC 3) Pippa SCR/LR/03.02.2022/updated Final Report 35 Learning Point 6: Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma. (REC 1) Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful to ensure that all assessments for adolescent thought to be at risk contain a stand-alone section which requires professionals, including health colleagues, to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps should be taken to minimise opportunities for a young person to harm themselves. (REC 1) Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up conversations with young people will be limited and they may be left vulnerable. (REC 1) Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable. (Rec 2) Learning Point 10: When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information, the use of chronologies to inform good assessments and decision making will not happen. (REC 3) Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they can give the impression of progress. (REC 3) Learning Point 12: Unless all children’s plans have SMART17 objectives and are regularly scrutinised, work with families will lack focus and will likely be ineffective, leaving some child vulnerable (REC 3) Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly. (REC 1) 17 Specific, Measurable, Achievable, Realistic and Time bound (SMART) 9. Recommendations for the Safeguarding Children Partnership18 (SCP) 9.1.1. The recommendations have been discussed and agreed with the review team. Recommendation 1: SCP should support the development and implementation of a multi-agency framework for work with vulnerable at-risk adolescents.19 Learning Point 1: It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours. Learning Point 2: Child Sexual Abuse in the family environment will often come to the attention of statutory and non-statutory agencies because of a secondary presenting factor, which then becomes the focus of intervention. It is worth considering, especially in light of the findings from the Children’s Commissioner whether more work is needed in the locality to increase professional understanding and awareness of familial child sexual abuse. This might be particularly helpful given the range of ways the impacts of physical and emotional neglect can mediate or set the scene for a young person’s increased vulnerability to risk, including Child Sexual Exploitation Learning Point 6: Where CSE is suspected, it is essential that risk assessments take into account not only the presenting risk factors but also those risks, which emerge from vulnerabilities arising from past experiences such as abuse, loss and trauma. Learning Point 7: Given the vulnerability of children coming into the care system, it would be helpful to ensure that all assessments for adolescent thought to be at risk contain a standalone section which requires professionals, including health colleagues, to consider and carefully comment upon self-harm or suicide ideation. The triggers and control measures associated with these harms are distinct and require careful consideration of what steps should be taken to minimise opportunities for a young person to harm themselves. Learning Point 8: Curiosity and inquisitiveness should be part and parcel of professional practice. Unless professionals maintain a questioning and curious response to what they are told or what they see, opportunities for exploring the unthinkable or opening up sensitive conversations with young people will be limited and they may be left vulnerable. Learning Point 13: A lack of knowledge among professionals about the evidence base related to risk indicators for adolescents who die as a result of their own actions, could leave them ill equipped to discuss and/ or recognise signs and respond accordingly. 18 From September 2019, the Local Safeguarding Children Board was replaced by the Safeguarding Children Partnership (SCP) 19 See ‘That Difficult Age: Developing effective response to risks in adolescence’ Research in Practice 2016t Pippa SCR/LR/03.02.2022/updated Final Report 37 Recommendation 2: STSCP should seek assurance that all agencies a) have systems which can evidence robust managerial oversight of actions, decisions and plans relating to work with adolescents b) have systems to ensure practitioners have regular supervision from a senior manager, safeguarding lead or an appropriate external source c) provide practitioners with access to learning and development opportunities about ACES, Trauma and familial Child Sexual Abuse Learning Point 1: It is important that professionals consider how childhood experiences can impact on the behavior and vulnerabilities of troubled adolescents so that work focuses not only on presenting issues but also addresses the visible and hidden complexities of childhood trauma. It is possible that more might have been achieved with Pippa, had professionals been better supported to understand the impact of her early life experiences and how these influenced and continued to influence her thoughts and behaviours. Learning Point 9: Without robust managerial oversight to ensure that work plans are in place and are regularly reviewed, the effectiveness of interventions cannot be easily determined, and work with families can drift leaving children vulnerable. (REC 2) Recommendation 3: SCP should audit the effectiveness of VEMT meetings, LAC reviews and all Child Protection meetings and take steps to ensure these multi-agency meetings are robust and lead to improved and timely outcomes for children and young people. Learning Point 3: Whilst social workers and other professionals are skilled at communicating and gathering information, there is evidence that they need greater support to analyse and evaluate the data they collect so multi-agency analysis can support and be seen to support professional judgments and decision-making. Learning Point 4: When working with children, practitioners need to proactively assess and engage with significant men in a child’s life, recognising that some may pose risks, some may be assets to the family and some may incorporate aspects of both. Where concerns exist and there is evidence of conflict between a child/young person and significant none- birth related males in a family, this should always be explored in multi-agency assessments and be incorporated into ongoing work Learning Point 5: Professionals need to be able to make informed decisions not only about which parents/family members are able/unable to meet their children’s needs and why, but also what aspects of a parent’s behaviour needs to change. Consideration also needs to be given whether parents/family Pippa SCR/LR/03.02.2022/updated Final Report 38 members have the motivation and capability to make such changes in line with their child’s needs and timeframe. Learning Point 10: When concerns are raised about a child, a clear chronology of significant events can show agencies where risks lie but unless practitioners are supported to identify and share significant events or incidents in a child’s life, and without clear systems to gather, record and share this information in multi-agency settings, the use of chronologies to inform good assessments and decision making will not happen. Learning Point 11: Unless multi-agency meetings are well chaired, structured, and purposeful, work with families can drift but because the meetings take place, they can give the impression of progress. Learning Point 12: Unless all children’s plans have SMART20 objectives and are regularly scrutinised, work with families will lack focus and will be ineffective, leaving some child vulnerable 20 Specific, Measurable, Achievable, Realistic and Time bound (SMART) |
NC52563 | Thematic review on infants under 1-year-old, covering seven rapid reviews from August 2019 to March 2020. Cases involve infants who suffered abusive head trauma, fractures consistent with non-accidental injury and concerns in relation to neglect, substance misuse and domestic abuse. Learning includes: children aged 0-2-years-old are not always visible to services; the totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk; the single point of access for children's services needs to be embedded and thresholds well understood and applied consistently; improving the knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children; information sharing continues to create challenges for professionals, including misunderstandings of data protection legislation; the need to understand and assess the emotional and physical risk to babies and children of being present in a household where there is known domestic abuse; professionals need to robustly consider the likelihood of future risk to children, considering how parental mental health concerns, substance misuse and domestic abuse can fluctuate over time; professionals should challenge colleagues if new information is not sufficiently considered which may lead to a safeguarding risk; fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met; professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen.
| Serious Case Review No: 2023/C9779 Published by the NSPCC On behalf of an unnamed local safeguarding children board This report was written by an independent author and is owned by the commissioning LSCB. This report is published by the NSPCC with the agreement of the National Panel of Independent Experts. Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB. 1 Thematic Local Child Safeguarding Practice Review of Infants under 1 Year Executive Summary March 2022 2 Contents 1. Introduction Page 3 2. Methodology Page 4 3. Context Page 4 4. The Parent’s Voice Page 5 5. The Review Findings Page 5 6. Positive Practice Page 5 7. What needs to be done differently to prevent harm occurring in similar circumstances Page 5 8. What needs to happen to ensure that agencies learn from this review? Page 7 9. Evidence of changes since the thematic review commenced Page 8 10. Conclusion Page 9 11. How will this learning be disseminated? Page 9 3 1. Introduction A Thematic Local Child Safeguarding Practice Review of Infants under 1 year old was commissioned by a Local Safeguarding Children Partnership. This Executive Summary provides an overview of the process and scope of the thematic review, sets out the findings from the thematic review, the key recommendations and the learning for practice including the dissemination of the learning. 1.1 Incidents which led to the Thematic Child Safeguarding Practice Review Between the period of August 2019 and March 2020 there were seven Rapid Reviews1 completed by the Local Safeguarding Children Partnership relating to children under the age of one. It is important to note that not all of the cases met the criteria for a Child Safeguarding Practice Review, however there were some common themes identified in all of the Rapid Reviews. Two of the infants suffered Abusive Head Trauma, an additional two had fractures consistent with Non-Accidental Injury and the remaining lived in household with concerns in relation to Neglect, Substance Misuse and Domestic Abuse. All the families were involved with Early Help Services and two of the parents were care experienced parents. The key themes identified during the Rapid Reviews included: • The quality, timeliness and appropriateness of early help assessments • The lack of and/or limits of multi-agency working and how this affects professionals’ expectations when a number of agencies are involved • An over reliance on what parents say • Timeliness and quality of referrals, including any follow up • Escalation and professional challenge • Our professional response to disclosures of domestic abuse • Care leavers and cross boundary working 1.2 Scope of the Review As agreed in the submissions to the National Review Panel, the Local Safeguarding Children Partnership agreed to complete a thematic review in order to better understand recurring themes and identify learning for all agencies working with children and families. The following themes were identified from the seven rapid reviews and were agreed as the focus for the review with the National Panel. The key themes identified for the Rapid Review and agreed with the National Review Panel include: ➢ Professional Challenge, Curiosity & Escalation ➢ Voice of the child (pre-verbal children) 1 Locally, safeguarding partners must make arrangements to identify and review serious child safeguarding case which, in their view, raise issues of importance in relation to their area. Serious child safeguarding cases are those in which abuse or neglect of a child is known or suspected or the child has died or been seriously harmed. The Rapid Review process involves the initial scoping and analysis of information to ensure a child’s safety, identify learning for the system. 4 ➢ Quality and Timeliness of Early Help Assessments (EHA), including parental experience of the EHA process ➢ Domestic Abuse The other key themes identified were already being addressed as part of the strategic business plan for the Local Safeguarding Children Partnership. It was also agreed that the work completed as part of the Rapid Review process would not be duplicated but inform the thematic review. 2. Methodology The thematic review was led and authored by Stephanie Nightingale. The fieldwork for the review involved practitioner focused groups relating to each of the themed areas. Practitioners involved in the seven cases were invited to attend the themed focus group alongside other practitioners that expressed an interest in that area. Professionals that were unable to attend a focus group were contacted by email in order to collate their views and enhance this particular line of enquiry. The parents of the seven children were also invited to contribute to the thematic review and one parent spoke to the lead reviewer. Their responses are included in this executive summary. 3. Context All the Rapid Reviews were completed before the first Covid lockdown (March 2020) therefore Covid would not have been a contributing factor within the Rapid Reviews. The thematic review was a holistic review which included children who were the subject of a Rapid Review but not all of the cases met the criteria for a Child Safeguarding Practice Review. The lockdown impacted on the capacity of the local areas to progress the thematic review. In addition, practitioners experience of safeguarding children in lockdown was a powerful experience and provided an additional lens to the discussions in the focus groups. 4. The Parent’s Voice It was important that the parent’s views were also captured as learning for the local area’s safeguarding systems. The parent feedback provided important areas for services to consider including ensuring parents have telephone numbers and consideration of the environment when domestic abuse is discussed. “There have been so many Social Workers, changed so many times. I’ve got the email for the Social Worker but not a telephone number. This would be helpful.” “I think parents like me should do a parenting course before the baby is born NOT just focus on preparing for the birth.” “If I saw a professional somewhere else I feel I could have talked about what was happening more. Because he was there all the time I couldn’t talk about the domestic abuse. Nobody gave me the opportunity to talk about it.” 5 5. The Review Findings - How agencies worked together and learning from this The review found that there was evidence of positive practice and areas for improvement and recommendations have been made for practice improvement across the safeguarding systems. 6. Positive practice ✓ There is evidence of collaborative working and good professional relationships in some situations. ✓ Clearly defined tier two early help services are working well. In addition, the Early help quality assurance process was described as not being compliance lead. The starting point is ‘tell me about this child.’ ✓ Practice standards have improved timeliness of assessments and there is better consistency. ✓ Practitioners believed they took a holistic approach to the welfare of children. ✓ Low level professional challenge was something that practitioners were comfortable practicing as part of their day to day regular work, questioning decisions made by others, and asking what the rationale for the decision. ✓ Practitioners noted that generally professionals challenge decisions and practice comfortably and helped to train more junior members of staff and those new to organisations to have the confidence to do so within an open and supportive working environment. ✓ One agency demonstrated advocating for young children going above and beyond due to professional curiosity. ✓ Evidence of good practice by asking manager to attend on joint visit when complex concerns emerged. ✓ Evidence of working with families requiring interpreter services and adapting to cultural practices to engage parents. ✓ Whilst prioritising life-saving medical treatment also parallel work to have a sense of the story behind the child’s journey and potential for safeguarding concern. ✓ Restorative practice being rolled out and promoting to partner agencies, will strengthen professional relationships. 7. What needs to be done differently to prevent harm occurring in similar circumstances • Children aged 0-2 are not always visible to services. At the time of the review fewer universal groups existed and practitioners explained that not enough services offer support directly to parents of new babies other than Midwifery and Health Visiting services. • The totality of commissioned services for infants needs to be mapped and a gap analysis completed in order to strengthen earlier identification of need and risk. • The single point of access for Children’s Services needs to be embedded and threshold well understood and applied consistently across the partnerships with the emphasis on ensuring ‘children are receiving the right service at the right time.’ • Practitioners need to report safeguarding concerns through the single point of access and not through the early help lead when an early help plan is in place. • The knowledge and skills of practitioners to observe and assess the lived experience of pre-verbal and non-verbal children needs to be improved including understanding child development. 6 • Information sharing continues to create challenges for professionals and an ongoing misunderstanding of data protection legislation including GDPR and consent. • The emotional and physical risk to babies and children of being present in a household (not necessary in the room where the incident occurred) where there is known domestic abuse needs to be understood and assessed. • All professionals across and within agencies need to robustly consider the likelihood of future risk to the children. Parental mental health concerns, substance misuse and domestic abuse can fluctuate over time, and therefore require a dynamic view of the risks. • Professionals should avoid assumptions about attendance and progress made at Domestic Abuse Recovery Programme course and ensure that the professionals running the course are an integral part of the assessment of risk and team around the child/ren. • It is the responsibility of all professionals to challenge their colleagues if new information is not sufficiently considered which may lead to a safeguarding risk. There needs to be a culture of respectful uncertainty and challenge between professionals if risks are not adequately considered or addressed by any agency. • Professionals across agencies must challenge their own practice as well as the practice of colleagues to ensure that their assessments of risk are not based on self-reporting from parents; that they consider the impact of parental history of drug misuse, domestic abuse and mental health; and that they are not over-optimistic in their analysis. • Fathers or co-parents need to be an equal part of assessments, support and plans in order to ensure that the needs and risks to a child are known and met. Professionals need to consider how they can meaningfully engage with a father/ co-parent. • All professionals need to know when a formal pre-birth assessment needs to be undertaken, and provide challenge if this does not happen. • All professionals that work with children and families are essential to keeping children safe and improving their outcomes. The contribution that all professional’s offer needs to be valued and respected. 7 8. What needs to happen to ensure that agencies learn from this review? The following recommendations will be progressed through action plans by the Local Safeguarding Children Partnership. 1. Map and publish the multi-agency pathway from conception to two-year-old and identify any gaps in current provision. 2. The Local Safeguarding Children Partnership should assure themselves that the standards set in the Public Health England health visiting and school nursing service delivery model published in May 2021 are being met 3. Promote the early help services within communities to ensure that families that need the services know how to self-refer. 4. Ensure all professionals know how to escalate concerns and are supported to do this. 5. Seek assurance from training providers to ensure that all domestic abuse training offered to partners takes account of the emotional and physical risk to infants and children. 6. Seek assurance from Domestic Abuse Commissioning Board that the current offer of Domestic Abuse Perpetrator Programmes considers risks to children and how they are monitored. 8 9. Evidence of changes since the thematic review commenced Across the Local Safeguarding Children Partnership, the learning from the Rapid Reviews was disseminated and the change particularly at a strategic level has been identified in the following areas since the reviews were completed. 9.1 Referral Processes and Front Door The reviews identified that changes to an on-line referral process the front doors in the local area was challenging for practitioners. This may have been due to initial implementation issues but practitioners were unsure if their referrals had been accepted. Children’s Services implemented a new approach at their Front Doors based on the work of Professor David Thorpe. The new approach removes the focus on risk and ‘child protection’ and moves to Early Help and preventative services and support. There has been a move away from agencies making written referrals and more of an emphasis on meaningful phone conversations with experienced social work consultants. 9.2 Early Help Offer At the time of the Rapid Reviews Early Help was underdeveloped in one of the local authority areas. However, as part of the DfE improvement work they have since developed and launched their Early help and prevention strategy and implemented the THRIVE model, a relationship-based and restorative approach to practice and has been working closely with local communities to implement early help across the locality. 9.3 Domestic Abuse offer including Recovery Programmes The local area published the Domestic Abuse Strategy 2021-2024, which is based upon the Domestic Abuse Act 2021 which recognises children as victims of domestic abuse. The multi-agency strategy promote the safeguarding of vulnerable individuals, families and children, seeking and listening to the voice of the child. The Local Safeguarding Children Partnership will seek assurance to ensure the impact of strategy is effective in safeguarding children at risk of Domestic Abuse. 9.4 Commissioning of 0-19 services The reviews coincided with the recommissioning of 0-19 health services in line with the National Commissioning Framework. There were some concerns initially expressed particularly from health practitioners that the new services may not meet the needs of families in the respective communities. Since then the CCG Executive Director of Nursing and Quality has advised the Local Safeguarding Children Partnership that there is no documented evidence that the 0-19 commissioned service is not fit for purpose but that the CCGs, and subsequently the ICS, will continue to monitor this. 9 10. Conclusion Restorative and trauma informed practice has been identified as an effective approach to child protection in the locality and focus group feedback sees the value in this being considered as crucial knowledge for all professionals working with babies, children and families, underpinning family assessments and care plans, with an aim of preventing harm to babies and children. As key agencies move into Integrated Care Systems (ICS) there is the prospect of joined up, meaningful working together and with that an increased understanding and trust of each other’s specialism and knowledge. There is a willingness and appetite for this to improve and there has been progress made since these rapid reviews were completed. This will continue to be monitored by the Local Safeguarding Children Partnership. 11. How will this learning be disseminated? In addition to the strategic changes identified above, on a practice level the learning has been and will continue to be incorporated into training, lunchtime learning bites, 7-minute briefings and the review of relevant policies and guidance. It will also be disseminated through briefings for staff in individual agencies. 11.1 Take the Learning into your Practice Take the issues raised in this thematic review into your supervision, team meeting and single or multi-agency group supervision for discussion. Consider the following: • Do I consider the likely ‘lived experience’ of children, including how to capture the voices of pre-verbal and non-verbal children? • Do I consider the longer-term risks to children if parental mental health issues and/or domestic abuse reoccurs? • Do I ensure that all relevant professionals providing services to the adults in the family are represented at meetings and contribute to plans for children? • Do I follow up concerns, escalate professional disagreements, and keep the child’s welfare at the heart of all communications? • Do I always engage both parents/carers regardless of their gender and ensure I seek their views independently? • Do I always challenge myself and others to ensure that our practice is not based entirely on self-reporting from parents and if the analysis is over-optimistic? • Am I clear about when and why a specific pre-birth assessment should be undertaken? • Do my strengths-based assessments robustly consider and focus on any risks and vulnerabilities? |
NC52471 | Death of 14-year-old boy and serious injuries to a 15-year-old boy from a traffic collision whilst travelling in a stolen car. Learnings include: a child's exposure to domestic violence constitutes emotional abuse and neglect; professionals need to be clear and persistent with parents about their concerns, their offer of help and the potential impact on their children if parents fail to engage; minimisation of multiple professionals working with the same family; child protection processes are necessary where parents do not engage in meaningful long-term change; lack of school attendance can be indicative of a safeguarding issue; where ongoing significant harm due to neglect is suspected, the holding of a strategy meeting is appropriate; professionals should always ask 'what is the impact of our actions on the child's outcomes?' and if a plan is not working, it needs to be changed; any solution or amelioration of the problem of criminality linked to familial neglect needs to be part of a multi-agency strategy including police and CSC. Recommendations include: prioritise an enhanced focus on the part of all agencies on effective, impactful engagement with families with young children, where neglect is identified; CSC should provide assurances that appropriate thresholds are applied in relation to neglect and that step-up processes are appropriately used in situations where parents are resistant to making the changes needed for their children; CSC should review and strengthen arrangements for dialogue and information sharing with schools and other agencies in order to better connect with the insight that these professionals can offer.
| Title: Child 1 and 2: LCSPR. LSCB: Wigan Safeguarding Partnership Author: Anthony Haley Date of publication: 2021 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Child 1 and 2 LCSPR Anthony Haley 2 Contents Executive Summary ................................................................................................................................................ 3 Methodology .......................................................................................................................................................... 5 Abbreviations .......................................................................................................................................................... 6 Terms of Reference ................................................................................................................................................ 7 Family Participation in the Review ......................................................................................................................... 7 Significant incidents for Child 1 .............................................................................................................................. 8 Significant incidents for Child 2 ............................................................................................................................ 10 Analysis of Practice and Learning ......................................................................................................................... 16 Recommendations ................................................................................................................................................ 25 Recommendation 1 .......................................................................................................................................... 25 Recommendation 2 .......................................................................................................................................... 25 Recommendation 3 .......................................................................................................................................... 25 3 Executive Summary This case concerns the circumstances leading up to the tragic death of Child 2, a 14 year-old boy and the serious injury of Child 1, a 15 year-old boy when they were both involved in a road traffic collision while travelling in a stolen car. Both boys were of white British heritage and lived with their respective mothers in the same locality. Neither child attended school regularly. Child 1 was exposed to criminal activity and domestic violence perpetrated by his father and his mother’s subsequent partners. Child 2 experienced a lack of effective parenting and, over time, was increasingly out of his home, seeking food and shelter where he could. Both boys had suffered neglect at home and were known to Children’s Social Care (CSC) from an early age. In both cases parents had been resistant to efforts to bring about improvements in their parenting. Notwithstanding this both children’s cases were closed to CSC and directed towards early help. Support for the families had always been at a level which presumed that the parent would agree to work in partnership with services and, when this did not happen, it failed to achieve significant change in the boys’ home lives. Neither child’s mother had prioritised their needs and, for years, both boys had spent a great deal of time, both day and night, out of their homes and involved with anti-social and criminal behaviour; often while part of a larger group of young people in the area. During the timeline under review, Child 1’s mother was convicted of failing to ensure that he attended school on the last of three occasions. When agencies escalated concerns about Child 2’s neglect, these did not result in a social work assessment. Resource issues and very high workloads in CSC had led to gatekeeping outside of the published thresholds for service. Child 2’s mother then asked for him to be accommodated due to her needing hospital treatment. At this point he was already out of her control and resistant to any placement, and was reported as repeatedly missing. Child 2’s mother was given a great deal of practical support by CSC. The focus of the work was on the mother’s demands rather than the child’s needs and his lived experience remained substantially unaffected. Despite the plan having been recognised as ineffective, it was continued for some time. In the case of Child 2, when early help services recognised that the case required social work input, they were unable to get beyond what was referred to by professionals as a ‘glass ceiling’ where the threshold would not be found to be met. This was notwithstanding the extensive knowledge, experience and insights of many early help professionals. Particularly good practice was seen on the part of Child 1 and Child 2’s different schools. They were persistent, supportive and creative in their attempts to engage the boys and to communicate with parents and CSC. The review identified a need to improve CSC’s communication with schools and partner agencies around critical decision making and processes. 4 Over the last summer before the critical incident, the boys’ criminal activity continued and reported incidents increased without an effective response from services. The review has identified missed opportunities to address early problems indicative of significant neglect and emotional harm for both boys. Later intervention became much more difficult for agencies as problems became entrenched and worsened. When the families proved resistant to working to improve the children’s respective circumstances, in their early life, step-up processes were not used and the impact and risks of allowing the neglect to continue were not fully understood. 5 Methodology This Local Child Safeguarding Practice Review was commissioned by Wigan Safeguarding Partnership under Working Together 20181. This is a systems-based review which has benefitted from the considerable work of a wide range of professionals and the involvement of frontline practitioners and managers who proved invaluable in informing the analysis and conclusions that have been arrived at. The work of the review was overseen by a review panel. Interviews were held with professionals who had been involved at the time, and relevant professionals participated in an online learning event. Participants are thanked for their insightful contributions. The review has focussed mainly on the period from the 1st of April 2018 to the 12th of October 2019. The review panel was comprised of: Designation Agency Review Author and Chair of Panel Independent Business Manager Wigan Safeguarding Partnership Learning and Improvement Officer Wigan Safeguarding Partnership Service Lead Children’s Social Care, Wigan Council Service Manager - Inclusion Wigan Council SEND Representative Wigan Council Detective Constable Serious Case Review Team, Greater Manchester Police Service Lead, Practice Improvement and Quality Assurance Children’s Social Care, Wigan Council Education Psychologist Wigan Council Specialist Nurse Safeguarding Children, (also representing Acute Services) WWL Community Practice Manager Targeted Youth Support Services (TYSS) Safeguarding Lead Newbridge Community Learning Headteacher Cansfield High School Senior Assistant Head and DSL Cansfield High School Deputy Headteacher and DSL Platt Bridge Community Primary School Deputy Headteacher and DSL Platt Bridge Community Primary School Startwell Worker Startwell Deputy Designated Nurse - Safeguarding Wigan Borough CCG 1https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/ Working_Together_to_Safeguard-Children.pdf 6 Abbreviations CSC Wigan Children’s Social Care M1 Mother of Child 1 F1 Father of Child 1 M2 Mother of Child 2 F2 Father of Child 2 TESS Targeted Education Support Services CIN Child In Need IRO Independent Reviewing Officer SW1 Social worker for the period when Child 2 initially became looked after SW2 Social worker for the period when Child 2 following the first period of accommodation FSW Family support worker PCSO Police Community Support Officer ACT Achieving Change Together Project 7 Terms of Reference The terms of reference below were used to establish learning through the prism of Child 1 and 2’s experiences: • How effectively did partners identify and address neglect where it was combined with parental non-engagement? • How confident can WSP be in the robustness of CIN and CP step-ups and step-downs and in the use of escalation processes to resolve professional differences? • To what extent were safeguarding considerations sufficiently in focus for children who had challenging behaviour, poor attendance and potential involvement in Child Criminal Exploitation? Was the multi-agency support for these children sufficient? • Where parents have been convicted for failing to ensure that their children attend school, what should the partnership response have been? Family Participation in the Review The panel would like to express thanks to Child 1’s mother who agreed to be interviewed. Her own life experience had been affected by considerable trauma and it had influenced her approach to school. She believed that the area in which she lived was not safe to walk around and that there was a lot of crime. She thought that the police knew what was going on and should be taking more action. When her son was much younger, she did not see any benefit in the support she was offered by CSC but is appreciative of what is now being done. She recognised the benefits of the support that her son had had from his school in the weeks immediately before the incident. The panel would also like to thank Child 2’s mother and sister who shared their views in an interview. They described Child 2’s personality and approach to life in warm terms. Child 2’s mother spoke about the large number of professionals that had been involved with the family. She perceived some to have been very supportive but she was critical of most social workers and other professionals as not helping her. She recalled unhappiness in her own childhood and her lack of a model for her parenting of her own children. Child 2’s mother was highly critical of the role of the police in their dealing with youth crime in the area and around the tragic incident. 8 Significant incidents for Child 1 Child 1 lived with his mother (M1), his father and two brothers, one 2 years older and one two years younger. The family is of white British heritage. Child 1’s father was known to be a drug user and had committed a large number of criminal offences. In 2015 his father left the family home and following this Child 1 has had little contact with him. Child 1, from his very early years, experienced many incidents of domestic violence between his mother and father and then between his mother and her subsequent partners. Prior to the period covered by this review, there were a number of years where there was a pattern of referrals to Children’s Social Care (CSC). These resulted in offers of voluntary support for the family’s complex issues. They particularly related to the impact of continuing domestic violence, neglect and housing issues on the children. Parenting support was offered but there was very limited take up by M1, and each time the case would be closed with a report of failure to engage with services. The Attendance Service and the school had been working to improve Child 1 and his brother’s school attendance. M1 had been prosecuted for failure to send them to school in October 2017 and January 2018 and had been found guilty on both occasions. On the second occasion M1 received a conditional discharge. Neither conviction significantly impacted on the children’s attendance. A referral to CSC in late 2017 related to Child 1’s poor school attendance and to neglect. A social work assessment concluded that the case should be again dealt with at family support level without the need for allocation to a social worker. Child 1’s behaviour at school was often challenging and his progress was limited. The school requested a learning assessment in 2017 from the Targeted Education Support Service (TESS) which identified him as having needs relating to language and communication, social and emotional skills, literacy and medical issues. The TESS and the school felt that his educational needs were more as a result of poor attendance than underlying ability, but it was thought to be important that nothing had been missed. Although a support programme was planned, Child 1’s continued sporadic attendance meant that he did not engage with the support. At the beginning of the time period covered by this review, Child 1’s absences from school continued and M1 did not wish to work with the professionals from several family support initiatives. The 9 issues with the family were discussed at Huddle meetings2. As M1’s voluntary engagement was required for these services to be provided, agencies planned to close the case. In June 2018 M1 and Child 1 were involved in an altercation involving an ex-partner of M1 and she was advised by the police to prioritise her children above her relationships. A referral by the police to CSC resulted in failed attempts by CSC to contact M1 by phone and a subsequent letter to her offering support, to which she did not respond. Another referral by police, in September 2018, relating to Child 1’s school attendance did not progress as it was felt by CSC that there were no safeguarding concerns. Both the school attendance team and the local authority attendance and enforcement team made approximately 80 home visits but this proved unsuccessful in sufficiently improving Child 1’s attendance. In November 2018 M1 took Child 1 to A &E with a suspected anxiety attack. He was subsequently referred to CAMHS but M1 then did not take him to appointments, so he was not seen. At Huddle meetings, concerns that Child 1 was carrying a knife, and had taken it into school, were discussed. His mother refused consent for him to complete sessions with the Targeted Youth Support Service (TYSS) on knife crime awareness despite tenacious efforts by the service to engage her. The school felt that there was little alternative provision for children like Child 1 locally and developed provision within the school. They identified highly skilled staff and created a small unit in order to address the needs of Child 1 and others with similar issues while avoiding having to exclude him. The attendance officer made another referral to CSC as M1 potentially faced a custodial sentence if convicted again for failing to send her children to school. A letter was sent to M1 asking her to make contact to discuss arrangements for the children but M1 did not respond, and the case was closed. In February 2019 M1 was convicted in her absence and a warrant was issued for her arrest. M1 was shocked and distressed when she was later arrested and taken to court by the police. She received a further 12-month community order with an unpaid work requirement. Following the hearing she was spoken to by probation and said that the boys would not miss a day of school. 2 Meetings held as part of Wigan’s place based integrated working. https://www.wigan.gov.uk/Docs/PDF/Council/The-Deal/Deal-conference/Place-based-working- Presentation.pdf 10 M1 did then send her children to school. Child 1 attended his part-time timetable every day for several weeks, and began to benefit from the alternative provision. M1 failed to attend subsequent probation appointments or meetings with the school. By the end of May 2019 Child 1’s attendance and behaviour had deteriorated again and his anxiety about returning to mainstream classes had meant that he remained on a part-time timetable. Over the summer months, there were an escalating number of police reports involving Child 1 who was with Child 2, smoking cannabis and being involved in vehicle crime and anti-social behaviour in the area. Much of their time was spent with a gang of up to 30 young people, aged between 11 and 19, who were well known to the police and other services. Child 1 returned to school in September to start year 11 and attended well for the first few weeks but, when not in school, was still often out with others involved in crime and anti-social behaviour. M1 failed to attend court for the breach of her probation order and a warrant was issued. This warrant was still live, many months later, at the time of the incident when Child 1 sustained his injuries. Significant incidents for Child 2 Child 2 had a sister who was 2 years older than him. Their parents had split up early in Child 2’s life and their father had moved away, having little subsequent contact with the family. Two half siblings were born as a result of his mother’s later relationship; a brother 2 years younger than Child 2 and a sister 6 years younger. At the beginning of the time period of this review the new relationship had ended and Child 2 was living with his mother (M2). All his siblings had all been living for some time with the father of the younger children and their grandmother. Child 2 had an extensive history of involvement with CSC from his early years because of neglect. He was known to be associating with a large group of mainly older youths and had smoked cannabis from the age of 9. He first came to the attention of the police at the age of 10 for threatening to stab another child. Police records indicate that he perpetrated a number of assaults and was himself a victim of several assaults. However, prosecutions were not supported by the victims. At the age of 12 there were concerns from his school that Child 2 was ‘sofa surfing’. He was often sleeping and being fed in the homes of various friends. His behaviour problems had become evident when he was in nursery. He had attendance and behaviour issues at primary school and after a short period at a mainstream secondary school he was transferred to a specialist school for pupils with social, emotional and mental health needs. 11 Child 2’s mother said that she thought that he had ADHD. Notwithstanding this, she did not take him to appointments for diagnosis or to other health appointments. In late 2017 Child 2 reported to school staff that he had been camping out and taking cars, driving cars, racing with other drivers and taking spice. He told staff that he had earned £150 in a week by going into people’s houses and stealing car keys. A few months later Child 2 had an injured back and leg. There was evidence shared with his school by another pupil that he had been driving a stolen car and had gone through the windscreen when he crashed it. His mother said that this was not true. TYSS attempted to engage with Child 2 and to encourage him to attend school but he was often avoidant. At this point the family had been open to early help for around six years. M2’s interactions with professionals were often characterised by her demanding and threatening behaviour. At the start of the timeline the primary school that Child 2 had attended, and which his younger siblings still attended, had already used the Professional Conflict Resolution Policy to inform CSC senior managers of concerns that they were not addressing the multitude of emerging and longstanding issues in the whole family which had already been raised. The escalation was accompanied by a thorough analysis of how the case met thresholds of need against the CSC published threshold document. It identified that CSC appeared to see each issue as an individual piece of work and issues were never viewed holistically or in context. These included “many examples of ineffective and absentee parenting”. When CSC continued not to attend meetings to discuss the issues, the matter was escalated to the safeguarding board manager. In response to this escalation, a CSC manager made a commitment that social workers would attend meetings on the family but this was not followed through. Because of the concerns about neglect shared by Child 2’s school and TYSS, a Graded Care Profile3 was completed by a TYSS worker and passed on to CSC. This identified significant issues, but no action by CSC resulted. TYSS then persisted in engaging with Child 2 and arranged with the school that he could attend a bike mechanics course if he attended school. At the end of May 2018, M2 contacted CSC as she had to go into hospital and, although her other children were able to live with her ex-partner and his family, they would not look after her son, Child 2, while she was in hospital and had a period of recovery at home. 3 https://www.wigan.gov.uk/Docs/PDF/WSCB/Wigan-Graded-Care-Profile-toolkit.pdf 12 It would appear that M2 had initially contacted the CSC team which she had dealt with previously as she felt that they knew all her family history but the manager of that team would not accept the case so it had been passed to the duty team. A senior manager decided that it should stay with the duty team. A neighbour had been previously supporting Child 2 when he needed a meal or a shower. M2 initially agreed to the neighbour being a potential carer but then withdrew her consent. She also refused to allow Child 2 to be introduced to his foster carers to prepare him for his placement. As no alternatives could be found, a decision was made to accommodate him under Section 20 of the Children Act 19894 for a period of 6 weeks. At this point Child 2 had poor attendance at school. Staff at school had not seen Child 2 to be violent or aggressive but M2 had described him as violent towards her. She was, however, adamant that she did not want the care arrangement to be permanent. Once placed, Child 2 went missing repeatedly from a series of foster care placements over the next few weeks. Each time this was reported to the police. He was often either sleeping in an old caravan or in his home, which he had broken into while M2 was in hospital. He was regularly seen with the large group of young people which also included Child 1. Child 2 continued stay out at night or stay at his home when M2 returned from hospital. A CSC strategy discussion agreed a plan to take Child 2’s case to a Legal Gateway meeting. His Independent Reviewing Officer (IRO) reviewed the case; finding that Child 2 was not attending school and very reluctant to engage with professionals. M2 had been obstructive during missing from home investigations and denied that he was home when neighbours had seen him there. M2 reluctantly agreed to discharge Child 2 from Section 20 accommodation at the end of July 2018 as he had effectively not been residing in a care placement. His social worker was then not in work and, in her absence, an assessment concluded that M2 was willing to engage with services and that Child 2 had self-care skills. M2 spoke, in interview, about her experience with social workers throughout Child 2’s life. She felt that when she asked for help they would often want her to do something and she felt blamed. She described her response as “giving it them straight” and did not recognise herself as having been given any advice on improving the situation. M2 did remember benefitting from the delivery of a specific program of Multi-Systemic Therapy (MST) to help with her relationship with another child. This service, however, had been discontinued by the time she asked for similar support for her issues with Child 2. 4 https://www.legislation.gov.uk/ukpga/1989/41/section/20 13 In interview, the social worker recalled how extremely difficult it had been to work with M2. Less senior staff had been advised not to take calls from M2 because of the emotional impact of her difficult calls. She found M2 very angry and resistant to any suggestion that she modify her parenting behaviour. M2 would become very upset if a conversation was not focused on her needs and demands. This was the same pattern of behaviour that had already been observed by both of Child 2’s schools. It was also observed in M2’s interactions with health professionals and early help staff. On the occasions where the duty social worker (SW1) spoke to Child 2, he avoided eye contact. He was poorly dressed with torn and dirty clothes and had holes in his shoes. He did not want to be in care and believed that he could look after himself. M2 had received, and continued to receive, a great deal of practical support, organized by CSC. This consisted of deep cleaning the house, removing large quantities of refuse, and repairing and replacing windows and doors. Household appliances and money were provided, as were new clothes for Child 2. Child 2 was bought a mobile phone so that he could be contacted when missing. In addition, food parcels were frequently provided by a Family Support Worker (FSW). M2 was transported to her hospital visits and GP appointments by Child 2’s subsequent social worker (SW2). This type of support by professionals, in clearing and repairing damaged houses was one that had repeated several times over in Child 2’s earlier life. The local community were also known to have helped by re-clearing the house prior to CSC arranged visits. Unfortunately the community efforts also had the effect of removing some of Child 2’s clothing and therefore made his personal situation worse. In mid-September M2 again requested that Child 2 be accommodated as she was due to have further tests in hospital. Child 2 was clear in his view that he wanted to stay at home. CSC recorded that M2 was unable to prioritise her son’s needs above her own and that Child 2 did not recognise the danger and risk as he had been exposed to this on a regular basis previously when he had been left to spend his time as he wished. During this period of accommodation, the same pattern was repeated of Child 2 being reported missing and often then found by police to be spending his time with other youths in the area. Child 2’s use of the house while his mother was away contributed to very poor living conditions and CSC again arranged for professional cleaning, removal of refuse and the removal and replacement of broken beds. The Complex Safeguarding Team recorded 29 Missing From Home (MFH) episodes for Child 2, and had been unable to contact M2. Child 2 refused to engage with MFH interviews and a letter was 14 sent to M2 asking her to contact them. She did not do so. It was then decided not to report any further MFH if his whereabouts were believed to be known. M2 did make requests for information about his whereabouts via social media. The school continued to engage with Child 2 and he began to attend a bike mechanics course. Child 2 had an interest in mechanics and motorbikes and was motivated to attend the course. At night he was either at his home, out with other young people, or at the homes of friends including Child 1 rather than with his foster carers. Despite only sporadic attendance at school, he was allowed to continue with the bike mechanics course, as this was seen to be a safe place for him to be. Child 2 was very well regarded on the bike mechanics course. His passion and natural talent would have been likely to have made him successful in a career as a mechanic. He was always cheerful when on the course and the first to offer help to less able students. Child 2 had not had a foster placement since mid-October as each one had broken down. This period of accommodation was formally ended at the end of March 2019 when M2 advised CSC that Child 2 was now staying with her friend M1. From that point his case was stepped down to CIN level. M2 would cancel appointments on the grounds of her or Child 2’s ill health. She had accompanied him to A&E when he was suffering from a severe tooth abscess but failed to take him to follow up appointments or to appointments to assess him for ADHD. CSC social workers and managers recognised that M2 was avoiding an assessment of her own needs by adult social care and she was using the CSC social worker to fulfil her needs rather than her son’s. When the case was discussed with the social worker in supervision this was acknowledged but no better plan was suggested than to continue to attempt to engage with M2 and Child 2. M2 was allocated an adult social care social worker but continued to ask for, and accept, support from SW2 and FSW in the form of transport to appointments, funding for her needs and support in sorting out her benefits. She was still reluctant to allow professionals into her house. Visits were cancelled or took place on the doorstep. SW2 took Child 2 to his appointment and he was diagnosed with ADHD. M2 then applied for Disability Living Allowance (DLA). In a further supervision discussion between the principal manager and team manager, it was acknowledged that little had been done for Child 2 as most of the support had been for M2, and she was leaving him to fend for himself rather than parenting him. After a discussion with early help 15 services which had previously withdrawn due to lack of engagement, CSC’s involvement was to be reconsidered. During the summer Child 2 was seen repeatedly with other young people, including Child 1, on stolen motorcycles riding around the area and causing damage to property. In October 2019 Child 1 and 2 were involved in a road traffic collision where Child 2 was driving a stolen car. Child 1 was one of several passengers. Child 2 died shortly afterwards and Child 1 was seriously injured. 16 Analysis of Practice and Learning The considerable trauma that M1 had experienced in her own life, impacted on her capacity to allow services to become involved in her family. She had disengaged from school herself and her poor experience would have affected her understanding of the potential of education. Her perception of agencies’ attempts to engage with her, when her son was younger, was that they were not helping her. She recalled, in interview, that she did not feel they offered her anything useful. A critical factor in Child 1’s life was his exposure to domestic violence. The Greater Manchester safeguarding procedures5 recognise the repeated exposure of a child to domestic violence and abuse as neglect in itself. Each time CSC were involved with the family, avoidance by M1 led to case closure as effective work could not be done. There is little indication that any of the attempts to work with Child 1’s family resulted in any progress that would be meaningful for him. M2’s parenting was affected by her life experiences and her illnesses. Her lack of a positive parental model meant that she was very much in need of support and advice when she became a parent. M2 had developed a pattern of highly confrontational behaviour when dealing with others that was functional to the extent that it had the effect of deflecting from any professional challenge and maintained the focus on her needs as she perceived them. It was against this context that professionals struggled to focus on Child 2. It was clear from M2’s interview that there had been attempts by professionals to offer some challenge but that this had not been sufficient or persistent enough to overcome her resistance to advice or for her to understand their cause for concern. She did not understand that the purpose of CSC’s involvement was to improve the lived experience and outcomes of her children. She saw them as either succeeding or failing in the extent to which they met her perceived needs which were largely material and practical. As challenge from social workers never got through her resistance, M2 genuinely did not develop any insight into the potential of her parenting to improve her children’s life chances. 5 https://greatermanchesterscb.proceduresonline.com/chapters/p_neglect.html?zoom_highlight=neglect Key Learning – A child’s exposure to domestic violence constitutes emotional abuse and neglect. 17 Both Child 1 and Child 2’s separate lives were known to services significantly before the timeline. A lack of parental supervision and structure in their lives had already led to them spending a great deal of time out of their homes and out of their respective schools. In these circumstances they had both found a sense of belonging within a group of boys with similar backgrounds who were involved in criminality and anti-social behaviour. Social workers dealing with challenging parents and carers need to be particularly skilled, and have a clear plan which is persistently followed until the child’s needs are sufficiently met. To do this they will need to be well supported and the vital importance of early intervention with parents of young children should be understood. Although neglect was identified early in Child 2’s life, it was strongly linked to material conditions in the home. A short-term focus by CSC on temporary improvements led to the case being stepped - down without proper consideration of other aspects of the child’s lived experience. Inappropriate closure, and a new social worker every time the case was re-opened, did not assist in meeting Child 2’s needs. Given the difficulty of working with Child 2 and his mother, the number of individuals who were trying to deliver services was problematic. Multiple services and individuals with differing emphases attempted to engage M2 and her son. What happened, in effect, was that the impact of collective efforts was diluted. It was entirely appropriate to begin work with both these distinct families by attempting to support them to engage with services which assumed a willingness on the part of the parent to work in partnership. However, when it became clear that there was no prospect of real cooperative engagement, despite the persistence of professionals, and the welfare of a child continued to be compromised, there was a need to use statutory processes at the appropriate level. This did not happen in either case; primarily as a result of workload pressures within CSC. There was some consensus between professionals that CSC routinely dealt with workload pressure by responding to issues in isolation rather than holistically. Consequently, once attempts had been made to address the immediate presenting issue, the case could be closed without reference to the Key Learning – Professionals need to be clear and persistent with parents about their concerns, their offer of help and the potential impact on their children if parents fail to engage. Key Learning – Multiple professionals working with the same family should be minimised wherever possible. 18 overall context of the child’s life. Social workers were carrying very heavy caseloads and, at the time, the threshold for a social work assessment was much higher than the published thresholds. Much is in the public domain about the effects of the application of thresholds in Wigan’s Childrens Services. An Ofsted focused visit in January 2020, looking back at the second half of 2019, commented on the effects of extremely high caseloads. A subsequent visit by Ofsted in November 2020 recorded that ‘inconsistency remains in the quality of practice and not all children receive the right level of support, particularly those experiencing chronic neglect’6. Recent changes in management and resourcing have seen significant improvements in the operation of thresholds in CSC. However, it remained the view of many stakeholders in this process, at an event held in February 2021, that they were not yet confident that neglect would be managed very differently. This area therefore needs to remain in focus until the effect of changes is seen. The best opportunities to significantly improve both individual children’s life chances were missed early on. This would have been when issues were first identified, pre-school. Dr Julie Wilkinson explored the issue of parental vulnerabilities in the evidence review ‘The impacts of abuse and neglect on children’. She identified a number of parental vulnerabilities that are associated with increased risk of maltreatment of children including: parent's exposure to adverse experiences during childhood (e.g. parental domestic violence, substance misuse, mental health issues); domestic abuse; mental health difficulties; drug or alcohol misuse; a history of crime; patterns of multiple consecutive partners; acrimonious separation; multi-generational cycles of child maltreatment. Providing earlier, effective support to parents, whilst keeping the child's welfare in mind, can reduce the risk of maltreatment7. Early, assertive and impactful intervention is vital. Where persistent offers of support for children are declined or minimal progress is achieved, closure should not be the next step. Rather, in the face of continuing harm through neglect, the step-up process should be followed until such time as positive engagement achieves an improvement in the child’s life chances. M2 benefitted from a program of support (Multi-Systemic Therapy) when another of her children experienced significant health and behavioural problems and M2 was having difficulty with this. The therapy was very specific in its focus but was effective in engaging M2 who has retained some of 6 https://files.ofsted.gov.uk/v1/file/50156333 7https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/602148/ Childhood_neglect_and_abuse_comparing_placement_options.pdf Key Learning – Only holistic assessments will draw out the impact of neglect on children over time. 19 the learning from the process. This serves to illustrate that there was potential to undertake meaningful work with M2. During the timeline, CSC received referrals where the presenting issue was Child 1’s lack of school attendance. This was not seen as a safeguarding issue, and not seen in the known family context of neglect and domestic violence. It has been acknowledged by CSC as part of this process, that the situation would have been better dealt with by undertaking a social work assessment, but this was not done. Had it been done, Child 1’s lived experience, and the risks therein, might have been better understood. Poor attendance can have a number of causes, including child physical and mental health or parental capacity, and professional curiosity is required to identify the service required. Good practice was seen in the work of both children’s schools. Child 1 had missed a great deal of learning and was anxious about attending mainstream lessons. His school was persistent in trying to find a way of working with him and his mother. They were mindful of his vulnerabilities and when his behaviour in school potentially merited his exclusion, they were determined not to give up on him. By creating high quality alternative provision within the school, they benefitted Child 1 by improving his engagement and confidence, and ultimately, by the start of year 11, his attendance. A great deal of persistence was evident in the work that the school and the attendance service undertook together in attempting to engage with M1. There is considerable evidence that these efforts significantly contributed to eventual progress with his attendance and better engagement and confidence as he moved into his last year at school. The attendance service worked well with the school to try to engage with M1 and ultimately, when this proved impossible, to bring a series of prosecutions, which led, eventually, to her making her children’s attending school a greater priority. It was her concern at her arrest which changed, for a time, M1’s pattern of avoidance and improved Child 1’s attendance at school. When M1 did want the children to attend school they did so, demonstrating that this was not outside of her control. The role of the attendance service in the life of Child 2 during our timeline was complicated by his mother’s illness and a lack of clarity about whether M2 had sufficient influence to get him to attend school. While he was accommodated it became the responsibility of CSC to ensure his school Key Learning – Child protection processes are necessary where parents do not engage in meaningful long-term change, in order to avoid a child suffering significant harm through neglect. Key Learning – Lack of school attendance can be indicative of a safeguarding issue. 20 attendance. This meant that attempting to go down the route of prosecution would have been inappropriate. Child 2’s primary school were persistent in pursuing his welfare even after he had left the school. This included the thorough analysis of his issues which accompanied a complaint to CSC about their lack of engagement which was later passed to the safeguarding board manager. The detailed breakdown of the family issues set against the local authority’s published threshold document were not effective in changing decision making as managers believed that the case did not meet the thresholds that they were applying and these were not the published thresholds. An issue raised at the learning event is that many find the Resolution of Professional Disagreements Policy8 difficult to use as it requires contacting an equivalent professional without the structures being clear who that might be. The use of this policy in the case of Child 2 only occurred because of the longstanding contacts the school had already made, and their tenacity in spending considerable time putting the concerns in writing and attempting to contact CSC at social worker and management level. Child 2’s school offered him some refuge at times of particular stress. Child 2’s community special school demonstrated high quality pastoral care and he developed significant relationships at school. The school did not experience the levels of aggressive and destructive behaviour that were reported by his mother and seen in the community. Child 2 was seen by the school as not violent and very honest. This may have been because of the good relationships they had formed with him and because he had no boundaries at home and there was no consequence to his revealing his criminal activity. The school worked with TYSS to provide a route for Child 2 to attend Bike Mechanics which engaged with his interests and skills. Child 2’s interest in eventually pursuing a career as a mechanic was a real positive in his troubled life. TYSS were persistent in attempting to gain M1’s consent to knife crime awareness work with Child 1. Given his mother’s refusal to permit this, they might have considered escalating the matter as a safeguarding concern and given CSC clearer understanding of the risks. However, the high thresholds at the time would have made the case unlikely to progress to an assessment. When TYSS’s concerns about Child 2 led them to complete a Graded Care Profile and they shared their concerns with CSC. At the time, CSC did not give proper consideration to concerns of neglect raised by partners. Again, high thresholds meant that no action was taken. 8 https://greatermanchesterscb.proceduresonline.com/chapters/p_resolv_prof_dis.html 21 Neglect is a very difficult issue for CSC and partners to deal with. It is the most prevalent form of child harm and often does not manifest as a serious incident that can be investigated but causes cumulative damage over time if not effectively addressed. Given its nature, it is less likely that neglect will trigger a strategy discussion or meeting under Section 47 of the Children Act 19899 but a strategy meeting should be held whenever there is reasonable cause to suspect that a child is suffering or is likely to suffer significant harm. By the time M2 requested accommodation for Child 2 the local authority had few good options. He was very much beyond parental control and was resistant to being in the care of the local authority. Without the use of powers to place him in secure detention under Section 25 of the Children Act 198910, he was unlikely to stay where he was placed. At this point in his life Child 2 would have been likely to have absconded from any non-secure residential provision. A period of secure accommodation would have allowed intensive work with him that would not have been possible otherwise. This might have been beneficial in dealing with his health issues and providing educational opportunities. It would have given him an experience of boundaries and may have helped him to develop insight into his predicament. However, the local authority could not make an application under Section 25 without being able to demonstrate that every other option had been comprehensively considered and rejected. The case had been previously managed and closed without the use of child protection planning, and without exhausting all other options so the criteria was not met. Even if secure accommodation had been an option, it would not have been a long-term solution and would not have been without psychological risks. Both boys had been discussed in Huddle meetings. When Huddles were established, the intention was that there would be an integrated response by services including CSC. In practice this did not occur and the lack of social work involvement limited the usefulness of these meetings as a vital component service was not present. It is recognized that this was a significant gap. Huddles are now being replaced by Complex Care Panels and this model is currently being developed. Going 9 https://www.legislation.gov.uk/ukpga/1989/41/section/47 10 https://www.legislation.gov.uk/ukpga/1989/41/section/25 Key Learning – Where a Graded Care Profile is completed and significant concerns are identified by agencies, CSC should always provide a response. Key Learning – Where ongoing significant harm due to neglect is suspected, the holding of a strategy meeting is appropriate. 22 forward it will be important that there is an appropriate link with CSC so that social work supports, and is engaged with, forthcoming complex care panels. Reflecting on the situation at the time, professionals identified general issues with lack of communication from CSC about critical decision making, including not being informed of changes of social worker, moving between teams or changes in plans including case closures. This meant that, for example, schools and partners often believed that children were being worked with when they were not, and had to take the initiative to seek out the information. They recognised this as a symptom of a system under considerable pressure with a high turnover in staff at the time. A change in working practices during the pandemic has led to online meetings which are much more accessible for professionals. This should be capitalized on as future processes are developed to facilitate more consistent attendance by agency representatives so that those attending are familiar with the cases being discussed and the content of previous discussions. An agenda with specific timeslots for discussion of individual children might make more efficient use of school staff and other professional’s time as they would then need only attend to discuss relevant cases. Day-to-day information sharing might be improved by the use of a single point of contact in the local authority. Such a person might also be best placed to consistently chair the meetings. When Child 2 had become a looked after child, the focus of services was on the time consuming and expensive, but easily achievable, practical support that failed to address or impact on the underlying behaviour of both M2 and Child 2 and its cause. It was therefore likely that M2 would not maintain the material conditions of the home and that, when she was in hospital, Child 2 would enter the property and do significant damage. Child 2 did not see much benefit from the material improvements to the house and released his frustration by damaging again the internal doors that had just been replaced. M2’s diagnosis with illness made challenge more difficult as professionals became focused on the support of M2’s health needs and priorities. A clear understanding of M2’s health issues was obscured by M2’s own lack of understanding of her health, compounded by her health anxiety and her refusal to allow social workers to speak to her GP. Key Learning – High quality communication between services and schools is crucial. Changes necessitated by the pandemic, allowing easier attendance at meetings, should be capitalized upon as they present opportunities for more efficient working. Clearer supportive links with CSC might further enhance what schools are able to achieve. 23 Services encountered resistance from M2 except where they were responding to her demands. Her positive response to the practical and material help, created a false sense that she was engaged with services, but she remained resistant to issues that were not on her agenda. Her often challenging approach to professionals was functional as it had the effect of deflecting from Child 2’s needs to her demands. Help was provided to M2 and a great deal of professional time and effort was expended but there is little evidence of any effective challenge which resulted in a change in her parenting. It was clear to the social worker, and to the managers who reviewed the case in supervision sessions, that the effort being put in to supporting M2 was not effective in improving Child 2’s life. It was recognised as being more appropriately provided by her own adult social worker. Professionals worked hard but neither the family support workers nor the social workers were engaged in focused action in support of a potentially impactful plan. Wigan, together with Rochdale, pioneered a model of complex and contextual safeguarding working which has been recognised and widely adopted across Greater Manchester. The formation of a complex safeguarding team followed from the previously successful project Achieving Change Together (ACT) which worked intensively with young people vulnerable to child sexual exploitation (CSE). This work was done in a way that recognised that children at risk of exploitation were not being effectively protected by becoming looked after. Evidence that the project was successful11 led to the use of its evidence base to inform the development of complex safeguarding across Greater Manchester. The principles that underpinned the ACT model were recognised as having a broader application to other forms of exploitation beyond CSE alone and would involve collaboration between agencies, including the police and CSC. The ambition for this work, as briefed in January 2019 and reported by BASW, was to encompass criminal activity involving children where there was ‘exploitation and/or a clear or implied safeguarding concern’12. 11 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/601976/ Child_sexual_exploitation_project_Wigan_and_Rochdale_evaluation.pdf 12 https://www.basw.co.uk/system/files/resources/Safeguarding%20during%20adolescence- Briefing_Jan19_v3.pdf Key Learning – Professionals should always ask ‘What is the impact of our actions on the child’s outcomes?’ If a plan is not working over time, it needs to be changed. 24 In practice this wide a remit has not been implemented and the current model is focused on CSE and Child Criminal Exploitation (CCE). The criminal and anti-social behaviour of the group of boys which included Child 1 and 2 did not meet the current remit of the complex safeguarding team as these boys were associating with a group of similar young people without a strong hierarchy and there was no evidence of grooming or exploitation but rather more of participation in loosely organized joint enterprise. Both boys were believed by the police, to not directly commit crimes but were often involved on the periphery. For example, they were not stealing the vehicles themselves but were driving stolen cars and motorbikes. In reality, no agency had a strategy for dealing with the activities of these young people and the problem had become entrenched. Key Learning – Any solution or amelioration of the problem of criminality linked to familial neglect needs to be part of a multi-agency strategy including Police and CSC. 25 Recommendations Recommendation 1 The safeguarding partnership should prioritise an enhanced focus on the part of all agencies on effective, impactful engagement with families with young children, where neglect is identified. Recommendation 2 Children’s services should provide assurances to the partnership that appropriate thresholds are applied in relation to neglect and that step-up processes are appropriately used in situations where parents are resistant to, or avoidant of, making the changes needed for their children. Step-down processes should not be used unless there is assurance that the necessary progress has been achieved. Recommendation 3 CSC should review and strengthen arrangements for dialogue and information sharing with schools and other agencies in order to better connect with the rich seam of knowledge and insight that these professionals can offer. Greater effort should be made to consult with schools about changes in plans, allocations and planned closures. |
NC52235 | Unexpected death from bronchial asthma of Khalsa, a 14-year-old boy, in October 2019. Khalsa had received medical care for acute asthma since he was 3-4-years- old and was admitted to hospital three times in the two years prior to his death. Khalsa was raised by his father following the death of his mother when he was 7-years -old. He lived with his father and three older adult siblings. Concerns raised by Khalsa's general practitioner about the management of his asthma and his father's understanding of how to support his son led to Khalsa being made the subject of a Child in Need Plan. A pattern of cancelling and rescheduling appointments by Khalsa's father was noted, however he was otherwise well cared for. Khalsa was raised within the Sikh faith. Key findings include: communication between multiple medical services and trusts did not allow practitioners to understand and contribute to the risk discussion; the need to create systems that enable young people to have a voice to participate in their health plans, specifically when this may be overridden by parental influence; the perception of asthma as not being potentially life threatening can impact on how some professionals engage in professional curiosity. Recommendations include: ensure timely information sharing between multiple universal services and acute hospital trusts; and increase awareness of asthma and its management across agencies and communities.
| Title: Child safeguarding practice review – Khalsa. LSCB: Waltham Forest Safeguarding Children Board Author: Gill Nash, Suzanne Elwick and Dave Peplow Date of publication: 2020 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. Waltham Forest Safeguarding Children Board Child Safeguarding Practice Review - Khalsa November 2020 Authors Gill Nash, Head of Settings and Workforce Safeguarding, LBWF Supported by Suzanne Elwick and Dave Peplow Page 1 of 10 Contents 1. Introduction and reason for the review 2. Methodology and agencies involved 3. Findings and learning points 1. Introduction and reason for the review. Under Working Together 2018, The Local Safeguarding Partnership for Waltham Forest Children Safeguarding Board agreed to the recommendation from the One Panel (multi-agency forum that takes referrals for local or statutory reviews and makes recommendations against the statutory criteria) to undertake a Child Safeguarding Practice Review in respect of Khalsa who sadly died aged 14 years old, in October 2019. This Child Safeguarding Practice Review concerns the unexpected death of a 14-year-old boy, who we are calling Khalsa, and the services provided to Khalsa and his father during the 24 months preceding his death. Khalsa had a diagnosis of acute asthma and had been in receipt of medical services for the treatment of this since he was approximately 3-4 years old. The cause of death was recorded as bronchial asthma, a natural death caused by an acute asthmatic event. It is imperative that Khalsa and his family have their identity protected, so while the review has looked in detail at his circumstances this report does not include these details. Khalsa had been a resident of Waltham Forest with his father and 3 older, adult siblings. They resided in a 3-bedroom property which the father described as cramped for the size of their family and with issues such as damp which he had been trying to resolve with the local authority housing department. Khalsa was being raised by his father following the sudden death of his mother when he was 7 years old. The death of his mother was understandably devastating for the family and they struggled to adapt to the changes of their world. Khalsa attended a local secondary school and there were no concerns about his educational attainment or presentation. Khalsa was raised within the Sikh faith and this was important to him and his family. Khalsa was described by those who knew him as a kind and helpful young person who sought to do the right thing and was loyal to those who knew him. Khalsa often presented as “well” which meant that some people involved with him may have underestimated the severity of his illness. This ‘over optimism of wellness’ Page 2 of 10 created a contradiction for professionals about the possible risks to Khalsa within the safeguarding context. Khalsa’s asthma was said to be “managed” We know from the information presented as part of the review that he also experienced episodes of significant incidents which resulted in emergency medical services being called on 3 occasions prior to his death. On the 3rd occasion ambulance and hospital staff were unable to revive him and he was pronounced dead on the 12th October 2019 with the cause of death given as respiratory arrest due to asthma Family Involvement Khalsa’s father was approached and agreed to contribute to this review. Khalsa’s father met with the lead reviewer and a review team member connected to the school. His contributions have been included in this report and we are grateful for this. The pseudonym Khalsa was chosen by his father, as a recognition of his child, who he was and his strong commitment to his Sikh faith. 2. Methodology and agencies involved. This review has been carried out in a way that reflects the principles of a systems-based approach. The review seeks to understand why things happened in the way that they did. Broadly this means using this case as a ‘window on the system’, asking the question: What does Khalsa’s experience tell us about how systems work? This systems approach focuses on multi-agency professional practice. The goal is to move beyond the case specifics of the particular case and ask what happened and why, to identify the underlying issues that are influencing practice more generally. The aim is to look for areas that relate to systemic issues, which will lead to changes in practice. The review is not about blame. The focus of the review is very much on learning and improving practice for the future. Data was gathered from a variety of sources, including the review of existing documentation alongside data provided by front line practitioners and their managers and senior managers in the review team. Additional advice and reflections were sought from a specialist asthma health professional. The final report has been authored by Gill Nash and Suzanne Elwick (Head of Strategic Partnerships) who are employed by the London Borough of Waltham Forest and Dave Peplow (Independent Scrutineer for the WFSCB) who is independent of the partnership. Significant contributions were provided by Liz Royale, Designated Nurse for Children at Newham CCG. The Senior Responsible Officer for the partnership overseeing the review was Ghislaine Stephenson, Associate Director of Nursing for Children, Barts Health Trust. The review period is from November 2017 to October 2019, covering the two-year period preceding Khalsa’s death. The review group was made up of senior managers from all those agencies involved with Khalsa and his family in the 24 months before his death. The review group met Page 3 of 10 with the lead reviewer to consider emerging issues and took part in a workshop with frontline practitioners who knew Khalsa and his family. The review team appreciated the professional, open and honest way all concerned conducted themselves throughout the process. The agencies involved were: London Borough of Waltham Forest • London Borough of Waltham Forest Safeguarding Team • London Borough of Waltham Forest Early Help Team • London Borough of Waltham Forest Housing Department Health • Barts Heath Trust – Royal London Hospital • Waltham Forest CCG • GP • Homerton University Hospital NHS Foundation Trust – Named Nurse and Asthma Nurse. • North Middlesex University Hospital Trust • North East London Foundation Trust NELFT – Asthma Nurse/school nurse London Metropolitan Police Service • Specialist Case Review Group 3. Findings and learning points Asthma Asthma is the most common long-term medical condition in children. It is an inflammatory condition that affects the airways. The usual symptoms include wheeze, difficulty in breathing, chest tightness and coughing, particularly at night or in the early hours. Its severity varies from mild, moderate to severe and can cause physical and psychological distress affecting quality of life. It cannot be cured but, with appropriate management, quality of life can be improved. (Healthy London Partnership, August 2020) Safeguarding pathways. There was much discussion during the review with both the review team and practitioners about pathways. We explored professionals’ recognition of appropriate safeguarding pathways, with specific reference to how asthma is viewed and how this impacted on professional’s confidence to manage the concern. The concerns in this case were health specific. Khalsa was otherwise well cared for and his overall needs were met. When concerns are raised about parental capacity in relation to a singular issue the overwhelming positivity of other factors can minimise the real risk Page 4 of 10 of the health concerns. The following findings impacted on how the issues in this case were managed but we highlighted a definitive need for all professionals within the safeguarding partnerships to understand the different local health safeguarding pathways as this was not known to all. This would enable the relevant agencies to understand and access the expertise of the professional’s networks, specifically access to those with medical expertise. Summary of Findings Finding 1 Systems communication between multiple universal and acute medical services and Trusts was not conducive to allowing practitioners to understand and contribute to the risk discussion. At times the right people did not have the right information at the right time. Finding 2 There is a need to create systems that enable young people to have a voice to influence and participate in their own health plans – specifically when young peoples’ competence to do this is overridden by parental influence. Finding 3 The perception of asthma as not being potentially life threatening can impact on how some professionals engage in professional curiosity, specifically in the context of safeguarding. Finding One Finding 1 Systems communication between universal and acute medical services was not conducive to allowing practitioners to understand and contribute to the risk discussion. At times the right people did not have the right information at the right time. How are these issues evident in this case? Khalsa had acute asthma for which his overall treatment was led by a named hospital consultant. Acute asthma for Khalsa meant that he would experience sudden onset of an exacerbation of his asthma that were life threatening on several occasions (and ultimately lead to his death). These sudden incidents meant that Khalsa also received services from hospital emergency departments in conjunction with his usual interactions with universal services such as school nursing, general practitioner and a specialist asthma nurse. Dependent upon the information or presentation of Khalsa at the time, they had different understandings of the risks that Khalsa was exposed to by his asthma. In general, Khalsa was presenting as well and managing his asthma to the point that some professionals perceived his asthma to be less of an issue as it appeared to be under control. Other professionals saw different information such as presentation via ambulance at the emergency department following a serious asthma incident which led them to a different assessment of risk. The differing professionals were not in possession of the same information at the same time, altering their risk assessments at different points. Page 5 of 10 Khalsa’s medical practice had increasing concerns about the management of Khalsa’s asthma and made two referrals to social care in 2018. They were concerned about the repeated requests for reliever inhalers made by Khalsa’s father and what this meant for Khalsa’s management of his asthma and his father’s understanding of how to support Khalsa with managing his asthma. Following an assessment, a decision was made that Khalsa’s situation should be presented to a child protection conference, the lead consultant was unable to attend and was not in possession of all of the information known to professionals. Whilst some health practitioners attended the conference, Khalsa had attended different emergency departments in different Trust areas so they were not in possession of all the information. This meant that professionals were partially reliant on self-reporting from Khalsa and his parent. This led to a different understanding of risk. Some professionals who attended the child protection conference felt that there was a ‘confusion’ about what the risks were for Khalsa and how this risk was managed by his parent. The decision made at the Child Protection Conference was that Khalsa would be made the subject of a Child in Need plan. Some professionals expressed concerns that Khalsa’s asthma was not being managed properly and there was an over reliance of salbutamol inhalers with 40 being prescribed in a 12-month period as opposed to a usual prescription being one inhaler every one to two months. Khalsa’s asthma would result in episodic periods of hospitalisation including being admitted to the Intensive Care Unit on 2 occasions prior to his death. Some professionals expressed concerns that they had tried to advise father of the concerns about over reliance on the salbutamol inhalers, and how this raised concerns about Khalsa’s asthma management. They reported that when challenged about his approach to Khalsa’s asthma management father would seek advice from another health provider. Khalsa’s lead asthma consultant said that he was not aware of these concerns presenting in universal services, and this impacted on his assessment contributions to the child protection conference, being that Khalsa’s asthma was well managed and possible allergy related and was likely to improve. Whilst the communication between universal health services was relaying the information, they knew between themselves, information from acute and specialist health services was not known and the pathways between them were not effective. On the 20/11/18 Khalsa was taken to see his lead asthma consultant by his father. The notes of that session state that he had no hospital admissions since the last review. The following information was not shared with the lead consultant in time for the asthma review: • 01/07/2018 – Khalsa is admitted to the Hospital via ambulance due to acute exacerbation of his asthma • 23/07/2018 -Khalsa attends the emergency department due to an asthma incident. • Page 6 of 10 • 31/07/2018 -Barts Health is informed via letter of Khalsa’s admission to Hospital. • 13/08/2018 The school nursing team receives information via letter that Khalsa attended the emergency department on 23/07/2018. There is a reliance on parental self-reporting to support the ethos of people as experts of their own health. Whilst this ethos is important there is a difficult balance to strike and there is a need for professionals to be curious to consider if there are questions around risk management. The communication systems between universal and acute and specialist health services did not support the lead consultant to explore what risks were being presented for Khalsa by his current management of his asthma. Khalsa’s father reported to the review that he believed that the health professionals had systems that would tell them all the health information and attendances for Khalsa. When health professionals did not raise it, he believed that they did not consider there to be risk. He did not provide the health professionals with these parts of Khalsa’s medical history as he was concerned that to bring attention to it would raise concerns about his care of Khalsa and Father was concerned that Khalsa would be removed from his care. The lead consultant shared with the review that had he known this other information he would have presented a very different contribution to the risk discussion at the child protection conference. The delays in information being provided to relevant professionals enabled minimisation of risk considering Khalsa’s presentation at the time. As his acute asthma incidents were episodic, an over optimism of wellness enables a minimisation of how at risk Khalsa’s asthma made him. Does this happen in other cases? Professionals told us that this is a continuing problem and that the outdated systems within the health service do not support the wider conversation for professionals when supporting and addressing health concerns with children and their families. Whilst this has been addressed in universal services, the acute and specialist systems have not managed to find a way to share this information in a timely way. Why does it matter? An over reliance on self-reporting means that professionals can become limited in how they view the child’s world and act in a responsive way. It places an emphasis on parents, carers and young people to lead the discussion and allows avoidance of conversations that some people may not want to have. It limits professionals’ abilities Page 7 of 10 to engage their responsibilities for wider safeguarding and therefore places some children at risk of harm. Having communication systems that ensure information is relayed to the right people at the right time would help to reduce this risk. Questions for the Waltham Forest Children’s Safeguarding Partnership What changes need to take place between multiple universal and acute hospital trusts to ensure robust and timely information sharing between them? Finding two Finding 2 There is a need to create systems that enable young people to have a voice to influence and participate in their own health plans – specifically when young peoples’ competence to do this is overridden by parental influence. How are the issues evident in this case? Khalsa met with a range of professionals, many of whom; such as his education professionals, some health professionals and his social workers, tried to encourage Khalsa to share his views and influence his own care plan. Khalsa often echoed the views of his father and as such his voice could not be loudly or consistently heard in the reflections of the review. There were some representations of good practice in the provision of some of the support offered to Khalsa but there was not a consistency in the approach. These incidents of good practice were dependent on the skills and experience of the practitioner. Practitioners in the review process shared many of the positive approaches that they tried in this case, and which have been successful in many others, but all agreed that the challenge was presented by Khalsa’s carer as an expert in his child’s health and well-being. As there was not a standardised approach or framework to the work, they attempted to undertake with Khalsa professionals experienced feeling disempowered with being able to move it forward. Khalsa’s father informed the review that Khalsa was a shy young person with some people in positions of “power” and so it was easier for him to repeat his father’s views than have his confidence developed to air his own. There have been many developments in how the professional networks have developed practice to support children and young people to be empowered with their own health. For example, children with diabetes are taught very early on to recognise changes in their bodies and to administer insulin. Does this happen in other cases? Page 8 of 10 Practitioners described many positive examples of ways in which children and young people were encouraged to have influence over their own health care plans in the context of asthma. This was not consistent and was practitioner dependent. They also informed the review that as this practice was not standardised it deskilled them when presented with parents and carers who were more vocal of their own perspectives of health management. This enables young peoples’ involvement to be placed secondary to the maintenance of parental relationships with practitioners. The Healthy London Partnership1in August 2020, recognised the vast variations of practice and responses to children with asthma. The report states its ambition for children and young people with asthma is that they are enabled to “….. manage their own asthma by having access to a personalised, interactive, evidence-based asthma management plan that they understand and that is linked to their medical record” (pg. 6) Practitioners confirmed that there was inconsistency across London and nationally with how young people are engaged in their health care plans. Why does it matter? Asthma is one of the most common medical conditions for children. Our current data shows that there are 16,268 residents of Waltham Forest with a diagnosis of asthma. Of these 1851 are young people aged 10-18 years old. Approximately 10 people per year die in Waltham Forest every year from Asthma which is above the national benchmark. In August 2019, Asthma UK reported that there had been a 17% increase in London of deaths from asthma. Engaging children and young people in their asthma health care plans enables there to be equal recognition of the severity of asthma for children’s health outcomes, on a par with other conditions such as epilepsy and diabetes. Engaging young people early in recognition and management of their health conditions enables them to develop the competency for long term management of their conditions. Questions for the Waltham Forest Children’s Safeguarding Partnership How confident is the partnership that it meets the recommended London Asthma Standards for Children as detailed in the report from the Healthy London Partnership? Finding 3 1 https://www.healthylondon.org/wp-content/uploads/2017/11/London-asthma-standards-for-children-and-young-people.pdf Page 9 of 10 Finding 3 The perception of asthma as not being potentially life threatening can impact on how some professionals engage in professional curiosity, specifically in the context of safeguarding. How were the issues evident in this case? Khalsa’s acute asthma had a devastating impact on him, resulting in his death in October 2019. In the 24 months preceding his death he was admitted to hospital due to asthma related concerns on the following occasions; • 03/03/18 – North Middlesex Hospital; • 01/07/18 Homerton Hospital and • 12/01/19 North Middlesex Hospital. At all other times, there were mild symptom presentation but otherwise, Khalsa did not present with any other indicators that he was unwell. Father states that Khalsa’s asthma difficulties were more prevalent when he was at home, and this is evidenced by his emergency admissions from home. This meant that many of the practitioners involved with Khalsa did not see the impact that the acute asthma exacerbations had. There were additional challenges brought by a pattern of cancelling and rescheduling appointments by Khalsa’s father, which meant there were periods of time when Khalsa was not brought to appointments. There is not currently a system that highlights cancelled or rescheduled appointments to signal to health professionals of a need for additional engagement to explore why this is happening. Concerns were raised by the General Practitioners that the father was requesting excessive amounts of the salbutamol inhalers, indicating concerns about how Khalsa’s asthma was being managed, but in the community the impact of this was not being seen consistently by professionals engaged with the family as Khalsa presented as ‘well’. Coupled with perceptions of asthma as a manageable condition, this inconsistency in terms of the concerns led to differing opinions on the risk presented by asthma to Khalsa and the impact of the concerns raised about how this was being acknowledged and managed. The people who could guide this understanding were not in possession of the other concerns and as such this impacted on the advice provided to universal services. Does this happen in other cases? Asthma is a common condition, and perhaps its commonality leads to complacency about its impact on people’s lives. In 2018, 1400 people died from an asthma related condition. Despite this, Asthma is not given the same deference as other conditions such as epilepsy and diabetes. There is a greater understanding of the need to manage these other conditions and the significant health risks associated with them. The specific discipline of the professionals involved, and the information they were Page 10 of 10 provided impacts on how they view the risks and therefore the risk management of asthma. Why does it matter? Asthma UK2 published the National Asthma Survey in 2019 showing that 8 in 10 people still do not have well controlled asthma resulting in 75,000 emergency admissions for asthma. In Waltham Forest, 16, 268 of residents’ experience asthma with a mortality rate of 10 deaths per year. Specific data of how many of these are children is not recorded but does show that we need to increase awareness and responses to how this is managed in the borough. Hospital admissions for Waltham Forest show that 80 residents aged 10 to 18 years old are admitted to hospital every year which is above the national benchmark and higher than expected based on prevalence (Waltham Forest Public Health data 2020). This demonstrates that there is a need in Waltham Forest for consistent understanding and response to adolescents with asthma in Waltham Forest Questions for the Waltham Forest Children’s Safeguarding Partnership How will the partnership increase awareness of asthma and its management across agencies and communities in Waltham Forest? 2 https://www.asthma.org.uk/58a0ecb9/globalassets/campaigns/publications/The-Great-Asthma-Divide.pdf |
NC52481 | Death of 2-and-a-half-month-old boy in June 2019. Cause of death has not been formally determined. Learning includes: need for all agencies to ensure practitioners are aware of the lived experience of the child and understand the cumulative effects of continued neglect; where there is concern regarding safe sleeping, despite advice, there is a need for escalation and differentiated response; clear procedure required once disguised compliance is identified; suspected drug use by parents should be effectively considered in social work assessments, to allow this is be ruled in or ruled out; there should be a clearer pathway between children's social care and early help; exploration required of how well children leaving care are prepared for parenthood; pre-birth assessment should be considered when there are concerns around neglect or other vulnerabilities; where a referral is made to the MASH and a strategy meeting takes place, the professional making the referral should attend, and any assessment by children's services should seek the views of other involved professionals. Recommendations for the local safeguarding partnership include: review of the neglect strategy, including implementation and embedding of the Graded Care Profile 2 (GCP2); review the approach to safe sleeping, with particular focus on parents that are suspected or are known to use substances and/or alcohol; review the support, training and advice for professionals dealing with families demonstrating disguised compliance or who are avoidant and/or resistant.
| Title: Serious case review overview report: serious case review in respect of Matt. LSCB: Coventry Safeguarding Children Partnership Author: Jon Chapman Date of publication: 2022 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC. This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above. version 5 1 SERIOUS CASE REVIEW OVERVIEW REPORT Serious Case Review in respect of Matt Date of Incident June 2019 Author Jon Chapman Date of submission 26th October 2020 Version Version 5 Version control Version Date Amendments 1 15/05/20 Draft to panel meeting 15/05/20 2 17/05/20 Amendments post panel meeting 3 17/09/20 Amendments post practitioner event 4 07/10/20 Amendment post panel feedback 5 26/10/20 Amendment post subgroup feedback version 5 2 TABLE OF CONTENTS Page no 1. Introduction 3 2. Terms of reference / Scope including time-frame to be covered 3 3. Methodology 4 4. Family and parallel proceedings 5 5. Summary of Facts 6 6. Analysis of involvement 13 7. What are the learning points from this case? 22 8. Recommendations 24 Appendix • Author details • # • • 27 version 5 3 1. Introduction 1.1 The subject of this review is Matt, who at the time of his death in June 2019 was 2 and a half months old. At the time of his death, Matt was in the care of his parents. The ambulance service attended the home address at the request of the parents and sadly Matt was found deceased. Both parents were arrested to allow the circumstances of Matt’s death to be fully investigated, the Crown Prosecution Service have reviewed the evidential file and decided to NFA the case. There was evidence at the time that the parents had used cannabis and/or alcohol on the night of Matt’s death. 1.2 The cause of Matt’s death has not been formally determined and this review has been undertaken on the basis that abuse or neglect is suspected. 1.3 In July 2019, the case was discussed by the Coventry Safeguarding Partnership Rapid Review Group and it was agreed that the case met the criteria for a serious case review. 1.4 The names of those involved in this review have been changed. 2. Terms of reference 2.1 The subject of this review is Matt. Matt had one older sibling Luke. 2.2 The dates that the review focused on were from the time that Luke was born in February 2018 and to the date of Matt’s death in June 2019. In addition to the dates within scope, agencies were asked to consider any information that impacted on or had potential to impact on matters that related to safeguarding Matt or Luke. 2.3 As well as generic safeguarding issues, agencies were asked to consider the below areas. (i) What were the indicators of neglect in the lives of the children? - consider the following: • non-attendance at appointments/ occasions when children were not brought to appointments. This should include the antenatal period and the period in the special care unit. Factors to be considered should include the following: • Cleanliness of the children • Nappy rash version 5 4 • Home conditions • Nutrition • Disguised compliance • And any other indicators (ii) Were there indicators of substance misuse? (iii) Were there indicators of domestic abuse? (iv) How did agencies respond to these indicators of neglect? – Please include inter agency communication and working. (v) How did agencies respond to indicators of substance abuse? (vi) Is there evidence that the childhood experiences of the parents’ influenced their ability to care for their own children? • how was this addressed? • Have you identified any areas that you consider to be good practice? 3. Methodology 3.1 Working Together 2015, the guidance under which this review was completed, allows Local Safeguarding Children Boards to determine their own processes for the review. The Case Review Sub-Group of the Coventry Safeguarding Board, which managed the review process, identified which organisations were involved in the case. Each organisation was asked to prepare and submit an Individual Management Review (IMR) and a chronology detailing the relevant interaction they had with the family. The organisations supplying IMRs and Chronologies were: - South Warwickshire Foundation NHS Trust Coventry Children Services National Probation Service University Hospital Coventry and Warwickshire NHS Trust NHS City of Coventry Healthcare Centre GP surgeries West Midlands Police Coventry and Warwickshire NHS Partnership Trust The below organisations were involved to a lesser degree and were asked to provide covering reports of their involvement. Keystage 2 Housing 3.2 The review was paused between March and September 2020 due to the challenges presented by the Covid19 pandemic. In September 2020, a virtual learning event took place, with professionals from all the agencies involved gathering to discuss the case. The outcome of this discussion is reflected in the report. version 5 5 4. The family and parallel proceedings 4.1 Matt’s birth parents are Kate and Jake. It is not known exactly how long they have been together as a couple, but for at least for the time period focussed on by this review. Matt’s older brother, Luke, was born in February 2018. Kate was a former looked after child and as a result, during the first part of this review, lived in supported accommodation before moving to a flat and taking up her own tenancy. It is apparent that Jake lived at both addresses for large parts of the time. 4.2 Kate was known to Children Social Care (CSC) from the age of 4. She had experienced domestic abuse and neglect in her childhood and as a result became the subject of a care plan on two occasions. Kate was the subject of care proceedings on three occasions with a care order being made in March 2012, when Kate was 12 years of age. Kate was then accommodated in several placements and was considered vulnerable to Child Sexual Exploitation (CSE). There were a number of incidents recorded where Kate was suspected of using cannabis. This was denied by Kate. 4.3 Kate was 17 years and 10 months when Luke was born and was 19 years old when Matt was born. When Kate attained the age of 18 years, she received services from Coventry Local Authority as a former relevant child1. She had the support of a personal advisor and was provided accommodation from a housing support organisation before she secured her own tenancy. 4.4 Little was known regarding Jake’s early life. There are records which suggest that he had a strong family network and this is reflected in the chronology, where Matt’s paternal grandfather told CSC that he had concerns regarding the ability of Jake and Kate to 1 Relevant children are those aged 16 and 17 who meet the criteria for eligible children but who leave care. Former relevant children are those who before reaching the age of 18 were either eligible or relevant children. – Children Leaving Care Act 2000 - http://www.legislation.gov.uk/ukpga/2000/35/notes/division/2 version 5 6 manage financially and that he had assisted them (March 2018). The worker completing the CSC pre-birth assessment of Luke mentioned separately that there was evidence that Jake had used cannabis, but this is not fully reflected in the actual assessment At the time of the birth of Matt, Jake was 22 years of age and was 3 years Kate’s senior. 5. Summary of Facts 5.1 In mid-February 2018, Matt’s sibling, Luke was born. At the time of his birth, his mother Kate, was 17 years and 10 months of age and was a Looked after Child. Prior to his birth there had been concerns expressed by the community midwife that Kate had not been engaging with the Family Nurse Partnership (FNP)2. This resulted in a referral being made to Children Social Care (CSC). 5.2 In early February 2018, there was also a referral from police after they had attended a domestic incident involving Kate and Jake at their home address. The incident had been reported by a third party. The incident was relatively low level, being a verbal altercation and no offences were disclosed. 5.3 At the time CSC undertook a pre-birth children and family assessment and deemed that Kate should be supported by the Common Assessment Framework (CAF)3. The CAF was not in fact utilised as it was considered that the agencies already involved with Kate could provide the required support. 5.4 Kate’s key worker, from the supported accommodation, visited the address 5 days after Luke’s birth, at the time Kate was not in, but the key worker noted that the property was in a poor state. There were dirty nappies on the coffee table in the lounge, there was rubbish and uneaten food evident in various areas and a concern that Luke was not sleeping in his moses basket. The key worker contacted Kate’s LAC social worker and made a safeguarding referral to the Multi Agency Safeguarding Hub (MASH). 5.5 Kate’s meaningful engagement with services continued to be a concern after Luke’s birth. The community midwife attempted to visit twice but was not able to see Kate or the baby on these visits and was not able see Luke until one week after his birth. At this time the community midwife noted no concerns. The key worker re-attended the address and found that the property was spotless. Kate apologised for the previous condition of the property and attributed the mess to Jake. 5.6 Kate was discharged by the midwifery service two weeks after the birth of Luke to the support of the GP and health visiting services. At the beginning of March 2018, the family nurse contacted Kate’s social worker and disclosed that Kate had been visited. The 2 Family Nurse Partnership - voluntary programme for young first-time mothers (and their partners), aged 19 years or under. Specially trained nurses provide regular home visits, from early pregnancy until the child is aged two. FNP uses methods on attachment, relationships and self-efficacy. 3 Common Assessment Framework (CAF) - The Common Assessment Framework (CAF) is the process to identify children who have additional needs, assess needs and strengths and to provide them with a co-ordinated, multi-agency support plan to meet those needs. version 5 7 nurse noted that the state of the property had declined, as had Kate’s personal hygiene. Kate also stated that she was giving Luke larger feeds to prevent him requiring feeding so frequently. The social worker completed a request for Early Help outlining the poor engagement with professionals, missed health appointments and poor home conditions. There is no evidence that the early help requested was provided. 5.7 The key worker visited in early March and highlighted concerns that Jake had been feeding Luke next to an open window, exposing him to a draft and was seen to be washing plates with bathroom bleach. Around this time there were also a number of visits made by family nurse and LAC social worker where access could not be gained. In mid-March 2018, Kate’s social worker visited the address and access was directly denied and a suitcase was placed across the letterbox to obscure vision through it. The social worker made a referral to the MASH. 5.8 The following day the social worker and key worker visited the address. They again found it very difficult to gain access to the address and Kate was verbally abusive. Kate and Jake were arguing with each other, shouting with Luke present. Initially Kate refused to allow the professionals to see Luke, but finally relented. Luke had a full nappy; his bottom was described as being ‘red raw’ and he had dried vomit on his clothing. When Luke’s bottom was wiped, he was described as being in pain. It was also noted that Kate handled Luke roughly and was not supporting his head. The social Worker advised the parents to take Luke to seek treatment at the ‘walk in centre’ to have his bottom treated. There is no evidence that any measures were put in place to ensure this happened. The professionals made a referral to the MASH, drawing attention to the poor condition of the property, the ability of the parents to provide basic care to Luke, lack of food at the property and unhygienic conditions. 5.9 Three days after this referral was made Luke was admitted to hospital with an abscess/swelling at the top of his buttocks. Luke was treated with intravenous antibiotics and transferred to the children’s hospital for ongoing care. Luke also had conjunctivitis and it was noted that he was not registered with a GP. A strategy meeting took place the day, following Luke’s admission. The previous information regarding the concerns on poor engagement, concerns on parenting ability and neglect were shared. It was agreed that CSC would undertake a single agency investigation with a view to progressing to an Initial Child Protection Conference (ICPC). If the parents continued to fail to engage, CSC would present the case to the legal panel to consider proceedings. The case was closed by police at this stage, after being recorded as not being a recordable crime. 5.10 During the course of Luke’s stay in hospital, staff raised concerns over the inappropriate behaviour by the parents. There were also concerns raised regarding the personal hygiene of the parents. Two days after Luke’s admission, he was discharged from hospital. On discharge, the social worker put a written agreement in place with the parents to agree to both announced and unannounced visits, recognising that any failure to cooperate would result in legal advice being taken. Before Luke was discharged, the social worker and key worker visited and checked the living conditions of the home address. version 5 8 5.11 Unannounced visits were undertaken through the remainder of March 2018, with conditions noted as generally good with no safeguarding concerns noted. On one occasion, there was no one in, but a faint smell of cannabis could be detected through the letterbox. The parents were challenged with this on the next visit and refuted that they were responsible, attributing the smell to a neighbour. 5.12 In early April 2018, the family nurse visited and recorded no concerns. The home was clean and uncluttered. Safe sleeping was discussed at some length, and the nurse was shown a photo of Luke asleep on Jake. It was noted that there was good family support, and this had been witnessed on a previous visit with grandparents being present. Luke had still not been registered with a GP and this was, according to the parents, to be undertaken the following day. A similar picture was noted by the social worker who visited two days later. 5.13 There followed evidence that engagement became patchy with visits cancelled for the key worker who was supposed to visit the family every other day and the family nurse. Luke was not taken to a previously arranged paediatric appointment to explore a heart murmur that had been identified at birth. On 20th April 2018, the CSC children and family assessment was completed. It concluded that there were no current safeguarding concerns and the original concerns were no longer apparent, and it was left for the agencies supporting the family to remain involved. Luke’s case was closed to CSC. 5.14 Towards the end of April and into May 2018, there continued a pattern of missed and cancelled appointments by the parents. The housing key worker raised concerns as they were not able to see the family as required. On the same day in late May 2018, the records indicate that the family was visited by the social worker and housing key worker. Entry was not permitted initially, and the housing key worker facilitated entry using their own keys. They noted the property being untidy and cluttered. The same day the family nurse visited and noted the surroundings as being appropriate and Luke being well cared for. 5.15 In June 2018, the key worker expressed concerns to the social worker on a number of occasions. The concerns being that Luke was not being stimulated by the parents and the family nurse had not been able to gain access to the home on occasions. The social worker stated there should have been early help support in place as this had been requested in March. The social worker stated they would chase the referral. 5.16 The key worker was a regular visitor and continued to be concerned about the time the parents took to answer the door and felt that they were concealing something. They felt that Luke was not sleeping in the moses basket as there was no apparent bedding and he was sleeping with the parents. There was a dog at the premises that had been aggressive towards a worker. The service noted that the property could be poor one day and within a short space of time would be spotless. They felt that home conditions altered depending on when a visit was anticipated. 5.17 At the end of June 2018, the support/housing agency made three referrals with concerns over the home conditions. They stated that Luke’s mattress was heavily stained version 5 9 with urine. Luke was often seen in dirty nappies and his feeding bottles were dirty. Luke was also being left in his cot for extended periods of time. There had also been a domestic abuse incident where Jake had sustained bruises and bite marks. The support service also forwarded 11 photographs to support their concerns. 5.18 On the same day the Family Nurse attempted to visit and spoke to Jake, who stated that he and Kate had been in dispute for some days and had now separated. Luke and Kate were with her parents at the time. 5.19 No strategy meeting was convened but CSC undertook a children and family assessment. The support service arranged for the address to be cleaned and cleared. They found that the state of the house was extremely poor with rotting food found in cupboards, filthy nappies and used condoms all evident. 5.20 As part of the assessment the allocated social worker (same social worker as previously) visited Luke at his home address. Luke was observed to be’ thriving and secure attachments’ were observed. Jake was present during the visit but said not to be living at the address, but visiting daily. The parents were challenged on the previous poor condition of the address and domestic abuse and were said to appear contrite. 5.21 The result of the assessment was that a child in need plan would be put in place. The assessment had only included one visit and discussion with the parents, and this was undertaken with them both together. The plan included an action for the police to be called if access could not be gained to the address in the future for checks to be made. The family nurse remained concerned over the parents’ engagement. As a result of the inability to visit they had no record of Luke’s development or weight. 5.22 In early July 2018, the social sorker attended the address on an unannounced visit and saw Jake outside the address. Kate and Luke were not in. 5.23 During July 2018, the family were visited on a number of occasions, it was said that Jake was still living separately but visiting daily. Kate had financial pressures and was being supported by both maternal and paternal grandparents. CSC also provided support in the form of food vouchers on two occasions. 5.24 Towards the end of July 2018, the social worker and key worker attended the address and saw that Luke was suffering from a bad nappy rash. There also appeared to be a burn on his leg, which the parents claimed was part of the nappy rash. A Child Protection medical was arranged and it was confirmed that Luke was suffering from a severe nappy rash and this accounted for the rash on his leg. The medical was arranged outside of the child protection procedures and as such the family nurse had no knowledge of the medical taking place or the result of it. 5.25 At the start of August 2018, the family moved to a new address. On the same day they were visited by the family nurse and social worker. There was a good record made by the family nurse on the home conditions and how the parents were interacting with Luke. version 5 10 5.26 There were a number of Child In Need (CIN) meetings in July, August and September 2018. The meetings did not always have all the relevant agencies present and the minutes do not reflect the level of concerns that had previously been expressed. At the August 2018 meeting it was noted that the family had taken acquired two dogs, one being a large Pitbull type of dog. 5.27 At a visit in late August 2018, the family nurse advised regarding the safety issues associated with the dog and leaving Luke unsupervised with them. In this visit and one undertaken by the social worker, no safeguarding concerns were noted. Although the Family Nurse did note that Luke had a mis-shaped head and a red warm skin patch was observed on Luke’s back. At this time no nappy rash was observed. 5.28 In September 2018, the social worker attempted visits on two occasions but there was no reply. Kate failed to attend a Child In Need (CIN) meeting and it was re-scheduled. Kate and Luke had not been seen by professionals for two weeks and the social worker and family nurse liaised over their concerns. 5.29 At the reconvened CIN meeting in September 2018, it was recorded that ‘social care have no safeguarding concerns presently and the case to step down to CAF level 2. PA (personal advisor) to remain involved and family nurse until Luke is two’. It was recorded that CSC would undertake a couple more unannounced visits and then step the case down. The meeting was attended by Kate’s personal advisor, LAC social worker and the family nurse, and there is no record of professional disagreeing with the decision. 5.30 During October 2018, the social worker attempted to contact Kate on two occasions to arrange visits, but no response was forthcoming on each occasion. No unannounced visits were undertaken, and the case was closed to CSC in late October 2018. In the management oversight review, it was stated that the situation had significantly improved. It recognised that there had been no response to the request for Early Help but supported the decision for the case to be closed. 5.31 The day after the case was closed, Kate attended her first early scan appointment for her second pregnancy, the pregnancy of Matt. By the end of October 2018, the family nurse had further concerns over the parent’s lack of engagement and started to discuss referring the case back to CSC. 5.32 Through November 2018, the non-engagement continued with Kate cancelling and not responding to family nurse contact. The new housing provider also stated that the tenancy stipulated that in the first 10 days Kate had to be seen regularly. This had not been achieved and there was evidence that Kate was avoiding contact with professionals. Kate’s personal advisor was also not being contacted by Kate. 5.33 As a result of the lack of contact, the personal advisor made a referral to the MASH to request the police to undertake a safe and well check. This was done and whilst the home conditions, particularly Kate’s room was very untidy, there were no safeguarding concerns noted. The parents were very compliant with the police and claimed their lack of contact had been due to neither having a working mobile phone. The police confirmed that they would be visited by CSC the following day. version 5 11 5.34 A Child and Family Assessment was not undertaken as the previous case had been closed within 8 weeks. The social care team manager agreed that the family should be visited by the social worker within one week. 5.35 At the beginning of December 2018, the social worker attempted to visit the family but there was no reply. The social worker left a note at the address. In mid-December 2018 the personal advisor and staff from the housing association saw Kate at her home address, Luke was also seen, and no safeguarding concerns were noted. Kate stated that she was to be evicted due to rent arrears and that she was over 12 weeks pregnant and had not seen her GP. The social worker discussed the visit with the personal advisor and on the basis that Kate and Luke had been seen by them and the police, the case was closed to CSC. There was no management oversight on closure. The family nurse contacted the Central Team of CSC and the MASH requesting the name of the allocated Social Worker, to challenge the decision but this information was denied. There is no record that this decision was challenged. 5.36 During January 2019, there were a series of failed visits to Kate by the family nurse with messages being left. At this stage Kate was 20 weeks into her second pregnancy and had not booked an appointment with a midwife. The personal advisor had also been trying to have contact with Kate but had not been successful. 5.37 During February 2019, Kate saw her GP for an infection and stated that she had paid for a private pregnancy scan at 16 weeks and all had been normal. A midwife appointment was made for the end of February but despite numerous attempts to contact Kate, she did not attend this appointment. 5.38 At the end of February and beginning of March 2019, Kate, Luke and Jake were seen by the family nurse. Luke was seen to be well but still not registered with a GP and was aged 13 months. Safe sleeping was discussed with Kate and child safety in the garden, which was cluttered. Kate to be cleared. 5.39 At the beginning of March 2019, GP records show that Luke was not bought to a nurse appointment, which was re-arranged. In mid-March 2019, the personal advisor saw Kate. Kate stated that she had been unable to get a midwifery appointment. The personal advisor was concerned at the lack of antenatal care but did not make referral to CSC. 5.40 In mid- March 2019, Kate was seen by the community midwife at home for a booking in appointment, she stated she was 25 weeks pregnant. At the end of March 2019, the family nurse saw Kate, Luke and Jake at home. There were no concerns, the home was clean and uncluttered and the engagement between the family was viewed as warm and appropriate. 5.41 At the beginning of April 2019, the community midwife tried to visit on three occasions but there was no response. Kate also cancelled a family nurse appointment and did not attend an antenatal clinic appointment. On 9th April 2019, Matt was born prematurely, at 29+6 weeks gestation. Matt underwent 2 days intensive care, 9 days high dependency care and 32 days special care. The parents visited the hospital on most version 5 12 days. The hospital staff raised concerns regarding the parent’s personal hygiene, but this was only raised with the parents on two occasions. While Matt was in hospital, the personal advisor and family nurse submitted a referral to Children Social Care detailing their concerns regarding the parent’s engagement. The family nurse had completed 10 of 39 attempted contacts with Kate. There were concerns over the parent’s care of Luke and his diet, which was making him overweight for his age. Matt was discharged home on 21st May 2019. The hospital had heard from CSC on 16th May 2019 that a Child and Family Assessment would be undertaken as the family nurse still had concerns regarding the parent’s engagement. 5.42 Whist Matt was still in the Special Care Baby Unit (SCBU) his father Jake presented at A&E (the same hospital). He was registered at a different GP to the mother. He presented after being assaulted and having a slight injury to his neck. The A&E staff were not aware that he had a child in SCBU. There was no connection made between the mother and children and the father from a GP perspective, which could impact on the identification of any associated safeguarding concerns. 5.43 While Matt was still in hospital, the newly allocated social worker tried on a number of occasions to visit the family at the home address and no reply was received. On occasions the social worker felt that someone was in but not answering, as on checking it was established that the family were not at the hospital. 5.44 On 21st May 2019, a discharge planning meeting took place at the hospital. The day prior to this the social worker had attended the home address and spoke with both parents. The house and baby care items were checked for appropriateness and advice was given. The parents had purchased a new mattress and cover. The social worker discussed the use of controlled drugs, which they denied, and alcohol use which Jake stated he used irregularly. The social worker also discussed domestic abuse, which the parents stated was not currently present in their relationship. Prior to the discharge from the hospital the parents were given advice on safe sleeping for the baby. 5.45 The day after the hospital discharge the social worker visited the family at home, by arrangement, the maternal grandmother was present. Both Matt and Luke were seen, and no concerns were noted. The house and surroundings were clean and there was fresh food in the fridge. Advice was given on safe sleeping when it was noted that Luke was asleep with toys in his cot. 5.46 The social worker visited the following two days by arrangement, on one of the occasions the family nurse was present. The only matters of note were that the house smelt musty (which had previously been noted) and there was no stairgate. On the second occasion the notes of the visit were not completed by the social worker. The family nurse completed the new birth visit. Safe sleeping was again addressed, and the sleeping arrangements were seen and recorded as appropriate. The parents also stated they had been given information on Cardiopulmonary Resuscitation (CPR) at the hospital. Both parents stated they smoked outside, and the family nurse discussed the risks associated with smoking. At the end of May (29th) 2019, the social worker visited the version 5 13 family to complete family history for the assessment. The maternal grandmother was present. 5.47 The next visit by the social worker was a pre-arranged visit on 6th June 2019. In the interim Matt had not been taken to a routine ophthalmology appointment (this was re-arranged and Matt was taken as arranged on 10th June 2019) and the Family Nurse had visited the home and received no reply on a pre-arranged visit. On the June visit the social worker visited with a housing officer. It was noted that the home conditions were poor. Luke’s mattress was dirty and smelt unpleasant. There was bagged rubbish in the garden. The same day the family nurse visited and recorded that Matt was gaining weight well. 5.48 Social care records indicate that police were called to a domestic abuse incident at the family address on 10th June 2019. This incident actually involved Kate’s sister and her boyfriend. It would appear that Kate’s sister was staying on the sofa at the address at this time. During the argument the boyfriend is said to have armed himself with a knife. 5.49 The following day the social worker visited the family and noted that Kate’s sister was present. The home conditions were said to have improved slightly. 5.50 On 12th June 2019, the social worker visited the family home for a pre-planned visit. The home conditions were said to have improved on the previous days findings. The parents stated they were going to buy Luke a new mattress that day. There was a concern noted that Luke was overweight. 5.51 Early morning on 13th June 2019, an ambulance was called to the family home on the report of a child in cardiac arrest. Matt was conveyed by ambulance to hospital, where despite best medical efforts he was pronounced as deceased. In view of the circumstances and comments made by Kate, both parents were arrested on suspicion of neglect. 6. Analysis of involvement 6.1 Assessment of risk and intervention Pre-birth of Luke 6.1.1 Luke was born in February 2018, prior to his birth there had been a pre-birth assessment. Just prior to his birth there were two referrals received, these were concerns raised regarding Kate’s engagement with professionals during her pregnancy and police attendance at a domestic abuse incident. In addition, as a Looked after Child CSC would have had a history of Kate’s engagement with professionals and an awareness of any adverse childhood experiences that might have informed the decision making related to her ability to meet the needs of an infant. The outcome of the two referrals was that support should be provided by a CAF. The CSC IMR author recognises that the pre-birth assessment in 2018 and the response to these referrals focused on the issues relating to Kate as opposed to version 5 14 recognising the early stages of neglect and the potential risk factors to the unborn baby. It was also overly optimistic to expect the parents to engage meaningfully in a CAF when their previous engagement had been so poor. In fact, the CAF was not put in place as it was considered that agencies were already supporting the family. Whilst this may have been the case, it left the ongoing support without any real coordination. Post -birth of Luke 6.1.2 Once Luke was born a referral was received from the housing key worker who was scheduled to visit the family every two days. The referral detailed some serious concerns regarding the poor state of the address and neglectful care This is evidenced as Luke was being part bottle fed and Kate did not have a bottle steriliser. There was also a concern that Luke was not sleeping in his moses basket. 6.1.3 This referral was assessed in the MASH with contact made to other professionals, the key worker and midwife. Kate was spoken to, but Jake was not. Kate stated that the address had fallen into a poor state since Luke had been discharged from hospital. This contradicted what Jake had told the key worker, stating that he was responsible for the mess as he had been living in the address whilst Kate was in hospital. 6.1.4 The CSC IMR author makes the point that the referral enquiries and management oversight focused on Kate as opposed to the emerging picture of neglect and what interventions may be appropriate. There is no record to indicate that the sleeping arrangements for Luke were explored, which is surprising considering it was one of the principle concerns raised by the key worker. The key worker re-visited the address two days later and found that the home address had been tidied. This formed a pattern over the duration of the case with conditions varying according to the level of agency attention. 6.1.5 The outcome of the referral was that early help support should be coordinated by a CAF at Level 2. As identified by the CSC IMR author, due to Luke being a newborn baby and highly vulnerable to the adverse effects of neglect, the previous poor engagement by the parents and history of risk factors a more appropriate outcome would have been a Children and Family Assessment at this stage. 6.1.6 This was the third occasion that a request for early help had been made but at no stage was any service provided. The early help records indicate that the case was to be discussed at the next family hub integrated case management meeting. There is no record of this meeting taking place. The MASH Procedures4 state ‘Where the case does not meet the agreed threshold for Social Care Intervention and a diversion to Early Help is deemed necessary, the Triage Worker will discuss the case with the 4 Coventry Multi Agency Safeguarding Hub Operating Procedures (January 2018) - https://coventrychildcare.proceduresonline.com/files/mash_procedure.pdf (accessed 26/10/20) version 5 15 CAF Co-ordinator co-located in the Family Hubs. All families that require Family help intervention, will be diverted to the most appropriate agency by the Team Manager.’ There is no record of this discussion ever taking place. 6.1.7 The next referral was in March 2018 and followed a visit by the social worker where access was denied to the address with the parents placing a suitcase across the letter box to prevent any visual access. This followed a period where other professionals (the family nurse and personal advisor) had also experienced difficulties in seeing the family. At this point the Social Worker should have considered obtaining assistance from the police to gain access. This course of action would have ensured the safety and welfare of Luke was checked and demonstrated to the parents that there were boundaries which would be adhered by a robust and coordinated multi agency response. 6.1.8 The social worker made a referral to the MASH and visited the next day with the housing key worker. Again, initially the parents denied access and were abusive. When access was gained initial access to Luke was denied. When they did see him, they noted that Luke had a substantial abscess on his bottom which was causing obvious discomfort when wiped. Kate was also seen to handle Luke roughly. No action was taken at this time, but a further referral was made to the MASH. The social worker suggested that Luke should be taken to the walk-in health centre the next day, which did not occur. Considering the previous demonstrated lack of engagement and attempts to prevent professional access to the home, a more robust approach should have been considered to ensure that Luke obtained more immediate medical attention and to ensure that a strategy discussion was initiated. It is not clear how this, whether Luke did receive medical attention or not, was to be followed up. There was a significant concern and risk to Luke at this time which warranted immediate action. 6.1.9 A strategy meeting was convened three days later when Kate presented Luke at hospital with the abscess, which required intravenous antibiotic treatment. The strategy meeting was not attended by the social worker who made the referral. The hospital safeguarding nurse informed the meeting that the abscess was not believed to be caused by poor hygiene but it was unusual for a baby to have such a condition and there were concerns. 6.1.10 It is the view of both the Police and CSC IMR authors that more robust intervention should have been considered at this stage. The police author suggests that an offence of child cruelty5 should have been recorded by police and this would have necessitated an investigation. The case and rationale for this is well made out in the IMR basing it on the factors of the injury presented, the history of the parents’ avoidance of professionals, non-engagement and abusive behaviour to professionals and the neglectful state of the home address witnessed. Whilst it is accepted that a 5 Cruelty to persons under the age of 16 - Children and Young Persons Act 1933 (accessed 26/10/20) version 5 16 criminal prosecution may not have ensued or indeed would have been the desired outcome, the recording of the offence would have initiated and supported a clear response to the presenting concerns. 6.1.11 Both the police and CSC authors feel that the nature and cause of the injury to Luke should have been more fully investigated, whether this was by a child protection medical or a written report by a hospital consultant. 6.1.12 Another factor that was not effectively explored was the parents’ use of cannabis and what the impact of this would have been on the care afforded to Luke. There was evidence of historical use of cannabis by Kate and Jake and recent concerns from professionals, but this is not recorded as being considered. 6.1.13 There is little evidence that the professionals directly involved with raising the previous concerns and involved with the family were effectively consulted and liaised with during the section 47 enquiry and their views reflected. 6.1.14 Had there been a joint police/CSC investigation, there may not have been a criminal outcome and indeed this may have not been a desired outcome but it would have allowed a better understanding of the extent and complexities of parental neglect and injuries to Luke. It would also have allowed health records to be tri-angulated. 6.1.15 The outcome of the section 47 enquiry was that child protection concerns were not substantiated. It is clear from the information gathered by the IMRs and made available to the review author and the detailed analysis undertaken that there was evidence that Luke was at risk of significant harm and that an Initial Child Protection Conference (ICPC) should have been convened at this stage 6.1.16 There continued to be concerns regarding the parent’s meaningful engagement with agencies. Whilst Luke was in hospital, concerns were noted by the hospital staff regarding the appropriateness of the parents’ behaviour and their personal hygiene. On 20th April 2018, the Children and Family (CAF) assessment was completed, the conclusion of the assessment was that CSC had no present safeguarding concerns and the recommendation was for the case to close. Whilst there was management oversight on this decision, there is evidence that the conclusion was over optimistic and did not take into account other hypothesis, such as disguised compliance (discussed in more detail at section 7.2). 6.1.17 Within the assessment a number of safety factors were identified, which it would be difficult to rely upon. One of these was the involvement of the Family Nurse Partnership. Whilst this initiative provides real value to young parents, it is voluntary and relies on good parental engagement which could not be relied on in this case. In 39 attempted contacts, the FNP, despite best efforts only saw the family on 10 occasions. The assessment focused too much on the current period of time without considering the significant history and previous adverse childhood experiences of, in particular, the mother. In addition, as a Looked after Child the mother had a named LAC Nurse. The LAC Health team would have been involved version 5 17 with this mother for many years, and the management of her transition to adulthood and the organisational memory of her engagement would have provided additional evidence of her lack of engagement to meet her own health needs 6.1.18 The CSC IMR author also recognises that apart from considering the risks presented by the extended family the assessment also had the opportunity to explore any strengths presented by the family network, such as building on the information and support provided by the paternal grandfather. 6.1.19 The case was closed to CSC on 17th May 2018, this was despite continued concerns regarding access to and engagement with the family. There was also evidence of a large and aggressive dog now being present at the premises. The parents continued to fail to register Luke with a GP. Through this period, it is apparent that the social worker believed that there was early help support in place, which was not the case. 6.1.20 In late June 2018, significant concerns were raised by the key worker on the condition of the premises. During the previous assessment there was a written agreement put in place with the family, one condition of which was daily access by the key worker. The key worker made three referrals to the MASH regarding the ‘extremely poor condition’ of the premises. These referrals included 11 photographs to evidence the concerns. It is not clear that the photographs were used as part of the decision-making process. The referrals detailed concerning neglect and the presence of domestic abuse. The family address was thoroughly cleaned by the key worker organisation and this gave cause to further concerns over neglectful conditions. The outcome of the referrals was that a Children and Family assessment would be commenced. 6.1.21 The CSC author rightly recognises this point as a missed opportunity to convene a strategy meeting to consider a joint section 47 enquiry. The decision made did not appear to give due consideration to the long-term impact and continued neglect that was presenting. At this time Luke was five months of age and overall the conditions experienced by him were declining as opposed to improving. Child in need plan - Luke 6.1.22 The outcome of the assessment, which was completed in early July 2018, was that a Child In Need(CIN) plan would be put in place. Luke and his parents were only seen once during the assessment and the parents not seen separately. Domestic abuse was discussed but no DASH6 risk assessment was undertaken, which would have informed and assisted the assessment. The assessment did not include the views of all agencies, notably the personal advisor and the housing key worker. The CSC IMR identifies that the assessment lacked professional curiosity and insight into what life was like for Luke when professionals were not involved, and the plan failed to focus on the relevant issues. There is little evidence of consideration of what 6 DASH - The Domestic Abuse, stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management tool used by all professionals. version 5 18 factors could potentially impact on the parent’s ability to effectively parent Luke and what their parental ability and understanding of Luke’s needs were. 6.1.23 The CIN plan contained a condition that if access to the family home was denied or frustrated, police would be called and this would initiate child protection processes. Which did not occur. 6.1.24 In July 2018, the social worker and key worker visited the family and noted that Luke had a bad nappy rash and what they thought may have been a burn on his leg. A child protection medical was arranged but this was outside of the child protection process, there was no strategy meeting or any section 47 enquiry. This meant that there was no escalation considered and not all parties involved with the family were aware of the medical or the concerns. The red mark was thought to be part of the ongoing nappy rash. 6.1.25 In August 2018, the family also moved from the supported accommodation taking up a tenancy for new premises. One of the effects of this was that the key worker was no longer involved in daily checks and this decreased the professional attention on Luke. During September 2018, the social worker attempted visits but there was no reply and Kate failed to attend a CIN meeting. Whilst there were concerns, the police were not asked to undertake a check as was the contingency in the plan or any escalation in child protection processes 6.1.26 During the course of the child in need plan there was continued evidence of neglect and whether the parents were meaningfully engaging with professionals. The concerns included: the relationship of the parents being under pressure; Kate not working with her personal advisor; aggressive dogs being introduced to the house; concerns over Luke’s excessive weight and development; Luke’s cot being stained and without a properly fitted mattress; Luke not being registered with a GP. Despite these concerns the September 2018 CIN meeting agreed that the case could be stepped down to early help. CSC are recorded as there being no concerns at the time. There is no recorded disagreement or challenge from other agencies. This decision did not reflect the current situation and there was not enough evidence of any sustained and meaningful improvement. Any early help had not been delivered to date and it was not delivered at this time as a result of this step down. The Family Hub did not accept the referral, on the basis that agencies were involved in the family. This decision should have resulted in re-consideration of the appropriateness of the step down. 6.1.27 The case was closed to CSC at the end October 2018, there was management oversight which supported the decision and closure. This supported the fact that there had been significant improvement, which due to the factors outlined is not evident. The CSC IMR author makes the point that ‘the lack of evidence-based analysis of neglect meant that such judgements were subjective and did not consider the overall cumulative impact of neglect’. In conclusion, it would have to be said that the child in need plan did not achieve the required improvement and on this basis, it was closed prematurely. version 5 19 Pre -birth – Matt 6.1.28 By November 2018, the plan had only been closed one month and there were continued concerns regard in engagement. Kate was pregnant and was not contacting or responding to contact from her personal advisor, the family nurse or the teen age pregnancy midwife. The personal advisor made a referral to the MASH and requested a police safe and well check. The referral was not taken forward as Kate was considered to be less than 12 weeks pregnant. The previous social worker was asked to visit Kate, which they did but were not successful in making contact. 6.1.29 The police undertook a safe and well check in late November 2018, the police officers recorded the visit on body worn video, which was reviewed for the purposes of this review. The address was seen as cluttered but appropriate. The police officers walked through the address and assessed suitability of conditions. The officers assessed that there was no risk of significant harm at this time and made contact with CSC whilst at the address and arranged for the parents to be available for a visit the following day, which was good practice. The parents were compliant but the police IMR author assesses that their behaviour, taking into account the history, indicated disguised compliance. 6.1.30 The social worker did attempt to make contact with the family a week later but was not successful. On the basis that the family had been seen by police and the personal advisor, the case was closed to CSC. This was another missed opportunity to convene a strategy meeting and consider a pre-birth assessment for Kate’s unborn child and for Luke. The Coventry Safeguarding Pre- birth procedures state: - ‘Risk factors which could indicate that an unborn child may be likely to suffer significant harm and therefore be subject to a pre-birth assessment may include: Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care.’ The history of the case and concerns raised, the fact that Kate was pregnant again and failing to contact professionals was another opportunity to convene a strategy meeting and undertake a pre-birth assessment. 6.1.31 There then followed a number of missed appointments with the parents not engaging with professionals and missing appointments. Kate was not engaging with maternity services at all and claimed that she had paid for a private scan at 16 weeks, although this was never evidenced. During this period although there were concerns no further referrals were made. Matt is born 6.1.32 Matt was born prematurely in April 2019. Matt was in hospital for around 43 days in varying levels of special care. During this time the parents are said to have visited on most days. The hospital recorded that there were concerns over the parent’s personal hygiene. The hospital did not make referrals regarding this but did liaise with the family nurse. The family nurse made a referral and CSC agreed that a Children and Family assessment would be undertaken. This was another opportunity for a strategy meeting to be convened. version 5 20 6.1.33 A new social worker was allocated the case and started to try to have contact with the parents from 14th May 2019.There is some evidence of the parents still avoiding contact but the Social Worker explained that Matt would not be discharged until they were confident that all necessary measures were in place. There is some evidence of good practice by the social worker being intrusive around practical elements of care for Matt but some concerning elements still existed, for example the poor condition of the mattress that was to be used for Matt. 6.1.34 Matt was discharged home on 21st May 2019. Most of the visits that occurred after his discharge were announced and no concerns were noted except that during a visit in June 2019, the home conditions were noted as being poor and Luke’s mattress, smelt unpleasant. This was a re-occurring theme, which on each occasion Kate accounted for and her explanation was accepted. There was also a recorded domestic abuse incident between Kate’s sister and her partner, who appeared to be living at the address. 6.1.35 There were a number of opportunities for strategy discussions to be convened and a joint section 47 enquiry undertaken to better understand and deal with the fundamental concerns. Neither the child in need plan or the children and family assessments witnessed an improvement in the conditions for Luke and more latterly Matt. As Kate had been a looked after child much was known about her history, the challenges she had faced and her own adverse experiences. There is not much evidence that this was considered sufficiently when undertaking assessments and making key decisions. There is a strong theme of the parents responding when there was strong agency focus and when this diminished so did their attention to the care of Luke. There is little doubt that this case should have progressed to an initial child protection conference as discussed as early as March 2018. 6.2 Working with families who are difficult to engage and disguised compliance 6.2.1 The first concerns raised in this case were the meaningful engagement of the parents with professionals. This continued throughout the case, fluctuating at times. The engagement moved between avoidance of professionals to, on occasions, being outwardly aggressive and abusive and denying them access. 6.2.2 There was also a pattern of there being real concerns over issues such as the cleanliness of the home address and the conditions that the children were living in. When the parents felt that these aspects were under focus the parents improved the area of concern very quickly, but these positive changes were not maintained over any period of time. 6.2.3 Kate had a long history with CSC and to this degree may have had a ‘hardened’ approach to some agencies. The history and level of cooperation with agencies as a looked after child does not seem to have formed part of the assessments that were undertaken. There were many agencies involved with the family and a more coordinated approach may have assisted in building a better relationship with the family. 6.2.4 Disguised compliance involves parents and carers appearing to co-operate with professionals in order to allay concerns and stop professional engagement version 5 21 (Reder et al 1993). Disguised compliance was identified as being presented by the parents but there was little evidence of this being effectively addressed. The NSPCC Learning from Case Reviews briefings - Disguised Compliance7 notes reflect well many aspects of this case. Parents missing and cancelling appointments, professionals being over optimistic and disguised compliance being recognised but no effective action being taken. The briefing recognises that there should be more of a focus on the child’s lived experience instead of the parent’s actions. 6.2.5 The Coventry Safeguarding Children Partnership has disguised compliance practice guidance within their procedures8. This guidance highlights the necessity for professionals to discuss concerns over challenging families and disguised compliance at supervision. Work should be undertaken to enhance the practice guidance to a procedure which includes steps to escalate and address the behaviour. 6.2.6 Where measures are put in place or boundaries set it is important that they are adhered to. As part of the child in need plan a contingency was that if the family were not seen or avoided contact the police would be called, this did not happen as a matter of course. When the police were asked to see the family in November 2018, they did so and spoke to CSC from the family address, which was good practice. It was left that the social worker would visit the next day. This did not happen with the CSC manager setting a week for the visit to occur. In fact, when contact could not be made with the parents the case was closed, with the rationale of relying on the previous police and personal advisor contact. 6.3 Recognition, assessing and intervention for neglect. 6.3.1 There is no doubt that neglect was an ongoing concern in this case, the imminent risks and long-term harm and the cumulative effect of neglect are well evidenced and referenced in the Coventry Safeguarding Board Neglect Strategy 20189, which also links to other strategic initiatives. The strategy seeks to address neglect in Coventry under the themes of Identify, Prevent, Protect and Evaluate. 6.3.2 Whilst the concern of neglect was identified, there is little evidence that any contributory causes were investigated and assessed. There was the ongoing concern of the parents’ use of cannabis but what impact this may be having on the care afforded to and wellbeing of Luke, and more latterly Matt was not effectively considered. There is also little evidence on consideration of the parent’s basic ability to effectively provide good care to the children. 7 NSPCC learning from case review briefings 2019 – Disguised compliance (accessed 26/10/20) NSPCC disguised-compliance 8 Working with families who refuse to consent or engage, or demonstrate disguised compliance practice guidance (accessed 26/10/20) - West Mids Child Protection Procedures 9 Coventry LSCB Neglect Strategy – (accessed 26/10/20) Coventry neglect_strategy version 5 22 6.3.3 Where there was a focus on neglect, it tended to be on the parents’ and not on what the lived experience of the children was. In assessing the level of neglect, the use of a tool would have assisted in assessing the level of neglect and the risk presented. The Graded Care Profile 2 (GCPC2) is a tool that is used by the NSPCC in Coventry. An NSPCC evaluation found that use of GCPC2 resulted in practitioners feeling referrals were clearer and more likely to lead to actions that would support the child and some families were reported to make health and lifestyle changes as a result of use of the tool10. 6.3.4 The Coventry Strategy under the Prevent heading also seeks to use serious case reviews to learn the lessons in relation to neglect. The previous Coventry serious case review of Baby E11 undertaken in March 2018 involved the accidental co-sleeping death of a 5-month-old child. The review identified that ‘Training on a multi-agency basis to recognise the possible indicators of neglect arising from a series of low-level concerns, and particularly to understand the cumulative way in which these can impact in children, is needed.’ The need for this continued training, awareness and focus still exists. 6.3.5 The continued failure of the parents to register Luke with a GP was a concern which should have been more robustly followed up to ensure that he was able to access all health support. Another complicating factor was that the father was registered with a different GP, and it was not recorded that he had a partner and two children. Therefore, any safeguarding issues that might have been a concern would have not been seen in the light of his role as a father. For example, his attendance at A&E with a hand injury due to punching something was not connected to his family and any risk his behaviour might pose. 6.4 Co – sleeping 6.4.1 Whilst the cause of Matt’s death has not been formally determined there is sufficient information available to draw learning on how safe the sleeping arrangements were for Matt. 6.4.2 The majority of neglect related deaths of very young children involve accidental deaths and sudden unexpected deaths in infancy where there are pre-existing concerns about poor quality parenting and poor supervision and dangerous, sometimes unsanitary, living circumstances which compromise the children's safety. These issues include the risks of accidents such as fires and the dangers of co-sleeping with a baby, where parents have substance and/or alcohol misuse problems (Brandon et al, 2013). There is evidence throughout this case that there were concerns regarding the sleeping arrangements and condition of the cot and mattress. There is also evidence that safe sleeping advice was given, both routinely and when concerns were noted. There was also a suspicion of cannabis use. The impact of the 10 NSPCC - Implementation Evaluation of Graded Care Profile (accessed 26/10/20) – NSPCC GCP2 Evaluation 11 version 5 23 use of cannabis and the risks of co-sleeping cannot be underestimated, and the lived experiences of the children in this environment is of grave concern. 6.4.3 That said, there continues to be cases where, harm is caused by unsafe sleeping arrangements. The Baby E case review, already referenced made the following recommendation ‘Review the evidence of awareness by parents of the risks of co-sleeping, and where there are seen to be gaps, develop effective communication strategies about the risks and dangers, addressing both professional audiences and parents/families.’ This recommendation should be re-visited to understand if the message to both professionals and parents/carers should be refreshed and enhanced and whether this message to parents should be differentiated according to risk. 6.4.4 In July 2020, the National Child Safeguarding Review Practice Panel published their second thematic review, Out of Routine: A review of sudden infant death in infancy (SUDI) in children where children were considered at risk of significant harm.12 The report identifies that between June 2018 and August 2019, of the 568 incidents reported to the panel, 40 were cases of SUDI and sadly most of the deaths were preventable. The review examined 14 of these cases and identified that there was a range of pre-disposing risk factors. Many of the cases involved co-sleeping. Many of the identified risk factors are present in this case, co-sleeping, parental substance misuse, evidence of neglect, domestic violence and young parents who had suffered a number of adverse childhood experiences. These are all features of this SCR. 6.4.5 The report identifies the ‘need for local working that recognises a continuum of risk of SUDI, with support and interventions that are differentiated to all families, families with additional needs and families at significant risk.’ 6.4.6 The report identifies a number of areas of good practice including a SUDI risk assessment tool utilised by the Nottingham Safeguarding Board13, which seeks to help identify the families most at risk and focus discussions with them. 6.4.7 In the Coventry partnership, the Family Nurse Partnership already uses resources from the Lullaby Trust14. There is an opportunity to review the findings of the national report and to seek to locally to adopt the findings, in particular the identification of the most at-risk families and utilisation of a differentiated response according to the risk. 6.5 Multi agency working 6.5.1 There is evidence of agencies working together and undertaking some joint visits to the family. What this case lacked was overall coordination of the multi- agency approach, whether this came from Early Help or statutory intervention. Although early help was requested, it did not transpire and the approach to 12 Out of Routine: A review of sudden infant death in infancy (SUDI) in children where children were considered at risk of significant harm (accessed 26/10.20) - A review of sudden infant death in infancy (SUDI 13 Nottinghamshire Safeguarding Children Board safe sleeping risk assessment tool (accessed 26/10/20)– Nottinghamshire safe sleeping risk tool 14 The Lullaby Trust (accessed 26/10/20) - https://www.lullabytrust.org.uk/ version 5 24 assessment resulting in child in need and child protection procedure has already been discussed. Without this coordination, it was identified in agency reports that there should have been multi agency meetings to ensure that information was appropriately shared. 6.5.2 On occasions, not all agencies were involved in important aspects of the case, such as the family nurse in the child protection medical (July 2018) and the CIN meeting. The Family Nurse Partnership also requested information from CSC and the MASH on the name of the allocated social worker but was denied the information. This response should have been challenged and escalated. There is no evidence of this happening. 6.5.3 Where referrals were made to the MASH, they were graded as amber, before being re-graded as red once a strategy discussion had taken place. There was an agency view that the referral could have been more robustly assessed in the first instance to allow a timelier response.15 6.6 Management oversight and professionals experience 6.6.1 When the case was open to CSC, there were occasions when the case was closed without the required level of management oversight. The CSC IMR author recognises that there is now a clear expectation within Children Services that all children’s cases have a closure summary, which requires management oversight and authorisation. In this case the management oversight, at the point of closure, was overoptimistic and lacked the required level of scrutiny. The CSC author makes the point that at the point of closure the views and opinions of other professionals involved with the family should be sought and recorded on closure records. This would ensure that a range of professional opinion was reflected when considering if a case should be closed. 6.6.2 Any closure decision would have benefited from a clearer demonstration of reflective supervision, developing hypotheses and critical thinking. Consideration of the history of the case through the chronology may have led to a more cautious approach when considering the closure of the case. 6.6.3 This management is even more relevant where staff involved are less experienced, as was seen during periods of this case. The panel discussed and challenged whether less experienced staff had been fully supported and whether there could have been increased supervision to assist them in what was a difficult case. This was particularly seen where the social worker was within their assessed and supported phase of their career. The social worker did demonstrate good levels of curiosity and challenge, but it is not clear that the appropriate level of support was in place. 7. What are the learning points from this case? 7.1.1 All agencies need to be sure that practitioners: understand and are able to identify neglect and be aware of the lived experience of the child/children in the 15 Coventry MASH Procedure - coventrychildcare.proceduresonline (Accessed 26/10/20) version 5 25 family home. That they understand the harmful effect of the cumulative effect of continued neglect; that neglect is appropriately assessed. This would benefit from the use of the Graded Care Profile 2 tool. An important area for professionals to consider is the lived experience of the child. Management oversight is important in neglect cases from all agencies and it is important that this is not overly optimistic and carefully considers the history of the case to ensure that any improvements are sustained. 7.1.2 There should be a renewed assessment of whether safe sleeping is adequately covered by all agencies as appropriate to their function. Whilst there is evidence in this case that safe sleeping was discussed, it continued to be an area of concern. Where there is this concern, despite advice, there needs to be an escalation and consideration of a differentiated response according to risk. The use of cannabis by parents and safe sleeping message needs some additional focused attention by the Coventry Safeguarding Children Partnership. 7.1.3 There was clear disguised compliance identified by various professionals, and the parents at time were abusive and avoidant. If there had been greater liaison with the LAC Health Professionals from health at the LA, during Kate’s transition to adulthood, some of her patterns on non-engagement might have been predicted. Professionals need clear guidance, how having experienced these concerns, they proceed. This may require the current protocol being developed into a clear procedure. Where boundaries are set for parents they need to be adhered to. 7.1.4 Suspected drug use (cannabis) by the parents was challenged more latterly in this case, however it was not effectively considered in the CIN or CAF assessment, and neither in the section 47 enquiry. Consideration would have allowed for the hypothesis that the parents were using cannabis to be ruled in or ruled out. 7.1.5 Early Help was considered and requested on a number of occasions but was never delivered, one of these occasions being the step-down from child in need plan. There needs to be a clearer pathway between CSC and early help to ensure that a case is accepted and suitable for early help before it is closed to CSC. 7.1.6 An area for further exploration is how well children leaving care, particularly those who become pregnant at an early age, are prepared for parenthood and how the adverse childhood experiences of these parents may factor on their parenting understanding and ability, and how information is shared at the transition into adulthood. 7.1.7 Where there are concerns around neglect or other vulnerabilities, e.g. parents that are care leavers, a pre-birth assessment should be considered. This review may offer an opportunity to enhance professional knowledge of the pre-birth procedures and share information to inform future decision making. version 5 26 7.1.8 Where there are disagreements or unresolved challenge, professionals should use the Resolution and Escalation of Professionals Disagreement Procedures. This review should present an opportunity to promote the procedure. 7.1.9 Where a referral is made to the MASH and a strategy meeting takes place, the professional making the referral should attend the meeting unless it would prevent the meeting taking place within timescales. Any CSC assessment should seek the views of other involved professionals and this should be reflected in the recorded assessment and similarly the views of other involved professionals should be sought and recorded when closure is being considered. 7.1.10 All children should be registered at a GP surgery to ensure their health needs are being met. There is evidence that Luke was not registered until his second year of life which complicated his health needs being met and understood from Primary Care 7.1.11 Jake, the children’s father, was registered at a different GP surgery to Kate and the children. This makes understanding family dynamics and information sharing more complicated from a Primary Care perspective. There was no connection between the father and his children, therefore this has the potential for concerns to be understood regarding his role as a father. This is an area that requires review and strengthening the information that is held in Primary care. 8. Recommendations 1. The Coventry Safeguarding Children Partnership should review the neglect strategy to ensure that the identification of neglect is identified and appropriately responded to. This should include: - • The continued implementation and embedding of the Graded Care Profile 2 to all relevant staff. • Recognition of the harm caused to children by the cumulative effect of all types of neglect. • Using this and previous reviews which have focused on neglect as learning for professionals. 2. The Coventry Safeguarding Children Partnership should use this review and the findings of the National Children Safeguarding Practice Panel to review the approach to safe sleeping by: - • Review commissioning to promote safe sleeping within a local strategy for improving child health outcomes. • Promoting the identification of pre-disposing risks of SUDI and delivering differentiated interventions according to risk, with particular focus to parents that are suspected or know to use substances and/or alcohol. version 5 27 3. The Coventry Safeguarding Children Partnership should consider what support, training and advice is in place for professionals dealing with families demonstrating disguised compliance or who are avoidant and/or resistant and determine whether further support is required which could include: - • A tiered and robust multi agency approach, utilising the skills and powers available from each agency providing consistency and clear boundaries. • Undertaking coordinated but unannounced visits. • Triangulating historic and family information with other agencies, extended family and community. 4. The Coventry Safeguarding Children Partnership should be assured that :- • Referrals to the MASH are appropriately triaged and where appropriate a strategy meeting takes place; this meeting should include where possible the agency making the referral. • That assessments include all relevant agency information. • That pre-birth assessments are undertaken in relevant cases and the procedure is embedded. • That prior to closure of Child in Need plans, there is clear evidence that the desired outcomes have been addressed. 5. Coventry Children Social Care should ensure that the pathway to allow families to access Early Help provision is clear and robust, in particular where cases are stepped down. This should include a notification to the social worker that the case has been accepted by Early Help , where consent is given, before the case is closed. 6. The Coventry Safeguarding Children Partnership should ensure that the Coventry and Warwickshire Resolution and Escalation of Professionals Disagreement Procedure is understood by professionals and there are no barriers to it being used. 7. Coventry Safeguarding Partnership should review what provisions are available to support and understand the needs young people leaving care in anticipation of impending parenthood. version 5 28 Appendix A Details of author The author in this review has no prior involvement with the case and is not connected to any of the agencies involved. He is a retired senior police officer, who had responsibility for strategic and operational safeguarding and was a senior investigating officer. He has undertaken serious case reviews, safeguarding adult reviews, MAPPA case reviews and domestic homicide reviews, with various boards across the country. He has also worked with Clinical Commissioning Groups, The Church of England and the third sector on safeguarding matters. |
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